A challenging A nursing care
Faculty of Nursing
Sri Ramachandra University
Date: 2.!".2!#$
• The digestive system consists of the GI tract and its associated organs and glands
• Physical factors such as dietary intake, ingestion of alcohol and caffeine containing products,
cigarette smoking, poor sleep and fatigue also affect GI function
Review of related anatomy and physiology
• The large intestine is a hollow muscular tube approimately ! to " feet long and # inches in
• The four parts of the large intestine are,
• The cecum and appendi
• The colon
• The rectum
• The anus
Related terminology
• $stomy is the surgical creation of an opening through the abdominal wall to allow feces or
urine to eit
• A person who has had an ostomy is called an ostomist or ostomate
• A stoma is the actual end of the ureter or small or large bowel that can be seen protruding
through the abdominal wall
• A colostomy is a surgical procedure that brings one end of the large intestine out through the
abdominal wall
• A colostomy is performed when it is necessary to bypass or remove the distal colon, rectum,
or anus
• %lockage in the colon
• inflammatory bowel disease
• colonic polyps
• imperforate anus
• birth defects to the colon
• irritable bowel syndrome
• diverticulitis
• tumor of the colon or rectum
• obstructive disorders
• traumatic disruption of the intestinal tract
• gastrointestinal trauma, and
• gynecological cancers
&%eit', #(()*
Types of colostomy
• +uring a partial colectomy, only part of the colon is removed and the remaining colon is
reattached to the ostomy
• Removal of the entire colon necessitates an ileostomy
Types of colostomy
Temporary colostomy
• Creation of internal ileorectal pouches, and stapling surgeries to reconnect the remainder of
the intestine to the anus
• $ne from the top portion of the intestine, which will remain active in the digestion of food,
and from which waste will eit
• A second for the temporarily inactive lower portion of intestine, called the mucus fistula,
from which only mucus will emerge
Types of colostomy
• temporary colostomy performed to decompress an obstructed or perforated distal colon, to
permit healing of a fistulous tract or acute inflammatory process distal to the colostomy
• temporary colostomy performed at the midpoint of the left colon or transverse colon

Types of colostomy
• permanent colostomy will not be closed in the future, The stoma will be the permanent eit
for the stool
Types of colostomy
• -ingle barreled colostomy
only one loop end of bowel is
opened onto the abdominal
• .nd colostomy is permanent if the bowel distal to it has been resected
• +ouble barreled
both loops distal and proimal are open onto the abdominal wall
- Two separate stomas, a loop with one stoma and two openings or one stoma and a mucus
Types of ostomy and continent procedure
Types of ostomy and continent procedure
Types of ostomy and continent procedure
• loo% of colon also be brought out to the skin/s surface, The look of stool will depend on the
part of the colostomy
Types of ostomy and continent procedure
• 01pouch &ileoanal anastomosis with reservoir*
• the small intestine is folded back onto itself to form a 0 shape, then stitched together to create
a wider reserve, The sphincter muscle and the anus are left intact
Types of ostomy and continent procedure
• Continent ileostomy
• surgery involves creation of an abdominal stoma implanted with a valve that remains closed
until the patient opens it to drain the intestine
• The advantage of this implant is that no pouch is needed for collection
• the segment of the bowel utili'ed &eg, sigmoid, colon, ileum*
• surgical construction &eg, loop, end*
• both anatomic location
• 2ocation of the ostomy &eg, whether it is proimal or distal to the ileocecal valve or proimal
to the anus*
• the type and volume of output &effluent*, Ileostomies, cecostomies, and ascending
colostomies typically produce 3!(( ml per day of output
Appearance and location
• The ostomy4s eit through the skin of the abdomen is called the stoma
5ormal characteristics
• healthy6 the stoma is pliant, painless, red, and moist
• healthy stoma will shrink, protruding a bit past the skin of the abdomen and developing a
puckered appearance
• -toma come in all shapes and si'es, It may stick out &a budded stoma* or be flat &a flush
