OSTOMY CARE

LEARNING MANUAL DESCRIPTION

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. This opening serves as the exit point for fecal matter. Changing and
emptying an ostomy appliance, needs scientific knowledge, nursing technique and nursing intervention
when unexpected situation arises. It is very critical to be familiar with the procedures on ostomy care to
properly render the skill base on professional standard. Methods and procedures for ostomy care and
changing one-piece appliance are presented in this module.

COURSE LEARNING OUTCOMES

At the end of this module, you will be able to:

1. Assess and recognize any abnormality of the stoma.

2. Determine related factors to formulate nursing diagnoses based on the status of a patient.

3. Plan the care for a patient with ostomy.

4. Perform and implement action in caring for patient with ostomy and understand the rationale

for each action.

5. Evaluate and document the outcome of the procedure.

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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. The opening serves as an exit point for fecal matter through an appliance either one-piece or
two pieces appliance. 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 – the pouch and the skin barrier are bound together as in one segment. When
the pouch needs to be changed, so is the barrier.
2. Two-piece pouch system – the skin barrier and the pouch are separated. Only the pouch needs
to be removed while the skin barrier remains in place.
Image credit: StomaBags.com/google.com

TYPES OF OSTOMY
 Ileostomy – liquid fecal matter from the ileum of the small intestine pass through the stoma.
 Colostomy – formed fecal matter from the colon allows exit to the stoma.
o Colostomies are classified according to its origin (part of the colon).
 Transverse Colostomy
 Ascending Colostomy
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 Descending Colostomy
 Sigmoid Colostomy (the most common type)

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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.
a. The stoma should be dark pink to red and moist.
b. Pale stoma means anemia
c. Dark or purple blue color means ischemia or compromised blood circulation.
d. Minimal bleeding might be present along the stoma and its stem. For persistent and
continuous bleeding or if it is excessive, notify the doctor, also if change in the color of
the stoma occur.
3. Always note the size of the stoma
a. Stable stoma is expected within 6 to 8 weeks
b. ½ to 1inch protrusion of the stoma from the abdominal skin may initially present,
swollen and edematous that usually subsides 6 weeks after.
c. The final stoma may be flush with the skin
d. Skin erosion along the stoma may also lead to flush stoma
e. In the presence of abdominal dressing, always check for drainage and bleeding.
4. Keep peristomal area clean and dry
a. Leaking appliance may result to skin irritation.
b. Moist stoma is suitable for yeast or Candida infection
5. Monitor intake and output
a. Note for the discharge characteristics (quality and quantity)
b. Once peristalsis returns, stool elimination is through the stoma.
c. For the first 3 days postoperatively, intake and output should be recorded every 4 hours
d. Report immediately once output decreases while intake remains the same.
6. Explain the patient’s role and participation in the aspect of care
a. Educating the patient and his family (if suitable) is of the most importance in the care of
colostomy
b. Patient education should start before the surgery to give time to the patient to
understand the given knowledge.
7. Motivate the client to take part in the care of ostomy and to inspect it.
a. When emotional depression is present which is normal at first after surgery, be of help
by being a good listener and explain necessary procedure and information.

Equipment: (One-pouch appliance)

 Basin with warm water
 Towel, washcloth and skin cleanser
 Silicone-based adhesive remover
 Cotton balls
 Nonsterile disposable gloves
 Skin protectant
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 One-piece ostomy appliance

 Closure clamp for appliance

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 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
o Product style
o Condition
 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

Outcome Identification and Planning

 The expected outcome to be met when changing and emptying the ostomy appliance.
o The stoma is correctly put in place to allow draining of the stool freely.
o Patient’s skin around the stoma is intact and stoma remained red and moist.
o The patient demonstrates knowledge, positive attitude and coping skills on the
application of appliance.
o Stool output is suitable for the ostomy location.
o Portrays and verbalizes positive outlook and self-image

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. 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.
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Emptying the Appliance

7. Don gloves. Remove clamp and fold end of the pouch upward like a cuff.

Image credit: Mount Nittany Health/googgle.com image credit: YouTube

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.
a. Make sure that the clamp follows the curve of the patient’s body
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.
a. Water proof pad must be placed under the patient at the stoma site.
b. Empty the pouch.
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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.

