Basics of ostomy care
A variety of gastrointestinal/genitourinary etiologies may necessitate the creation of a fecal or urinary diversion. Teaching the patient how to care for a new ostomy can be a challenging experience for the nurse. The patient with an ostomy needs encouragement, support, and counseling to learn how to integrate self-ostomy care into daily activities.
A variety of gastrointestinal/ genitourinary etiologies may necessitate the creation of a fecal or urinary diversion. These may include diverticular disease, inflammatory bowel disease, colon-rectal cancer, intestinal obstruction, gastrointestinal trauma, and gynecological cancers (Beitz, 2004). Indications for creating a urinary stoma are bladder cancer, neurogenic bladder, interstitial cystitis, and refractory radiation cystitis. The etiology of the disease will determine if the ostomy is going to be temporary or permanent (Tomaselli & McGinnis, 2004).
Among the different types of surgically created ostomies, a colostomy is an opening constructed in the colon (large intestine) to allow for the elimination of stool. A colostomy may be located in the ascending, transverse, or sigmoid colon. The point of surgical resection will determine the consistency of the stool output. An ileostomy is surgically constructed from the ileum (small intestine). It is created high in the gastrointestinal tract; therefore, the stool output is of relatively high amount and of liquid consistency (Vasilevsky & Gordon, 2004). A urostomy or ileal conduit is created using a short segment of the ileum to aid in eliminating urine. The ureters are connected to the conduit for urine to flow out of the body via the stoma into an ostomy pouch (Tomaselli & McGinnis, 2004).
Whether an ostomy is permanent or temporary, nurses must have the knowledge to provide the patient and family with the appropriate information to maximize recovery and allow for a positive experience when learning ostomy care.
When a patient is scheduled for ostomy surgery, he or she may experience many feelings, such as anxiety, fear, loss of body image, and depression, especially if a diagnosis of cancer is the cause for surgery. Preoperative teaching can help relieve some of these feelings and contribute to the patient’s positive recovery (O’Shea, 2001). One essential component of the patient’s preoperative teaching is a consultation with a wound ostomy and continence nurse (WOCN). Preoperative counseling provides the opportunity to assess the patient’s knowledge of the disease, educational level, support systems, employment, involvement in physical activities such as sports or hobbies, and financial concerns regarding purchase of ostomy supplies. In addition, assessment of any physical limitations is important because poor vision, poor manual dexterity, or any loss of hearing may interfere with the patient’s ability to perform ostomy self-care. The patient’s cultural and spiritual beliefs also should be assessed because specific rituals regarding ostomy care may need to be incorporated into the ostomy teaching plan. Addressing all of these factors can help the patient transition to a successful recovery and a feeling of confidence in managing the ostomy (O’Shea, 2001).
During the consultation, the WOCN reviews the disease etiology, surgical procedure, stoma characteristics, stoma and peristomal skin care, dietary considerations, and different ostomy appliances. If appropriate, the teaching session may allow the patient to visualize an ostomy pouching system. The use of illustrations and teaching booklets will help to enhance the education.
Stoma site marking is another component of preoperative teaching. Stoma marking is recommended for all patients who are scheduled for a temporary or permanent stoma (Carmel & Goldberg, 2004). A stoma that is located poorly on a patient’s abdomen can result in stoma and peristomal skin complications, leakage of stool or urine, and physical and emotional stress for the patient. During the stoma site marking, the abdomen is assessed with the patient in the lying, sitting, and standing positions. In addition, the abdomen is assessed for abdominal skin folds, creases, bony prominences, and scars. The stoma site should avoid the patient’s belt line and not interfere with any prosthetic devices. The stoma site also should be placed in an area that the patient can reach and visualize. The ideal stoma site is located within the abdominal rectus muscle that extends from the xyphoid process to the symphysis (Carmel & Goldberg, 2004).
