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10 Ileostomy and Colostomy Nursing Care Plans

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By Matt Vera, BSN, R.N.
Ileostomy and Colostomy Nursing Care Plans
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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:

  1. Risk for Impaired Skin Integrity
  2. Disturbed Body Image
  3. Acute Pain
  4. Impaired Skin Integrity
  5. Deficient Fluid Volume
  6. Risk for Imbalanced Nutrition: Less Than Body Requirements
  7. Risk for Sexual Dysfunction
  8. Disturbed Sleep Pattern
  9. Risk for Constipation or Diarrhea
  10. Deficient Knowledge
  11. Other Nursing Care Plans

5. Risk for Deficient Fluid Volume

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Risk for Deficient Fluid Volume

Nursing Diagnosis

Risk factors may include

  • Excessive losses through normal routes, e.g., preoperative emesis and diarrhea; high-volume ileostomy output
  • Losses through abnormal routes, e.g., NG/intestinal tube, perineal wound drainage tubes
  • Medically restricted intake
  • Altered absorption of fluid, e.g., loss of colon function
  • Hypermetabolic states, e.g., inflammation, healing process

Possibly evidenced by

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  • 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.

Desired Outcomes

  • Client will maintain adequate hydration as evidenced by moist mucous membranes, good skin turgor and capillary refill, stable vital signs, and individually appropriate urinary output.
Nursing InterventionsRationale
Monitor intake and output (I&O) carefully, measure liquid stool. Weigh regularly.Provides direct indicators of fluid balance. Greatest fluid losses occur with an ileostomy, but they generally do not exceed 500–800 mL/day.
Monitor vital signs, noting postural hypotension, tachycardia. Evaluate skin turgor, capillary refill, and mucous membranes.Reflects hydration status and/or the possible need for increased fluid replacement.
Limit intake of ice chips during the period of gastric intubation.Ice chips can stimulate gastric secretions and wash out electrolytes.
Monitor laboratory results, e.g., Hct and electrolytesDetects homeostasis or imbalance, and aids in determining replacement needs
Administer IV fluid and electrolytes as indicated.May be necessary to maintain adequate tissue perfusion/organ function.
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5. Risk for Deficient Fluid Volume

Recommended Resources

Recommended nursing diagnosis and nursing care plan books and resources.

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See also

Other recommended site resources for this nursing care plan:

More nursing care plans related to gastrointestinal disorders:

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Matt Vera, BSN, R.N.
Matt Vera is a registered nurse with a bachelor of science in nursing since 2009 and is currently working as a full-time writer and editor for Nurseslabs. During his time as a student, he knows how frustrating it is to cram on difficult nursing topics. Finding help online is nearly impossible. His situation drove his passion for helping student nurses by creating content and lectures that are easy to digest. Knowing how valuable nurses are in delivering quality healthcare but limited in number, he wants to educate and inspire nursing students. As a nurse educator since 2010, his goal in Nurseslabs is to simplify the learning process, break down complicated topics, help motivate learners, and look for unique ways of assisting students in mastering core nursing concepts effectively.
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