6 American Nurse Today Volume 12, Number 9 AmericanNurseToday.com

AN OSTOMY is a surgically createddiversion for feces or urine after re-moval of part or all of the intestineor bladder. According to the Unit-ed Ostomy Associations of America(UOAA), an estimated 750,000 Ame -r i cans are living with an ostomy and130,000 new ostomy surgeries occurin the United States annually.

Due to the complex nature andlabor intensity of ostomy manage-ment, many hospitals employ certi-fied wound, ostomy, and continencenurses (CWOCN) as resource per-sons. Also known as WOC nurses,they have advanced education inthese specialties. But even if yourhospital has a nurse ostomy spe-cialist (and especially if it doesn’t),you need to be able to care for pa-tients who have an ostomy. Thisarticle will provide the nuts andbolts so you can do just that.

About ostomiesWhether temporary or permanent,an ostomy may be created for suchindications as cancer, inflammatorybowel disease (Crohn’s disease orulcerative colitis), trauma, bowelobstruction, and bowel perforation.Common types of diversions in-clude ileostomy, colostomy, andileal conduit. (See Understandingileostomies, colostomies, and ilealconduits.) The diversion may beincontinent or continent; this arti-cle discusses incontinent diversionsonly.

Preoperative preparation andpostoperative care are essential tohelping patients with a new osto-my adapt to this major life event.

Preoperative preparationBefore surgery, the nurse ostomyspecialist or another nurse meets

with the patient and home care-giver to provide information andsupport and to assess for an opti-mal surgical site for stoma cre-ation. This critical session alsoprovides an opportunity for pa-tients to express their thoughtsand feelings about the upcomingsurgery and ostomy.

Postoperative careAfter surgery, you’ll need to identifywhich type of ostomy the patienthas, its indication, and whether it’stemporary or permanent. This in-formation helps you gauge the pa-tient’s overall health status, guideinterventions, and determine edu-cational needs. If necessary, youmay need to check another source,such as the operative notes, to getanswers to these questions. (Note:You can’t determine the type of os-

Ostomy management: Nuts and bolts for every nurse’s toolbox

Learn the facts about ostomy care.By Mary H. Zeigler, MS, CRRN, CWON, and Allison Min, BSN, CRRN

AmericanNurseToday.com September 2017 American Nurse Today 7

tomy a patient has based just on itsabdominal location.)

You also need to understandvarious ostomy appliances and ac-cessories, how to assess the pa-tient, and principles of emptyingand changing the pouch.

Ostomy appliancesThe nurse ostomy specialist choos-es the initial appliance (pouchingsystem) after measuring the stoma.(Measurement devices are availablefrom appliance companies.) At eachappliance change, you should meas-ure the stoma because swellingmay change its size or position.Swelling typically subsides over thefirst 6 weeks after surgery.

Wear time may vary; in mostcases, it’s 5 to 7 days for a colo -sto my and 3 to 4 days for an ile -osto my or ileal conduit. After thefirst 6 weeks, the patient maychange to a different appliancewith professional guidance.

The ostomy appliance consists ofa skin barrier and pouch to containfecal or urine effluent. (See Typesof skin barriers.) Disposable andwaterproof, the appliance is de-signed to contain odor and has ei-ther a drainable clamp or Velcroclosure or is a nondrainable closed-ended pouch.

Some appliances are clear; oth-ers are opaque. An opaque appli-ance may make it difficult to centerthe pouch directly over the stoma.All pouching systems are equallyeffective, so the choice dependslargely on patient preference.

The ostomy appliance mayhave one or two pieces.• A one-piece system has a single

seal, with the skin barrier per-manently attached to the pouch.Appropriate for patients with aflat peristomal profile, it entailsone less application step than a two-piece system.

