GCC Nurse Stoma Care Guide

Output Monitoring Protocol

Normal Output Progression — Colostomy

1. First 24 h: Nil output is normal — bowel in ileus
2. 24–48 h: Flatus (wind) — first sign of returning peristalsis
3. 48–72 h: Liquid effluent begins
4. 3–5 days: Semi-formed to formed stool depending on stoma site

Check viability by inserting a lubricated finger or glass tube with torchlight to assess intramural colour. Superficial discolouration may be skin-deep only; intramural assessment determines extent.

Oedema of stoma is normal and expected post-operatively. Key points:

• Peaks at day 2–3 post-operatively
• Gradually resolves over 6–8 weeks
• During this period, stoma size must be re-measured at each bag change
• Bag aperture must accommodate size change to prevent constriction or leakage
• Teach patient that final stoma size is not known for 6–8 weeks

The mucocutaneous junction (MCJ) is the join between stoma mucosa and peristomal skin. Complications at MCJ:

Consequences of High Output

• Severe dehydration (especially critical in GCC heat)
• Hyponatraemia, hypokalaemia, hypomagnesaemia
• Renal impairment (pre-renal AKI)
• Medication malabsorption

Management Steps

1. Fluid restriction to 1–1.5 L/day (counterintuitive — reduces hypotonic fluid intake that worsens Na loss)
2. Oral rehydration with isotonic or hypertonic solutions (St Mark's solution: 1L water + 6 tsp glucose + 1 tsp salt)
3. Loperamide (Imodium) 2–4 mg before meals and at night — reduces intestinal transit
4. Codeine phosphate 30 mg QDS if loperamide insufficient
5. Dietary modification: low-fibre, avoid high-osmolality foods
6. IV electrolyte replacement if oral route inadequate
7. Monitor: daily weight, electrolytes, urine output (aim >800 ml/day), serum urea

1. Use manufacturer's measuring guide template — a card with graduated circular/oval holes
2. Select the hole that fits snugly around the stoma without pressing on mucosa
3. Record the measurement in millimetres (width and height if oval)
4. Cut the bag aperture 3 mm larger than stoma measurement to allow for normal movement and oedema
5. Re-measure at each change during first 6–8 weeks post-operatively
6. Once stoma size is stable, create a personal template card for the patient

Step-by-Step Application

1. Wash hands thoroughly
2. Prepare all equipment before removing old bag
3. Remove old bag: Push skin gently away from bag edge (do NOT pull bag away from skin — prevents skin stripping)
4. Dispose of bag contents; fold and seal used bag
5. Clean peristomal skin gently with warm water and soft cloth; pat dry thoroughly
6. Assess stoma and peristomal skin (document findings)
7. Measure stoma if within 6–8 weeks post-op; cut new bag accordingly
8. Apply any barrier rings, paste, or protective wipes as indicated
9. Warm the bag barrier between hands for 30 seconds (improves adhesion)
10. Peel backing off barrier
11. Centre aperture over stoma — align carefully
12. Smooth adhesive from stoma outward — no air pockets or folds
13. Press firmly for 1 minute with warm hand — activates heat-sensitive adhesive
14. For two-piece: attach pouch to flange — listen/feel for click
15. Close drain outlet if drainable bag
16. Document: time, stoma appearance, output, skin condition

Most common peristomal skin complication. Caused by prolonged contact of effluent or urine with skin due to leakage or poor seal.

Causes

• Incorrect bag size (aperture too large)
• Poor application technique (air pockets, folds in adhesive)
• Stoma retraction below skin surface — effluent pools under flange
• Excessive sweating (very relevant in GCC hot climate)
• Delayed bag change

Management

• Correct the underlying cause first (sizing, technique, products)
• Use barrier rings to improve seal
• Apply stoma powder (absorbs moisture) — shake off excess, then apply protective film over powder before bag
• Consider convex appliance if retraction causing leakage
• Allow skin to rest with open exposure briefly if tolerates

Type IV (delayed) hypersensitivity reaction to adhesive, barrier material, or accessory products. Appears as pruritic, erythematous, weeping rash in exact pattern of the adhesive (diagnostic).

