Chpt 54: Caring for Ileostomy or Colostomy

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Chpt 54 Caring for Ileostomy or Colostomy

• Medical Surgical I

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Overview

• The term ostomy refers to an opening between an
  internal body structure and the skin.
• Fecal material exits through a stoma, an opening
  on the exterior abdominal surface.
• Most ostomies are created in response to an
  inflammatory bowel disorder that fails to respond
  to medical treatment or complications such as
  rupture of a portion of intestine, irreversible
  obstruction, compromised blood supply to the
  intestine, or cancerous tumor.

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Ileostomy and Colostomy

• Ileostomy-opening from the distal small intestine
  --entire colon and rectum are removed (total
  colectomy). Stool and gas continually released
  from stoma. It is liquid or paste like and
  contains enzymes
• Colostomy-opening from the colon. Consistency
  depends upon site--Ascending and transverse it is
  semiliquid and sigmoid is formed and can have
  fecal control

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Ileostomy and Colostomy

• When an ascending or transverse colostomy is done
  the fecal material is semi-liquid
• Descending and sigmoid colostomies are easier to
  manage because the content of the bowel is
  semi-formed
• Patient with a conventional ileostomy cannot
  control bowel elimination or establish a regular
  evacuation pattern (liquid and mushy)

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Collection appliance

• Collection appliance should be changed or emptied
  when the bowel is relatively quiet. Thoroughly
  clean each time the temporary appliance or the
  disk of the permanent appliance is changed

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Pre-op Pg 912

• Bowel cleansing routine necessary to reduce risk
  of infection by fecal contamination. Laxatives
  and enemas given. (GoLytely)
• Most surgeons order a combination of IV
  antibiotics before surgery and continue
  administration after surgery. As they decrease
  the number of bacteria in the bowel and decrease
  the possibility of infection.

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Pre-op

• Possible bladder and sexual dysfunction secondary
  to parasympathetic nerve injury, which is a risk
  of a total colectomy.
• Young male clients may wish to collect and store
  sperm for later use if they plan to have
  children.

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Pre-op

• Whenever possible, prednisone should be tapered
  and discontinued before surgery to avoid negative
  effects of the drug on tissue healing.
• A preoperative stress dose of IV steroid (I.e.,
  hydrocortisone) is given to clients who have been
  on prednisone within the previous 6 months to
  prevent adrenal crisis.

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Pre-op

• Immunosuppressive agents should be discontinued 3
  to 4 weeks before surgery.
• Aspirin-containing compounds are d/cd at least 1
  week before surgery to minimize the risk of
  bleeding.
• Pt. is typed and cross-matched for replacement of
  blood if needed.

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Nursing Management

• Obtain a complete medical, allergy, diet and drug
  history
• assess general physical and emotional status
• Inspect skin over abdomen and auscultate bowel
  sounds.
• Check labs to make sure electrolytes and blood
  cell counts are normal

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Nursing Management

• Closely monitor if on steroids for signs and
  symptoms of adrenal insufficiency such as
  weakness, lethargy, hypotension, N/V
• Review care plans

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Teaching

• Provide information covering ostomy care and
  general principles of ostomy management. Arrange
  a preop visit with the enterostomal therapist

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Post-op

• Rectal packing removed 5 to 7 days post-op and
  irrigations may be ordered to promote healing
• NG tube used for GI decompression until normal
  bowel motility returns.
• Possible complications include intestinal
  obstruction, impaired blood supply to stoma,
  stenosis of stoma, and prolapse or excessive
  protrusion of the stoma

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Complications

• Intestinal obstruction is a serious complication.
  It may result from a twisted, strangulated or
  incarcerated segment of the remaining intestine
  or a bolus of poorly chewed or inadequately
  digested food. Stoma may be irrigated to dislodge
  food. If twisted or strangulated needs surgery

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Complications

• Prolapse or protrusion of the ileostomy is
  common. If only 1 or 2 inches no treatment done.
  But if more then it is a serious complication
• Edema can cause an obstruction and restrict
  stomal blood supply. Stoma necrosis results if
  the prolapse is not managed.

