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Continuing Education
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COLOSTOMY CARE

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A Guide for Home Care Clinicians
Surgical creation of a colostomy can have significant physical, emotional, and social effects. Adapting to
a new ostomy can be overwhelming and interventions aimed at decreasing barriers to self-care should
be a priority for home care patients. Advances in surgical procedures, coupled with decreased length of
hospital stays, require home care clinicians to have the skills and knowledge to care for this population
through postoperative recovery and the initial phases of learning self-care. This article will focus on the
care of patients with a colostomy in the home care setting.

T
he gastrointestinal tract is comprised of sev- and is responsible for peristalsis (propulsive and
eral segments: stomach, small intestine, large mixing movements). Lastly, the peritoneum is a
intestine, rectum, and anus (Netsch, 2016). It layer of connective tissue that covers over most of
is a complex system with many functions, but the gastrointestinal tract in the abdomen (John-
the main function is to ensure food is available in stone et al.).
a form that allows cells to use it (Johnstone et al., The large intestine (colon) is approximately
2014). It consists of four main layers: mucosa, sub- four to five feet in length and is wider in diameter
mucosa, muscle, and peritoneum. The mucosa than the small intestine. It connects the end of the
consists of epithelial cells and secretory glands ileum to the anal canal. The large intestine con-
that aid in absorption and secretion. The submu- sists of several distinct segments: cecum, ascend-
cosa is a thick layer of connective tissue that joins ing colon, transverse colon, descending colon,
the mucosa to the muscle layer. It also contains
blood vessels, nerves, and glands. The muscle
layer is comprised of two smooth muscle layers, a
circular inner sheet and a longitudinal outer sheet. Linda Berti-Hearn, MSN, RN, CWOCN,
It is innervated by the autonomic nervous system and Brenda Elliott, PhD, RN, CNE

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sigmoid rectum, and anal canal. Its functions in- disease and inflammation can extend into the
clude sodium and water absorption, secretion of submucosa and eventually result in abscess for-
mucous to lubricate and aid in defecation, and mation. Symptoms will depend on the area that is
storage of feces until defecation. Fecal matter is affected. Patients may experience frequent bloody
75% water and 25% solid waste. The average per- stools, abdominal pain, weight loss, and obstruc-
son defecates five to seven times a week. Those tive symptoms.
who eat a diet rich in fiber will produce more stool Ulcerative colitis affects the large bowel only
in a quicker transit time (Johnstone et al., 2014). and extends continuously and circumferentially,
A colostomy is a surgically created opening in unlike Crohn, which is patchy and segmental in its
the abdomen where a portion inflammation (Stein et al., 2016).
of the colon is brought through Inflammation is superficial and
to allow feces/stool to pass. A does not extend into the sub-
colostomy can be temporary or Peristomal skin is exposed mucosa like Crohn. Symptoms
permanent depending on the to mechanical, chemical, and of ulcerative colitis include fre-
reason for its creation. A tempo- microbial threats that can quent bloody diarrhea with ur-
rary colostomy will allow the gency. A patient with ulcerative
cause complications.
affected bowel a chance to rest colitis may or may not experi-
and heal. Once the bowel has ence abdominal pain, and as
healed, the colostomy will be the disease increases, may ex-
reversed. A temporary stoma usually remains in hibit fever, weight loss, and fatigue. Medical man-
place for 3 to 6 months (Stricker et al., 2016). A agement of ulcerative colitis and Crohn consists of
permanent colostomy is required when the dis- corticosteroids, antidiarrheal medications, and
ease affects the lower end of the intestine and/or immunosuppressive agents (Wound, Ostomy, and
rectum, or the patient has significant comorbities Continence Nurses Society [WOCN], 2010). When
that would place them at a higher risk if they had medical management is exhausted, surgery is the
reversal surgery. The most common colostomies definitive treatment and may result in an ostomy.
are the sigmoid colostomy located in the lower left Diverticular disease includes diverticulosis,
quadrant, a transverse colostomy that is located small sac-like pouching of the intestinal wall, as
in the upper right and left quadrants near the mid- well as diverticulitis that occurs when these
line, and an ascending colostomy located on the pouches become inflamed. Diverticular disease
right side of the abdomen. can present with a spectrum of clinical presenta-
tions from totally asymptomatic to symptomatic
Indications for a Colostomy requiring surgery, resulting in a stoma to divert
Colon or rectal cancer, chronic inflammatory stool. Radiation enteritis is a complication of
bowel diseases, diverticular disease, irradiation radiation therapy for prostate, pelvic, rectal, or
damage, and trauma are among the top health is- gynecological cancers (Beitz, 2016). It can result in
sues that lead to the need for a temporary or per- acute symptoms of intestinal mucosal injury or
manent colostomy (Claessens et al., 2015). inflammation, or chronic symptoms of fibrosis
Colorectal cancer is the fourth most common and vascular sclerosis in the bowel. Abdominal
cancer and the second most common cause of trauma, either blunt or penetrating, can lead to an
cancer-related death (Centers for Disease Control ostomy depending on the site of the injury (Cross
and Prevention, 2018). Crohn disease and ulcer- et al., 2014). Lastly, intestinal obstruction of the
ative colitis are chronic inflammatory bowel dis- peritoneal cavity such as adhesions, twisting or
eases that present according to the location and narrowing of the bowel and hernias are also pos-
severity of the disease. Traditional treatments, sible indications for a colostomy.
such as steroids, treat the symptoms of inflamma-
tion but not the actual disease (Stein et al., 2016). Anatomy of the Stoma
Crohn disease most commonly affects the end of There are three anatomical stoma construction
the small intestine and the beginning of the large types: end, loop, and double barrel (Stricker et al.,
intestine, but can occur anywhere in the gastroin- 2016). The end stoma is one stoma. After the dis-
testinal tract from the mouth to the anus. The en- eased or traumatized bowel is repaired, the sur-
tire thickness of the bowel is affected in Crohn geon will bring the proximal bowel through the

