Module 32. Assisting with Ostomy Care

Transcription

1 Home Health Aide Training Module 32. Assisting with Ostomy Care Goal The goal of this module is to prepare participants to assist a home care client who has an ostomy. Time 7 hours and 30 minutes [1 hour and 30 minutes on the first day; 6 hours on the second day] Trainer s Manual Page 32.1

2 Day 1 Activities Teaching Methods Time 1. Introduction to Ostomies Interactive presentation 15 minutes 2. Assisting with Ileostomies, Colostomies, and Urostomies Day 2 Interactive presentation and demonstrations 1 hour and 15 minutes 3. Assisting with Catheter Care Demonstration 40 min 4. Skills Practice: Assisting with Ileostomies, Colostomies, Urostomies, and Catheter Care Pairs practice, interactive presentation, pairs and largegroup discussion 5. Assisting with Tracheostomies Interactive presentation, demonstration, pairs practice, and pairs discussion 1 hour and 10 minutes 1 hour and 10 minutes 6. Assisting with Gastrostomies Interactive presentation 30 minutes 7. Practice Lab and Return Demonstations: Assisting with Ostomy Care 8. How to Approach Assisting with Ostomies; Summary Pairs practice and return demonstrations Small-group work, large-group discussion, and interactive presentation 1 hour and 45 minutes 45 minutes Supplies Flip chart, markers, and masking tape Pencils and paper Index cards and glue or tape Equipment for tube feeding Pouches for ileostomies and colostomies (disposable, reusable, and openended) Urinary drainage bags Pitcher for measuring urinary output Belts and fasteners for pouches Trainer s Manual Page 32.2

3 Stoma measuring guides and face plates Sample adhesives and adhesive removers, skin sealants, skin barriers, deodorizers, germicides, and lotions that might be used by clients with an urostomy, ileostomy, or colostomy Colostomy irrigation system (container, sleeve and belt, and stoma cap) Tracheostomy kits Tracheostomy tubing and ties Models or mannequins, if available, with stomas for colostomies, ileostomies, and/or tracheostomies Condom catheters Catheter tubing Model of a penis (for practice with a condom catheter) Learner s Book 1. What Is an Ostomy? 2. Basic Information about Digestion 3. Basic Information about Ileostomies and Colostomies 4. Your Role in Assisting with Ileostomies, Colostomies, and Urostomies 5. Diet for a Client with a Colostomy 6. Diet for a Client with an Ileostomy 7. Equipment for Urinary and Bowel Care 8. Assisting with a Urostomy 9. What to Observe, Record, and Report When Assisting with Ileostomy, Colostomy, Urostomy, or Catheter Care 10. Basic Information about Tracheostomies 11. Your Role in Assisting Clients with Tracheostomies 12. Safety for Clients with Tracheostomies 13. What to Observe, Record, and Report When Assisting with Tracheostomies 14. What Is Tube Feeding? 15. Your Role in Assisting with Tube Feeding 16. Mouth Care for Clients with Gastrostomies 17. What to Observe, Record, and Report While Assisting with Tube Feeding 18. Share What You Know Case Studies 19. Your Approach Is Important! Trainer s Manual Page 32.3

4 Worksheets Worksheet 1. Share What You Know Skills Checklists Skills Checklist 1. Assisting with Changing a Colostomy or Ileostomy Pouch (DOH Procedure Checklist H-1) Skills Checklist 2. Assisting with Emptying an Open-Ended Ileostomy or Colostomy Pouch (DOH Procedure Checklist H-2) Skills Checklist 3. Assisting with Cleaning a Reusable Pouch (DOH Procedure Checklist H-3) Skills Checklist 4. Assisting with Colostomy Irrigation (DOH Procedure Checklist H-4) Skills Checklist 5. Assisting with the Emptying of a Urinary Drainage Bag (DOH Procedure Checklist E-4 and XII-21) Skills Checklist 6. Measuring Urinary Output (DOH Procedure Checklist XII- 33) Skills Checklist 7. Assisting with the Use of a Condom Catheter (DOH Procedure Checklist E-2) Skills Checklist 8. Assisting with Cleaning the Skin and Catheter Tubing (DOH Procedure Checklist E-3) Skills Checklist 9. Assisting with Routine Tracheostomy Care (DOH Procedure Checklist H-5) Handouts Handout 1. Key Terms Handout 2. Summary of Key Information Advance Preparation Review all training and presentation materials for this module. Note that icons are used to remind the trainer of the following: Trainer s Manual Page 32.4

5 When you are presenting or covering Key Content in the discussion. (Key Content is also addressed in the Learner s Book and the handouts, but we use the key icon only when it is covered elsewhere in the learning process.) When it is important to ask a particular question to get participants input. When it is time to refer to the Learner s Book. When it is time to distribute a worksheet. When it is time to distribute a skills checklist. When it is time to distribute and discuss a handout. Copy all worksheets and handouts for participants. Prepare copies of the skills checklists. You will need one copy for each participant, to be collected and reused for subsequent trainings. Laminating the skills checklists will make them more durable and reusable. Gather all necessary supplies and equipment. Please note that the Key Content is meant to be background information for the trainer. DO NOT READ OUT LOUD TO PARTICIPANTS. Activity 1. Introduction to Ostomies Prepare the following flip chart pages: Learning Agenda (Step 1) Activity 2. Assisting with Ileostomies, Colostomies, and Urostomies You may want to use an illustration of the digestive system. See the digestive system illustration in the Teaching Tools for the Body Systems and Common Diseases module. Place all the equipment for urinary and bowel care on a large display table (or several desks). Trainer s Manual Page 32.5

