Approach

• Expose the patient adequately

1. Inspect
   • Site (RIF, LIF)
   • Whether covered by bag or whether bag has been removed
   • Appearance - mucosal lining, presence of spout or flush with skin, end or loop
   • Contents - urine, formed stool, semi-formed or liquid stool
   • Move on to describe rest of abdominal wall
   • Are there any other drains / healed stoma sites?
2. Palpate
   • (if asked only to inspect, do not touch the patient at any time)
3. Percuss
4. Auscultate
   

   	Ileostomy	Colostomy
   Site	RIF	LIF
   Surface	Spout (contents are corrosive)	Flush with skin
   Contents	Watery - small bowel content	Faeculent
   Temporary stomas	Loop ileostomy over low anastamosis of anterior resection	Hartmann's procedure (end colostomy)
   Permanent stomas	Post Panproctocolectomy	Abdomino-perineal resection of rectum

Completion

1. Examine the rest of the abdomen to look for reasons why the stoma was formed in the first place 

Indications for Stoma

1. Input
   • Feeding (PEG - percutaneous endoscopic gastrostomy)
   • Lavage (appendicostomy)
2. Ouput
   • Diversion (protect distal anastamosis - previously contaminated bowel, technical considerations)
   • Decompression
   • Exteriorisation - permanent stoma, urinary diversion (ileal conduit)

Preparation for Stoma formation

1. Psychological / physical preparation
2. Stoma nurse
3. Marking of site - with patient standing up as must be able to see the stoma
   • 5cm from umbilicus
   • away from scars or skin creases
   • away from bony points or waistline of clothes
   • Site easily accessible to patient - not under a large fold of fat
4. Must be within rectus sheath

Complications of Stomas

1. General complications
   • Stoma diarrhoea - water / electrolyte imbalance, hypokalaemia
   • Nutritional disorders
   • Stones (following terminal ilectomy)
   • Psychosexual
2. Specific complications
   • Ischaemia / gangrene
   • Haemorrhage
   • Retraction
   • Prolapse / intussusception
   • Parastomal hernia
   • Stenosis - leads to constipation
   • Skin excoriation

Rehabilitation following placement of stoma

1. Normal diet
2. Bag should be changed once / twice daily
3. Ileostomies should have base plate under bag changed every 5 days and bag changed daily
4. Psychological and psychosexual support