Learning Objectives
By the end of this section, you will be able to:
- Discuss the role of the nurse pre- and postoperatively for the patient with an ostomy
- Describe the nursing care of a patient with a colostomy and continent ileostomy
- Identify troubleshooting methods when skin breakdown occurs with an ileostomy
Some patients have surgical diversions for diseases such as diverticulitis or cancer. A surgical opening in the abdomen for the expulsion of stool into a bag-like appliance is called an ostomy. In ostomies related to elimination, a stoma is an opening on the abdomen that is connected to the GI or urinary system to allow waste (i.e., urine or feces) to be collected in a pouch. This unit focuses on ostomy care and the nurse’s role in the patient’s positive coping and self-image.
Nursing Care of the Ostomy Surgical Patient
Approximately 500,000 individuals in the United States have an ostomy. A stoma can be permanent, such as when an organ is removed, or temporary, to allow for organ healing. Ostomies are created for patients with conditions such as cancer of the bowel, inflammatory bowel diseases, or perforation of the colon.
The two common types of ostomies related to elimination are:
- ileostomy: the lower end of the small intestine (ileum) is attached to a stoma to bypass the colon, rectum, and anus.
- colostomy: the colon is attached to a stoma to bypass the rectum and the anus.
Figure 19.26 compares the anatomic locations of ileostomies and various sites of colostomies. It is important for the nurse to understand the site of a patient’s colostomy because the site affects the characteristics of the waste. For example, due to the natural digestive process of the colon and absorption of water, waste from an ileostomy or a colostomy placed in the anterior ascending colon will be watery compared with waste from an ostomy placed in the descending colon.
Preoperative Care
In preparing for surgery, preoperative education and ostomy site marking are completed, allowing the patient to prepare for ostomy care and ensure optimal ostomy location (WOCN et al., 2021). This is usually done by a certified wound and ostomy nurse who collaborates with the surgeon. During the patient education session, the nurse will explain ostomy care, give an overview of the different types of supplies used, and provide the patient a rationale about the anatomic placement of the stoma (WOCN et al., 2021). It is important that the primary nurse collaborate with the surgical team to answer patient questions honestly, emphasize that a quality of life is still available with a stoma, and encourage family involvement during these education sessions.
Life-Stage Context
Advanced Age with an Ostomy
Quality of life of older patients with an ostomy is an area of concern but not as much as it is for younger clients. A research study showed that patients aged 66 to 75 years had a reduced activity level when compared with other individuals of the same age. In those older than 76 years who had an ostomy, there was a reduction in social and physical functioning compared with other individuals in the same age range. The study then compared younger adults with ostomies with other individuals without an ostomy in their age range. The former were even more likely to experience decreased functionality than those of advanced age. The conclusion was that although the ostomy reduced quality of life, it actually was less of a factor for those of advanced age than for younger adults.
(Verweij et al., 2018)
Postoperative Care
The tissue of a stoma is very delicate. Immediately after surgery, a stoma is swollen, but it will shrink over several weeks. A healthy, healed stoma appears moist and dark red or pink (Figure 19.27). Stomas that are swollen, dry, have malodorous discharge, or are bluish, purple, black, or pale should be reported to the provider. The skin surrounding a stoma can easily become irritated from the pouch adhesive or leakage of fluid from the stoma, so the nurse must perform interventions to prevent skin breakdown. Any identified signs of skin breakdown should be reported to the provider. The ostomy nurse will be visiting intermittently to perform education, which should be regularly enforced by the primary nurse. The stoma should start producing stool in 2 to 3 days.
Emotional Support and Education
The emotional burden of coping with an ostomy may be devastating for some patients and may affect their self-esteem, body image, quality of life, and ability to be intimate. Providing education is important throughout patient care and before discharge. It is common for patients with ostomies to struggle with body image and their altered pattern of elimination. Nurses can promote healthy coping by ensuring that the patient has appropriate referrals to a wound and ostomy nurse specialist, a social worker, and support groups. Nurses should also be aware of their nonverbal cues when assisting a patient with their appliance changes. It is vital not to show signs of disgust at the appearance of the ostomy or at the odor that may be present when changing an appliance or pouching system.