6 Activity 3. Assisting with Catheter Care Assemble supplies for demonstration: condom catheters, catheter tubing, supplies for care of the skin, penis model (if available), urinary drainage bag and pitcher. Activity 4. Skills Practice: Assisting with Ileostomies, Colostomies, Urostomies, and Catheter Care Set up workstations for assisting a client with: changing an ileostomy or colostomy pouch; emptying an open-ended ileostomy or colostomy pouch; cleaning a reusable pouch; colostomy irrigation; emptying a urinary drainage bag; use of a condom catheter; and cleaning the skin and catheter tubing. Organize the equipment for the number of practice pairs that you will have. If you don t have enough equipment for every pair to be practicing the procedures, provide the pairs that do not have equipment with stoma measuring guides and face plates so that they can practice cutting the face plate to different sizes while they are waiting. Activity 5. Assisting with Tracheostomies Organize the equipment for the number of practice pairs that you will have; each pair should get two tracheostomy kits. You will likely not have one mannequin with a tracheostomy available for each pair. In this case, provide the pairs that do not have a mannequin with a tracheostomy face plate with ties and tubing. (One person in each pair can tie the tubing around their neck as if they were the client while their partner practices the procedure.) You may want to use an illustration of the respiratory system. See the respiratory system illustration in the Teaching Tools for the Body Systems and Common Diseases module. Activity 6. Assisting with Gastrostomies No advance preparation needed. Trainer s Manual Page 32.6

7 Activity 7. Practice Lab and Return Demonstrations: Assisting with Ostomy Care This practice lab is intended to give participants a chance to practice and do return demonstrations of the skills related to assisting a client with an ostomy. Additional trainers may be needed to assess return demonstrations. Use the same workstations that you had for Activities 4 and 5. Trainers should be prepared with extra copies of the skills checklists to assess return demonstrations. Depending on the number of participants, you may need additional trainers available to observe and document return demonstrations. Some participants may need to do return demonstrations for skills covered earlier in the training. It may be possible to do those return demonstrations during this activity, if needed. Set up workstations accordingly. Activity 8. How to Approach Assisting with Ostomies; Summary No advance preparation needed. Trainer s Manual Page 32.7

8 Activity 1. Introduction to Ostomies 15 minutes Learning Outcomes By the end of this activity, participants will be able to: Define ostomy. Describe the types of ostomies that they may assist with: gastrostomy, ileostomy, colostomy, urostomy, and tracheostomy. Key Content An ostomy is a surgically formed opening in the body that allows a person to either take substances into the body (like food and air) or eliminate substances from the body (like urine and stool). There are five types of ostomies covered in this unit: A gastrostomy is an opening in the stomach. An ileostomy is an opening in the small intestine. A colostomy is an opening in the large intestine. A urostomy is an opening in the urinary system. A tracheostomy is an opening in the trachea (windpipe). Activity Steps Interactive Presentation 15 minutes 1. Introduce module. Explain that this module will introduce participants to ostomies and to the participants role in assisting clients with ostomies. Participants will have the opportunity to observe and then practice procedures related to ostomies, and they will also learn what to observe, record, and report when assisting with ostomies. They will also explore their own feelings about assisting with ostomies. Finally, they will have a chance to hear stories from clients about what it s like to have an ostomy, and Trainer s Manual Page 32.8

9 will apply what they already know about how to approach their role to the specific task of assisting clients with ostomies. Flip Chart LEARNING AGENDA: Assisting with Ostomies Define the different kinds of ostomies. Understand how ostomies affect the body. Identify equipment used to provide care to clients with ostomies. Understand your role in assisting clients with different kinds of ostomies. Identify what to observe, record, and report when assisting with ostomies. Understand how clients may feel about having an ostomy. Explore your own feelings about assisting clients with ostomies. Teaching Tip If you have a large group, write the text on two flip chart pages, so that the print will be large enough to be read by people in the back of the room. Trainer s Manual Page 32.9

10 2. Define ostomy. Explain that an ostomy is a surgically formed opening in the body. Explain that there are different kinds of ostomies and that they have different purposes. Display the flip chart and briefly describe the purpose of each type of ostomy. Explain that you will discuss each type of ostomy in more detail later in the module. 3. Refer to 1. What Is an Ostomy? in the Learner s Book. Emphasize that their role in assisting a client with an ostomy will depend on the type of ostomy that the client has, and that they will assist only with ostomies that are mature and stable (not new and not changing). Explain that the client will have a routine for how they manage their ostomy, and will have selected the equipment that works best for them. Ask if participants have any questions. Trainer s Manual Page 32.10