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a. A silicon – based adhesive remover may be used by spraying or wiping it around the
area.
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.
c. Ensure to remove all old adhesive from the skin with the use of adhesive remover.
d. Lotion is recommended to peristomal area.
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.
b. Apply gentle pressure for 5 minutes.
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

Evaluation
1. Expected outcome is met:
a. The patient endures the procedure without pain
b. Peristomal skin remains intact and without scrape or irritation
c. Odor is suppressed within the pouch.
d. Patient participates and demonstrates positive response in the appliance care as well as
in coping skills.
e. Stool output is pertinent in consistency and amount for the ostomy location.
Documentation
1. Appearance and condition of the stoma and peristomal skin, the drainage characteristics
(amount, color, consistency, unusual odor) and patient’s response to the procedures must be
documented.
Unexpected Situations and Associated Interventions
1. Excoriated or irritated peristomal skin
a. Make sure that the appliance is not cut too large
b. Assess for the presence of fungal skin infection and seek appropriate treatment.
c. Ensure to properly and thoroughly cleanse skin before applying skin barrier
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d. Ensure to dry the area before applying the appliance

e. Check pouch adhesion and change pouch immediately if a break is present.

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2. Odor is leaking from the appliance

a. Check for any leaks or poor adhesion
b. Clean the outside of the bag properly and thoroughly after emptying.
3. Falling off or loose bag
a. Thoroughly and properly clean then apply skin barrier and allow to dry completely
before replying the pouch.
b. Check and monitor for any sings of break in the adhesion and change if any.
4. Protruding stoma into the bag.
a. It is called a prolapse
b. Let the patient rest for 30 minutes, if remains the same notify the physician.

Applying a Two-Piece Appliance

1. Composition/parts
a. Pouch – this is the bag that needs to be replaced when changing is required
b. Adhesive faceplate – this is left in place usually for 2 to 5 days
2. Types of Two-Piece Appliance
a. Clicking Tupperware-type – provides extra security due to the sensation it gives that the
appliance is secured.

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

b. Adhesive system type – more discreet, simpler to use

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

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.
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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.

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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.
c. Ensure to remove all old adhesive from the skin with the use of adhesive remover.
d. Lotion is recommended to peristomal area.
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.
b. Apply gentle pressure for 5 minutes.
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.
ii. Press firmly and smoothen the pouch onto the faceplate and avoid creases.
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.
a. Assess patient’s reaction to the procedure.
20. Remove gloves and PPE
a. Perform hand hygiene.

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

NOTE: Irrigation is not for ileostomy due to already fluid fecal content that cannot be controlled.
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Equipment
1. Disposable irrigation system and irrigation sleeve
2. Waterproof pad
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.
a. Usually 750 to 1000 ml for an adult
b. 250 to 500 ml for initial irrigation
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

OUTCOME IDENTIFICATION/PLANNING: it is met if

1. Patient expels soft formed fecal matter
2. Absence of trauma on both stoma and intestinal mucosa
3. Patient participate in the care of the ostomy
4. Patient manifest positive coping mechanism and confidence in the ostomy care

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
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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.

Image credit: Taylor’s Clinical Nursing Skills

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

Image credit: Taylor’s Clinical Nursing Skills

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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.

EVALUATION
Expected outcome is achieved when:
1. Irrigation solution flows easily into the stoma opening
2. Patient expels soft formed fecal output
3. No evidence of trauma to the stoma and intestinal mucosa
4. Patient cooperates and participate in the procedure of irrigation with confidence
5. Patient demonstrate positive coping mechanism.

