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Home Healthcare Procedure Presentation: Ostomy Care

Ciara Andrews, Julia Kirchner, Elizabeth Sisk, Chloe Zocolo

Youngstown State University

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Description of procedure and equipment used

Caring for an ostomy includes assessing and cleaning the stoma, and changing and

emptying the ostomy appliance. When assessing the stoma, you should inspect the stoma and

the skin surrounding the stoma. The stoma should be pink to beefy red and appear moist, like the

lining on the inside of your mouth. The stoma contains no nerve endings, but many blood

vessels. It is normal to have a small amount of bleeding when cleaning the stoma. For the first

six to eight weeks after formation of the ostomy, the stoma will be shrinking in size as the edema

subsides after surgery. Clean the stoma with soap and water using soft cloths or gauze. Avoid

soaps that contain moisturizers, oils, or aloe, as these will interfere with adhesion of the skin

barrier wafer. You can clean the stoma whenever you change the ostomy pouch. This can be

done in the shower with the pouch removed. After cleaning the stoma be sure to thoroughly dry

the skin surrounding the stoma for optimal adhesion of the skin barrier wafer. An optional step

is to apply a skin protectant to the skin around the stoma and allow it to dry completely (about

thirty seconds) before applying the wafer.

Along with assessing and cleaning the stoma, you also need to empty and change the

ostomy pouch. The pouch is what is catching and collecting the stool produced. There are many

types of pouches including, closed, drainable, one piece, two piece, opaque, and transparent.

Drainable pouches are good for ileostomies and colostomies of the upper gastrointestinal region

where the stool is more liquid and frequently produced. The pouch is open at one end and can be

emptied, rinsed, and secured with a clip or Velcro closure. A drainable pouch needs to be

emptied when it is one third full. A closed pouch is a good option for colostomies of the lower

gastrointestinal region, where the stool is thicker and more formed. The pouch can be thrown
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away when half full. In a one-piece system the pouch is connected to the skin barrier wafer,

which provides fewer places for possible leakage. With a two-piece system, the wafer is applied

to the skin and then the pouch connects separately to the wafer. This helps prevent skin irritation

from changing wafers. There are also filtered pouches with vents and filters that release gas, but

not odors. This prevents ballooning and the need to burp the pouch.

Along with emptying the pouch when it gets to be a third to a half full, you will also need

to change the entire appliance every three to seven days or when there is leakage. The best time

to change the pouch is before eating or drinking in the morning, when the stoma is less active.

Or you can also do it after a shower, or at least two hours after a meal. It is best to have all your

supplies at hand and ready before removing the old pouch. You will remove the pouch and

wafer and discard. Then assess, clean, and measure the stoma using a supplied measuring tool.

You do not want to measure more than one eighth inch around the stoma. This will minimize the

amount of skin surrounding the stoma that comes in contact with stool, thus decreasing skin

irritation. When you decide on your desired stoma size, next trace this measurement onto the

wafer and cut out the opening. Once the opening of the wafer is cut, peel off the paper backing

and apply the adhesive side to the skin surrounding the stoma. Press down around the wafer

edge to get a good seal with the skin.

You may also need to use a skin barrier paste. The paste fills in gaps and creases. It

allows you to even out the skin surface surrounding the stoma to get a better seal, which prevents

leakage. The paste is applied to the wafer in a bead or a line shape and is not spread. Allow the

paste to set for one minute before applying to the skin.

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Reasons for choosing this home care procedure

The group's choice of ostomy care for the home health care procedure presentation was

twofold. First, this was a subject that has touched every member of the group. Ciara's uncle had

one after a colectomy due to ulcerative colitis for a year. Liz's grandpa has had one since 1978.

Julia's younger brother had one when he was very young and her grandfather just recently had a

colectomy due to colon cancer and has a new, temporary ileostomy. Chloe works as an aide at St.

Elizabeth's and often has patients in her care with ostomies.

