What would the nurse assess in a normal healthy stoma?
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Association of Stoma Care Nurses UK. ASCN stoma care. National clinical guidelines. 2016. https://tinyurl.com/y9q295fu (accessed 30 November 2020) The Royal Marsden manual of clinical nursing procedures, 10th edn. In: Lister S, Hofland J, Graton H (eds). Oxford: Wiley Blackwell; 2020 Royal College of Nursing. Bowel care: management of lower bowel dysfunction, including digital rectal examination and digital removal of faeces. 2020. https://tinyurl.com/y4fu89vn (accessed 1 December 2020) 02 December 2020
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| 2. Gather supplies. | Supplies include flange, ostomy bag and clip, scissors, stoma measuring guide, waterproof pad, pencil, adhesive remover for skin, skin prep, stomahesive paste or powder, wet cloth, non-sterile gloves, and additional cloths. |
| 3. Identify the patient and review the procedure. Encourage the patient to participate as much as possible or observe/assist patient as they complete the procedure. | Proper identification complies with agency policy. Encouraging patients to participate helps them adjust to having an ostomy. |
| 4. Create privacy. Place waterproof pad under pouch. | The pad prevents the spilling of effluent on patient and bedsheets. |
| 5. Apply gloves. Remove ostomy bag, and measure and empty contents. Place old pouching system in garbage bag. |  |
| 6. Remove flange by gently pulling it toward the stoma. Support the skin with your other hand. An adhesive remover may be used. If a rod is in situ, do not remove. | Gentle removal helps prevent skin tears. An adhesive remover may be used to decrease skin and hair stripping. A rod may be used during the formation of a stoma. It can only be removed by a physician or wound care nurse. If a rod is in place, it can be slid to allow the pouch to be removed. |
| 7. Clean stoma gently by wiping with warm water. Do not use soap. | Aggressive cleaning can cause bleeding. If removing stoma adhesive paste from skin, use a dry cloth first. |
| 8. Assess stoma and peristomal skin. | A stoma should be pink to red in colour, raised above skin level, and moist. Skin surrounding the stoma should be intact and free from wounds, rashes, or skin breakdown. Notify wound care nurse if you are concerned about peristomal skin. |
| 9. Measure the stoma diameter using the measuring guide (tracing template) and cut out stoma hole. Trace diameter of the measuring guide onto the flange, and cut on the outside of the pen marking. | The opening should be 2 mm larger than the stoma size. Keep the measurement guide with patient supplies for future use. |
| 10. Prepare skin and apply accessory products as required or according to agency policy. | Accessory products may include stomahesive paste, stomahesive powder, or products used to create a skin sealant to adhere pouching system to skin to prevent leaking. Wet skin will prevent the flange from adhering to the skin. |
| 11. Remove inner backing on flange and apply flange over stoma. Leave the border tape on. Apply pressure. Hold in place for 1 minute to warm the flange to meld to patient’s body. Then remove outer border backing and press gently to create seal. If rod is in situ, carefully move rod back and forth but do not pull up on rod. | The warmth of the hand can help the appliance adhere to the skin and prevent leakage. |
| 12. Apply the ostomy bag. Attach the clip to the bottom of the bag. | This step prevents the effluent from soiling the patient or bed. |
| 13. Hold palm of hand over ostomy pouch for 2 minutes to assist with appliance adhering to skin. | The flange is heat activated. |
| 14. Clean up supplies, and place patient in a comfortable position. Remove garbage from patient’s room. | Removing garbage helps decrease odour. |
| 15. Perform hand hygiene. | This minimizes the transmission of microorganisms. |
| 16. Document procedure. | Follow agency policy for documentation. Document appearance of stoma and peristomal skin, products used, and patient’s ability to tolerate procedure and assistance with procedure. |
| Data source: BCIT, 2015b; Berman & Snyder, 2016; Perry et al., 2014. |
Special Considerations
- When patients are discharged from an acute care facility, ensure they have referrals to a community nurse, are able to empty their pouch system independently or with assistance from a caregiver, have spare supplies, and know the signs and symptoms of complications and where to seek help.
- Patients should be seen by the wound care or ET nurse and have a dietitian referral for new dietary needs related to the ileostomy or colostomy (Registered Nurses Association of Ontario, 2009).
- The ostomy bag may become filled with gas from the intestine and may let out a “farting” sound that is usually quiet, but uncontrollable. Patients may “burp” the bag through the opening at the top in a two-piece system by opening a corner of the ostomy pouch from the flange to let the air out. Dietary restrictions may also help decrease the amount of gas produced by the intestines (Ostomy Canada Society, n.d.).
Urostomy Care
A urostomy is similar to a fecal ostomy, but it is an artificial opening for the urinary system and the passing of urine to the outside of the abdominal wall through an artificially created hole called a stoma. A urostomy is created for the following reasons:
- Bladder cancer
- Cystectomy
- Trauma/surgery
- Incontinence
- Painful bladder/overactive bladder
- Congenital abnormalities
- Conversion of continent urinary diversion to incontinent stoma
- Neurological conditions and diseases
- Spinal cord injury
- Chronic inflammation of bladder
- Interstitial cystitis
- Radiation damage
- Inability to manage a continent urinary diversion or a neobladder
A urostomy patient has no voluntary control of urine, and a pouching system must be used and emptied regularly. Many patients empty their urostomy bag every two to four hours, or as often as they regularly used the bathroom prior to their surgery. Urostomy pouches (see Figure 10.9) have a drain at the end, and the pouch should be emptied when one-third full. The pouch may also be attached to a drainage bag for overnight drainage. Patients with a urostomy are more at risk for urinary tract infections (UTIs) and should be educated on the signs and symptoms of such infections (Perry et al., 2014).
