Colostomy and ileostomy are surgical procedures that create an opening from the intestines through the abdominal wall, known as a stoma. One difference is the part of the bowel that is used. A colostomy uses part of the colon while an ileostomy uses part of the ileum.
Both procedures can be temporary or permanent depending on the reason they are needed. Conditions that may require a colostomy or ileostomy include:
- Cancer of the colon, rectum, or anus
- Ulcerative colitis
- Crohn’s disease
- Bowel obstructions
- Diverticulitis
After a colostomy or ileostomy surgery, the patient will no longer have control of their bowel movements and will have to wear a pouch system over their stoma. Living with an ostomy will require adapting to changes in lifestyle habits, diet, and sexual intimacy.
In this article:
- Nursing Process
- Nursing Care Plans
- Disturbed Body Image
- Dysfunctional Gastrointestinal Motility
- Ineffective Tissue Perfusion
- Risk for Impaired Skin Integrity
Nursing Process
Nurses may assist patients who are undergoing surgery for a colostomy/ileostomy and will be responsible for providing education and immediate care post-op. For patients with long-term ostomies, the nurse can assist with reinforcing education and ensuring the patient is caring for their ostomy correctly to prevent complications.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for colostomy and ileostomy, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for colostomy and ileostomy.
Deficient Knowledge
Preparing for, adapting to, and managing an ostomy can present a large learning curve.
Nursing Diagnosis: Deficient Knowledge
Related to:
- Lack of exposure/unfamiliarity with colostomy/ileostomy
- Cognitive limitation
- Lack of interest in ostomy care
As evidenced by:
- Inability to recall or demonstrate ostomy care
- Verbalizes incorrect/inaccurate statements regarding colostomy/ileostomy
- Develops a complication due to lack of knowledge
Expected outcomes:
- Patient will demonstrate the ability to remove, clean, and reapply a new ostomy device.
- Patient will verbalize dietary changes to control stool output.
- Patient will recognize signs of a complication and seek immediate assistance.
Assessment:
1. Assess understanding and capability.
Review education regarding the need for a colostomy/ileostomy and how to care for it. Assess the patient’s developmental level and cognition to ensure understanding and ability to perform necessary care.
2. Assess for family assistance.
Depending on the aforementioned assessment, the patient may require support from family. If the patient is too young, disabled, or unable to follow directions, provide education to an involved family member.
Interventions:
1. Encourage confidence in the patient.
Patients may lack confidence in performing ostomy care. Boost confidence by having them participate in care and providing positive feedback.
2. Educate on ostomy care.
Ensure the patient understands to empty their pouch when it is ⅓-½ full to prevent pouch loosening. Educate on how to bathe, how to prevent gas and odors by not eating certain foods and other nuances.
3. Manage complications.
Complications such as bowel obstructions, diarrhea, and short bowel syndrome can develop. Educate the patient on signs and symptoms and when to contact their provider.
4. Have the patient demonstrate.
The best way to ensure ostomy teaching has been effective is to observe the patient perform emptying, cleaning, and changing their ostomy system.
5. Coordinate with an ostomy nurse.
A nurse who specializes in ostomy care is a wealth of information in teaching the patient all about their colostomy and ileostomy. The nurse can also recommend supplies that can make managing their ostomy easier.
Disturbed Body Image
An ostomy is a major physical change that can result in psychological distress and affect the patient’s self-confidence and relationships.
Nursing Diagnosis: Disturbed Body Image
Related to:
- Alteration in appearance
- Loss of control over bowel movements
- Major lifestyle changes (bathroom habits, clothing choices, exercise)
As evidenced by:
- Verbalization of concerns in appearance, sexuality, relationships, lifestyle changes
- Negative self-concept
- Refusal to participate in ostomy care
- Chosen isolation from socialization
Expected outcomes:
- Patient will begin to demonstrate comfort with body image as evidenced by viewing/touching ostomy and performing stoma care.
- Patient will verbalize acceptance of change in body image.
- Patient will seek information on navigating life with an ostomy.
Assessment:
1. Assess family/spousal support.
A supportive family and/or spouse is vital in helping the patient cope with this new change. Involve their support system only if the patient is comfortable doing so.
2. Note age and lifestyle factors.
While an ostomy can be difficult to navigate at any age, the physical change is usually more traumatic for those who are younger and more active.
3. Observe behavior and withdrawal.
Observe the patient’s response to their ostomy and if they are willing to look at it, participate in care, or seek information. Patients may need time to adapt.
Interventions:
1. Take a positive approach.
Always provide ostomy care with confidence and a positive attitude. Never show facial expressions of disgust so as not to cause further harm to the patient’s ego.