• The color should be a deep red or pink color, The stoma is warm and moist
• The stoma can be an end&the end of the colon is brought out to the skin level*or a loop stoma
&a loop of colon is brought out*
7actors determining the ostomy position
• location of the tumor
• etent of disease
• kind of surgery performed
• Certain physical characteristics of the patient, including weight, posture, and skin folding
Problems associated with stomas
• Psychological %ro&lems
• patients can become very anious and depressed
• 8uality of life can deteriorate , low mood
• body image and intimate relationships may suffer
• sudden urges to defecate &phantom rectum *
• 'hanges in faeces
• changes to the amount and consistency of faeces
• 2eakage of the contents of the stoma bag
• Skin %ro&lems
• erythematous and fissured
• allergic reaction to the materials used in stoma e9uipment
Problems associated with stomas
• risk of dehydration
(leeding from the stoma
• flare1up of inflammatory bowel disease, portal hypertension
Stoma e)it*related %ro&lems
• prolapse, narrowing or blockage of the stoma, stenosis
• mucocutaneous :unction may become detached
• paristomal hernias, -toma retraction
• ;emorrhage, -tomal necrosis
5ursing diagnosis
• Aniety related to impending surgery
• Risk for ineffective therapeutic regimen management related to knowledge deficit
concerning self care after discharge
• Impaired skin integrity related to the surgical incision, the formation of stoma, and
fre9uent fecal contamination of peristomal skin
• +isturbed body image related to colostomy
• Ineffective seuality pattern related to presence of ostomy and changes in body image
5ursing intervention
• Attainment of optimal level of nutrition
• =aintenance of fluid and electrolyte balance
• Reduction of aniety
• =aintenance of optimal tissue healing
• Protection of peristomal skin
• Avoidance of complication
Preoperative care
• Provide information about post operative care
• Physical preparation
• %owel is cleansed with laatives, enemas or colonic irrigation
• Record intake and output chart
• Restrict intake of oral food> fluids
• $bserve for signs of hypovolemia
• Assess hydration status & decreased skin turgor, dry mucus membrane and concentrated
Preoperative care
• Assess the abdomen noting abnormalities such as pain, distention and masses
• +iet high in calories, protein and carbohydrates but low in residue to reduce peristalsis
• 2ower the bacteria level in the bowel to decrease the risk of infection
• Administration of enema to clean the bowel
• %lood transfusion to correct severe anemia and enhance wound healing
• .plain all treatments and procedure fully
• Clarify and reinforce the information
• -toma site marking The ideal stoma site is located within the abdomipronal
rectus muscle that etends from the yphoid process to the symphysis
&Carmel ? Goldberg, #(()*
Postoperative care
• -toma assessment: the stoma may appear to be edematous, red, moist, and shiny, The stoma
is generally a red1to1pink color depending on the tissue used for construction, A brown1to1
black color may indicate stoma ischemia
• Assess for peristalsis and GI motility
• Assess for Patency of 5G tube, =onitor for colostomy output
• Assess the stoma for the presence of stomal ischemia
• Ideally, the stoma should protrude at least (,@ inches from the skin level
&Colwell, #(()*
5ursing intervention
• Assess the location of the stoma and the type of colostomy performed
• Assess stoma appearance and surrounding skin condition fre9uently
• Position a collection bag or drainable pouch over the stoma
• Irrigate the colostomy, instilling water into the colon
• .mpty a drainable pouch or replace the colostomy bag as needed
• Replace pouching system as needed &usually every A to B days*
• Care for skin and stoma and watch for skin irritation
• Assess for initial stool characteristics
• Complete nutritional assessment
• -uggest fluid intake
• .amine abdominal dressing to assess for hemorrhage
Care for an ostomy
• clean and care for the skin around the stoma
• choose, empty, and clean appliances that attach to the stoma to collect waste
• select clothing that will not in:ure the stoma or interfere with its emptying
• choose foods to avoid constipation and diarrhea
• irrigate bowel through the stoma, if a sigmoid colostomy