11 Activity 2. Assisting with Ileostomies, Colostomies, and Urostomies 1 hour and 15 minutes Learning Outcomes By the end of this activity, participants will be able to: Identify equipment used to provide care to a client with an ileostomy, colostomy, or urostomy. Describe the care required by a client with an ileostomy, colostomy, or urostomy. Demonstrate their role in assisting a client with an ileostomy, colostomy, or urostomy. Identify their own feelings about assisting a client with an ileostomy, colostomy, or urostomy. Key Content In the normal process of digestion, food that leaves the stomach moves into the small intestine, where nutrients are absorbed into the blood stream. Anything that cannot be absorbed into the body then passes into the large intestine as waste. In the large intestine, the water is removed from this waste so that it becomes solid (stool). This stool is then stored in the colon and is eliminated from the body through the anus. There are three types of ostomy related to urinary and bowel care: An ileostomy is an opening in the small intestine. A client may have an ileostomy if their small or large intestine is diseased or damaged. A colostomy is an opening in the large intestine. A client may have a colostomy if their large intestine is diseased or damaged. A urostomy is an opening in the urinary system. A client may have a urostomy if the bladder is diseased or not working as it should be. Trainer s Manual Page 32.11

12 There are certain tasks that the home health aide may assist with related to ileostomies and colostomies. These tasks are: Selecting and preparing foods that are appropriate for the client s diet Assisting the client to eat an appropriate diet Changing a pouch Emptying stool or gas from a pouch Cleaning a reusable pouch Irrigating (colostomy only) Caring for the skin around the stoma Under special circumstances, the home health aide may also assist a client with a urostomy. When it is indicated in the care plan and the home health aide has been specially trained by the nurse in the client s home, the home health aide may change or empty a pouch. There are certain tasks that the home health aide may not assist with. In particular, the home health aide may not assist with any care of an ostomy that has a stoma that is new or still healing. Home health aides may assist clients with ostomies only if the stoma is stable and if the client has an established routine for ostomy care. Clients with ileostomies and colostomies need to be aware of what and how they eat. Clients with ileostomies need to avoid food blockage. Certain foods are known to cause blockage and should be avoided. Clients should also be careful to chew slowly. Clients with colostomies can generally eat the same foods as they did before. However, some foods may cause gas, odor, constipation, or diarrhea. Knowing which foods contribute to these problems will help the client and home health aide to address these problems when they arise. Clients with urostomies, ileostomies, and colostomies will have a range of feelings about it. Some clients may have difficulty adjusting. It is important that the home health aide be sensitive to these emotions while assisting. In particular, the home health aide should be careful about what they say while assisting, and also about their facial expressions and tone of voice. Trainer s Manual Page 32.12

13 Participants may have difficult feelings about the idea of assisting with these procedures. It is important to know that these feelings are normal, and that it can take time to feel comfortable assisting with these procedures. If participants need support, they should speak with their trainer or their supervisor (once they are on the job). Activity Steps Interactive Presentation 35 minutes 1. Review basic information about digestion. Review 2. Basic Information about Digestion in the Learner s Book. Explain that, in this activity, participants will learn about assisting clients who have ostomies in their lower digestive system. These ostomies help clients eliminate waste from their bodies when they are no longer able to do so through the processes of urination and defecation. 2. Refer to 3. Basic Information about Ileostomies and Colostomies in the Learner s Book. Then explain that a urostomy is very similar, except that it is an opening in the urinary system that allows urine to leave the body. Ask if there are any questions. 3. Explore client s feelings. Ask participants: If you had a urostomy, an ileostomy, or a colostomy, how do you think you might feel about it? After participants share their responses, emphasize that elimination is a very private matter for most people. Point out that most people learn to control elimination at a very early age. So it is understandable that some clients with ostomies experience difficult feelings when they can no longer control this part of their body s functioning. For some, having an ostomy changes their self-image in ways that are challenging. The home health aide plays an important role in supporting the client emotionally. This will be covered in more detail in a later activity in this module. Trainer s Manual Page 32.13

14 4. Review their role in assisting clients with urostomies, ileostomies, and colostomies. Refer to 4. Your Role in Assisting with Ileostomies, Colostomies, and Urostomies in the Learner s Book. 5. Discuss diet for a client with a colostomy or ileostomy. Review 5. Diet for a Client with a Colostomy and 6. Diet for a Client with an Ileostomy in the Learner s Book. Ask participants if they have any questions. 6. Review equipment. Refer to 7. Equipment for Urinary and Bowel Care in the Learner s Book and show the equipment that you have assembled. Demonstrations 40 minutes 7. Conduct first demonstration. Demonstrate assisting with changing an ileostomy or colostomy pouch by following the steps in Skills Checklist 1. Assisting with Changing a Colostomy or Ileostomy Pouch and Skills Checklist 2. Assisting with Emptying an Open-Ended Ileostomy or Colostomy Pouch. Explain why each step is important. Explain that participants can also assist clients in releasing gas from their ileostomy or colostomy pouch. To do this, they simply unsnap the pouch until the air is released, and then snap the pouch back into place. Emphasize that participants should never attempt to pop or puncture the pouch to release gas. Be sure to emphasize that they should not assist a client with a new ileostomy or colostomy, or with an ileostomy or colostomy that shows any signs of problems (such as skin irritation). Answer any questions. Teaching Tips Note that participants will NOT get the checklists for these skills now, but will get them LATER when they are ready to practice. Remind them that you like to have them give their full attention to OBSERVING and LISTENING while you are doing a demonstration. The trainer should demonstrate these procedures with models or mannequins that have stomas, if available. Trainer s Manual Page 32.14

