Steps

Rationale/Points of Emphasis

1 Gather the necessary supplies.

Promotes efficient time management and provides an organized approach to the procedure.

2 Perform hand hygiene. Don gloves.

Standard precautions to reduce transmission of microorganisms.

3 Cover the stoma site with petroleum gauze or petroleum jelly and gauze until output begins. Check with surgical team as to timing of pouch application.

Keeps the stoma moist, protecting it from friction damage and allowing for ease of observation.

4 Remove gloves and perform hand hygiene.

Reduces transmission of microorganisms.

Steps

Rationale/Points of Emphasis

1 Gather the necessary supplies. Perform hand hygiene.

Promotes efficient time management and provides an organized approach to the procedure. Reduces transmission of microorganisms.

2 Prepare the pouch for application:

Multiple factors need to be considered when choosing the ostomy application system including (but not limited to) size of pouching surface area, type of stoma, diameter and profile of the stoma, skin integrity, and type of drainage from the stoma site). Consultation with a WOCN certified nurse is needed to ensure the pouching system fits well, contains the effluent, and meets the needs of the user (ease of use, cost, etc.).

2a Measure the stoma with the stoma guide provided with the box of pouches (Figure 79-1). You may have to cut the hole off-center to avoid the umbilicus or other abdominal landmarks. If the stoma is oval or double barreled, make a custom pattern by tracing the stoma shape on a paper towel or piece of transparent film. Pouch opening should be about 2 mm larger than the base of the stoma. Save pattern to use as a guide in the future.

If new ostomy, need to check stoma size each time the pouch is applied. The stoma will decrease in size after surgery for about 6 weeks as the edema resolves. The guide assists in getting a proper fit around the stoma. The stoma may also change secondary to peristalsis. For premature and full-term infants the pouch wafer should be large enough to accommodate all stomas within the same pouch appliance.

2b Trace the selected circle on the release paper on the back of the wafer or the pouch if one-piece system.

Provides a guide to follow for cutting.

Figure 79-1 The measuring guide is used to determine the size of the hole in the pouch wafer. Templates may need to be customized to fit the child.

2c Before cutting the pouch stoma opening of a one-piece appliance pull the front of pouch away from wafer or place fingers inside the pouch to separate panels and to prevent puncturing the pouch. Using small scissors (preferably with a rounded tip), cut the barrier on the marked circle.

Prevents the pouch from being cut. If it is accidentally cut, use a new pouch and prepare as previously described.

2d Smooth the cut edge by running a finger around the circle.

Not all barriers can be smoothed.

2e Some barriers may benefit from being warmed to make them more moldable. Warm by placing between your hands or placing under infant or child while cleansing the peristomal skin.

Assists with the adhesion of the pouch to child’s skin contours, especially if barrier is somewhat stiff.

caREminder

Do not warm the barrier with heat lamp, heel warmer, or other warming devices that will melt the barrier or pose a burn risk to the skin.

3 Position infant and young child in a supine position, holding as necessary. Older children and adolescents may sit or stand, depending on which position is more comfortable.

Promotes ease of access to site. Allows child or teen to see stoma site so that he or she can actively participate. Protect the child’s privacy.

caREminder

Perform the procedure in the bathroom or bedside on the basis of child’s and family’s preference. If working with premature newborns whose temperature is unstable, work through portholes in isolette. Excessive exposure of the child during this procedure can cause hypothermia. You may want to warm infant afterward with warmed blankets.

4 Don gloves.

Standard precaution to reduce transmission of microorganisms.

5a Remove old appliance or dressing using a damp, soft, lint-free cloth, paper towel or gauze.

Lift the edge of the pouch wafer with one hand, while gently pushing down to separate the skin from the wafer with the damp cloth or a finger. Use adhesive removers/solvents as needed to aid in removal.

Cleanse peristomal skin using warm water.

Clean skin allows for better adhesion of the pouch. It generally is not necessary to use soap. Soap can leave a film on the skin that interferes with pouch adherence and may increase the risk for peristomal skin breakdown.

Do not use commercial diaper wipes as these contain lanolin and other emollients that may decrease pouch adhesion.

caREminder

Adhesive removers and solvents should not be used on premature infants and rarely on infants or toddlers. Premature infants and young children do not metabolize and excrete chemicals as efficiently as adults, and their surface area to body weight is much greater making them more at risk for absorbing products through the skin. Therefore, it is important to minimize exposure to unnecessary chemicals. A soft cloth dampened with warm water can be used to loosen barrier adhesive.

