Caring for an Ostomy
By
Sue Kohl, RN, BSN
Definition of an ostomy
• A surgical procedure in which a small
opening, or stoma is created to serve as an
exit site for either fecal matter or the
urinary stream.
• The ostomy may be a continent or an
incontinent diversion
Thompson, J. “A practical Ostomy Guide” Vol 63, No. 11,
pg 62
Small Intestine
• 20-25 ft long
• Made up of the
• jejunum
• Duodnum
• Ileum
• Digestion and
absorption
Large intestine
• Ascending
• Transverse
• Descending
• Sigmoid
• Rectum
• Removes water from
fecal matter
STOMAL SITES
Urinary Diversions
• Ileal Conduit
– Made from small
bowel
– 4-5 day hospital
stay or more
– Midline incision
– External pouch
Continent Urinary Diversions
Bladder Cancer
Trauma
Elective
Kochs Pouch Indiana Pouch
Gastrocystoplasty Mainz
Florida Pouch Mitrofanoff
Studer
Neobladder
• Bladder is removed
• New bladder is formed
from large bowel
• Pt. will go home with
stents in place
• Pt. will do timed
voiding
• Many pts. are
incontinent at night
Ileostomy (small intestine)
• Indications
– Crohn’s
– Ulcerative Colitis
– Diverticulitis
• Permanent
• Temporary
• Toothpaste
consistency stools
Ulcerative Colitis
• Limited to large bowel distally • Treatment
• Limited to submucosa • Anti-inflammatory agents ie
• Does not kip Azulfidine, 5’ASAm Systemic
• Frequent Urgent defecation steroids
• Bloody stools, mucous in stools * Methotrexate, 6-MP
• Diarrhea * Probiotics i,e, lactobacillus &
• Risk of Cancer bifidobacteria
– 2% after 10 yrs * Proctocolectomy
– 8% after 20 yrs * Continent Ileal Resevoir
– 18% after 30 yrs
Ileal Resevoir
Chrohn’s
• Anti inflammatory agents
Entire GI tract • Remicade
• Surgery not curative
Full thickness
• Continent diversion not
May see skip lesions recommended
Common in • 4 organ systems affected—
skin (erythema nodosum,
ileum/colon fistulas, skin tags, pyderma
Abdominal pain, wt gangrenosum), joints
(arthritis of spine), eyes
loss, diarrhea ( uvitis, dry eyes,
episcleritis) liver
( Hepatitis)
DIVERTICULITIS
Possible cause include intestinal motility disorder, or
deficiencies of dietary fiber.
S/S:abdominal pain, usually on the left side. You may also have fever,
nausea, vomiting, chills, cramping, and constipation.
Treatment: low fiber, clear liquid diet, antibiotics
Diverticulitis flow chart
Electrolyte Concerns with
Ileostomy
• High Risk of
dehydration, monitor
Na and K+ (Normal
range) Sodium 135 to
145 mEq/L Potassium
3.5 to 5 mEq/L
• Distal ileum only
receptor for Vitamin B
12
Fluid and Electrolyte Imbalance
Signs & Symptoms
• Dry mouth & mucosa • Tingling or cramping in feet
membranes and hands
• Orthostatic hypotension • Confusion
• Decreased urine volume • Nausea and vomiting
• Increased urine concentration
• Dehydration (loss greater that 4
• Sunken eyes cups in 24 hours)
• Extreme weakness
• Decreased muscle tone
• Diminished reflexes
• Muscle cramps
(abdominal/legs)
• Lethargy (fatigue/sleepy)
Fluid and Electrolyte Imbalance
Prevention and
Treatment
Drink 10-12 glasses of
water a day (the body
looses about 500-750
ml of fluid through
ileostomy stools)
Notify physician or
WOCN if unable to
replace or retain fluids
Ileostomy Food Blockage
Signs and Symptoms
• Partial • Complete
– Absence of output – Cramping, abdominal
– Severe cramping pain
– Abdominal distension – Watery output with
– foul odor
Stomal swelling
– Abdominal distension
– Nausea and vomiting
– Stomal swelling
– Nausea and vomiting