15 8. Conduct second demonstration. Demonstrate assisting with cleaning a reusable pouch by following the steps in Skills Checklist 3. Assisting with Cleaning a Reusable Pouch. Explain why each step is important. Answer any questions. 9. Conduct third demonstration. Demonstrate assisting with colostomy irrigation by following the steps in Skills Checklist 4. Assisting with Colostomy Irrigation. Explain why each step is important. During your demonstration, be sure to mention the following points: Irrigation is like an enema given through the stomach. The purpose of irrigation is to empty the large intestine of stool so that it will eliminate stool only once a day or once every other day. Usually, nothing is discharged between irrigations except gas. Irrigation is never done for a client with an ileostomy or a colostomy who has frequent stool. Many clients experience cramping during irrigation. If this happens, stop the flow of solution and encourage the client to take deep breaths. Teaching Tip The demonstration of these procedures should follow the steps that are included in the skills checklists as closely as possible. Some steps will not be possible to demonstrate in a classroom setting (for example, Step 21 of Skills Checklist 4, the skills checklist for assisting with colostomy irrigation: allow time for irrigation fluid and stool to be passed through stoma into irrigation sleeve and out into the toilet. ). These steps should be described to participants. 10. Discuss urostomy. Refer to 8. Assisting with a Urostomy in the Learner s Book. Explain that participants will assist clients with urostomies only under special circumstances. Explain that any assistance will be indicated on the care plan. If they are expected to assist with a urostomy, they will be shown how to do so by the supervising nurse in the client s home. Emphasize that the equipment that clients with urostomies use is very similar to the equipment used by clients with ileostomies and colostomies. Trainer s Manual Page 32.15

16 Activity 3. Assisting with Catheter Care 40 minutes Learning Outcomes By the end of this activity, participants will be able to: Identify equipment used for catheter care. Describe the care required by a client with a catheter. Demonstrate their role in assisting a client with a catheter. Identify their own feelings about assisting a client with a catheter. Key Content A nurse is required for inserting or removing a catheter. However, the home health aide may be asked to: Empty a drainage bag for a catheter. Assist with using a condom catheter. Assist with cleaning the skin and the catheter tubing. There are certain tasks that the home health aide may not assist with. In particular, the home health aide may not insert or remove catheter tubing. Activity Steps Demonstration 35 minutes 1. Discuss catheter care. Show the sample catheters with drainage bags. Discuss why a catheter would be used and explain how they work. Note that a nurse would be responsible for inserting and removing a catheter NOT the home health aide but that a home health aide could be responsible for providing perineal care for a client with a catheter, plus draining the collection bag. Trainer s Manual Page 32.16

17 2. Demonstrate how to drain a catheter bag. Explain that catheters have drainage bags that are very similar to the pouches for urostomies, and home health aides may assist in emptying these drainage bags. Demonstrate how to empty the drainage bag of a folie or condom catheter by following the steps on Skills Checklist 5. Assisting with Emptying a Urinary Drainage Bag. Teaching Tips Again, note that participants will NOT get the checklists for these skills now, but will get them LATER when they are ready to practice. Remind them that you like to have them give their full attention to OBSERVING and LISTENING while you are doing a demonstration. 3. Demonstrate how to measure urinary output from the drainage bag. Follow the stpes on Skills Checklist 6. Measuring Urinary Output. Explain how this would be different if the client is NOT ursing a urinary drainage bag. 4. Demonstrate how to assist with a condom catheter. Follow the steps on Skills Checklist 7. Assisting with the Use of a Condom Catheter. 5. Demonstrate how to assist with cleaning the skin and catheter tubing. Explain that, while HHAs are permitted to assist with applying a condom catheter, they are not permitted to insert or remove tubing in a folie catheter. What they can and should do is assist with cleaning the skin around the catheter as well as the catheter tubing. Demonstrate how to do this by following the steps in Skills Checklist 8. Assisting with Cleaning the Skin and Catheter Tubing. Large-Group Discussion 5 minutes 6. Facilitate large-group discussion. Ask: How do you avoid causing the client discomfort when cleaning the skin around the catheter? What steps are most important to the client s safety and for preventing the spread of infection when assisting with catheter care care? What steps prevent the spread of infection when draining the catheter bag? Trainer s Manual Page 32.17

18 Activity 4. Skills Practice: Assisting with Ileostomies, Colostomies, Urostomies, and Catheter Care 1 hour and 10 minutes Learning Outcomes By the end of this activity, participants will be able to: Demonstrate their role in assisting a client with an ileostomy or colostomy. Demonstrate how to cut the face plate to properly fit around the stoma of an ileostomy or colostomy. Demonstrate their role in assisting a client with the use of a condom catheter. Demonstrate their role in assisting with cleaning the skin and catheter tubing. Activity Steps Pairs Practice 50 minutes 1. Give instructions for pairs practice. Explain that participants will now have 45 minutes to practice some of the procedures they have just seen demonstrated. Ask participants to form pairs. Then distribute Skills Checklists 1 8 and remind them how to practice in pairs: Participants will practice some or all of the following procedures: assisting with changing an ileostomy or colostomy pouch, assisting with emptying an open-ended ileostomy or colostomy pouch, assisting with cleaning a reusable pouch, assisting with colostomy irrigation, assisting with emptying a urinary drainage bag, assisting with putting on a condom catheter, and assisting with cleaning the skin and catheter tubing. Trainer s Manual Page 32.18

