DAVAO ORIENTAL STATE UNIVERSITY

FACULTY OF NURSING AND ALLIED HEALTH SCIENCES

Bachelor of Science in Nursing
Guang-guang, Dahican, City of Mati, Davao Oriental

Modified Observe Structure Clinical Examination (OSCE) Checklist

OSTOMY CARE
(Pouching)
Name:___________________________________________________ Grade:
Year and Section:__________________________________________ Date:_______________
Performance Rubrics
Score Qualitative Description Criteria
4 Excellent Demonstrates accuracy and integrates knowledge
and skills appropriately. Clearly stated the steps
of every procedure and profoundly demonstrate
with rationale
3 Good Demonstrate moderately with assistance in
P integrating knowledge and skills. Clearly stated
E the steps of every procedure and properly
R demonstrated; however, failed to state the
F complete rationale.
2 O Acceptable Demonstrates average performance integrating
R the knowledge and skills. Clearly stated the steps
M of every procedure and properly demonstrated
E but fail to state the rationale. Consequently, failed
D to answer pertinent queries appropriately.
1 Needs Improvement Demonstrate the gaps in the necessary
knowledge and requires frequent and utmost
assistance that lacks the skills. Partially stated the
steps of every procedure, incorrectly
demonstrated without rationale, or stated the
rationale but failed to perform the procedure or
vice versa.
0 Not Performed Frequently lacks knowledge and skills that are
unable to perform and state every procedure and
rationale.
Definition

Ostomy care refers to the management and maintenance of a surgically created opening in the
body, known as a stoma, through which bodily waste (such as urine or stool) is diverted to a collection
pouch or bag. Ostomies are typically created as a result of various medical conditions or surgical
procedures, such as colorectal cancer, inflammatory bowel disease, or bladder dysfunction.

Effective ostomy care involves several key aspects:

Stoma Care: Proper cleaning and care of the stoma to prevent irritation, infection, and damage to the
surrounding skin. This includes gently cleansing the area with water and mild soap, and ensuring a good
seal with ostomy appliances or pouching systems.

Skin Care: Regular inspection and maintenance of the skin around the stoma to prevent irritation,
breakdown, and leakage. This may involve using protective barriers, skin sealants, or barrier creams to
promote skin health.

Appliance Management: Ensuring that the ostomy appliance or pouching system fits properly, provides
a secure seal, and effectively collects waste. Regular changing of the pouching system is necessary to
maintain hygiene and prevent leaks.

Diet and Hydration: Monitoring diet and fluid intake to help regulate bowel movements and prevent
complications such as constipation or diarrhea. Some individuals may need to adjust their diet or fluid
intake based on their specific condition and stoma type.

Emotional Support: Providing emotional support and education to individuals living with an ostomy, as
adjusting to life with an ostomy can be challenging both physically and emotionally. Support groups,
counseling, and educational resources can be valuable in helping individuals cope with the changes and
challenges associated with ostomy surgery

Ostomy care aims to optimize quality of life, promote independence, and prevent complications
for individuals living with an ostomy. It often involves collaboration between healthcare professionals,
including nurses, ostomy care specialists, and other members of the healthcare team.

Purpose

Immediately after a fecal surgical diversion, it is necessary to place a pouch over the newly
created stoma to contain effluent when the stoma begins to function. The pouch will keep the patient
clean and dry, protect the skin from drainage, and provide a barrier against odor. A cut-to-fit, transparent
pouching system is preferred because it will cover the peristomal skin without constricting the stoma and
allow for visibility of the stoma.
In the immediate postoperative period, the stoma may be edematous and the abdomen distended.
These symptoms will resolve over a 4- to 6-week period after surgery, but, during this time, it will be
necessary to revise the pouching system to meet the changing size of the stoma and the changes in body
contours (Dietz and Gates, 2010a).

Delegation Considerations
 The skill of pouching a new ostomy/ileostomy cannot be delegated to nursing assistive personnel
(NAP). In some agencies, care of an established ostomy (4 to 6 weeks or more after surgery) can be
delegated to NAP. The nurse directs the NAP about:
■ The expected amount, color, and consistency of drainage from the ostomy.
■ The expected appearance of the stoma.
■ Special equipment needed to complete the procedure.
■ Changes in the patient’s stoma and surrounding skin integrity that should be reported.

Equipment:

■ Skin barrier/pouch, clear drainable one-piece or two-piece, cut-to-fit or precut size

■ Pouch closure device, such as a clip, if needed
■ Ostomy measuring guide
■ Adhesive remover (optional)
■ Clean gloves
■ Washcloth
■ Towel or disposable waterproof barrier
■ Basin with warm tap water
■ Scissors
■ Waterproof bag for disposal of pouch
■ Gown and goggles (optional) (for use if there is risk of splashing when emptying pouch)