2. Help the patient visualize a normal life.
Living with an ostomy does not have to affect everyday activities. Patients may be relieved to learn that they can still wear clothing they prefer, eat the foods they love, and participate in sports such as swimming or weight lifting. Remind the patient there are many ways to hide their ostomy if they prefer.
3. Consider a support group.
Adapting to a colostomy or ileostomy takes time. Talking to others with ostomies who understand the difficulties can be empowering. Support groups may be in person or online and can provide tips and advice to ease the transition.
4. Recommend counseling.
Depression and anger can develop and the patient may grieve their loss of appearance. A patient struggling with acceptance of their body image may require counseling to overcome challenges to their lifestyle and intimacy.
Dysfunctional Gastrointestinal Motility
Surgical procedures like colostomy and ileostomy can affect the nerves and muscles of the gastrointestinal tract, causing disruption in normal gastrointestinal functions like nutrient and water absorption in the affected area, dysfunction in gastrointestinal motility, and an increase in the risk of developing intestinal obstruction.
Nursing Diagnosis: Dysfunctional Gastrointestinal Motility
Related to:
- Disease process
- Inflammatory process
- Surgical intervention
- Colostomy placement
- Ileostomy placement
As evidenced by:
- Abdominal cramping
- Abdominal pain
- Hypoactive bowel sounds
- Diarrhea
- Increased gastric residual
- Constipation
- Gas
- Nausea
- Vomiting
- Accelerated gastric emptying
Expected outcomes:
- Patient will be free from any signs of dysfunctional gastrointestinal motility like diarrhea, gas, and changes in bowel habits.
- Patient will show no signs of intestinal obstruction and postoperative ileus.
Assessment:
1. Assess for postoperative ileus after colostomy or ileostomy.
Postoperative ileus is characterized by a temporary delay in gastrointestinal motility and is not uncommon after colon or rectal surgery. Its signs and symptoms include nausea, vomiting, abdominal pain, abdominal distention, and delayed passage of stool and flatus.
2. Assess bowel sounds and their characteristics.
Inspect and auscultate the patient’s bowel sounds and percuss and palpate the abdomen. Decreased bowel sounds can indicate reduced gastrointestinal motility and ileus.
3. Assess the patient’s diet.
For several weeks after surgery, the patient will need to eat soft, low-fiber foods to avoid diarrhea, bloating, and gas. Over time, the patient can return to a regular diet. An ileostomy is more prone to blockages since it involves the small intestine. The patient with an ileostomy should avoid insoluble fiber and eat more soluble fiber to prevent diarrhea and gas.
Interventions:
1. Administer IV fluids.
Postoperative ileus is often resolved through supportive measures such as IV fluid and electrolyte replacement.
2. Encourage adequate intake of soluble fiber.
After colostomy or ileostomy, a diet high in soluble fiber, like apples, bananas, oats, rye, and barley, is recommended as this can significantly improve motility problems. Instruct the patient to avoid foods rich in insoluble fiber like bran, cereals, legumes, dried beans, and certain fruits and vegetables.
3. Monitor the patient for signs and symptoms of fluid and electrolyte imbalance.
As peristalsis returns after an ileostomy or colostomy procedure, drainage in the stoma can increase (high output) as the patient has lost the absorptive function of some parts of the intestines. The patient must be monitored for fluid and electrolyte deficits, especially sodium and potassium.
4. Encourage ambulation.
Early ambulation is very important following bowel resection to prevent or reduce ileus and promote bowel motility.
5. Administer medications as indicated.
Medications like antidiarrheals and antimotility medications that reduce stoma output or gut secretions may be indicated to slow bowel motility in patients experiencing high stoma output after colostomy or ileostomy procedures. Antimotility medications should be administered before meals for optimal effects through counteracting postprandial hypermotility.
Ineffective Tissue Perfusion
Complications of ostomy procedures include tissue perfusion problems like ischemia, necrosis, dehydration, nutrient malabsorption, bleeding, stoma complications, infection, and inflammation.
Nursing Diagnosis: Ineffective Tissue Perfusion
Related to:
- Impaired skin integrity
- Inadequate primary defenses
- Underlying disease process
- Inflammatory process
- Intestinal obstruction
- Altered circulation
- Delayed healing
As evidenced by:
- Dusky, purple stoma
- Bleeding stoma
- Prolapsed stoma
- Retracted stoma
- Abdominal pain
- Peristomal irritation
Expected outcomes:
- Patient will be free from any signs of necrosis and infection at the stoma site.
- Patient will be free from any perfusion complications including bleeding, infection, and inflammation.
Assessment:
1. Assess the stoma and the surrounding area.
The stoma is expected to be moist, pink to red, and above skin level, and the surrounding area must not exhibit signs of irritation, infection, and inflammation. The stoma is measured regularly and will be swollen for 6-8 weeks following surgery.