19 When the pairs are at a practice station, they will choose one person to start in the role of the direct-care worker. The other person will be the observer. The observer will use the skills checklist to provide guidance to their partner and to give feedback afterwards. This is also a tool to help participants reinforce their knowledge of the steps involved in performing the task and prepare for the return demonstration. After the person who played the home health aide finishes a procedure, she will switch roles with her partner. Explain that, if they do not have time to practice all of the procedures, they will have additional time in a practice lab at the end of the module. 2. Explain the trainers role. Explain that the trainer(s) will be moving around the room to monitor how participants are doing, to answer questions, and to provide additional instructions as necessary. 3. Conduct the practice activity. Circulate as described in the previous step to answer questions and provide additional instructions as needed. Interactive Presentation 10 minutes 4. Review 9. What to Observe, Record, and Report When Assisting with Ileostomy, Colostomy, Urostomy, or Catheter Care in the Learner s Book. Ask participants if they have any questions. Pairs and Large-Group Discussion 10 minutes 5. Introduce Ella and read her story. Explain to participants that it is normal to have some difficult feelings when learning how to assist clients with procedures related to urinary and bowel care. Explain that you are going to read a short story so that they can hear how a home health aide named Ella felt the first time she assisted her client with irrigating her colostomy. Read the following story out loud: Trainer s Manual Page 32.19

20 The first time that I had to assist Mrs. Martinez with irrigating her colostomy, I felt kind of grossed out. I had to remind myself that Mrs. Martinez was probably feeling even more uncomfortable than I was after all, she just met me and here I was looking at her stool! That s why I tried not to let Mrs. Martinez see how I was feeling. Instead, I made sure that my voice sounded professional and reassuring. 6. Set up discussion in pairs. Ask participants to spend two minutes with their practice partner answering the following question: How are you feeling right now about assisting clients with these procedures? 7. Debrief pairs discussion. After two minutes, ask if anyone would like to share how they are feeling with the whole group. Listen to participants responses. Be sure to reassure participants that it is okay to have difficult feelings. Emphasize that participants can talk to their supervisors about how they feel, and they can also get advice from their supervisors if they need it. Explain that participants can also approach you to talk more about how they are feeling if they would like. Trainer s Manual Page 32.20

21 Activity 5. Assisting with Tracheostomies 1 hour and 10 minutes Learning Outcomes By the end of this activity, participants will be able to: Identify equipment used to provide care to a client with a tracheostomy. Describe the care required by a client with a tracheostomy. Demonstrate their role in assisting a client with a tracheostomy. Identify their own feelings about assisting a client with a tracheostomy. Key Content A tracheostomy is a surgically formed opening in the windpipe. Clients may have a tracheostomy if the larynx is removed or injured, or if the client has difficulty breathing. The home health aide may assist a client with routine tracheostomy care. The home health aide may also assist with keeping the area clean and dry and with dressing changes. There are certain tasks related to tracheostomy care that the home health aide may not assist with. It is very important for the home health aide to know which tasks are not permissible. The home health aide must take certain safety precautions when assisting clients with tracheostomies. These precautions are important in order to prevent infection or difficulty with breathing. In particular, the home health aide must keep all equipment very clean and ensure that nothing gets into the tracheostomy tube that could result in choking. Trainer s Manual Page 32.21

22 Activity Steps Interactive Presentation 15 minutes 1. Review basic information about tracheostomies. Refer to 10. Basic Information about Tracheostomies, 11. Your Role in Assisting Clients with Tracheostomies, and 12. Safety for Clients with Tracheostomies in the Learner s Book. 2. Discuss feelings. Ask participants: If you had a tracheostomy, how do you think you might feel about it? After participants share their responses, explain that clients may have different feelings about having a tracheostomy. Some clients may be glad that they can breathe more easily than they could before they got their tracheostomy. Others may be frustrated, particularly if they cannot speak the way they used to. Emphasize that speech helps people feel in control of their lives and their relationships. Some people with tracheostomies feel powerless when they cannot speak. Emphasize that home health aides need to learn to communicate through whatever methods work for their client. Demonstration 20 minutes 3. Display and discuss equipment. Display the equipment that is used for routine tracheostomy care (see Advance Preparation). Describe the purpose of each type of equipment, and explain that the next thing you will do is demonstrate how to use this equipment for routine tracheostomy care. Ask participants if they have any questions. 4. Demonstrate procedures. Demonstrate the procedure as described on Skills Checklist 9. Assisting with Routine Tracheostomy Care. Emphasize the following information: Trainer s Manual Page 32.22