Management

• Identify the offending product — patch testing may be needed
• Switch to alternative brand / formulation
• Topical corticosteroid (short-term) for acute reaction
• Ensure complete removal of residual adhesive from skin
• Document allergy and update care plan

Optimal Site Criteria

• Within the rectus abdominis muscle (reduces hernia risk)
• Below belt line — patient can see it, less likely to be occluded by waistband
• Visible to patient — patient must be able to see site in sitting and standing position
• Flat skin surface — allows secure bag adhesion
• Away from scars, folds, bony prominences, umbilicus, and skin creases
• Away from intended incision line and drain sites
• Accommodates patient's occupation, clothing, and lifestyle (e.g., patient who wears thobe/abaya)

Education is progressive — do not overwhelm patients post-operatively. Follow structured stages:

Body Image Concerns

Address directly — many patients feel their body is "broken" or "unclean." Normalise the stoma as a life-saving measure. Share success stories (with consent). Refer to stoma support groups.

Sexual Health

Discuss intimacy proactively — patients rarely initiate. APR and pelvic surgery may cause nerve damage → erectile dysfunction (men) or vaginal dryness/dyspareunia (women). Refer to sexual health specialist if needed. Advise emptying bag before intimacy; opaque covers/wraps available.

Return to Activity

• Work: sedentary work 4–6 weeks; avoid heavy lifting indefinitely (hernia risk)
• Swimming: waterproof bag covers available; check seal before entering water; freshwater pools are fine; sea swimming is fine
• Sports: all sports permitted — hernia support belt recommended for contact sports and weight training
• Driving: not before 6 weeks post-op (laparotomy) — seatbelt comfort pad available

Practical Guidance for Hajj/Umrah

• Carry 3–5 days extra appliance supplies — availability in Makkah/Madinah may be limited
• Use the most secure appliance system available (two-piece with belt)
• Pack supplies in hand luggage — not checked baggage
• Drainable bag preferred for long periods without private bathroom access
• Pre-cut bags prepared in advance for easy self-care while travelling
• Consider stoma nurse pre-travel consultation and letter for airline/customs
• Ihram garment can be worn normally — stoma bag is concealed underneath

Wudu and Stoma

The classical fiqh position is that any exit of najasa (impurity) from the body invalidates wudu. However, contemporary scholars apply the principle of umum al-balwa (widespread necessity / unavoidable hardship):

Nurses should reassure patients of this ruling and advise them to consult their local Islamic scholar or hospital chaplain for personal religious guidance. Do not dismiss this concern — it is a significant barrier to rehabilitation for many GCC patients.

Halal Stoma Products

• Some skin barrier products historically contained porcine-derived gelatin as a component
• Major manufacturers (Coloplast, ConvaTec, Hollister) have addressed this — most current products are porcine-free or have halal-certified lines
• Nurses should check product data sheets when patients raise concerns
• The Islamic ruling is that necessitated external use of non-halal material is generally permitted when no alternative exists — but patient autonomy and preference should be respected

Advise patients travelling within GCC or internationally to carry minimum 2-week supply. Provide a letter with product specifications for customs and healthcare providers.

Key Clinical Concerns

• Dehydration: Monitor closely — ileostomy patients should be strongly advised to maintain fluid intake during non-fasting hours (Iftar to Suhoor)
• Colostomy patients generally tolerate Ramadan fasting well with planning
• Urostomy patients must maintain at least 1.5–2 L urine output — vital for UTI prevention
• Islamic ruling: serious medical risk (e.g., documented dehydration, electrolyte imbalance) exempts a patient from fasting (fidya applicable)
• Advise: medical consultation before Ramadan; adjusted medication timing; front-load fluids at Iftar and Suhoor

Oral Medications Through Stoma

Ileostomy patients may have reduced medication absorption (short transit time). Consider: liquid formulations, buccal/sublingual routes. Discuss with pharmacist. Specifically: slow-release preparations may pass through intact — check with prescriber.

The Enterostomal Therapist (ET) / Wound, Ostomy, and Continence (WOC) nurse is the specialist nurse for stoma care. Role includes:

• Pre-operative siting and counselling
• Post-operative teaching and appliance selection
• Management of complications (skin problems, appliance failure)
• Ongoing community follow-up and telephone support
• Liaison with surgical team and multidisciplinary team

GCC status: ET/WOC nurse numbers are growing but remain below international standards. Many hospitals rely on general surgical nurses trained in stoma care. Advocacy for dedicated stoma nurse posts is ongoing in MOH policy discussions across KSA, UAE, and Qatar.

Support groups: Formal patient support groups are limited in GCC. Online communities (Arabic language) are emerging. International Ostomy Association has GCC contacts. Hospital-based patient education groups are the primary model.