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abdomen, invert it and suture it to form a stoma. are considered late complications. Table 1 displays
The distal portion of bowel is sewn over for surgi- descriptions of various stomal complications that
cal reconnection at a later time. The loop stoma is can occur with corresponding treatments.
one stoma with two openings, a proximal opening
that allows stool to pass through and a distal open- Peristomal Skin
ing that allows small amounts of mucous to pass Normal peristomal skin should be intact and
through (Stricker et al.). During the creation of a should appear like the rest of the abdominal skin.
loop stoma, a bridge is placed under the loop of Peristomal skin will stay healthy if the pouching
intestine to support the stoma and prevent retrac- system adheres well and is changed regularly. Peri-
tion. This device can be a plastic device, rod, or stomal skin problems are not uncommon, how-
catheter-like tubing. A double barrel stoma is rarely ever. In a recent Danish study of patients with
seen. Two stomas are created resembling end sto- permanent stomas, 80% of the participants with
mas. The proximal stoma allows stool to pass and skin issues did not perceive they had skin irritation
the distal is a mucous fistula. Depending on the (WOCN, 2010). Therefore, it is important to teach
location of the stoma in the large intestine will de- the patient to change their appliance/pouching
termine the frequency and consistency of stool. system on a schedule and not wait for it to leak.

Stoma Complications Peristomal Complications

Stoma complications involve both physiological Peristomal skin is exposed to mechanical, chemi-
and psychological aspects (Pittman et al., 2014), cal, and microbial threats that can cause complica-
as well as an economic impact (Maydick, 2014). tions (Salvadalena, 2016). Determining the cause of
Studies have shown quality of life of patients living these peristomal skin conditions is the first step in
with an ostomy could be improved with effective treatment and management. Once identified, the
management of stomal problems (Bare et al., 2017; goal is to promote healing while maintaining an
Pittman et al.). Stomal complications within 30 days adequate wear time of the pouching system. The
following surgery are identified as early complica- most common peristomal skin conditions are due
tions and those occurring after this 30-day window to leakage of stool resulting in irritation, redness,

Table 1. Summary of Stomal Complications and Treatments

Complication Description Treatment
Mucocutaneous separation—early Detachment of the stomal tissue from Treat like a wound and fill with a wound
the peristomal skin product such as hydrofiber or calcium
alginate or stoma powder
Stomal necrosis—early Death of stomal tissue from impaired If necrosis is above facial level
blood flow (superficial), then need to wait and
observe
If necrosis below skin level, then will
need to be debrided
Stomal retraction—early Stoma tissue is below skin level Adjust pouching system that can be
achieved with a convex skin barrier and/
or belt
Stomal stenosis—late Narrowing or contracting of the stomal Modify diet to include low-residue foods,
tissue at the skin or fascia level stool softeners, and increase fluids
Stomal prolapse—late Telescoping of intestine through the Adapt pouching system to
stoma accommodate prolapse
Apply pouching system when reduced
Reduce by using a cold compress or
sugar
Peristomal hernia—late Bulging of the intestine into the Conservative management:
parastomal area Flexible pouching system, hernia support
binder, spandex garments