• With a two-piece system, thepouch can be detached fromthe skin barrier and discarded

Ileostomies and colostomies are fecal diversions. Created from the last section ofthe small bowel (ileum), an ileostomy is typically created in the right lower ab-dominal quadrant. Once it begins to function (usually in 1 to 3 days), effluent(stool) volume may be high, but in most cases will subside in a few weeks. At first,effluent volume is about 1,200 mL/24 hours, and then it decreases to around 800to 1,000 mL/24 hours. Although the stoma is created from the ileum and outputinitially is liquid, the body learns to compensate and eventually stool consistencymay become more like toothpaste. A colostomy is created from any part of the large bowel—ascending, trans-

verse, descending, or sigmoid colon. Expected stool volume is approximately 600to 1,000 mL/24 hours. The closer the stoma to the end-point of digestion (de-scending or sigmoid colon), the more formed the stool is. • With a colostomy at the ascending colon, stool consistency is similar to thatcreated by an ileostomy.

• A colostomy at the transverse colon leads to a stool consistency like tooth-paste.

• A colostomy at the descending colon causes semiformed stool.

An ileal conduit is a urinary diversion. If the bladder is removed, a cystectomyis done, followed by a 12- to 18-cm (5- to 7-inch) resection of the ileum, in whicha conduit is formed from the ureters to the outer abdomen. The proximal end ofthe ileal conduit is closed and the distal end serves as the stomal opening on theoutside of the abdomen; the ureters are anastomosed to the ileal conduit seg-ment. Urinary volume should be at least 800 mL/24 hours.

Understanding ileostomies,colostomies, and ileal conduits

Ascendingcolostomy

Transversecolostomy

Descendingcolostomy

Cecostomy IleostomySigmoidcolostomy

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instead of emptied. However, it requires an extra step—re-attaching the pouch to the skinbarrier.

Ostomy accessoriesVarious ostomy accessories pro-mote comfort, adherence, andhealthy peristomal skin. Skin-barri-er paste and powder, as well asbarrier rings, wafers, and strips,are made from adhesive pectin.Skin-barrier prep and powder areavailable as sprays, wipes, or “lol-lipop” sticks. Applied directly toskin around the stoma before bar-rier or pouch application, theyprotect the skin by preventing ef-fluent from leaking and touchingthe skin under the appliance.(Caustic stool enzymes in effluentcan harm peristomal skin.)

Clinicians must read all manu-facturer directions before usingthese products. If peristomal skinis denuded (a condition calledepidermal skin stripping), powdercan be sprinkled directly on thedenuded skin and sealed by dab-bing at it with the corner of skin-barrier film prep—a techniquecalled crusting.

Other ostomy accessories include:• ostomy belts, which help secure

the appliance• binders, which support a peri -

stomal hernia• wraps, which can provide a

flatter body contour• special swimwear and intimate

apparel that allows for privacy.

Patient assessmentWhen assessing the patient with anew ostomy:• inspect the appliance to verify

that it’s secure and functioningproperly

• check for effluent leakage • note the date of the last pouch

change• evaluate output character and

volume • check for flatus.

When emptying and changing

the pouch, inspect the stoma, notingits anatomic location and proximityto drains or the surgical incision, aswell as stoma characteristics andperistomal skin condition. Normal-ly, the stoma is red, moist, andfirm and protrudes 2.5 cm (1 inch)above the skin surface. The open-

ing should point directly upward. Stoma shape and size depend on

how the stoma was created and itslocation in the GI tract. Stomal dis-coloration, inadequate output, ab-sent or diminished bowel sounds,and abdominal distention or tender-ness may indicate stomal dysfunc-tion, poor perfusion, or both. Ifthese signs or symptoms occur, asurgical consult may be necessary.Be aware that slight bleeding mayoccur with gentle cleansing becausestomal mucosal tissue has a richblood vessel supply.

Emptying and changing the pouch The pouch should be emptiedwhen it’s one-third to one-half full.In a high-volume system, such as a new ileostomy or ileal conduit,an appliance with an output spoutmay be connected by a conduitconnection to a urinary leg-bagdrainage system, allowing for alarger reservoir and less frequentchanges.

Ideally, patients should emptythe pouch while standing at or sit-ting on a toilet with their legsopen. Patients with impaired mo-bility may lie on their side anddrain the pouch into a urinal orwash basin, then dispose of theoutput in a toilet.

