Western Mindanao State University

College of Nursing
Zamboanga City

Level IV-SKILL PROCEDURES

NAME: ROTATION:

SECTION: DATE:

Evaluation Checklist
COLOSTOMY CARE
Procedure

STEPS 1 2 3 4
I. ASSESSMENT
1. Identify patient using at least two identifiers (e.g., name and birthday or name and
medical record number), according to agency policy.
2. Perform hand hygiene and apply clean gloves.
3. Observe existing skin barrier and pouch for leakage and length of time in place.
The pouch should be changed every 3 to 7 days, not daily (Carmel et al., 2016). If
an opaque pouch is being used, remove it to fully observe the stoma and dispose
of such a pouch in a proper receptacle.
4. Observe the amount of effluent in the pouch and empty it if it is more than 1/3 –
1/2 full by opening the pouch and draining it into a container for measurement of
output. Note the consistency of effluent and record intake and output.
5. Observe stoma for the following:
a. Type
b. Location
c. Color
d. Swelling
e. Presence of sutures
f. Trauma
g. Healing or irritation of peristomal skin
6. Observe placement of stoma concerning abdominal contours and presence of
scars or incisions.
7. Remove and dispose of gloves; perform hand hygiene.
8. Explore patient’s attitudes, perceptions, knowledge, and acceptance of stoma;
discuss interest in learning self-care. Identify others who will be helping the
patient after leaving the hospital.
II. PLANNING
9. Explain the procedure to the patient; encourage patient’s interaction and
questions.
10. Assemble equipment and close room curtains or door.
a. Skin barrier/pouch—clear, drainable one-piece or two-piece, cut-to-fit or
precut size
b. Pouch closure device such as a clip if needed
c. Ostomy measuring guide
d. Adhesive remover (optional)
e. Clean gloves
f. Washcloth
g. Towel or disposable waterproof barrier
h. Basin with warm tap water
i. Scissors
j. Waterproof bag for disposal of the pouch
k. Gown or goggles optional if there is any risk of splashing when emptying
pouch
 Western Mindanao State University
College of Nursing
Zamboanga City

Level IV-SKILL PROCEDURES

STEPS 1 2 3 4
III. IMPLEMENTATION
11. Have the patient assume the semi-reclining or supine position (same position
assumed during assessment and pouching). (Note: Some patients with established
ostomies prefer to stand.) If possible, provide the patient with a mirror for
observation.
12. Perform hand hygiene and apply clean gloves.
13. Place towel or disposable waterproof barrier under the patient and across the
patient’s lower abdomen.
14. If not done during the assessment, remove the used pouch and skin barrier gently
by pushing the skin away from the barrier.
15. Use adhesive remover to facilitate the removal of the skin barrier.
16. Empty pouch and dispose of it in an appropriate receptacle. Measure output if
needed. Note: There may be no output at the time of the first pouch change.
17. Clean peristomal skin gently with warm tap water using a washcloth; do not
scrub the skin. If you touch stoma, minor bleeding is normal.
18. Pat the skin dry.
19. Have a washcloth handy for additional cleaning if there is output from the stoma
while preparing the pouch.
20. Measure stoma. Expect the size of the stoma to change for the first 4 to 6 weeks
after surgery.
21. Trace pattern of stoma measurement on pouch backing or skin barrier
22. Cut an opening on the backing or skin barrier wafer. If using moldable or shape
to fit barrier, use fingers to mold shape to fit stoma.
23. Customize the pouch to provide an appropriate fit over the stoma.
24. Remove protective backing from adhesive backing or wafer.
25. Apply pouch over stoma.
26. Press firmly into place around the stoma and outside edges. Have the patient hold
a hand over the pouch to apply heat to secure the seal.
27. Close end of pouch with a clip or integrated closure.
28. Remove drape from the patient. Help the patient to assume a comfortable
position.
29. Remove and dispose of gloves and other disposables.
30. Perform hand hygiene.
IV. EVALUATION
31. Observe the condition of the skin barrier and adherence of the pouch to the
abdominal surface.
32. Observe the following:
a. The appearance of stoma
b. Peristomal skin
c. Abdominal contours
d. Suture line
e. Presence of any flatus during pouch change.
33. Note if there is the presence of any flatus during pouch change.
34. Observe patient’s and family caregiver’s willingness to view stoma and ask
questions about the procedure.
V. DOCUMENTATION
35. Document the following in the patient’s medical record:
a. Type of pouch and skin barrier applied
b. Time of procedure
c. Amount and appearance of effluent in the pouch
d. Location
e. Size
f. Appearance of stoma
g. Condition of peristomal skin
 Western Mindanao State University
College of Nursing
Zamboanga City

Level IV-SKILL PROCEDURES

STEPS 1 2 3 4
36. Record patient and family caregiver’s level of participation, teaching that was
done, and response to teaching.
37. Advise the patient to report any of the following to the nurse and/or health care provider.
a. Abnormal appearance of stoma, suture line, peristomal skin
b. Character of output

RATING
244 - 256 = 1.00 96-100 % Total Score:
231 - 243 = 1.25 91-95 %
218 - 230 = 1.50 86-90 %
205 - 217 = 1.75 81-85 % Rating:
193 - 204 = 2.00 76-80 %
180 - 192 = 2.25 71-75 %
167 - 179 = 2.50 66-70 % Student’s Signature:
157 - 166 = 2.75 62-65 %
152 - 156 = 3.00 60-61 %
142 - 151 = 3.25 56-59 % CI’s Signature:
127 - 141 = 3.50 51-55 %
116 - 128 = 3.75 46-50 %
101 - 115 = 4.00 41-45 % Remarks:
91 - 102 = 4.25 36-40 %
78 - 90 = 4.50 31-35 %
67 - 77 = 4.75 26-30 %
Below 66 = 5.00 0-25 %

Prepared By: Ma. Esperanza E. Reavon, MAN, RN

Clinical Instructor

Noted By: Sarah Jane C. Demayo, PhD, RN

Level IV - Coordinator

Maria Socorro C. Domingo, DNS, MAN, RN

Recommending Approval: Clinical Coordinator

Approved By: Mary Joselyn C. Biong, DPA, MN

OIC-Dean

Reference:

Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2018). In Clinical Nursing Skills & Techniques (9th ed., pp. 934–938). essay, Elsevier.