23 No shreds of fabric or moisture should be left inside the inner cannula after it is cleaned. When cleaning the neck-plate and inner cannula, be careful not to get moisture inside the outer tube. Be sure to tie new ties to the tube before removing the old ties. This will prevent the tube from popping out if the client coughs while the old ties are being removed. It is important to prevent the tube from popping out because this can cause the airway to close. Be sure to tie with a double or triple knot. Never tie a bow. Pairs Practice 15 minutes 5. Introduce activity. Explain that participants will now have 15 minutes to practice some of the procedures they have just seen demonstrated. Ask participants to return to the partner that they practiced with in the last activity. Distribute Skills Checklist 9. Assisting with Routine Tracheostomy Care. Then explain the following: In their pairs, participants will take turns practicing the procedures. One person will play the role of the home health aide, and the other person will observe. If no mannequin with a tracheostomy is available, the person who is in the observer s role will tie a tracheostomy tube around their neck as if they were the client. They can then provide guidance to their partner as she is practicing and and give feedback afterwards. After the first person completes the practice of a procedure, participants will switch roles. Note that, if participants do not have enough time to finish their practice, they will have more time at the end of the module. 6. Explain the trainer s role. Explain that the trainer(s) will be moving around the room to monitor how participants are doing, to answer questions, and to provide additional instructions as necessary. Trainer s Manual Page 32.23

24 Interactive Presentation 10 minutes 7. Discuss ORR for tracheostomies. Refer to 13. What to Observe, Record, and Report When Assisting with Tracheostomies in the Learner s Book. Pairs Discussion 10 minutes 8. Introduce Carmen and read her story. Explain to participants that they are going to have a few minutes to talk about how they feel about assisting a client with routine tracheostomy care. Explain that you are going to read a short story so that they can hear how a home health aide named Carmen felt when she found out she would be assisting her client with his tracheostomy. Read the following story out loud: When I found out that I was going to have to assist Mr. Santos with his tracheostomy, I was really nervous that I would do something wrong. But the nurse on the case spent time with me to review how to do everything correctly. Now I feel very confident when I assist Mr. Santos. 9. Set up discussion in pairs. Ask participants to spend two minutes with their practice partner answering the following question: How are you feeling right now about assisting clients with this procedure? 10. Debrief pair discussion. After two minutes, ask if anyone would like to share how they are feeling with the whole group. Listen to participants responses. Be sure to reassure participants that it is okay to have difficult feelings. Emphasize that participants can talk to their supervisors about how they feel, and they can also get advice from their supervisors if they need it. Explain that participants can also approach you to talk more about how they are feeling if they would like. Trainer s Manual Page 32.24

25 Activity 6. Assisting with Gastrostomies 30 minutes Learning Outcomes By the end of this activity, participants will be able to: Describe the physical effects of a gastrostomy. Describe how to assist with tube feedings. Describe their role is assisting with skin care and mouth care for clients with gastrostomies. Describe what to observe, record, and report. Key Content The process of digestion begins when a person takes food into the mouth. The food is then chewed, mixed with saliva, and swallowed. Clients who are no longer able to take nutrients into the body in this way may have a gastrostomy. A gastrostomy is a surgically created opening in the stomach. Clients who have gastrostomies have special needs that the home health aide may assist with: Keeping the skin around the stoma (opening) clean and dry Special mouth care Trainer s Manual Page 32.25

26 The home health aide should record and report: Any changes to the stoma or signs of irritation or leakage around the stoma Any problems with the client, such as sadness or discomfort Any changes in the client s eating patterns, including refusal to eat The home health aide may not administer the feeding itself. The home health aide also may not insert or remove the tubing from the stoma. Activity Steps Interactive Presentation 30 minutes 1. Refer to 2. Basic Information about Digestion in the Learner s Book. Explain that some clients are not able to chew or swallow normally because of disease or injury to their upper digestive tract (their mouth or throat). These clients need to consume their food in liquid form through a tube that is either inserted in the nose or through a hole that is surgically created in the neck, chest, stomach, or intestine. Explain that food that is consumed in this manner must be liquid, or the texture of cream soup. It can be prepared at home in a blender or it can be purchased as a commercial formula. 2. Review 14. What Is Tube Feeding? and 15. Your Role in Assisting with Tube Feeding in the Learner s Book. Note that the client should remain in an upright position after tube feeding because they might throw up. Ask if they have any questions. 3. Introduce additional tasks related to caring for clients with gastrostomies. Remind participants that they are permitted to assist with tube feedings only under special circumstances. However, they can assist clients with feeding tubes by keeping the area around their stoma clean and dry. They can also assist the client with special mouth care. Trainer s Manual Page 32.26

27 4. Discuss skin care. Explain that clients with gastrostomies need to take special care of the skin around the opening for the feeding tube. This is because digestive juices from the stomach may back up in the tube and leak onto the skin. These juices are very acidic, and they can irritate the skin. Emphasize that it is important to keep this area clean by washing it with water and mild soap; the area should then be dried thoroughly. Explain that some clients may apply an ointment, salve, or lotion to the skin as well. Emphasize the importance of washing and drying this area at feeding time. Explain that participants should also change the dressing at feeding time, and whenever it is soiled or wet. Finally, remind participants that they already know about how to assist with a clean dressing change, because they learned about this in the module on Assisting with Dressing Changes. However, there are some tasks associated with changing a dressing that participants are not permitted to assist with. In particular, emphasize that they may not assist with a dressing change on a gastrostomy that is new or that shows any sign of skin irritation. Ask if participants have any questions. 5. Discuss mouth care. Explain that clients with gastrostomies also need to take special care of their mouths. This is because chewing and eating are activities that help to keep the mouth healthy. Ask participants: How do you think chewing and eating help to keep the mouth healthy? Listen to participants responses, then refer to 16. Mouth Care for Clients with Gastrostomies in the Learner s Book. Briefly review this information with participants. 6. Discuss what to observe, record, and report. Ask participants: What do you think you might need to observe, record, or report when assisting a client with a gastrostomy? Listen to participants responses, then refer to 17. What to Observe, Record, and Report While Assisting with Tube Feeding in the Learner s Book. Trainer s Manual Page 32.27

