OSTOMY CARE

 An ostomy is a term for surgically made opening from the inner side of the organ then going out through the
skin through a stoma.
 Changing and emptying an ostomy appliance, needs scientific knowledge, nursing technique and nursing
intervention when unexpected situation arises.

OSTOMIES

 Ostomy is the term used for an opening that is surgically made from the inner side of the organ, where part of
the intestinal mucosa, is brought out to the abdominal wall creating a stoma by suturing it to the skin.
 An appliance consists of a collection pouch with an integral adhesive barrier called a flange, a skin barrier or
wafer that adheres and protects the skin around the stoma.

TYPES OF POUCHES
1. One-piece pouch

2. Two-piece pouch system

TYPES OF OSTOMY
 Ileostomy
 Colostomy
o Colostomies are classified according to its origin (part of the colon).
 Transverse Colostomy
 Ascending Colostomy
 Descending Colostomy
 Sigmoid Colostomy
Guidelines
Specific physical care for ostomy is a nurse responsibility. The following guidelines will help promote the patient’s
psychological comfort.
1. Empty the ostomy appliance as many times as possible thus keeping the patient free from fecal odor.

2. Check the stoma regularly.

3. Always note the size of the stoma

4. Keep peristomal area clean and dry

5. Monitor intake and output

6. Explain the patient’s role and participation in the aspect of care

7. Motivate the client to take part in the care of ostomy and to inspect it.
[Date]

Equipment: (One-pouch appliance)

 Basin with warm water
 Towel, washcloth and skin cleanser
 Silicone-based adhesive remover
 Cotton balls
 Nonsterile disposable gloves
 Skin protectant
 One-piece ostomy appliance
 Closure clamp for appliance
 Stoma measuring guide
 Bedpan or graduated container
  Ostomy belt (optional)
 PPE if indicated
 Gauze
 Trash bag
 Water proof disposable pad

Assessment
 Check and assess the present ostomy appliance and stoma
 Account the time span of appliance placement.
 Ascertain the patient know how about ostomy care.
 Assess the skin around the stoma once the appliance is removed
 Check and assess the stools characteristics.
Nursing Diagnosis
 Nursing diagnosis should always base on the patient’s present status.
o Risk for impaired skin integrity
o Deficient knowledge
o Disturbed body image
o Ineffective coping
o Constipation
o Diarrhea

Implementation
1. Assemble and bring necessary equipment at bedside or overhead table.
2. Perform hand hygiene and don PPE if necessary.
3. Identify the client.
4. Close door of the room/curtain
5. Explain the procedure and the need for the intervention to the client.
6. Assist patient to a comfortable sitting or lying position in bed / standing or sitting position the bathroom.

Emptying the Appliance

7. Don gloves. Remove clamp and fold end of the pouch upward like a cuff.
8. Empty the contents into a bedpan, graduated container or toilet.
9. Clean the lower portion of the appliance by a tissue paper at least 2 inches.
10. Uncuffed the pouch and apply the clamp to close it.
11. Remove gloves and PPE if it was used, remove and perform hand hygiene.
12. Assist patient in a comfortable position.

Changing the pouch or appliance

13. Ensure to place a disposable pad on the work surface.

a. Arrange all the necessary materials and supplies, including a basin of warm water and a trash bag that is
within reach.
14. Don on gloves.
[Date]

a. Water proof pad must be placed under the patient at the stoma site.

15. Gently and carefully remove the appliance by pushing the skin from the appliance and not by pulling. Starting
from the top, while ensuring that the skin is taut.
a. A silicon
16. For disposable appliance, place it in the trash bag, for reusable, set aside and wash it with lukewarm water and
soap, air dry once the new appliance is already in place.
17. Use toilet paper to remove any stool around the stoma
a. Cover the stoma with a gauze pad
b. Using a mild soap and water, clean the area with a washcloth.

