The procedure I will be rationalizing is the
Ostomy Stoma Care.
Ostomy is a surgical opening created on the
surfaces of the abdomen to allow stool to exit
the body rather than through the rectum.
Pwede po siyang sa small intestine na ang
tawag po ay ileostomy or sa large intestine na
ang tawag po ay colostomy.
Ginagawa po ito if you have gastrointestinal
disease or genital defects
Ileostomy (right lower)
Location for a colostomy:
Descending (left upper abdomen), Ascending
(right upper abdomen), Transverse (mid ng
abdomen), Sigmoid (left lower abdomen)
o Double-barrel ostomy: Type po siyang
transverse colostomy na may dalawang stoma.
May proximal stoma na nakaconnect sa colon
na nilalabasan po ng stool o output ng patient
and yung distal stoma nan aka connect naman
sa rectum na naglalabas lang ng mucus.
Purpose
• Maintains integrity of stoma and peristomal
skin (skin surrounding stoma)
•Prevents lesions, ulcerations, excoriation, and
other skin breakdown caused by fecal
contaminants
• Prevents infection
• Promotes general comfort
• Promotes positive self-concept
Equipment:
• 2 pairs of non-sterile gloves
• Graduated container
• Linen saver
• Basin of warm, soapy water
• Washcloth and towel
• 4x4 in gauze
• Room deodorizer
• New pouch and wafer appliance
Scissors
• mirror
• pen
- to outline the measurement on the
skin barrier (if not already
prelabeled)
ASSESSMENT
• assess appearance of stoma (should be pink
and moist) and peri stomal skin (should be
intact)
- Yung stoma should be pink to red color
and moist and peristomals skin should
be intact. pale pink patient (may have a
low hgb and hct) anemia, dark red or
black could mean compromised yung
circulation to the stoma.
- Ensures that the stoma is in
• dimension of stoma to ensure correct bag and
wafer size
- 1/8 inch po yung sobrang diameter ng
wafer para hindi mairitate yung stoma
kasi may peristalsis po yun and pwede
pa raw pong lumaki
• characteristic of fecal waste
- consistency
- odor
- color
- sa ileostomy liquid stool siya so may
increase risk for dehydration and
electrolyte imbalance kasi diba po ang
major reabsorption po ay nangyayari sa
colon. After surgery, drainage is dark
green and then turns yellow when
patient starts to eat
- after surgery sa colostomy may pass
mucous stool at first….stool will be
liquid at first and then progress to what
it should look like depending on its
location. It can take up to 2 days before
 stool is produced. A petroleum gauze
will be over the stoma to keep the
stoma moist, and then a sterile dry
dressing until the pouching system is in
place.
- Sa colostomy po sa ascending, liquid
stool
- Transverse lose to partly formed stool
Descending and sigmoid similar to
normal consistency
• abdominal status
- infection transmission
• teaching needs ability and preference of client
for self-care
- seepage of feces and to avoid
PROCEDURE
1. Perform hand hygiene organize
equipment and prepare new stoma
pouch and wafer
o To reduce microorganism
transmission; to facilitate ease
of access when doing the
procedure.
2. Explain general procedure to client and
then explain each step as it is
performed, allowing client to ask
questions or perform any part of the
procedure.
o To reduce anxiety of the client
and to promote cooperation.
o We need to explain the
procedure to the client kasi
when they go home, sila na
mismo ang gagawa ng stoma
care.
3. Determine if the client is allergic to
iodine – based antiseptics and use
alternative if indicated
o To avoid any allergic reactions
that may lead to skin
breakdown
4. Provide privacy
o To facilitate comfort for client
5. Position mirror to reveal stoma area to
client
o Position mirror to reveal stoma
area to client
6. Don gloves
o To prevent contamination of
hands and reduce the risk of
7. Place linen saver on abdomen around
and below stoma opening
o To protect the patient from
the bed linens from soiling
8. Carefully remove pouch and wafer
appliance and place in plastic waste bag
(save tail closure for reuse) Remove
wafer by gently lifting corner with
fingers of dominant hand while pressing
skin downward with fingers of non-
dominant hand; remove small section at
a time until entire wafer is removed.
Place 4x4 in gauze over stoma opening.
o Holding the skin taut minimizes
client discomfort and prevents
abrasion of the skin
o Placing a gauze in the opening
allows absorption of any
discharge from the stoma
o This reduces trauma, jerking,
and skin irritation.
9. Empty pouch; measure waste in
graduated container before discarding
and record amount of fecal contents
o Emptying before removing the
pouch prevents spillage of stool
onto the client’s skin
o This maintains accurate records
10. Remove and discard gloves, perform
hand hygiene and don new gloves.
 o Discarding the gloves that is 16. Documentation
soiled is necessary to avoid • Completion of procedure date, time
infecting the stoma while and color, consistency and amount of
cleaning it stool in pouch
11. Gently clean entire stoma and • Condition of stoma and peristomal
peristomal skin with gauze or washcloth skin
soaked in warm, soapy water (if some • Abdominal assessment
fecal matter difficult to remove. Leave • Client’s response to the procedure
wet gauze for a few minutes before o This allows the healthcare
gently removing fecal matter) rinse and provider to know about the
pat dry thoroughly next plan of care to follow for
o This is to remove the fecal the patient
matter from skin and stoma o  
opening
o Warm soapy water, yung soap
dapat ay mild or hypoallergenic
to avoid irritation sa stoma and
peristomal skin
o Pat dry is advisable due to
excess rubbing can abrade the
skin
12. Apply a new pouch device
o Trace yung pattern
o Cut out yung pattern and
ensure yung pattern and cut out
is not more than 1/8inch sa
stoma
o Cut out po yung traced stoma
pattern to make an opening in
the skin barrier
o Aalisin yung adhesive pattern
and apply to the peristomal skin
13. Restore or discard all equipment
appropriately.
o Para ma reduce yung risk for
infection, transmission and
contamination
14. Remove and discard gloves and perform
hand hygiene
o To prevent the spread of
microorganisms
15. Spray room deodorizer if needed
o To minimize the odor and
growth of microbes