An ileostomy is an opening constructed in the terminal ileum to treat regional and ulcerative colitis and to divert intestinal contents in colon cancer, polyps, and trauma. It is usually done when the entire colon, rectum, and anus must be removed, in which case the ileostomy is permanent. A temporary ileostomy is done to provide complete bowel rest in conditions such as chronic colitis and in some trauma cases.
A colostomy is a diversion of the effluent of the colon and may be temporary or permanent. Ascending, transverse, and sigmoid colostomies may be performed. Transverse colostomy is usually temporary. A sigmoid colostomy is the most common permanent stoma, usually performed for cancer treatment.
Nursing Care Plans
Nursing care management and planning for patients with ileostomy or colostomy includes: assisting the patient and/or SO during the adjustment, preventing complications, support independence in self-care, provide information about procedure/prognosis, treatment needs, and potential complications.
Here are 10 nursing care plans for fecal diversions: colostomy and ileostomy:
- Risk for Impaired Skin Integrity
- Disturbed Body Image
- Acute Pain
- Impaired Skin Integrity
- Deficient Fluid Volume
- Risk for Imbalanced Nutrition: Less Than Body Requirements
- Risk for Sexual Dysfunction
- Disturbed Sleep Pattern
- Risk for Constipation or Diarrhea
- Deficient Knowledge
- Other Nursing Care Plans
Risk for Impaired Skin Integrity
Risk factors may include
- Absence of sphincter at stoma
- Character/flow of effluent and flatus from stoma
- Reaction to product/chemicals; improper fitting/care of appliance/skin
Possibly evidenced by
- Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.
- Maintain skin integrity around stoma.
- Identify individual risk factors.
- Demonstrate behaviors/techniques to promote healing/prevent skin breakdown.
|Inspect stoma and peristomal skin area with each pouch change. Note irritation, bruises (dark, bluish color), rashes||Monitors healing process and effectiveness of appliances and identifies areas of concern, need for further evaluation and intervention. Early identification of stomal necrosis or ischemia or fungal infection (from changes in normal bowel flora) provides for timely interventions to prevent serious complications. Stoma should be red and moist. Ulcerated areas on stoma may be from a pouch opening that is too small or a faceplate that cuts into stoma. In patients with an ileostomy, the effluent is rich in enzymes, increasing the likelihood of skin irritation. In patient with a colostomy, skin care is not as great a concern because the enzymes are no longer present in the effluent.|
|Clean with warm water and pat dry. Use soap only if area is covered with sticky stool. If paste has collected on the skin, let it dry, then peel it off.||Maintaining a clean and dry area helps prevent skin breakdown.|
|Measure stoma periodically: at least weekly for first 6 wk, then once a month for 6 mo. Measure both width and length of stoma.||As postoperative edema resolves (during first 6 wk), the stoma shrinks and size of appliance must be altered to ensure proper fit so that effluent is collected as it flows from the ostomy and contact with the skin is prevented.|
|Verify that opening on adhesive backing of pouch is at least 1⁄16 to 1⁄8 in (2–3 mm) larger than the base of the stoma, with adequate adhesiveness left to apply pouch.||Prevents trauma to the stoma tissue and protects the peristomal skin. Adequate adhesive area prevents the skin barrier wafer from being too tight. Note: Too tight a fit may cause stomal edema or stenosis.|
|Use a transparent, odor-proof drainable pouch.||A transparent appliance during first 4–6 wk allows easy observation of stoma without necessity of removing pouch/irritating skin.|
|Apply appropriate skin barrier: hydrocolloid wafer, karaya gun, extended-wear skin barrier, or similar products.||Protects skin from pouch adhesive, enhances adhesiveness of pouch, and facilitates removal of pouch when necessary. Note: Sigmoid colostomy may not require use of a skin barrier once stool becomes formed and elimination is regulated through irrigation.|
|Empty, irrigate, and cleanse ostomy pouch on a routine basis, using appropriate equipment.||Frequent pouch changes are irritating to the skin and should be avoided. Emptying and rinsing the pouch with the proper solution not only removes bacteria and odor-causing stool and flatus but also deodorizes the pouch.|
|Support surrounding skin when gently removing appliance. Apply adhesive removers as indicated, then wash thoroughly.||Prevents tissue irritation or destruction associated with “pulling” pouch off.|
|Investigate reports of burning, itching, or blistering around stoma.||Indicative of effluent leakage with peristomal irritation, or possibly Candida infection, requiring intervention.|
|Evaluate adhesive product and appliance fit on ongoing basis.||Provides opportunity for problem solving. Determines need for further intervention.|
|Consult with certified wound, ostomy, continence nurse.||Helpful in choosing products appropriate for patient’s particular rehabilitation needs, including type of ostomy, physical/mental status, abilities to handle self-care, and financial resources.|
|Apply corticosteroid aerosol spray and prescribed antifungal powder as indicated.||Assists in healing if peristomal irritation persists and/or fungal infection develops. Note: These products can have potent side effects and should be used sparingly.|
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Gastrointestinal Care Plans
Care plans covering the disorders of the gastrointestinal and digestive system:
- Appendectomy | 4 Care Plans
- Cholecystectomy | 12 Care Plans
- Cholecystitis and Cholelithiasis | 4 Care Plans
- Gastroenteritis | 4 Care Plans
- Hemorrhoids | 3 Care Plans
- Hepatitis | 7 Care Plans
- Ileostomy & Colostomy | 10 Care Plans
- Inflammatory Bowel Disease | 7 Care Plans
- Intussusception | 3 Care Plans
- Liver Cirrhosis | 8 Care Plans
- Pancreatitis | 8+ Care Plans
- Peritonitis | 6 Care Plans
- Peptic Ulcer Disease | 5 Care Plans
- Subtotal Gastrectomy | 2 Care Plans
Recommended books and resources:
- Nursing Care Plans: Diagnoses, Interventions, and Outcomes
- Nurse's Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
- Nursing Diagnoses 2015-17: Definitions and Classification
- Diagnostic and Statistical Manual of Mental Disorders (DSM-V-TR)
- Manual of Psychiatric Nursing Care Planning
- Maternal Newborn Nursing Care Plans
- Delmar's Maternal-Infant Nursing Care Plans, 2nd Edition
- Maternal Newborn Nursing Care Plans