COLOSTOMY AND ILEOSTOMY MEDICAL-SURGICAL NURSING

BOLUSO, BRUSAS, CASTANARES, ELIZARDE, FRANCO, REYES, RUIZ, SALVO, SANCHEZ, UMLAS

COLOSTOMY AND ILEOSTOMY need for a new stoma, back-to-zero progress = new
operation
DEFINITION
• A surgical opening created on the surface of the CLEANSING ENEMA
abdomen to allow stool (waste) to exit the body rather • Aside from putting the client on NPO, it is important to
than through the rectum cleanse the bowel
• A GI ostomy can be created for the small (ileostomy) • Solutions are commercially prepared
or large intestine (colostomy) • Manually prepared solutions are usually made up of:
o Water
REASONS FOR A GI OSTOMY o Grated soap (tutunawin hanggang mag-bubbles)
• GI diseases
o Crohn’s PRE-OPERATIVE NURSING CARE
o Ulcerative colitis • Educate about what to expect (many patients are
o Diverticulosis scared), how the stoma will look (show them a
o Infection picture), and where it will be on the abdomen
o Cancer (rectum and colon) • Start teaching them about the pouching system
o Injury (trauma to the GI system) • Doctor may prescribe oral antibiotics to reduce
o Congenital defects (obstructions) bacteria in the colon (which normally lives there) to
prevent post-op infection
COLOSTOMY • 2 to 3 days before surgery soft or semi-liquid diet may
• An opening created to bring the LARGE INTESTINE be ordered
to the surface of the abdomen • A cleansing solution and laxative may be ordered to
• The large intestines is also called the colon clean the colon and that the patient follows a clear
• “DATS a Colostomy” liquid diet prior to surgery (24 hours).
o D – descending colostomy • Patient may have to be hospitalized due to the
▪ Solid, with form profuse diarrhea they will be experiencing and may
o A – ascending colostomy need an IV solution to maintain hydration
▪ Fluid-like • NPO day of surgery
o T – transverse colostomy
▪ Mashed potato-like consistency POST-OPERATIVE NURSING CARE
▪ Double-barrel ostomy – type of • Monitor the electrolytes, sign of dehydration (urinary
transverse colostomy where there is the output) site and stoma:
creation of two stomas which divide the o After the surgery, stoma will be swollen and
bowel. large, but after a couple months it will shrink to
• Proximal – puts out stool normal size.
• Distal – puts out mucus; also known o Ostomies SHOULD ALWAYS look pink or red
as mucus fistula and be moist/shiny.
o S – sigmoid colostomy ▪ Notify doctor if the stoma is: pale pink
(patient may have a low hgb and hct), dark
ILEOSTOMY red or black could mean compromised
• An opening created to bring the SMALL INTESTINE circulation to the stoma.
to the surface of the abdomen, specifically the ileum. • After the surgery stool:
• Ileum – last part of the small intestine before it opens o Ileostomy – drainage is dark green and then
into the large intestine turns yellow when patient starts to eat
• Usually harder to manage than the colostomy o Colostomy – may pass mucous stool at first,
• Skin irritation surrounding the stoma is more common stool will be liquid at first and then progress to
in ileostomy what it should look like depending on its location;
• Sepsis – can be the cause of death of a patient with it can take up to 2 days before stool is produced.