Not
Procedures Performed Remarks
Performed
4 3 2 1 0
1. Preliminary Activities (SN to CI)
1.1. Greeting and introducing self to
Clinical Instructor.
1.2. Explain the procedure.
1.3. State purpose.
1.4. State the materials or equipment
needed.
2. Assessment
2.1. Assess the location of the area.
2.2. Assess the existing supply for any
damage.
3. Planning
3.1. Identify the availability of the
equipment.
3.2. Assemble supplies and gather all
required equipment near the area.
4. Implementation
4.1. Complete pre-procedure protocol.
Establish rapport by introducing
self to the client and explaining the
purpose of the procedure. Perform
hand hygiene and apply clean
 gloves. R: Reduces transmission of
microorganisms.
4.2. Observe existing skin barrier and
pouch for leakage and length of
time in place. Pouch should be
changed every 3 to 7 days for
colostomy and every 3 to 5 days for
ileostomy, not daily (Goldberg et
al., 2010). In case of an opaque
pouch, remove it to fully observe
stoma. R: Assesses effectiveness of
pouching system and detects
potential for problems. To minimize
skin irritation, avoid unnecessary
changing of entire pouching
system. When pouch leaks, skin
damage from the effluent causes
more skin trauma than early
removal of wafer.
SAFETY ALERT Repeated leaking may indicate need for different type of pouch. If the pouch is
leaking, change it. Taping or patching it to contain effluent leaves the skin exposed to chemical or
enzymatic irritation.
4.3. Observe amount of effluent in
pouch. Empty pouch if it is more
than one-third to one-half full by
opening clip and draining it into a
container for measurement of
output. Note the consistency of
effluent and record output. R:
Weight of pouch may disrupt seal of
adhesive on skin. Monitors fluid
balance and bowel function after
surgery. Normal colostomy effluent
is soft or formed stool, whereas
normal ileostomy effluent is liquid.
4.4. Observe stoma for type, location,
color, swelling, presence of sutures,
trauma, and healing or irritation of
peristomal skin. Remove and
dispose of gloves. R: Stoma
characteristics are one of the
factors to consider in selecting an
appropriate pouching system.
Convexity in the skin barrier is
often necessary with a flush or
retracted stoma.
4.5. Position patient semi-reclining or
supine during assessment and
pouching. (NOTE: Some patients
with established ostomies prefer to
 stand.) If possible, provide patient
with mirror for observation. R:
When patient is semi-reclining,
there are fewer skin wrinkles, which
allows for ease of application of
pouching system.
4.6. Perform hand hygiene, and apply
clean gloves. R: Reduces
transmission of microorganisms.
4.7. Place towel or disposable
waterproof barrier across patient’s
lower abdomen. R: Protects bed
linen; maintains patient’s dignity.
4.8. Remove used pouch and skin
barrier gently by pushing skin away
from barrier. An adhesive remover
may be used to facilitate removal of
skin barrier. R: Reduces skin
trauma. Improper removal of pouch
and barrier can cause peristomal
skin irritation or breakdown.
4.9. Cleanse peristomal skin gently with
warm tap water using a washcloth;
do not scrub skin. Pat the skin dry.
R: Avoid soap. It leaves residue on
skin, which may irritate skin. Pouch
does not adhere to wet skin.
4.10. Measure stoma. R: Allows for
proper fit of pouch that will protect
peristomal skin.
4.11. Trace pattern of stoma
measurement on pouch backing or
skin barrier (Fig. 1). R: Prepares
for cutting opening in the pouch.

4.12. Cut opening on backing or skin

barrier wafer (Fig. 2). Be sure that
opening is at least 1 8-inch larger
than stoma to avoid pressure on it.
R: Customizes pouch to provide
appropriate fit over stoma.
4.13. Remove protective backing from
adhesive (Fig. 3). R: Prepares skin
barrier for placement.

4.14. Apply pouch. Press firmly into

place around stoma and outside
edges. Have patient hold hand over
pouch to apply heat to secure seal
(Fig. 4). R: Pouch adhesives are
heat activated and will hold more
securely at body temperature.

4.15. Close end of pouch with clip or

integrated closure. Remove drape
from patient. R: Ensures pouch is
secure. Contains effluent.
4.16. Complete post procedure protocol.
Recording and Reporting
■ Record type of pouch and skin barrier applied, amount and appearance of effluent in pouch, size and
appearance of stoma, and condition of peristomal skin.
■ Record patient/family level of participation, teaching that was done, and response to teaching.
■ Report any of the following to nurse and/or physician: abnormal appearance of stoma, suture line,
peristomal skin, or character of output.
Unexpected Outcomes Related Interventions
Skin around stoma is irritated, blistered, or bleeding, or • Remove pouch more carefully.
a rash is noted. May be caused by undermining of pouch • Change pouch more frequently, or use a
seal by fecal contents, allergic reaction, or fungal skin different type of pouching system.
eruption. • Consult ostomy care nurse.
Necrotic stoma is manifested by purple or black color, • Report to nurse/health care provider.
dry instead of moist texture, failure to bleed when • Document appearance.
washed gently, or tissue sloughing.
Patient refuses to view stoma or participate in care. • Obtain referral for ostomy care nurse.
• Allow patient to express feelings.
• Encourage family support.
5. Evaluation (Clinical Instructor 4 3 2 1 Not Remarks
evaluation to Student Nurse Performed
Performance)
5.1. Maintains good body mechanics
throughout the performance of the
procedure.
5.2. Manifest neatness in the performed
procedure.
5.3. Ensure safety and comfort.
5.4. Receptive to criticisms.
5.5. Observes courtesy.
5.6. Show calmness while performing
the procedure.
5.7. Show mastery of the procedure.
TOTAL

Student's Signature over Printed Name

FERMIN S. BRIONES, RN

Clinical Instructors’ Signature over Printed Name