Evidence-
Based Practice
Ostomies: Nursing Care and
Management
s he began his shift, the nurse answered Mrs.
A Long’s call light. Mrs. Long was complaining of
pain at her new ileostomy site and requested a
dry gown. Upon inspection, the nurse found the wafer
of the appliance was not adhering well to the peristomal
skin. The inferior area of the adhesive wafer was saturat-
ed with effluent, and the skin and gown below the osto-
my were damp. The area of leakage had been reinforced
with tape across the wafer and directly onto the skin
below the wafer. The wafer and ostomy bag had not
been removed so the skin could be cleansed and dried,
and a new appliance applied properly. The nurse med-
icated Mrs. Long for pain, gathered the necessary sup-
plies, and gently removed the tape and wafer from Mrs.
Long’s ostomy site. He cleansed and dried the peristom-
al skin. Mrs. Long was wincing and moaning with pain.
Significant skin breakdown was apparent. She glanced
at the site and began to cry.
Ostomy Types
Ostomies emerged on the health care front in the
mid-1800s as a means of managing intestinal and uri-
nary elimination needs from certain disease processes
(Costa, 2013; Minkes, 2015). Ostomies create unique
physical and psychological needs for patients, and in
many cases, create financial hardships related to the
cost of supplies. Data are not available to confirm the
number of people who currently have ostomies in the
United States (Maydick, 2014; Walker & Lachman,
2013); however, the estimate surpasses 1 million
(Maydick, 2014). Colostomies, ileostomies, and
urostomies will be explored, including five nursing diag-
noses related to essential aspects of ostomy care and
management.
Ostomy surgeries can be required related to bowel
obstruction, incontinence of urine or stool, cancer,
bowel perforation, inflammatory bowel disease,
ischemic bowel, spinal cord injury, and other trauma
(Burch, 2011; Piras & Hurley, 2011). Colostomies and
ileostomies can be permanent or reversible (Minkes,
2015). Urostomies are permanent (Costa, 2013).
The opening, or stoma, for ileostomies and
colostomies is created surgically in the abdominal wall
with the ileum or colon sutured to the outer skin
(Minkes, 2015; Piras & Hurley, 2011). The stoma has no
Mary L. Schreiber, MSN, RN, CMSRN, is Nursing Faculty Member,
Orangeburg-Calhoun Technical College, Orangeburg, SC, and a
national speaker for PESI Healthcare.
March-April 2016 • Vol. 25/No. 2
Mary L. Schreiber
sphincter control and requires a collection system
(Burch, 2011; Piras & Hurley, 2011). The ostomy system
can be one piece or two pieces. A wafer or flange adheres
to the skin around the stoma opening and a pouch (also
called an appliance) contains the fecal drainage. The
location of the ostomy will determine the form of efflu-
ent from the site: loose, liquid, and caustic to the skin
from ileostomies and proximal colostomies; soft and
more formed for more distal colostomies (Minkes, 2015;
Piras & Hurley, 2011). Continent ileostomies also can be
formed through creation of an internal reservoir
(Nowicki, 2011).
Urostomies can be formed by two methods: nonconti-
nent and continent diversions. Noncontinent diversions
are accomplished by ureteral anastomosis to the ileum
or colon, with the stoma being formed by the bowel seg-
ment sutured to the outer skin (ileal conduit) (Costa,
2013; McDonald, 2011; Piras & Hurley, 2011).
Urostomies that bypass the bowel and are sutured
directly to the outer skin are performed less frequently,
mainly as a temporary solution (Costa, 2013).
Noncontinent diversions require an appliance to be
used at all times to contain the effluent, which can be a
combination of urine and mucous (McDonald, 2011;
Piras & Hurley, 2011).