Note. Based on information from Pittman (2016)

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Patients who have had ostomy surgery will need to eat a

well-balanced diet that includes calories, protein, vitamins,
and minerals and drink six to eight glasses of fluids a day to
aid in the postoperative healing.

and maceration. If not treated or addressed, peris- Pouching Options

tomal ulceration and erosion will occur. The initial pouching system will be guided by
Peristomal mechanical skin damage results product availability at the hospital but can be
from medical adhesive related injuries and pres- changed as needed. Selection of a pouching sys-
sure injuries. Adhesive injuries include blisters, tem will depend on the characteristics of the
skin tears, or skin stripping after the removal of a abdomen and location of the stoma, as well as
medical adhesive product such as tapes, and the patient’s preference and ability. A pouching
bonding agents, as well as frequent application and system should provide predictable and reliable
removal of skin barriers (Salvadalena, 2016). Skin wear time. Wear time is the ability to maintain a
stripping occurs when the surface layer of the skin seal for a predictable amount of time with no
is removed by frequent and rough removal of the leakage between application and removal of the
skin barrier. Instruct the patient to gently push pouching system (Colwell, 2016). Wear time de-
skin down around stoma as the skin barrier is lifted pends on stomal characteristics and consistency
off the skin. Also, adhesive remover wipes can be of the stool. If the stoma is flush or retracted, or
used to remove the skin barrier. if it is located in an abdominal crease or fold,
Peristomal chemical damage results from efflu- wear time could be compromised. A pouching
ent containing digestive enzymes, soaps, or adhe- system should be comfortable, secure, and easy
sives coming in contact with the skin (WOCN, to manage no matter what type of system the
2010). It is usually a result of a leaking pouching patient chooses to use. A pouching system that
system, excessive wear time, or inadequate pouch fits and adheres well will keep the stoma and
seal. It is corrected by reevaluating current skin skin healthy.
barrier and ensuring a good seal around the Ostomy pouching systems are available as
stoma. If the skin is irritated or denuded, it may be one- or two-piece appliances. A two-piece system
treated with a stoma powder and nonsting barrier has a skin barrier (also called a wafer or face-
wipe. plate) and a pouch. A skin barrier is the part of
Peristomal fungal/candidiasis is an overgrowth the system that adheres to the skin and should fit
of fungal organisms that can cause inflammation, snugly around the stoma so peristomal skin is not
infection, or skin disease (WOCN, 2010). Patients exposed (WOCN, 2010). The opening can be cut
who have been on antibiotics or on corticosteroid out or molded to fit around the stoma. The stoma
therapy, are immunosuppressed or diabetic, are at will need to be measured weekly and the opening
risk for this type of complication. Peristomal skin in the skin barrier adjusted. Once the stoma has
will have a maculopapular rash with satellite le- matured (about 6 to 8 weeks), precut skin barri-
sions, erythema, and possibly itching. Rash is ers can be ordered. The pouch is the device that
treated by cleansing skin with warm water, drying collects and contains the output. There are sev-
thoroughly, and dusting with an antifungal powder eral mechanisms, depending on the manufac-
followed by a nonsting barrier wipe (Salvadalena, turer, to attach a pouch to a skin barrier: a rigid
2016). Patients should be instructed to pat dry the ring that allows the pouch to snap on; a rigid ring
pouching system (tape border and pouch), after that allows the pouch to click and lock on; and an
showering to prevent moisture against skin that adhesive backing on the pouch that adheres by
can lead to possible fungal overgrowth. sticking to the skin barrier wafer.

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 Pouches are odor free and odor should only be
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present when the patient empties or changes the

