 Colostomy

- Surgical opening into the colon by means of a stoma to allow drainage of bowel contents;
one type of fecal diversion.
- an opening in the belly (abdominal wall) that's made during surgery. A colostomy may be
needed if you cannot pass stools through your anus.
 Effluent
- Stool discharged from an stomy.
- Fecal drainage from intestinal diversions (ileostomies and colostomies) is called effluent.

1. Describe the following:

A. Types of Colostomy (Duration)

 Temporary colostomies
- are generally performed for traumatic injuries or inflammatory conditions of the bowel.
They allow the distal diseased portion of the bowel to rest and heal.
- Certain lower bowel problems are treated by giving part of the bowel a rest. It’s kept empty
by keeping stool from getting to that part of the bowel. To do this, a short-term
(temporary) colostomy is created so that the bowel can heal.

 Permanent colostomies
- are performed to provide a means of elimination when the rectum or anus is nonfunctional
as a result of a birth defect or a disease such as cancer of the bowel.
- When part of the colon or the rectum becomes diseased, a long-term (permanent)
colostomy must be made. The diseased part of the bowel is removed or permanently
rested. In this case, the colostomy is considered permanent and is not expected to be
closed in the future.

B. Types of Colostomy (Location)

Types of Colostomy Description Picture Drainage

1. Sigmoid The most common Feces are normal
Colostomy location of an ostomy or formed
is the sigmoid colon. It consistency, and
is the surgical the frequency of
construction of an discharge can be
opening into the regulated.
sigmoid colon, and is
commonly referred to
as sigmoid colostomy

People with a
sigmoidostomy may
not have to wear an
appliance at all times,
 and odors can usually
be controlled.
2. Descending Empties from the Feces are more
Colostomy descending colon. solid or semi-
Located on the lower formed.
left side of the
abdomen Produces
increasingly solid
fecal drainage.

3. Transverse Empties from the Feces are soft and

Colostomy transverse colon. unformed. It
produces a
The surgical opening malodorous,
created in the mushy drainage
transverse colon because some of
resulting in one or two the liquid has been
openings. reabsorbed. There
is usually no
It is located in the control.
upper abdomen,
middle, or right side

4. Ascending Empties from the Feces are

Colostomy ascending colon. fluid/liquid and
cannot be
A relatively rare regulated, and
opening in the digestive enzymes
ascending portion of are present.
the colon.
Odor, is a problem
It is located on the requiring control.
right side of the
abdomen.
C. Forms of ostomy appliances:

 Purpose of Ostomy Appliance

- Protect the skin
- Collect stool
- Control odor

 Appliance consists of:

- Skin barrier
- Pouch

 Ostomy Appliances

1. Adjustable ostomy belt – some clients may prefer to also wear an adjustable ostomy
belt, which attaches to an ostomy pouch to hold the pouch firmly in place.

Appliances can be one-piece or two-pieces:

2. One-piece Ostomy Appliance – where the skin barrier is already attached to the pouch
(Figure 49–16 A).

3. Two-piece Ostomy – an appliance can consist of two pieces: a separate pouch with a flange
and a separate skin barrier with a flange where the pouch fastens to the barrier at the
flange (Figure 49–16 B). The pouch can be removed without removing the skin barrier
when using a two-piece appliance.
 Pouches can be closed or drainable:

4. Drainable Pouches – a drainable pouch usually has a clip where the end of the pouch is
folded over the clamp and clipped. Newer drainable pouches have an integrated clo- sure
system instead of a clamp. The client folds up the end of the pouch three times and presses
firmly to seal the pouch. Drainable pouches are usually used by people who need to empty
the pouch more than twice a day.

5. Closed Pouches - are often used by people who have a regular stoma discharge (e.g.,
sigmoid colostomy) and only have to empty the pouch 1 or 2 times a day. Some people
find it easier to change a closed pouch than emptying a drainable pouch, which requires
some dexterity.

2. Purpose of the following:

 Purpose of Stoma Care

- To assess and care for the peristomal skin.

 - To collect stool for assessment of the amount and type of output.
- To minimize odors for the client’s comfort and self-esteem.

 Purpose of Colostomy Irrigation

- To distend the bowel sufficiently to stimulate peristalsis, which stimulates evacuation.

- To empty the colon of gas, mucus, and feces.
- To regulate the passage of fecal material.
- To stimulate peristalsis.
- To promote evacuation of the stored waste.

