SAMPLE
SKILLS CHECK LIST

Child's Name: ___________________________	Colostomy Care
	Skills Checklist
Person Trained: _________________________
Position: _______________________________	Instructor: _________________

	Demo Date		Return Demonstration
		Date	Date	Date	Date	Date	Date
A. State name and purpose of procedure
B. Preparation: 1. Reviews Universal Precautions
2. Completes at ___________ time(s)
3. Identifies where procedure is done (consider privacy and access to bathroom)
4. Position for ostomy care:
5. Identifies possible problems and appropriate actions
C. Identifies Supplies:
1. Soap and water
2. Soft cloth and gauze
3. Skin preparation
4. Adhesive
5. Clean box
6. Belt if needed
7. Scissors and measuring guide
8. Clean gloves
9. Adhesive tape, if needed
D. Procedures 1. Washes hands
2. Assembles equipment
3. Explains procedure to child and encourages participation
4. Puts on gloves
5. Empties contents of bag before removal, if ordered
6. Removes used bag
7. Washes to stoma area
8. Inspects skin for redness/irritation
9. Dries stoma and skin
10. Places skin barrier around stoma
11. Applies adhesive to bag or removes backing from adhesive

C-17