COLOSTOMY CARE

COLOSTOMY CARE
By Rommel Luis C. Israel III

LEARNING OBJECTIVE
At the end of the lecture, the students will be able to:
• Identify the indications for colostomy and the different types of colostomies.
• Explain the importance of colostomy care and the steps in colostomy care.
• Summarize the risks associated with a colostomy.
• Explain the importance of improving care coordination among the interprofessional
team to enhance the delivery of care for patients with a colostomy.

THE TAKE AWAY
• Together your small and large intestines are about 15 feet or more in length.
• According to a 2014 study Trusted Source, the total surface area of your intestines is
about half the size of a badminton court.
• Your intestines have the very important job of helping to break down and absorb
nutrients from what you eat and drink. Once these nutrients are absorbed, they can
be delivered via the bloodstream to the rest of your body.
Source:
Seladi-Schulman, J 2019, How Long Are Your Intestines? Length of Small and Large Intestines, Healthline, viewed 24 February 2022,
https://www.healthline.com/health/digestive-health/how-long-are-your-intestines#large-intestines-length .

HOW THE DIGESTIVE SYSTEM WORKS
Source:
Bryce, E 2017, How your digestive system works - Emma Bryce, YouTube, viewed 24 February 2022,
https://www.youtube.com/watch?v=Og5xAdC8EUI .
Click the picture to
watch the video
Copy-paste
the link
below to
watch the
video online

ANATOMY
OF THE
SMALL AND
LARGE
INTESTINES
Source:
Organs of the Body. Image of the Small and Large Intestines, www.organsofthebody.com/small-intestine/ . Accessed 22 Feb. 2022.

3 MAJOR PARTS OF SMALL INTESTINES
1. DUODENUM
• the first and shortest segment of the small bowel
• connects the stomach to the jejunum.
• this C-shaped hollow tube measures around a foot or sometimes 15 inches in length.
• it receives food from the stomach in the form of chyme and mixes it with bile juice
and the pancreatic secretions.
Source:
“Small Intestine Function, Location, Parts, Diseases & Facts.” Organsofthebody.com, 2011, www.organsofthebody.com/small-intestine/ .

1. DUODENUM
• It neutralizes the partially digested food
with the help of alkaline mucus containing
a high concentration of bicarbonate ions.
• The mucus is secreted by the Brunner’s
glands present only in the duodenum.
Source:
Image:
Cabrera, Carlos León. Brunner’s Gland, 29 Aug. 2017, twitter.com/ilovepathology1/status/902278556725731336. Accessed 22 Feb. 2022.

1. DUODENUM
• The enzymatic secretions help in the digestion of
carbohydrates, proteins and fats.
- the process of chemical digestion that started
in mouth gets completed here.
• It also prepares food for absorption in jejunum.
Source:
Image:
Christiansen, Sherry. Duodenum, 19 Mar. 2020, www.verywellhealth.com/duodenum-anatomy-4780308 . Accessed 22 Feb. 2022.

2. JEJUNUM
• It is the second or middle part of the small intestine.
• It is longer than duodenum and shorter than ileum.
• Measuring around 8 feet, the duodenum is as many as 8 times longer than the
duodenum.
• While duodenum carries out and completes the chemical digestion, jejunum is the
principle site for the absorption of nutrients from the digested food. This is the place
where over 90% absorption of the foodstuffs takes place.
Source:

2. JEJUNUM
• Nutrients move across the epithelium of
jejunum and ileum.
• It absorbs nutrients (vitamins, minerals,
carbohydrates, fats, proteins) and water
from food so they can be used by the body.
Source:
Image:
Cleveland Clinic. 20 Mar. 2019, my.clevelandclinic.org/health/diseases/15850-small-bowel-obstruction. Accessed 22 Feb. 2022.

3. ILEUM
• It is the third and longest segment of small bowel.
• It runs for the length of 12 feet, accounting for
three-fifths the length of the small bowel.
• Continuous with the jejunum, it ends at the ileocecal
valve ( a sphincter muscle) which separates it from
the cecum.
Source:
Image:
Cleveland Clinic. 20 Mar. 2019, my.clevelandclinic.org/health/diseases/15850-small-bowel-obstruction. Accessed 22 Feb. 2022.
Silva, Alvin, et al. Drawings Illustrate the Anatomic Structures of the Terminal Ileum, ICV, Cecum, and Appendix. M. = Muscle., 1 July 2007,
pubs.rsna.org/doi/full/10.1148/rg.274065164. Accessed 22 Feb. 2022.

3. ILEUM
• It contains receptors for absorption of vitamin B12 and bile salts.
• It reabsorbs about 95% of the conjugated bile salts (that act as detergents, emulsifying
large fat droplets into small ones) and reused by the liver by the process of enterohepatic
circulation.
- Fat emulsification is the process of increasing the surface area of fats in the
small intestine by grouping them into small clusters. This is the responsibility
of bile, a liquid created by the liver and stored in the gallbladder. Actual digestion
of the fats is then accomplished by lipase, an enzyme from the pancreas.
Source:
Kester, J. E. “Liver.” ScienceDirect, Academic Press, 1 Jan. 2014, www.sciencedirect.com/science/article/pii/B9780123864543006291 . Accessed 22 Feb.
2022.

