Chapter 48: Caring for Clients With Ostomies

Overview of Ostomies and Learning Objectives

  • Learning Objectives

    • Differentiate between an ileostomy and a colostomy.
    • Explain the excretion of stool from three distinct types of ileostomies.
    • Describe the two-part surgical procedure required to create an ileoanal reservoir.
    • Discuss various types of colostomies and their purposes.
    • Explain methods for clients with descending or sigmoid colostomies to regulate bowel elimination.
    • Discuss preoperative nursing care for clients undergoing ostomy surgery.
    • List potential complications associated with ostomy surgery.
    • Discuss postoperative nursing management for ileostomy and colostomy clients.
    • Describe the components used to apply and collect stool from an intestinal ostomy.
    • Cite the specific reasons for changing an ostomy appliance.
    • Summarize the procedure for changing an ostomy appliance.
    • Focus on Evidence-Based Practice (EBP), nursing judgment, and safety (Student Learning Objectives - SLOs).

  • Fundamental Definitions

    • Ostomy: An opening created between an internal body structure and the surface of the skin.
    • Stoma: The actual opening on the exterior abdominal surface.
    • Causes for Ostomy Surgery:
      • Inflammatory Bowel Disorder (IBD).
      • Rupture of the intestine.
      • Irreversible intestinal obstruction.
      • Compromised blood supply to the intestine.
      • Presence of a cancerous tumor.

Understanding Ileostomies

  • Definition and Location

    • An ileostomy is a surgical opening into the distal small intestine (the ileum).

  • Types of Ileostomies

    • Standard or Brooke Ileostomy: A conventional ileostomy involving the removal of the colon and rectum.
    • Continent Ileostomy (Abdominal Pouch): Also known as a Kock pouch or abdominal pouch.
    • Ileoanal Reservoir: Also known as a J-pouch or pelvic pouch.

  • Ileostomy Physiology and Characteristics

    • Matured Stoma: The process and healing that results in a smooth peristomal area (the skin surrounding the stoma).
    • Fecal Material (Effluent): For an ileostomy, the stool is liquid and contains high levels of digestive enzymes that can be caustic to the skin.
    • Appliance: Often referred to as an ostomy pouch or collection system; the user is referred to as an "ostomate."
      • Karaya Gum: A material used to protect the skin and promote better adhesion of the appliance.

  • The Ostomy Appliance

    • Disposable Appliances: Often replaced daily during bathing.
    • Reusable Equipment: Long-term equipment that can be cleaned.
    • Temporary Appliances: Used specifically during the immediate postoperative phase.

Preoperative Nursing Management

  • Surgical Management and Interventions

    • Primary provider discusses the purpose, benefits, and risks of the surgery.
    • Stoma Site Selection: The stoma appearance and function are explained; the site is marked on the abdomen.
    • Collaborative Care: Providers include Enterostomal Therapists (ET), Enterostomal Therapy Nurses, and Wound, Ostomy, and Continence Nurses (WOCNs).

  • Risk Identification and Physical Preparation

    • Risks of Total Colectomy: Potential for bladder dysfunction and sexual dysfunction.
      • Sexual Dysfunction: Men may be advised to collect and store sperm; women may experience slightly diminished fertility.
    • Bowel Cleansing: Involves dietary restrictions combined with laxatives or lavage agents.
    • Antibiotic Prophylaxis: Administration of IV antibiotics to prevent infection.

  • Pharmacological Adustments

    • Prednisone: Must be tapered and discontinued to avoid negative effects on tissue healing.
    • Stress Dose Steroids: A preoperative "stress dose" of IV steroids may be administered to prevent an adrenal crisis in patients who were previously on long-term steroids.
    • Immunosuppressive Agents: Discontinued to prevent negative effects on tissue healing.
    • Aspirin-containing Compounds: Discontinued to minimize the risk of bleeding.
    • Blood Preparation: Obtain blood samples for typing and cross-matching to replace any surgical blood loss.

Postoperative Nursing Management of Ileostomies

  • Surgical Postoperative Interventions

    • Rectal Pack: Absorbs drainage and promotes gradual healing; typically remains in place for 55 to 77 days.
    • Irrigations: Used to promote healing.
    • Nasogastric (NG) Tube: Used for gastrointestinal decompression.
    • IV Fluids: Crucial to maintain fluid, electrolyte, and nutritional balances.
    • Medications: Antibiotic therapy and analgesics for pain management.
    • Monitoring: Close observation of wound healing and monitoring for intestinal obstruction, which is a serious complication.