bag/barrier or if they experience leakage. If a pa-
tient states they smell stool, always remove the
skin barrier to ensure there is no leakage of stool
underneath. A one-piece closed end pouch is re-
moved, disposed of and replaced one to two times
a day (WOCN, 2010). A two-piece closed-end
pouch is removed twice a day but the skin barrier
remains attached to the skin and may be changed
The patient or caregiver should be taught one to two times a week. Pouches can be transpar-
how to change the pouching system and ent or opaque. After surgery, transparent pouches
then should be able to demonstrate how are used so the output can be visualized. After the
to remove, cleanse skin, and reapply patient becomes comfortable with the pouch, a
transparent or opaque pouch is their preference.
independently before discharging.
Pouches also come with or without charcoal fil-
ters located at the top. These filters allow gas to
pass through while deodorizing. If there is liquid
A one-piece system has a skin barrier and pouch output such as with an ileostomy, the filter may
manufactured as one unit and when the pouch is clog and become less effective.
removed, the skin barrier is also removed. A There are many accessories that can be used
one-piece pouch is more flexible and low profile to obtain a secure seal and enhance wear time of
compared with a two-piece system, so it is less con- the pouching system, as well as manage the
spicuous under clothing. For some patients, it will stoma characteristics (flat or retracted). Acces-
be simpler to use as it is one less step to apply; sories should be used only as needed. Table 2
however, it can be challenging to line up over the provides an overview of commonly used acces-
stoma. A one-piece system may be used if the stoma sories that patients may need to improve wear
is located in a deep abdominal fold or crease, or if time. Many manufactures will send free samples
the patient has poor manual dexterity. A patient for the patient to trial but they do not sell directly
with a descending colostomy can choose between to patients.
a two-piece closed pouching system or a one-piece A patient will need to choose a durable medi-
closed pouch. An ascending or transverse colos- cal equipment (DME) supplier to order their
tomy, depending on the output and how often they supplies. Most large DME suppliers will bill the
empty, will most likely need a drainable pouching patient’s insurance and accept Medicare and
system whether it is a one piece or two. Insurance Medicaid (Berti-Hearn & Elliott, 2018). It is very
will cover 60 closed/disposable pouches a month. A important when ordering supplies to be aware
patient can choose either a closed or drainable of the patient’s insurance. As long as a patient is
pouch in order to accommodate their bowel habits. receiving home healthcare, it is the responsibil-
If the patient has two bowel movements a day, a ity of the agency to provide ostomy supplies if
closed pouch is a good option because two pouches the patient has traditional Medicare. Even if the
a day are allowed. If a patient is emptying more than patient is receiving only therapy services
twice a day, they will need more than two closed through home healthcare and is independent
pouches a day and will need to use a drainable with their ostomy, the patient is to receive their
pouch. Patients can also purchase additional supplies through the agency under Medicare
pouches if they prefer one pouch over the other. guidelines and consolidated billing. If the pa-
Skin barriers, whether a one- or two-piece sys- tient has managed care, managed Medicare, or
tem, are available with a flat or convex surface. A private insurance, supplies are ordered through
flat barrier works best for a stoma that is budded a DME company and the insurance is directly
or protrudes above skin level. A convex skin bar- billed. When discharging the patient from home
rier is best for a stoma that is flush, retracted, or healthcare services, it is important to educate
in a skin fold. Convex skin barriers can be soft and them on ordering their monthly supplies. In-
flexible or firm and rigid. clude in the discharge instructions, the phone

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 Table 2. Commonly Used Accessories for Colostomies
Type Use Considerations Tips
Barrier ring Hydrocolloid washer that May not need if stoma protrudes— Stretch the ring to the size of the
can be placed around stoma barrier ring may not allow stoma opening, place on back of skin
or on back of skin barrier to output to drain over ring into pouch barrier or around stoma. Press and
enhance seal May also be used instead of stoma mold against back of skin barrier
paste
Barrier strips Elastic piece of hydrocolloid May not need if pouching system Can stabilize peristomal skin such as
that is placed on the outer remains intact for predictable wear when patient has peristomal hernia
edge of the skin barrier to time Can protect tape borders when
increase security patient wants to shower daily and/
or swim
Strip paste Stick of adhesive hydrocolloid Requires manual dexterity to break and Pull off small pieces and roll to fit
that can be used around mold into sizes and shapes needed into areas or creases that need to
stoma or to fill increases or Can be used in place of paste be filled
folds in peristomal skin
Stoma Absorbs moisture on denuded Should not be used routinely but only Dust the denuded peristomal skin
powder peristomal skin on compromised peristomal skin and then brush off excess before
Too much powder left on peristomal applying skin barrier
skin can interfere with adherence
Stoma paste Adhesive hydrocolloid used to Contains alcohol and burns when Use as caulk directly around stoma
enhance the seal by caulking applied to denuded skin to enhance seal especially if stool
along edge of skin barrier Can be difficult to squeeze out of tube is watery
closet to stoma to prevent after a few uses Moisten finger before adjusting paste
leakage or else it will stick to your finger
Skin barrier Clear liquid film placed on Select skin barriers will not adhere It can facilitate application onto
wipes peristomal skin to provide when barrier wipe is used denuded skin
protection from stool or Barrier wipes with alcohol will cause Allow barrier wipe to dry before
adhesive stripping burning when applied to denuded skin applying skin barrier
Belt Attached to pouch to apply It can help apply increased convexity Should fit snuggly
pressure to pouching system when using with convex skin barrier Comes in differing lengths and most
to enhance seal are adjustable
Deodorant Liquid or tablets placed in Liquid deodorant will not harm stoma Need to apply after each emptying
pouch to eliminate odor when but may contain dye that can change or when applying a new pouch
emptying color of stool

