Colostomy Nursing Care Plans Diagnosis and Interventions
Colostomy NCLEX Review and Nursing Care Plans
A colostomy is a surgical procedure wherein an opening is created from the abdomen wall to the large intestine. The procedure involves the one end of the colon, diverted through an incision to create a Stoma.
Stoma refers to an opening formed on the abdominal wall, In this case, the opening is connected to the end of the colon. Feces will be collected through a colostomy pouch or bag attached to the stoma. Colostomy could be temporary or permanent, depending on the patient’s condition.
Types of Colostomy
- Transverse colostomy. This type involves the middle section of the colon and the stoma is placed within the part of the upper abdomen. The bowel will leave the body by the stoma before passing the descending colon. The stoma could have one or two openings. The one stoma is for the feces and the second possible opening is for the passage of mucus that the colon produces. In most cases, conditions involving transverse colostomy are inflammatory bowel disease, cancer, diverticulitis, blockage, injury, or a congenital defect. Most of the time, this type of colostomy is temporary, especially in young people with congenital defects.
- Ascending colostomy. This type is performed on the right side of the abdomen, usually in the low to the middle section. Only a small part of the colon is left active. Ascending colostomy is usually done when there is blockage along the colon. Most of the time, the stool is semi liquid to liquid, containing many digestive enzymes. Thus, colostomy care should be done carefully to avoid leaking of the enzymes and to protect the skin from abrasion secondary to irritation.
- Descending colostomy. This involves surgery that is located on the lower left side of the abdomen at the descending part of the colon. The consistency of stool is usually formed to pasty and gas formation is common. Also, nearly all of the colon remains active. Natural reflex to the bowel is also maintained at a regular time.
- Sigmoid colostomy. This type involves placing the stoma a few inches lower than the descending colostomy, done from the sigmoid colon. Similar to descending colostomy, the bowel is usually formed with a pasty consistency.
Indications of Colostomy
Several diseases and medical conditions may require Colostomy, in some cases, it will last for only a limited time, but in some conditions, it may require permanent colostomy especially if the colon is completely removed.
The following conditions may indicate the need for colostomy:
- Complete or partial blockage in the large intestine.
- Inflammatory bowel disease (IBD)- is a group of disorders that involves chronic inflammation of the gastrointestinal tract. The two types of IBD are Crohn’s Disease and Ulcerative colitis.
- Chronic infection- infection in the digestive tract may require removal of the affected part and as a result, a colostomy is necessary. One example is Diverticulitis, a condition wherein the small sac on the colon called Diverticula gets infected.
- Imperforate anus – a congenital defect characterized by a blocked or missing opening of the anus.
- Anal fistula – an abnormal connection between the anal canal and perianal area.
- Colorectal polyps- a growth of extra tissues, that often fill out the lining of the large intestine.
- An injury to the colon or rectum
- Colon or rectal cancer
Risks of Colostomy
One of the major risks for colostomy is related to allergies and anesthesia reactions. Other post-surgical risks include:
- Injury to nearby organs
- Intestinal blockage due to scar tissues.
- Prolapsed stoma
- Hernia at the incision site
Colostomy: Before the Surgery
Preparation and preoperative meetings are done before the scheduled surgery. During a doctor’s visit, physical assessment, taking of medical and surgical history are performed. The patient must provide complete and accurate information during the assessment and history taking, some of the vital points before surgeries are undergone, list of medicine currently taken including over-the-counter drugs, vitamins, and supplements.
Allergies on foods and medicine, and family medical history are also necessary. The surgeon will thoroughly discuss the details of the surgery, why is it needed, the whole procedure process, and what to expect after the surgery.
The patient will be asked to sign a consent, this is to certify that the patient permits the doctor to do the surgery. Once the consent was signed, routine tests are requested and should be done before the procedure. These are part of the medical clearance requirement if the patient has an existing medical condition or to identify an unknown condition that may affect the surgery.
Most likely, the patient will be asked to fast for at least 6 to 12 hours, sometimes laxatives and enema are also administered the night before the procedure to relieve constipation and clear the bowel. Prepare for a short stay in the hospital, on average 3 to 7 days confinement. Depending on the outcome of the surgery.
Colostomy: During the Surgery
On the day of surgery, the patient will be changed into a hospital gown, intravenous access will be placed in the patient’s arm, and ready for transfer to the pre-operation room.