2. Inspect for any signs of potential stoma complications.
A prolapsed stoma is the abnormal protrusion of the stoma from the abdominal wall. Retraction of the stoma into the abdomen is also abnormal.
3. Assess for signs of bleeding.
Post-surgical bleeding can occur within the first 48 hours after a colostomy or ileostomy and requires further investigation. Bleeding that stops after several minutes with slight pressure is likely superficial. Frank blood or oozing blood requires alerting the surgeon to perform cauterization, suture placement, or ligation.
Interventions:
1. Initiate routine stoma monitoring.
Pallor, duskiness, or necrosis can indicate poor perfusion requiring immediate intervention.
2. Instruct the patient to change the colostomy bag every 5-7 days.
Frequent colostomy pouch changes can cause skin irritation and perfusion problems and must be avoided. Routine colostomy pouch changes should be done every 5-7 days unless the pouch is leaking.
3. Take extra care when removing the pouching system from the surgical site.
An appropriate method for removing the pouching system involves pushing the skin away from the sticky barrier rather than pulling the sticky barrier from the skin. This technique prevents further impairment of the surrounding skin and reduces the incidence of ineffective tissue perfusion.
4. Encourage the patient to ambulate after the colostomy procedure as tolerated.
Early mobilization can help reduce postoperative ileus, promote adequate tissue perfusion, prevent inter-bowel adhesions, and prevent intestinal obstruction.
5. Encourage lifestyle modifications as indicated.
Stoma placement may be temporary or permanent. Patients can benefit from lifestyle modifications to nutrition, exercise, and smoking cessation to improve tissue perfusion, promote adequate circulation, reduce the risk of infection, and promote timely wound healing at the stoma site.
Risk for Impaired Skin Integrity
Since the stoma brings waste products through the abdominal wall, the risk of irritation to the surrounding skin is very high.
Nursing Diagnosis: Risk for Impaired Skin Integrity
Related to:
- Improper emptying of the pouch
- Diet changes affecting output
- Improper wafer fitting/application causing leakage
- Improper hygiene
- Delayed healing of the stoma
Note: A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.
Expected outcomes:
- Patient will demonstrate proper sizing and application of the wafer.
- Patient will display intact skin surrounding the stoma without redness or swelling.
- Patient will verbalize two strategies to prevent skin irritation.
Assessment:
1. Inspect the stoma and surrounding skin.
Assess for redness, bleeding, and rashes. Assess the stoma to ensure it is a beefy red color and measure it to monitor if it has retracted or is protruding. This is most important in the weeks following colostomy/ileostomy surgery.
2. Assess diet.
A low-residue diet may be prescribed for the first few months. Assess the foods the patient is eating that may be causing diarrhea and increased output, leading to skin irritation.
3. Assess for allergies.
Monitor for an allergy to barrier pastes, adhesives, and pouch systems. Sensitivities can develop even after months or years of using a product.
Interventions:
1. Clean and keep dry.
Keep the area surrounding the stoma free from stool. Use warm water and a washcloth or toilet paper to clean the area. Soap is usually not recommended. Ensure the area is completely dry before applying adhesives.
2. Apply a protective paste.
Pastes and powders can be used that assist the adhesive in fitting better to the skin, preventing leakage.
3. Measure the wafer.
The wafer, or skin barrier, attaches the pouch to the skin. Wafers should be measured correctly so they are not too tight or too loose around the stoma. This is accomplished by measuring the stoma and then cutting the wafer so that it is no larger than 1/16 to ⅛ the diameter of the stoma.
4. Provide education on the pouch system.
Ensure the patient understands that frequent changing of the pouch is irritating to the skin. This should only be done every few days. Educate to take care when removing the pouch so as not to pull on the skin.
References
- American Cancer Society. (2019, October 16). Caring for a Colostomy. American Cancer Society. Retrieved April 20, 2022, from https://www.cancer.org/treatment/treatments-and-side-effects/treatment-types/surgery/ostomies/colostomy/management.html
- Colostomy and ileostomy. (n.d.). Canadian Cancer Society. Retrieved April 20, 2022, from https://cancer.ca/en/treatments/tests-and-procedures/colostomy-and-ileostomy
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). Nurse’s Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th ed.). F. A. Davis Company.
- Maria A, Lieske B. Colostomy Care. [Updated 2021 Sep 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560503/
- Ostomy: Adapting to life after colostomy, ileostomy or urostomy. (2020, November). Mayo Clinic. Retrieved April 20, 2022, from https://www.mayoclinic.org/diseases-conditions/colon-cancer/in-depth/ostomy/art-20045825