Stoma assessment. The patient should exit the operating room with an ostomy pouching system on the stoma. During the immediate postoperative period, the author generally recommends a transparent pouch which allows the nurse to visualize stoma characteristics and presence of urine/stool (Carmel & Goldberg, 2004). During the initial postoperative period, the stoma may appear to be edematous, red, moist, and shiny. The stoma is generally a red-to-pink color depending on the tissue used for construction. A brown-to-black color may indicate stoma ischemia, and the physician should be consulted. The shape of the stoma may be round or oval. The stoma will change in size and shape for at least 6-8 weeks after surgery. Because the stoma will decrease in size over time, the nurse should use a skin barrier that is cut-to-fit and not pre-sized to the stoma (Carmel & Goldberg, 2004). During the first 6-8 weeks after surgery, the stoma should be measured each time the skin barrier is changed. Measuring guides are available for measuring round stomas; if the stoma is oval, it is best to measure the stoma length and width for the appropriate size (Colwell, 2004). Because the stoma does not have a sphincter to control the passage of stool or urine, the stoma’s opening should be located toward the center of the stoma to facilitate the flow of stool or urine directly into the pouch (McCann, 2002).
The stoma may or may not protrude from the skin surface. Degrees of stomal protrusion can range from a flush stoma (below skin level) to moderately protruding (1-3 cm) or long (greater than 3 cm) (Erwin-Toth & Doughty, 2002). Ideally, the stoma should protrude at least 0.8 inches from the skin level (Colwell, 2004). A protruding stoma will help facilitate stool and urine to drain directly into the pouch. A flush stoma is not ideal as it can lead to difficulty with skin barrier adherence and stool leakage under the skin barrier, resulting in peristomal skin irritation.
Stoma output. The site of ostomy creation in the colon will determine the amount, consistency, and frequency of stool output. Output from a colostomy located in the ascending colon will have a semi-liquid consistency, that from a colostomy located in the transverse colon will have a semi-liquid to pasty consistency, and that from a colostomy located in the descending or sigmoid colon will be a more formed stool (McCann, 2002).
The stool output from an ileostomy is watery and constant, and contains large amounts of digestive enzymes and salt. During the initial postoperative period, the stool may be thick and greenish. Stool output from an ileostomy can be 800-1,700 cc in 24 hours (Colwell, 2004). When the patient resumes a regular diet, the stool output from the ileostomy will develop some consistency and the amount of output in a 24-hour period may begin to decrease (500-800 cc/day). Over time, the small intestine compensates and the stool output decreases (McCann, 2002). Ileal conduit stomas produce urine immediately after surgery. In the immediate postoperative period, it is normal for the urine to be blood-tinged. As the patient recovers from surgery, the bleeding subsides and the urine is a clear straw color. In addition, the small intestine normally produces mucous, and as a result mucous shreds may appear in the urine (Colwell, 2003).
Peristomal skin care. Stool and urine contain enzymes that can be irritating to the skin. The peristomal skin should be protected from contact with stool or urine to prevent peristomal skin complications. The skin barrier should be measured properly to fit around the stoma. If the opening of the skin barrier is too large, stool or urine will cause irritation to the peristomal skin area. The skin barrier opening should be no more than 1/8 inch larger than the stoma size. The peristomal skin can be cleaned with warm water and gently dried. Soaps with moisturizers should be avoided as they may interfere with skin barrier adherence. Male patients should be taught to shave peristomal hair using scissors, electric razor, or safety razor, moving outward away from the stoma (McCann, 2002).
Choosing the Right Ostomy Appliance
Choosing a patient’s ostomy pouching system will depend on some of the information that was gathered preoperatively. Other factors to consider are the stoma’s location, size and shape, and anatomical location. The pouching system should provide an expected wear time and protect the skin from urine or stool (Colwell, 2003). Most ostomy pouching systems are designed to be lightweight, odor-proof, and relatively low maintenance (Colwell, Goldberg, & Carmel, 2001).