28 Activity 7. Practice Lab and Return Demonstrations: Assisting with Ostomy Care 1 hour and 45 minutes Learning Outcomes By the end of this activity, participants will be able to: Demonstrate how to assist with changing a colostomy or ileostomy pouch. Demonstrate how to assist with emptying an open-ended ileostomy or colostomy pouch. Demonstrate how to assist with cleaning a reusable pouch. Demonstrate how to assist with colostomy irrigation. Demonstrate how to assist with emptying a urinary drainage bag. Demonstrate how to assist with the use of a condom catheter. Demonstrate how to assist with cleaning of skin and catheter tubing. Demonstrate how to assist with routine tracheostomy care. Key Content By the end of this activity, every participant should have had the opportunity to demonstrate each of the skills for which there are skills checklists in this module (see Learning Outcomes above). For each return demonstration, a trainer will observe and assess the participant, using the skills checklist. While some participants are doing their return demonstrations, other participants will continue to practice these skills, working in practice pairs, as before. Trainer s Manual Page 32.28

29 Some participants may need to do return demonstrations for other skills covered in this training. Activity Steps Pairs Practice and Return Demonstrations 1 hour and 45 minutes 1. Note the workstations for this activity. Point out which skills will be practiced at each location: changing an ileostomy or colostomy pouch; emptying an open-ended ileostomy or colostomy pouch; cleaning a reusable pouch; colostomy irrigation; emptying a urinary drainage bag; use of a condom catheter; cleaning the skin and catheter tubing; and routine tracheostomy care. 2. Set up pairs and explain your role. Participants will continue to work in the same practice pairs until they are ready to do their return demonstrations. Explain that you (and other trainers, if available) will be observing their practice and answering questions as needed. Participants will use their own skills checklists as they practice. Teaching Tips As before, each participant should take a turn in each role: practicing the task as a direct-care worker and observing (reviewing the steps for each task on the checklist while observing their partner and encouraging her as she performs the steps). For return demonstrations, participants will remain in their pairs, depending on time, space, and the number of trainers available to observe return demonstrations (see Advance Preparation). Trainers should have extra copies of all the skills checklists to assess return demonstrations for all participants who did not do their return demonstrations earlier. 3. Conduct practice and return demonstrations. Trainer s Manual Page 32.29

30 Activity 8. How to Approach Assisting with Ostomies; Summary 45 minutes Learning Outcomes By the end of this activity, participants will be able to: Identify how a client might feel about having an ostomy. Describe the importance of their approach in assisting clients with ostomies. Key Content Clients may have a range of feelings about having an ostomy. It is an important part of the home health aide s role to offer the client emotional support. The home health aide can be emotionally supportive by listening and offering encouragement to the client. The home health aide should also be aware of his or her own body language and tone of voice. Home health aides may find it emotionally challenging to assist clients with their ostomies, but they should not discuss these feelings with their clients. Activity Steps Small-Group Work 15 minutes 1. Set up discussion in small groups. Form new small groups, with three participants in each group. Explain that you would like participants to think about how they can give emotional support to clients who have ostomies. Explain that they are going to read case studies about different clients who each need assistance with an ostomy. Refer to 18. Share What You Know Case Studies in the Learner s Book. Trainer s Manual Page 32.30

31 Then distribute Worksheet 1. Share What You Know. Assign one case study to each small group. Explain that the small groups will have ten minutes to read the case study that they have been assigned and answer the question on the worksheet. Teaching Tip With more than 9 participants, you will have more than three triads. That means you will assign each case study to more than one group. Large-Group Discussion 15 minutes 2. Debrief small-group work. After ten minutes, ask the small groups to wrap up their discussions. Read the first case study out loud and then ask the group(s) that were assigned to this case study to share their responses to the discussion question. Then repeat this process for the second and third case studies. Interactive Presentation 15 minutes 3. Summarize important points about the aide s approach to assisting with ostomy care. Refer to 19. Your Approach Is Important! in the Learner s Book. Emphasize that the client s attitudes and feelings will have an effect on their ability to be independent. Some clients may struggle to adjust to living with their ostomy, so it is very important to observe for signs of this adjustment. For example, the home health aide can observe the client s body language as well as listen to what they say during ostomy care. The aide can also observe whether or not the client seems to take an interest in their own physical appearance, if they seem willing to care for their ostomy as prescribed, and their attitude toward socializing. All of these observations should be reported to the supervising nurse, because they will give the nurse and other members of the care team important information about how the client is adjusting to their ostomy. Trainer s Manual Page 32.31