may occur
Conservative Management of Food
Blockage
• Take a warm tub bath • If stoma is swollen
to relax the abdominal remove the current
muscles pouch and try
applying an appliance
• Massage around the with a larger opening
stoma; • If able to tolerate
• Try a knee chest fluids i.e. not vomiting
position to attempt to and passing stool,
dislodge any fibrous avoid solids and push
mass fluids
Sigmoid/Descending Colostomy
• Trauma/Perforation
• Malignancy
• Obstruction
• Rectal cancer
• Diverticulitis
• Incontinence
• Fistula
• Semiformed to solid
Continent Fecal Diversions
• Koch’s Pouch
– 60 ml catheter
– May need to dilute stool
with 20-25 ml of water
– Procedure takes
approximately 5 minutes
to drain pouch
– Pouchitis 30% of
population ( increased
stooling, malaise,
bleeding, or fever,
treated with Flagyl tid x
7 days)
Ball, E. 2000. “A teaching guide for continent ileostomy” RN Vol 63 No 12 pg 38
Patient Teaching
• Discharge planning starts before admission
or on admission
– Includes family physician, surgeon, dietician,
social services or discharge planner, WOCN or
ostomy nurse and home health nurse
– Include family
Psychosocial Adaptation
• Change in body image
• Sometimes change in
sexual function
• Anger, shame,
frustration can lead to
withdrawal and
depression
• Coping skills
• Support System
Cause Increase Stools
• Alcoholic beverages • Raisins
• Whole grains • Raw vegetables
• Bran cereals • Spices
• Cooked cabbages
• Fresh fruits
• Greens, leafy
• Milk
• Prunes
Can Cause Stoma Obstruction
• Apple peels • Nuts
• Cabbage, raw • Oranges
• Celery • Pineapple
• Chinese vegetables • Popcorn
• Corn, whole kernel • Seeds
• Coconuts
• Dried fruits
• Mushrooms
Food Reference Chart
Color Changes Odor Control
• Asparagus • Buttermilk
• Beets • Cranberry juice
• Food colors • Orange juice
• Iron pills • Parsley
• Licorice • Tomato juice
• Red jello • Yogurt
• Strawberries
• Tomato sauces
Food Reference Chart
Constipation Relief Diarrhea Control
• Coffee, warm/hot Applesauce
• Cooked fruits Bananas
• Cooked vegetables Boiled rice
• Fresh fruits Peanut butter
• Water Pectin supplement
• Any warm or hot (fiber)
beverages Tapioca
Toast
WARNING
• Ileostomy patients
should never take
laxatives as they can
interfere with
electrolyte balance.
Instead for bowel
preps they should
restrict oral intake for
24 hours or follow a
clear liquid diet for 24
hours.
Care of Stoma
• Cleanse skin with
water or dial soap
• Pat dry, (nothing
abrasive)
• Empty ¼ to 1/3 full
– Keep tail clean, no
flushing with water
• Change barrier every 7
days or individualized
to patient
Emptying Pouch
Colostomy Products
• Convatec Adhesive Coupling
system
– 2 piece, 1 piece
• Flushable
• Nonadhesive – Silicone ring
Product Information
• Sealant
– Skin prep pad
• Provides a thin
protective film to the
skin surace. Helps
prevent skin stripping
and acts as a moisture
barrier.
Product information continued
• Paste is used as a
caulking agent. It seals
the junction between
the stoma and the skin
known as the
mucocutaneous
junction. (Don’t
confuse this with an
adherant)
Product information continued
• Paste strip products such
as Eakin seal, Coloplast
paste strip and Hollisters
paste strips hold there
form better than paste and
work well for molding.
You can create you own
convexity or fill dead
space and crevices.
Accessory Products
•Clamps
•Belts
•Adhesive Remover
•Overnight drainage bags
•Deodorizing drops