-toma and skin care
• Peristomal skin is more likely to be scratched or scraped
• Peristomal skin should be cleaned gently with very mild soap and patted dry1never rubbed
• Cse caulking agents such as stomahesive or karaya paste, and a skin barrier wafer as needed
to maintain a secure ostomy pouch
• A skin barrier or seal is a li9uid, powder, paste, or membrane that rests between skin and the
stoma attachment in order to protect the skin from bacteria, moisture, and the irritants in
• =ake sure the skin barrier opening fits well
Colostomy care
• Gather e9uipment
• .ncourage patients to look at the stoma
A, .plain the procedure to the patient
), Provide privacy
!, Perform hand hygiene and wear
", Inspect the ostomy and determine
the need for change of appliance
B, Assist the patient to stand or sit
@, .mpty the pouch and remove the
ostomy skin barrier
Colostomy care

D, Clean and dry the stoma and the
peristomal skin
E(, Place a piece of cloth > tissue over the
stoma as it is being cleaned
EE, Prepare the skin barrier, the peristomal
seal &#+, to #+$ allo-ance on the si'e to
allow the stoma to epand when
E#, Remove the adhesive backing to epose
the sticky side, Place the skin barrier over
the client/s skin and press for A( seconds
EA, Remove the tissue from the stoma and snap the pouch onto the skin barrier wafer,
E), +ocument
Types of Pouch
• .ne*%iece %ouch or %ouch %late
• The skin plate of a one1part pouch that4s glued in place must be changed whenever the pouch
is changed
• /-o*%iece %ouch
• continue to reattach fresh pouches to the skin plate for several days or a week until it4s time to
change the skin attachment
• 'olostomy +0leostomy Pouches - open1ended>closed ended
• .ne*Piece System - either draina&le or closed
Colostomy pouch
• need to be changed routinely every ) to B days, and when any
• 2eakage
• Itching ? burning under the pouch
• traveling
• spell of diarrhea
• Prepared for a colonoscopy
• engage in sports or any physical activity
Change of pouch
• Assemble supplies
• Cse skin products to help reduce irritation
• Cse slight pressure to place pouch
• +ispose of the used pouch correctly
• .mpty the pouch when it is F to G full
• ;old the pouch up by the bottom end
• +rain the pouch
• Clean the end of the pouch
• Close the end of the pouch
• Cse a pouch with the right si'e opening &H of an inch larger than stoma*
Colostomy irrigation
• Irrigation is when fluid is put into stoma to empty bowel
• Gather all supplies
- a plastic irrigating container with a
long tube and a cone
1 irrigation sleeve
1 ad:ustable belt
• Choose the same time every day to irrigate
• Inow how much li9uid to use
• Attach the irrigation sleeve to stoma
• Release air bubbles from the tubing
• =oisten the end of the cone
• Place the tip of the cone A inches into stoma
• Remove the cone
Colostomy pouch
• Cse deodorant tablets or li9uids in the bottom of the pouch, room deodori'er
• Clean and dry reusable pouches carefully
• Pretest pouches that contain charcoal filters
• .at yogurt to ameliorate odors
• .nsure that the skin attachment fits well and is firmly attached
• A small needle hole high on the colostomy pouch will allow flatus to escape
• Passage of waste material and gas through the stoma can create whee'es, sighs, rumbles, or
gas1like noises
• .ther sensations
• feel warmth against skin as waste material collects in the pouch
• sensations of movement or mild gas pains
$stomy appliances and supplies
• Two parts6 a collection pouch and a positioning plate
• +isposable pouches
• Reusable pouches that empty from the bottom, or from the top
• Pouches with filters to control odor
• Pouches with a belt
• Irrigation tubes &catheters*
• ;ypoallergenic gluing and skin1sealing products made from vegetable matter
• Pouches that hang sideways instead of down &5eoprene pouch belts*
• -mall patches similar to %and1Aids to cover and protect the stoma during swimming
• $rnamental stoma covers
$stomy appliances and supplies
• -kin barrier creams
• $ne1piece appliances, or two1piece appliances
• Appliances in different si'es to accommodate individual stomas
$stomy accessories
Travel tips
• Pre1cut all pouches at home
• Pack ostomy supplies
• Take etra supplies
• A statement from physician stating need for ostomy supplies also advocating a private area