Continent urinary diversions are constructed and
involve a urine storage system formed through use of
the bowel, usually at the terminal ileum or ascending
colon. Three methods of continent urinary diversions
can be achieved: orthoptic (urethral rhabdosphincter
controlled), cathertizable (self-catheterization required),
and uterosigmoidostomy (anal sphincter controlled)
(Costa, 2013). The various forms and management of
continent ileostomies and urinary diversions will not be
explored further in this article.
An important presurgical action involves planning
for the location of the stoma. While the abdomen is
assessed with the patient in lying, sitting, and standing
positions, the ostomy site selection ultimately depends
on the patient’s clinical condition (Minkes, 2015;
Stelton, Zulkowski, & Ayello, 2015). See Figure 1 for var-
ious locations for ostomies; Figure 2 for an example of
an ileal conduit. Ideally, an enterostomal therapy nurse
(EOTN) or a wound, ostomy, and continence nurse
(WOCN) should be consulted to perform preoperative
evaluation, select the ostomy site, and provide in-depth
patient education (Gonzalez, 2015; Stelton et al., 2015;
Walker & Lachman, 2013).
127
Evidence-Based Practice
FIGURE 1.
Ostomy Locations
Source: Carter, 2016. Reprinted with permission.
Risk for Impaired Skin Integrity
Monitoring the integrity of the peristomal skin is a
major nursing responsibility and an essential patient
education point (Maydick, 2014). The skin must be
kept clean and dry as fecal or urinary effluent can cause
severe skin breakdown (McDonald, 2011; Minkes,
2015; Nowicki, 2011). Stomas vary in size and shape
and must be measured accurately so the flange can be
cut for a proper fit. The stoma is edematous before
decreasing to its normal size a few weeks after surgery
(Nowicki, 2011; Piras & Hurley, 2011). No more than
1/8 inch of skin should be visible between the stoma
edge and the flange (Stelton et al., 2015). Ostomy
pastes and special seals can be used to fill creases and
uneven skin areas to aid in preventing leakage. Stoma
adhesive powders can help reduce irritation and protect
the peristomal skin by absorbing moisture (Piras &
Hurley, 2011). The appliance should be emptied when
it becomes 1/3 to 1/2 full. The weight of too much
effluent can weaken the seal and result in leakage
(Nowicki, 2011; Piras & Hurley, 2011).
128
FIGURE 2.
Urostomy (Ileal Conduit)
Source: Carter, 2016. Reprinted with permission.
Showers and baths are acceptable with or without the
appliance secured (Nowicki, 2011; Piras & Hurley, 2011).
While water will not pose a problem with the stoma,
using soap around the peristomal skin should be avoid-
ed. Soap can cause a change in pH, promoting excess
skin dryness, and may contribute to irritation or break-
down (Piras & Hurley, 2011; Stelton et al., 2015). When
the appliance is left in place while showering, a close
inspection should be performed for leakage and the sys-
tem replaced if necessary (Nowicki, 2011).
Risk for Infection
The stoma must be inspected regularly. It should be
moist and pink-to-beefy red in color, and should rise
slightly above the peristomal skin (Nowicki, 2011; Piras
& Hurley, 2011; Wound Ostomy and Continence Nurses
Society, 2014). A poorly perfused stoma can appear pale
or bluish in color; a black stoma indicates necrosis
(Nowicki, 2011; Piras & Hurley, 2011). The peristomal
skin must be kept clean and dry. The patient must be
reassured if mild bleeding at the stoma site occurs. This
March-April 2016 • Vol. 25/No. 2

TABLE 1.
Potential Peristomal Skin Problems
Interventions
Primary strategies must involve keeping
Skin the peristomal skin clean (using warm tap
Problem water) and dry (patting gently).
