Skill 13-6

Emptying and Changing an Ostomy Appliance

Skill Variation: Applying a Two-Piece Ostomy Appliance

Patients sometimes undergo a bowel diversion (surgical procedure) to create an opening into the abdominal wall for fecal elimination. The word ostomy is a term for a surgically formed opening in an organ of the body. In the case of the GI tract, the intestinal mucosa is brought out to the abdominal wall, and a stoma , the part of the ostomy that is attached to the skin, is formed by suturing the mucosa to the skin. An ileostomy allows liquid fecal content from the ileum of the small intestine to be eliminated through the stoma. A colostomy permits formed feces in the colon to exit through the stoma. Colostomies are further classified by the part of the colon from which they originate.

Ostomy appliances or pouches are applied to the opening to collect stool. Empty an ostomy appliance before it is half-full to reduce the risk of separation from the skin and leakage (Blevins, 2019; WOCN, 2018); remove and change nondrainable pouches when they are half-full. Ostomy appliances are available in a one-piece (barrier backing already attached to the pouch) or two-piece (separate pouch that fastens to the barrier backing) system. How frequently a drainable appliance should be changed depends on the type being used and specific patient circumstances, but usually every 3 to 7 days (Berti-Hearn & Elliott, 2019; O'Flynn, 2018; Stelton, 2019). Proper application minimizes the risk for skin breakdown around the stoma. The skill outlined below addresses changing a one-piece appliance. A one-piece appliance consists of a pouch with an integral adhesive section that adheres to the patient's skin. The adhesive flange is generally made from hydrocolloid. The accompanying Skill Variation addresses changing a two-piece appliance. Box 13-1 summarizes guidelines for care of the patient with a bowel diversion.

Delegation Considerations

Emptying a stoma appliance on an ostomy may be delegated to assistive personnel (AP) as well as to licensed practical/vocational nurses (LPN/LVNs). Changing a stoma appliance on an ostomy may be delegated to an LPN/LVN. The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Premoistened disposable washcloths or
- Basin with warm water
- Skin cleanser, towel, washcloth
Toilet tissue or paper towel
Silicone-based adhesive remover
Gauze squares
Skin protectant, such as Skin-Prep™
One-piece ostomy appliance
Closure clamp, if required, for appliance
Stoma measuring guide
Graduated container, toilet, or bedpan
Ostomy belt (optional)
Disposable gloves
Additional PPE, as indicated
Small plastic trash bag
Waterproof disposable pad

Assessment

Assess the current appliance, looking at product style, condition of appliance, and stoma (if the bag is clear). Note the length of time the appliance has been in place. Determine the patient's knowledge of ostomy care, including their level of self-care and ability to manipulate the equipment. After removing the appliance, assess the stoma and the skin surrounding the fecal diversion. The stoma should ideally protrude about 1 to 3 cm above skin level and be dark pink to red in color and moist (Berti-Hearn & Elliott, 2019; Stelton, 2019). The peristomal skin should look like the skin on the rest of the abdomen (Stelton, 2019). If an abdominal dressing is in place at the surgical incision, check it frequently for drainage and bleeding. The dressing is usually removed after 24 hours. Assess the condition of any abdominal scars or incisional areas, if surgery to create the diversion was recent. Assess the amount, color, consistency, and odor of stool from the ostomy.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Altered skin integrity risk
Knowledge deficiency
Altered body image perception

Outcome Identification and Planning

The expected outcome to be met when changing and emptying a bowel diversion appliance is that the stoma appliance is applied correctly to the skin to allow stool to drain freely and without leakage. Other outcomes may include that the patient exhibits a moist red stoma with intact skin surrounding the stoma, demonstrates knowledge of how to apply the appliance, demonstrates positive coping skills, expels stool that is appropriate in consistency and amount for the ostomy location, verbalizes positive self-image.

