CHANGING A BOWEL DIVERSION OSTOMY APPLIANCE Definition: All appliances have three things in common: a pouch to collect the

effluent, an outlet at the bottom for easy emptying and a faceplate. Purposes: 1. To change ostomy appliances whenever the effluent leaks onto the peristomal skin or when it cannot be rinsed completely away. 2. To change them daily or whenever they become soiled. Equipments Needed: Solvent (pre-saturated sponges or liquid) Waste Receptacle Cleaning Materials (Tissues, soap) Gauze pad Measuring Guide Pen or Marker Scissors Tail closure or an elastic band Stoma guide strip A deodorant (tablet or liquid) for non-odorproof colostomy bag Tape Gloves

PROCEDURE 1. Assessment of the stoma 2. If the client has suspected or documented allergic reaction to adhesives, do a 24hour tape patch test, Experiment with atleast three or four different types of tape. Cut strips of each type and label them with marking pen, and place them on the clients abdomen. The abdomen rather than the inner arm is used since the abdominal skin is more sensitive. During the next 24 hours, note and document the specific allergies, if present, and provide the client with an allergic arm band. 3. Explain the procedure to the client and support person if present

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Support persons are often more supportive if informed.

PROCEDURE 4. Communicate acceptance Colostomy dirty. It is effluent important

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unpleasant odor, and the client may feel appliance completely and quickly and not to convey disgust. Timing is also an important factor. Avoid times close to meal and visiting hours whenever possible 5. Provide privacy, preferably in the

bathroom,, where the client can learn to deal with the ostomy as he or she would be at home 6. Assist the client to a comfortable sitting or lying position, and expose only the stoma area. 7. Don gloves and unfasten the belt if one is being worn 8. Empty the pouch when it is one-third to one half full. Assess the consistency and amount of effluent. When the fluid level in the bag becomes too high, the weight of it may loosen the faceplate and separate it from the skin, causing the effluent to leak and irritate the peristomal skin. 9. Remove the appliance. Apply solvent with an applicator if needed. Peel the bag off slowly while holding the clients skin taut. Occasionally adhesives require the application of a solvent before removing. Holding the skin taut minimizes discomfort and prevents skin abrasion. 10. If the appliance is disposable, discard it in a moisture proof bag. 11. Using warm water and mild soap, clean the peristomal skin and the stoma. Check agency policy on the use of soap. 12. Dry the area thoroughly by patting with a towel or cotton swabs. Excessive rubbing can abrade the skin Soap is sometimes not advised because it can be irritating to the skin.

PROCEDURE 13. Assess the stoma and peristomal skin 14. Place a piece of tissue or gauze pad over the stoma, and change it as needed. 15.a. Use the stoma measuring guide to measure the size of the stoma b. Trace a circle on the backing of the skin barrier the same size as the stomal opening. c. Make a template of the stoma pattern

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The tissue will absorb any seepage from the stoma.

A template aids other nurses and the client d. Cut out the traced stoma pattern to make an opening in the skin barrier e. Remove the backing to expose the sticky adhesive side on certain products, such as Stomahesive or Reliaseal. Moisten and rub a CollySeel ring with tap water until the ring becomes sticky; knead the ring to make it more flexible. f. Center the skin barrier over the stoma and gently press it onto the skin, smoothing out any wrinkles or bubbles. with future appliance changes but will need to be adjusted as the stoma size decreases.

16. If using skin prep liquid or wipes or a similar product, eg, liquid stomahesive: a. Cover the stoma with a gauze pad to avoid getting the skin prep on the stoma. b. Either wipe the product evenly around the peristomal skin or use a brush to apply a thin layer of the liquid plastic coating the same area. c. Allow the skin barrier to dry, until it no longer feels tacky.

