COLOSTOMY/ILEOSTOMY CARE
I. Purpose: To provide means of fecal evacuation. To maintain the integrity of the stoma and
peristomal area. To prevent lesions, ulceration, excoriation, and other skin breakdown caused
by fecal contaminants. To promote general comfort and positive self-image.
II. Responsibility:
A. Training: Training will be conducted by a licensed nurse.
B. Performance:
1. Direct care staff who have completed:
a. Baseline competency training checklist of DDS.
b. Procedure task specific training.
2. Trained staff will follow individual procedural guidelines including notifying the
licensed nurse as indicated.
C. Monitoring:
1. The licensed nurse.
2. Trained staff performing the task under the clinical direction of a licensed nurse,
will notify the nurse of issues and/or outcomes as directed by the nurse.
D. Documentation:
1. Individuals who perform the tasks will record all pertinent information as
instructed by the licensed nurse.
2. The licensed nurse will ensure agency compliance with required documentation.
III. Training to Include:
A. Initial: overview of the procedure, its purpose. Demonstration of techniques by
licensed nurse and return demonstration by the student.
B. Documentation of Training and Monitoring:
1. Training: Licensed nurse completes training record of staff on “DDS Nursing
Delegation Procedure Performance Evaluation Form”.
2. Monitoring: Licensed nurse completes DDS “Nursing Delegation Task
Competency Monitoring Form”.
C. Frequency of Monitoring and Task Performance:
1. Staff will be monitored in their proficiency at this skill as determined by the
licensed nurse but not to exceed 12 months.
IV. Related Knowledge:
A. Background of the disease
B. Medical history of the person
C. Basic anatomy and physiology of the gastrointestinal tract
D. Skin care
E. Characteristics of ostomy drainage
PROCEDURE: APPLYING ADHESIVE STOMA PLATE AND/OR POUCH
Name:
Residence:
Date of Initial Order: Date Order Renewed:
(in pencil)
Order:
I. Diagnosis:
II. Purpose of Procedure: Maintains integrity of stoma and peristomal skin, prevents lesions,
ulcerations, excoriation, and other skin breakdown caused by fecal contaminants, prevents
infection, promotes general comfort and positive self-image/self-concept, provides clean
ostomy pouch for fecal evacuation, reduces odor from overuse of old pouch.
___________________________________ __________________
Signature of Delegating R.N. Date of Delegation
III. Procedure
TASK RATIONALE
A. Gather equipment:
1. Gloves To facilitate changing the face
2. Protective pad plate with the least amount of
3. Basin of warm water distress and discomfort to the
4. Soap individual.
5. Washcloth/towel or gauze
6. Measuring guide
7. New pouch appliance(s)
8. Scissors
9. Pen/pencil
10. Peristomal skin paste and stoma
plate (if needed)
11. Waste receptacle
B. Preparation of Individual:
1. Provide privacy. Reduces embarrassment.
2. Explain procedure to individual. Reduces anxiety, promotes a calm
approach and eliminates fear and
apprehension.
C. Perform Task:
1. Wash hands and put on gloves. Reduces microorganism transfer.
Avoids exposure to individual’s
body secretions.
2. Place disposable protective pads Removes old pouch for new pouch
around stoma pouch close to application; maintains clean
stoma, remove old stoma plate environment.
and/or pouch, and discard
contents; discard gloves. Reduces microorganism transfer.
3. Perform hand hygiene and put on
fresh gloves. Provides data.
4. Inspect stoma and peristomal skin. Removes stool soilage and
5. Perform stoma care: Gently clean promotes secure pouch
entire stoma and peristomal skin application.
with gauze or washcloth soaked in
warm, soapy water (if some fecal
matter is difficult to remove, leave
wet gauze or cloth on area for a
few minutes before gently
removing fecal matter); rinse and Protects skin and linens during
pat dry. procedure.
6. Place gauze pad over stoma
opening to prevent spillage while Provides for accurate fit of pouch.
preparing adhesive stoma plate and
pouch.
7. Measure stoma with measuring Cuts barrier to appropriate size for
guide. Use measuring guide to trace stoma; allows pouch to be placed
opening on back of plate. over stoma without adhering to it.
8. Leaving intact adhesive covering of
plate, cut out circle, allowing an Prevents skin irritation of
extra 1/8 inch for placement over uncovered peristomal skin.
stoma.
9. Remove gauze and apply stomal
paste around stoma or apply
Adheres plate to skin; warmth of
stomal paste to edges of opening in
skin and fingers enhances
plate.
adhesiveness once plate makes
10. Remove adhesive covering of plate,
contact with skin.
and place plate on skin with hole
Secures pouch for collection of
centered over stoma; hold in place
feces.
for about 30 seconds.