18. Pat dry the skin gently, while assessing the condition of the stoma and surrounding skin.
 19. Skin protectant can be applied at 2inch. (5cm) radius around the stoma, wait for at least 30 seconds to dry.
20. Measure the stoma opening (lift the square gauze for a while, then put in place again once done in measuring),
with the use of the measuring guide.
a. Trace the same-size opening on the back center of the appliance and cut 1/8 inch. Larger than the stoma
size.
21. Remove the backing of the appliance and quickly remove the square gauze covering the stoma and ease the
appliance over the stoma.
a. Gently press onto the skin while smoothing over the appliance surface.

22. Fold the end of the pouch and use the clamp to secure it.
a. The curve of the clamp should follow the curve of the patient’s body.
23. Remove gloves and assist the patient to a comfortable position.
a. Use the bed linens to cover the patient and place the bed in the lowest position.
24. Put on clean gloves and discard used materials
25. Assess patient’s response to the procedure.
26. Remove gloves and PPE if used
27. Perform hand hygiene

Unexpected Situations and Associated Interventions

1. Excoriated or irritated peristomal skin

2. Odor is leaking from the appliance

a. Check for any leaks or poor adhesion

3. Falling off or loose bag

a. Thoroughly and properly clean then apply skin barrier and allow to dry completely before replying the
pouch.

4. Protruding stoma into the bag.

a. It is called a prolapse

APPLYING A TWO-PIECE APPLIANCE

1. Composition/parts
a. Pouch
b. Adhesive faceplate
2. Types of Two-Piece Appliance
a. Clicking Tupperware-type

Disadvantage
i. Those with decreased manual capability, securing the device becomes harder.
ii. Bulky appliance making it less discreet.

b. Adhesive system type

Disadvantage
i. Adhesive is not joined forming a crease, which may be the cause of leaking feces or flatus
[Date]

Steps on applying the Two-Piece Appliance

1. Assemble and bring all necessary equipment and materials at bedside.
2. Perform hand hygiene and don PPE if necessary
3. Identify patient
4. Close door of room /pull curtain.
5. Explain the procedure and the need for the intervention to the client. Answer any enquiries if needed. Motivate
patient to observe or participate if feasible.
6. Assist patient to a comfortable sitting or lying position in bed / standing or sitting position the bathroom.
7. Place the disposable pad over work place
a. Prepare and set all the necessary supplies, with the wash basin with warm water. Place a trash bag
within reach.
8. Don on gloves, ensure that waterproof pad is placed under the patient at the stoma site. Empty the appliance.
 9. Carefully and gently remove pouch faceplate by pushing the skin away from the appliance and not by pulling it.
Begin at the top of the appliance and keep the skin taut while doing so.
a. Spray an adhesive silicon-based remover by spraying or wiping.
10. If disposable, put the appliance inside the trash bag. Set aside if reusable, place the new appliance, and wash the
used appliance with soap and lukewarm water before air drying.

11. Use toilet paper to remove any stool around the stoma
a. Cover the stoma with a gauze pad
b. Using a mild soap and water, clean the area with a washcloth.

12. Pat dry the skin gently, while assessing the condition of the stoma and surrounding skin.
13. Skin protectant can be applied at 2inch. (5cm) radius around the stoma, wait for at least 30 seconds to dry.
14. Measure the stoma opening (lift the square gauze for a while, then put in place again once done in measuring),
with the use of the measuring guide.
a. Trace the same-size opening on the back center of the appliance and cut 1/8 inch. Larger than the stoma
size.
15. Remove the backing of the appliance and quickly remove the square gauze covering the stoma and ease the
appliance over the stoma.
a. Gently press onto the skin while smoothing over the appliance surface.

16. Follow the manufacturer’s direction in applying the pouch to the faceplate
a. For click – system – lay the ring over the pouch over the faceplate ring.
i. Begin at one edge of the ring, push the pouch ring to the faceplate ring
ii. Ensure to hear a clicking sound which means the pouch is secured onto the faceplate.
b. For adhere/adhesive system – remove the paper backing of the faceplate and pouch
i. Start at one edge and carefully match the adhesive of the pouch with that of the faceplate.