DOCUMENTATION
Ensure to document the procedure.
1. Include the date, time, and amount of irrigating solution,
2. The color, amount and consistency of the fecal matter returned
3. The condition of the stoma, patient’s degree of cooperation and reaction to the procedure

e.g. 9 / 12/ 2020 10:00 AM 1000 ml of warmed tap water used to irrigate the colostomy. Moderate
amount of soft, dark brown stool returned. Patient performed the procedure with minimal assistance.
Stoma is pink and moist with no signs of bleeding or irritation. Procedure is tolerated by the patient
without any incident. New ostomy bag is applied after pat drying of the skin. R. Abinsay, RN

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.

https://www.youtube.com/watch?v=h8CtsPAaa5Y
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https://www.youtube.com/watch?v=vxnveaa9GYI

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POST TEST

Let’s have some mental exercise.

1. A client with colostomy refused to look at the stoma and verbalized that it is a sore thing to the
eyes during irrigation. Which of the following nursing diagnosis is most appropriate?
a. Risk for injury
b. Anxiety
c. Deficient knowledge
d. Disturbed body image
2. To prevent skin irritation and breakdown when removing a stoma appliance, which of the
following should the nurse suggest to the patient during home teaching?
a. To use an oil base remover
b. Petroleum jelly is the only best appliance remover
c. Use a silicon-based adhesive remover
d. Tap water can be used to loosen the adhesive appliance.
3. Five days postoperative patient with colostomy is under your care, which of the following
findings is abnormal?
a. Red and moist stoma
b. Swollen and protruding stoma
c. Minimal bleeding around the stoma
d. Moist and pale stoma
4. The patient inquires if it is possible to put lotion on the skin around the stoma. Which of the
following is the best response?
a. No, it will prevent tight adhesive seal
b. No, it will irritate the surrounding skin on the stoma
c. Yes, it will help moisturize the area
d. Yes, have some healing property that will prevent skin erosion
5. Which of the following rationale best explain why the stoma needs to be covered by a gauze
while the skin is being cleaned during appliance replacement?
a. To prevent damage to the stoma
b. To prevent skin adhesion
c. To absorb drainage from the stoma
d. To infection-control
6. Your patient is complaining of fecal odor coming from his appliance. Which of the following best
address the problem?
a. Check if the peristomal size is the same as that of the opening of the appliance.
b. Check the system for a break in adhesion
c. Cleanse the pouch/bag after emptying the appliance bag
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d. Ask the patient to put on facemask

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7. You noticed during colostomy irrigation that the irrigation solution is not flowing. The best that
you can do is which of the following?
a. Check the opening of the cone
b. Clamped and re-clamp the tubing
c. Squeeze the tubing to promote pressure
d. Ask the patient to stand and walk for a while
8. A 14 days postoperative patient voice out her fear about her swollen and edematous stoma.
Which of the following best addressed the patient’s concern?
a. Normally stomal opening becomes edematous after surgery and in 6 weeks, swelling will
subside.
b. it is believed to be a normal healing process, so just wait for the right time for healing.
c. Swelling is a sign of infection, but you don’t have to worry I will report it to your doctor
immediately.
d. Yes, it is swelling would you like me to, check if there are other signs of abnormality?
9. During assessment you noticed a prolapsed to a patient with colostomy. Your first nursing action
would be which of the following?
a. Let the patient rest for 30 minutes, assess if it will be back to normal.
b. Notify the physician immediately to prevent further complication
c. Instruct the patient to relax, and shift position every 30 minutes
d. Remove the appliance and slightly pushback the stoma
10. To ensure a snugly fit appliance, the nurse should do which of the following?
a. Cut the faceplate opening 1/8 inch. slightly smaller than the size of the stoma.
b. Cut the faceplate opening 1/8 inch. slightly bigger than the size of the stoma.
c. Cut the faceplate opening as the same size of the stoma.
d. Use the measurement guide and ensure to cut the opening exactly the same size that of
the stoma.

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REFERENCE

Taylor’s Clinical Nursing Skills (3rd Edition), Pamela Lynn

Clinical Nursing Skills and Techniques, Perry, Anne, Griffin

REFERENCE

https://www.cancer.org/cancer/acs-medical-content-and-news-staff.html

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