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Nursing care of Stoma

• Inspect stoma frequently and report any darkening
  of stoma stat.
• Measure size of stoma and allow an extra 1/8 inch
  to prevent swelling
• Empty frequently to avoid tension on skin

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To Prevent Leaking

• Avoid wrinkles by pressing from stoma edge
  outward
• Ask him to stay inactive 5 min to strengthen
  adhesive bond
• Trap some air within the pouch so feces drains
  from bottom

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Healthy Stoma

• Bright red or pink
• Moist, shiny surface with an overlying of mucus
  may bleed slightly when cleaning
• Painless and has regular passage of feces,
  opening is patent and unobstructed

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Unhealthy Stoma

• Dusky blue or black, opening is tight or narrow
• Surface is dull, dry and has excessive bleeding
• Protrudes beyond 2 inches from the skin or
  retracts beneath
• Peristomal burning and sparse or absent
  elimination of feces

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Teaching

• Eat slowly and chewing food well with mouth
  closed to lessen gas
• avoid foods that cause discomfort, excessive gas,
  or loose stools
• Drink extra fluids
• dilate stoma if volume of stool decreases for
  unexplained reason. Cut nail of index finger and
  put on glove with lubrication and insert for a
  few minutes

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Teaching

• Clean pouch thoroughly to prevent odors
• Use old pouch if medications or offending foods
  cause odors
• Slip a plastic cover over pouch to reinforce
  against odors
• Do not take laxatives or anti-diarrhea med
  without asking Dr.

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Continent Ileostomy or Kock Pouch Pg. 917

• Internal reservoir for storage of feces until
  removed by catheter.
• Cath in place until healed. Dr. may order cath to
  be connected to low suction
• Rectal area is packed. reinforce packing PRN
• Note color and amount of drainage and size and
  color of stoma

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Kock Pouch

• Check ileal catheter for signs of obstruction
  (lack of fecal material or complaint of feeling
  full in the area of the ileal pouch, or leakage
  of liquid stool around catheter.
• May need to irrigate with small amount of saline
  if obstructed. Keep skin clean around stoma.
  Change gauze dressing PRN
• Drainage will be high initially but stabilizes10
  to 14 days post-op

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Kock Pouch

• After drainage stable, cath is removed and
  reservoir holds feces until removed by cath.
  Empty q 2 hours at first and after about 6 months
  can empty QID
• See tips to manage an obstructed cath page Box
  54-2 pg. 918

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Teaching

• If catheter becomes obstructed teach the patient
  to Bear down as if to have a BM
• Rotate cath tip inside stoma
• Milk the cath
• If not successful, remove cath, clean and
  reinsert, Call Dr. if still doesnt work
• Never wait longer than 6 hrs without drainage

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Ileoanal Reservoir (ileoanal anastomosis)

• Surgery done in two stages
• First stage is a temporary colostomy
• Following the first stage of creating an ileoanal
  reservoir, the drainage from the anus will have
  the appearance of mucus
• Following a second surgical stage the stored
  fecal material is removed from the reservoir by
  means of irrigation

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• Preop care is the same as one with a conventional
  ileostomy but also should check for drainage from
  rectum.
• After second stage, continue to check both the
  ileostomy and rectum for drainage.
• Review nursing interventions

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Colostomy

• Single -Barrel--Colon is cut above diseased area
  and healthy end brought thru abdominal wall
• Double Barrel-has both a proximal and distal
  stoma. Feces is expelled from the proximal stoma
  and mucus is expelled from the anus

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• When opening a loop colostomy, the procedure will
  be done in the hospital bed. When the segment of
  the exposed bowel is opened forming a loop
  colostomy, they will not feel any pain
• By delaying the opening of the intestinal loop 24
  to 72 hours, the initial healing of incision
  occurs without danger of contamination

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Nursing Care

• Report a sudden elevation in temp over 101 or an
  increase in pain and abdominal tenderness or
  distention stat
• Check site frequently and observe the
  characteristics of stoma
• Monitor Ua output and amount of suctioned gastric
  secretions.
• Review nursing interventions

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Foods that Produce Gas Odors

• Beans, corn, chocolate, coconut, green pepper,
  legumes, onions, vegetables of the cabbage family
  
• Beets, simple sugars, pork, oat bran, dark rye
  and pumpernickle breads, carbonated beverages,
  beer and other alcoholic beverages and fried foods

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Foods that Cause Obstruction

• Celery, cabbage, bamboo shoots, nuts, and foods
  with kernels
• Low fiber diet for 6 to 8 weeks used to prevent
  irritation until healing occurs
• Drink one to two quarts of water daily