Colostomy & Colostomy Care

Arellano University College of NursiArellano University College of Nursingng

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ColostomyColostomy

By: Jose ByronBy: Jose Byron

Dadulla-EvardoneDadulla-Evardone


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DefinitionDefinition

A colostomy is a surgical procedure A colostomy is a surgical procedure that brings a portion of the that brings a portion of the large large intestineintestine through the abdominal through the abdominal wall to carry feces out of the body.wall to carry feces out of the body.


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PurposePurpose

A colostomy is created as a means to treat A colostomy is created as a means to treat various disorders of the large intestine, various disorders of the large intestine, including including cancercancer, obstruction, , obstruction, inflammatory bowel disease, ruptured inflammatory bowel disease, ruptured diverticulum, ischemia (compromised diverticulum, ischemia (compromised bloodblood supply), or traumatic injury. supply), or traumatic injury. Temporary colostomies are created to Temporary colostomies are created to divert stool from injured or diseased divert stool from injured or diseased portions of the large intestine, allowing portions of the large intestine, allowing rest and healing. rest and healing.


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Permanent colostomies are Permanent colostomies are performed when the distal bowel performed when the distal bowel (bowel at the farthest distance) must (bowel at the farthest distance) must be removed or is blocked and be removed or is blocked and inoperable. Although inoperable. Although colorectal colorectal cancercancer is the most common is the most common indication for a permanent indication for a permanent colostomy, only about 10–15% of colostomy, only about 10–15% of patients with this diagnosis require a patients with this diagnosis require a colostomy.colostomy.


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DescriptionDescription

Surgery will result in one of three Surgery will result in one of three types of colostomies:types of colostomies:


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End colostomyEnd colostomy

The functioning end of the intestine, The functioning end of the intestine, the section of bowel that remains the section of bowel that remains connected to the upper connected to the upper gastrointestinal tract, is brought out gastrointestinal tract, is brought out onto the surface of the abdomen to onto the surface of the abdomen to form a stoma (an artificial opening) form a stoma (an artificial opening) by cuffing the intestine back on itself by cuffing the intestine back on itself and suturing the end to the skin. and suturing the end to the skin.


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The surface of the stoma is actually The surface of the stoma is actually the lining of the intestine, usually the lining of the intestine, usually appearing moist and pink. The distal appearing moist and pink. The distal portion of bowel (now connected only portion of bowel (now connected only to the rectum) may be removed or to the rectum) may be removed or sutured closed and left in the sutured closed and left in the abdomen. An end colostomy is abdomen. An end colostomy is usually a permanent colostomy, usually a permanent colostomy, resulting from trauma, cancer, or resulting from trauma, cancer, or another pathological condition. another pathological condition.


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End ColostomyEnd Colostomy


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Double-barrel colostomyDouble-barrel colostomy

This colostomy involves the creation of This colostomy involves the creation of two separate stomas on the abdominal two separate stomas on the abdominal wall. The proximal (nearest) stoma is the wall. The proximal (nearest) stoma is the functional end that is connected to the functional end that is connected to the upper gastrointestinal tract, and will drain upper gastrointestinal tract, and will drain stool. The distal stoma, connected to the stool. The distal stoma, connected to the rectum, drains small amounts of mucus rectum, drains small amounts of mucus material. This is most often a temporary material. This is most often a temporary colostomy, performed to rest an area of colostomy, performed to rest an area of bowel and to be later closed. bowel and to be later closed.


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Double-barrel colostomyDouble-barrel colostomy


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Loop colostomyLoop colostomy

This colostomy is created by bringing This colostomy is created by bringing a loop of bowel through an incision in a loop of bowel through an incision in the abdominal wall. The loop is held the abdominal wall. The loop is held in place outside the abdomen by a in place outside the abdomen by a plastic rod placed beneath it. An plastic rod placed beneath it. An incision is made in the bowel to allow incision is made in the bowel to allow the passage of stool through the loop the passage of stool through the loop colostomy. colostomy.


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The supporting rod is removed The supporting rod is removed approximately seven to 10 days after approximately seven to 10 days after surgery, after healing has occurred surgery, after healing has occurred that will prevent the loop of bowel that will prevent the loop of bowel from retracting into the abdomen. A from retracting into the abdomen. A loop colostomy is most often loop colostomy is most often performed for the creation of a performed for the creation of a temporary stoma to divert stool away temporary stoma to divert stool away from an area of intestine that has from an area of intestine that has been blocked or ruptured. been blocked or ruptured.