When a patient is discharged from acute care with a new ostomy, ensure they are able to empty the pouch system independently or with the assistance of the caregiver. Provide enough supplies for 2 or 3 days of home care or until ordered supplies are expected to arrive. Provide education and evaluate the patient’s and caregiver’s understanding of the signs of complications. Instruct them to call the provider if the stoma becomes swollen, dry, discolored, or develops a malodorous discharge. Topics to be included are:
- adequate fluid intake
- appliance options, supply needs, and self-care process
- bag leakage prevention and troubleshooting
- colostomy irrigation, if desired
- community support
- conditions to call the provider, such as signs of infection, stoma prolapse, retraction or color change, change in stool appearance, signs of electrolyte imbalance
- exercise adaptions
- foods to avoid reducing gas
- ileostomy special needs
- sexual activity adjustment
Clinical Safety and Procedures (QSEN)
Nursing Care of a Patient with a Colostomy
Purpose: To ensure nurses provide comprehensive, safe, and patient-centered care for individuals with a colostomy, promoting optimal health outcomes and quality of life.
QSEN Competencies: Patient-Centered Care, Safety, Evidence-Based Practice (EBP), Teamwork and Collaboration
Clinical Safety and Procedures: Nursing Care of a Patient with a Colostomy
Steps:
- Hand hygiene and PPE (Safety):
- Perform hand hygiene thoroughly.
- Don appropriate personal protective equipment (PPE) before handling the ostomy site to prevent infection.
- Patient assessment (Patient-Centered Care, Safety):
- Assess the stoma for color, size, and output. A healthy stoma should be pink to red and moist.
- Evaluate the peristomal skin for signs of irritation, redness, or breakdown.
- Emptying and changing the ostomy bag (Safety, EBP):
- Empty the ostomy bag when it is one-third to one-half full to prevent leakage and skin irritation.
- Change the ostomy bag and wafer every 3 to 5 days or as needed if there is leakage or skin irritation.
- Use warm water and mild soap to gently clean the stoma and peristomal skin, avoiding alcohol-based or harsh products.
- Application of a new ostomy bag (Safety, EBP):
- Measure the stoma to ensure the opening of the new wafer is appropriately sized to fit snugly around the stoma without causing constriction.
- Apply skin barrier products if necessary to protect the peristomal skin.
- Attach the new ostomy bag securely, ensuring there are no gaps or leaks.
- Monitoring and documentation (Safety, Teamwork and Collaboration):
- Monitor the patient’s ostomy output, noting any changes in color, consistency, or volume.
- Document the stoma’s appearance, condition of the peristomal skin, and any patient-reported symptoms or concerns.
- Patient Education and Support (Patient-Centered Care, Teamwork and Collaboration):
- Educate the patient on proper ostomy care techniques, including emptying and changing the bag, skin care, and signs of complications.
- Provide emotional support and resources, such as support groups or counseling services, to help the patient adjust to life with an ostomy.
- Involve the patient in care planning and decision-making, respecting their preferences and needs.
Skin and Stoma Care
Stoma appliances are supplied as a one- or two-piece set (Figure 19.28). A two-piece set consists of an ostomy barrier (also called a wafer) and a pouch. The ostomy barrier is the part of the appliance that sticks to the skin; it has a hole that is fitted around the stoma. The pouch collects the waste and must be emptied regularly. It attaches to the ostomy barrier in a clicking motion to secure the two parts, similar to how a plastic storage-container cover snaps to a container to create a seal. The pouching system must be completely sealed to prevent leaking of the waste and to protect the surrounding skin. The pouch has an end with an opening where the waste is drained and is closed using a plastic clip or Velcro strip. In a one-piece stoma appliance set, the ostomy barrier and the pouch are one piece.
