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 (NCP) and nursing diagnosis for patients with 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
Acute Pain
Nursing Diagnosis
May be related to
- Physical factors: e.g., disruption of skin/tissues (incisions/drains)
- Biological: activity of disease process (cancer, trauma)
- Psychological factors: e.g., fear, anxiety
Possibly evidenced by
- Reports of pain, self-focusing
- Guarding/distraction behaviors, restlessness
- Autonomic responses, e.g., changes in vital signs
Desired Outcomes
- Client will verbalize that pain is relieved/controlled.
- Client will display relief of pain, able to sleep/rest appropriately
- Client will demonstrate the use of relaxation skills and general comfort measures as indicated for an individual situation.
| Nursing Interventions | Rationale |
|---|---|
| Assess pain, noting location, characteristics, intensity (0–10 scale). | Helps evaluate the degree of discomfort and effectiveness of analgesia or may reveal developing complications. Because abdominal pain usually subsides gradually by the third or fourth postoperative day, continued or increasing pain may reflect delayed healing or peristomal skin irritation. Note: Pain in the anal area associated with abdominal-perineal resection may persist for months. |
| Encourage patient to verbalize concerns. Active-listen these concerns, and provide support by acceptance, remaining with the patient, and giving appropriate information. | Reduction of anxiety/fear can promote relaxation or comfort. |
| Provide comfort measures, e.g., mouth care, back rub, repositioning (use proper support measures as needed). Assure patient that position change will not injure stoma. | Prevents drying of oral mucosa and associated discomfort. Reduces muscle tension, promotes relaxation, and may enhance coping abilities. |
| Encourage use of relaxation techniques, e.g., guided imagery, visualization. Provide diversional activities. | Helps patient rest more effectively and refocuses attention, thereby reducing pain and discomfort. |
| Assist with ROM exercises and encourage early ambulation. Avoid prolonged sitting position. | Reduces muscle/joint stiffness. Ambulation returns organs to normal position and promotes the return of usual level of functioning. Note: Presence of edema, packing, and drains (if perineal resection has been done) increases discomfort and creates a sense of needing to defecate. Ambulation and frequent position changes reduce perineal pressure. |
| Investigate and report abdominal muscle rigidity, involuntary guarding, and rebound tenderness. | Suggestive of peritoneal inflammation, which requires prompt medical intervention. |
| Administer medication as indicated, e.g., narcotics, analgesics, patient-controlled analgesia (PCA). | Relieves pain, enhances comfort, and promotes rest. PCA may be more beneficial, especially following anal-perineal repair. |
| Provide sitz baths. | Relieves local discomfort, reduces edema, and promotes healing of perineal wound. |
| Apply/monitor the effects of transcutaneous electrical nerve stimulator (TENS) unit. | Cutaneous stimulation may be used to block transmission of the pain stimulus. |
Recommended Resources
Recommended nursing diagnosis and nursing care plan books and resources.
Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy.
- Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use. - Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively. - NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023Â (12th Edition)
The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales. - Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
Another great nursing care plan resource that is updated to include the recent NANDA-I updates. - Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
Useful for creating nursing care plans related to mental health and psychiatric nursing. - Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans. - Maternal Newborn Nursing Care Plans (3rd Edition)
If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you. - Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023. - All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.
See also
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch. - Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
More nursing care plans related to gastrointestinal disorders:
- 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
Thank you for these nursing care plans! They’re great!
Readiness for enhanced learning (if they are willing to learn)
Thank you for this informative site!
Thank you for the Nursing process its very helpful.
This information is very helpful for us,,thank you so much for helping us
Thanks for these wonderful care plans.