Skin barriers. The skin barrier is one of the most important components of the pouching system, protecting the peristomal skin from urine or stool and sealing the pouch to the barrier (Colwell, 2004). Skin barriers are available in either a pre-cut or cut-to fit product. Pre-cut barriers are for round stomas. The opening of the barrier should just fit the size of the stoma to minimize the chance that stool or urine will come into contact with the peristomal skin. Cut-to-fit barriers can be used for stomas that are oval or irregular in shape. Cut-to-fit barriers usually are recommended in the early postoperative period because the stoma will decrease in size for at least 6-8 weeks after the surgery. If the skin barrier opening is too large, peristomal skin problems may occur from stool or urine exposure (Colwell, 2004).
The wear time of the skin barrier also is important. Skin barriers are classified as standard or extended wear. The difference lies in how the two types interact with moisture and how high they adhere to the skin. Both barriers absorb moisture, but the extended-wear product has a slower moisture absorption, which delays the erosion or “melt down” of the skin barrier (Colwell, 2003).
Skin barriers are designed to be flat or convex. The back of a flat skin barrier is level, while the back of a convex wafer has an outward protrusion. Skin barriers are manufactured with built-in convexity, or convexity can be created by inserting a ring into the skin barrier. The purpose of convexity is to place downward pressure to the peristomal skin area allowing the stoma to protrude outward (Colwell, 2003). The different depths of convexity are described as shallow, moderate, and deep. Convexity is generally used with stomas that are flat or retracted to help minimize stool or urine leakage under the pouch. In addition, convexity can be used for abdomens that are soft or when skin folds are present in the peristomal skin (Colwell, 2004).
Ostomy pouches. A variety of ostomy pouching systems are available. It is important to explain to the patient that the pouching system applied in the hospital after surgery may not be the system he or she will continue to use after recovering from surgery. Factors to consider during selection of an ostomy pouching system include the type of ostomy, type of effluent, size and shape of the stoma, and presence of abdominal contours and/or skin folds. The patient’s visual and manual dexterity are considered as well as daily activities and participation in recreational sports (Colwell, 2004).
Pouches that are sealed to the skin barrier are categorized as one-piece, and pouches that attach to a skin barrier are considered two-piece (Colwell, 2004). A two-piece pouch provides the patient the ability to remove and/or change the pouch without changing the skin barrier; it also is easier to center the skin barrier to the stoma. One mechanism for closing a two-piece pouch depends on the patient’s ability to snap the wafer and pouch together. When applying the pouch to the wafer, the patient is instructed to listen for an audible click to ensure the pouch is secure to the skin barrier. Another two-piece pouch has a built-in locking mechanism. When the pouch and wafer are snapped together, the locking mechanism secures the two in place. A floating flange is another type of two-piece pouching system that allows the patient to pinch the wafer and pouch together to create a seal.
A one-piece pouch may make it difficult for the patient to center the stoma, especially if using an opaque pouch. A one-piece pouch cannot be changed without removing the skin barrier. It has a lower profile under the patient’s clothing, however, and the possibility of the pouch separating from the skin barrier is unlikely (Colwell, 2004).
Other features of ostomy pouches include the choice between transparent and opaque. A transparent pouch may be preferred in the immediate postoperative period because it allows for easy stoma assessment and observation of the type and amount of stool or urine in the pouch. An opaque pouch may be the choice for the patient if the stool does not need to be assessed, perhaps after recovery from surgery and resumption of normal daily activities. Pouches are available in a variety of lengths (6, 8, 9, 10, 12, and 16 inches). Choosing the length of a pouch may depend on the amount of stool or urine output, as well as where the pouch rests on the body when the patient is dressed (Colwell, 2004).
Pouches to contain stool are categorized as drainable or closed-ended. A drainable pouch is securely closed with either a clip or Velcro[R] closure. When the pouch is emptied, the clip or Velcro is opened and the stool is emptied from the bottom of the pouch. The tip of the pouch is cleaned of any stool residue and the pouch is resealed. A closed-end pouch does not require the use of a closure device. A closed-end pouch can be discarded when removed from the skin barrier. Closed-end pouches are recommended if stool output is formed and if the pouch is emptied less frequently during the day. Both drainable and closed-end pouches are available with gas filters (Colwell, 2004).