Second, ostomy care was something the group reviewed in Professional 1, but had not

had much experience with since then. The group felt that the presentation would be a good

review and a great opportunity to get more information on things that may not have been covered

in class. Things that weren't covered in class include: lifestyle post ostomy, differences in

equipment, and the range of all complications that could arise. This subject gave the group an

opportunity to speak with the Wound Care nurses at length about the procedure. The WC nurses

gave the group invaluable insight into past experiences and techniques for teaching and care.

Comparison of home procedure vs. procedure in the acute care setting

While caring for an ostomy in an acute care setting, you will be using a transparent

pouch. This will allow you to easily visualize and assess your patients stoma and stool. You

want to assess the stoma to make sure that it is pink to beefy red and moist. A dusky or cyanotic

stoma could signify compromised circulation. In the acute care setting you will likely be caring

for your patient and their newly formed ostomy after surgery. You will need to document strict

intake and output on your patient during your shift. When you are measuring the output of the

ostomy you will want to use a graduated measuring device that will allow you to get an accurate

volume of the stool produced. After surgery they will have an abdominal surgical incision that
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you will be caring for as well. For six to eight weeks after formation of the ostomy, the stoma

will be shrinking as the edema decreases, so you will be using a cut-to-fit skin barrier wafer in

the acute care setting.

While caring for an ostomy in a home setting, your patient might be using an opaque

pouch. Many patients prefer the opaque pouches because they are more discreet, and then the

patient does not have to constantly see the stool being produced. The patient will likely be

emptying the pouch themselves straight into the commode. You can teach your patient to float

tissue paper in the commode to prevent splashing. The patient might be having you come out to

their home on the days that they need to change their ostomy appliance. They will be ordering

their own ostomy supplies through whatever company their insurance covers. You can assist

them with the ordering process if needed. Once their stomas shape and size has stabilized they

can start ordering precut skin barrier wafers.

In both acute care and home settings you need to be very conscious of your non-verbal

communication. Always keep in mind that getting an ostomy is a huge life change for patients,

and it might take them awhile to become comfortable in caring for the ostomy themselves.

Provide ample patient teaching and encourage them to watch you whenever you provide ostomy

care, whether it is assessing and cleaning the stoma, emptying the pouch, or changing the entire

appliance. Every interaction in the hospital and at home is a great opportunity for teaching.

Documentation needed for this type of procedure

When a nurse is taking care of a patient with an ostomy there is a lot of information he or

she must assess and then document. The nurse should be aware of the baseline and/or most

recent documentation so the he or she knows when they are dealing with an abnormal finding.

Some important information to document include the following:

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If the patient is a fresh post-op, he or she will have a long abdominal incision in addition

to the stoma. The nurse should be assessing/documenting on both the incision and stoma

condition because if the incision were to get infected it could negatively affect the stoma.

Assessment of the stoma: color, size, if any bleeding is present on or around the stoma,

condition of the stoma (abnormalities such as protrusion or retraction).

Assessment of the bag: condition of the bag (intact, leaking, needing changed, etc.),

consistency of the stool, amount in the bag (too little amount of contents could indicate

an obstruction), any abnormalities such as: medications in the bag or blood.

Assessment of the skin: document what the skin looks like both around the abdominal

incision and the stoma. Does it look red and irritated? Is there any drainage on the skin?

That could indicate an infection if around the surgical incision or a leakage in the bag if

around the stoma.

What did nurse do for patient: whenever a bag is drained or changed, stoma cleaned,

paste applied, etc. it must be documented.

Equipment used: its very important to document the supplies you used. Just in case the

patient happens to have a reaction to a new type of paste, wafer, powder, etc. you know

for future reference not to use it if it was irritating to patients skin.

Document how the patient tolerated the procedure

Patient teaching: document any teaching that was done and how patient is handling

having an ostomy. This procedure is life changing and is difficult both physically and

mentally for the patient. Some teaching may need to be repeated.

If a complication arose and the primary physician and/or WOC nurse was contacted.
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References in support of the procedure

There are many companies including Convatec, Hollister, and Coloplast that are all

available for new and current ostomates to reach out to via phone number or through the internet

to receive free samples, home care packages, and insurance referrals can be made through a

prescribing doctor to receive coverage for all ostomy products available.

