STATE OF CONNECTICUT

DEPARTMENT OF DEVELOPMENTAL SERVICES

NURSING DELEGATION PROCEDURE

PROTOCOL: COLOSTOMY/ILEOSTOMY CARE

I. Purpose: To provide means of fecal evacuation. To maintain the integrity of the stoma and
peristomal area. To prevent lesions, ulceration, excoriation, and other skin breakdown caused
by fecal contaminants. To promote general comfort and positive self-image.

Definitions: Licensed Nurse: A Registered Nurse (R.N.) or a Licensed Practical Nurse

(L.P.N.), working under the direction of a registered nurse, who holds a current license
issued by the State of Connecticut under Chapter 378 of the Connecticut General
Statutes.

II. Responsibility:

A. Training: Training will be conducted by a licensed nurse.

B. Performance:
1. Direct care staff who have completed:
a. Baseline competency training checklist of DDS.
b. Procedure task specific training.
2. Trained staff will follow individual procedural guidelines including notifying the
licensed nurse as indicated.
B. Monitoring:
1. The licensed nurse.
2. Trained staff performing the task under the clinical direction of a licensed nurse,
will notify the nurse of issues and/or outcomes as directed by the nurse.
C. Documentation:
1. Individuals who perform the tasks will record all pertinent information as
instructed by the licensed nurse.
2. The licensed nurse will ensure agency compliance with required documentation.

III. Training to Include:

A. Initial: overview of the procedure, its purpose. Demonstration of techniques by licensed

nurse and return demonstration by the student.
B. Documentation of Training and Monitoring:
1. Training: Licensed nurse completes training record of staff on “DDS Nursing
Delegation Procedure Performance Evaluation Form”.
2. Monitoring: Licensed nurse completes DDS “Nursing Delegation Task
Competency Monitoring Form”.
B. Frequency of Monitoring and Task Performance:
1. Staff will be monitored in their proficiency at this skill as determined by the
licensed nurse but not to exceed 12 months.

IV. Related Knowledge:

A. Background of the disease
B. Medical history of the person
C. Basic anatomy and physiology of the gastrointestinal tract
D. Skin care
E. Characteristics of ostomy drainage

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 STATE OF CONNECTICUT
DEPARTMENT OF DEVELOPMENTAL SERVICES
NURSING DELEGATION PROCEDURE

PROCEDURE: APPLYING ADHESIVE STOMA PLATE AND/OR POUCH

Name:      

Residence:      

Date of Initial Order:       Date Order Renewed:      

(in pencil)

Order:      

I. Diagnosis:      

II. Purpose of Procedure: Maintains integrity of stoma and peristomal skin, prevents lesions,
ulcerations, excoriation, and other skin breakdown caused by fecal contaminants, prevents
infection, promotes general comfort and positive self-image/self-concept, provides clean ostomy
pouch for fecal evacuation, reduces odor from overuse of old pouch.

___________________________________ __________________
Signature of Delegating R.N. Date of Delegation

III. Procedure

TASK RATIONALE
A. Gather equipment:
1. Gloves  To facilitate changing the face plate
2. Protective pad with the least amount of distress
3. Basin of warm water and discomfort to the individual.
4. Soap
5. Washcloth/towel or gauze
6. Measuring guide
7. New pouch appliance(s)
8. Scissors
9. Pen/pencil
10. Peristomal skin paste and stoma
plate (if needed)
11. Waste receptacle
B. Preparation of Individual:
1. Provide privacy.  Reduces embarrassment.
2. Explain procedure to individual.  Reduces anxiety, promotes a calm
approach and eliminates fear and
apprehension.

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 STATE OF CONNECTICUT
DEPARTMENT OF DEVELOPMENTAL SERVICES
NURSING DELEGATION PROCEDURE

C. Perform Task:
1. Wash hands and put on gloves.  Reduces microorganism transfer.
Avoids exposure to individual’s
body secretions.
2. Place disposable protective pads  Removes old pouch for new pouch
around stoma pouch close to application; maintains clean
stoma, remove old stoma plate environment.
and/or pouch, and discard contents;
discard gloves.  Reduces microorganism transfer.
3. Perform hand hygiene and put on
fresh gloves.  Provides data.
4. Inspect stoma and peristomal skin.  Removes stool soilage and
5. Perform stoma care: Gently clean promotes secure pouch
entire stoma and peristomal skin application.
with gauze or washcloth soaked in
warm, soapy water (if some fecal
matter is difficult to remove, leave
wet gauze or cloth on area for a few
minutes before gently removing
fecal matter); rinse and pat dry.  Protects skin and linens during
6. Place gauze pad over stoma procedure.
opening to prevent spillage while
preparing adhesive stoma plate and
 Provides for accurate fit of pouch.
pouch.
7. Measure stoma with measuring
guide. Use measuring guide to
 Cuts barrier to appropriate size for
trace opening on back of plate.
stoma; allows pouch to be placed
8. Leaving intact adhesive covering of
over stoma without adhering to it.
plate, cut out circle, allowing an
extra 1/8 inch for placement over
stoma.  Prevents skin irritation of
9. Remove gauze and apply stomal uncovered peristomal skin.
paste around stoma or apply stomal
paste to edges of opening in plate.
10. Remove adhesive covering of plate,  Adheres plate to skin; warmth of
and place plate on skin with hole skin and fingers enhances
centered over stoma; hold in place adhesiveness once plate makes
for about 30 seconds. contact with skin.
11. Center pouch over stoma and place  Secures pouch for collection of
on plate. If applying a two-piece feces.
appliance, snap pouch on the
flange of the plate.
12. Remove gloves and perform hand
hygiene.  Reduces microorganism transfer.

