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.
- 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 Deficient Fluid Volume
- Risk for Deficient Fluid Volume
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
- 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.
- 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.
|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 electrolytes||Detects 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.|
Recommended nursing diagnosis and nursing care plan books and resources.
- 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, 2021-2023 (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.
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