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Ostomy Care (Adult) (2.18A)

Ostomy Care (Adult) (2.18A) - Policies, Clinical, UWHC Clinical, Department Specific, Nursing Patient Care, Gastrointestinal

2.18A

NURSING PATIENT CARE POLICY & PROCEDURE





Effective Date:
September 22, 2017

Administrative Manual
Nursing Manual (Red)
Other _______________

Policy #: 2.18A

Original
Revision

Page
1
of 3

Title: Ostomy Care (Adult)

I. PURPOSE

To provide guidance for ostomy care for adults.

II. POLICY

A. The nurse caring for the adult patient is responsible for routine ostomy care and
teaching.
B. Routine ostomy care (refer to Ostomy Care Management Algorithm) is
performed every two (2) to three (3) days and more often if necessary as
specified in the orders, while the patient is hospitalized.
C. The Certified Wound Ostomy Care Nurses function as consultants to assist with
stoma marking, product selection, application, complications, patient education
and discharge teaching.

III. EQUIPMENT

A. Pouching system: 2 piece appliance (wafer/barrier and pouch) or
1 piece system (pouch attached to wafer/barrier).
B. Pouch closure (tail clamp if using non-Velcro system closure)
C. Measuring guide or stoma pattern
D. Non-sterile exam gloves
E. 4x4 non-sterile gauze pads
F. Adhesive remover
G. Skin protectant
H. Accessories as needed per orders

IV. PROCEDURE

A. Prepare patient by explaining the procedure.
B. Assemble supplies.
C. Position patient in a comfortable position for ostomy care.
D. Perform hand hygiene according to UW Health Clinical Policy 4.1.13, Hand
Hygiene.
E. Don non-sterile gloves and empty pouch prior to removal.
F. With the same non-sterile exam gloves, remove existing pouch and wafer/barrier
with adhesive remover. Dispose of used pouch in a trash can (biohazard trash can
is not necessary). Use gauze pad to collect waste while the appliance is off.
Dispose of gauze and gloves in trash can.

Page 2 of 3

G. Perform hand hygiene according to UW Health Clinical Policy 4.1.13, Hand
Hygiene, don new non-sterile gloves and clean peristomal skin and stoma gently
with gauze soaked in lukewarm tap water.
H. Dry skin thoroughly with gauze.
I. Assess stoma and surrounding skin. Consult Certified Wound Ostomy Care
Nurse for noted complications such as persistent leak, non-adherence of pouch
system, peristomal skin irritation, separation of skin from stoma, or stoma not
red or not above skin level.
J. Use measuring guide to measure stoma for appropriate size of pouch system.
Choose appropriate pouching system (appliance) Refer to Product Selection
Guide in U- Connect.
K. Mold or cut wafer to stoma size and shape.
L. Apply skin protectant to skin around stoma and allow to dry.
M. Remove clear round plastic backing from wafer. Leave outer release paper on the
tape collar in place. Use tape collar to hold onto when applying wafer/barrier to
abdomen.
N. Apply wafer/barrier or prepared one piece pouch system to abdomen. Press and
maintain with gentle pressure for 30 seconds.
1. If non-accordion obtain low pressure adapter or attach pouch to wafer
prior to applying wafer.
2. Place wafer over white rigid stomal support OR
3. Place wafer under flexible red rubber stomal support
O. Attach pouch to wafer’s/barrier’s flange/plastic ring.
1. If present feed stents and/or red rubber catheter through ostomy pouch.
P. Ensure pouch closure
1. Secure drainable (fecal) tail end pouch closure with built in Velcro
integrated closure system or with a bag clamp if using non Velcro closure
system
2. Close accuseal valve for urostomy pouch.
3. Connect urostomy pouch or high output pouch to drainage bag as needed
Q. During the procedure, demonstrate and explain each step to the patient.
It is the expectation that patients observe and/or participate in ostomy
care/appliance change a minimum of twice and to be able to empty and close the
pouch prior to discharge with assistance of the nursing staff to ensure increased
comfort level with procedure.
R. Remove gloves and perform hand hygiene according to UW Health Clinical
Policy 4.1.13, Hand Hygiene.
S. Document in output, site condition and patient education in the clinical record

V. UW HEALTH CROSS REFERENCES

A. UW Health Clinical Policy 4.1.8, Standard Precautions and Isolation
B. UW Health Clinical Policy 4.1.13, Hand Hygiene
C. Inpatient Ostomy Plan of Care, Specific Ostomy Care Algorithms (found on U-
Connect)
D. Ostomy Product Selection Guide (found on U-Connect)




Page 3 of 3

VI. REFERENCES

A. Erwin-Toth, P., & Doughty, D. (2010). Principles and procedures of stomal
management. In: Hampton, B., & Bryant, R. (Eds.). Ostomies and continent
diversions: nursing management (pp. 53-75). St. Louis, MO: Mosby.
B. Wound, Ostomy, Continence Nurses Society (2010). Management of the patient
with a fecal ostomy: best practice guideline for clinicians. Mount Laurel, NJ:
Wound, Ostomy, and Continence Nurses Society (WOCN).

VII. REVIEWED BY

Clinical Nurse Specialists, Wound & Skin
Certified Wound Ostomy Care Nurses
Nursing Patient Care Policy and Procedure Committee, September 2017

SIGNED BY

Beth Houlahan, DNP, RN, CENP
Senior Vice President, Chief Nurse Executive