Skill 12-11

Emptying and Changing a Stoma Appliance on a Urinary Diversion

Skill Variation: Applying a Two-Piece Stoma Appliance on a Urinary Diversion

Urinary diversions may be used as part of the treatment for patients with obstructions or tumors in the urinary tract, a neurogenic bladder, radiation cystitis, or congenital anomalies of the lower urinary tract. An ileal conduit (also known as a urostomy) is the most common type of incontinent cutaneous urinary diversion (Berti-Hearn & Elliott, 2019; Goldberg et al., 2018). An ileal conduit involves a surgical resection of the small intestine, with transplantation of the ureters to the isolated segment of small bowel. This separated section of the small intestine is then brought to the abdominal wall, where urine is excreted through a stoma , a surgically created opening on the body surface. Such diversions are usually permanent, and the patient wears an external appliance to collect the urine because urine elimination from the stoma cannot be controlled voluntarily. 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 and choice of use is based on the physical needs and personal preferences of the patient (Goldberg et al., 2018). The appliance is usually changed every 3 to 7 days, although it could be changed more often (American Cancer Society, 2019; Berti-Hearn & Elliott, 2019; O'Flynn, 2018; Stelton, 2019). Proper application minimizes the risk for skin breakdown around the stoma. This skill 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.

The appliance is usually changed after a time of low fluid intake, such as in the early morning. Urine production is less at this time, making changing the appliance easier. Proper application minimizes the risk for skin breakdown around the stoma. Box 12-3 summarizes guidelines for care of the patient with a urinary diversion.

Delegation Considerations

The emptying of a stoma appliance on a urinary diversion may be delegated to assistive personnel (AP) as well as to licensed practical/vocational nurses (LPN/LVNs). The changing of a stoma appliance on a urinary diversion may be delegated to LPN/LVNs. 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
Silicone-based adhesive remover
Gauze squares
Skin protectant, such as Skin-Prep™
Ostomy appliance
Stoma-measuring guide
Graduated container
Ostomy belt (optional)
Disposable gloves
Additional PPE, as indicated
Waterproof, disposable pad
Small plastic trash bag

Assessment

Assess the current urinary diversion appliance, observing product style, condition of appliance, and stoma (if bag is clear). Note the length of time the appliance has been in place. Determine the patient's knowledge of urinary diversion care, including their level of self-care and ability to manipulate the equipment. After the appliance is removed, assess the stoma and the skin surrounding the urinary 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). Assess the condition of any abdominal scars or incisional areas, if surgery to create the urinary diversion was recent.

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 body image perception
Altered skin integrity risk
Knowledge deficiency

Outcome Identification and Planning

The expected outcome to achieve when changing a patient's urinary stoma appliance is that the stoma appliance is applied correctly to the skin to allow urine to drain freely and without leakage. Other outcomes may include that the patient exhibits a moist red stoma with intact skin surrounding the stoma, the patient demonstrates knowledge of how to apply the appliance, and the patient 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 the 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 prevents 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 for learning 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 the Appliance
7. Put on gloves. Hold the end of the appliance over a bedpan, toilet, or measuring device. Remove the end cap from the spout. Open the spout and empty the contents into the bedpan, toilet, or measuring device (Figure 1).	Gloves protect the nurse from exposure to blood and body fluids. Emptying the pouch before handling it reduces the likelihood of spilling the excretions.
8. Close the spout. Wipe the spout with toilet tissue. Replace the cap.	Drying the spout removes any urine.
9. Remove equipment. Remove gloves. Perform hand hygiene. Assist the patient to a comfortable position.	Proper removal of PPE prevents the transmission of microorganisms. Positioning ensures patient comfort. Hand hygiene prevents the spread of microorganisms.
10. If the appliance is not to be changed, place the bed in the lowest position. Remove additional PPE, if used. Perform hand hygiene.	Lowering the bed promotes patient safety. Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.
Changing the Appliance
11. Place a disposable waterproof pad on the overbed table or other work area. 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 surface. Organization facilitates performance of the procedure.
12. Put on gloves. Place a waterproof pad under the patient at the stoma site. Empty the appliance, if necessary, as described in Steps 6 to 8.	The waterproof pad protects linens and the patient from moisture. Emptying the contents before removal prevents accidental spillage of fecal material.
13. Put on gloves. Use two hands to gently remove the appliance faceplate, starting at the top and keeping the abdominal skin taut (Figure 2). Remove the appliance faceplate from the skin by pushing the skin from the appliance rather than pulling the appliance from the skin (Figure 3). 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. 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).
14. 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, used appliances should be discarded appropriately.
15. Clean the skin around the stoma with mild skin cleanser and water or a cleansing agent and a washcloth (Figure 4). Remove all old adhesive from the skin; additional adhesive remover may be used. Do not apply lotion to the peristomal area.	Cleaning the skin removes excretions and 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.
16. 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.	Careful drying prevents trauma to the skin and stoma. An intact, properly applied urinary collection device protects skin integrity. Any change in color and size of the stoma may indicate circulatory problems.
17. Place one or two gauze squares over the stoma opening (Figure 5).	Continuous drainage must be absorbed to keep the skin dry during appliance change.
18. Apply skin protectant/barrier film to a 2-inches (5-cm) radius around the stoma, and allow it to dry completely, which takes about 30 seconds.	The skin needs protection from the potentially excoriating effect of 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. Replace the gauze. Trace the same-size opening on the back center of the appliance. Cut the opening 1/8 inch (2 to 3 mm) larger than the stoma size (Hill, 2020) (Figure 6). Use a finger to gently smooth the wafer edges after cutting. Check that the spout is closed, and the end cap is in place.	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 urine. Wafer edges may be uneven after cutting and could cause irritation to and/or pressure on the stoma. A closed spout and secured end cap prevent urine from leaking from the appliance.
20. Remove the paper backing from the appliance faceplate. Quickly remove the gauze squares and discard appropriately; ease the appliance over the stoma. Gently press them onto the skin while smoothing over the surface (Figure 7). 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 faceplate allows the faceplate to mold to the patient's skin and improves the seal.
21. Secure the optional belt to the appliance and around the patient.	An elasticized belt helps support the appliance for some people.
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. Positioning and covering provide warmth and promote comfort. The bed in the lowest position promotes patient safety.
23. Put on gloves. Remove or discard any remaining equipment and assess the patient's response to the procedure.	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 ileal conduit appliance has been emptied and/or changed without trauma to the stoma or peristomal skin or leaking; urine has drained freely into the appliance; the skin surrounding the stoma has remained clean, dry, and intact; and the patient has showed an interest in learning to perform the pouch change and has verbalized positive self-image.

