41. CCA Study Notes: Ostomy Care, Colostomy, Ileostomy, and Changing an Ostomy Pouch

The Big Picture

An ostomy is a surgically created opening called a stoma. A pouch fits over the stoma to collect feces and gas.

Two types you need to know are a colostomy and an ileostomy. For a colostomy, its location affects whether the stool is more liquid or more formed.

Ostomy care also involves protecting the skin, checking the stoma, respecting the client’s dignity and preferences, and following the correct steps when changing a pouch.

Look for Nova Scotia CCA Notes throughout this page for current provincial guidance.

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Course Notes: Key Ideas You Need to Know

What Is an Ostomy?

An ostomy is a surgically created opening called a stoma. It may be needed after part of the intestines is surgically removed because of cancer, bowel disease, or trauma.

The client wears a pouch over the stoma. The pouch collects feces ⓘ and flatus, which is gas from the digestive system.

Having an ostomy may strongly affect a client’s self-image ⓘ. Some clients become reluctant to take part in activities they once enjoyed, including swimming, exercise, or intimate contact. These changes may affect mental health and may contribute to depression in some people.

Colostomy

A colostomy is an artificial opening between the colon and the abdominal wall. Part of the colon is brought through the abdominal wall to create the stoma.

Feces and flatus leave the body through the stoma instead of through the anus.

A colostomy may be:

• Permanent: The diseased part of the colon has been removed.
• Temporary: The bowel needs time to heal, but the colon does not need to be removed. Another surgery may later reconnect the bowel.

What a Healthy Stoma Looks Like

A healthy stoma usually looks pink. Some healthy stomas appear red.

The colour should generally resemble other moist body tissues, such as the inside of the mouth.

A red appearance does not mean that touching or cleaning the stoma will cause pain.

Report: A stoma that looks greyish, or dusky, or has a blue tinge could mean the tissue lacks oxygen. This may signal a life-threatening condition and must be reported.

Colostomy Location and Stool Consistency

The location of the colostomy depends on where the colon is diseased or injured.

The amount of colon that remains affects how much water the colon absorbs.

• A colostomy near the beginning of the colon produces more liquid stool.
• A colostomy near the end of the large intestine produces more formed stool.
• The more colon that remains to absorb water, the more solid and formed the stool becomes.

Protecting the Skin Around a Colostomy

Feces can irritate the skin around the stoma.

Whenever the pouch is removed:

• wash the skin
• dry the skin
• apply a skin barrier around the stoma

The skin barrier keeps feces away from the skin. It may form part of the pouch or come as a separate device.

Ileostomy

An ileostomy is an artificial opening between the ileum, which is part of the small intestine, and the abdominal wall.

Part of the ileum is brought through the abdominal wall to create the stoma. Part or all of the colon is removed.

Because water is not absorbed, liquid feces drain continuously from the ileostomy. The drainage has a pungent ⓘ odour.

Why Skin Protection Matters With an Ileostomy

Feces in the small intestine is highly acidic and contains digestive juices. These substances strongly irritate the skin.

The ileostomy pouch must fit well so feces does not reach the skin.

Poor protection can lead to excoriation and skin breakdown. Good skin care is essential.

Ostomy Pouches

An ostomy pouch has an adhesive backing that sticks to the skin.

Some clients who have had a colostomy for many years use a pouch attached to a belt.

Many pouches have a drain at the bottom. A clip, clamp, or wire closure keeps the drain closed.

Open the drain:

• to empty feces from the pouch
• when flatus causes the pouch to balloon or bulge

Wipe the drain with toilet tissue before closing it again.

How Often the Pouch Is Changed

The pouch is changed:

• every 3 to 7 days
• whenever it leaks

Some clients prefer a pouch change every day or whenever the pouch becomes soiled.

Two Common Pouch Systems

Two-Part System

A two-part system separates the appliance from the bag.

Frequent bag changes should not damage the skin because the appliance stays in place while only the bag is changed.

All-in-One System

With an all-in-one system, frequent changes can damage the skin.

Independence With Ostomy Care

Many clients manage their own ostomy pouches without help.

Support should respect the client’s independence, preferences, dignity, privacy, individualized care, and safety.

Ostomies in Children

Children of different ages, including premature infants, may have ostomies.

If you are assigned to change a child’s ostomy pouch, pay close attention to the delicate skin around the stoma.

Report: Report abnormal observations immediately.

Reducing Ostomy Odour

Odour may be prevented by:

• good hygiene
• emptying the pouch regularly
• avoiding gas-forming foods
• placing deodorant in the pouch as directed by the care plan

Clothing and the Ostomy Pouch

A client can wear normal clothing with an ostomy pouch.

Tight undergarments may prevent feces from moving into the pouch.

Tight clothing may also make a pouch bulging with feces or flatus more visible.

Disposing of Used Pouches

Do not flush used pouches down the toilet.

Follow employer policy when disposing of used pouches.

Changing an Ostomy Pouch

Changing an ostomy pouch involves preparation, removing the old pouch, cleaning and observing the stoma and skin, applying the new pouch, and completing post-procedure care.