6 Dry skin thoroughly. Application of a skin-protective barrier wipe may be useful in certain situations such as under a tape border to prevent epidermal stripping when the tape is removed or to “set” stoma powder (see Step 8).

Alcohol-free barrier wipes are preferred if used at all.

caREminder

There is limited safety information on the use of barrier wipes with premature infants and infants younger than 30 days. Do not use skin bonding agents or other adhesives on this population.

7 Inspect the child’s stoma and peristomal skin for color and condition, stomal hernia, prolapse, retraction, and infection around stoma or at the incision.

Provides early detection of complications from poor pouch adherence. Stoma should be pink to red in color and moist. Peristomal skin should look like the skin on the rest of the body. Infants with ileostomies tend to have higher incidence of stomal hernias. If outward telescoping of bowel is present, notify surgeon. If stoma is below skin surface or retracted, the pouch opening needs to be slightly larger than the stoma to keep a good seal. Swelling or firm abdomen, redness, tenderness to touch, and/or a Candida yeast rash may all indicate signs of infection.

8a If the infant, child, or teen has reddened or denuded peristomal skin due to epidermal tissue loss, apply a small amount of stoma powder to cleansed skin. Gently brush away excess powder with dry gauze or tissue, being careful not to brush toward face. Optional step: set powder with water or an alcohol-free barrier wipe. Allow to dry completely before applying the pouch.

Powder can assist with healing of peristomal skin. For very young infants, use a finger moistened with water to “set” powder. Barrier wipes that are alcohol-free are recommended to prevent discomfort when applied to nonintact skin. When setting the powder, pat (do not wipe) the preparation to trap powder in place.

8b If it is necessary to fill in creases or gaps in the skin around the stoma, barrier paste, rings, or strips may be used. After removing the release paper on the back of the pouch wafer so the adhesive on the pouch wafer is exposed, apply either a thin layer of paste or a small ribbon of the ring or strip only around the stoma opening.

Paste helps to caulk around the stoma and protect the skin. It may also increase wear time of the barrier.

caREminder

Unlike paste, adhesive barrier rings and strips do not contain alcohol. Because of this, these products are safe to use on the skin of premature infants and will not cause discomfort when applied to nonintact skin. Newborn skin is fragile and is easily traumatized. Use as few products as possible to obtain adequate seal.

9a Remove paper backing and apply prepared pouch over stoma. Press the pouch with fingertips, especially around the base of stoma.

Improves adhesion of the pouch.

9b Hold your hand gently over the pouch for 1 to 2 minutes.

Improves adhesion of the pouch.

9c Angle the pouch to the lateral side of the child.

Improves drainage away from the pouch when the infant or child is in a recumbent position. For the ambulatory child, angling the pouch toward the groin makes emptying the pouch easier.

10 Close bottom of the pouch with tail closure or clamp provided with the pouches. The tail closure on the infant and pediatric pouch needs to be rolled at least three times before folding ties in. When using a clamp to close the pouch, make sure that the end of the pouch is folded over just one time and clamp is closed.

Keeps drainage in the pouch. With infants and toddlers, it is easier to apply the tail closure before applying the pouch. Be careful not to pull on the pouch when applying the closure—this could break the adhesive seal. If clamp is not closed properly, it may come open and leak from the weight of stool.

For infants the pouch may be placed inside or outside the diaper.

If the pouch is worn inside the diaper, use waterproof tape around the outside of the wafer to help prevent moisture eroding of the wafer from a wet diaper.

KidKare Do not use small clips or rubber bands with young children because these are choking hazards. Most infant and pediatric pouches are now manufactured with a closure system integrated on to the pouch itself, eliminating the need for a separate piece to close the pouch.

11 Remove gloves and perform hand hygiene. Dispose of waste in appropriate receptacle. Return equipment to secure area.

Reduces transmission of microorganisms. Equipment should be easily located for next use.

12 If a pattern has not been made, save the paper backing to provide a pattern for the next pouch change. Date pattern.

Assists others in preparation of future pouches.

13 Return child to position of comfort. For nonmobile infants avoid laying the child on the pouch closure.

Laying the infant on the pouch closure, especially if it has a plastic hard-style clamp, can cause pressure ulceration or skin breakdown at the site.