Every area has home health care nursing available for ostomy care. This will be

prescribed through your physician and a plan of care will be reached together for what will work

best for the ostomate. The number of visits and frequency of visits may differ from case to case

but getting home care nursing is available and is a great tool to discuss with new ostomates and

their physicians. These home visits will include proper uses and care of the stoma, ostomy, and

all supplies. Our group utilized the wound and ostomy care nurses at North Side hospital who

went over application and removal of the devices and provided many different products to use

for our presentation.

Youtube.com is a great source for ostomates to learn about their procedure before

undergoing surgery, and for after surgery for visual demonstrations on how to change and care

for their ostomy. This can be especially helpful for a new ostomate who may need to change

their pouch but may have some questions or concerns about the procedure and performing it on

their own. Step by step tutorials are available which can be great teaching tools. We utilized

youtube.com during our presentation to show a short video of an ostomy surgical procedure.

Ostomy.org is another great tool for ostomates to refer to for all things ostomy care. It is

the website for United Ostomy Associations of America, Inc. and they have everything from

general information, support groups, conferences, and events that are all available for ostomates.

This website is a wonderful resource for everyone and anyone who may have an ostomy or may
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have a friend or family member with an ostomy because of all the different information

available. We utilized this website to find information regarding living, eating, and working with

an ostomy. And we also utilized this website to find the travel cards available that are printable

wallet size cards explaining an ostomy that can be useful for airport security.

OstomySecrets.com is a website dedicated to ostomy accessories such as pouch covers,

swimmable pouch covers, and they make support belts that can provide extra protection during

physical activity. They also sell lingerie for ostomates. All of these products are available to

order and are useful to help ostomates gain confidence and maintain normal living without

feeling self-conscious of their ostomy showing.

For the Youngstown OH area there is an ostomy support group located in Austintown and

is run by Anna Fitzgerald upcoming location, times, and meeting places can be established

through emailing Anna. Support groups are excellent resources for ostomates because they

provide an environment where they can be open about their feelings and get advice and support

from others that are currently or have previously been in the same situations.

Evaluation of the class presentation

The group felt that the presentation on ostomy care went very well. There was a lot of

valuable information provided that covered nearly every angle of ostomy care, from why an

ostomy would be needed to what sort of lifestyle modifications should be expected with an

ostomy. The group felt that the presentation covered most topics that would be important to a

new ostomate after speaking with the WC nurses and relatives with ostomies.

However, there were a few modifications that the group would consider. First, the length

of the presentation would likely be modified. The presentation was approximately 45 minutes

long, and that would be a very long time for a new ostomate to sit and a lot of information to
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absorb in one sitting. Modifications that could remedy this problem would be to condense the

information to major points that are essential for a first teaching and to leave time for the patient

to ask questions that concern them specifically. Perhaps there could follow up teaching sessions

to build upon that information. Ideally, the setup of the presentation would be customized to the

patient.

Another modification that the group identified was for the demonstration of the

application and removal of an ostomy bag. The ostomy was small and probably difficult for

everyone in the classroom to visualize. A video on the board may alleviate that problem. A

patient with an ostomy may also want to see a real ostomy with fecal matter being emptied. A

video could also be shown the solve that.

Finally, if the group were teaching a single patient and their family, the teaching would

ideally begin prior to the surgery. A common nursing diagnosis for a patient with a new ostomy

is "alteration in body image." The sooner the teaching begins, the more time the patient would

have to cope with this alteration in body image, and the sooner they could come to acceptance,

hopefully.
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References

Lynn, P. (2015). Bowel elimination- changing and emptying an ostomy appliance. In Taylor's

clinical nursing skills: A nursing process approach (Fourth ed., pp. 744-753).

Philadelphia, PA: Wolters Kluwer.

Ostomy secrets. (2008). Retrieved November 13, 2015, from https://www.ostomysecrets.com

United Ostomy Associations of America Inc. (2005, May 1). Retrieved November 13, 2015,

from http://www.ostomy.org/Home.html

UVA Ostomy Bag Change and Cleaning. (2015, February 15). Retrieved November 13, 2015,

from https://www.youtube.com/watch?v=2lxucf2Ikjg