Irritation or • Alternative brand of flange/pouch
excoriation • Pectin-based powder
• Skin protectant
Skin stripping • Slow removal of adhesive flange
when changing (care not to strip
skin further)
• Skin protectant before applying new
system
• Adhesive remover to aid in
subsequent pouch removals
• Pectin-based powder
Folliculitis • Electric razor to shave excess hair
• Shaving in direction away from
stoma
• Topical antibiotic
Fungus • Site cleaned with water only
• Timely pouch changes every 2-3
days
• Antifungal creams or powders
Pseudoveruccus • Appropriate brand of pouch
lesions • Silver nitrate
• Possible surgical removal of lesion
Maceration • Pouch refit appropriately
• < 1/8 inch skin between stoma and
flange
Uric acid crystals • Dilute acetic acid solution
• Pouch refit appropriately
Peristomal skin • Pouch fit appropriately
bleeding • Pouch changed less often
Pyoderma • Steroid cream
gangrenosum • Pectin-based powder
(rare)
Sources: Minkes, 2015; Piras & Hurley, 2011; Stelton et al., 2015
is typically a brief occurrence (Minkes, 2015). Numerous
skin conditions can develop around the stoma and
when left untreated, can result in infection. Table 1 dis-
plays examples of skin problems that place the patient
at risk for infection.
Risk for Imbalanced Nutrition: Less than
Body Requirements
The type of ostomy determines initial dietary recom-
mendations. By the 4th or 5th postoperative day, an
ileostomy or colostomy should begin functioning.
Patients with a colostomy or an ileostomy have few
dietary restrictions after the initial postoperative period.
March-April 2016 • Vol. 25/No. 2
Ostomies: Nursing Care and Management
TABLE 2.
Dietary Considerations for the Patient with Ostomy
Increase
Gas- Odor- Risk for Natural
Producing Producing Blockage Deodorizer
• Onions • Onions • Corn • Yogurt
• Broccoli • Asparagus • Celery • Parsley
• Cruciferous • Cruciferous • Cabbage • Buttermilk
vegetables vegetables • Nuts
• Carbonated • Eggs • Popcorn
liquids • Fish
• Seeds
• Alcohol
Sources: Nowicki, 2011; Piras & Hurley, 2011; Quatrara, 2016
However, an important consideration includes deficien-
cies that can result from ileostomies. In addition to poor
absorption of vitamin B12, iron, magnesium, fat, and
folic acid, excess water and sodium can be lost through
liquid ileostomy effluent. Although the bowel can
adjust over time to compensate for some absorption
losses, patients must be monitored for complications
and supplements provided as necessary. Patients with an
ileostomy are also more susceptible to kidney and gall-
bladder stones (Minkes, 2015).
Maintaining adequate hydration is critical for
patients with a urostomy (Burch, 2011). Uric acid crys-
tals can cause a slimy-gray film around the stoma that
can interfere with adequate flange sealing (Stelton et al.,
2015). Taking vitamin C tablets or cranberry juice can
help acidify urine, aiding in prevention of crusty
deposits around the stomal opening (Burch, 2011;
Wound Ostomy and Continence Nurses Society, 2014).
A dilute vinegar solution can be used to remove uric acid
crystals when cleaning the peristomal skin (Stelton et
al., 2015).
Chewing food well and increasing hydration are pri-
mary factors for preventing stomal blockages (Burch,
2011; Piras & Hurley, 2011). Specific changes in diet are
targeted mainly to minimize gas and odor (Piras &
Hurley, 2011). The patient’s appetite can be impacted by
anxiety or depression, and the presence of these condi-
tions must be assessed regularly (Quatrara, 2016). See
Table 2 for specific dietary considerations for the patient
with an ostomy.
Deficient Knowledge: Self-Care Deficit,
Toileting, Bathing, and Feeding
Patient and caregiver education is a paramount nurs-
ing responsibility and can impact patient care outcomes
directly (Walker & Lachman, 2013). When available, an
EOTN or WOCN should be consulted. The expertise pro-
vided by nurses with this specialty training has
decreased ostomy and peristomal skin complications
and promoted positive patient perceptions, which can
impact the patient’s ability to adapt to having an osto-
129
Evidence-Based Practice
TABLE 3.