Individuals with colostomies and ileostomies have no sensation and no control over the output of the stoma. Depending on the type of system, the ostomy appliance can last from 4 to 7 days, but the pouch must be changed if there is leaking, odor, excessive skin exposure, or itching or burning under the skin barrier. Patients with pouches can swim and take showers with the pouching system on.
Link to Learning
This video compares different types of ostomy bag systems and the pros and cons of each.
Irrigation
One way to help train the colon to empty at a regular time each day is colostomy irrigation. This can be done with a descending or sigmoid colostomy and allows the patient the freedom of fewer pouch changes and ability to wear lower-profile ostomy pouches (Hollister, n.d.). The procedure is similar to an enema in the stoma and takes about an hour to complete. To be effective, it must be done at the same time, every other day. Contraindications include stoma abnormalities such as prolapse or an irregular functioning stoma, cancer treatments such as chemotherapy or pelvic or abdominal radiation treatments, and medications that have diarrhea as a side effect (Agastya & Bettina, 2023).
Colostomy
The presence of a colostomy is a life-changing event. Evaluation of nursing care of a patient with a colostomy includes the patient providing care of the colostomy, discussion of feelings, and identifying signs to the ostomy nurse or provider. The abdominal incision should be well approximated and free of excessive redness or drainage.
Continent Ileostomy
When a continent ileostomy is formed, there is an internal pouch created inside the abdomen. There is a stoma on the abdominal wall. Approximately 3 times a day, the patient will need to empty the contents with a catheter through the stoma. There is another option called ileoanal pouch surgery. This is created by two or three surgeries. An ileal pouch is created and attached to the anus. The patient is then continent, but the bowel movements will be liquid and require six to seven bowel movements a day, including one at night; this allows continence (NIDDK, 2021).
Preventing Complications
Minor complications of ostomies include repeated appliance leakage, offensive smell, and frequent need to empty the appliance bag. The nurse can help the patient manage these through repetitive counseling on appliance application, the use of stoma deodorant drops in the collection bag, and the suggestion of dietary changes to reduce odors (e.g., avoidance of fish, eggs, onions). Other complications are skin excoriation, diarrhea, and constipation. Validating the size of the appliance, proper cleaning of the skin around the stoma site in between appliance changes, and the appropriate use of creams, skin barriers, or powders to the skin around the stoma can protect it from further irritation from stool.
Diarrhea in a colostomy can be problematic. If it persists, fluid and electrolyte imbalance may occur. Antidiarrheal medications may be ordered. The patient may be checked for infections, such as with Clostridioides difficile bacteria.
Frequent visual assessment of the stoma and auscultation of bowel sounds are important in the first 2 to 4 days after surgery. Serious colostomy complications include stomal gangrene, stomal retraction, colostomy prolapse, surgical site infection, herniation, dehiscence, atelectasis and pneumonia (Agastya & Bettina, 2023).
Interdisciplinary Plan of Care
Recovery from Ostomy Surgery Interdisciplinary Plan of Care
The inderdisciplinary plan of care for a patient recovering from an ostomy surgery can involve several health care disciplines working collaboratively. Members of the team may include physical therapists, occupational therapists, social workers, nutritionists, case managers, and a wound and ostomy nurse, each with their own role.
The physical therapist aims to improve the patient’s mobility and strength after surgery, initiating ambulation within 24 hours and conducting range of motion exercises. The occupational therapist focuses on promoting independence in daily activities despite the ostomy, teaching ostomy care techniques, and providing adaptive equipment. The social worker assesses psychosocial needs, offers emotional support, and facilitates counseling for adjustment.
The nutritionist or dietitian optimizes nutrition for wound healing and advises the patient on dietary adjustments related to the ostomy. The case manager coordinates care across disciplines, develops a comprehensive care plan, and arranges necessary services. The wound and ostomy nurse monitors stoma and skin integrity, educates the patient on proper ostomy care, and intervenes promptly in case of complications.
Together, these disciplines ensure holistic support for recovery and adjustment to living with an ostomy.