Types of Ostomies
When many people hear “ostomy,” they immediately think of colostomy. However, a colostomy is not the only type of “ostomy” that a caregiver might encounter. An ostomy is any surgical opening created to connect an internal organ to the outside of the body. Most function to eliminate bodily waste, but a few serve to take in nutrition.
The most common ostomies include:
- Colostomy – Created by bringing part of the large intestine (the colon) to the surface of the abdomen. The external stoma sits on the left side of the stomach. The waste products from the body exit through the stoma into the pouch in a solid-state. Some colostomies are of the double-barrel variety, meaning they have two stomas. Most of the time, the second stoma drains mucus and may only need a covering rather than a pouch or bag once it heals.
- Ileostomy – Digestive complications related to the small intestine may require the creation of an ileostomy. In creating an ileostomy, the ileum of the small intestine connects to the outside abdomen. The stoma appears on the right side of the body. Since the small intestine produces a significant number of digestive enzymes to break down food, the discharge into the pouch is liquid or semi-liquid and can be very irritating to the skin. Caregivers need to work with an ostomy nurse to achieve a good fit for an ostomy appliance and identify the best products for preventing skin irritation or corrosion from the stomach acids.
- Urostomy (ileal conduit) – With bladder removal or significant impairment, ureters are detached from the bladder on one end and attached to the “back portion” of the ileum that is sewn shut. The stoma appears on the right-hand side at the other end of the ileum. Urine and mucous empty into the pouch used as a collection device. Both are very irritating to the skin — a separate neobladder stores urine as needed for access.
- Nephrostomy: A nephrostomy eliminates a blockage preventing the flow of urine from the kidney out of the body. The surgical opening created allows the urine to drain through a tube (Nephrostomy tube) into a pouch.
- Cecostomy: When regular bowel irrigations are necessary, a cecostomy may be helpful. A cecostomy allows the performance of colon irrigation using a tube inserted directly into the cecostomy like an enema.
- Gastrostomy: An opening created through the skin into the stomach. A tube used for venting or drainage or insertion of a feeding tube for nutritional support directly into the stomach.
- Jejunostomy: An opening created through the skin into the jejunum (part of the small intestine) that can be used for a feeding tube or as a bypass during bowel resection.
- Cholecystojejunostomy (Partial External Biliary Diversion): This surgery involves connecting a small piece of intestine between the gallbladder and the abdominal wall. A small hole made in the gallbladder and one end of the intestine is attached to that opening. The other end of the intestine is attached to a hole in the abdominal wall to create a stoma.
Reference: United Ostomy Associations of America.
New ostomy patients should check out their website and get a copy of their New Ostomy Patient Guide. It has lots of great information in it that you will find very useful
Caring for an Ostomy
Steps To Follow to Change an Appliance
- Wash hands, put on gloves, and gather equipment and supplies, wash clothes, barrier supplies, etc.
- Empty, remove and discard the old appliance.
- Clean around the stoma and inspect for skin breakdown.
- Get clean gloves to measure stoma. You want the barrier you cut to measure about 1/8 inch larger than stoma. Decide on the size you want to cut for the barrier.
- Cut the barrier out of the center of the pouching system. Peel off the backing to apply to the skin.
- To provide a better seal and extra protection against leakage, you can apply a ring of stoma paste to the edge of the ring as an additional measure to help it stick.
- Stick the pouch system to the skin pressing it firmly into place around the stoma. Seal all edges entirely by pushing all around them.
- Leave a little air in the bag, so it drains well. Clamp the end of the bag closed.
- Clean up supplies and discard gloves.
The following YouTube video provides a demonstration of how to perform the task properly.
- Consider having at least two pouching systems – one to wear and one ready to use. The back-up comes in handy if you suddenly need an appliance change with little warning.
- Though most pouches are odor-free, add pouch deodorants for odor-free assurance. Avoiding foods such as fish, eggs, onions, and garlic is also helpful.
- New stomas take approximately 6-8 weeks to shrink to their final size. Therefore, buying items based on the size of the stoma should be delayed for six-eight weeks.
Perform colostomy irrigation for two primary reasons. (1) to remove excessive stool from the colon or (2) for bowel training.
When performed for bowel training, the procedure is conducted at the same time each day using the warm water (about 1000 ml) and being as consistent as possible so that the bowel forms an expectation for evacuating at a specific time each day. The process takes about one hour: 5-10 minutes to put in the solution but forty minutes or so for the completion of the returns.
When bowel training is successful, the individual no longer needs to wear a colostomy bag. They can wear a cap over the stoma. They have more freedom of movement in their lives. Bowel training is not an option for individuals with ileostomies due to their having liquid stools frequently throughout the day.
The following YouTube video reviews the process for Colostomy Irrigation.
- Gather supplies – colostomy irrigation sleeve, drainage pouch clip, ostomy belt, lubricant, cone, tubing,
- Fill the irrigation bag with warm water and hang it from an IV pole or another device that allows for the gravity flow of water. The bag needs to be higher than the family member’s stoma. The height of the bag should be such that the bottom of it is level with the individual’s shoulder.
