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
Risk for Imbalanced Nutrition: Less Than Body Requirements
Nursing Diagnosis
- Imbalanced Nutrition: Less Than Body Requirements
Risk factors may include
- Prolonged anorexia/altered intake preoperatively
- Hypermetabolic state (preoperative inflammatory disease; healing process)
- Presence of diarrhea/altered absorption
- Restriction of bulk and residue-containing foods
Possibly evidenced by
- Not applicable for risk diagnosis. 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 weight/demonstrate progressive weight gain toward the goal with normalization of laboratory values and be free of signs of malnutrition.
- Client will plan diet to meet nutritional needs/limit GI disturbances.
| Nursing Interventions | Rationale |
|---|---|
| Obtain a thorough nutritional assessment. | Identifies deficiencies/needs to aid in the choice of interventions. |
| Auscultate bowel sounds. | Return of intestinal function indicates readiness to resume oral intake. |
| Resume solid foods slowly. | Reduces the incidence of abdominal cramps, nausea. |
| Identify odor-causing foods (e.g., cabbage, fish, beans) and temporarily restrict from the diet. Gradually reintroduce one food at a time. | Sensitivity to certain foods is not uncommon following intestinal surgery. Patient can experiment with food several times before determining whether it is creating a problem. |
| Recommend patient increase use of yogurt, buttermilk, and acidophilus preparations. | May help prevent gas and decrease odor formation. |
| Suggest patient with ileostomy limit prunes, dates, stewed apricots, strawberries, grapes, bananas, cabbage family, beans, and avoid foods high in cellulose, e.g., peanuts. | These products increase ileal effluent. Digestion of cellulose requires colon bacteria that are no longer present. |
| Discuss the mechanics of swallowed air as a factor in the formation of flatus and some ways the patient can exercise control. | Drinking through a straw, snoring, anxiety, smoking, ill-fitting dentures, and gulping down food increases the production of flatus. Too much flatus not only necessitates frequent emptying but also can cause leakage from too much pressure within the pouch. |
Recommended Resources
Recommended nursing diagnosis and nursing care plan books and resources.
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- 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.