 Purpose of Colostomy Care

- To maintain the integrity of the stoma and peristomal care, prevent lesions, ulcerations,
excoriations and other skin breakdown.
- Prevent infections
- Minimize odor
- To protect the skin.
- Patient's acceptance and self care.
- To prevent stoma related complications.
- Collect effluent for assessment of amount and type of output

3. Explain the indication and contraindications of Colostomy care and Irrigation

 Indications:

- Birth defect
- Injury to the colon or rectum
- Bowel cancer
- Bowel blockage

 Contraindications:

- Patients with Extensive Pelvic Irradiation

- Patients receiving chemotherapy
- Patients with IBS
- Patients with Crohn’s Disease
- Patients with Diverticulitis
- Patients with Peristomal Hernias

4. State the various signs to assess in patients with colostomy

• Stoma color:

- The stoma should appear red, similar in color to the mucosal lining of the inner cheek and
slightly moist.
- Very pale or darker-colored stomas with a dusky bluish or purplish hue indicate impaired
blood circulation to the area. Notify the surgeon immediately.
• Stoma size and shape:

- Most stomas protrude slightly from the abdomen.

- New stomas normally appear swollen, but swell- ing generally decreases over 2 or 3 weeks
or for as long as 6 weeks.
- Failure of swelling to recede may indicate a problem, for example, blockage.

• Stomal bleeding:

- Slight bleeding initially when the stoma is touched is normal, but other bleeding should be
reported.

• Status of peristomal skin:

- Any redness and irritation of the peristomal skin—the 5 to 13 cm (2 to 5 in.) of skin

surrounding the stoma—should be noted.
- Transient redness after removal of adhesive is normal.

• Amount and type of feces:

- Assess the amount, color, odor, and consistency.

- Inspect for abnormalities, such as pus or blood.

• Complaints:

- Complaints of burning sensation under the skin barrier may indicate skin breakdown.
- The presence of abdominal discomfort and/or distention also needs to be determined.

• Learning needs of the client and family members regarding the ostomy and self-care.

• The client’s emotional status, especially strategies used to cope with the body image changes and the
ostomy.

Fecal Drainage

 Expect within 3-6 days after surgery for a colostomy.

Managing Stoma Care:

 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 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).

Changing an Appliance:
  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.
 Most pouches are disposable and odor proof.

Food deodorizers: Spinach, Sparsley

Foods that cause odors:

Asparagus
Cabbage
Onions
Fish

5. Medications:

 Bismuth subcarbonate tablets – effective in reducing odor, taken PO, TID or QID.

 Oral diphenoxylate with atropine – diminish intestinal motility, thereby thickening the stool and
assisting in odor control.
Foods that thicken stool:
Rice
Mashed potatoes
Applesauce

1. Materials: discuss purpose briefly

Colostomy Care
Colostomy Irrigation 2 pairs of gloves

1 pair of gloves
Mirror
NSS
French 18 Catheter New colostomy appliances
2 kidney basins ( 1 sterile )
2 kidney basins ( 1 sterile )
Aseptic syringe
Cotton pledgets
KY jelly
Betadine solution

2. Nursing responsibilities before, during, and after Colostomy Care and Irrigation

 Before

1. Check the physician’s order.

 2. Inform the patient and explain the procedure.
3. Perform medical hand washing.
4. Assemble all the equipments needed.
5. Provide privacy to the patient.
6. Provide a mirror to the patient.
7. Do first gloving.
8. Place the kidney basin below the colostomy appliance.
9. If appliance is non-drainable: Remove the pouch.
If appliance is drainable: unfasten the edge of the appliance and drain the fecal matter.
10. Ask permission from the patient to use th comfort room.
11. Remove the gloves and do hand washing again, if necessary.
12. Go back to the bedside table and prepare materials needed for cleaning the stoma area.
 During
1. Unwrap the sterile kidney basin, as well as the pledgets and drop is de the basin.
2. Pour a little amount of betadine solution onto the trash can and to the kidney basin.
3. Do second gloving.
4. Place kidney basin and waste receptacle at the side near the stoma.
5. Clean the stoma starting from the inside, to the top to the sides and to the peristomal skin with
one pledget for each area using one stroke only.
6. Apply ointment to the peristomal skin after cleaning with betadine.
7. If patient is not for irrigation, attach the pouch and let the patient see the site using the mirror.
8. If patient id for irrigation, unglove and loosen all the materials needed for irrigation.
9. Unwrap the 2 sterile kidney basins, the tubing, asepto syringe and place a small amount of KY
jelly at the side of one of the basins which is where he tubing and the asepto syringe are to be
placed, too.
10. Open the NSS solution and pour at the kidney basin.
11. Do gloving.
12. Lubricate your little finger with KY jelly.
13. Insert the little finger inside the stoma: 1 ¼ inch.
14. Lubricate the tubing with KY jelly.
15. Insert the tubing carefully to the stoma.
16. Aspirate NSS with the use of an asepto syringe and attach it to the tubing.
17. Infuse the NSS and aspirate. Then place te irrigation outflow to the kidney basin. Do this until
the outflow is clear.
18. Remove the tubing and discard the outflow.
19. Attach appliance and place deodorizer, if necessary.
 After
1. Document the procedure in the client record
2. Report any increase in stoma size, change in color, and presence of skin irritation or erosion.
3. Record on he clients chart discoloration of the stoma, the appearance of peristomal skin, the
amount and type of drainage.
4. Evaluate the patients response or reaction to the procedure.
5. Do after care.