Basic pouches should be changedat least weekly or whenever leak-age occurs. High-volume outputsystems, such as ileostomies andileal conduits, need to be changedmore often. (See Changing the osto-my appliance.)

Educating patients and homecaregivers The initial phase of a new ostomycan be overwhelming for patientsand caregivers. To build their confi-dence, work closely with them,conveying confidence and patience.Teaching points to cover includeostomy type, expected output, theneed to alert nursing staff of leak-

Skin barriers have either a cut-to-fitopening or a stretch-back openingto accommodate the stoma. Theopening should match stoma sizeand shape; the barrier should beflush with the stoma to prevent un-dermining of the skin from effluent.

• With a cut-to-fit opening, theclinician cuts an opening fromthe starter hole so it just clearsthe stoma, then peels off thestarter-hole piece and uses it asa pattern for future pouchchanges.

• A stretch-back opening elimi-nates the need to measure, cut,or rely on a pattern. It’s ideal forpatients unable to use bothhands and those with weaknessor dexterity issues. No matterhow much or how little theopening is stretched, it conformssnugly around the stoma.

Types of skin barriers

(continued on page 10)

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age or seal compromise, and theimportance of emptying the pouchwhen it’s one-third to one-half full.Also teach patients and caregiversabout an appropriate diet to follow.(See Dietary considerations.)

Determine the patient’s readi-

ness to learn about the ostomy.For patients who won’t look at ortouch the pouch, use a gradual,supportive, step-by-step approach.For those who seem receptive toseeing, touching, and learningabout the pouch, explain the role

of each ostomy item and urge thepatient to touch and practice withthese items. (Manufacturer-sup-plied ostomy models can aid thispro cess.) Once the patient is com-fortable with the pouch, demon-strate a pouch change; if the pa-tient expresses readiness, he orshe may participate.

At the next pouch change, en-courage the patient to perform areturn demonstration with coach-ing. Have the patient open andclose a sample pouch, attach apouch to a skin barrier, and prac-tice emptying his or her ownpouch. Reassure patients that theirappliance will adhere successfullyeven if challenges occur at first.

Many patients and caregivers arefar less anxious after the returndemonstration. At subsequentpouch changes, supervise or helpthe patient or caregiver, as needed.

At discharge, the patient shouldbe able to empty the pouch inde-pendently. Otherwise, explore al-ternatives, such as a family mem-ber or caregiver, who can help thepatient. Provide written materials,resource information, and peer-support referral, all available fromthe UOAA (ostomy.org), WoundOstomy and Continence Nurses So-ciety (wocn.org), and Ostomy Se-crets (ostomysecrets.com). As ap-propriate, arrange for a homehealth nursing referral for addition-al support. Other helpful resourcesinclude ostomy clinics and certifiedostomy nurses who practice in thecommunity; for information on thelatter, contact the WOCN Society.

From anxiety to empowermentPatients with new ostomies face aninitial period of challenging psy-chological and social adjustments.Major concerns include altered self-image, fear of rejection, intimacychanges, and fear that the ostomyappliance will lose adherence in apublic or social situation.

Provide emotional support andurge patients to express feelings of

Follow these steps when changing the patient’s ostomy appliance.

1 Gather all needed supplies.

2 Perform hand hygiene.

3 Assemble and open supplies on a clean surface near the patient.

4 Stretch back the skin-barrier opening, or cut an opening on a starter hole andpeel back to remove. Connect the skin barrier to the pouch.

5 Tuck an incontinence pad inside the patient’s clothing to prevent soiling.

6 Set up a mirror on the bedside table so the patient can observe the procedure.

7 Don gloves.

8 Remove the old appliance by holding the skin taut with one hand and gentlypulling back the skin with your other hand (push-pull technique).

9 Discard the old pouching system.

10 Clean the stomal and peristomal areas with moistened paper towels. Avoidusing soap or baby wipes, as they may leave a residue that can interfere withthe appliance seal.

