Management of the Patient Requiring an Ostomy

  • Approximately 725,000 to 1,000,000 people in the United States are living with an ostomy.

  • An additional 100,000 patients undergo surgery annually to create fecal diversions (Burgess-Stocks et al., 2022).

Indications for Ostomy Procedures

  • Common reasons for ostomy procedures include:
      - Inflammatory Bowel Disease (IBD)
      - Diverticulitis
      - Advanced colorectal cancer (discussed later)
      - Fecal incontinence
      - Severe abdominal and pelvic trauma (Burgess-Stocks et al., 2022).

Types of Fecal Diversions

  • Fecal diversions may include:
      - Ileostomies: Surgically creates an opening into the small intestine.
      - Colostomies: Surgically creates an opening into the colon.
      - Both types may be permanent or temporary.
      - Both divert fecal drainage to the abdominal wall via a stoma.

Preoperative Nursing Management

  • Bowel Preparation is necessary before surgery.
      - If the patient has been on corticosteroids (e.g., for IBD), these will continue during the surgical phase to prevent steroid-induced adrenal insufficiency.
      - Other preoperative measures are similar to general abdominal surgery.
      - Antibiotic cefazolin may be prescribed IV for prophylaxis (Anderson, 2024).

  • Stoma Site Marking
      - The abdomen is marked for the stoma's placement by the surgeon or WOC nurse (Davis et al., 2022).
      - Care is taken to ensure proper placement, usually in the right lower quadrant, about 2 inches (5 cm) below the waist.
      - Must avoid placement near previous scars, bony prominences, skin folds, or fistulas.
      - The stoma site must be visible to the patient.

  • Patient Education
      - Delivered primarily by a WOC nurse, includes:
        - Understanding of the surgery and postoperative expectations.
        - Management of stoma drainage.
        - Introduction to common ostomy appliances.
        - Potential need for parenteral fluids and possibly nasal gastric intubation (NG) (Burgess-Stocks et al., 2022; Francone, 2024).

Postoperative Nursing Management

  • Standard care for abdominal surgery is necessary.
      - Early ambulation is encouraged.
      - Administer prescribed pain medications as needed.

  • Stoma Monitoring
      - Observe for color and size of the stoma, ensuring the peristomal skin matches the abdomen’s color (Ratliff et al., 2021).
      - A temporary clear or transparent plastic pouch with adhesive is placed during surgery.

  • Fecal Drainage Monitoring
      - Ileostomy drainage begins within 24 to 48 hours post-surgery.
      - Colostomy drainage begins 3 to 6 days post-surgery.
      - Drainage characteristics:
        - Ileostomy: Continuous liquid, no sphincter control.
        - Transverse colostomy: Soft and unformed stool.
        - Descending/sigmoid colostomy: More solid stool (Landmann & Cashman, 2024).

  • Fluid Management
      - Accurate recording of fluid intake/output is essential due to significant fluid loss during the early postoperative period (500-1,300 mL daily from ileostomy; 200-600 mL daily from colostomy).
      - Sodium and potassium depletion is monitored; electrolyte replacements will be given as prescribed.
      - May require IV fluids for several days.
      - NG suction may be used to prevent gastric content buildup while intestines are non-functional.
      - Once the tube is removed, gradual progression from clear liquids to a regular diet is made; monitor for abdominal distention or nausea (Landmann & Cashman, 2024).

  • Postoperative Procedures
      - Rectal packing removal occurs by the end of the first week; an analgesic may be given beforehand if discomfort is anticipated.
      - Perineal irrigation is done 2-3 times daily until healing is complete.

Providing Emotional Support

  • Patients may experience grief phases (denial, anger, bargaining, depression, acceptance) post-surgery due to loss of body part and significant functional changes.

  • Nursing support through these phases is vital; understanding the patient's emotional state informs the nursing approach.
      - Education may not be effective until the patient is in the acceptance phase.

  • Concerns about body image can lead to inquiries about family relations, sexual function, and reproductive abilities in childbearing age patients (Burgess-Stocks et al., 2022).

  • A calm, nonjudgmental attitude builds trust and fosters confidence.

  • Recognizing that serious illness, such as cancer, may lead to increased irritability and anxiety is crucial for nursing care coordination.

  • In contrast, an ileostomy can lead to positive outcomes for patients with chronic IBD after discomfort subsides and proper care is learned (Burgess-Stocks et al., 2022).
      - Empathetic support by nursing staff plays a critical role in recovery.

  • Peer support from others with ostomies, such as the United Ostomy Associations of America, aids in patient rehabilitation through education and resources.

Managing Skin and Stoma Care

  • Continuous Pouch Use: Patients wear a pouch continuously due to fluid discharge from the ileum. Initial stomal size should be rechecked 3 weeks after surgery due to edema.

  • Monitoring for Complications:
      - The normal post-operative stoma check includes:
        - Swelling (slight edema normal), color should match peristomal skin, limited discharge with minimal bleeding.