a stoma • Help patient understand the pouch system:
o Empty pouch when 1/3 to 1/2 full
EVISCERATION o Change pouch when gut less active (morning
before breakfast)
• Gauze with saline solution to prevent drying
o Change pouching system every 3 to 5 days
• STAT OR
o Keep stoma and skin around stoma clean
• Petrolatum gauze – used to keep the stoma from o Watching for burning around the skin or leaking
drying; to prevent it from necrotizing (patients need to be taught how to perform by
• Stoma necrosis – occurs when the blood flow to or self and become independent with it)
from the stoma is impaired or interrupted; results in a o Be familiar with the various pouching systems:
COLOSTOMY AND ILEOSTOMY
BOLUSO, BRUSAS, CASTANARES, ELIZARDE, FRANCO, REYES, RUIZ, SALVO, SANCHEZ, UMLAS
▪ One piece – skin barrier and pouch are one
unit
▪ Two piece – pouch and skin barrier are
separate
o Skin barrier application
▪ Covers the skin surrounding the stoma
▪ Prevents stool from coming into contact with
skin
▪ Measure stoma (with measuring guide that
comes with the kit)
▪ Cut opening of skin barrier to be 1/8” larger
than the stoma
• Too small – constricts the stoma
• Too large – there would be leakages
o Ostomy pouch before used to be opaque, but
now it’s transparent for better visualization and
assessment of the stoma
MEDICATION PRECAUTIONS
• NO: Enteric coating medications (do not dissolve until
reaching a specific part of the small intestine) OR
sustained-released medication (releases slowly over
a period of time)
DIET TEACHING
• Start out slow (first 6 weeks):
o Low fiber
o Small meals throughout the day
o Monitor hydration and electrolyte status
o Eat slowly and chew thoroughly
o Then advance as tolerated
• Patients with ileostomy need to stay hydrated and
consume fluid and electrolyte solutions like Gatorade
o Remember they are losing a lot of rich fluids that
cannot pass through the colon
• Patients will be able to eat a regular diet eventually,
but should avoid foods that caused problem before
surgery and MUST keep in mind the following:
o Corn, celery, peas, coleslaw, popcorn
o Nuts and seeds, raisins, skin of fruits
o Raw mushrooms and pineapple, etc.
• Gas / Odor causing foods:
o Pouch will expand as gas collects in bag
▪ Teach patient how to “burp” the bag
o There are bags with filters that allow gas to
escape while filtering the smell or drops for the
bag
o Beans, onions, eggs, broccoli, cabbage, garlic,
alcoholic beverages, fish, high fiber foods
POST OPERATIVE COLOSTOMY INTERVENTIONS
• Monitor the pouch system for proper fit and sigs of
leakage.
o Immediate post-op is moist gauze and dried
resin on top but once pouch is available, use it.
o Initially, stoma is large due to edema and fluid
shifting but as time goes by, it decreases
MEDICAL-SURGICAL NURSING
o Dapat turuan ang patient about this and pag
alam nya na nagli-leak na, dapat mareport or if
kaya na magchange, palitan na since it can
cause irritation to the skin and infection that can
lead to peritonitis to sepsis
• Empty the pouch when it is 1/3 full.
o 1/2 is okay
o Pwede i-drain by removing the clip and can be
drained sa bowl and clean it after
• Fecal matter should not be allowed to remain on the
skin.
o It can cause irritation and infection
• Administer analgesics and antibiotic as prescribed.
o Analgesics are usually given routinely 24 hours
post op and as time goes by, only as needed
• Irrigate the perineal wound (if preset) as prescribed
and monitor for signs of infection.
• Instruct the client to avoid foods that cause excess
gas formation and odor.
o To lessen ang paglobo ng bag
• Instruct the client about stoma care and irrigations as
prescribed.
o Dapat matutunan ng patient kung paano gawin
iyon
o Dapat maging independent ang patient unless di
talaga siya capable
• Place petrolatum gauze dressing over the stoma as
prescribed – to keep it moist, followed by a dry sterile
dressing if a pouch system is not in place
• Place a pouch system on the stoma as soon as
possible
• Monitor the stoma size, unusual bleeding, or necrotic
tissue
• Monitor for color changes in the stoma
• Note that the normal stoma color is pink to bright red
and shiny, indicating high vascularity
o Intestine is highly vascular to facilitate absorption
better
o Large colon is responsible for the absorption of
water
• Note the following conditions of stoma, requiring HCP
notification:
o Pale pink stoma – low hemoglobi and hematocrit
levels
▪ Due to complications like bleeding
o Purple-black stoma – compromised circulation
▪ If masyado masikip ang base plate or
adhesive
• Assess the functioning of the colostomy
o Wala agad lalabas na stool since postop palanng
lalo na if nag enema, kung meron man, fluid like
or mucus only
o Pag narestore na ang peristaltic activity and diet,
magkakastool na
• Expect that stool is liquid in the immediate
postoperative period but becomes more solid
depending in the area of the colostomy
o Ascending colon – liquid
COLOSTOMY AND ILEOSTOMY
BOLUSO, BRUSAS, CASTANARES, ELIZARDE, FRANCO, REYES, RUIZ, SALVO, SANCHEZ, UMLAS
o Transverse colon – loose to semi-formed
o Descending colon – close to normal
DRAINABLE STOMA APPLIANCES
• Used to collect the stool expelled from the stoma.