11 Have gauze ready when preparing the peristomal area to wick leaking effluent.

12 Inspect the stoma and peristomal areas for abnormalities and irritation.

13 Measure the stoma with a measuring guide to determine if the patient needsa larger or smaller appliance.

14 If you note peristomal skin irritation, perform the crusting technique, usingskin-barrier powder and prep.

15 Apply skin-barrier prep to remaining peristomal skin and let dry for 2 to 3minutes.

16 If using a barrier ring, apply so it fits directly around stoma.

17 With a two-piece appliance, attach the skin barrier to the pouch at the flange(where the barrier and pouch connect) by snapping it in place. Then check forsecurement, if you didn’t do this earlier.

18 Remove adhesive backing from the barrier and center the barrier or pouchdirectly over the stoma. Secure adhesive to skin around the barrier.

19 Have the patient put one hand, palm side down, directly over the pouch ad-hesive for 5 to 10 minutes to warm the materials, allowing for a stronger seal.

20 Close and secure the bottom opening of the pouch.

21 Optional: Frame the appliance with tape, or apply an ostomy belt.

22 Remove gloves and perform hand hygiene.

Changing the ostomy appliance

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anxiety and fear. Teach them howto take control of their situation toimprove their quality of life. Withemotional support, information,and practice, ostomy patients canfeel empowered and achieve posi-tive outcomes.

The authors work at the Shirley Ryan AbilityLab,the former Rehabilitation Institute of Chicago, inIllinois. Mary H. Zeigler is a clinical nurse special-ist. Allison Min is a staff nurse.

Selected referencesColwell JC. Selection of pouching system. In:

Carmel JE, Colwell JC, Goldberg MT, eds.Wound, Ostomy and Continence Nurses So-ciety® Core Curriculum: Ostomy Manage-ment. Philadelphia: Lippincott Williams andWilkins; 2016:120-30.

Cross HH, Roe CA, Wang D. Staff nurse confi-dence in their skills and knowledge and barriersto caring for patients with ostomies. J WoundOstomy Continence Nurs. 2014;41(6):560-5.

Prinz A, Colwell JC, Cross HH, Mantel J,Perkins J, Walker CA. Discharge planning fora patient with a new ostomy: Best practicefor clinicians. J Wound Ostomy ContinenceNurs. 2015;42(1):79-82.

Recalla S, English K, Nazarali R, Mayo S,Miller D, Gray M. Ostomy care and manage-ment: A systematic review. J Wound OstomyContinence Nurs. 2013;40(5):489-500.

Stricher L, Hocevar B, Asburn J. Fecal andurinary stoma construction. In: Carmel JE,Colwell JC, Goldberg MT, eds. Wound Osto-my and Continence Nurses Society Core Cur-riculum: Ostomy Management. Philadelphia:Lippincott Williams and Wilkins; 2016:90-8.

United Ostomy Associations of America. Phoe nixmagazine. phoenixuoaa.org/?v=7516fd43adaa

Zeigler M. How do we promote independentostomy management for people with disabil-ity? Rehabil Nurs. 2012;37(2):53-5.

Most patients can resume a normal diet after ostomy surgery but should limittheir intake to small, frequent meals with low fiber intake for the first 2 weeks(due to bowel edema). Encourage them to chew foods thoroughly to maximizehealthy digestion. During the initial high-volume effluent period, an ileostomy must be moni-

tored closely because of the risk of fluid and electrolyte imbalances. Patients withloose stools may benefit from stool-thickening foods, such as applesauce, ba-nanas, rice, peanut butter, and bread. They should chew these foods, particularlythose high in fiber, thoroughly to avoid bowel blockage. Patients with ileal con-duits don’t require dietary modification but should drink plenty of fluids, especial-ly water, to help prevent mucus buildup in the urine. Know that certain foods and beverages, including dairy foods, onions, cab-

bage, broccoli, mushrooms, beans, cucumbers, and alcohol, may trigger gas. Gascauses the pouch to expand; to release gas, instruct the patient to open thepouch at the flange (where the pouch and skin barrier connect). To help reducegas, advise patients to avoid chewing gum, drinking carbonated beverages, andusing beverage straws.

Dietary considerations