Learning Content: Caring for a Colostomy

A colostomy is the surgical creation of an opening of the colon onto the surface of the
abdomen.

Colostomy surgery may be needed to treat several different diseases and conditions.
These include:
 Birth defect, such as a blocked or missing anal opening, called an
imperforate anus
 Serious infection, such as diverticulitis, inflammation of little sacs on the
colon
 Inflammatory bowel disease
 Injury to the colon or rectum
 Partial or complete intestinal or bowel blockage
 Rectal or colon cancer
 Wounds or fistulas in the perineum. A fistula is an abnormal connection
between internal parts of the body, or between an internal organ and the skin.
A woman's perineum is the area between her anus and vulva; a man's lies
between his anus and scrotum.

Preoperative Care

Reinforce the physician's explanation of the planned surgical procedure. The patient is told as
accurately as possible what anatomic and physiologic changes will occur with surgery. The
location and number of incision sites and drains are also discussed. Before evaluating the tumor
and colon during surgery, the surgeon may not be able to determine whether a colostomy (or less
commonly, an ileostomy) will be necessary. The patient is told that a colostomy is a possibility.
If a colostomy is planned, the surgeon consults a certified wound, ostomy, continence nurse
(CWOCN) to recommend optimal placement of the ostomy. The CWOCN teaches the patient
about the rationale and general principles of ostomy care. In many settings, the CWOCN marks
the patient's abdomen to indicate a potential ostomy site that will decrease the risk for
complications such as interference of the undergarments or a prosthesis with the ostomy
appliance.

Key Points of Psychosocial Assessment

 Patient's and family's level of knowledge of disease and ostomy care

 Patient's educational level
 Patient's physical limitations (particularly sensory)
 Support available to patient
 Patient's type of employment
 Patient's involvement in activities such as hobbies
 Financial concerns regarding purchase of ostomy supplies
Key Points of Physical Assessment

 Before marking the placement for the ostomy, the nurse specialist considers:
 Contour of the abdomen in lying, sitting, and standing positions
 Presence of skinfolds, creases, bony prominences, and scars
 Location of belt line
 Location that is easily visible to the patient
 Possible location in the rectus muscle

The surgeon discusses the risk for these problems with the patient before surgery and allows him
or her to verbalize concerns and questions related to this risk before he or she gives informed
consent. Reinforce teaching about abdominal surgery performed for the patient under general
anesthesia and review the routines for turning and deep breathing. Teach the patient about the
method of pain management to be used after surgery such as IV patient controlled analgesia
(PCA), epidural analgesia, or other method. If the bowel is not obstructed or perforated, elective
surgery is planned. The patient may be instructed to thoroughly clean the bowel, or “bowel
prep,” to minimize bacterial growth and prevent complications. Mechanical cleaning is
accomplished with laxatives and enemas or with “whole-gut lavage.” The use of bowel preps is
controversial, and some surgeons do not recommend it because alterations in comfort may arise.
Older adults may become dehydrated from this process. To reduce the risk for infection, the
surgeon may prescribe one dose of oral or IV antibiotics to be given before the surgical incision
is made. Teach patients that a nasogastric tube (NGT) may be placed for decompression of the
stomach after surgery. A peripheral IV or central venous catheter is also placed for fluid and
electrolyte replacement while the patient is NPO after surgery. Patients having minimally
invasive surgeries do not need an NGT.

Postoperative Care

General abdominal surgery care is required. As with other patients undergoing abdominal
surgery, the nurse encourages those with an ostomy to engage in early ambulation. It is important
to administer prescribed pain medications as required. The nurse observes the stoma for color
and size. It should be pink to bright red and shiny. Typically, a temporary clear or transparent
plastic bag (i.e., appliance or pouch) with an adhesive facing is placed over the ostomy in the
operating room and firmly pressed onto the surrounding skin. The nurse monitors the ostomy for
fecal drainage, which should begin about 24 to 48 hours after surgery for an ileostomy and
within 3 to 6 days after surgery for a colostomy.

The drainage from an ileostomy is a continuous liquid from the small intestine because the stoma
does not have a controlling sphincter. The contents drain into the pouch and are thus kept from
coming into contact with the skin. They are collected, measured, and discarded when the pouch
becomes full. If a continent ileal reservoir was created, as described for the Kock pouch,
continuous drainage is provided by an indwelling reservoir catheter for 2 to 3 weeks after
surgery. This allows the suture lines to heal. Stool drainage from transverse colostomies may be
soft and unformed; whereas, stool from descending and sigmoid colostomies is more solid.