3. ILEUM
• It has bundles or patches (around 30 to 40)
of lymphatic cells called Peyer’s patches.
- Peyer’s patches have B and T cells similar
to those found in the peripheral lymph
nodes. So, they are said to play a role in
the generation of immunologic response
in the body.
Source:

LARGE INTESTINES
Source:
Phillips, Michael, et al. “Large Intestine (Colon): MedlinePlus Medical Encyclopedia Image.” Medlineplus.gov, 23 Apr. 2021,
medlineplus.gov/ency/imagepages/19220.htm. Accessed 22 Feb. 2022.
Image:
Phillips, Michael, et al. Large Intestine, 23 Apr. 2021, medlineplus.gov/ency/imagepages/19220.htm. Accessed 22 Feb. 2022.
• It is most responsible for the absorption of
water from the indigestible residue of food.
• The ileocecal valve of the ileum (small
intestine) passes material into the large
intestine at the cecum.
• Material passes through the ascending,
transverse, descending and sigmoid
portions of the colon, and finally into the
rectum.
• From the rectum, the waste is expelled
from the body.

LARGE INTESTINE
• It is about 5 feet long
• Most of the bacteria that live in your body—and there are billions of them—live
inside your large intestine.
• The good bacteria that live in your colon are called your normal flora. They help
prevent bad bacteria from multiplying and causing problems.
• Bacteria also help break down fiber. This is an important part of your diet that
contributes to digestive health by preventing constipation.
• Normal bacterial flora also secrete vitamin K and vitamin B that you can absorb.
• The gas that you produce is the result of the hard-working normal flora in your
colon.
Source:
“The Digestive Process: The Large Intestine | University Hospitals.” Www.uhhospitals.org, 2021, www.uhhospitals.org/health-information/health-
and-wellness-library/article/adult-diseases-and-conditions-v1/the-digestive-process-the-large-intestine . Accessed 22 Feb. 2022.

8 PARTS OF THE LARGE INTESTINE
1. Cecum
- Digested food from the small intestine goes into
this pouch. The appendix hangs off the end of
the cecum.
2. Ascending colon
- This segment extends along the right side of
the abdomen. It's about 9 inches long.
3. Hepatic flexure
- In the upper right part of the abdomen, under
the liver, this part of the large intestine makes a
turn to the left.
Source:
Image:
Kilgore, Lon. The Gastrointestinal System: The Large Intestine, 7 May 2021, www.crossfit.com/essentials/the-gastrointestinal-system-the-large-
intestine . Accessed 22 Feb. 2022.

4. Transverse colon
- It travels across the upper part of the
abdomen, from right to left.
5. Splenic flexure
- In the left upper side of the abdomen,
the large intestine is located under
the spleen. At this flexure, the large
intestine turns downward.
Source:
Image:

6. Descending colon
- In the left side of the abdomen, the
large intestine descends for about 5
inches.
7. Recto-sigmoid colon
- This part is about 5 inches long and leads
into the rectum.
Source:
Image:

8. Rectum
- This part of the large intestine stores
stool.
- It's about 6 to 8 inches long and leads
to the anal canal.
Source:
Image:

WHAT IS AN OSTOMY?
• Causes a change in the way urine or stool exits the body as a result of a surgical
procedure.
• Bodily waste is rerouted from its usual path because of
malfunctioning parts of the urinary or digestive system.
• An ostomy can be temporary or permanent.
Source:
“What Is an Ostomy? L United Ostomy Associations of America.” United Ostomy Associations of America, 2017, www.ostomy.org/what-is-
an-ostomy/ . Accessed 22 Feb. 2022.
Image:
What Is Ostomy? www.ostomy.org/what-is-an-ostomy/ . Accessed 22 Feb. 2022.

WHAT IS A STOMA?
• It is the opening created by ostomy surgery.
• It is located on the abdomen.
• It is dark pink in color.
• For most ostomies, a pouch is worn over
the stoma to collect stool or urine.
Source:
“What Is an Ostomy? L United Ostomy Associations of America.” United Ostomy Associations of America, 2017, www.ostomy.org/what-is-
an-ostomy/ . Accessed 22 Feb. 2022.
Image:
What Is Ostomy? www.ostomy.org/what-is-an-ostomy/ . Accessed 22 Feb. 2022.

OSTOMY SURGERY OF THE BOWEL
• It is an operation that changes the way intestinal
contents leave the body when part or all of the
bowel is diseased, injured, or missing.
• The surgeons connect the large or small intestine
to the skin on the outside of your abdomen.
Source:
“Ostomy Surgery of the Bowel | NIDDK.” National Institute of Diabetes and Digestive and Kidney Diseases, 10 May 2019,
www.niddk.nih.gov/health-information/digestive-diseases/ostomy-surgery-bowel . Accessed 22 Feb. 2022.
Image:
Healy, Marisa. Living with a Bowel Ostomy, 22 Oct. 2021, www.oncolink.org/cancers/gastrointestinal/colon-cancer/treatments/living-with-
a-bowel-ostomy . Accessed 22 Feb. 2022.

