298 Section VII ■ Tube Replacement

Table 42.3 Complications and Complex Ostomies

Complication Interventions

Multiple stomas Customize pouch to fit around or accommodate stomas in bag; mucous fistulas

may be in or out of pouch.

Open incision or wound Two-piece pouches without starter hole may allow for easier customization.

Keep wound as clean as possible.

Use hydrocolloid wound dressing (e.g., DuoDERM, ConvaTec, Skillman, New

Jersey; Replicare, Smith and Nephew, London, UK; Memphis, TN) or calcium

alginate in wound bed covered with a piece of clear film dressing to protect

wound from stool.

Paste and powders may also be used to protect peristomal skin.

In some cases it may not be possible to apply a pouch; however, the skin must be

protected from caustic effluent, using a barrier such as Sensi-Care Protective

Barrier (ConvaTec, Skillman, New Jersey), or Calmoseptine Ointment

(Calmoseptine Inc., Huntington Beach, California).

Flush/retracted stoma Apply paste or moldable barrier around hole in wafer.

Use convex insert/convex pouch and belt to push skin back and allow stoma to

protrude.

Prolapsed stoma Notify surgeon if evidence of circulatory compromise.

Protect the stoma from injury. When using two-piece pouch with plastic flange,

the stoma could be pinched in the flange that secures the pouch to the wafer

when closed.

Adjust size of hole accordingly; cover exposed skin with moldable barrier or paste.

Peristomal hernia Use a flexible wafer and pouching system to adjust to contour of the skin.

Mushroom-shaped stoma Modify opening to accommodate size of “crown”; protect skin around base with

moldable barrier or paste.

Irritant dermatitis Ensure that hole is cut to fit properly.

Use paste/moldable barrier to protect from leakage.

Apply powder to open, weepy skin.

Assess for sensitivity to products.

Apply topical steroids if needed to decrease inflammation, pain, and itching.

Peristomal Candida

albicans

Appears as red, shiny, macular, papular rash that is pruritic.

Apply topical antifungal powder (e.g., nystatin) to skin. The powder should be

mixed with a small amount of water, painted smoothly on the skin with a cotton swab, and allowed to dry before placing the appliance. Continue to use

with each pouch change until rash resolves.

Dry skin completely when changing pouch.

Resize pouch so that no skin is exposed.

Dehydration, metabolic

acidosis, electrolyte

imbalance

Monitor intake and output carefully, especially for infants with ileostomy and/or

high output.

Assess lab values regularly. Infants can develop electrolyte imbalance rapidly.

Data from Borokowski S. Pediatric stomas, tubes, and appliances. Pediatr Clin North Am. 1998;45:1419; Craven DP, Fowler

JS, Foster ME. Management of a neonate with necrotizing enterocolitis and eight prolapsed stomas in a dehisced wound.

J Wound Ostomy Continence Nurs. 1999;26:214; Garvin G. Caring for children with ostomies and wounds. In: Wise B,