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Loop colostomyLoop colostomy


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PreparationPreparation

The physician will outline the The physician will outline the procedure, possible side effects, and procedure, possible side effects, and what the patient may experience what the patient may experience after surgery. The physician or an after surgery. The physician or an enterostomal therapist will explain enterostomal therapist will explain the general aftercare to the patient the general aftercare to the patient before surgery, so the patient has all before surgery, so the patient has all of the information necessary to make of the information necessary to make an informed decision about surgery an informed decision about surgery and medical care.and medical care.


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Blood and urine studies, along with Blood and urine studies, along with various x rays and an various x rays and an electrocardiograph (EKG), may be electrocardiograph (EKG), may be ordered as necessary. If possible, the ordered as necessary. If possible, the patient should visit an enterostomal patient should visit an enterostomal therapist, who makes the decision therapist, who makes the decision about the appropriate place on the about the appropriate place on the abdomen for the stoma and who abdomen for the stoma and who offers pre-operative education on offers pre-operative education on colostomy management.colostomy management.


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To empty and cleanse the bowel, the To empty and cleanse the bowel, the patient may be placed on a low-patient may be placed on a low-residue diet for several days prior to residue diet for several days prior to surgery. A liquid diet may be ordered surgery. A liquid diet may be ordered for at least the day before surgery. A for at least the day before surgery. A series of series of enemasenemas and/or oral and/or oral preparations (GoLytely or Colyte) preparations (GoLytely or Colyte) may be ordered to empty the bowel may be ordered to empty the bowel of stool. of stool.


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Oral anti-infectives (neomycin, Oral anti-infectives (neomycin, erythromycin, or kanamycin sulfate) erythromycin, or kanamycin sulfate) may be prescribed to decrease may be prescribed to decrease bacteriabacteria in the intestine and help in the intestine and help prevent postoperative prevent postoperative infectioninfection. On . On the day of surgery or during surgery, the day of surgery or during surgery, a nasogastric tube is inserted into a nasogastric tube is inserted into the nose to connect it to the the nose to connect it to the stomachstomach to remove gastric to remove gastric secretions and prevent nausea and secretions and prevent nausea and vomiting. vomiting.


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A urinary catheter may also be A urinary catheter may also be placed to keep the bladder empty placed to keep the bladder empty during surgery, giving more space in during surgery, giving more space in the surgical area and decreasing the the surgical area and decreasing the risk of accidental injury.risk of accidental injury.


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Post-operative care for the patient with a Post-operative care for the patient with a new colostomy involves monitoring of new colostomy involves monitoring of blood pressureblood pressure, pulse, respirations, and , pulse, respirations, and temperature. The patient is instructed how temperature. The patient is instructed how to support the operative site during deep to support the operative site during deep breathing and coughing, and given breathing and coughing, and given painpain medication as necessary. Fluid intake and medication as necessary. Fluid intake and output is measured, and the operative site output is measured, and the operative site is observed for color and amount of wound is observed for color and amount of wound drainage. drainage.


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The nasogastric tube will remain in The nasogastric tube will remain in place, attached to low-intermittent place, attached to low-intermittent suction until bowel activity resumes. suction until bowel activity resumes. For the first 24 to 48 hours after For the first 24 to 48 hours after surgery, the colostomy will drain surgery, the colostomy will drain bloody mucus. Fluids and electrolytes bloody mucus. Fluids and electrolytes are infused intravenously until the are infused intravenously until the patient's diet can gradually be patient's diet can gradually be resumed, beginning with liquids. resumed, beginning with liquids.


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Usually within 72 hours, passage of Usually within 72 hours, passage of gas and stool through the stoma gas and stool through the stoma begins. Initially the stool is liquid, begins. Initially the stool is liquid, gradually thickening as the patient gradually thickening as the patient begins to take solid foods. The begins to take solid foods. The patient is usually out of bed in eight patient is usually out of bed in eight to 24 hours after surgery and to 24 hours after surgery and discharged in two to four days.discharged in two to four days.


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A colostomy pouch or bag will A colostomy pouch or bag will generally have been placed on the generally have been placed on the patient's abdomen, around the patient's abdomen, around the stoma, during surgery. During the stoma, during surgery. During the hospital stay, the patient and the hospital stay, the patient and the caregivers will be educated on how caregivers will be educated on how to care for the stoma and the to care for the stoma and the colostomy bag. colostomy bag.


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Determination of appropriate Determination of appropriate pouching supplies and a schedule of pouching supplies and a schedule of how often to change the pouch how often to change the pouch should be established. Regular should be established. Regular assessment and meticulous care of assessment and meticulous care of the skin surrounding the stoma is the skin surrounding the stoma is important to maintain an adequate important to maintain an adequate surface on which to apply the pouch. surface on which to apply the pouch.


