An ileostomy is a surgical procedure that creates a new pathway for digestive waste to exit the body when the colon or rectum cannot be used. This involves bringing a part of the small intestine, specifically the ileum, through an opening in the abdominal wall, which is called a stoma. Since the stoma does not have a muscle to control the passage of stool, a specialized external pouching system, often called a bag, is worn over the stoma to collect the output. Learning the correct technique for changing and caring for this system is essential for protecting the skin around the stoma, known as the peristomal skin.
Gathering Supplies and Hygiene Preparation
Before beginning the change process, having all necessary supplies organized and within easy reach is important to ensure a smooth transition. Thorough hand washing with soap and water should be the first step to prevent the introduction of bacteria to the stoma site.
The required items include:
- A new pouching system.
- A measuring guide and specialized scissors for cutting the wafer.
- A disposal bag.
- Adhesive remover spray or wipes.
- Barrier products like paste or rings.
- A clean towel or dry wipes.
- Warm water for cleaning the skin.
Finding a comfortable, private location for the change helps relax the abdominal muscles, which can make the process easier. Some individuals may find it helpful to use a handheld mirror or to lie down to better see and manage the stoma site.
Step-by-Step Removal of the Old Pouch
The process should begin by emptying the contents of the used pouch into the toilet. The used appliance must then be removed gently to prevent skin stripping, which is mechanical injury caused by pulling off the adhesive too aggressively. Skin stripping compromises the integrity of the peristomal skin, leading to irritation and potential breakdown.
A gentle removal technique involves using one hand to apply light pressure to the skin, pushing it away from the adhesive barrier while the other hand slowly peels the appliance downward. This “push and pull” method minimizes the traction exerted on the delicate skin layers. If the barrier is strongly adhered, an adhesive remover spray or wipe can be used to dissolve the bond between the skin and the hydrocolloid material.
Once the old appliance is fully detached, it should be immediately placed into the disposal bag and sealed, along with any used wipes or tissues. Ostomy supplies should never be flushed down the toilet, as they can cause plumbing blockages.
Stoma Site Cleaning and Skin Barrier Application
With the old pouch removed, the peristomal skin and stoma can be gently cleaned using only warm water and a soft cloth or dry wipe. Soaps, especially those with perfumes, moisturizers, or oils, should be avoided as they can leave a residue that compromises the adhesion of the new barrier. The cleaning motion should be a gentle pat or wipe, avoiding vigorous rubbing that can irritate the skin.
A healthy stoma appears moist, beefy red or pink, and may bleed slightly when touched due to the presence of many small blood vessels. The peristomal skin should resemble the skin on the rest of the abdomen, without redness, open sores, or signs of rash. After cleaning, the skin must be patted dry; a hairdryer on a cool setting can be used if necessary, as the new adhesive will not bond securely to moist skin.
If the skin is uneven due to scars, creases, or dips, accessory products are used to create a flat surface for the barrier. Barrier rings or seals, which are moldable hydrocolloid products, can be stretched or shaped to fit snugly around the stoma base and fill in any gaps. Barrier paste can also be applied directly around the stoma to ensure a smooth surface, protecting the skin from output.
Securely Attaching the New Pouching System
Before applying the new pouching system, the stoma must be measured to determine the correct size for the skin barrier opening. The stoma’s size can change, particularly following surgery, so measurement is necessary, often using a specialized guide. The opening cut into the skin barrier should be sized to leave only a minimal clearance of about 1/16 to 1/8 of an inch around the stoma.
This small margin ensures that the corrosive ileostomy effluent, which is loose or porridge-like, does not contact the peristomal skin. The opening is traced onto the paper backing of the skin barrier, and curved scissors are used to cut the hole. If using a two-piece system, the new pouch is then attached to the wafer or flange.
The adhesive surface of the barrier can be warmed with a hand or by holding it against the body, which helps the hydrocolloid material become more pliable and conform better to the skin. The backing paper is then removed, and the barrier is carefully centered over the stoma, aligning the opening precisely. Firm, gentle pressure is applied to the barrier, starting at the stoma and smoothing outward toward the edges, and held in place for 30 to 60 seconds to ensure a secure seal.
Important Considerations for Long-Term Stoma Health
Monitoring the stoma and peristomal skin is essential for long-term care. Minor bleeding from the stoma’s surface, often a result of friction or cleaning, is generally not a concern. However, persistent itching or redness around the stoma often indicates that the pouching system seal is failing, allowing effluent to contact the skin.
Certain warning signs necessitate immediate medical attention from a healthcare professional or ostomy nurse. A significant change in the stoma’s color, such as turning purple or black, may signal a lack of blood flow.
Other serious symptoms include:
- Continuous bleeding from inside the stoma.
- Severe skin breakdown that is weeping or deeply ulcerated.
- Severe cramping, nausea, or vomiting.
- A complete absence of output for more than 12 hours, indicating a potential bowel obstruction.
Ileostomates must manage the risk of dehydration and electrolyte imbalance due to the liquid nature of the output, which bypasses the large intestine’s water absorption function. A high-volume output, defined as more than 1,000 mL in a 24-hour period, can lead to fluid depletion. Patients should discuss fluid and dietary intake with their healthcare team to maintain a safe balance.