D. Check Individual’s Status:

1. Make sure the individual is comfortable  To maintain the individual’s mental
and tolerated the procedure well. and physical well being.

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 STATE OF CONNECTICUT
DEPARTMENT OF DEVELOPMENTAL SERVICES
NURSING DELEGATION PROCEDURE

E. Care of Equipment:
1. Restore or discard all equipment  Provides clean environment.
appropriately.
F. Documentation:
1. Record date and time treatment  Communication of information.
completed.
2. Record color, consistency, and amount
of feces in pouch (small, medium,
large).
3. Record condition of stoma and
peristomal skin.  Reporting and communication of
4. Record size of stoma. information.
5. Record individual’s response.
6. Report to nurse any problems that
were encountered.
7. Nurse notification as appropriate.

PLEASE NOTE: NO TASK IS CONSIDERED COMPLETED UNTIL THE DOCUMENTATION

AND REQUIRED REPORTING OCCURS. ANY CHANGE OR VARIATION FROM THE
INDIVIDUAL’S BASELINE SHOULD BE REPORTED PROMPTLY TO THE LICENSED
NURSE.

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 STATE OF CONNECTICUT
DEPARTMENT OF DEVELOPMENTAL SERVICES
NURSING DELEGATION PROCEDURE

PROCEDURE: EVACUATING AND CLEANING A COLOSTOMY OR ILEOSTOMY POUCH

Name:      

Residence:      

Date of Initial Order:       Date Order Renewed:      

(in pencil)

Order:      

I. Diagnosis:      

II. Purpose of Procedure: Removes fecal material from ostomy pouch, cleans pouch for
reuse, maintains integrity of stoma and peristomal skin, promotes general comfort, promotes
positive self-concept.

___________________________________ __________________
Signature of Delegating R.N. Date of Delegation

III. Procedure

TASK RATIONALE
A. Gather equipment:
1. Gloves  To facilitate changing the colostomy
2. Bedpan (if needed) bag with the least amount of
3. Protective pads distress and discomfort to the
4. Washcloths individual.
5. Toilet paper
6. Closure device
7. Waste receptacle
B. Preparation of Individual:
1. Provide privacy.  Reduces embarrassment.
2. Explain procedure to individual.  Reduces anxiety, promotes a calm
approach and eliminates fear and
apprehension.
C. Perform Task:
1. Put on gloves.  Avoids exposure to individual’s
body secretions.
2. Place protective pad on abdomen  Prevents seepage of feces onto
around and below pouch. skin.
3. If using toilet, seat client on toilet or in
a chair facing toilet, with pouch over  Positions individual so feces drain
toilet; if using bedpan, place pouch into receptacle.
over bedpan.  Promotes efficiency; cuff keeps
4. Remove closure device on bottom of bottom of pouch clean, which helps
pouch and place within easy reach. to prevent odor and helps keep
(Fold bottom of pouch up to form a cuff hands clean during procedure.
before emptying.)  Removes feces from pouch.

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 STATE OF CONNECTICUT
DEPARTMENT OF DEVELOPMENTAL SERVICES
NURSING DELEGATION PROCEDURE

5. Slowly unfold end of pouch and allow  Expels additional feces from pouch.
feces to drain into bedpan or toilet.  Removes excess feces from lower
6. Press sides of lower end of pouch end of pouch.
together.  Reduces embarrassment and room
7. Open lower end of pouch and wipe out odor.
with toilet paper.  Cleans exterior closure device.
8. Flush toilet or empty bedpan.
9. Wash closure device while in
bathroom and dry with paper towel.  Reduces microorganism transfer.
10. Remove gloves, perform hand
hygiene, and reglove.  Prevents leakage of feces.
11. Reclamp pouch with cleaned closure
 Completes cleaning of pouch.
device.
12. Wipe outside of pouch with clean, wet
 Reduces microorganism transfer.
washcloth; be sure to wipe around
closure device at bottom of pouch.
13. Remove gloves and perform hand
hygiene.
D. Check Individual’s Status:
1. Make sure the individual is comfortable  To maintain the individual’s mental
and tolerated the procedure well. and physical well being.
E. Care of Equipment:
1. Restore or discard all equipment  Provides clean environment.
appropriately.
F. Documentation:
8. Record date and time treatment  Communication of information.
completed.
9. Record color, consistency, and amount
of feces in pouch (small, medium,
large).  Reporting and communication of
10. Record individual’s response. information.
11. Report to nurse any problems that
were encountered.
12. Nurse notification as appropriate.

PLEASE NOTE: NO TASK IS CONSIDERED COMPLETED UNTIL THE DOCUMENTATION

AND REQUIRED REPORTING OCCURS. ANY CHANGE OR VARIATION FROM THE
INDIVIDUAL’S BASELINE SHOULD BE REPORTED PROMPTLY TO THE LICENSED
NURSE.

Nursing Delegation Procedure Colostomy-Ileostomy Care Final 1-18-12