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TUBINGS
Stoma care
Stoma formation in childhood is performed during the surgical correction of congenital
abnormalities, following trauma and/or to defunction the bowel, treatment of inflammatory
bowel disease, intestinal motility disorders, infections e.g. necrotising enterocolitis and
malignancy of gastrointestinal tract or urinary system.
Ileostomy: a portion of ileum is brought out through the abdominal wall and is normally
sited in the right iliac fossa.
Colostomy: a portion of the colon is brought through the abdominal wall and is normally
sited in the left iliac fossa (the transverse, descending or sigmoid colon may be used).
Urinary diversion:
Vesicostomy: the neck of the bladder is brought through the abdominal wall low
down in the pelvis.
Ureterostomy: one or two of the ureters can be brought out to the abdominal wall
either side by side or at either side of the abdomen or flanks.
Ileal conduit: a small segment of ileum is isolated to act as a reservoir and the
ureters implanted into it. This stoma can be sited either in the left or right iliac
fossa.
A one-piece pouch has an adhesive flange with a pouch bonded onto it.
A two-piece pouch has an adhesive flange and a separate pouch, which attaches to the
flange.
Both the one piece and the two-piece pouch can have a closed end or an open or
drainable end.
Urinary pouches have non-refluxing valves and an adaptor to attach to an overnight
drainage bag
Children with colostomies, which produce formed stool, have the opportunity to use a colostomy
plug:
A faceplate is attached to the skin and a plug is inserted into the stoma. A cap on the end
of the plug is then clipped onto the faceplate.
The plug has to be removed at least twelve hourly and a bag attached to the faceplate
In the early post-operative period a one piece, drainable transparent pouch should be applied.
Skin care
The skin around the stoma is called the peristomal skin and it is just the same as other
skin on your child's body. It is not more or less sensitive. Although the stoma has no
feeling, the skin does.
One of the most important goals is to keep the skin healthy. If the skin does not stay
healthy, problems with pouch leaking may occur.
To clean the skin around the ostomy, use just water. Or we can use a mild soap that does
not leave a film or residue on the skin, then rinse with plain water. Always rinse off any
soap. Soap or water will not hurt the stoma.
Do not use any baby wipes, oils, powders, ointments, lotions on the skin around the
stoma. These products contain ingredients that can prevent the pouching system from
sticking.
For a preterm infant, the baby's skin has not yet had the chance to develop and mature.
For that reason, we will have to take extra care with all products used on the newborn's
skin. Gentle products, such as SoftFlex skin barriers from Hollister, are designed to
prevent tearing. Because substances can be absorbed through immature skin.
The skin should not be irritated as this can be uncomfortable for child. Open areas, a
persistent redness or red bumps on the skin are not normal. It is essential to determine the
cause and treat it appropriately.
Stoma siting
The majority of stoma formation in childhood is carried out in the neonatal period. Stomas are
generally a temporary measure until definitive surgery is performed. Babies do not have their
stomas sited as they are formed during an emergency surgery.
Time and consideration should be spent ensuring the optimal site is marked. The following
points should be considered:
There can be problems with stoma management in pediatric patients. In the post-operative period
a drainable transparent pouch is used so that the stoma can be observed easily, the main
observation should be the colour of the stoma. Any concerns should be reported and recorded in
the patient's notes.
Colour
A healthy stoma is red/pink in colour. It is very important, especially in the postoperative period,
to check the colour of the stoma regularly. If the stoma appears darker in colour medical advice
should be sought.
Oedema
In the early postoperative period all stomas will be oedematous. Parents and children should be
aware that the stoma will change shape and size. At six weeks the stoma should have shrunk to
its actual size. This is important as the parent/child needs to cut the pouch or flange to the exact
size of the stoma.
Prolapse
Prolapse of loop stomas in infants and children is common. Parents and children need to be
advised of the possibility, given a description of what a prolapse looks like, and when to seek
medical advice. Older children should be discouraged from lifting heavy weights.
Retraction
Some stomas can become retracted. This will cause more problems with an ileostomy as the
output is loose, and stool will leak under the adhesive of the pouch. Parents can seek the advice
of the stoma nurse or the doctor if the stoma appears sunken.