Implementation

Action	Rationale
1. Gather equipment.	Assembling equipment provides for an organized approach to the task.
2. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
3. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
4. Close the curtains around the bed and close the door to the room, if possible. Explain to the patient what you are going to do and why. Encourage the patient to observe or participate, if possible and as appropriate.	This ensures the patient's privacy. Explanation relieves anxiety and facilitates engagement. Having the patient observe or assist encourages self-acceptance and helps patient develop self-care skills.
5. Assemble equipment on the overbed table or other surface within reach.	Arranging items nearby is convenient, saves time, and avoids unnecessary stretching and twisting of muscles on the part of the nurse.
6. Assist the patient to a comfortable sitting or lying position in bed or a standing or sitting position in the bathroom. If the patient is in bed, adjust the bed to a comfortable working height (VHACEOSH, 2016). Place a waterproof pad under the patient at the stoma site.	Either position should allow the patient to view the procedure in preparation to learn to perform it independently. Lying flat or sitting upright facilitates smooth application of the appliance. Having the bed at the proper height prevents back and muscle strain. A waterproof pad protects linens and the patient from moisture.
Emptying an Appliance
7. Put on gloves. Remove the clamp (Figure 1) and fold the end of the appliance or pouch upward like a cuff.	Gloves prevent contact with blood, body fluids, and microorganisms. Creating a cuff before emptying prevents additional soiling and odor.
8. Empty the contents into a bedpan, toilet, or measuring device (Figure 2).	Appliances do not need rinsing because rinsing may reduce the appliance's odor barrier.
9. Wipe the lower 2 inches of the appliance or pouch with toilet tissue or a paper towel (Figure 3).	Drying the lower section removes any additional fecal material, thus decreasing odor problems.
10. Uncuff the edge of the appliance or pouch and apply a clip or clamp, or secure the Velcro closure. Ensure the curve of the clamp follows the curve of the patient's body. Remove gloves. Perform hand hygiene. Assist the patient to a comfortable position.	The edge of the appliance or pouch should remain clean. The clamp secures closure. Hand hygiene deters spread of microorganisms. Positioning ensures patient comfort.
11. If the appliance is not to be changed, place the bed in the lowest position. Remove additional PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.
Changing an Appliance
12. Place a disposable pad on the work surface. Open the premoistened disposable washcloths or set up the washbasin with warm water and the rest of the supplies. Place a trash bag within reach.	The pad protects the work surface. Organization facilitates performance of the procedure.
13. Put on clean gloves. Place a waterproof pad under the patient at the stoma site. Empty the appliance as described in Steps 7-10.	The pad protects linens and the patient from moisture. Emptying the contents before removal prevents accidental spillage of fecal material.
14. Put on gloves. Use two hands to gently remove the appliance faceplate, starting at the top and keeping the abdominal skin taut. Remove the appliance faceplate from the skin by pushing the skin from the appliance rather than pulling the appliance from the skin (Figure 4). Apply a silicone-based adhesive remover by spraying or wiping with the remover wipe, as indicated.	Gloves prevent contact with blood and body fluids. The seal between the surface of the faceplate and the skin must be broken before the faceplate can be removed. Harsh handling of the appliance can damage the skin and impair the development of a secure seal in the future. A silicone-based adhesive remover loosens the adhesive bond to make removal easier and less likely to damage the skin and is particularly beneficial for patients with fragile skin and those at increased risk for medical adhesive-related skin injury/stripping (Collier, 2019; LeBlanc et al., 2019; Swift et al., 2020).
15. Place the appliance in the trash bag, if disposable. If reusable, set it aside to wash in lukewarm soap and water and allow it to air dry after the new appliance is in place.	Thorough cleaning and airing of the appliance reduces odor and deterioration of the appliance. For aesthetic and infection control purposes, discard used appliances appropriately.
16. Use toilet tissue to remove any excess stool from the stoma (Figure 5). Cover the stoma with a gauze pad. Clean the skin around the stoma with skin cleanser and water or a cleansing agent and a washcloth. Remove all old adhesive from the skin; use an adhesive remover, as necessary. Do not apply lotion to the peristomal area.	Toilet tissue, used gently, will not damage the stoma. The gauze absorbs any drainage from the stoma while the skin is being prepared. Cleaning the skin removes excretions, old adhesive, and skin protectant. Excretions or a buildup of other substances can irritate and damage the skin. Lotion will prevent a tight adhesive seal.
17. Gently pat the area dry. Make sure the skin around the stoma is thoroughly dry. Assess the stoma and the condition of the surrounding skin (Figure 6).	Careful drying prevents trauma to the skin and stoma. An intact, properly applied fecal collection device protects skin integrity. Any change in color and size of the stoma may indicate circulatory problems. Refer to Box 13-1 on page 817.
18. Apply skin protectant/barrier film to a 2-inch (5 cm) radius around the stoma, and allow it to dry completely, which takes about 30 seconds.	The skin needs protection from the excoriating effect of the excretion and potentially from the appliance adhesive (WOCN, 2018). The skin must be perfectly dry before the appliance is placed to get good adherence and to prevent leaks.
19. Lift the gauze squares for a moment and measure the stoma opening, using the measurement guide (Figure 7). Replace the gauze. Trace the same-sized opening on the back center of the appliance (Figure 8). Cut the opening 1/8 inch (2 to 3 mm) larger than the stoma size (Hill, 2020) (Figure 9). Using a finger, gently smooth the wafer edges after cutting.	The appliance should fit snugly around the stoma, with only 1/8 inch of skin visible around the opening. A faceplate opening that is too small can cause trauma to the stoma. If the opening is too large, exposed skin will be irritated by stool. The wafer edges may be uneven after cutting and could cause irritation to, and/or pressure on, the stoma.
20. Remove the paper backing from the appliance faceplate (Figure 10). Quickly remove the gauze squares and ease the appliance over the stoma (Figure 11). Gently press it onto the skin while smoothing over the surface. Apply gentle, even pressure to the appliance for approximately 30 seconds (Burch, 2019a; Hill, 2020).	The appliance is effective only if it is properly positioned and adhered securely. Pressure on the appliance faceplate allows it to mold to the patient's skin and improve adhesion (Burch, 2019a; Hill, 2020).
21. Close the bottom of the appliance or pouch by folding the end upward and using the clamp or clip that comes with the product (Figure 12), or secure the Velcro closure. Ensure the curve of the clamp follows the curve of the patient's body.	A tightly sealed appliance will not leak and cause embarrassment and discomfort for the patient.
22. Remove gloves. Perform hand hygiene. Assist the patient to a comfortable position. Cover the patient with bed linens. Place the bed in the lowest position.	Removing gloves reduces risk of transmission of microorganisms. Hand hygiene prevents the spread of microorganisms. Covering provides warmth and promotes patient comfort and safety. The bed in the lowest position promotes patient safety.
23. Put on clean gloves. Remove or discard equipment and assess the patient's response to the procedure.	Gloves prevent contact with blood, body fluids, and microorganisms that contaminate the used equipment. The patient's response may indicate acceptance of the ostomy as well as the need for health teaching.
24. Remove gloves and additional PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.