Monitoring of vital signs is done while waiting for the surgery to start. The patient will be moved to the operation room and the team members including the surgeon, assistant surgeons, anesthesiologists, nurses, and other staff are also all inside the O.R. If the vital signs are normal and no contraindications are noted, the anesthesiologist will administer the anesthesia and put the patient to sleep.
Continuous monitoring will take place until the surgery is completed. There are two ways to perform a colostomy, Laparoscopic surgery, and open surgery. In Laparoscopic surgery, the surgeon will make a small cut in the abdomen and insert the Laparoscope, a camera used during the surgery. This will serve as a guide during the surgery as it shows on the screen the abdominal organs.
The surgeon will find the ideal location for the stoma in the large intestine. A part of the intestine will be cut and brought through the abdominal wall. A ring will be implanted onto the abdomen, the purpose of this ring is to hold in place the end of the intestine.
It can be permanent, or temporary. Laparoscopic colostomy has fewer complications, lesser pain, and faster recovery since the incision is smaller. But some cases have a complication during the surgery that requires them to change to open surgery.
Another type of colostomy is Open surgery, in this method, the surgeon will make one long incision on the abdomen to open up the abdominal cavity. This allows better access to the abdominal organs, however, it requires a longer time for recovery.
Generally, there are two types of colostomy procedures done, Loop colostomy and End colostomy
A loop colostomy is intended to be temporary since it is easier to reverse. End colostomy is performed when the colostomy is permanent. After all things are placed, the doctor will close the wound through stitches. T
he patient will be on monitoring for the next hours in the recovery room, until fully awake before returning to the respective room. During recovery, oral intake is reintroduced gradually, from liquids to food to assure that no digestive problem has occurred.
Initially, ice chips are given, afterwards, clear liquids will follow, then soft foods in the next few days. Diet management is also provided by the Nutrition and Dietary section, the allowed activity level will be discussed as well. It is highly important to follow these instructions.
Colostomy Care: After the Surgery
Once the surgery is done, the patient needs to stay in the hospital for the next few days to a week, in these days the patient will learn the proper way of taking care of the colostomy and be familiarized with the materials needed in cleaning and maintaining it.
The patient can try the equipment needed and see what works the best with the type of colostomy the patient has. Proper instruction regarding the use of a colostomy bag, colostomy care, and proper way of cleaning will be discussed by an ostomy expert.
At first, the stoma may appear a bit swollen and dark red, with bruises. But after weeks, the color will change to lighter red, and bruises are expected to disappear. Empty the pouch when it is one-third full to avoid leaking feces. Learn tips to protect the skin surrounding the stoma to avoid irritation and wounds.
Nursing Considerations for Patients with Colostomy
Abdominal surgery may bring postoperative risks to the patients who underwent such kinds of procedures. It is the role of nurses to assess the pain level, surgical wound, nutritional level, hydration status, and cardiopulmonary condition of a post colostomy patient.
Considerations must take place for every patient with new colostomies. Evaluation of the patient’s stoma, checking the pouching system, skin integrity around the stoma, and protrusion. In addition, the emotional and psychological status of the patient, and how they deal with the changes brought by having the pouch.
Evaluate the patient’s level of knowledge on colostomy care before they leave the hospital. Identify if any existing medical conditions may hinder the patient’s ability in colostomy care such as arthritis, body weakness, or problem with their vision. Also, assess the amount, consistency, and frequency of the output.
Nursing Diagnosis for Colostomy
Nursing Care Plan for Colostomy 1
Risk for Impaired Skin Integrity
Nursing Diagnosis: Risk for Impaired skin integrity related to flow of leaked fecal drainage from the stoma secondary to colostomy.
- Good skin integrity will be observed around the stoma, no rashes, wounds, or any signs of irritation will be observed.
- The patient will demonstrate knowledge about the individual risk factors.
