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4 If the bag is of the drainable type, empty the contents into a jug before removing the bag. For ease of handling the appliance and prevention of spillage. E

Procedure

5 Remove the appliance. Peel the adhesive off the skin with one hand while exerting gentle pressure on the skin with the other. To reduce trauma to the skin. Erythema as a result of removing the appliance is normal and quickly settles (Broadwell 1987, C).

6 Remove excess faeces or mucus from the stoma with a damp tissue. So that the stoma and surrounding skin are clearly visible. E

7 Slide the bridge gently to one side to ensure the mobile wing of the bridge is away from the stoma. Turn this wing so that it becomes flush with the bridge. Gently slide the bridge through the stoma loop (see Action Figure 7). To prepare bridge for removal. E

8 Fold the bridge in half so that the bridge appears in a ‘C’ shape. Gently slide the bridge through the stoma loop (see Action Figure 7).

9 Examine the skin and stoma for soreness, ulceration or other unusual phenomena. If the skin is unblemished and the stoma is a healthy red colour, proceed. If the skin is red and/or broken, apply barrier cream. If the stoma is not a healthy red colour inform medical and/or stoma care nurse. For the prevention of complications or the treatment of existing problems (see Table 6.5). E

10 Wash the skin and stoma gently until they are clean. To promote cleanliness and prevent skin excoriation. E

11 Dry the skin and stoma gently but thoroughly. The appliance will attach more securely to dry skin. E

12 Apply a clean appliance. To contain effluent from the stoma. E

13 Dispose of soiled tissues, the bridge and the used bag. To prevent environmental contamination. E

14 Wash hands with bactericidal soap and water or bactericidal alcohol handrub. To reduce risk of cross-infection (Fraise and Bradley 2009, E).

Action Figure 7 Removal of stoma bridge or rod.

Postprocedural considerations

Immediate care

Colostomy function

In the first few days a sigmoid colon stoma will produce haemoserous fluid and wind. By day 5 there should be some faecal fluid and then by day 7–14, semi-formed stool (Cottam 1999). A closed appliance may be used. In the case of a stoma formed in the transverse colon, only a small amount of water will be reabsorbed from the faecal matter, so the faecal matter will be unformed. This means a drainable pouch will need to be used.

Patients with a sigmoid colostomy may find that wholemeal foods assist in producing a formed stool once or twice daily (Black 1998, Myers 1996). Medications that reduce peristaltic action, for example codeine phosphate, may also be used to control diarrhoea. The only means of controlling a sigmoid colostomy, however, is by regular irrigation or by use of a Conseal plug system. Stoma care nurses will need to assess patients before teaching them how to perform the irrigation procedure or to use Conseal plugs.

Ileostomy function

For the first few days the stoma will produce haemoserous fluid and wind. By days 5–10 there will be brown faecal matter (Cottam 1999). The fluid output after surgery can be as much as 1500 mL/24 hours but this will gradually reduce to 500–850 mL/24 hours as the bowel settles down (Black 2000). Sometimes the output from a stoma remains high (>1000 mL/24 hours), which may be due to the amount of small bowel removed at surgery or an underlying bowel condition; these patients require careful management.

It is important that fluid balance recordings are made and serum electrolytes are measured as patients are at risk of sodium and/or magnesium depletion (Burch 2004). Patients with a high-output stoma may need to be managed by specialist teams which include gastroenterologists, dietitians and stoma care nurses. The effluent takes on a porridge-like consistency when a normal intake of food is established. A drainable appliance is therefore used. The effluent contains enzymes, which will excoriate the skin, so if the pouch leaks, it must be changed promptly to prevent