1. Define the following terms:

 Ostomy
- is an opening for the gastrointestinal, urinary, or respiratory tract onto the skin.
 - Refers to the actual opening in your abdomen.

 Gastrostomy
- surgical creation of an opening into the stomach for the purpose of administering fluids,
nutrition formulas, and medications via a feeding tube or for decompression and drainage
of stomach contents
- surgical creation of an opening into the stomach.

 Stoma
- the opening created in the abdominal wall by the ostomy.
- an artificially created opening between a body cavity (e.g., stomach or intestine) and the
body surface.

 Periostomal skin
- the skin right around the stoma.
- It's the skin that the ostomy wafer adheres to.

2. Different types of stoma:

 Gastrostomy
- gastrostomy is an opening through the abdominal wall into the stomach.
- For the purpose of administering fluids, nutrition formulas, and medications via a feeding
tube or for decompression and drainage of stomach contents

 Jejunostomy
- surgical creation of an opening into the jejunum for the purpose of administering fluids,
nutrition formulas, and medications.
- opens through the abdominal wall into the jejunum.

 Ileostomy
- surgical opening into the ileum by means of a stoma to allow drainage of bowe contents;
one type of fecal diversion.
- a stoma is created using your small intestine so waste can bypass your colon and rectum.
This is the most common type of temporary stoma, but they can also be permanent. You
may need an ileostomy if you have Crohn’s disease, ulcerative colitis, or bowel cancer.

 Colostomy
- opens into the colon (large bowel).
- a stoma is created with part of your colon, also known as your large intestine, to bypass
your rectum.
 Urostomy
- an opening in the belly (abdominal wall) that's made during surgery. It re-directs urine
away from a bladder that's diseased, has been injured, or isn't working as it should.
 - Your doctor will make a pouch using your small intestine. They’ll connect your ureters to
this pouch so that urine can drain outside of your body without passing through your
bladder. You might need a urostomy if your bladder is diseased or damaged.

3. Purpose of Gastrostomy

 To administer nutrition, fluids, and medications via a feeding tube.

 Gastric decompression
 Drainage gastric contents

Indications

 Patients with Gastroparesis

 Patients with Gastroesophageal Reflux Disease
 Patients with Intestinal Obstruction

Possible Complications Picture

Wound Infection/Cellulitis

Bleeding

Leakage

Dislodgement
 Tube Insertion:

Nasogastric or Orogastric feedings – patients who are comatose

Types of Gastrostomy Tube

Types: Time of Removal Routine Replacement
Balloon Gastrostomy Tube (G 6 weeks to 3 months after 3 to 6 months
Tube) initial insertion

Non-balloon Gastrostomy Tube 6 weeks to 3 months after 6 to 12 months

(G tube) initial insertion
Indications for Replacement:

 Clogged tube
 Ruptured Balloon

Cleaning:

 G tube site is cleaned daily and as needed with soap and water, or 2% chlorhexidine gluconate
and dried thoroughly.

Assessment and Management:

 The site is assessed for tube deterioration, drainage, and signs and symptoms of possible
infection, including redness, swelling and foul-smelling drainage.
 If there is excessive drainage, a gauze pad may be secured over the external anchor, taking
caution to avoid excessive tension on the tube

Alternative: Low-profile Gastrostomy Devices (LGPDs)

 LPGDs may be inserted 6 weeks to 3 months after initial G tube placement or placed as the initial
G tube.
 These devices are flush with the skin, eliminate the possibility of inward tube migration, have

antireflux valves to prevent gastric leakage, and do not require tape or other securement
devices.
  Patients requiring enteral nutrition support are able to conceal the feeding tube access site
under their clothing.
 LPGDs require special connection tubing so they can be attached to the feeding container.
 Patients must be instructed to bring this connection tubing with them when traveling, going to
the emergency department or hospital, or undergoing diagnostic procedures that require access
into the GI tract.