Checklist 88 describes how to change a urostomy pouch.
Checklist 88: Changing a Urostomy Pouch/ApplianceDisclaimer: Always review and follow your hospital policy regarding this specific skill. | |
Safety considerations:
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Steps | Additional Information |
| 1. Perform hand hygiene and collect supplies. | Hand hygiene reduces the transmission of microorganisms. Supplies include urostomy bag (one- or two-piece system), measuring guide, urinary collection bag, non-sterile gloves, scissors, pencil, adhesive remover, skin barrier pad, wick made from sterile gauze (rolled 2 x 2 gauze), waterproof garbage bag, waterproof pad, cleaning cloth, and drying cloth. |
| 2. Identify the patient and review the procedure. Encourage patient to participate as much as possible or observe/assist as they complete the procedure. | Proper identification complies with agency policy. Encouraging patients to participate helps them adjust to having an ostomy. |
| 3. Create privacy and place waterproof pad under pouch. | This maintains patient dignity and the pad protects the patient’s bed. |
| 4. Apply non-sterile gloves. Empty and measure urostomy contents. Discard old urostomy pouch. | A full urostomy bag may spill on the patient or bed. |
| 5. Remove flange by gently pulling it toward the stoma. Support the skin with your other hand. An adhesive remover may be used. If stent is in place, do not remove it. | Gentle removal helps prevent skin tears. An adhesive remover may be used to decrease skin and hair stripping. |
| 6. Place rolled gauze at stoma opening. Maintain gauze at the stoma opening continuously during pouch measurement and change. | This prevents urine from spilling on cleaned skin and new pouching system. |
| 7. While keeping rolled gauze in contact with the stoma, cleanse peristomal skin gently with warm tap water using washcloth; do not scrub skin. If you touch stoma, minor bleeding is normal. Pat skin dry. | Aggressive cleaning can cause bleeding. If removing stomahesive paste from skin, use a dry cloth first. |
| 8. Assess stoma and peristomal skin. | A stoma should be pink to red in colour, raised above skin level, and moist. Skin surrounding the stoma should be intact and free from wounds, rashes, or skin breakdown. Notify wound care nurse if concerned about peristomal skin. |
| 9. Measure the stoma diameter using the measuring guide (tracing template) and cut out stoma hole. Trace diameter of the measuring guide onto the flange and cut on the outside of the pen marking. | Customizing the opening of the flange is important to ensure proper fit and prevent leakage.The opening should be 2 mm larger than the stoma. Keep the measurement guide with patient supplies for future use. |
| 10. Prepare the skin and apply accessory products as required or according to agency policy. | Accessory products may include stomahesive paste, stomahesive powder, or products used to create a skin sealant to adhere pouching system to skin to prevent leaking. Wet skin will not allow for proper adhesion of flange. |
| 11. Remove inner backing on flange. | Prepare flange to be placed on stoma. |
| 12. Remove wick from stoma and apply flange around stoma. Leave the border tape on. Apply pressure. Hold in place for 1 minute to warm the flange to meld to patient’s body. Then remove border backing and attach to patient. | The flange is heat activated. |
| 13. Apply the urostomy bag by ensuring the drain is turned to the “off” position, or connect the urostomy bag to a drainage bag at the bedside. | This prevents effluent from soiling the patient or bed. If drainage bag is used, ensure the bag is hanging below the urostomy to prevent backflow of urine into the stoma. |
| 14. Hold palm of hand over pouch for 2 minutes to assist with appliance adhering to skin. | Pouches are heat activated and adhere more effectively when heat is applied. |
| 15. Remove waterproof pad, clean up supplies, place patient in a comfortable position, and perform hand hygiene. | This step prevents contamination from equipment and reduces the transmission of microorganisms. |
| Data source: BCIT, 2015b; Perry et al., 2014; Vancouver Coastal Health, 2014b |
Special Considerations:
- Teach patients how to change a urostomy bag even if they appear disinterested. Do not insist that they look at the ostomy; allow them time to adjust.
- Educate patients on the importance of drinking adequate fluids each day (unless contraindicated) to prevent a UTI. Patients should drink at least 2 litres of fluid per day (unless contraindicated).
- Some mucous in the urine is normal, but blood is not a normal or expected finding.
- Educate patients on the signs and symptoms of a UTI, which include fever, flank (back) pain, cloudy or smelly urine, and feeling of malaise.
- Educate patients on where to buy supplies and which supplies to have on hand in case the flange leaks and needs replacing (Perry et al., 2014).
- What dietary or medication changes might be considered for a patient who has a new ileostomy and no longer has a small bowel?
- A patient with a new colostomy refuses to look at his stoma or participate in changing the pouching system. What are some suggestions to help your patient adjust to the stoma?
