Procedure: Irrigating a Colostomy/Ileostomy
PREPARATION RATIONALE
Purpose Proper assembling of equipment facilitates continuous
• Facilitate emptying the colon and smooth-flowing procedure; thus, saving time and
energy for the nurse and the client. It also avoids leaving
Equipment client unattended in retrieving any missing equipment.
• 2 pairs of nonsterile gloves
• IV pole or wall hook
• Irrigating bag and tubing
• Irrigating cone
• Irrigating sleeve
• Water soluble lubricant
• Toilet or toilet chair
• Warm saline or tap water
• Two towels and two wash cloths
• Two linen savers
• Mild soap
• Room deodorizer
• Bath basin
• Fresh pouch
• Pen
Assessment Irrigating a colostomy or ileostomy require a health
• Check doctor’s order for frequency of care provider’s order.
irrigation and type and amount
ofsolution • Type of colostomy and nature Proper assessment aids in providing proper interventions
and prevention of complications.
of drainage • Client’s ability and preference
to perform colostomy care
• Client teaching needs
Procedure
1. Perform hand hygiene and organize Reduces microorganism transfer; promotes efficiency
equipment.
2. Explain procedure to client. Reduces anxiety; promotes cooperation; reinforces
detailed instructions client will need to perform self-care
3. Determine if client is allergic to Avoids allergic reactions
iodine-based antiseptics and use alternative,
if indicated.
4. Obtain extra lighting, if needed. Ensures proper amount of light to perform procedure
5. Provide for warmth and privacy. Promotes comfort; decreases embarrassment
6. Prepare irrigating solution and tubing Allows bowel to adjust to fluid pressure; allows for control
as follows: of fluid flow; prepares irrigation solution
• Obtain irrigation bag and solution (usually
tepid water). Use 250-500 ml for initial
irrigation, 500-1000 ml for subsequent
irrigations (minimal amount are Prevents injury from hot solution or cramping from
recommended). cold solution
• Check temperature of solution. Place in
Allows for control of fluid flow
warm bath if necessary, to increase
Prepares irrigation solution
solution temperature.
Prevents air from infusing into bowel
• Close tubing clamp. Allows for control of fluid flow
• Fill bag with tap water or ordered
solution. • Open clamp and expel air from
tubing. • Close off clamp.
7. Don gloves. Prevents contamination of hands; reduces risk of
infection transmission
8. Place client comfortably in any of the Provides for effective irrigation
following positions (place pad linen saver
under client if performing procedure in bed)
• On toilet
• Sitting; on chair facing toilet
• In side lying position; turned towardside of
stomal opening, with head of bead
elevated 30-40 degrees
• In supine position
9. Gently remove pouch from stomal area. Avoid skin irritation or injury
10. Assess site for redness, swelling, Determines need for other skin care measures
tenderness and excoriation.
11. Gently wash stoma area with warm, Removes secretions
soapy water.
12. Rinse with clear water and dry thoroughly. Removes soap and prevents irritation of stoma
and surrounding skin area
13. Snap irrigation sleeve to water ring. Holds irrigation bag in place to prevent spillage
14. Position irrigation bag (with tubing Avoids undue pressure on mucosal tissues from rushing
attached) 18 inches above stoma of fluid; prevents irritation of stoma tissue
approximately shoulder level). Lubricate
the cone tip of the tubing with water
soluble gel.
15. Place lower end of sleeve into toilet Provides receptacle for drainage; begins flow of irrigation
or large bedpan and unclamp.
16. Expose stoma through upper Provides access to stoma for insertion of irrigation tubing
opening of sleeve.
17. Gently ease lubricated cone into stoma Prevents escape of bowel contents onto skin
opening. Hold tip securely in place to
prevent backflow.
18. Release irrigation tubing clamp and Slow infusion prevents cramping from overdistention
allow solution to infuse over 10-15
minutes.
19. Encourage client to take slow, deep breaths Relaxes client; decreases cramping of bowel
as solution is infusing.
20. If client complains of cramping, stop Allows bowel time to adjust to fluid
infusion for several minutes, thenresume
infusion
slowly.
21. After all the solution has emptied out of Completes irrigation
bag, clamp and remove tubing.
22. Observe for return of fecal material Indicates effectiveness of irrigation
and solution and assess drainage.
23. Remove bottom of sleeve from drainage Restores room cleanliness
receptacle and flush toilet or empty and
clean bedpan.
24. Dry bottom of sleeve and clamp. Prevents soiling and collects further drainage
25. Remove irrigation sleeve. Concludes irrigation procedure
26. Restore or discard all equipment appropriately. Reduces transfer of microorganisms among clients;
prepares equipment for future use
27. Remove and discard gloves, perform Reduces microorganism transfer
hand hygiene, and don a fresh pair of
gloves.