OSTOMY SURGERY OF THE BOWEL
• When the connection is to the colon,
it is called a colostomy.
• When the connection is to the small bowel,
it is called an ileostomy or a jejunostomy.
Source:
Healy, Marisa. “Living with a Bowel Ostomy | OncoLink.” Www.oncolink.org, 22 Oct. 2021,
www.oncolink.org/cancers/gastrointestinal/colon-cancer/treatments/living-with-a-bowel-ostomy. Accessed 22 Feb. 2022.
Image:
Healy, Marisa. Living with a Bowel Ostomy, 22 Oct. 2021, www.oncolink.org/cancers/gastrointestinal/colon-cancer/treatments/living-with-
a-bowel-ostomy . Accessed 22 Feb. 2022.

WHAT IS A COLOSTOMY?
• It is a surgical procedure that brings one end of the
large intestine out through the abdominal wall.
• During this procedure, one end of the colon is
diverted through an incision in the abdominal wall
to create a stoma.
Source:
Krans, B 2012, Colostomy, Healthline, Healthline Media, viewed 24 February 2022, https://www.healthline.com/health/colostomy .

PURPOSE: TEMPORARY
• Colostomies are performed because of problems with
the lower bowel. Some problems can be corrected by
temporarily diverting stool away from the bowel-to
keep stool out of the colon.
Source:

PURPOSE: PERMANENT
• Birth defect, such as a blocked or missing anal opening, called an
imperforate anus
• an injury
• Crohn’s disease, which is an autoimmune form of inflammatory bowel
disease
• colorectal cancer
• colonic polyps, which is extra tissue growing inside the colon that may
be cancer or may turn into cancer
Source:
Colostomy n.d., www.hopkinsmedicine.org .

PURPOSE: PERMANENT
• diverticulitis, which occurs when small pouches in your digestive
system, called diverticula, become infected or inflamed
• imperforate anus or other birth defects
• irritable bowel syndrome, which is a condition affecting the colon
that causes diarrhea, bloating, constipation, and pain in the
abdominal area
• ulcerative colitis, which is an inflammatory bowel disease that
causes the long-term inflammation of the digestive tract
Source:

NURSING DIAGNOSIS
• Risk for Impaired Skin Integrity
• Disturbed Body Image
• Acute Pain
• Impaired Skin Integrity
• Deficient Fluid Volume
• Risk for Imbalanced Nutrition: Less
Than Body Requirements
• Risk for Sexual Dysfunction
• Disturbed Sleep Pattern
• Risk for Constipation or Diarrhea
• Deficient Knowledge
Source:
Vera, M 2012, 10 Ileostomy and Colostomy Nursing Care Plans, Nurseslabs, viewed 24 February 2022, https://nurseslabs.com/10-
ileostomy-colostomy-nursing-care-plans/?fbclid=IwAR0XWMqiJb5BKvJgAadv9cKOBnh8pJPEwEZqTkP5B0u6sZLAaXsRO7mNbBA

PLANNING
PHYSIOLOGIC
• Patient will achieve optimal bowel
function without complications
• . Patient's wound will heal with no sign
of infection
PSYCHOLOGIC
• Patient will demonstrate a level of
acceptance of modified lifestyle.
COGNITIVE
• Patient/primary care person will
demonstrate Independence with ostomy
care

RISK OF A COLOSTOMY
• Allergic Reaction to anaesthesia
• Excessive bleeding
• a blockage of the colostomy
• damage to other organs
• a hernia, which occurs when an internal organ pushes
through a weak area of muscle
Source:

RISK OF A COLOSTOMY
• an infection
• internal bleeding
• problems from scar tissue
• a prolapse of the colostomy
• a wound breaking open
Source:

4 TYPES OF COLOSTOMY
1. TRANSVERSE COLOSTOMY
- it is located in the upper abdominal region,
on the right side or the middle of the body
- are usually performed on a temporary basis,
but they may also be permanent:
• Loop colostomy - results in two stomas, one that releases
waste from the colon and another, called a mucus fistula,
that releases mucus from the part of the colon that is
still active.
Source:
Poruk, K 2021, Colostomy, Cancer Treatment Centers of America, COH HoldCo Inc, viewed 24 February 2022, https://www.cancercenter.com/cancer-types/colorectal-
cancer/treatments/surgery/colostomy .
Image:
The StayWell Company, LLC 2020, What Is a Colostomy?, viewed 24 February 2022, https://www.fairview.org/patient-education/82952 .

1. TRANSVERSE COLOSTOMY
Single-barrel colostomy – it is permanent, may involve
the removal of the colon below the surgical site, as well
as the rectum and anus.
• Double-barrel colostomy - the bowel is usually divided into two parts,
each with a separate opening. Similar to the loop colostomy, one releases
waste and the other releases mucus. However, in some cases, only one
stoma is created, and mucus leaves the body through the anus.
Source:
Image:
Image:
The StayWell Company, LLC 2020, What Is a Colostomy?, viewed 24 February 2022, https://www.fairview.org/patient-education/82952 .

2. DESCENDING COLOSTOMY
- Located on the lower left side of your abdomen (or descending colon)
- this stoma placement results in waste close to normal in firmness.
- may be either single-barrel or double-barrel, but single-barrel is more
common.
Source:
Poruk, K 2021, Colostomy, Cancer Treatment Centers of America, COH HoldCo Inc,
viewed 24 February 2022, https://www.cancercenter.com/cancer-types/colorectal-
Image:
Lualdi, SM 2021, Colostomy Diet: What Can I Eat Without Consequences, viewed 24 February 2022,
https://farmoderm.it/en/colostomy-diet-guidelines/ .