Evaluation

The expected outcomes have been met when the stoma appliance has been applied correctly to the skin to allow stool to drain freely and without leakage, and the patient has exhibited a moist red stoma with intact skin surrounding the stoma, has demonstrated knowledge of how to apply the appliance, has demonstrated positive coping skills, has expelled stool appropriate in consistency and amount for the ostomy location, and has verbalized a positive self-image.

Documentation

Guidelines

Document the appearance of the stoma, the condition of the peristomal skin, characteristics of drainage (amount, color, consistency, unusual odor), the patient's reaction to the procedure, and pertinent patient teaching.

Sample Documentation

Practice documenting changing and emptying an ostomy appliance in Lippincott DocuCare.

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

Peristomal skin is excoriated or irritated: Make sure that the appliance is not cut too large. Skin that is exposed inside of the ostomy appliance will become excoriated. Assess for the presence of a fungal skin infection. If present, consult with the health care team to obtain appropriate treatment. Thoroughly cleanse and dry the skin and apply a product made for excoriated skin before reapplication of the appliance. Allow it to dry completely. Reapply the pouch. Monitor pouch adhesion and change the pouch as soon as there is a break in adhesion. Confer with the health care team for a wound, ostomy, and continence nurse consult to manage these issues. Document the assessment findings and related interventions in the patient's health record.
Patient continues to notice odor: Check the system for any leaks or poor adhesion. Clean the outside of the bag thoroughly when emptying.
Bag continues to come loose or fall off: Thoroughly cleanse the skin and apply a skin barrier. Allow it to dry completely. Reapply the pouch. Monitor pouch adhesion and change the pouch as soon as there is a break in adhesion.
Stoma is protruding into bag: This is called a prolapse. Have the patient rest for 30 minutes. If the stoma is not back to normal size within that time, notify the health care team. If the stoma stays prolapsed, it may twist, resulting in impaired circulation to the stoma.
Stoma is dark brown or black: Stoma should appear pink to red, shiny, and moist. Alterations indicate compromised circulation. If the stoma is dark brown or black, suspect ischemia and necrosis. Notify the health care team immediately.

Applying a Two-Piece Ostomy Appliance

A two-piece colostomy appliance is composed of a pouch and a separate adhesive faceplate that attach together (Figure A). The faceplate is left in place for a period of time, depending on the type being used and specific patient circumstances, but usually every 3 to 7 days (American Cancer Society, 2019; Berti-Hearn & Elliott, 2019; O'Flynn, 2018; Stelton, 2019). The pouch/bag may be replaced as needed during this time. The two main types of two-piece appliances are (1) those that “click” together, and (2) those that “adhere” together. The clicking Tupperware-type joining action provides extra security because there is a sensation when the appliance is secured, which the patient can feel. One problem with this type of system is that those with reduced manual dexterity may find it difficult to secure. Another disadvantage is that it is less discreet because the parts of the appliance that click together are bulkier than that of the one-piece system. Two-piece appliances with an adhesive system have the advantage of being more discreet than conventional two-piece systems. They may also be simpler to use for those with poor manual dexterity. A potential disadvantage is that if the adhesive is not joined correctly and forms a crease, feces or flatus may leak out, causing odor and embarrassment. Regardless of the type of two-piece appliance in use, the procedure to change it is basically the same.