Documentation

Guidelines

Document the procedure, including the appearance of the stoma, condition of the peristomal skin, characteristics of the urine, the patient's response to the procedure, and pertinent patient teaching.

Sample Documentation

7/23/25

1245 Ileal conduit appliance changed. Mr. Jones present. Mrs. Jones asking questions about care for ileal conduit, states, “I don't know if I'll ever be able to care for this thing at home.” Tearful at times. Patient encouraged to express feelings. Patient agreed to talk with wound, ostomy, and continence nurse about concerns. Mr. Jones very supportive, also asking appropriate questions. Patient states they would like to watch change one more time before they attempt to do it. Stoma is moist and red, peristomal skin intact, draining yellow urine with small amount of mucus.

—B. Clapp, RN

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

You remove appliance and find an area of skin excoriated: 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. Consult with the wound, ostomy, and continence nurse to identify appropriate treatment. Cleanse the skin thoroughly and pat dry. Apply products made for excoriated skin before placing the appliance over the stoma. Frequently check the faceplate to ensure that a seal has formed and that there is no leakage. Document the assessment findings and related interventions in the patient's record.
Faceplate is leaking after applying a new appliance: Remove the appliance, clean the skin, and start over.
You are ready to place the faceplate and notice that the opening is cut too large: Discard the appliance and begin over. A faceplate that is cut too large may lead to excoriation of the skin and leakage.
Stoma is dark brown or black: The stoma should appear pink to red, shiny, and moist. Alterations may indicate compromised circulation. If the stoma is dark brown or black, suspect ischemia and necrosis. Notify the health care team immediately.

Special Considerations

Patients with urinary diversions created using a portion of the gastrointestinal (GI) tract will experience the presence of mucus in the urine (Berti-Hearn & Elliott, 2019). The segment of the GI tract continues to produce mucus, as part of its normal functioning. This mucus production does not decrease over time but is usually not a problem for patients with an ileal conduit (Berti-Hearn & Elliott, 2019).
Key components in postoperative education before the patient is discharged from the hospital include assessment and care of the stoma and peristomal skin, pouch emptying, changing the appliance, drainage collectors, common complications, clothing, fluid guidelines, medications, and obtaining supplies (Goldberg et al., 2018).

Applying a Two-Piece Stoma Appliance on a Urinary Diversion

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.

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 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. 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.
Put on gloves. Place a waterproof pad under the patient at the stoma site. Empty the appliance as described previously in Skill 12-11.
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 reusable, set it aside to wash in lukewarm soap and water and allow it to air dry after the new appliance is in place.
Clean the skin around the stoma with a mild skin cleanser and water or a cleansing agent and a washcloth. Remove all old adhesive from skin; additional adhesive remover may be used. 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 the surrounding skin. Place one or two gauze squares over the stoma opening.
Apply skin protectant/barrier film to a 2-inches (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-size 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).
Remove the backing from the faceplate. Quickly remove the gauze squares and ease the faceplate over the stoma. Gently press them onto the skin while smoothing over the surface (Figure B). Apply gentle, even pressure to the appliance for approximately 30 seconds (Burch, 2019a; Hill, 2020).
Apply the appliance pouch to the faceplate following the manufacturer's directions. Check that the spout is closed, and the end cap is in place. 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. A “click” should be heard when the pouch is secured onto the faceplate.
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 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 12-11

EVIDENCE FOR PRACTICE