  • Skin Integrity:
      - Skin excoriation is common, especially with ileostomies. Can be influenced by:
        - Allergies to the ostomy appliance or skin barriers.
        - Chemical irritants from effluent.
        - Mechanical injury from appliance removal.
        - Infections.
      - Treatment includes antifungal sprays, creams, or powders applied to irritated skin areas, covered with a skin barrier pouch (Merkert, 2022; Ratliff et al., 2021).

Changing an Appliance

  • Establish a schedule for changing the pouch before leakage occurs; education on maintenance is essential.

  • Typical wearing time of the appliance is 5 to 10 days; the pouch should be emptied when one-third full (Landmann & Cashman, 2024).

  • A spout at the bottom of the pouch must be securely closed.

  • If bathing or showering, micropore tape can secure the pouch (when applicable).

  • Most pouches are disposable and odor-proof. Foods like spinach, parsley can reduce odors, while foods that increase odors include:
      - Asparagus
      - Cabbage
      - Fish

  • Medications like Bismuth subgallate may be prescribed for odor control (better for ileostomy) and to thicken stool, or Chlorophyllin copper complex for descending/sigmoid colostomies (Landmann & Cashman, 2024).

Irrigating a Colostomy

  • Purpose: To empty the colon of gas, mucus, and feces to allow uninterrupted daily activities.

  • Irrigation can regulate fecal material passage only in descending or sigmoid colostomies.
      - Best candidates are those with a regular bowel cycle pre-stoma placement.

  • Patients should learn to instill 500 to 1,000 mL tap water into the colostomy regularly (daily or every other day) to stimulate peristalsis and facilitate emptying.
      - Once established, patients can use a stoma cap or closed ostomy appliance between irrigations (Landmann & Cashman, 2024).

Managing Dietary and Fluid Needs

  • Few dietary restrictions exist post-ostomy; reintroduction of foods should be gradual, one at a time.

  • Dietary education should include:
      - Foods causing gas (e.g., beans, broccoli).
      - Foods impacting stool consistency (e.g., creamy peanut butter thickens stool).

  • Fluid Management:
      - Patients with ileostomies face higher risks for dehydration and should increase fluid intake by 500 to 750 mL daily increasing as needed (Landmann & Cashman, 2024).
      - Monitor for electrolyte imbalances, especially hyponatremia and hypokalemia, due to excessive fluid loss.

  • Recognize signs of dehydration (reduced urine output, orthostasis) and complications (high-output stoma exceeds 1,500 mL/day, requiring fluid replacement).

  • Soluble fiber can slow stool passage and thicken stool; antidiarrheal medications may be prescribed (e.g., loperamide) (Landmann & Cashman, 2024).

Gerontologic Considerations

  • Older adults may require ostomy management with challenges like decreased vision, impaired hearing, and fine motor coordination issues.

  • Skin care is critical for older adults due to aging’s impact on skin integrity (Eliopoulos, 2022).

  • Special care is needed to prevent skin breakdown around the stoma.

  • Proper fitting of appliances and careful skin cleansing are necessary.

  • Decreased blood flow from arteriosclerosis may delay healing.

Preventing Complications

  • Monitoring for complications is ongoing; over 80% of ostomy patients experience some peristomal complication, most notably irritant contact dermatitis within two years (Burgess-Stocks et al., 2022; Ratliff et al., 2021).

  • Drainable Pouching System: Proper fit is essential. Components include:
      - Pouch
      - Solid skin barrier
      - Adhesive

  • The solid skin barrier protects the surrounding skin from effluent and must be appropriately sized to avoid exposing peristomal skin (Merkert, 2022).

Other Common Complications Include:

  • Diarrhea (can lead to dehydration).

  • Stomal stenosis (scar tissue formation at the stoma site requiring dilation or surgical intervention).

  • Patients may also be at risk for urinary calculi and cholelithiasis due to changes in absorption (see Chapters 50 and 45 for further discussion).

Promoting Home, Community-Based, and Transitional Care

  • Educating Patients About Self-Care: WOC nurses should provide adequate education to patients and families preoperatively and at discharge (Burgess-Stocks et al., 2022).
      - Family should understand potential changes and needs, facilitating smoother recovery.

  • Continuing and Transitional Care:
      - The patient must know the commercial name for their drainable pouching system and how to obtain supplies.
      - Ongoing professional support for patients and caregivers is essential for long-term management of the stoma (Burgess-Stocks et al., 2022).

Patient Education: Managing Ostomy Care

Patients and caregivers should be able to:

  • Name the procedure performed and identify anatomical changes.

  • Describe effluent frequency and characteristics.

  • Identify sources for ostomy care supplies.

  • State medication details including name, dose, and schedule.

  • Demonstrate ostomy care, cleansing, irrigation, and appliance changing.

  • Describe the importance of maintaining peristomal skin integrity.

  • Identify dietary restrictions affecting gas, consistency, and odors.

  • Recognize signs of dehydration and electrolyte imbalance and when to seek help.

  • Know how to contact healthcare providers and support resources.

  • Acknowledge health promotion and disease prevention strategies.

ADLs, activities of daily living; IADLs, instrumental activities of daily living.