Gather necessary equipment.
Perform hand hygiene and put on PPE, if indicated.
Identify the patient.
Close the curtains around the bed and close the door to the room, if possible. Explain to the patient what you are going to do and why. Encourage the patient to observe or participate, if possible and as appropriate.
Assemble equipment on the overbed table or other surface within reach.
Assist the patient to a comfortable sitting or lying position in bed or a standing or sitting position in the bathroom.
Place a disposable pad on the work surface. Set up the washbasin with warm water and the rest of the supplies. Place a trash bag within reach.
Put on gloves. Place waterproof pad under the patient at the stoma site. Empty the appliance as described previously in Skill 13-6.
Use two hands to gently remove the pouch faceplate from the skin by pushing the skin from the appliance rather than pulling the appliance from the skin. Start at the top of the appliance, while keeping the abdominal skin taut. Apply a silicone-based adhesive remover by spraying or wiping with the remover wipe, as indicated.
Place the appliance in the trash bag, if disposable. If it is reusable, set it aside to wash in lukewarm soap and water and allow it to air dry after the new appliance is in place.
Use toilet tissue to remove any excess stool from the stoma. Cover the stoma with a gauze pad. Clean the skin around the stoma with skin cleanser and water or a cleansing agent and a washcloth. Remove all old adhesive from the skin; use an adhesive remover as necessary. Do not apply lotion to the peristomal area.
Gently pat the area dry. Make sure the skin around the stoma is thoroughly dry. Assess the stoma and the condition of surrounding skin.
Apply a skin protectant/barrier film to a 2-inch (5-cm) radius around the stoma, and allow it to dry completely, which takes about 30 seconds.
Lift the gauze squares for a moment and measure the stoma opening, using the measurement guide. Replace the gauze. Trace the same-sized opening on the back center of the appliance faceplate. Cut the opening 1/8 inch (2 to 3 mm) larger than the stoma size (Hill, 2020). Use a finger to gently smooth the wafer edges after cutting.
Remove the backing from the faceplate. Quickly remove the gauze squares and ease the faceplate over the stoma. Gently press it onto the skin while smoothing over the surface. Apply gentle pressure to the faceplate for approximately 30 seconds (Burch, 2019a; Hill, 2020) (Figure B).
Apply the appliance pouch to the faceplate following the manufacturer's directions. If using a “click” system, lay the ring on the pouch over the ring on the faceplate. Ask the patient to tighten their stomach muscles, if possible. Beginning at one edge of the ring, push the pouch ring onto the faceplate ring (Figure C). A “click” should be heard when the pouch is secured onto the faceplate.
If using an “adhere” system, remove the paper backing from the faceplate and pouch. Starting at one edge, carefully match the pouch adhesive with the faceplate adhesive. Press firmly and smooth the pouch onto the faceplate, taking care to avoid creases.
Close the bottom of the pouch by folding the end upward and using the clamp or clip that comes with the product, or secure the Velcro closure. Ensure the curve of the clamp follows the curve of the patient's body.
Remove gloves. Perform hand hygiene. Assist the patient to a comfortable position. Cover the patient with bed linens. Place the bed in the lowest position.
Put on clean gloves. Remove or discard equipment and assess the patient's response to the procedure.
Remove gloves and additional PPE, if used. Perform hand hygiene.

EVIDENCE FOR PRACTICE

Evidence-Based Practice Guideline

Providing Care for Patients With Ostomies

Goldberg, M., Colwell, J., Burns, S., Carmel, J., Fellows, J., Hendren, S., Livingston, V., Nottingham, C. U., Pittman, J., Rafferty, J., Salvadalena, G., Steinberg, G., Wound, Ostomy and Continence Nurses Society, & Guideline Development Task Force. (2018). WOCN Society Clinical Guideline: Management of the adult patient with a fecal or urinary ostomy-An executive summary. Journal of Wound, Ostomy and Continence Nursing, 45(1), 50-58. https://doi.org/10.1097/WON.0000000000000396

These guidelines provide evidence-based recommendations to guide care for patients with ostomies, prevent or decrease complications, and improve patient outcomes.

section name header

Skill 13-6

EVIDENCE FOR PRACTICE