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 Constipation or Diarrhea
Nursing Diagnosis
- Constipation
- Diarrhea
Risk factors may include
- Placement of ostomy in descending or sigmoid colon
- Inadequate diet/fluid intake
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.
Desired Outcomes
- Client will establish an elimination pattern suitable to physical needs and lifestyle with the effluent of appropriate amount and consistency.
| Nursing Interventions | Rationale |
|---|---|
| Ascertain patient’s previous bowel habits and lifestyle. | Assists in the formulation of a timely or effective irrigating schedule for a patient with a colostomy, if appropriate. |
| Investigate delayed onset or absence of effluent. Auscultate bowel sounds. | Postoperative paralytic and/or adynamic ileus usually resolves within 48–72 hr and ileostomy should begin draining within 12–24 hr. Delay may indicate persistent ileus or stomal obstruction, which may occur postoperatively because of edema, improperly fitting pouch (too tight), prolapse, or stenosis of the stoma. |
| Inform patient with an ileostomy that initially the effluent is liquid. If constipation occurs, it should be reported to enterostomal nurse or physician. | Although the small intestine eventually begins to take on water-absorbing functions to permit a more semi-solid, pasty discharge, constipation may indicate an obstruction. Absence of stool requires emergency medical attention. |
| Review dietary pattern and amount, type of fluid intake. | Adequate intake of fiber and roughage provides bulk, and fluid is an important factor in determining the consistency of the stool. |
| Review physiology of the colon and discuss irrigation management of sigmoid ostomy, if appropriate. | This knowledge helps the patient understand individual care needs. |
| Demonstrate use of irrigation equipment per institution policy or under the guidance of a physician or certified wound, ostomy, continence nurse. | Irrigations may be done on a daily basis if appropriate, although there are differing views on this practice. Many believe cleaning the bowel on a regular basis is helpful. Others believe that this interferes with normal functioning. |
| Instruct patient in the use of closed-end pouch or a patch, dressing or Band-Aid when irrigation is successful and the sigmoid colostomy effluent becomes more manageable, with stool expelled every 24 hr. | Enables the patient to feel more comfortable socially and is less expensive than regular ostomy pouches. |
| Involve patient in the care of the ostomy on an increasing basis. | Rehabilitation can be facilitated by encouraging patient independence and control. |
| Instruct in use of TENS unit if indicated. | Electrical stimulation has been used in some patients to stimulate peristalsis and relieve postoperative ileus. |
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)
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Thanks for these wonderful care plans.