Stenosis
Stenosis of the stoma can also occur. Often the narrowing of the bowel is at the skin surface, but
it can occur inside the abdomen. This may present with:
Granuloma
Nodules of granulation tissue can form on the surface of the stoma. These can bleed easily and
may cause concern, as they will bleed whenever the stoma pouch is changed.
Assessment
Vital signs
o PICU and NICU children’s should be on continuous monitoring
o HR, SpO2, BP, RR
o Routine observations:
For ward areas:
o On insertion of chest drain monitor patient observations of HR, SpO2, BP, RR:
15 minutely for 1 hour
1 hourly for 4 hours
o Includes HR, SpO2, BP, RR, Respiratory Effort and temperature
o 1-4 hourly as indicated by patient condition
o Observations to be recorded in the Observation Flowsheet on EMR
Pain
Chest tubes are painful as the parietal pleura is very sensitive. Children’s require regular
pain relief for comfort.
Pain assessment should be conducted frequently and documented.
Suction
Suction is not always required, and may lead to tissue trauma and prolongation of an air
leak in some patients
If suction is required orders should be written by medical staff
o Atrium Oasis- The wall suction should be set at >80mmHg or higher
o Atrium Ocean- Suction needs to be titrated so that the fluid in suction chamber is
gently bubbling
Suction on the Drainage unit should be set to the prescribed level
o -5 cmH20 is commonly used for neonates
o -10 cmH20 to -20 cmH20 is usually used by convention for children
To check suction:
o Any visible expansion of the bellows is adequate for suction <20 cmH20
o If the bellows deflate, check the wall suction is still working, set to > 80mmHg
and that the suction tubing is not kinked
Atrium Ocean UWSD:
o The water level in the suction chamber should be at prescribed level and gentle
bubbling should be observe
o The level may drop due to evaporation or over-vigorous bubbling, if this occurs
top fluid level up as per manufacturer’s instructions
Drainage
Milking of chest drains is only to be done with written orders from phusician. Milking
drains creates a high negative pressure that can cause pain, tissue trauma and bleeding
Volume
o Document hourly the amount of fluid in the drainage chamber in the Fluid
Balance flowsheet on EMR
o Calculate and document total hourly output if multiple drains
o Calculate and document cumulative total output
o Greater than 5mls/kg in 1 hour
o Greater than 3mls/kg consistently for 3 hours
o Blocked drains are a major concern for cardiac surgical patients due to the risk of
cardiac tamponade
o Notify medical staff if a drain with ongoing loss suddenly stops draining
o If the chamber tips over and blood has spilt into next chamber, simply tip the
chamber up to allow blood to flow to original chamber
Oscillation (swing)
The water in the water seal chamber will rise and fall (swing) with respirations. This will
diminish as the pneumothorax resolves.
Watch for unexpected cessation of swing as this may indicate the tube is blocked or
kinked
Cardiac surgical patients may have some of their drains in the mediastinum in which case
there will be no swing in the water seal chamber.
Document on Fluid Balance Flowsheet on EMR
Positioning
who are ambulant post operatively will have fewer complications and shorter lengths of
stay. Consider converting to a portable flutter valve system such as the pneumostat to
facilitate this. If chest drain will be required for prolonged period
if patient is an infant, regular changes in position should be encouraged to promote
drainage, unless clinical condition prevents doing so
Patient Transport
If the patient needs to be transferred to another department or is ambulant, the suction
should be disconnected and left open to air.
do not clamp the tube
Clamps must not be used on the patient for transport because of the risk of tension
pneumothorax
Ensure the chamber is below the patient’s chest level during transport
Flutter Valve systems (pneumostat, Heimlich) may be used for patient interhospital
transfers (e.g. NETS and PETS)
Specimen Collection
Collect drainage specimens for culture through the needless sampling port located by the in line
connector.
Equipment Required
Specimen container
Alcohol swab
10ml syringe
Dressing pack
Gloves
Eye Protection
Procedure:
no longer dry and intact, or signs of infection e.g. redness, swelling, exudate
Infected drain sites require daily changing, or when wet or soiled
No evidence for routine dressing change after 3 or 7 days
This procedure is a risk for accidental drain removal so avoid unnecessary dressing
changes
Use a securement device such as a grip-lockTM to secure the drains to the skin
Removal of Dressings
To remove dressing when placed flat against the skin
o Lift corner from the skin and slowly stretch the in dressing in a motion that is
parallel to the skin
To remove semi permeable dressing placed in a sandwich position
o Hold the corners of the dressing on either side of the drain and pull them away
from each other; this should create a pocket around the drain
o Peel each of the dressings away from each other until we reach child’s skin
o Slowly stretch the rest of the pressing in a motion that is parallel to the skin to
remove the rest of the dressing.