Note. Based on information from Colwell (2016).

number to the DME and product numbers to or psychological limitations the patient may have.
order. Also, the customer service representa- Assess what they were taught (usually only how
tives for the manufactures of the ostomy sup- to empty their pouch) prior to leaving the hospi-
plies are a good resource and can assist the tal. Determine if a caregiver has been instructed
patient with finding a DME company and order- and can assist in the postoperative period.
ing their supplies. The patient and caregiver need to be taught how
to correctly empty the pouch and change the
Role of the Home Care Clinician pouching system. They must also be able to rec-
Patients who undergo abdominal surgery have ognize any developing skin conditions, manage
common postoperative risks. Home care clinicians activities of daily living with an ostomy, order
should assess for pain control, surgical incision monthly ostomy supplies, and know available
infection or complications, nutrition and hydra- resources to manage any problems (Berti-Hearn
tion status, and cardiopulmonary status. Patients & Elliott, 2018). Assess for any comorbidities or
with new colostomies have specific care consid- psychomotor deficits that may hinder the
erations. At the initial visit, evaluate your patient’s patient’s ability to care for their ostomy such as
stoma, pouching system, abdominal configura- arthritis, poststroke weakness, frailty and fatigue,
tion, peristomal skin integrity, and any physical or visual problems.

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alamy

it travels too quickly, diarrhea can occur because

Selection of a pouching less water is absorbed. The type of stool output is
system will depend dependent on the location of the stoma in the
large intestine. For a patient with an ascending
on the characteristics
colostomy, the stool will be more liquid due to the
of the abdomen and proximity to the small intestine (Stricker et al.,
location of the stoma, 2016). The transverse intestine is in the middle
as well as the patient’s section of the bowel and the stoma can be located
preference and ability. at the midline or in the upper abdomen toward the
right or left side. Patients with a transverse colos-
tomy will have stool that is loose or of oatmeal
consistency. Lastly, a patient with a descending or
Post-op Changes in Stoma sigmoid colostomy generally will have a soft or
The stoma should be assessed each visit for size, formed stool, but it can be paste-like or hard de-
shape, and protrusion. Initially, the new stoma pending on food and/or water intake. This stoma
will be red, moist, shiny, and edematous. Due to is located on the left side of the abdomen, usually
good blood supply it may bleed, especially when in the left lower quadrant.
cleansing. The stoma will get smaller and less
edematous during the first 6 weeks after surgery, Psychosocial Status
then eventually will stop changing (Colwell, 2016). Assess the emotional and psychological effects
As it matures, the stoma mucosa should be red, the ostomy may be having on the patient. Dealing
moist, and have some texture; it has no nerve end- with not only the reason for the ostomy, but the
ings. Patients may complain of stomal discomfort, ostomy itself, can be devastating for some pa-
but what they may be feeling is the sutures tients. Common problems include fear of leakage,
around the stoma that will eventually dissolve or depression, anxiety, and embarrassment caused
the peristomal skin around the stoma. Stomas are by noises, gas and odor, and concerns about
different in size and shape (round or oval) due to changes in appearance and need for increased
location of the bowel. Not all stomas are alike, privacy that can lead to feelings of social isolation.
some stomas may be flush (at skin level) or re- Psychosocial barriers to self-care should be as-
tracted (below skin level). Ideally, stomas pro- sessed and interventions used to help mitigate
trude at least 2 cm above the skin level so that them (Werth et al., 2014).
stool drains directly into the pouching system
(Colwell). If there is not adequate protrusion, the Education
stool may leak under the skin barrier causing peri- Body image changes, as well as physical changes,
stomal skin issues; in this case a specific convex can be very challenging for patients with a new
pouching system may be needed. Adjust the size ostomy and they will require encouragement and
of the opening in the skin barrier to accommodate support. The ability to care for the stoma and
stoma changes to prevent peristomal skin dam- output are the first steps in the patient’s rehabili-
age. Always assess the color of stoma as well as tation (Goldberg, 2016). It will be important to
the peristomal skin. A stoma that becomes very include a family member or caregiver in this pro-
pale, purple, or black needs to be reported to the cess, as well as to support the patient in their
surgeon immediately because these are signs of acceptance. It is important to teach the patient
possible necrosis. that the stoma size and shape will change over
At each visit, assess the type, amount, and fre- time and it is necessary for the patient to measure
quency of the output. The large intestine is filled or make a pattern to use when preparing/applying
with bacteria that causes the release of gases as a a new skin barrier. A good fitting skin barrier will
result of bacteria fermentation, resulting in flatus/ prevent peristomal complications and the patient
gas. Colostomy output includes feces/stool and should be educated on the normal appearance of
flatus/gas. Fecal matter will travel through the the stoma and peristomal skin so they can identify
large intestine and as it travels, water is absorbed. if there are any changes. The patient should also
The longer it takes to travel through, the more be educated on stomal or peristomal skin compli-
water is absorbed and can lead to constipation. If cations that would require medical attention.