  • Stomal Complications

    • Bleeding: Excessive blood loss from the stoma site.
    • Impaired Blood Supply: Look for changes in stoma color.
    • Stenosis: Narrowing of the stomal opening.
    • Prolapse/Protrusion: Excessive protrusion of the ileostomy through the abdominal wall.
    • Edema: Postoperative swelling that may cause obstruction or restrict stomal blood supply.
    • Stomal Necrosis: Can occur if prolapse or blood supply issues are not managed promptly.

Care for Specific Ileostomy Types

  • Standard/Brooke Ileostomy

    • Monitor specifically for anal leakage.
    • Remove rectal packing in 55 to 77 days.

  • Continent Ileostomy (Kock Pouch)

    • Description: An internal reservoir formed with a portion of the terminal ileum to store GI effluent; includes a nipple valve for drainage.
    • Postoperative Care:
      • Temporary catheter insertion.
      • Perineal area pack remains for 11 week.
      • Reinforce perineal packing and check abdominal dressings for drainage.
      • Connect the stomal catheter to low intermittent suction.
      • Monitor the ileal catheter for obstruction (draining color and amount).
      • Perform routine saline irrigations of the ileal catheter as needed.
      • Maintain skin cleanliness around the stoma.

  • Ileoanal Reservoir (J-Pouch)

    • Goal: Maintains bowel continence; typical for clients with ulcerative colitis where the anorectal sphincter is still functional.
    • Benefits: Preserves innervation of male genitalia; bladder and erectile dysfunction are unlikely; however, infertility remains a risk.
    • Two-Stage Procedure:
      • Stage 1: Creation of a temporary ileostomy; continuous discharge of mucus from the anus and frequent, uncontrollable watery fecal discharge from the ileostomy.
      • Stage 2: Performed 22 to 33 months later; closes the temporary ileostomy and reunites the two sections of the ileum (anastomosis). Fecal material is eventually expelled through the anus as the anal sphincter strengthens.
    • Specific Nursing Actions:
      • Monitor the anal area for drainage and check the presacral drainage tube in the first stage.
      • Teach clients to perform perineal (Kegel-style) exercises to manage bowel incontinence.
      • Post-stage 1: Teach client to use a squirt bottle for hygiene.
      • Post-stage 2: Cleanse the anus with warm, soapy water and emphasize drying the area well.

Colostomy Management

  • Definitions and Types

    • Colostomy: An opening into the large bowel (colon).
    • Indications: Cancerous lesions, ulcerative inflammatory processes, multiple polyposis, or bowel injury.
    • Classifications:
      • Ascending Colostomy
      • Transverse Colostomy
      • Descending Colostomy
      • Sigmoid Colostomy

  • Surgical Configurations

    • Single-barrel: A single stoma created after a segmental resection or abdominoperineal resection (common for tumors in the lower third of the sigmoid).
    • Double-barrel: Two stomas (proximal and distal). The nursing care plan must distinguish which stoma is functional and requires irrigation.
    • Loop Colostomy: A loop of bowel is lifted and supported by a glass rod or plastic butterfly device.
      • Opening the Loop: The bowel itself lacks pain receptors.
      • Nursing Care: Protect bedding and clothing from pungent odors and liquid fecal flow when the loop is opened (often using a temporary pouch).

  • Duration

    • Permanent: Lifelong.
    • Temporary: Treats disorders like acute diverticulitis or chronic constipation.
    • Reestablishment: The interval before closing a temporary colostomy and reestablishing bowel continuity may be 1616 months or longer.

Regulating Bowel Elimination

  • Methods for Descending and Sigmoid Colostomies
    • These types can often be regulated through regular irrigations, essentially "training" the bowel.
  • Dietary and Pharmacological Aids:
    • Suppositories: For stimulating movements.
    • Dietary fiber: Fiber-rich foods.
    • Natural Laxatives: Prune juice.
    • Stool Softeners and Laxatives:
      • Dulcolax: Provides gentle, dependable constipation relief; usually in tablet form with relief in 66 to 1212 hours.
      • MiraLAX: Powder form that softens stool and relieves occasional constipation/irregularity.
    • Hydration: Electrolyte-balanced drinks like Gatorade (e.g., Lemon-Lime flavor) help maintain fluid balance during bowel preparation or regulation.