The procedure should support the client’s:

• dignity
• independence
• individualized care
• preferences
• privacy
• safety

Supplies to Collect

Before starting, collect the supplies needed for the procedure:

• clean pouch with skin barrier
• separate skin barrier, if ordered
• pouch clamp, clip, or wire closure
• clean ostomy belt, if used
• four to eight gauze squares
• adhesive remover
• cotton balls or cloths
• bedpan with cover
• waterproof pad
• bath blanket
• toilet tissue
• wash basin
• bath thermometer
• graduated measuring container, if liquid stool needs measuring
• soap or cleansing agent according to the care plan
• pouch deodorant
• paper towels
• gloves
• disposable bag

Collecting everything first prevents unnecessary trips away from the client’s side.

Pre-Procedure Steps

1. Identify the client according to employer policy. Correct identification prevents mistaking one client for another.
2. Explain the procedure to the client.
3. Perform hand hygiene.
4. Collect all required supplies.
5. Arrange paper towels on the work area and place the supplies on them.
6. Provide privacy.
7. Raise the bed to a comfortable working height when this step applies.

Removing the Old Pouch

8. Lower the bed rail nearest you if it is raised. This helps reduce back strain.
9. Cover the client with a sheet and fan-fold the linen toward the foot of the bed. This supports warmth and privacy.
10. Place the waterproof pad under the client’s buttocks to protect the linen.
11. Put on gloves.
12. If the client wears a belt, disconnect the pouch and remove the belt. Observe for redness. Record and report redness to your supervisor.
13. Gently remove the pouch. Push the skin down and away from the skin barrier while removing it. Place the pouch in the bedpan. Gentle removal helps prevent skin tearing.
14. Wipe around the stoma with toilet tissue or gauze to remove mucus and feces. Place the used tissue in the bedpan.
15. Moisten gauze with adhesive remover. Clean around the stoma from the stoma outward to remove remaining skin barrier.
16. Cover the bedpan and take it to the bathroom. If bed rails are used, raise them before leaving the bedside.
17. Measure the feces if the care plan directs you to do so.
18. Observe the colour, amount, consistency, and odour of the feces. If the feces is abnormal, report it and show it to the appropriate person. Empty the pouch and bedpan into the toilet. Place the used pouch in the disposable bag.

Cleaning and Checking the Stoma and Skin

19. Remove your gloves. Perform hand hygiene. Put on clean gloves.
20. Fill the wash basin with warm water. Measure the water temperature with a bath thermometer and check the care plan for the correct temperature. Place the basin on the paper towels. Lower the nearby bed rail if it is raised.
21. Clean the skin around the stoma with warm water and the soap or cleansing agent directed by the care plan. Rinse the skin and pat it dry.
22. Observe the stoma and the surrounding skin. Report irritation or skin breakdown.

Feces left on the skin can quickly cause irritation and breakdown. Moist skin can harbour pathogens and contribute to skin breakdown.

Applying the New Pouch

23. Apply a separate skin barrier if one is used.
24. Put on a clean ostomy belt if the client wears one and changes it daily. Some clients do not change the belt every day. Follow the care plan for the client’s preference.
25. Add deodorant to the new pouch. Some pouches already contain deodorant. Check the care plan.
26. Remove the adhesive backing from the pouch.
27. Centre the pouch over the stoma. Point the drain downward and secure it with a clip. The pouch empties from the bottom.
28. Press around the skin barrier so the pouch seals against the skin. Apply gentle pressure outward from the stoma.
29. Maintain pressure for 1 to 2 minutes to help form a good seal.
30. Connect the belt to the pouch if the client wears one.
31. Remove the waterproof pad.
32. Remove your gloves.
33. Perform hand hygiene.
34. Cover the client.

Post-Procedure Steps

35. Provide for the client’s safety and comfort.
36. Place the call bell within reach so the client has a safe way to contact staff when needed.
37. Return the bed to its lowest position. Follow the care plan for bed rail use.
38. Remove the privacy measures.
39. Put on gloves and clean the bedpan, wash basin, and other equipment.
40. Return the equipment to its proper place.
41. Dispose of the disposable bag according to employer policy. Follow employer policy for soiled linen.
42. Remove your gloves and perform hand hygiene.

The steps for raising the bed, placing the call bell within reach, and returning the bed to its lowest position with bed-rail directions may not apply in community settings.

What to Report and Record

Report and record your actions and observations according to employer policy.

Important observations during ostomy care include:

• redness where the belt was worn
• irritation around the stoma
• skin breakdown
• abnormal feces
• abnormal stoma colour

Actions, observations, and basic assessments are reported and recorded for legal reasons and to keep the health care team informed.

Common Mix-Ups

Wrong Idea	Better Idea
A colostomy and an ileostomy involve the same part of the intestine.	A colostomy involves the colon. An ileostomy involves the ileum of the small intestine.
A red stoma always means something is wrong.	Pink and red stomas can both be healthy.
A greyish or blue-tinged stoma is a normal colour variation.	This colour could mean the tissue lacks oxygen and must be reported.
Stool from every colostomy has the same consistency.	Stool ranges from liquid to formed depending on how much colon remains and where the colostomy is located.
Frequent pouch changes affect two-part and all-in-one systems the same way.	A two-part system leaves the appliance in place, while frequent all-in-one changes can damage the skin.
The pouch only needs changing on a fixed schedule.	It is changed every 3 to 7 days and whenever it leaks.