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Types of stoma

Colostomy

A colostomy may be formed from any section of the large bowel. Its position along the colon will dictate the output and consistency of faeces. Therefore an understanding of the anatomy and physiology is essential to fully care for stoma patients.

The most common site for a colostomy is on the sigmoid colon. This will produce a semi-solid or formed stool and is generally positioned in the left iliac fossa and is flush to the skin (Black 2000). Stomas formed higher up along the colon will produce a slightly more liquid stool. A colostomy tends to act on average 2–3 times per day, but this can vary between individuals.

Colostomies can either be permanent (end) or temporary (loop). Permanent (end) colostomies are often formed following removal of rectal cancers, as in abdominoperineal resections of the rectum, whereas a temporary (loop) colostomy may be formed to divert the faecal output, to allow healing of a surgical join (anastomosis) or repair, or to relieve an obstruction or bowel injury (Taylor 2005). This type of stoma is often referred to as a defunctioning stoma, which indicates that the bowel distal to the stoma is being rested (Black 2000, Taylor 2000).

End and loop colostomies are very different in appearance. An end colostomy tends to be flush to the skin and sutured to the abdominal wall and consists of an end-section of bowel, whereas a loop colostomy is larger in size. During the perioperative period it is supported by a stoma bridge or rod (Figure 6.14). This is placed under the section of bowel and is generally left in place for 3–10 days following surgery and then removed (Wright and Burch 2008).

Figure 6.14 Loop colostomy with bridge in situ.

Ileostomy

Ileostomies are formed when a section of ileum is brought out onto the abdominal wall. This is generally positioned at the end of the ileum on the right iliac fossa, but can be anywhere along the ileum. Consequently, the output tends to be looser, more liquid stool, as waste is being eliminated before the water is absorbed from the large bowel (colon). Due to the more acidic, abrasive nature of the stool at this stage, a spout is formed with this type of stoma. The ileum is everted to form a spout which allows the effluent to drain into an appliance, without coming into contact with the peristomal skin (Black 2000). This prevents skin breakdown and allows for better management. The average output from an ileostomy is 200–600 mL per day.

Ileostomies can also be either permanent (end) or temporary (loop). Permanent ileostomies are often formed following total colectomies (removal of the entire colon) for diverticular disease. Loop ileostomies are more common and are often formed to allow healing of a surgical join (anastomosis) lower down, to allow healing of an ileo-anal pouch or to aid healing of diseased bowel (Taylor 2005). These are sometimes held in place by a stoma bridge or rod. Refer to Procedure guideline 6.13 for more information on bridge/rod care and removal.

Evidence-based approaches

Stoma care has developed greatly over the years and is mainly based on experiential learning. Although an evidence base for this does exist, it mainly centres around clinical practice and experience.

Stoma care is very individual and requires full holistic patient assessment. The primary aim is to promote patient independence by providing care and advice on managing their stoma, therefore allowing the patient to continue with all the necessary activities of daily living.

Rationale

Indications

Stoma care is essential:

to collect faeces or urine in an appropriate appliance

to achieve and maintain patient comfort and security

to maintain psychological adaptation and independence of the patient.

Legal and professional issues

As already discussed, stoma care is primarily based on experience and therefore the development of skills. It is a basic nursing task that all qualified nurses should be able to carry out. It has recently been recognized that many of the basic nursing skills are being carried out by healthcare