General characteristics

Document if the diversion is an intestinal or urinary ostomy, whether it’s temporary or permanent, and the location— abdominal quadrant, skin fold, umbilicus. (See Descriptor reference.)

Describe the type of ostomy:

• colostomy (colon)—sigmoid or descending colostomy, transverse colostomy, loop colostomy, ascending colostomy

• ileostomy (small bowel)—ileoanal reservoir (J-pouch), continent ileostomy (Kock pouch)

• urostomy (bladder)—continent urostomy, Indiana pouch, orthotopic neobladder.

Document the presence and location of bowel sounds.

Stoma information

Note the type:

• loop (two openings through one stoma)

• end (one stoma)

• double barrel (two distinct stomas).

Document the overall appearance (shiny, taut, edematous, dry, moist, pale, textured, smooth, bloody) and the presence of stents, rods, drains (include type and location).

Describe the color (red, beefy red, pink, pale pink, purple, blue, black) and shape (round, oval, budded).

Note the height:

• flush—at skin level

• prolapsed—telescoped out from the abdominal surface.

Document the size in millimeters:

• Round stomas are measured by diameter.

• Oval stomas are measured by widest length and width.

Describe the lumen:

• location—straight up, side, level with skin, or centrally located

• number of lumens, stenosis, or stricture.

• Note: Document the location of the lumen by using the clock system, with the patient’s head at 12:00.

Describe the odor—presence or absence of odor, strong, foul, pungent, fecal, musty, sweet.

Note whether the stoma and peristomal skin junction is intact or separated.

Effluent

For a fecal stoma, describe the amount, consistency, and overall appearance of effluent— thick, viscous, liquid, pasty, oily, formed, soft, thin, tarry.

For a urinary diversion, describe urine characteristics, volume, presence of odor (musty, fishy, fecal, acid), color (clear, cloudy, amber, straw, colored, blood tinged), and presence of substances other than fluid (grit, crystals, mucous strands).

Peristomal skin

• Describe the characteristics of peristomal skin—color, edema, firmness, intactness, induration, pallor, lesions, texture, scar, incision, rash, staining, moisture.

• Assess a minimum of 2 inches out from around the stoma.

Appliance and accessories

• Document the type of ostomy appliance and accessories. Include the pouching system product, size, and product number. Note the presence of a spout, the convexity, and whether it’s a one-piece or two-piece system,

• Observe and document proper function and adhesion, and complications experienced with appliance systems. Document any modifications to the care plan, implementation of new orders, and referrals.

Other important information

• Document pain—location, causative factors, intensity, quality, duration, alleviating factors, patterns, variations, interventions.

• Note stoma or peristomal skin complications— mucocutaneous separation, stenosis, necrosis, bleeding, dermatitis, folliculitis, peristomal hernia, caput medusae, peristomal hyperplasia, pseudoverrucous lesions, allergic dermatitis, contact dermatitis, pouch leakage, infection.

• Document patient and caregiver education— topics covered, level of understanding, and education materials distributed.

Nancy Morgan, cofounder of the Wound Care Education Institute, combines her expertise as a Certified Wound Care Nurse with an extensive background in wound care education and program development as a nurse entrepreneur.

Information in Apple Bites is courtesy of the Wound Care Education Institute (WCEI), © 2016.