3. ASCENDING COLOSTOMY
- Located on the right side of the abdomen
- this type of colostomy is rare.
- most of the colon will likely be removed,
so waste is liquid with this stoma.
Source:
Image:
Lualdi, SM 2021, Colostomy Diet: What Can I Eat Without Consequences, viewed 24 February 2022, https://farmoderm.it/en/colostomy-diet-guidelines/ .

4. SIGMOID COLOCTOMY
- Located at the bottom of the large intestine
- are the most common
- because of its location near the rectum, there is still some functioning colon,
so the waste produced is firmer and more normal in consistency than with
other colostomy types.
- as with a descending colostomy, single-barrel is more common, though a
double-barrel procedure is also a possibility.
- a loop-sigmoid colostomy is also a possibility.
Source:
Image:
Lualdi, SM 2021, Colostomy Diet: What Can I Eat Without Consequences, viewed 24 February 2022, https://farmoderm.it/en/colostomy-diet-guidelines/ .

COLOSTOMY BAG/POUCH
Image:
United Ostomy Associations of America n.d., COLOSTOMY AND ILEOSTOMY POUCHES, viewed 24 February 2022, https://www.ostomy.org/types-pouching-
systems/ .

TYPES OF A COLOSTOMY POUCH (BAGS OR
APPLIANCES)
• The 2-piece system
- consists of a base-plate attached to the skin with a
removable ostomy bag.
- although it is very durable and long-lasting, it requires
an amount of skill to use and has a weaker adhesive
and does not fit very well.
On the left is a drainable pouch and on the right is a closed-end one.
Pictured clockwise is a Convatec Sur-fit Natura drainable pouch with
an Invisiclose tail, a closed-end pouch, and a Durahesive cut-to-fit wafer.
Source:
Maria, A & Lieske, B 2021, Colostomy Care, PubMed, StatPearls Publishing, Treasure Island (FL), viewed 24 February 2022,
https://www.ncbi.nlm.nih.gov/books/NBK560503/ .
Image:
ostomyoutdoors 2013, How to select ostomy pouch styles for the outdoors, viewed 24 February 2022, https://ostomyoutdoors.com/tag/two-piece-ostomy-pouch/ .

APPLIANCES)
• The one-piece system
- consists of a single unit wherein the skin
barrier and the pouch are joined.
- it is simpler to use but must be replaced
every 1 to 3 days.
• In a one-piece ostomy system, the wafer is permanently
attached to the pouch. Because of this, swapping out
different pouch styles on the same wafer is impossible.
Pictured is a Coloplast SenSura X-Pro drainable one-piece
appliance (open ended).
Source:
Image:

APPLIANCES)
• The closed pouch system
- is generally used by patients who have a
constant elimination pattern and
have to be discarded after a single-use
On the left is a drainable pouch and on the right is a
closed-end one.
Pictured clockwise is a Convatec Sur-fit Natura drainable
pouch with an Invisiclose tail, a closed-end pouch, and a
Durahesive cut-to-fit wafer.
Source:
Image:

APPLIANCES)
• The open-ended pouches
- are also commonly used and consist of a single piece attached to the skin
around the stoma with a drainable pouch and can be left attached to the
skin
while removing stomal content.
*Generally in a colostomy, as compared to an ileostomy, a
closed bag must be required, unless the content is excessively
fluid, when a drainable bag may also be used.
Source:

SIZES OF A COLOSTOMY POUCH (BAGS OR
APPLIANCES)
• Larger sized bag
- may be used while sleeping at night
• Smaller sized bag
- may be used during sexual activity or while
exercising
• Pediatric sized stoma bags are also available.
Source:
Image:
https://www.dreamstime.com/close-up-top-view-transparent-colostomy-pouch-attached-to-baby-patient-ostomy-bag-filter-medical-theme-close-up-top-view-
image140073408

STOMA CAPS
• They are like lids applied over the stoma.
• They may be worn by certain people like those with continent ileostomies or those
who require stomal irrigation for movement at their discretion, for short intervals
during the day.
• They are the smallest of all the stoma pouches, hence it is classified as a cap rather
than a bag. Stoma caps are a tiny, closed pouch, which have capacity to hold a very
small amount of stool so they can only be worn for a very short period of time.
Source:
Mini Pouches & Stoma Caps - what are they and what are they used for? 2021, Oakmed Healthcare, viewed 24 February 2022, https://www.oakmed.co.uk/help-
advice/advice-articles/mini-pouches-stoma-caps-what-are-they-and-what-are-they-used-for/ .

WHO ARE SUITABLE FOR STOMA CAPS?
• Often ostomates who are quite petite in stature, find the mini pouches fit the
contours of their bodies better than the standard or larger pouches, which can be too
long and can crease into the groin area, causing discomfort.
• Stoma caps are most suited to people who have an end colostomy or those people
with a relatively inactive mucus fistula.
• But this is not to say if you have an ileostomy or urostomy you cannot use them, this
is completely personal choice. If you are interesting it trialling one, try wearing it at
home first, so any accidents can be dealt with swiftly!
Source:

WHO ARE SUITABLE FOR STOMA CAPS?
• Stoma caps are most suited to people who have an end colostomy or those people
with a relatively inactive mucus fistula.
• But this is not to say if you have an ileostomy or urostomy you cannot use them, this
is completely personal choice. If you are interesting it trialling one, try wearing it at
home first, so any accidents can be dealt with swiftly!
Source:

WHAT ARE THE BENEFITS OF USING A MINI
POUCH OR CAP?
The main benefits are for discretion.
• Swimming: a smaller pouch/cap is easily concealed beneath trunks or a swimming costume.
• Intimate moments: The stoma cap is still visible but can be less obtrusive.
• Exercising: Moving around during high impact sports can be easier whilst wearing a stoma cap or
small pouch. Stoma caps can also be combined with a stoma protector to provide a barrier and
prevent injury whilst playing contact sports.
• Colostomy irrigation: A stoma cap should only be worn full time if colostomy irrigation is successful
and well established. Irrigation allows the bowels to be flushed and emptied via a strict irrigation
regime set by the Stoma Care Nurse. This can have the advantage of enabling the person to control
when their colon is emptying, meaning there is little or no need to wear a full-sized pouch.
Source:

STOMA CAPS
Source:
All About Stoma Caps! 2022, VeganOstomy, viewed 24 February 2022, https://www.veganostomy.ca/stoma-caps/ .
A stoma cap (left)
compared to a
traditional “large”
ostomy bag (right).

STOMA CARE
• BEFORE THE ACTUAL SURGERY
- It begins when the patient is diagnosed and informed about the possibility of
stoma creation.
- It requires mental health and guidance counselors to address any concerns
the patient may have about their self-image and societal status.
- It also requires an entero-stomal therapist to discuss with the surgeon the
location of the possible creation of the stoma and to go on and mark the
colostomy site in the preoperative period.
Source:

STOMA CARE
• PREPARATION FOR SURGERY
- Marking of the stoma preoperatively by an entero-stomal therapist helps to
place the stoma in an appropriate location away from the beltline and away
from folds of skin on the anterior abdominal wall to prevent repeated
colostomy bag peel-off and leak.
- A nasogastric tube may be placed in the pre or intraoperative period for
bowel decompression
- a Foley catheter must also be placed to keep the bladder empty to prevent
intraoperative injury and also to monitor urine output, especially during
emergency procedures.
Source:

STOMA CARE
• PREPARATION FOR SURGERY
- Antibiotics must be given just prior to the surgery.
- For colostomy care preparation, a nurse or attendant is equipped with all the
required equipment, including the appliance, the paste, and the scissors. A
Macintosh sheet is placed under the patient, and gloves are worn.
Source:

STOMA CARE
• POST-OPERATIVE
- the colostomy may need dilatation and application of hyperosmotic agents like
glycerine by the nursing staff so as to reduce stomal edema.
- When the stoma becomes functional, generally between postoperative days 2 and
4, the colostomy will need a colostomy bag or appliance application. In the initial days, it is
either
done by the nursing staff or in larger hospitals, by an entero-stomal therapist.
> This is done with a view to teaching patients or in case of children, their
guardians, how to do it themselves at home.
> They are informed about the various devices available, about the functioning of these
devices, about their own colostomy and the kind of effluent that would be
seen, about
the complications of the stoma and the colostomy bags.
Source:

STOMA CARE
• POST-OPERATIVE
- the most important person involved in colostomy care is the patient himself.
- once the patient is discharged from the hospital, they are in charge of their
own colostomy care.
- the patient must regularly change their colostomy bag as required and
should
visit the provider regularly to assess the stoma in the normal run, or in case
of
any complications.
- as a rule, the stoma bag should be emptied when it is filled up to 1/3rd to
prevent peeling off of the baseplate from the skin and leaks
Source:

TECHNIQUE
• The colostomy appliance should be changed every 5-7 days, depending on the
appliance.
- Patients generally do this themselves or with the help of the primary
caregiver, or parent in case of children.
- Any case of skin breakdown or skin irritation or difference in stomal
appearance should be seen by a health worker.
Source:

TECHNIQUE
Materials needed:
• A new pouch (a 1-piece system, or 2-piece
system that has a wafer)
• A pouch clip
• Scissors
• A clean towel or paper towels
• Stoma powder
• Disposable pad (if necessary)
• Skin Barrier If necessary)
• Stoma paste or a ring seal
• Skin wipes
• A measuring card and a pen
• Plastic Bag
• Bed Pan
• Water or special solution to clean pouch
• Gauze Pad
• Disposable Gloves
• Deodorant for pouch (if necessary)
Source:
Phillips, M & Zieve, D 2020, Changing your ostomy pouch: MedlinePlus Medical Encyclopedia, medlineplus.gov, viewed 24 February 2022,
https://medlineplus.gov/ency/patientinstructions/000204.htm .

