Colostomy Care Nursing Intervention and Care Plan

image

DEFINITION:

Stoma – a surgical operation in which an artificial opening of a part of the colon is brought above the abdominal wall in a colostomy.
Colostomy – is the surgical creation of an opening into the colon in order to drain or decompress the intestine.
Temporary – eventually being closed to restore continuity.
Permanent – usually when the rectum or lower colon has been removed.
POLICIES
1.  Infection control policy should be observed.
2.  Colostomy care should be rendered frequently every time colostomy bag is changed.
3.  Provide privacy all throughout the procedure.

EQUIPMENTS/SUPPLIES:
1.  Disposable gloves
2.  Mask
3.  Sterile gauze 10×10
4.  Warm tap water
5.  Scissors
6.  Pen or pencil
7.  Colostomy appliance with skin barrier

PREPARATIONS

1- Assess:
    Stoma color
Stoma size and shape
Stomal bleeding
Any redness and irritation of the peristomal skin
Amount and type of feces
Complaints
The client’s and family members’ learning needs regarding the ostomy and selfcare
The client’s emotional status, especially strategies used to cope with the ostomy
The used appliance for leakage of effluent
2- Determine:
    The need for an appliance change
The kind of ostomy and its placement on the abdomen
The type and size of appliance currently used, and the special barrier substance applied  to the skin

Taoe allergy
If client has any discomfort at or around the stoma
The fullness of the pouch
If there is pouch leakage or discomfort at or around the stoma, change the
appliance.
   3- Assemble equipment and supplies:
       Disposable gloves
Electric or safety razor
Bedpan
Solvent
Moisture-proof bag
Cleaning materials, including issues, warm water, mild soap optional), washcloth or cotton balls, and towel
Tissue or gauze pad
Skin barrier
Stoma measuring guide
Pen or pencil and scissors
Clean ostomy appliance, with optional belt
Tail closure clamp
Special adhesive, if needed
Stoma guide strip, if needed
Deodorant (liquid or tablet) for a nonodor-proof colostomy bag
   4- Select an appropriate time to change the appliance:
       Avoid times close to meal or visiting hours.
Avoid times immediately after meals or the administration of any medications that may stimulate bowel evacuation.

PROCEDURES:PROCEDURES:
1. Explain to the client what you are going to do, why it is necessary, and how she can  cooperate.
2.  Wash hands and observe other appropriate infection control procedures. Apply clean gloves.
3.  Provide for client privacy.
4.  Assist the client to a comfortable sitting or lying position in bed or, preferably, a
sitting or standing position in the bathroom.
5.  Unfasten the belt, if the client is wearing one.
6.  Shave the peristomal skin of well-established ostomies, as needed. Use an electric or safety razor on a regular basis, to remove excessive hair.
7.  Empty and remove the ostomy appliance:
Empty the contents of the pouch through the bottom opening into a bedpan.
Assess the consistency and the amount of effluent.
Peel the bag off slowly while holding the client’s skin taut.
If the appliance is disposable, discard it in a moisture-proof bag.
8.  Clean and dry the peristomal skin and stoma:
Use toilet tissue to remove excess stool.
Use warm water, mild soap (optional), and cotton balls or a washcloth and towel to clean the skin and stoma.
Use a special skin cleanser to remove dried, hard stool.
Dry the area thoroughly by patting with a towel or cotton balls.
9.  Assess the stoma and peristomal skin.
Inspect the stoma for color, size, shape, and bleeding.
Inspect the peristomal skin for any redness, ulceration, or irritation.
Place a piece of tissue or gauze pad over the stoma, and change it as needed.
10. Apply paste-type skin barrier, if needed:
Fill in abdominal creases or dimples with paste.