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These would include the inability to maintain a Table 3. Role Play Scenarios and Questions for
skin barrier seal for a predictable time; rash; ulcer; Patients
or denuded skin that does not resolve after one to Scenario Questions to Ask
two pouch changes; separation of stoma from
Going Ask patient what they will do about emptying
peristomal skin; change in stoma color from red to back to pouch when they go back to work. Do they
dark maroon or black; and changes in possible work have a private bathroom and if not how will
length of stoma such as prolapsed or a bulging they empty if they need to go into a stall?
What supplies will they take with them? Some
hernia (Colwell, 2016). patients like to carry small dispensers of air
The patient and caregiver need to be educated freshener or perfume with their supplies. Do
on the stoma output and what to expect. Output is they have a place at work to store their extra
pouching system?
largely dependent on the type of ostomy created so
Traveling If a patient is going to travel, they will need
a sigmoid colostomy will be softer and more
to take supplies with them. Depending on
formed compared with an ascending or transverse amount of time they will be away, they may
colostomy. However, in the initial postoperative need to pack supplies in checked baggage
but must always have a few changes in their
period through when they first return home, output
carry-on luggage.
will be more of a liquid consistency. The patient
Going out Suggest patient carry small deodorant spray
should also be taught to seek medical attention if to dinner or perfume in purse if they are worried about
no output for more than 2 days, blood in output, or to visit odor when they empty. Instruct to place toilet
prolonged abdominal pain, nausea or vomiting, or family tissue in bowl before emptying so it will not
splatter.
abdominal distension (Goldberg, 2016).
Carry a small disposable trash bag with them
Whenever possible, changing the pouching in case they need to remove pouch and
system and emptying the pouch should be per- dispose of it.
formed in the bathroom as this is where these
bodily functions are usually managed. Have the bowl prior to emptying will prevent splashing.
patient select a place in the bathroom to organize After emptying, the end of the pouch or outlet is
their supplies. Instruct the patient to always have cleaned with toilet tissue or a paper towel and
a second pouching system ready in case they then closed. A closed pouch is removed, skin bar-
have a leak and need to change emergently. Have rier wiped off, and pouch then discarded in a
everything needed for a change placed together plastic bag. Gas or air is emptied in the same way,
in a purse or backpack. Some patients feel more or if wearing a two piece system can be released
confident if they carry a change of clothes in by unsnapping the pouch from the flange and
their car or trunk. In a study by Werth et al. allowing it to escape and then resnapping. The
(2014), 15% of patients reported they felt unpre- patient or caregiver should be taught how to
pared for their first leak, despite having had change the pouching system and then should be
education about it. Role playing can help the pa- able to demonstrate how to remove it, cleanse
tient build confidence and can be done by talk- skin, and reapply independently before discharg-
ing/acting through various scenarios the patient ing (Colwell et al., 2016).
may encounter and then discussing how to pro- Patients may shower daily and swim with their
actively handle each situation. Changing before pouching system. Water will not harm the stoma
eating or drinking will decrease the chance of the or pouching system if left in place. Most pouches
stoma of being overly productive during the with filters will need to be covered. If so, you will
change. Table 3 provides some ideas to role-play find a round or oval sticker in the box of pouches
with your patients. that are to be placed over the filter prior to show-
Instruct the patient to empty when the pouch ering or swimming. Instruct the patient to dry the
is 1/3–1/2 full because the fuller the pouch, the tape border and pouch with a towel or use a hair
more weight exerted on the skin barrier, which dryer on the lowest setting to prevent moisture-
may decrease wear time or cause leakage. In- associated dermatitis. When swimming, the pa-
struct the patient to empty the pouch either by tient should empty the pouch before going into
sitting on the toilet as far back on the seat as pos- the water. Most patients protect their barrier by
sible to empty between legs into the bowl, sitting using barrier strips or waterproof tape on the skin
on the toilet facing the tank, or sitting on a chair barrier edges (Goldberg, 2016). If the patient
in front of the toilet. Placing toilet tissue in the chooses, the pouching system may be removed