Because patients lose large fluid volumes in the early postoperative period, an accurate record of
fluid I&O, including fecal discharge, is necessary to help gauge each patient’s fluid needs. There
may be 1,000 to 2,000 mL of fluid lost each day in addition to expected fluid loss through urine,
perspiration, respiration, and other sources. With this loss, sodium and potassium are depleted.
The nurse monitors laboratory values and administers electrolyte replacements as prescribed.
Fluids are given IV for 4 to 5 days to replace lost fluids.

NG suction may be a part of the immediate postoperative care, with the tube requiring frequent
irrigation, as prescribed. The purpose of NG suction is to prevent a buildup of gastric contents
while the intestines are not functioning. After the tube is removed, the nurse offers sips of clear
liquids and gradually progresses the diet. Nausea and abdominal distention, which may indicate
intestinal obstruction, must be reported immediately.

If rectal packing has been used, it is removed by the end of the first week. Because this
procedure may be uncomfortable, the nurse may administer an analgesic agent an hour before the
removal. After the packing is removed, the perineum is irrigated two or three times daily until
full healing takes place.

 Placement of permanent colostomies. The nature of the discharge varies with the site.
Shaded areas show sections of bowel removed. A. With a sigmoid colostomy, the feces
are formed. B. With a descending colostomy, the feces are semi formed. C. With a
transverse colostomy, the feces are unformed. D. With an ascending colostomy, the feces
are fluid.

Providing Emotional Support

The patient may think that everyone is aware of the ostomy and may view the stoma as a
mutilation compared with other abdominal incisions that heal and are hidden. Because there is
loss of a body part and a major change in anatomy and function, the patient often goes through
the phases of grief—denial, anger, bargaining, depression, and acceptance. Nursing support
through these phases is important, and understanding of the patient’s emotional state should
determine the approach taken. For example, education may be ineffective until the patient is
ready to learn. Concern about body image may lead to questions related to family relationships,
sexual function, and, for women, the ability to become pregnant and deliver a baby normally.
Patients need to know that someone understands and cares about them. A calm, nonjudgmental
attitude exhibited by the nurse aids in gaining the patient’s confidence. It is important to
recognize that treatment of a possibly terminal illness (e.g., cancer) makes patients irritable,
anxious, and unhappy. The nurse can coordinate patient care through meetings attended by
consultants such as the physician, psychologist, psychiatrist, social worker, WOC nurse, and
dietitian.
Conversely, a surgical procedure to create an ileostomy can produce dramatic positive changes in
patients who have suffered from IBD for several years. After the discomfort of the disease has
decreased and the patient learns how to take care of the ileostomy, he or she often develops a
more positive outlook. Until the patient progresses to this phase, an empathetic and tolerant
approach by the nurse plays an important part in recovery. The sooner the patient masters the
physical care of the ostomy, the sooner he or she will psychologically accept it. Strong self-care
skills are associated with better outcomes and adjustment for patients.

Managing Skin and Stoma Care

The patient with an ileostomy cannot establish regular bowel habits because the contents of the
ileum are fluid and are discharged continuously. The patient must wear a pouch at all times.
Stomal size and pouch size vary initially; the stoma should be rechecked 3 weeks after surgery,
when the edema has subsided. The final size and type of appliance is selected in 3 months, after
the patient’s weight has stabilized and the stoma shrinks to a stable shape.

The incidence of complications related to a colostomy is usually less than that of an ileostomy.
Postoperatively, the stoma is examined for swelling (slight edema from surgical manipulation is
normal), color (a healthy stoma is pink or red), discharge (a small amount of oozing is normal),
and bleeding (an abnormal sign if bright red or more than trace amounts).

Skin excoriation around the stoma can be a persistent problem, particularly for ileostomies.
Peristomal skin integrity may be compromised by several factors, such as an allergic reaction to
the ostomy appliance, skin barrier, or paste; chemical irritation from the effluent; mechanical
injury from the removal of the appliance; and infection. If irritation and yeast growth occur,
nystatin powder (Mycostatin) is dusted lightly on the peristomal skin and a pouch with skin
barrier is applied over the affected area.

Assess the color and integrity of the stoma frequently. A healthy stoma should be reddish pink
and moist and protrude about inch (2 cm) from the abdominal wall. During the initial
postoperative period, the stoma may be slightly edematous. A small amount of bleeding at the
stoma is common.

Also assess the condition of the peristomal skin (skin around the stoma) and frequently check the
pouch system for proper fit and signs of leakage. The skin should be intact, smooth, and without
redness or excoriation.

Nursing Safety Priority!

Action Alert!
 

