Ostomy Care: Stoma Assessment, Pouching, and Complications

This note reviews essential ostomy care for nursing exams, including types of ostomies, how to recognize a healthy versus compromised stoma, correct pouching technique, peristomal skin care, complications, and diet and fluid considerations. Mastery of these points helps prevent skin breakdown, dehydration, and missed ischemic stomas.

Definition

• An ostomy is a surgically created opening (stoma) on the abdominal wall for waste elimination.
• A colostomy expels stool from the colon; an ileostomy expels liquid stool high in digestive enzymes.
• A healthy stoma is pink, moist, and slightly raised.
• The stoma has no nerve endings, so it is not painful to touch, but it bleeds easily with minor trauma.

Types of Ostomies

• Colostomy output varies by location: ascending = liquid, descending/sigmoid = formed.
• Ileostomy has high output (500–1500 mL/day) and risks fluid and electrolyte imbalances. Output begins within 24–48 hours after surgery.
• A urostomy (ileal conduit) diverts urine through a stoma. Mucus in urine is normal. Drain frequently due to continuous flow.

Healthy vs. Abnormal Stoma

• Mild swelling is normal for the first 6 weeks post-op; the stoma will shrink to its final size during this time.
• Do not push a prolapsed stoma back into the abdomen. Cover it with moist gauze and notify the provider.

Ostomy Pouching System

• Drainable pouch: opens at the bottom for emptying. Used for ileostomies and urostomies.
• Closed-end pouch: discarded after each use. Used for colostomies.
• One-piece system: pouch and adhesive barrier are a single unit.
• Two-piece system: separate barrier and pouch.
• Empty the pouch when it is one-third to one-half full. Overfilling causes leakage and skin breakdown.
• For urostomies, empty every 2–4 hours due to continuous urine flow.
• Change the pouch every 3–7 days or when leaking. Have a new pouch ready before removing the old one.

Peristomal Skin Care

• Clean peristomal skin with warm water. Avoid oil-based soaps (leave residue, prevent adhesion). A mild, non-residue soap may be used if needed.
• Dry the skin completely before applying a new pouch — moisture causes poor adhesion and breakdown.
• Apply skin barrier powder to moist or denuded skin; brush off excess before applying the pouch.
• Apply skin barrier wipe (liquid adhesive) to intact skin; allow to dry 30–60 seconds.
• Measure the stoma with a measuring guide. Cut the pouch opening 2–3 mm (1/8 inch) larger than the stoma.
• Opening too large → effluent on skin. Opening too small → constricts the stoma.

Applying an Ostomy Pouch

1. Remove the old pouch by pushing the skin away from the adhesive — do not pull the pouch off.
2. Clean the peristomal skin with warm water; pat completely dry.
3. Measure the stoma and cut the pouch opening to the correct size.
4. Apply skin barrier wipe and allow to dry 30–60 seconds.
5. Center the opening over the stoma; press the adhesive onto the skin for 30–60 seconds.
6. For a urostomy, ensure the pouch has an anti-reflux valve to prevent backflow to the stoma.
7. Dispose of the old pouch in a sealed bag.

Complications of Ostomies

• Peristomal skin breakdown is the most common complication, caused by effluent leakage from an oversized opening or overfilled pouch.
• Ischemia = pale, dusky, or purple stoma. Venous congestion = dark purple or blue stoma. Both require immediate provider notification.
• Dehydration is a major risk for ileostomy patients due to high fluid output. Monitor for thirst, dry mucous membranes, and decreased urine output.

Dietary and Fluid Considerations

Ileostomy

• Increase fluid intake (8–10 glasses/day) to prevent dehydration. Sodium and potassium losses may require supplementation.
• Chew food thoroughly. Avoid nuts, seeds, corn, and raw vegetables that may cause obstruction.
• Odor control foods: yogurt, buttermilk, parsley. Avoid: asparagus, eggs, onions, fish.

Colostomy

• A high-fiber diet may be recommended unless the patient has a stricture. Odor control sachets or drops are available for pouches.
• Colostomy irrigation may be used to regulate bowel movements if ordered. Not all colostomies are suitable for irrigation.

Urostomy

• Increase fluid intake to prevent UTIs. Mucus in urine is normal.
• Vitamin C / cranberry juice can help acidify urine and reduce infection risk.

Common Exam Traps

• Do not ignore a pale, dusky, or black stoma — indicates ischemia or necrosis.
• Do not push a prolapsed stoma back into the abdomen; cover with moist gauze.
• Do not use oil-based soaps on peristomal skin; use warm water or mild non-residue soap.
• Do not cut the pouch opening too large — exposed skin leads to breakdown.
• Do not allow the pouch to fill more than half full — overfilling causes leakage.
• Remember: ileostomy output begins in 24–48 hours; colostomy output may take 2–5 days.

Key takeaways

• A healthy stoma is pink, moist, and slightly raised; pale, dusky, or black signals ischemia or necrosis and requires immediate provider notification.
• Never push a prolapsed stoma back in — cover with moist gauze and notify the provider.
• Empty the pouch at one-third to one-half full; change every 3–7 days; cut the opening 2–3 mm larger than the stoma.
• Ileostomy patients are at high risk for dehydration and electrolyte imbalance and should drink 8–10 glasses of fluid daily.
• Urostomy pouches need an anti-reflux valve and frequent draining; mucus in urine is normal.
• Peristomal skin breakdown is the most common complication — prevent it with correct sizing, good skin prep, and timely pouch changes.