Allow the paste to dry for 1 to 2 minutes, or as recommended by the manufacturer.
Prepare and apply the skin barrier (peristomal seal).
11. For a Solid Water or Disc Skin Barrier:
Use the guide to measure the size of the stoma.
On the backing of the skin barrier, trace a circle the same size as the stomal
opening.
Cut out the traced stoma pattern to make an opening in the skin barrier.
Make the opening no more than 0.3–0.4 cm (1/8–1/6 in) larger than the stoma.
Remove the backing to expose the sticky adhesive side.
Center the skin barrier over the stoma, and gently press it onto the client’s skin,
smoothing out any wrinkles or bubbles.
12. For Liquid Skin Sealant:
Either wipe or apply the product evenly around the peristomal skin to form a thin
layer of the liquid plastic coating to the same area.
Allow the skin sealant to dry until it no longer feels tacky.
13. Fill in any exposed skin around an irregularly shaped stoma:
Apply paste to any exposed skin areas. Use a nonalcoholic-based product if the
skin is  excoriated. Or:
Sprinkle peristomal powder on the skin, wipe off the excess, and dab the powder with  slightly moist gauze or with an applicator moistened with a liquid skin
barrier.
14. Prepare and apply the clean appliance:
Remove the tissue over the stoma before applying the pouch.
15. For a Disposable Pouch with Adhesive Square:
If the appliance does not have a precut opening, trace a circle 0.3–0.4 cm (1/8–1/6 in)
larger than the stoma size on the appliance’s adhesive square.
Cut out a circle in the adhesive.
Peel off the backing from the adhesive seal.
Center the opening of the pouch over the client’s stoma, and apply it directly onto the skin barrier.
Gently press the adhesive backing onto the skin, and smooth out any wrinkles,
working    from the stoma outward.
Remove the air from the pouch.
Place a deodorant on the pouch (optional).
Close the pouch by turning up the bottom a few times, fanfolding its end
lengthwise, and securing it with a tail closure clamp.
16. For a Reusable Pouch with Faceplate Attached:
Apply either adhesive cement or a double-faced adhesive disc to the faceplate of the appliance.
Insert a coiled paper guide strip (15- cm [6-in] strip of 1.3-cm- [_ in] wide paper)
into the  faceplate opening.
The strip should protrude slightly from the opening and expand to fit it.
Using the guide strip, center the faceplate over the stoma.
Firmly press the adhesive seal to the peristomal skin.
Place a deodorant in the bag, if the bag is not odor-proof.
Close the end of the pouch with the designated clamp.
Attach the pouch belt, and fasten it around the client’s waist (optional).

17.Variation: Applying a Reusable Pouch with Detachable Faceplate:
Apply a skin sealant to the faceplate before attaching the adhesive disc.
Remove the protective paper strip from one side of the double-faced adhesive disc.
Apply the sticky side to the back of the faceplate.
Remove the remaining protective paper strip from the other side of the adhesive disc.

Center the faceplate over the stoma and skin barrier, then press and hold the
faceplate against the client’s skin for a few minutes, to secure the seal.
Press the adhesive around the circumference of the adhesive disc.
Tape the faceplate to the client’s abdomen using four or eight 7.5-cm (3-in) strips of  hypoallergenic tape.
Place the strips around the faceplate in a “picture-framing” manner, one strip
down    each side, one across the top, and one across the bottom.
The additional four strips can be placed diagonally over the other tapes to secure  the   seal.
Stretch the opening on the back of the pouch, and position it over the base of the faceplate. Ease it over the faceplate flange.
Place the lock ring between the pouch and the faceplate flange, to seal the pouch against the faceplate.
Close the base of the pouch with the appropriate clamp.
Attach the pouch belt, and fasten it around the client’s waist (optional).
Dispose of equipment, or clean reusable equipment.
Discard a disposable bag in a plastic bag before placing in the waste container.
If feces are liquid, measure the volume. Note the feces’ character, consistency,
and   color before emptying the feces into a toilet or hopper.
Wash reusable bags with cool water and mild soap, rinse, and dry.
Wash a soiled belt with warm water and mild soap, rinse, and dry.
Remove and discard gloves.
Variation: Applying the Skin Barrier and Appliance as One Unit:
Prepare the skin barrier by measuring the size of the stoma, tracing a circle on the backing of the skin barrier, and cutting out the traced stoma pattern to make an opening in the skin barrier.
Prepare the appliance by cutting an opening 0.3–0.4 cm (1/8–1/6 in) larger than the stoma size (if not already present) and peeling off the backing from the adhesive seal.
Center the opening of the pouch over the skin barrier.
Remove the skin barrier backing to expose the sticky adhesive side.
Center the skin barrier and appliance over the stoma, and press it onto the client’s  skin.
18.Document the procedure in the client’s record. Report and record:
     Pertinent assessments and interventions
Any increase in stoma size
Change in color indicative of circulatory impairment
Presence of skin irritation or erosion
Discoloration of the stoma
Appearance of the peristomal skin
Amount and type of drainage
Client’s experience with the ostomy
Skills learned by the client
10Client reaction to the procedure

Related posts:

facebook comments:

Posted in Nursing Care Plans, Nursing Intervention, Surgical and Medical

FaceBook Page