Placement Description Picture

1.Endoscopically Lighted endoscope is
inserted via the patient’s
Percutaneous Endoscopic mouth toward the stomach
Gastrostomy (PEG) and then the stomach is
inflated with air. The PEG
tube is guided down the
esophagus, into the
stomach, and out through
the abdominal incision.
2.Fluoroscopically G tubes can also be placed
fluoroscopically by a skilled
provider when an
endoscope cannot be
passed through a strictured
or obstructed esophagu

4. Guidelines in the care of patients with gastrostomy

 Determine the patient’s ability to understand and cooperate with the procedure.
 The nurse assesses the ability of both patient and family to adjust to a change in body image and
to participate in self-care.
 The purpose of the procedure and expected postoperative course should be explained.
 The patient needs to know that the feeding tube will bypass the mouth and esophagus so that
liquid feedings can be given directly into the stomach or intestine.
 If the feeding tube is expected to be permanent, the patient should be made aware of this.
 In the postoperative period, the patient’s fluid and nutritional needs are assessed to ensure proper
intake and GI function.
 The nurse inspects the tube for proper maintenance and the incision for any drainage, skin
breakdown, or signs of infection.
 As the nurse evaluates patients’ responses to the change in body image and their understanding
of the feeding methods, interventions are identified to help them cope with the tube and learn
self-care measures

5. Nursing Responsibilities Before, During, and After Gastrostomy Feeding

 Before

1. Check the patient's chart.

2. Go to the patient's room and explain the procedure.
3. Go back to the nurse’s station and perform medical hand washing.
4. Prepare necessary equipment and bring it to the patients room.

 During

1. Position patient in a semi-Fowler’s position.

2. Expose the insertion site.
3. Remove the small dressing attached to the tip of gastrostomy tube then kink tube.
4. Attach syringe to the tube then link again as you get the asepto bulb.
5. Infuse feeding.
 - Hold the syringe 6 inches above the insertion site.
- Fill syringe with feeding and allow to flow into gastrostomy tube.
- Follow the medication, then water for flushing (30-60ml of water).
- Do not allow syringe to empty until feeding water infusion are completed.

 After

1. Clamp or pull a small dressing secured with a rubber band in the gastrostomy tube and remain
client in semi-Fowler’s position.
2. Document the procedure ein client’s record.
3. Evaluate patient's reaction to the procedure.
4. Do after care.

6. Identify the different care management of patients with gastrostomy

 Meeting nutritional needs

 Preventing infection and providing skin care
 Enhancing body image
 Monitoring and managing potential complications
 Educating patients about self-care

 MEETING NUTRITIONAL NEEDS

- The first fluid nourishment is given soon after tube insertion and can consist of a sterile
water or normal saline flush of at least 30 mL.
- Formula feeding can begin as prescribed, typically within 2 to 24 hours post tube insertion.
- The infusion rate or bolus amount given is gradually increased.

 PREVENTING INFECTION AND PROVIDING SKIN CARE

- The nurse washes the area around the tube under the bumper with soap and water or 2%
chlorhexidine gluconate daily and as needed to remove any encrustation.
- If soap and water is used, the area is rinsed well with water and patted dry.
- If chlorhexidine is used, the area is allowed to air dry.
- A protective skin barrier may be applied.

 ENHANCING BODY IMAGE

- Eating is a major physiologic and social function, and the patient with a gastrostomy has
experienced a major change in body image.
- It is necessary to evaluate the existing family support system, because adjustment takes
time and is facilitated by family acceptance.

 MONITORING AND MANAGING POTENTIAL COMPLICATIONS

 - The nurse closely monitors the patient’s vital signs and observes all operative site drainage,
vomitus, and stool for evidence of bleeding.
- The nurse should notify the primary provider if excessive pain occurs at the incision site
post insertion.

 EDUCATING PATIENTS ABOUT SELF-CARE

- The nurse assesses the patient’s level of knowledge and interest in learning about the tube,
as well as an ability to understand how to flush, provide site care, and administer feedings
or facilitate decompression and drainage.

7. Materials:

Materials

Feeding bag

Gauze

Medicine cup

Clean asepto syringe

Gloves

Drape/towel