- The patient will exhibit proper behavior and techniques to prevent skin irritation and develop healing.
|Nursing Interventions for Colostomy||Rationale|
|Check the stoma and skin around the stoma every after bag change. Notice any signs of irritation such as redness, swelling, raches, bleeding, and bruises (dark and bluish color). Take note of the characteristics of drainage.||Regular monitoring of the stoma’s condition is important for the effectiveness of treatment and prevention of any complications that may arise. Early identification of necrosis or infection in the stoma provides timely treatment and prevention of any serious trouble. Bleeding after the surgery is most likely to happen in the first 48 hours, infection is also at risk to happen|
|Clean the stoma with warm water and pat dry after. If the area is covered with a sticky stool, use soap only. Change the dressing when necessary, using a sterile technique.||Keeping the area clean and dry prevents skin irritation and breakdown. If the dressing is soaked with drainage, change immediately to avoid the occurrence of infection.|
|Get the measurement of the stoma periodically, both the width and length. At least weekly for the first 6 weeks, and then once a month for the next 6 months||During the first 6 weeks, the postoperative edema resolves, resulting in the stoma shrinking and the size of the appliance must be checked for the proper fitting to prevent leak of drainage.|
|Irrigate as indicated. Empty and clean ostomy pouch routinely, using the required equipment.||Changing the pouch frequently may irritate the skin. To avoid this, emptying and irrigating the pouch removes dirt, bacteria, and odor. It also deodorizes the bag.|
Nursing Care Plan for Colostomy 2
Nursing Diagnosis: Acute Pain related to disruption of skin secondary to colostomy as manifested by pain at the incision site, irritability, not able to sleep, and restlessness.
- The patient will verbalize a feeling of comfort, being able to sleep and rest appropriately.
- The patient will exhibit relaxation techniques and pain management skills.
|Nursing Interventions for Colostomy||Rationale|
|Evaluate the pain, location, level of intensity (0-10 scale), characteristic, duration, and frequency.||Proper assessment of the degree of pain will describe the effectiveness of pain management and will show any developing complications. Abdominal pain will usually subside on the third or fourth day postoperative, continuous and increasing pain may indicate delayed healing or irritation at the peristomal area. This must be monitored regularly.|
|Encourage the patient to speak up if they have any concerns. Listen to their concerns, show acceptance and give appropriate advice.||By reducing the level of anxiety or fear, the patient feels relaxed and comfortable.|
|Offer comfort measures such as mouth care, back rub, repositioning using proper support when needed. Ensure the patient that doing these will not harm the stoma.||Oral care prevents the drying of oral mucosa which may cause discomfort. Back rub and repositioning reduce muscle tension and provide relaxation.|
|Use relaxation techniques like guided imagery and visualization. Perform diversional activities.||These activities allow the patient to rest functionally and refocus attention, in that way it reduces pain and discomfort.|
|Assist the patient with Range of Motion (ROM) exercises and encourage early ambulation. Discourage prolonged sitting position.||Range of motion exercises lessens muscle and joint stiffness. Early ambulation promotes the return of a normal level of functioning and returns the organs to a normal position. It also reduces pressure in the perineal area.|
|Observe for any abdominal muscle stiffness, rebound tenderness, and involuntary guarding.||These are the following signs of peritoneal inflammation, requiring immediate medical intervention.|
Nursing Care Plan for Colostomy 3
Nursing Diagnosis: Disturbed sleep pattern related to required colostomy care and excessive flatus and colostomy effluent secondary to colostomy as evidenced by verbalization of not having enough sleep, changes in behavior such as irritability, restlessness, and weakness.
- The patient will have enough sleep without disturbances, as manifested by a rested appearance, verbalization of feeling comfortable and energetic and demonstrating improvement in the sleeping cycle.
- The patient will exhibit improved and relaxed well-being.
|Nursing Interventions for Colostomy||Rationale|
|Discuss the importance of monitoring the intestinal function in the early post colostomy days.||It is more appropriate for the patient’s tolerance with regards to the disturbances by the staff if they understood the reasons for the importance of monitoring as it is included in post-operative care.|
|Provide an appropriate pouching system. Clean the pouch before it gets full and on a pre-agreed schedule with the patient.||Emptying the pouch on a regular schedule prevents leakage and disturbance to the sleep of the patient.|
|Discuss to the patient that stoma will not be harmed when sleeping.||Assure the patient that they can have a night of better sleep and the stoma is kept secure.|
|Put a limit on taking caffeine-containing foods or liquids.||Caffeine may affect the patient’s sleep cycle as it interferes with the Rapid eye movement sleep. This will result in a feeling of not resting.|
|Identify the cause behind the excessive flatus or effluent. Consult a Dietitian about the diet restriction applicable to the patient.||Knowing the cause will institute corrective steps that may avoid excessive flatus and effluent, resulting in undisturbed sleep.|
|Provide a relaxing environment, with no distractions, and free of noise.||Reducing external stimuli that may disturb sleep will help in establishing better sleep and avoids awakening in between at night.|
|Encourage the patient to have a consistent sleep and rest schedule.||Having a consistent sleeping time helps in regulating the circadian rhythm, and reduces adaptation to alteration.|
Nursing Care Plan for Colostomy 4
Risk for Constipation
Nursing Diagnosis: Risk for constipation related to inadequate diet and fluid intake secondary to colostomy.