TECHNIQUE
• All supplies should be arranged
• handwashing
• donning of gloves
• The used stoma bag should be first emptied of all content, and then the flange
removed by gentle traction on the bag or flange towards the stoma with counter-
traction on the skin. An adhesive remover may also be used.
Source:

TECHNIQUE
• The stoma and parastomal area should be gently cleaned with water, dabbed rather
than scrubbed, without using soap.
• The stoma should be assessed and must be moist, above skin level, and pink to red
in color, and the peristomal skin should be normal. Any deviation from this should
be notified to the surgeon.
• The stoma should be measured, or the previous measurement remembered and size
should not be more than 1/16-1/8.
Source:

TECHNIQUE
• The peristomal skin should be dried appropriately to allow good seal formation.
Adhesive pastes or powders may also be applied peristomally.
• The paper cover on the back of the flange is then removed with the border tape in
place. It is then placed around the stoma and held in place for 1 to 2 minutes to
create an adequate seal.
Source:

TECHNIQUE
• If it is a 2-piece bag, the bag is then clipped on to the flange. A belt may be applied
around the abdomen and clipped to the sides of the flange to hold it in place.
• After this, safe disposal of the stoma bag.
• Handwashing
• Documentation of the procedure must be done.
Source:

TECHNIQUE
• Another integral aspect of colostomy care is mental health support through a
thorough assessment of the patients’ psychomotor status as to how they are coping
and dealing with the stoma.
• Poor body image perception, sexual dissatisfaction, and depression are common in
patients with colostomies.
• Reassurance, psychiatric, and behavioral counseling may be needed to alleviate
these symptoms.
Source:

STOMA CARE- CHANGING A COLOSTOMY BAG
(NURSING SKILLS)
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CHANGING YOUR TWO-PIECE POUCHING
SYSTEM
Image:
Types of Pouching Systems l United Ostomy Association Of America 2021, United Ostomy Associations of America, viewed 24 February 2022,
https://www.ostomy.org/types-pouching-systems/ .

CHANGING TWO PIECE STOMA BAG
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CHANGING ONE PIECE STOMA BAG
Image:
Pamela & Squire, S n.d., Changing A One Piece Stoma Bag, viewed 24 February 2022, https://www.clinimed.co.uk/stoma-care/stoma-bag-
changing/changing-a-one-piece-bag .

CHANGING ONE PIECE STOMA BAG
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HOW TO APPLY A ONE-PIECE DRAINABLE
POUCHING SYSTEM
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COMPLICATIONS
• Minor troublesome complaints of the patient include offensive smell, the repeated
requirement of draining the colostomy appliance, or repeated colostomy bag leakage.
• Offensive smells can be managed by stomal deodorants or deodorized colostomy bags
or avoidance of food like fish, eggs, or onions that release such odors.
• Repeated bag leakage can be prevented by preoperative stoma site marking and
reassurance and counseling in the postoperative period.
Source:

COMPLICATIONS
• Moderately severe complaints include pain and skin excoriation around the stomal
site, stomal diarrhea, or constipation or requirement for colostomy irrigation or
enemas.
- Cutting pouch appliances too large exposes the peristomal skin to
ileostomy output, which is rich in enzymes. The exposed stratum
corneum becomes or excoriated. Excoriated skin is defined as that
which has been traumatized, worn away, or abraded, often in the
presence of maceration due to incontinence.
Source:
Image:
Hollister Incorporated n.d., https://www.hollister.com/en/ostomycare/importanceofhealthyskin, viewed 24 February 2022,
https://www.hollister.com/en/ostomycare/importanceofhealthyskin .

COMPLICATIONS
• Pain and skin excoriation may be managed by application of creams around the
stomal site, with the application of the right size of the cut end on the back of the
baseplate to be not more than 1/16 to 1/8 larger than the diameter of the stoma to
prevent contact of fecal matter with the peri-stomal skin.
• Regular change of stomal appliances should be done, with the removal of the older
bag with gentle pressure on the skin towards the abdomen and not with the severe
force pulling the colostomy bag.
Source:

COMPLICATIONS
• Colostomy diarrhea may be complained by the patient in case of ascending or
transverse colostomies in case they are not fully explained about the nature of
content expected, but stomal diarrhea may be the result of extensive resection with
failure of bowel adaptation or if associated with short bowel syndrome.
• It may also be due to infectious causes like bacterial overgrowth or Clostridium
difficile enteritis or secretory tumors like VIPoma, carcinoid, gastrinoma or
radiation enteritis or due to medical disorders like hyperthyroidism or adrenal
insufficiency in which case the fluid and electrolyte balance of the patient should be
restored, with the possible use of anti-diarrhoeal agents and the underlying disorder
treated appropriately.
Source:

COMPLICATIONS
• In the case of stomal constipation:
- the stomal obstruction should be ruled out by checking for absent or greatly
increased bowel sounds,
- doing an X-ray abdomen in the anteroposterior view with the patient in the
erect posture to rule out proximal obstruction or ileus.
Source:

COMPLICATIONS
• Postoperative ileus may be present in the first few days after surgery
- the colostomy should be expected to be functional within 2 to 4 days after
surgery
- the period of ileus may be reduced by early patient mobilization and
following the ERAS (Enhanced Recovery After Surgery) protocol.
* Ileus - functional obstruction of the gastrointestinal tract and especially the small intestine that is marked by the absence of
peristalsis, is usually accompanied by abdominal pain, bloating, and sometimes nausea and vomiting, and typically
occurs following abdominal surgery.
Source:

COMPLICATIONS
• Inter bowel adhesions
- may be a cause of obstruction in the late postoperative period.
- Adhesions occur after abdominal surgery and can cause your tissues to stick
together, when normally they would just move around freely.
Source:
Maria, A & Lieske, B 2021, Colostomy Care, PubMed, StatPearls Publishing,
Treasure
Island (FL), viewed 24 February 2022,
Abdominal Adhesions: What Are They, Symptoms, Treatment 2020, Cleveland
Clinic, viewed 24 February 2022,
https://my.clevelandclinic.org/health/diseases/15254-abdominal-adhesions .
Image:
Bowel Adhesions - Clinical Features - Management 2020, TeachMeSurgery,
viewed 24 February 2022,
https://teachmesurgery.com/perioperative/gastrointestinal/bowel-adhesions/ .