Report any of these problems related to the colostomy to the surgeon:

• Signs of ischemia and necrosis (dark red, purplish, or black color; dry)

• Unusual bleeding

• Mucocutaneous separation (breakdown of the suture line securing the stoma to the abdominal
wall)

The colostomy should start functioning in 2 to 3 days after surgery. When it begins to function,
the pouch may need to be emptied frequently because of excess gas collection. It should be
emptied when it is one-third to one-half full of stool. Stool is liquid immediately after surgery
but becomes more solid, depending on where in the colon the stoma was placed. For example,
the stool from a colostomy in the ascending colon is liquid, the stool from a colostomy in the
transverse colon is pasty, and the stool from a colostomy in the descending colon is more solid
(similar to stool expelled from the rectum).

Changing an Appliance

The patient who has a colostomy may return from surgery with a clear ostomy pouch system in
place. A clear pouch allows the health care team to observe the stoma. If no pouch system is in
place, a petrolatum gauze dressing is usually placed over the stoma to keep it moist. This is
covered with a dry, sterile dressing. The colostomy pouch system, also called an appliance,
allows more convenient and suitable collection of stool than a dressing does. A regular schedule
for changing the pouch before leakage occurs must be established for those with an ostomy. The
patient should be educated to change the pouch. The amount of time a person can keep the
appliance sealed to the body surface depends on the location of the stoma and on body structure.
The usual wearing time, which also depends on the type of skin barrier, is 5 to 10 days. The
appliance is emptied every 4 to 6 hours, or at the same time the patient empties the bladder. An
emptying spout at the bottom of the appliance is closed with a special clip or Velcro closure
made for this purpose. If the patient wishes to bathe or shower before putting on a clean
appliance, micropore tape applied to the sides of the pouch keeps it secure during bathing.

Most pouches are disposable and odor proof. Foods such as spinach and parsley act as
deodorizers in the intestinal tract; foods that cause odors include asparagus, cabbage, onions, and
fish. Bismuth subcarbonate tablets, which may be prescribed and taken orally three or four times
each day, are effective in reducing odor. Oral diphenoxylate with atropine can be prescribed to
diminish intestinal motility, thereby thickening the stool and assisting in odor control. Foods
such as rice, mashed potatoes, and applesauce may also thicken stool.
 
Nursing Safety Priority!

Action Alert!

Teach the patient and family to apply a skin sealant (preferably without alcohol) and allow it to
dry before application of the appliance (colostomy bag) to facilitate less painful removal of the
tape or adhesive. If peristomal skin becomes raw, stoma powder or paste or a combination may
also be applied. The paste or other filler cream is also used to fill in crevices and creases to
create a flat surface for the flange of the colostomy bag. If the patient develops a fungal rash, an
antifungal cream or powder should be used.

Irrigating a Colostomy

The purpose of irrigating a colostomy is to empty the colon of gas, mucus, and feces so that the
patient can go about social and business activities without fear of fecal drainage. A stoma does
not have voluntary muscular control and may empty at irregular intervals. Regulating the passage
of fecal material is achieved by irrigating the colostomy or allowing the bowel to evacuate
naturally without irrigations. This choice depends on the person and the type of the colostomy
(i.e., descending or sigmoid colostomies). By irrigating the stoma at a regular time, there is less
gas and retention of the irrigant. The time for irrigating the colostomy should be consistent with
the schedule that the person will follow after leaving the hospital.

Colostomy irrigation is not recommended for persons with extensive pelvic irradiation because it
carries a risk of perforation. Likewise, it is contraindicated in patients currently receiving
chemotherapy, those with IBS, Crohn’s disease, diverticulitis, and peristomal hernias.

As soon as the patient with a descending or sigmoid colostomy has established a routine for
evacuation with irrigations, pouches may be dispensed with, and a closed ostomy appliance or a
stoma cap is used to cover the stoma. Except for gas and a slight amount of mucus, nothing
escapes from the colostomy opening between irrigations. New assistive devices and ostomy care
algorithms are available to help nurses learn ostomy assessment and ostomy product selection.

 
PROCEDURE
1.       Gather materials needed for the procedure.