11. Center pouch over stoma and place
on plate. If applying a two-piece
appliance, snap pouch on the Reduces microorganism transfer.
flange of the plate.
12. Remove gloves and perform hand
hygiene.
D. Check Individual’s Status:
1. Make sure the individual is comfortable To maintain the individual’s mental
and tolerated the procedure well. and physical well being.
E. Care of Equipment:
1. Restore or discard all equipment Provides clean environment.
appropriately.
F. Documentation:
1. Record date and time treatment Communication of information.
completed.
2. Record color, consistency, and amount
of feces in pouch (small, medium,
large).
3. Record condition of stoma and
peristomal skin. Reporting and communication of
4. Record size of stoma. information.
5. Record individual’s response.
6. Report to nurse any problems that
were encountered.
7. Nurse notification as appropriate.
PLEASE NOTE: NO TASK IS CONSIDERED COMPLETED UNTIL THE DOCUMENTATION AND
REQUIRED REPORTING OCCURS. ANY CHANGE OR VARIATION FROM THE INDIVIDUAL’S
BASELINE SHOULD BE REPORTED PROMPTLY TO THE LICENSED NURSE.
PROCEDURE: EVACUATING AND CLEANING A COLOSTOMY OR ILEOSTOMY POUCH
Name:
Residence:
Date of Initial Order: Date Order Renewed:
(in pencil)
Order:
I. Diagnosis:
II. Purpose of Procedure: Removes fecal material from ostomy pouch, cleans pouch for reuse,
maintains integrity of stoma and peristomal skin, promotes general comfort, promotes positive
self-concept.
___________________________________ __________________
Signature of Delegating R.N. Date of Delegation
III. Procedure
TASK RATIONALE
A. Gather equipment:
1. Gloves To facilitate changing the colostomy
2. Bedpan (if needed) bag with the least amount of
3. Protective pads distress and discomfort to the
4. Washcloths individual.
5. Toilet paper
6. Closure device
7. Waste receptacle
B. Preparation of Individual:
1. Provide privacy. Reduces embarrassment.
2. Explain procedure to individual. Reduces anxiety, promotes a calm
approach and eliminates fear and
apprehension.
C. Perform Task:
1. Put on gloves. Avoids exposure to individual’s
body secretions.
2. Place protective pad on abdomen Prevents seepage of feces onto
around and below pouch. skin.
3. If using toilet, seat client on toilet or in
a chair facing toilet, with pouch over
toilet; if using bedpan, place pouch Positions individual so feces drain
over bedpan. into receptacle.
4. Remove closure device on bottom of Promotes efficiency; cuff keeps
pouch and place within easy reach. bottom of pouch clean, which helps
(Fold bottom of pouch up to form a to prevent odor and helps keep
cuff before emptying.) hands clean during procedure.
Removes feces from pouch.
5. Slowly unfold end of pouch and allow
feces to drain into bedpan or toilet. Expels additional feces from pouch.
6. Press sides of lower end of pouch Removes excess feces from lower
together. end of pouch.
7. Open lower end of pouch and wipe Reduces embarrassment and room
out with toilet paper. odor.
8. Flush toilet or empty bedpan. Cleans exterior closure device.
9. Wash closure device while in
bathroom and dry with paper towel.
10. Remove gloves, perform hand Reduces microorganism transfer.
hygiene, and reglove.
11. Reclamp pouch with cleaned closure Prevents leakage of feces.
device.
Completes cleaning of pouch.
12. Wipe outside of pouch with clean, wet
washcloth; be sure to wipe around
Reduces microorganism transfer.
closure device at bottom of pouch.
13. Remove gloves and perform hand
hygiene.
D. Check Individual’s Status:
1. Make sure the individual is To maintain the individual’s mental
comfortable and tolerated the and physical well being.
procedure well.
E. Care of Equipment:
1. Restore or discard all equipment Provides clean environment.
appropriately.
F. Documentation:
8. Record date and time treatment Communication of information.
completed.
9. Record color, consistency, and amount
of feces in pouch (small, medium,
large). Reporting and communication of
10. Record individual’s response. information.
11. Report to nurse any problems that
were encountered.
12. Nurse notification as appropriate.
PLEASE NOTE: NO TASK IS CONSIDERED COMPLETED UNTIL THE DOCUMENTATION AND
REQUIRED REPORTING OCCURS. ANY CHANGE OR VARIATION FROM THE INDIVIDUAL’S
BASELINE SHOULD BE REPORTED PROMPTLY TO THE LICENSED NURSE.
