An ostomy nurse for the past three years, Clara Collins, RNC-NIC, MA, CWOCN, cares for colostomy patients from neonates to early adulthood. In her role as a pediatric wound, ostomy and continence nurse at NewYork-Presbyterian Morgan Stanley Children’s Hospital in Manhattan, N.Y., she said she "has seen many changes in colostomy appliances that have advanced nurses’ care while improving the ability for patients/parents to perform their own care."

In adults, stomas usually are required for inflammatory bowel disease, malignant conditions or trauma. In infants and children, stomas may be required because of a variety of congenital and acquired conditions, including Hirschsprung’s disease, colon atresia, intestinal malrotation or volvulus, necrotizing enterocolitis, inflammatory bowel disease, imperforate anus or trauma.

Manufacturers of ostomy supplies offer products to fit a variety of patients. There are a range of pouch choices and sizes as well as skin barriers. Two systems of pouches are available: a one-piece appliance and a two-piece system in which the pouch and skin barrier are separate pieces that allow the pouch to be changed without removing the skin barrier each time.

Nurses caring for this population must combine their knowledge of clinical practices with an understanding of age-related physical, psychological, social and developmental issues.

SKIN CARE IMPORTANCE

At Blythdale Children’s Hospital in Valhalla, N.Y., Arleen Ott, RN, BS, CPN, is coordinator of the infant/toddler unit. She, along with Alyssa Tiedemann, RN, BSN, and Allison Banks, RN, work with children who are medically fragile and transferred from the NICU or PICU. Their average length of stay is 50 days. Some older children also are transported to the hospital for different therapies daily.

All three nurses stress the importance of proper skin care. They said they give the same advice to staff RNs and parents: find an appropriate skin protectant for each individual patient.

Collins said each patient age group has a different reaction to the ostomy and its care. "With infants, parents are quite concerned; this is something they had not expected," Collins said. "You need to address their concerns, provide guidance and educate them about their baby’s diagnosis, as well as teach them the care of the colostomy. For grade school patients, we usually provide teaching for the child and separate sessions with the parents."

Grade schoolers are capable of caring for their ostomy, but some need encouragement. Teens are more difficult to teach, Ott said, because they often refuse to look at the stoma. "Most initially don’t want to accept it, but usually pay attention when they realize that they can manage their ostomy themselves without detection," Ott said.

PATIENT-PARENT EDUCATION

Danielle Hilliard, RN, MSN, CCRN, APN, CPNP, is a pediatric nurse educator at Monmouth Medical Center in Long Branch, N.J., which is part of Barnabas Health. "Before discharge takes place, parents should feel comfortable with their child’s care," Hilliard said.

Many teaching materials are available. Dolls, for example, can be used to demonstrate care to parents, and older children can examine and practice ostomy care on them. Children who practice on dolls have more confidence in carrying out their own care.

After parents accept and become accustomed to their child’s condition they usually become experts in the child’s care, Hilliard said. She adds that for babies, parents should keep the diaper lower than the stoma to avoid urine contamination and to dress the baby in onesies to prevent the child from reaching the device.

Hilliard also counsels parents about activity levels. "Children can play most sports, although, of course, they should avoid any bodily contact sports. They also can wear a support belt to hold the appliance in correct alignment."

Nurses also educate school nurses to help integrate children with ostomies back into school. Collins and other WOCN nurses often serve as resources for RNs on other units. "RNs can certainly carry out the routine care of ostomies; they can evaluate skin and stoma and change pouches," Collins said. "If needed, they can consult a wound care nurse."

POSSIBLE COMPLICATIONS

Problems can include prolapse or retractions, stoma necrosis and skin reactions. "Goals of the care of intact ostomies are to avoid leakage and give optimal skin care," Tiedemann said. The best prevention is a secure fit. "For neonates and babies it’s important to measure and use the smallest optimal size," Hilliard said, "and the wafer can be warmed in the hand to render it more pliable."

It is important for nurses to watch for any changes in output volume or abdominal distention, barrier leaks or symptoms of Candidiasis, which could include itchy, patchy, red skin inflammation and tiny bumps that progress outward from lesions.

"We tell both our patients and staff nurses to watch for color and effective output — 'pink and active,’" Danks said. Hilliard agreed, adding "changes in color require immediate attention."

Since most pediatric ostomies are temporary, nearly all complications are eliminated once the stoma is closed.

Nurses who care for ostomy patients provide knowledge about their diagnosis, surgical procedures and care. They teach patients and caregivers how to live with minimal limitations and a high quality of life.

For information, visit www.WOCNCB.org.