32 4. Review the medical terms they need to know. Distribute and review Handout 1. Key Definitions. Let participants know that the definitions for all the important words from this module are included on this handout. Explain that they can review the words on their own time to make sure that they know the definitions. Also, they can refer to the Learner s Book for this module for more information about these words. And they can always ask you for more explanation, if none of these sources are helpful. 5. Review important points participants need to remember. Distribute Handout 2. Summary of Key Information. Review this handout with participants. Ask participants if they have any questions. Trainer s Manual Page 32.32

33 Learner s Book Module 32. Assisting with Ostomy Care Activity 1. Introduction to Ostomies 1. What Is an Ostomy? Activity 2. Assisting with Ileostomies, Colostomies, and Urostomies 2. Basic Information about Digestion 3. Basic Information about Ileostomies and Colostomies 4. Your Role in Assisting with Ileostomies, Colostomies, and Urostomies 5. Diet for a Client with a Colostomy 6. Diet for a Client with an Ileostomy 7. Equipment for Urinary and Bowel Care Skills Checklist 1. Assisting with Changing a Colostomy or Ileostomy Pouch Skills Checklist 2. Assisting with Emptying an Open-Ended Ileostomy or Colostomy Pouch Skills Checklist 3. Assisting with Cleaning a Reusable Pouch Skills Checklist 4. Assisting with Colostomy Irrigation 8. Assisting with a Urostomy Learner s Book Page 32.1

34 Activity 3. Assisting with Catheter Care Skills Checklist 5. Assisting with Emptying a Urinary Drainage Bag Skills Checklist 6. Measuring Urinary Output Skills Checklist 7. Assisting with the Use of a Condom Catheter Skills Checklist 8. Assisting with Cleaning the Skin and Catheter Tubing Activity 4. Skills Practice: Assisting with Urostomies, Ileostomies, Colostomies, and Catheter Care 9. What to Observe, Record, and Report When Assisting with Ileostomy, Colostomy, Urostomy, or Catheter Care Activity 5. Assisting with Tracheostomies 10. Basic Information about Tracheostomies 11. Your Role in Assisting Clients with Tracheostomies 12. Safety for Clients with Tracheostomies Skills Checklist 9. Assisting with Routine Tracheostomy Care 13. What to Observe, Record, and Report When Assisting with Tracheostomies Activity 6. Assisting with Gastrostomies 14. What Is Tube Feeding? 15. Your Role in Assisting with Tube Feeding Learner s Book Page 32.2

35 16. Mouth Care for Clients with Gastrostomies 17. What to Observe, Record, and Report While Assisting with Tube Feeding Activity 8. How to Approach Assisting with Ostomies; Summary 18. Share What You Know Case Studies 19. Your Approach Is Important! Learner s Book Page 32.3

36 1. What Is an Ostomy? An ostomy is a surgically formed opening in the body. There are different types of ostomies, and they each have a different purpose: Ileostomy This is an opening in the small intestine that allows waste (stool) to leave the body. A client may have an ileostomy if the small or large intestine is diseased. Colostomy This is an opening in the large intestine that allows solid waste (stool) to leave the body. A client may have a colostomy if the large intestine is diseased or injured. Urostomy This is an opening in the abdominal wall that detours urine away from the bladder. A client may have a urostomy if they have an injury or disease that prevents urine from being eliminated through the bladder and urethra. Tracheostomy This is an opening in the trachea (windpipe). A client may have a tracheostomy if their larynx (voice box) has been injured or removed, if their trachea has been injured, or if they have difficulty breathing due to lung problems. Gastrostomy This is an opening into the stomach. A client may have a gastrostomy if they cannot chew adequately or swallow safely. Learner s Book Page 32.4

37 2. Basic Information about Digestion 1 In order to get energy, a person needs to eat food and digest it. Here is how digestion works: Food is chewed in the mouth, where it is mixed with saliva, which helps to break it down. Food is swallowed and goes down the esophagus into the stomach. In the stomach, food mixes with digestive juices. These juices are very strong acids. Next, the food moves into the small intestine. Nutrients are absorbed into the bloodstream from the small intestine. Anything that cannot be absorbed into the body passes into the large intestine. Now it is called waste. Water is removed in the large intestine, so the waste becomes more solid. This solid waste (stool) is stored in the colon and then pushed out of the body through an opening called the anus. 1 The drawing of the digestive system in the Teaching Tools for Module 10 (Body Systems and Common Diseases) may be used as a visual aid. Learner s Book Page 32.5

38 3. Basic Information about Ileostomies and Colostomies Page 1 of 2 An ileostomy is an opening that is surgically formed in the small intestine. Clients may have an ileostomy if their large or small intestine is diseased. A colostomy is an opening that is surgically formed in the large intestine. Clients may have a colostomy if their large intestine is diseased or injured. Ileostomies and colostomies allow waste (stool) to leave the body. How that waste looks and smells will depend on where the ostomy is located in the digestive tract. When stool comes from an ostomy that is higher up in the digestive tract: o It has less odor. o It is more liquid in consistency. o It is eliminated more frequently from the body. When stool comes from an ostomy that is lower down in the digestive tract: o It has more odor. o It is more solid in consistency. o It is eliminated less frequently from the body. The stool leaves the body through an opening called a stoma. A normal stoma is shiny, wet, and dark pink or red (like the inside of the mouth). Stomas are not painful. Learner s Book Page 32.6