Intro_to_Ostomy_Care_10-2024-1

Introduction

  • Ostomy care introduction by Christina Manning, MSN, RN, CWS, COCN, CHRN.

Objectives

  • Understand basic ostomy pathophysiology.

  • Know the difference between normal and abnormal stoma presentations.

  • Learn how to change a basic ostomy pouch.

  • Understand the roles of the WOC Nurse versus the Staff Nurse in ostomy care.

  • Identify when to consult a WOC nurse.

  • Demonstrate pouch change through competency skills check-off.

What is an Ostomy?

  • A surgically created opening in the abdomen for waste discharge (stool, urine, or mucous).

  • A stoma is the end or loop of the bowel brought to the surface for waste expulsion.

  • Size and location of the stoma depend on surgery type and abdominal shape.

  • Types:

    • End Stoma

    • Loop Stoma

Reasons for Ostomy Creation

Fecal Diversions

  • Indications include:

    • Ischemic bowel

    • Crohn's disease

    • Trauma

    • NEC (Necrotizing enterocolitis)

    • Ulcerative colitis

    • Familial adenomatous polyposis

    • Cancer

    • Diverticulitis

    • Perforated bowel

    • Congenital diseases

Urinary Diversions

  • Indications include:

    • Cancer

    • Congenital abnormalities

    • Neurogenic bladder

    • Refractory interstitial cystitis

    • Incontinence/neobladder

    • Radiation/trauma damage

    • Conditions like pelvic exenteration, mega-ureter, bladder exstrophy, spina bifida/myelomeningeocele, prune belly syndrome.

Types of Ostomies

Colostomy

  • Derived from the large intestine.

  • Expels soft to formed stool.

  • Pouch emptied 1-2x/day or as per pre-surgery bowel routine.

  • Requires pouch changes 1-2x/week; a rod may be used initially if loop fashion.

Ileostomy

  • Created from the small intestine.

  • Expels stool of mustard/applesauce consistency.

  • Pouch emptied 6-8x/day; changes 2-3x/week.

  • Higher digestive enzymes increase skin breakdown risk. Encourages fluid intake and has dietary restrictions (no skins, fibrous foods, seeds, nuts).

Urostomy

  • Formed using a piece of small intestine connected to ureters.

  • Expels urine, may initially have stents for ureter patency.

  • Mucous shreds present in pouch/stents; pouch emptied 6-8x/day and changed 2-3x/week with encouragement for fluid intake. Connect to a bedside drainage bag for night use.

Stomas - Normal Characteristics

  • Red/pink, raised from skin level (budded), generally 1" or less above skin.

  • Round or oval; size varies with no nerve endings (thus no feeling).

  • Vascular, can bleed if cleansed too roughly; may appear swollen post-surgery but stabilizes in 6-8 weeks.

  • Peristomal skin must be clean, dry, and intact.

Peristomal Abnormalities

  • Common Conditions:

    • Irritant dermatitis (Peristomal MASD)

    • Candidiasis

    • Peristomal skin tear

    • Peristomal varices

    • Folliculitis

    • Pyoderma gangrenosum

Stomal Abnormalities

  • Conditions include:

    • Leukoplakia

    • Stomal necrosis

    • Prolapse

    • Stoma retraction

    • Stenosis

    • Hernia

Consultation with WOC Nurse

  • At Novant, consult WOC for:

    • Any stomal abnormalities

    • New ostomies

Crusting Technique

  • To heal broken skin around stoma, using:

    • Stomahesive powder

    • Barrier film wipes (Cavilon)

    • Multiple layers may be required for severe breakdown.

Pouches

  • Available as 1-piece or 2-piece systems based on patient preference and stoma type.

  • Pouches can be flat or convex; use an ostomy belt for extra support.

  • Pouch should be emptied when 1/3-1/2 full; change frequency depends on ostomy type and activity level.

Other Ostomy Items

  • Stomahesive Powder: For crusting.

  • Barrier Rings: Provides convexity to fill creases/divots.

  • Barrier Paste: Fills in irregular skin areas.

  • Barrier Film Wipes: Protects skin, adds tackiness.

  • Ostomy Belt: For additional securement.

  • Urostomy Pouch Connector: Connects urostomy bag to bedside drainage.

Special Considerations

  • Loop Ostomy: Rod to hold bowel above skin must be included in the pouch.

  • Urostomy: Stents need to be integrated within the pouch.

  • Skin Flaws: Use paste or barrier rings to level irregularities.

Pouch Change Procedure

Required Supplies

  • New pouch, cloth/towel, scissors, barrier ring, barrier film wipes (if crusting), stomahesive powder (if necessary), measuring guide, marker.

Steps

  1. Remove the old pouch gently to avoid spillage.

  2. Cleanse stoma and peristomal skin with water only; dry thoroughly.

  3. Assess appearance for abnormalities.

  4. Use measuring guide to determine fitting size.

  5. Mark the size on the pouch and cut carefully; ensure it fits before applying.

  6. Apply barrier ring, center pouch over stoma, and ensure a secure seal.

  7. Document changes and observations in the patient's records.

Documentation Procedures

  • Detailed documentation in Epic flowsheets regarding pouch changes, stoma assessment, and any observations.

Role of the WOC Nurse

  • Assist with pre-operative marking, education, and evaluation of abnormal stomas.

  • Provide resources and support for ostomy care.

Role of the Staff Nurse

  • Encourage patient independence in pouch changes and address diet fluid intake.

  • Monitor for any issues with pouching and engage in support to facilitate independence.

When to Consult WOC

  • For all new ostomies, abnormal stoma appearance, issues with pouching frequency (more than 3x/week), or related skin breakdowns.

Skills Check-Off

  • Assess competency in ostomy care through practical demonstrations using kit items.

References

  • (2019) Ostomy home skills kit. American College of Surgeons.

  • (2020) OST581: Fecal and urinary diversions chart, Web WOC Nursing Education Program.

  • Carmel, J.E., Colwell, J.C., & Goldberg, M.T. (2016). Wound, ostomy, continence nurses society: Core curriculum ostomy management. Philadelphia: Wolters Kluwer.