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Routine ostomy care: Clinical skills notes

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Notes

GI/GU

Routine Ostomy Care

INTRODUCTION
An ostomy is a surgically created opening used to connect an internal organ to the abdominal wall, through which waste products, like intestinal contents, are eliminated. The opening that can be seen on the body surface is called a stoma, and it’s usually connected to an ostomy pouch, also called a bag or appliance, where stool and flatus collect. An ostomy can be permanent or temporary, and it can be necessary because of fecal incontinence, an intestinal tumor, bowel trauma, or a bowel inflammatory disease. In these circumstances, part or all of the intestine is removed, and the remaining part of the intestine is brought up through the abdominal wall to allow for elimination of waste products. 
Figure 1: An ostomy, which includes a stoma and an ostomy pouch.
TYPES OF OSTOMIES

Depending on how much bowel is removed, an ostomy can be either an ileostomy or a colostomy. With an ileostomy, a part of the small intestine is connected to the abdominal wall. An ileostomy can be permanent when the entire large intestine is removed or temporary when it’s done to allow the large intestine to heal after trauma or surgery (Fig. 2a).  With a colostomy, only part of the large intestine is removed, and the remaining part is connected to the abdominal wall (Fig. 2b). Normally, in the small intestine, the nutrients are pretty liquidy because most of the water is reabsorbed in the large intestine. So, with an ileostomy, the feces are liquid, and they flow at a fairly constant rate. With a colostomy, on the other hand, feces have a different consistency depending on the location of the colostomy. If nearly all the large intestine was removed and the colostomy is near the beginning, feces are more liquid. If the colostomy is near the end of the digestive tract, feces are more solid. 

Figure 2: Two types of ostomy are A. ileostomy, and B. colostomy.
TYPES OF OSTOMY APPLIANCES
Like ostomies, ostomy appliances also come in different shapes and sizes. There are drainable appliances, also called “open-end” appliances, which are sealed with a clip or a Velcro-type system at the bottom so they can be drained and reused. Then there are closed-end, or disposable appliances which can be removed and replaced or emptied and rinsed when full. Additionally, some appliances are pre-cut, so they come in different sizes to match the various stoma sizes. For other appliances, you’ll need to cut out the opening yourself. Another variation refers to whether or not the skin barrier is attached to the appliance. If it is, it’s a one-piece; if not, it’s a two-piece. Finally, the ostomy appliance can be connected to an ostomy belt, and sometimes appliance deodorant can be placed inside.  
Figure 3: Types of ostomy appliances.
COMMON CARE TIPS
  • Close the door and bed curtains and keep the person covered as much as possible for privacy while providing ostomy care. 
  • The skin around the ostomy is in direct contact with feces, putting it at risk of irritation, so care should be taken to keep it clean.
  • If you’re using a pre-cut ostomy appliance, the opening should match the size of the stoma.
  • If you cut the opening yourself, measure the stoma using a measuring guide, then trace the measurement on the skin barrier. Cut the opening a little larger than the stoma, so as to not put pressure on it.
  • The ostomy appliance can be changed when the client is standing or sitting, and it can be done in the bathroom or while the person is lying in bed.
  • For colostomies, choose a time when the stoma is not active to provide care, such as first thing in the morning.
  • If you’re providing routine ostomy care in bed, place a bed protector next to the client to prevent the linens from getting soiled.
  • Use warm water for ostomy care and make sure it’s at a comfortable temperature by testing it with the inside of your wrist.
  • As a general rule, while providing routine ostomy care, dirty supplies go into a bedpan, and then you can dispose of them appropriately.
ROUTINE OSTOMY CARE PROCEDURE
To provide routine ostomy care, you’ll need:
  • toilet paper 
  • two pairs of gloves 
  • a clean ostomy appliance and belt 
  • a gauze pad 
  • a skin barrier 
  • a wash basin 
  • soap and water 
  • washcloths 
  • a towel
Figure 4: Supplies needed to provide routine ostomy care.
In order to care for someone with a pre-cut, one-piece disposable appliance:
  1. Raise the bed to a comfortable working height and position the client appropriately to have access to the stoma. 
  2. Observe what’s in the ostomy bag and report anything urgent to the healthcare provider. 
  3. To remove the ostomy appliance, disconnect it from the ostomy belt if one is used. Then, hold the skin and gently pull the appliance from the top to the bottom. You can use warm water to remove the adhesive more easily. 
  4. Place the appliance in the bedpan. 
  5. Use toilet paper to clean the stoma, then cover the stoma with a gauze pad. 
  6. Go to the bathroom to empty the ostomy appliance. Observe the color, amount, and consistency of feces in the appliance, as well as any abnormalities. 
  7. Dispose of the old gloves and wash your hands. 
  8. Fill the wash basin with warm water. 
  9. Put on a new pair of gloves.  
  10. Wrap a washcloth around your hand to form a sort of mitt. With your other hand, remove the gauze from the stoma; dip the washcloth mitt in the water; apply soap; and clean, rinse, and dry the skin surrounding the stoma. 
    • Observe the stoma, which should be reddish pink and moist. Sometimes the stoma can bleed a bit when you’re providing care, but that’s considered normal. 
  11. Apply a skin barrier, which can be a cream and / or a wafer, covering the skin for a two inch radius around the stoma. 
    • If using a cream, let it dry before putting the appliance back on. 
  12. Put the ostomy belt back on and place deodorant inside the new ostomy appliance, if used. 
  13. Remove the back adhesive from the new appliance and center it over the stoma with the end pointing down. Press the edges on the skin and make sure there’s a good seal to prevent leakage. 
  14. Connect the appliance to the belt, if used. 
  15. Check the client's clothing, gown, and bed linens to ensure they’re dry and not soiled. 
  16. Remove the bed protector and your gloves. 
  17. Adjust the person’s clothing to cover the appliance and help readjust their position so they’re comfortable. 
  18. Lower the bed to its original position.  
DOCUMENTATION
When providing routine ostomy care, you should report any abnormal findings, like signs of skin breakdown or excessive bleeding from and around the stoma.

Document:
  • the date and time 
  • the type of care
  • the type of ostomy appliance that you used
  • any abnormal observations

Summary

An ostomy is a surgically created opening used to connect an internal organ to the abdominal wall, through which waste products, like intestinal contents, are eliminated. The opening that can be seen on the body surface is called a stoma, and it's usually connected to an ostomy pouch, also called a bag or appliance, where stool and flatus collect. Some of the acts performed when caring for an ostomy include: Emptying the pouch as needed Cleaning the skin around the stoma Changing the pouch as per manufacturer's instructions Checking the skin for redness or irritation Maintaining skin hygiene Monitoring the stoma for changes in size, shape, and color. When providing routine ostomy care, you should report any abnormal findings, like signs of skin breakdown or excessive bleeding from and around the stoma.