Organizations for Ostomy Resources and Support
Crohn’s & Colitis Foundation of America
www.ccfa.org
United Ostomy Associations of America, Inc.
www.uoaa.org
Wound, Ostomy, and Continence Nurses Society
www.wocn.org
Sources: Maydick, 2014; Walker & Lachman, 2013
my (Duruk & Uçar, 2013; Gonzalez, 2015; Maydick,
2014; Minkes, 2015; Stelton et al., 2015).
Patients must be taught how to empty the appliance,
change the flange and appliance, provide appropriate
skin care, make good food choices, use resources for
obtaining supplies, recognize problems, and seek med-
ical assistance (Maydick, 2014). Hands-on instruction is
needed, with patient demonstration critical. Limited
resources and lack of nurses with specialized education
result in many ostomy patients being insufficiently pre-
pared for discharge (Stelton et al., 2015). Adding to this
dilemma is the reduced length of hospital stay, which
allows less time for adequate patient education. Patients
must have continual follow up and support after hospi-
tal discharge to be successful in meeting their physical,
emotional, and financial needs (Walker & Lachman,
2013).
Ostomy supplies can be costly, and many patients use
their appliances for an extended period because of the
financial impact of replacements (Arnold-Long, 2014).
While some patients have limited insurance coverage for
additional ostomy supplies, others have no coverage.
Support programs are available; however, many patients
are unaware of the programs or may not qualify for assis-
tance (Arnold-Long, 2014). Home care, rehabilitation
centers, and in some areas, ostomy centers are available
options. Organizations specializing in ostomy assistance
and manufacturers of ostomy products can provide
information, support, and associated improvements for
patients with ostomies (Arnold-Long, 2014; Maydick,
2014). See Table 3 for primary organizations offering sup-
port and resources for patients and caregivers.
Disturbed Body Image
Nurses should begin patient and caregiver education
as soon as possible after ostomy placement (Duruk &
Uçar, 2013). Learning to provide self-care for an ostomy
can be daunting (Maydick, 2014). Psychological adjust-
ments to having an ostomy can involve concerns relat-
ing to self-image and the perception of that image to
others. These critical foci must be included in the nurs-
ing care plan (Burch, 2011; Minkes, 2015).
The patient’s return to his or her usual lifestyle is pro-
gressive. The patient must have continued follow up
with the physician for ongoing medical advice. He or
she should get out of bed, dress every day, and move
130
about as tolerated. Fatigue is not unusual initially, and
rest periods should be incorporated into the daily
regime. Walking is recommended highly (Burch, 2011).
Driving may be allowed when the patient is walking
confidently and has regained general strength; however,
this activity depends on the patient’s overall condition.
Heavy lifting and strenuous activity are not recom-
mended for up to 3 months after surgery (Burch, 2011).
When the patient is comfortable, sexual activity can
be resumed safely (Burch, 2011). However, difficulties
may surface related to the patient’s self-image (Nowicki,
2011). Couples should be encouraged to share their feel-
ings. If erectile dysfunction is a concern, the patient
should see a urologist. Pouch covers, pouch emptying
and hygiene before sexual activity, and alternative posi-
tions can be helpful. The nurse may suggest the patient
see a sex counselor for additional helpful information
(Nowicki, 2011). The patient should be educated that
childbearing remains viable even though an ostomy is
in place (Burch, 2011). The manner of care and depth of
patient education provided by the nurse not only
impact the patient’s physical recovery, but also the
patient’s perception of and adaptation to this life-chang-
ing surgical procedure (Duruk & Uçar, 2013).
Conclusion
Nursing responsibility includes educating the patient
about ostomy care and management to achieve inde-
pendence. Arming the patient with suitable strategies to
handle physical problems, emotional stressors, and
social difficulties, including resources for ongoing sup-
port, can increase the patient’s confidence that quality
of life can be realized (Walker & Lachman, 2013). Nurses
are accountable to keep pace with ongoing changes
related to specific needs of patients with ostomies.
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