- Prime the bag and tubing to remove all the air.
- Remove the ostomy appliance if one is in place and clean around the stoma.
- Place an irrigation sleeve over the stoma. If the sleeve doesn’t have adhesive, secure it with an ostomy belt. If they use a two-piece pouching system, snap off the pouch and save it and snap on the irrigation sleeve.
- Place the open end of the sleeve into a bedpan or toilet
- Lubricate your gloved little finger and insert it into the stoma. The stoma will likely tighten around your finger. Just wait for it to relax for just a bit. When it does, then proceed with feeling the inside of the stoma to see which direction the bowel angles.
- Lubricate the cone generously. Bring the cone up through the irrigation bag. Insert the cone into the stoma following the angle identified previously. Insert gently but snugly.
- Have your family member take slow, deep breathes to reduce any cramping or discomfort caused by the introduction of the cone.
- Unclamp the tubing and allow the water to flow in over 5-10 minutes until all of it has entered the colon. If cramping occurs, slow down the flow and encourage slow, deep breaths.
- After the water is in, keep the cone in place for 15 minutes and then unclamp the sleeve to allow the bowel to evacuate over the next 30-40 minutes.
AmCollegeofSurgeons Published on Mar 7, 2013
The standardized interactive program has been developed by the American College of Surgeons (ACS) with input from the American Society of Colon and Rectal Surgeons (ASCRS), Wound Ostomy Continence Nurses Society (WOCN), and the United Ostomy Associations of America (UOAA).
Here’s how to fit a skin barrier and a pouch together before applying them to your skin.
- Obtain a stoma measuring guide and determine the current size of your stoma.
- Trace the appropriate size circle carefully on the back of the skin barrier.
- Cut the circular opening in the skin barrier (or cut the shape of the stoma if it’s not circular). Smooth any rough edges with your fingers.
- Remove the backing from the skin barrier and apply barrier paste or moldable barrier ring, as needed, along the edge of the circular opening.
- Center a one-piece system over the stoma, adhesive side down, and gently press it to the skin.
- When using a two-piece system, apply the wafer and then gently press the pouch opening onto the ring until it snaps into place. When using a two-piece adhesive coupling, devise line up the adhesive portion of the pouch to the “landing zone” of the wafer. Press together for adhesion. The pouches used in a two-piece system can be attached to the wafer before application and applied like a one-piece system. Other two-piece systems have a floating flange that allows the user to insert the fingers underneath so that snapping the flange to the pouch doesn’t exert pressure.
- Close the bottom of the pouch by folding the end upward and using the clip that comes with the product or close the integrated closure system.
Lippincott Nursing Procedures (2019) 8th Ed. Philadelphia: Wolters Kluwer, 195.
Types of Permanant Urinary Diversion
The two types of permanent urinary diversion are Ileal Conduit and the continent urinary diversion or Indiana pouch.
A segment of the ileum is cut out and the two ends are sewn together. Then the two ureters are disconnected from the bladder and connected to the ileum segment created. One end of the ileal segment is closed with ureters with sutures, and the other end is brought through the stomach to form a stoma.
Continent Urinary Diversion
The ureters are attached to a segment of the ileum and cecum. Urine drains out periodically by inserting a catheter into the stoma.
Lippincott Nursing Procedures (2019) 8th Ed. Philadelphia: Wolters Kluwer, 195.
- The pouch can become heavy and pull away if not emptied frequently because the bladder continuously produces urine — plan to empty the bag at least every 2-3 hours initially until you learn your pattern.
- Catheters may be reused up to one month if washed thoroughly with soap and water but discard them if they become discolored or cracked.
- Stomas bleed easily. Be careful to protect them against abrasions but also don’t be alarmed if they occasionally bleed.
Disposable Pouching Systems
Options for the disposable pouching system include a one-piece disposable system with spout closure and a two-piece drainable disposable pouch with a skin barrier. The one-piece system consists of a transparent or opaque odor-proof plastic bag with attached adhesive backing. Some bags have microporous tape edges or belt tabs. The spout opening enables easy draining.
The two-piece drainable, disposable pouch with a separate skin barrier permits more frequent pouch changes. Also made of transparent or opaque, odor-proof plastic, the style comes with a belt tab and usually snaps to the skin barrier with a flange mechanism. Newer two-piece pouches have an adhesive coupling. The pouch sticks to the wafer, allowing greater flexibility and comfort.
Reusable Pouching Systems
A reusable sturdy, opaque, hypoallergenic, plastic pouch is available with a separate custom-made faceplate and O-ring. The device has a 1-3-month life span depending on how frequently you empty the bag. The benefit is that it has a firm faceplate, may be used by those who need something with less sensitivity to adhesive, and saves money.
Lippincott Nursing Procedures (2019) 8th Ed. Philadelphia: Wolters Kluwer, 805.