Urinary stoma pouches have a drain valve at the bottom of the pouch to facilitate emptying. During the day, the pouch is emptied when it is about one-third to one-half full. At night, the urinary pouch is connected to a drainage system to allow urine to drain into a larger collection bottle, reducing the number of times a patient has to get up to empty the pouch (Colwell, 2004).
Ostomy accessories. Several ostomy accessories can be used in conjunction with the ostomy pouching system to improve the wear time (see Table 1).
Teaching the patient how to care for a new ostomy can be a challenging experience for the nurse. The patient with an ostomy needs encouragement, support, and counseling to learn how to integrate self-ostomy care into daily activities. Collaboratively, the WOCN and medical-surgical nurse can provide the patient and his or her family with a more comprehensive approach to ostomy teaching.
Beitz, J. (2004). Gastrointestinal etiologies leading to a fecal diversion. In J. Colwell, M. Goldberg, & J. Carmel (Eds.), Fecal & urinary diversions: Management principles (2nd ed.) (pp. 136-159). St. Louis: Mosby.
Carmel, J., & Goldberg, M. (2004), Preoperative and postoperative management. In J. Colwell, M. Goldberg, & J. Carmel (Eds.), Fecal & urinary diversions: Management principles (2nd ed.) (pp. 207-239). St. Louis: Mosby.
Colwell, J. (2004). Principle of stoma management. In J. Colwell, M. Goldberg, & J. Carmel (Eds.), Fecal & urinary diversions: Management principles (2nd ed.) (pp. 381-391). St. Louis: Mosby.
Colwell, J. (2003). Ostomy surgical procedures. In C. Milne, L. Corbett, & D. Dubuc (Eds.), Wound ostomy and continence nursing secrets (pp. 291-295). Philadelphia: Hanley and Belfus, Inc.
Colwell, J., Goldberg, M.,& Carmel, J. (2001). The state of the standard diversion. The Journal of Wound Ostomy and Continence, 28(1), 6-19.
Erwin-Toth, P., & Doughty, D. (2002). Principles and procedures of stomal management. In B. Hampton & R. Bryant (Eds.), Ostomies and continent diversions: Nursing management (pp. 296-298). St. Louis: Mosby.
McCann, E. (2002). Routine assessment of the patient with an ostomy. In C. Milne, L. Corbett, & D. Dubuc (Eds.), Wound ostomy and continence nursing secrets (pp. 299-305). Philadelphia: Hanley and Belfus, Inc.
O’Shea, H. (2001). Teaching the adult ostomy patient. Journal of Wound Ostomy Continence, 28(1), 47-54.
Tomaselli, N., & McGinnis, D. (2004). Urinary diversions: Surgical interventions. In J. Colwell, M. Goldberg, & J. Carmel (Eds.), Fecal & urinary diversions: Management principles (2nd ed.) (pp. 184-204). St. Louis: Mosby.
Vasilevsky , C., & Gordon, P. (2004). Gastrointestinal cancers: Surgical management. In J. Colwell, M. Goldberg, & J. Carmel (Eds.), Fecal & urinary diversions: Management principles (2nd ed.) (pp. 126-135). St. Louis: Mosby.
Vittoria Pontieri-Lewis, MS, RN, CWOCN, is a Clinical Nurse Specialist, Wound Ostomy Continence, Robert Wood Johnson, New Brunswick, NJ.
Table 1. Ostomy Accessories
Protective Barriers Mode of Action
Paste Fills in uneven skin folds or contours around
the peristomal skin. Helps prevent urine/stool
leakage, assists with increasing skin barrier
Sealants Improve pouch adherence and protect the
periwound skin from effluent.
Powders Absorb moisture from superficial denuded skin
before applying skin sealants or pouch.
Rings Fill in uneven skin folds or contours around
the peristomal skin. Adhesive on both sides.
Can enhance convexity and add wear time to skin
Source: Colwell, 2003
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