COMPLICATIONS
• Severe colostomy related complications include stomal gangrene
- Stoma necrosis occurs when the blood flow to or from the stoma is
impaired or interrupted, resulting in a change in the stoma viability or tissue
death. Ischemia is most often noticed within 24 hours postoperatively.
Source:
Part 1: Assessment and Management of Stomal Complications: A Framework for Clinical Decision Making 2022, Hmpgloballearningnetwork.com, viewed 24 February
2022, https://www.hmpgloballearningnetwork.com/site/wmp/article/part-1-assessment-and-management-stomal-complications-framework-clinical-decision-making .
Image:
https://quizlet.com/270619321/ostomies-rectal-tubes-rectal-medications-and-enemas-flash-cards

COMPLICATIONS
• Colostomy gangrene may be due to the disease process, if due to ischemia, involving
the stoma or due to technical errors like tying the mesentery or making too narrow a
defect in the rectus fascia, causing obstruction of the blood supply to the stoma.
- This should be managed by re-exploration and new stoma creation after
resection of the diseased bowel.
Source:

COMPLICATIONS
• Stomal retraction
- is generally detected when the stoma bag is being changed and
refers to the condition when the stoma passes below the level of the skin.
- It may recede inside the peritoneum,
which leads to the discharge of fecal
content inside the abdomen leading
to peritonitis, which is an emergency.
Source:

COMPLICATIONS
• Stomal Retraction
- Depending on the degree of retraction, it may be managed locally by pull up
of the stoma and re-fixation to the surrounding skin or may require
laparotomy
and re-creation of the stoma
Source:

COMPLICATIONS
• Colostomy prolapse
- is commonly seen in transverse colostomies
- is generally managed conservatively, however laparotomy with stomal
revision may be required, especially in case of large prolapses with
irreducibility.
Source:
Maria, A & Lieske, B 2021, Colostomy Care,
PubMed, StatPearls Publishing, Treasure Island
(FL), viewed 24 February 2022,
Image:
https://quizlet.com/270619321/ostomies-rectal-
tubes-rectal-medications-and-enemas-flash-cards/

NURSING, ALLIED HEALTH, AND
INTERPROFESSIONAL TEAM INTERVENTIONS
• The nursing staff and enterostomal therapists
- help in deciding and marking the stoma site in the preoperative period.
- In the postoperative period, they teach patients how to manage and change
their colostomy appliances as well as how to look out for complications.
Source:

• Dieticians
- help patients in the postoperative period by preparing a diet chart
individualized for the patient, based on his weight and the amount of bowel
resected and the amount of functioning bowel. They also help to reduce and
manage postoperative ileus.
Source:

• Psychologists
- help manage the psychosocial aspect of colostomy creation and conduct
counseling sessions and send patients to colostomy support groups.
• Physical health therapists
- help in early patient ambulation in accordance with the ERAS protocol to
decrease postoperative ileus and decrease the chances of developing DVT
Source:

INTERPROFESSIONAL TEAM MONITORING
• Purpose:
- to assess for complications
- to plan for colostomy closure.
* It is generally done in hospitals by a team of allied health workers and the nursing
staff.
• In the hospital setup, in the early postoperative period, the nursing staff must check
for viability and full functioning of the stoma and also look for complications like
stoma gangrene. Also, general surgical complications like post-op DVT, atelectasis,
and UTI must be looked for.
Source:

• After discharge:
- The patients’ weight and body mass index (BMI) should be calculated at
regular intervals by a dietician and be advised appropriate dietary and fluid
management advice as well as vitamin and mineral supplementation to
compensate for the reduced bowel length and reduced absorption.
• The mental status of the patient should also be assessed at regular intervals, before
and after stoma creation, by a psychologist.
Source:

• After discharge:
- the patients must be followed every couple of weeks to look for complications like
stomal prolapse, retraction, and parastomal herniation. This is generally done by
the nursing staff and, in case of complications, must be communicated to the
treating surgeon for appropriate action.
• The patients’ weight and body mass index (BMI) should be calculated at regular
intervals by a dietician and be advised appropriate dietary and fluid management advice
as well as vitamin and mineral supplementation to compensate for the reduced bowel
length and reduced absorption.
• The mental status of the patient should also be assessed at regular intervals, before and
after stoma creation, by a psychologist.
Source:

HOW TO EMPTY COLOSTOMY POUCH
PURPOSE
• You need to empty a drainable pouch when it gets to
be about one-third full. This keeps the pouch from
bulging under your clothes.
• It also helps prevent leaking and odor.
Source:
Ostomy Care: Emptying Your Pouch 2019, www.fairview.org, Fairview Health Services, viewed 24 February 2022, https://www.fairview.org/Patient-
Education/Articles/English/o/s/t/o/m/Ostomy_Care_Emptying_Your_Pouch_82173#:~:text=You%20need%20to%20empty%20a .