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 Table 4. Quick Tips to Reinforce Patient Education while showering. Instruct the patient to wash peri-
stomal skin with warm water and a nonoily soap.
Issues Quick Tips
Gently remove skin barrier from top down with a
General • change pouching system on routine basis and
push pull technique (push the skin down as you
do not wait for it to leak
• twice a week is a usual change for most people
pull at the barrier).
• best time to change is first thing in morning
when there is less output Nutritional Considerations
• prepare new pouching system before Patients with colostomies have few dietary re-
removing old system strictions after the initial postoperative period
• can shower with pouching system on or off (Schreiber, 2016). Patients who have had ostomy
• may need to change more frequently during surgery will need to eat a well-balanced diet that
warmer weather due to perspiring or outdoor
activities includes calories, protein, vitamins, and minerals
• empty pouch when 1/3–1/2 full and drink six to eight glasses of fluids a day to aid
• empty before bed and activities in the postoperative healing. The aim is to return
• no need to rinse out drainable pouch after to a diet that is well balanced nutritionally and
emptying high in fiber (Cronin, 2012). The colostomy
• store all supplies in a cool dry place should be functioning prior to leaving the hospi-
Skin • warm water is sufficient to clean skin with tal and the patient should expect at least one
care • avoid baby wipes that can leave residue bowel movement a day once home in the early
on skin weeks. As the patient begins to recover, it is not
• do not use lotions, baby powder, alcohol, essential for the colostomy to function on a daily
ointments, or soaps with aloe or moisturizers
under the skin barrier basis. Because these patients have had major
• always wash hands before and after emptying abdominal surgery, many patients do not have an
• adhesive remover wipes should be used appetite to eat three regular meals a day so they
sparingly and must wash off skin with warm would benefit from eating six smaller meals.
water and mild soap after using
Dietary teaching is a key to rehabilitation and
Odor • odor eliminating drops adaptation.
• place air fresheners in bathroom such as plug ins As the stoma may be edematous when the pa-
• spray bathroom with air freshener before tient returns home, a low-residue, low-fiber diet
emptying
will allow the stool to pass easily through the
• spray toilet spray such as Poo Pourri © into
toilet and leaves an oily film on water that stoma. As the edema resolves, encourage the pa-
traps odor tient to eat a well-balanced diet including fruits
Exercise • begin with walking and vegetables (Schreiber, 2016). Fiber is essential
• obtain physician approval for type of exercise for a patient with a colostomy because it adds
you can do bulk to the stool and aids in its passage through
• carry a water bottle with you because can the intestine. Because fiber can cause gas, intro-
dehydrate quickly
duce it gradually, adding small amounts of fruit
• eat after exercising
and vegetables at each meal (Cronin, 2012). If a
• protect abdomen and stoma with a hernia
binder or spandex garments patient does not take in enough fiber, the stool will
Intimacy • empty pouch ahead of time
be hard or very pasty, making flow into the pouch
• use a closed pouch
difficult. Fiber supplement or natural sources such
• ask physician about use of Imodium or Gas X
as prune juice or prunes may be needed, and will
before being intimate vary for each patient. To control gas, instruct pa-
• secure or cover pouching system with a wrap, tients to eat slowly, chew food thoroughly, and
bandeau, or special lingerie or underwear avoid straws, chewing gum, smoking, and eating
• online resources: Awestomy, Ostomy secrets, after 7 to 8 p.m. This will give the bowel time to
Vanilla Blush, Between You & Me
rest and quiet down before bed. Lactose intoler-
Travel • plan ahead
ance is also common after abdominal surgery and
• place supplies in carry-on luggage
dairy should be eliminated if the patient com-
• have skin barriers already pre cut
plains of gas, abdominal bloating, increase in liq-
• obtain a travel ID card (can be found on UOAA
website)
uid stool, or diarrhea after eating or drinking any
dairy product (Cronin).