17. Secure the bottom of the pouch by folding the end and use the clamp or clip
a. Place the curve of the clip following the curve of the patient’s body.
18. Remove gloves and assist the patient in a comfortable position.
a. Use the line to cover the patient and position the bed at the lowest position.
19. Don on clean gloves, then discard used equipment.

20. Remove gloves and PPE

IRRIGATING A COLOSTOMY

To aid in the regular expulsion or emptying of some colostomy, irrigation is used.

Factors in determining if irrigation can be used:
1. Site of colostomy
2. Patient’s preference
3. Physician’s preference

EQUIPMENT
1. Disposable irrigation system and irrigation sleeve
2. Waterproof pad
[Date]

3. Bedpan or toilet
4. Water-soluble lubricant
5. IV pole
6. Disposable gloves
7. Additional PPE, as indicated
8. Lukewarm solution at a temperature of 105F to 110F (40C to 43C) (as ordered by physician; normally tap water)
9. Washcloth, soap, and towels
10. Paper towel
11. New ostomy appliance, if needed, or stoma cover
ASSESSMENT
1. Assess for any abdominal discomfort
2. Inquire for the last date of irrigation and for changes in the consistency or change in the pattern of the stool
3. Ask for the amount of the solution the patient usually used in irrigating the device.

4. Check for the placement of the colostomy, noting the color and ostomy size, condition and color of the stoma
and the amount and consistency of the stool.

NURSING DIAGNOSIS
Nursing diagnosis should be based on the patient’s present status.
1. Deficient knowledge
2. Anxiety
3. Constipation
4. Ineffective coping
5. Disturbed bod image
6. Risk for injury

IMPLEMENTATION
1. Check for the doctor’s orders for irrigation. Bring all the necessary equipment at bedside and place on bedside
stand or overhead table
2. Perform hand hygiene and don on PPE if necessary
3. Identify the patient
4. Explain the procedure and the need for the intervention to the client. Answer any enquiries if needed.
a. Assist the patient to the place where he/she will receive irrigation, onto the bedside commode or to the
bathroom.
5. Warm irrigating solution at room temperature or slightly higher.
a. Test the solution temperature using the inner wrist.
6. Pour irrigating solution to the container and release clamp to allow fluid flow through the tube, then place the
clamp back.
7. Hang the container bag where the bottom is at the patient’s shoulder level once seated.
8. Don non-sterile gloves
9. Remove the ostomy appliance and replace it with the irrigation sleeve, ensure that the drainage end is place into
the toilet bowl or bedside commode
10. Lubricate end of stoma cone
11. Insert stoma cone into the stoma and introduce solution slowly for a period of 5 to 6 minutes.
a. Ensure to hold the cone and tubing all the time during the instillation of the solution. (patient can hold it
if he/she is able)
b. Control the solution flow by closing or opening the clamp
12. Once the solution is infused, hold the cone in place for another 10 minutes
13. Remove the cone and let the patient remain seated on the bedside commode or toilet bowl.
14. When majority of the solution has returned, closed the bottom of the irrigating sleeve with the clip and patient
may continue with his/her daily activities.
15. Once the flowing of the solution from the stoma has stopped, remove irrigating sleeve and ensure to clean the
skin along the stoma opening with mild soap and water then pat dry.
16. Attach new stoma appliance or cover as needed.
17. Remove gloves, assist patient to a comfortable position on bed. Use the linen to cover the patient.
18. Ensure to raise bed siderails and lower bed height.
19. Remove PPE if used and perform hand hygiene.
[Date]

UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS

1. Irrigation solution is flowing very slowly or is not flowing.
a. Check if the tubing is not clamped
b. Gently manipulate the cone and check if the opening is blocked, if so remove and clean the opening
then gently reinsert to the stoma.
c. Assist the patient in side-lying or sitting position in bed, alternately.
i. Place a waterproof pad under the irrigation sleeve and place the sleeve end in a bedpan
NOTE: irrigation is contraindicated to myelosuppressed patient and stoma manipulation to a neutropenic patient.