EMPTY THE POUCH
• Sit on or next to the toilet. Or stand in front of the toilet. Put a layer of toilet paper in
the toilet bowl to keep stool from splashing.
• Pull your clothes away from the pouch.
• Hold the bottom of the pouch up. Open the Velcro closures or remove the clamp and set it
aside.
• Slowly unroll the tail, or spout, over the toilet.
• Bend over the toilet to help prevent splashing
• Slide your fingers down the pouch to push out all the stool.
Source:

CLEAN THE POUCH
• Wipe the inside and outside of the tail with
toilet paper. This helps prevent any odor.
• Check both sides of the pouch for tears or
holes. If you find any, put on a new pouch.
• If the pouch closes with a clamp, rinse the
clamp if there is stool on it.
Source:

CLOSE THE POUCH
• Close the pouch
• If the pouch has Velcro closures:
• Properly fasten the Velcro closures to
close the pouch.
• If the pouch has a clamp:
- Hold the clamp open with the
curved side, or hinge, toward your body.
Source:

CLOSE THE POUCH
• Lay the bar, or “knife,” of the clamp flat on the
tail of the pouch, about 1 inch from the bottom of the tail.
• Fold the tail up over the bar. Make sure the tail lies flat
against the bar. Also make sure the whole width of the tail
is held within the bar. If it isn’t, the pouch may leak or smell.
Source:

CLOSE THE POUCH
• Hold the tail of the pouch firmly against the bar. Then close
the clamp by bringing the hinge up to the bar. Press the two
parts together until they lock.
• Wash your hands with clean, warm or cold water for at least
20 seconds when you are done. (Hum Happy Birthday twice
if you need a timer.) Or use a hand sanitizer that is 60% alcohol.
Source:

RELEASING GAS
• Gas can collect in the pouch even if there is
no stool. Never puncture the pouch to release
gas. If you do, you’ll break the odor-proof seal.
Stool can also leak if the pouch is punctured.
To release gas, follow these steps:
• Hold the tail of the pouch up slightly and open
the Velcro closures or remove the clamp.
• Hold the top of the pouch with one hand.
Source:

RELEASING GAS
• With the other hand, push the gas out by sliding
your thumb and index finger from the top to the
bottom of the pouch.
• Secure the Velcro closures or reclamp the pouch
as described above.
• Wash your hands when you are done.
Source:

Source:
Colwell, J 2015, How to Empty an Ostomy Pouch, www.youtube.com, University of Chicago Medicine Digestive Diseases Center,
viewed 24 February 2022, https://youtu.be/NVrO-jITUTQ .
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DESCRIBE THE TYPE OF OSTOMY
• colostomy (colon)—sigmoid or descending colostomy, transverse colostomy, loop
colostomy, ascending colostomy
• ileostomy (small bowel)—ileoanal reservoir (J-pouch), continent ileostomy (Kock
pouch)
• Document the presence and location of bowel sounds.
• Stoma information
Source:
Medical Billers and Coders 2019, Ostomy Documentation Tips for Medicare Payment, Leading Medical Billing Services - USA, viewed 24 February 2022,
https://www.medicalbillersandcoders.com/blog/ostomy-documentation-tips/ .

Note the type:
• loop (two openings through one stoma)
• end (one stoma)
• double barrel (two distinct stomas).
• Document the overall appearance (shiny, taut, edematous, dry, moist, pale, textured,
smooth, and bloody) and the presence of stents, rods, drains (include type and
location). Describe the color (red, beefy red, pink, pale pink, purple, blue, black) and
shape (round, oval, budded).
Source:

Note the height:
• flush—at skin level
• prolapsed—telescoped out from the abdominal
surface.
Source:

DOCUMENT THE SIZE IN MILLIMETERS
• Round stomas are measured by diameter.
• Oval stomas are measured by widest length
and width.
Source:

DESCRIBE THE LUMEN
• location—straight up, side, level with skin, or centrally located
• the number of lumens, stenosis, or stricture.
Note:
Document the location of the lumen by using the clock system,
with the patient’s head at 12:00. Describe the odor—presence
or absence of odor, strong, foul, pungent, fecal, musty, sweet.
Note whether the stoma and peristomal skin junction is intact
or separated.
Source:

EFFLUENT
• For a fecal stoma, describe the amount, consistency,
and overall appearance of effluent
• — thick, viscous, liquid, pasty, oily, formed,
soft,
thin, tarry.
Source:

PERISTOMAL SKIN
• Describe the characteristics of peristomal skin—
color, edema, firmness, intactness, induration,
pallor, lesions, texture, scar, incision, rash, staining,
moisture.
• Assess a minimum of 2 inches out from around the
stoma.
Source:

APPLIANCE AND ACCESSORIES
• Document the type of ostomy appliance and accessories.
Include the pouching system product, size, and product
number. Note the presence of a spout, the convexity, and
whether it’s a one-piece or two-piece system,
• Observe and document proper function and adhesion, and
complications experienced with appliance systems. Document
any modifications to the care plan, implementation of new
orders, and referrals.
Source:

OTHER IMPORTANT INFORMATION
• Document the type of ostomy appliance and accessories.
Include the pouching system product, size, and product
number. Note the presence of a spout, the convexity, and
whether it’s a one-piece or two-piece system,
• Observe and document proper function and adhesion, and
complications experienced with appliance systems. Document
any modifications to the care plan, implementation of new
orders, and referrals.
Source:

COLOSTOMY CARE

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