28. Wash, rinse, and dry stoma area. Cleanses peristomal area
29. Apply new ostomy pouch. Spray deodorizer Restores ostomy pouch; eliminates unpleasant odor
if needed.
30. Remove and discard gloves. Perform Reduces microorganism transfer
hand hygiene.
31. Evaluate / document related information. Documentation provides accurate details of response to
the procedure and clear communication among the
health care team.
This is to identify positive or negative response to the
procedure, provides objective measure of effectiveness,
and inspect if he/she needs other intervention
Procedure: Ostomy Stoma Care
PREPARATION RATIONALE
Purpose Proper assembling of equipment facilitates continuous
• Maintains integrity of stoma and peristomal and smooth-flowing procedure; thus, saving time and
skin (skin surrounding stoma) energy for the nurse and the client. It also avoids leaving
client unattended in retrieving any missing equipment.
• Prevents lesions, ulcerations, excoriation,
and other skin breakdown caused by
fecal contaminants
• Prevents infection
• Promotes general comfort
• Promotes positive self-concept
Equipment
• 2 pairs of nonsterile gloves
• Graduated container
• Linen saver
• Basin of warm, soapy water
• Washcloth and towel
• 4x4 in gauze
• Room deodorizer
• New pouch and wafer appliance
• Mirror
• Pen
Assessment Healthy stomas are pink to brick red in color. Notify
• Assess appearance of stoma (should be health care provider immediately if color is blue, brown,
pink and moist) and peristomal skin or black in color.
(should be intact)
Abdominal status and dimension of stoma determines
• Dimension of stoma to ensure correct bag
pouching system selection and need for other
and wafer size
equipment.
• Characteristic of fecal waste
• Abdominal status Patients who have difficulty using their hands or limited
• Teaching needs ability and preference of vision find a one-piece system or a precut pouch and skin
client for self-care barrier more desirable to use. Patients who have mobility
problems or spinal cord injuries benefit by using
equipment that has a longer pouch, which is easier to
empty independently when sitting. For patients who
prefer being able to keep the skin barrier in place for
several days and change just the pouch, the two-piece
system is desirable.
Procedure
1. Perform hand hygiene, organize Reduces microorganism transfer; promotes efficiency
equipment, and prepare new stoma pouch
and wafer.
2. Explain general procedure to client and then Reduces anxiety; promotes cooperation; reinforces
explain each step as it is performed, allowing detailed instructions client will need to perform self-care
the client to ask questions or perform any part
of the procedure.
3. Determine if the client is allergic to Avoids allergic reactions
iodine based antiseptics and use alternative
if indicated.
4. Provide privacy. Decreases embarrassment
5. Position mirror to reveal stoma area Allows client to observe and learn procedure
to client.
6. Don gloves. Prevents contamination of hands; reduces risk of
infection transmission
7. Place linen saver on abdomen around Prevents seepage of feces onto skin
and below stoma opening.
8. Carefully remove pouch and wafer Avoids tearing of skin; prevents leakage while
appliance and place in plastic waste bag (save changing pouch
tail closure for reuse). Remove wafer by gently
lifting corner with fingers of dominant hand
while pressing skin downward with fingers of
nondominant hand. Remove small section at a
time until entire wafer is removed. Place 4x4
in gauze over stoma opening.
9. Empty pouch. Measure waste in Maintains accurate records
graduated container before discarding and
record amount of fecal contents.
10. Remove and discard gloves, perform Reduces microorganism transfer
hand hygiene, and don new gloves.
11. Gently clean entire stoma and peristomal Removes fecal matter from skin and stoma opening
skin with gauze or washcloth soaked in
warm, soapy water (if some fecal matter
difficult to remove, leave wet gauze for a
few minutes before gently removing fecal
matter). Rinse and pat dry thoroughly.
12. Apply a new pouch device. Provides skin protection from fecal contaminants
13. Restore or discard all equipment Reduces transfer of microorganisms
appropriately. among clients; prepares equipment for future use
14. Remove and discard gloves and Reduces microorganism transfer
perform hand hygiene.
15. Spray room deodorizer if needed. Eliminates unpleasant odor
16. Documentation Documentation provides accurate details of response to
• Completion of procedure date, time, color, the procedure and clear communication among the
consistency, and amount of stool in pouch health care team.
• Condition of stoma and peristomal skin
This is to identify positive or negative response to the
• Abdominal assessment procedure, provides objective measure of effectiveness,
• Client’s response to the procedure and inspect if he/she needs other intervention
Reference:
Berman, A., Snyder, S., & Frandsen, G. (2016). Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice.
New Jersey: Pearson. Jean Smith-Temple and Joyce Young Johnson. Nurses’ Guide to Clinical Procedures 6th Ed.
(Wolter Kluwers / Lippincott Williams and Wilkins)