- The patient will determine measures that prevent and treat constipation.
- The patient will manage to pass stool within 1 day, soft and formed in character, and maintain a normal elimination cycle.
|Nursing Interventions for Colostomy||Rationale|
|Assess the patient’s bowel habits and lifestyle before the colostomy.||Helps in the formulation of a punctual and effective schedule of colostomy care such as emptying and irrigation.|
|Evaluate if there’s a delay or absence of drainage. Check for bowel sounds by auscultating the abdomen. Within the time of 48 to 72 hours, post surgery paralytic or adynamic ileus usually resolve, and drainage should start within 12 to 24 hours. A delay could mean an obstruction at the stoma or persistent ileus. These may occur after the surgery because of too tight-fitting of the pouch, stenosis of the stoma, or it can be because of edema.|
|Monitor dietary plan and the amount and type of fluid intake.||Intake of enough fiber and liquids are important points in identifying the consistency of stool.|
|Advised the patient to increase oral fluid intake, if not contraindicated. Check if the patient is restricted before doing so.||Increased fluid helps soften the stool.|
|Encourage early mobilization as tolerated. Evaluate the level of mobility and level of activity.||Lesser physical activity can reduce peristalsis and promote constipation. Monitoring a patient’s physical activities will identify if additional care is needed such as the use of an assistive device or assistance when going to the toilet.|
|Provide a stool chart||This is to record and monitor the pattern of elimination, including the amount and the character of stool passed.|
|Check if the patient is taking other medications.||Some medications can cause constipation in the patient. Notify the physician in this situation.|
|Review the patient’s other medical condition||Some medical conditions are related to constipation such as endocrine and metabolic disorders.|
Nursing Care Plan for Colostomy 5
Risk for Imbalanced Nutrition: Less than Body Requirements
Nursing Diagnosis: Risk for Imbalanced Nutrition: Less than Body Requirements related to altered absorption secondary to colostomy.
- The patient will exhibit progressive weight gain towards the ideal weight for height, achieve the required nutritional requirements, and manifest no signs of malnutrition.
- The patient will have a diet plan to achieve nutritional needs and reduce gastrointestinal disturbance.
|Nursing Interventions for Colostomy||Rationale|
|Interview the patient and complete a nutritional evaluation.||To identify the deficiency and needs to help in the choice of intervention.|
|Check for bowel sounds.||Return of GI function shows readiness to restart oral intake.|
|Restart giving solid foods gradually.||To avoid gastric upset, stomach cramps, nausea, and vomiting.|
|Determine which food causes odor like cabbage, fish, beans, and remove it from the food list temporarily. Introduce the food, one at a time.||It is uncommon to be sensitive to a certain food after intestinal surgery. A patient can experiment with food a couple of times, before identifying if it creates a problem.|
|Limit intake of prunes, dates, stewed apricots, strawberries, grapes, bananas, cabbage, beans and avoid food that contains much cellulose such as peanuts.||The mentioned products can increase the ileal effluent. Cellulose digestion requires colon bacteria that are no longer present.|
|Explain the movement of swallowed air as a factor in flatus formation and the ways to prevent it.||Using a straw when drinking, snoring, smoking, not fitting dentures, and swallowing a large amount of food increase the production of flatus. An increase in flatus requires frequent pouch emptying and causes leakage by too much pressure in the pouch.|
|Consult a dietitian about the nutritional status and diet planning. Refer the patient as required.||A dietitian can identify the patient’s daily calorie and nutritional requirements, that aids in maintaining the ideal weight. The patient’s ability and preference for food are also considered in making diet plans.|
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Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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