• Bags with outlet (open bags) can be emptied as
required, while bags with no outlet (closed bag) must
be disposed when full.
ONE-PIECE AND TWO-PIECE SYSTEMS
• The colostomy bag is attached to the skin surrounding
the stoma via adhesive.
o Either integral to the bag (one-piece system) or
supplied separately for attachment to the bag via
a special coupling system (two-piece system).
ADVANTAGES OF THE 1 PIECE SYSTEM
• Less bulky and more discreet than a 2-piece
appliance
• More flexible, molds to creases in the skin—an
advantage especially if the stoma is close to the
navel, operative scar or crest of the hip bone
o Absence of matigas na ring 2-piece appliance
makes the 1-piece appliance more flexible
• Fast and easy to replace
• The skin surrounding the stoma can be cleaned at
every change
• Can be changed without the need to apply firm
pressure to the abdomen
ADVANTAGES OF THE 2-PIECE SYSTEM
• Gentle on the skin because the adhesive does not
have to be removed every time the bag is changed
o “Click” sound – indicative that the appliance is
secured
o Mas madali ikabit ang 2-piece appliance for
maam E.
o Less likely na maipit ang stoma because 2 yung
kakabait mo mas likely na maiipt sa 1 piece.
▪ Mahirap din kasi walang feeling ang stoma
so kakapain mo.
▪ Bags before were opaque unlike ngayon na
semi-transparent na, so mahirap Makita
yung stoma from the outside.
• Easier to change the bag frequently, e.g. in the event
of odour
• The bag can be turned so that it is more comfortable
when lying down, sitting, or standing.
o You can twist the bag depending on the
orientation of the patient
• The stoma is visible when the adhesive is applied.
o Baseplate/face plate/adhesive/skin barrier –
yung unang kinakabit.
• Easy to attach correctly because of the rigidity of the
baseplate-an advantage if the wearer has shaky
hands.
• The ideal solution if the need for frequent inspection
or treatment of the stoma is required.
MEDICAL-SURGICAL NURSING
1-PIECE SYSTEM DRAWBACKS
• The skin suffers because the adhesive has to be
removed at every change.
o Masakit para sa mabubuhok na patient.
• The appliance may be difficult to pace because the
bag may block the view of the stoma.
o Increased likelihood na maiipit ang stoma.
• Changing the appliance can be a challenge for
beginners.
• Kapag mali kabit mo or naipit tatanggalin mo ng buo
and then kakabit mo ulit. Lalo na kapag mali ang
sukat mo.
2-PIECE SYSTEM DRAWBACKS
• The bag may be difficult to attach to the coupling of
the baseplate
o Especially if different brands
• Pressing he bag into place may be painful – e.g. for
those who have only recently had the operation
• The system is bulkier
• The system may seem rigid because of the coupling.
o Can also cause discomfort to the patient
• Choice of a 1-piece or a 2-piece product is up to the
individual and some people alternate between the two
types depending on the situation.
• Costs more than 1-piece appliance
• Hindi lagging pinapalitan yung skin barrier kasi yung
bag lang yung pinapalitan > hindi regularly nalilinis
yung skin under the skin barrier.
CHANGING COLOSTOMY APPLIANCE
1. Remove old appliance carefully, pulling from area
with least drainage to area with most drainage.
a. Can cause folliculitis kapag mabuhok client >
infection
2. Wash skin area with soap and water.
a. Depends on the institution. Can be warm water
lang or yung iba with soap.
b. Make sure na mawawala lahat ng soap suds to
avoid drying of skin.
c. Never soap the stoma. Use only water/NSS.
d. When checking for patency make sure your
pinky finger is wet with water or NSS.
e. Use soft cloth or wash cloth na basa gently.
f. Gauze can be irritating because matigas.