be used in case of an etended search
Types of foods
• .at a variety of healthy foods
• +rink at least @1E( glasses of li9uid a day
• Avoid whole grains at first
• +o not eat much fat at one time
• Avoid fried foods
• Try to have small, fre9uent meals throughout the day
• Add one food at a time when advancing diet
• Chew food very well before swallowing
• 7ood may cause gas and>or an increase in odor6
• Cabbage,=ushrooms
• $lives,+ried beans and peas
• Garlic,$nions
• Radishes,Pickles
• Cucumbers,=elons
• -trongly flavored cheeses
• 7ish,.ggs
• Cauliflower
• Avoid lying down immediately after eating
.lderly patient
• +ecreased vision, impaired hearing ? difficulty with fine motor coordination
• -kin changes with aging1 the epithelial and subcutaneous fatty layers become thin and
the skin is irritated easily
• Arterioscelerosis
Charter of $stomates Rights
The ostomate shall6
• Receive pre1operative counselling to ensure that they are fully aware of the benefits of the
• ;ave a well1constructed stoma placed at an appropriate site
• Receive eperienced and professional medical support, stoma nursing care and psychosocial
support in the pre1operative and post1operative period
• ;ave unrestricted access to a variety of affordable $stomy products
• Receive support and information for the benefit of the family, personal caregivers and friends
to increase their understanding of the condition
• Receive full and impartial information about all relevant supplies and products available in
their Country
• %e given information about their 5ational $stomy Association and the services and support
which can be provided
• %e protected against all forms of discrimination
5ew bowel operation
• APP.AR &Anterior Perineal Plane for ultra1low Anterior Resection* and involves removing
the diseased part of the bowel and fashioning part of the remaining bowel into a pouch to
recreate the rectum
Patient teaching
• +escribe normal colostomy function and normal stomal characteristics
• Teach how to empty the pouch and provide peristomal skin care
• Provide dietary guidelines
• Teach the methods to manage constipation and diarrhea
• Teach the way to obtain needed supplies
• Teach the signs and symptoms that to be reported to the .T 5urse
• +iscuss ways to manage the colostomy in business, recreational, social and
seual activity

-upport organi'ations
• $stomates of $stomy Association of India, =umbai
• International $stomy Association
• The Asia -outh Pacific $stomy Association &A-P$A*
• .uropean $stomy Association &.$A*
• The $stomy Association of the Americas &$AA*
• Jound $stomy and Continence 5urses -ociety
• The American Cancer -ociety
• Crohn/s and Colitis 7oundation of America
• Cnited $stomy Association of America &C$AA* Inc
• Jorld $stomy +ay India &#nd $ctober*
7ollow up
'ontact 'aregiver
• fever
• foul odor coming from colostomy bag or stoma
• skin around the stoma becomes red and irritated
• nausea, vomiting, pain, cramping, or bloating
Seek immediate care
• -eek care immediately or call DEE if6
- bowel movements are black or
- stoma is bleeding and cannot
stop the bleeding
1 too weak to stand up
1 severe abdominal pain
7ollow up
'all 1our Doctor
• Change in stoma color from pink1red to purple1black,
• .cessive bleeding from stoma opening
• Continuous bleeding between stoma and skin
• Cnusual bulging around stoma
• Any unusual problems with abdominal pain or continuous nausea and vomiting
'all 2.' Nurse
• skin irritation lasting for more than a few days &redness, itching or
• no bowel movement for more than # days
• any 9uestions or problems with pouching or leakage
• 7or additional information on activities of daily living
• Teaching the patient on care for a new ostomy can be a challenging eperience for the nurse
• The patient with an ostomy needs encouragement, support, and counseling to learn how to
integrate self1ostomy care into daily activities
E, Colwell, 0, &#((A*, $stomy surgical procedures,In C, =ilne, 2, Corbett, ? +, +ubuc &.ds,*,
Jound ostomy and continence nursing secrets &pp, #DE1#D!*,Philadelphia6 ;anley and %elfus,
#, Kasilevsky , C,, ? Gordon, P, &#(()*,Gastrointestinal cancers6 -urgical management,In 0,
Colwell, =, Goldberg, ? 0,Carmel &.ds,*, 7ecal ? urinary diversions6=anagement principles
&#nd ed,*&pp, E#"1EA!*, -t, 2ouis6 =osby