         bedside commode

          irrigation solution

         clamp

         IV pole

         disposable gloves

         water-soluble lubricant

2.       Prior to performing the procedure, introduce self and verify the client’s identity using agency protocol.
Explain to the client what you are going to do, why it is necessary, and how he or she can cooperate. Plan
where he or she will receive irrigation.
3.       Warm solution in amount ordered. If tap water is used, adjust temperature as it flows from the faucet.
4.       Assist patient onto bedside commode or into nearby bathroom.
5.       Perform hand hygiene.
6.       Add irrigation solution to container. Release the clamp and allow fluid to progress through the tube
before reclamping.
7.       Hang container so that the bottom of the bag will be at the patient’s shoulder level when seated.
8.       Put on disposable gloves.
9.       Remove appliance and attach irrigation sleeve. Place the drainage end into the toilet bowl or bedpan.
10.   Lubricate the end of the cone with water-soluble lubricant.
11.   Insert the cone into the stoma. Introduce the solution slowly over a period of 5 minutes. Hold tubing (or
if patient is able allow patient to hold tubing) all the time that the solution is being instilled. Control the
rate of the flow by closing or opening the clamp.
12.   Hold the cone in place for an additional 10 seconds after the fluid is infused.
13.   Remove the cone. Assist patient to remain seated on toilet or bedside commode.
14.   After most of the solution has returned, allow patient to clip (close) the bottom of the irrigating sleeve
and continue with daily activities.
15.   After solution has stopped flowing from stoma, remove irrigating sleeve and cleanse skin around stoma
opening with mild soap and water. Gently pat peristomal skin dry.
16.   Attach new appliance to stoma if needed.
17.   Document the procedure, including the amount of irrigating solution used; color, amount, and
consistency of stool returned; condition of the patient’s stoma; degree of patient participation; and
patient’s reaction to the irrigation.

Managing Dietary and Fluid Needs

A low-residue diet is followed for the first 6 to 8 weeks. Strained fruits and vegetables are
ingested. These foods are important sources of vitamins A and C. Later, there are few dietary
restrictions, except for avoiding foods that are high in fiber or hard-to-digest kernels, such as
celery, popcorn, corn, poppy seeds, caraway seeds, and coconut, which may result in a stomal
obstruction (food blockage) for the person with an ileostomy. Foods are reintroduced one at a
time.

Getting enough fluids during the summer may be a challenge, when fluid lost through
perspiration adds to the fluid loss through the ileostomy. Fluids such as sports drinks (Gatorade)
are helpful in maintaining electrolyte balance. If the fecal discharge is too watery, fibrous foods
(e.g., whole-grain cereals, fresh fruit skins, beans, corn, nuts) are restricted. If the effluent is
excessively dry, salt intake is increased. Increased intake of water or fluid does not increase the
effluent, because excess water is excreted in the urine.

Control of gas and odor from the colostomy is often an important outcome for patients with new
ostomies. Although a leaking or inadequately closed pouch is the usual cause of odor, flatus can
also contribute to it. Remind the patient with an ostomy that, although generally no foods are
forbidden, certain foods (such as vegetables) can cause flatus or contribute to odor when the
pouch is open. Charcoal filters, pouch deodorizers, or placement of a breath mint in the pouch
helps eliminate odors. The patient should be cautioned to not put aspirin tablets in the pouch
because they may cause ulceration of the stoma. Vents that allow release of gas from the ostomy
bag through a deodorizing filter are available and may decrease the patient's level of self-
consciousness about odor. The patient with a sigmoid colostomy may benefit from colostomy
irrigation to regulate elimination. However, most patients with a sigmoid colostomy can become
regulated through diet. An irrigation is similar to an enema but is administered through the stoma
rather than the rectum. In addition to teaching the patient about the signs and symptoms of
obstruction and perforation.

Preventing Complications

Monitoring for complications is an ongoing activity for the patient with an ostomy. Peristomal
skin irritation, which results from leakage of effluent, is the most common complication of an
ileostomy. A drainable pouching system that does not fit well is often the cause. Components of
the drainable pouching system include the pouch, a solid skin barrier, and adhesive. The WOC
nurse typically recommends the appropriate drainable pouching system. The solid skin barrier is
the component of this system that is most important in ensuring healthy peristomal skin. Solid
skin barriers are typically shaped as rectangular or elliptical wafers and are composed of
polymers and hydrocolloids. They protect the skin around the stoma from effluent from the
stoma and provide a stable interface between the stoma and the pouch. It is critical that the
barrier be sized appropriately to “hug” the stoma (up to the stoma but not touching) and not
expose peristomal skin.

Other common complications include diarrhea, stomal stenosis, urinary calculi, and
cholelithiasis. Even in the presence of a properly fitted drainable pouching system, diarrhea can
be problematic. Diarrhea, manifested by very irritating effluent that rapidly fills the pouch (every
hour or sooner), can quickly lead to dehydration and electrolyte losses. Supplemental water,
sodium, and potassium are given to prevent hypovolemia and hypokalemia. Antidiarrheal agents
are given. Stenosis is caused by circular scar tissue that forms at the stoma site. The scar tissue
must be surgically released. Urinary calculi may occur in patients with ileostomies and are at
least partly attributed to dehydration from decreased fluid intake. Crohn’s disease is a risk factor
for cholelithiasis (i.e., gallstones) due to altered absorption of bile acids.