3. Observe skin area for possible breakdown.
4. Use packet of skin prep on the skin around the stoma;
allow skin prep solution to dry on skin before applying
colostomy appliance.
a. Warm water and wash cloth kapag walang kit
b. Sa hospital nila maam they use calamine
lotion.
i. Make sure na dry muna before ikabit
ii. Problem here is less effective yung
adhesive.
c. Sometimes kapag irritated yung skin they use
underpads/diapers na cut sa circle para walang
COLOSTOMY AND ILEOSTOMY MEDICAL-SURGICAL NURSING
BOLUSO, BRUSAS, CASTANARES, ELIZARDE, FRANCO, REYES, RUIZ, SALVO, SANCHEZ, UMLAS

adhesive na nakadikit sa skin but still may nag iii. If patient can tolerate oral, they should drink
aabsorb sa mga leakage. as much as their output measurement.
5. Apply skin barrier you measured and cut to size. 3. Use a squeeze-type bottle filled with warm water to
6. Put appliance on so that bottom of the appliance is rinse inside of appliance
easily accessible to emptying (e.g. if patient is out of 4. Clean off clamp if soiled.
bed most of the time, put the bottom facing the feed; a. Can cause contamination kaya kelangan linisin.
if patient is in bed most of the time have bottom face 5. Put a few drops of deodorant in appliance if not odor-
the side); picture-frame the adhesive portion of the proof.
appliance with 1 inch tape. a. Yung iba they put charcoal sa ostomy bag to
a. If 2-piece appliance pwede mo i-rotate lessen the smell.
depending on the position ni client. b. Kapag wala you can turn on the exhaust fan (as
b. If hindi enough yung adhesion form the device consideration din for other patients) or spray air
pwede ka mag add ng tape (leucoplast) freshener.
7. Put a few drops of deodorant in appliance if odor 6. Fasten bottom of appliance securely (fold bag over
proof. clamp 2-3 times before closing.)
a. Some bags ngayon may charcoal na for the a. To avoid leakage
odor 7. Check for leakage under appliance every 2-4 hours.
8. Use clamp to fasten bottom of appliance. a. If the patient is awake and coherent, pwede mo
a. To avoid leakages habang nag kakabit ka ng sya tanungin.
pouch. b. Usually sa likod mag ddrain so pwede mo
9. Talk to patient (or communicate in best way possible kapain.
for patient) during and after procedure. Use good 8. Communicate with patient while attending to
handwashing technique. appliance.
a. Treat each patient with dignity
10. Use good hand washing technique THINGS TO AVOID
• Remove appliance each time if needs emptying.
THINGS TO AVOID • Use any materials that could irritate bowel.
• Tear appliance quickly form skin. o Do not use hard materials like gauze unless
• Wash stoma with soap; put anything dry onto stoma. nababad na.
• Irritate skin or stoma. o Wag maging marahas sa paglilinis ng stoma
• Put skin prep solution onto stoma; it will cause (kahit normally walang nararamdaman ang
irritation. patient)
• Make opening too large (increase risk of leakage). • Ignore patient’s needs.
o May cause leakage sa skin rendering the skin
barrier useless. QUESTIONS FROM THE CLASS
• Have appliance attached so patient can’t be involved • In the long run, stomas flatten but not totally flat.
in own care. • Stoma – edematous postoperatively.
• Use any materials that would irritate bowel. • When irritation is present stoma can be inflamed.
o Make sure na nakababad na sya for a few • Color is important in stoma – should be pinkish to red
minutes in warm water. and moist.
o Stoma has no feeling > pwedeng mag necrotize o Hindi dapat magiging cyanotic
na yung stoma before we know na na-irritate na
sya.
• Avoid conversation/eye contact.
• Contaminate other incisions.
o Last ginagawa ang colostomy care

EMPTYING COLOSTOMY APPLIANCE

1. Unclip the bottom of bag
2. Drain into bedpan.
a. Ginupit na IV bottle in public hospitals
i. In Ileostomy – measure output. Because of
its liquid consistency nasusukat yung output
when using IV bottles which promotes
accurate records.
ii. In ileostomy fluid replacement is important
because patients are prone to f&e
imbalances.