Procedure
Procedure
Indications
Equipment required
Procedure
Attend to patients comfort and sedation score as per procedural sedation guideline
CXR should be performed post drain removal
Patients in PICU may wait until routine daily CXR if clinically well
Clinical status is the best indicator of reaccumulation of air or fluid. CXR should be
performed if patient condition deteriorates
Monitor vital signs closely (HR, SpO2, RR and BP) on removal and then every hour for 4
hours post removal, and then as per clinical condition
Document the removal of drain in the LDA flowsheet in EMR
Remove sutures 5 days post drain removal
Dressing to remain insitu for 24 hours post removal unless contaminated
Complications post drain removal include pneumothorax, bleeding and infection of the
drain site
Drainage system
Adherence to a sterile continuously closed method of urinary drainage has been shown to
markedly reduce the risk of acquiring a catheter associated infection. Therefore breaches
to the closed system should be avoided.
Consider changing the catheter tube and/or bag based on clinical indicators including
infection, contamination, obstruction or if system disconnects, if the equipment is
damaged or leaks. Replace system and/or catheter using aseptic technique and sterile
equipment.
Hygiene
Infection surveillance
Consider daily the need for the IDC to remain in situ. Remove as soon as no longer
required to reduce risk of Urinary Tract Infection (UTI).
Cloudy, offensive smelling or unexplained blood stained urine is not normal and needs
further investigation.
Assessment:
Catheter leaking
Ensure the catheter is still draining and that the urine is not overflowing around a blocked
catheter. See above for tips regarding catheters not draining.
Make sure the balloon is still inflated. Hold the catheter tubing securely in the same
position and empty the balloon to make sure the amount that has been placed initially in
the balloon is still present. If not, reinflate the balloon to its initial volume with water.
Deflation of the balloon happens easily with a 6Fr catheter.
Check catheter size is correct for age/size of the child. Use of a balloon catheter in
neonates should only be with consultation with the treating medical team.
Consider the need to remove and reinsert a new catheter in consultation with the treating
medical team.
Discharge information
Some children will be discharged from the hospital with their IDC in situ.
It is important to teach the families how to care for the catheter, how to perform hygiene, how to
monitor the output and how to troubleshoot.
Discuss the following with the child and family:
Complications
Inability to catheterize: ensure appropriate catheter size has been selected based on the
age/size of the child. Ensure adequate procedural pain relief and distraction is in place
during the procedure.
o Escalate to the treating medical team and consider the need for a referral to the
urology team.
o In young girls, the urethra can be difficult to localize and the catheter can go
directly in the vagina. In this case, leave the first catheter in the vagina and use
another one to place immediately above, which will be more likely to go in the
urethra.
False passage (catheter pushed through urethral wall): The risk of false passage is
actually higher when using a smaller catheters, ensure catheter size utilised is appropriate
for child’s age and size.
Urethral strictures following damage to urethra. This may be a long term problem
Infection
o To minimize risk of infection insertion of IDC’s must be performed using surgical
aseptic technique with single use sterile gloves.
o Regular hygiene should be maintained whilst IDC is in situ.
o Where possible avoid disconnecting the IDC circuit to minimise risk of
contamination
o Monitor for and report signs of infection including fever, offensive smelling
urine, unexplained blood or cloudy urine.
Psychological trauma
Paraphimosis due to failure to return foreskin to normal position following catheter
insertion:
o To minimise risk remember to replace the foreskin in non-circumcised patients
and check at catheter care or nappy change that the foreskin is in place.
HOLY FAMILY COLLEGE OF NURSING
ASSIGNMENT ON
MANAGEMENT OF CHILD
WITH STOMA, CATHETER
AND TUBINGS
Submitted to: Mrs. Jibanlata Submitted by: Tanvi Kundra
Associate Professor M.sc Nursing 2nd year
HFCON HFCON