PROCEDURE 17. If applying a karaya ring seal; a. Select a seal with an opening that is the same size as the stoma b. Place the ring around the stoma, ensuring that it fits snugly around its base. c. Gently press the seal to the skin 18. To apply a disposable pouch with adhesive square; a. If the appliance does not have a precut opening, trace a circle 1/8 1/6 inches. larger than the stoma size on the appliance adhesive square. This can be done by tracing the template and cutting the circle slightly larger or by using a math compass and making the circle exactly the right size b. Cut out a circle in the adhesive. Take care not to cut any portion of the pouch c. Peel off the backing from the adhesive seal. d. Remove the tissue or gauze pad over the stoma. e. Center the opening of the pouch over the stoma and apply it directly onto the skin barrier. f. Gently press the adhesive backing onto the skin and smooth out any wrinkles, working from the stoma outward. g. Remove the air from the pouch. h. Place a deodorant in the pouch(optional)

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The opening is made slightly larger than the stoma to prevent rubbing, cutting, or trauma to the stoma.

Wrinkles allow seepage of effluent, which can irritate the skin or soil clothing.

Removing the air helps the pouch lie flat against the abdomen.

PROCEDURE i. Close the pouch by turning up the bottom a few times, fan folding its end lengthwise and securing it with a rubber band or tail closure clamp. 19. To apply a reusable pouch with faceplate attached: a. Apply either adhesive cement or a double faced adhesive disc to the faceplate of the appliance, depending on the type of appliance being used. Follow the manufacturers directions. b. Insert a coiled paper guidestrip into the faceplate opening. The strip should protrude slightly from the opening and expand to fit it. c. Using the guidestrip, center the

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The guidestrip helps you center the appliance over the stoma and prevents pressure or irritation appliance. to the stoma by an ill-fitting

faceplate over the stoma. d. Firmly press the adhesive seal to the peristomal skin. The guidestrip will fall into the pouch; commercially prepared guidestrips will dissolve in the pouch. e. Place a deodorant in the bag if the bag is not odorproof. Most pouches are odorproof. f. Close the end of the pouch with the designated clamp. g. Attach the pouch belt and fasten it around the clients waist (optional)

PROCEDURE 20. To apply reusable pouch with detachable faceplate: a. Apply a skin sealant to the faceplate

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This makes it easier to remove the adhesive disc from the faceplate.

b. Remove the protective paper strip from one side of the double faced adhesive disc. c. Apply sticky side to the back of the faceplate. d. Removing the remaining protective

paper strip from the other side of the adhesive disc. e. Center the faceplate over the stoma and skin barrier, then press and hold the faceplate against the clients skin for a few minutes to secure the seal. f. Press the adhesive around the

circumference of the adhesive disc. g. Tape the faceplate to the abdomen using four or eight 7.5cm (3 in) strips of tape. Place the strips around the faceplate in a picture framing manner, one strip down each side, one across the bottom. The additional four strips can be placed diagonally over the other tapes to secure the seal. h. Stretch the opening on the back of the pouch and position it over the base of the faceplate. flange. i. Place the lock ring between the pouch and the faceplate flange to seal the pouch against the faceplate. Ease it over the faceplate

PROCEDURE j. Close the base of the pouch with the appropriate clamp k. Attach the pouch belt and fasten it around the clients waist (optional). 21. Assess the clients response to the

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technique in terms of skills learned; the amount, color, and consistency of the drainage; the condition of the skin; and the fatigue, discomfort, and behaviour about the ostomy. 22. Discard the bag, or clean it if it is to be used again. Measure liquid feces, then empty the feces into a toilet or hopper. If the bag is to be reused, wash it with cool water and mild soap, rinse and dry. 23. Wash the soiled belt with warm water and mild soap, rinse and dry. 24. Remove and discard gloves. 25. Report to the nurse in charge any

increase in stoma size or skin irritation 26. Record on the of clients the chart all the

assessments and interventions such as: discoloration stoma; appearance of the peristomal skin; the amount and type of drainage; and the clients fatigue, discomfort, and significant behaviour about the ostomy. 27. Adjust the teaching plan and nursing care plan as needed. Include on the teaching plan the equipment and procedure used. Learning to care for the ostomy is facilitated if procedures implemented by nurses are consistent.