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 Table 4 lists quick tips you can share with Conclusions
patients to reinforce teaching. Upon discharge Improvements in surgical procedures, coupled
from home care, patient should be comfortable with shorter hospital stays, means more patients
and confident in applying the pouching system, with a new ostomy may have increased educa-
attaining and maintaining intact peristomal skin, tional needs upon returning home. It is impera-
managing ostomy supplies, and have awareness tive that home care clinicians stay abreast to best
of resources available to them (Berti-Hearn & practices in managing this patient population
Elliott, 2018). Patients will have many concerns postoperatively and prepare them physically and
about leaving their home and going out in public emotionally for discharge to self-care. This is no
and need to be reassured that no one will know small task. Using role play is a creative way to
they have a stoma unless they share that infor- help patients build confidence, which can posi-
mation. tively influence quality of life and a speedier road
to adaptation. It is safe to say that nurses who
Current and Future Research have confidence in caring for patients with an
Research on patients with an ostomy within the ostomy make a patient feel more confident too.
last 10 years has focused heavily on quality of There are many opportunities for conducting
life concerns, educational needs of patients, research in this area of nursing, especially in non-
barriers to adapting to an ostomy, and managing acute settings.
complications such as leakage and peristomal
issues. Only one study was found that examined Linda Berti-Hearn, MSN, RN, CWOCN, is a Wound Ostomy Nurse,
staff nurse confidence in skills, knowledge, and Virtua Health—Home Health Division, Mt. Laurel, New Jersey.
barriers to caring for a patient with an ostomy Brenda Elliott, PhD, RN, CNE, is an Assistant Professor, Wilson
College, Chambersburg, Pennsylvania.
(Cross et al., 2014). The researchers found that
The authors declare no conflicts of interest.
experience and specific training translated to Address for correspondence: Linda Berti-Hearn, MSN, RN,
higher confidence. With colostomy patients CWOCN, Virtua Health—Home Health Division, Mt. Laurel, NJ
leaving the hospital much sooner than even 08054 (berti50@comcast.net).

5 years ago, more research is needed in home Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
care and other community settings. Under-
standing the experiences and barriers to care DOI:10.1097/NHH.0000000000000735
in these settings can help give direction for
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better continuing education and competency Bare, K., Drain, J., Timko-Progar, M., Stallings, B., Smith, K., Ward,
development. N., & Wright, S. (2017). Implementation of an evidence-based and
In 2014, the WOCN™ Society sponsored a se- content validated standardized ostomy algorithm tool in home
care: A quality improvement project. Journal of Wound, Ostomy,
ries of consensus sessions to help identify and and Continence Nursing, 44(3), 262-266.
standardize clinical outcomes for patients with a Beitz, J. (2016). Other conditions that lead to a fecal diversion. In
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called upon to determine the minimum discharge Berti-Hearn, L., & Elliott, B. (2018). A resource guide to improve nurs-
ing care and transition to self-care for patients with ostomies. Home
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tal (colon) cancer. Retrieved from https://www.cdc.gov/cancer/
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Andersen, B. D., & Størling, Z. M. (2015). The ostomy life study:
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The everyday challenges faced by people living with a stoma in a
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For additional continuing education activities on

home healthcare topics, go to nursingcenter.com/ce.

Instructions for Taking the CE Test Online

Colostomy Care: A Guide for Home Care Clinicians

• Read the article. The test for this CE activity can be Provider Accreditation:
taken online at www.nursingcenter.com/ce/HHN. Lippincott Professional Development will award
Tests can no longer be mailed or faxed. 1.5 contact hour for this continuing nursing education
• You will need to create a free login to your personal activity.
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Lippincott Professional Development is accredited
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sional Development online CE activities for you.
by the American Nurses Credentialing Center’s
• There is only one correct answer for each question. Commission on Accreditation.
A passing score for this test is 14 correct answers.
This activity is also provider approved by
If you pass, you can print your certificate of earned
the California Board of Registered Nursing,
contact hours and the answer key. If you fail, you
Provider Number CEP 11749 for 1.5 contact
have the option of taking the test again at no
hour. Lippincott Professional Development is also
additional cost.
an approved provider of continuing nursing
• For questions, contact Lippincott Professional education by the District of Columbia, Georgia,
Development: 1-800-787-8985. and Florida CE Broker #50-1223.
Registration Deadline: March 5, 2021. Payment:
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