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Patients will be instructed in daily Patients will be instructed in daily irrigation of the stoma about seven irrigation of the stoma about seven to 10 days after surgery. This results to 10 days after surgery. This results in the regulation of bowel function. in the regulation of bowel function. Some patients with colostomies may Some patients with colostomies may need only a dressing or cap over the need only a dressing or cap over the stoma and do not wear a colostomy stoma and do not wear a colostomy pouch. pouch.


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Often, an enterostomal therapist will Often, an enterostomal therapist will visit the patient at home after visit the patient at home after discharge to help with the patient's discharge to help with the patient's resumption of normal daily activities.resumption of normal daily activities.


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ComplicationsComplications

Potential complications of colostomy Potential complications of colostomy surgery include:surgery include:

excessive bleeding excessive bleeding surgical wound infection surgical wound infection thrombophlebitis (inflammation and thrombophlebitis (inflammation and

blood clot in veins in the legs) blood clot in veins in the legs)


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pneumonia pneumonia pulmonary embolism (blood clot or pulmonary embolism (blood clot or

air bubble in the lungs' blood supply) air bubble in the lungs' blood supply) cardiac cardiac stressstress due to allergic due to allergic

reaction to the general anaesthetic reaction to the general anaesthetic


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if the colostomy becomes blocked if the colostomy becomes blocked if the stoma extends too far out from if the stoma extends too far out from

the abdomen, presenting the the abdomen, presenting the potential for physical damage or potential for physical damage or infection infection


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The physician should be made aware of any The physician should be made aware of any of the following problems after surgery:of the following problems after surgery:

increased pain, swelling, redness, increased pain, swelling, redness, drainage, or bleeding in the surgical area drainage, or bleeding in the surgical area

flu-like symptoms such as headache, flu-like symptoms such as headache, muscle aches, dizziness, or fever muscle aches, dizziness, or fever

increased abdominal pain or swelling, increased abdominal pain or swelling, constipation, nausea or vomiting, or black, constipation, nausea or vomiting, or black, tarry stoolstarry stools


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Stomal complications to Stomal complications to be monitored include:be monitored include:


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Necrosis (death) of stomal tissue.Necrosis (death) of stomal tissue.

Caused by Caused by inadequate blood inadequate blood supply, this supply, this complication is complication is usually visible 12 usually visible 12 to 24 hours after to 24 hours after the operation and the operation and may require may require additional additional surgery. surgery.


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RetractionRetraction

(stoma is flush with the (stoma is flush with the abdomen surface or has abdomen surface or has moved below it). Caused moved below it). Caused by insufficient stomal by insufficient stomal length, this complication length, this complication may be managed by the may be managed by the use of special pouching use of special pouching supplies. Elective revision supplies. Elective revision of the stoma is also an of the stoma is also an option. option.


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ProlapseProlapse

(stoma increases length above the (stoma increases length above the surface of the abdomen). Most often, surface of the abdomen). Most often, this results from an overly large this results from an overly large opening in the abdominal wall or opening in the abdominal wall or inadequate fixation of the bowel to inadequate fixation of the bowel to the abdominal wall. Surgical the abdominal wall. Surgical correction is required when blood correction is required when blood supply is compromised. supply is compromised.


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ProlapseProlapse


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StenosisStenosis

(narrowing at the (narrowing at the opening of the stoma). opening of the stoma). Often, this is associated Often, this is associated with infection around the with infection around the stoma or scarring. Mild stoma or scarring. Mild stenosis can be removed stenosis can be removed under under local anesthesialocal anesthesia, , while severe stenosis may while severe stenosis may require surgery for require surgery for reshaping the stoma. reshaping the stoma.


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Parastomal herniaParastomal hernia

(bowel-causing bulge in the abdominal (bowel-causing bulge in the abdominal wall next to the stoma). Usually, this is wall next to the stoma). Usually, this is due to placement of the stoma where the due to placement of the stoma where the abdominal wall is weak or the creation of abdominal wall is weak or the creation of an overly large opening in the abdominal an overly large opening in the abdominal wall. The use of a colostomy support belt wall. The use of a colostomy support belt and special pouching supplies may be and special pouching supplies may be adequate. If severe, the defect in the adequate. If severe, the defect in the abdominal wall should be repaired abdominal wall should be repaired surgically, and the stoma moved to surgically, and the stoma moved to another location. another location.


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Parastomal herniaParastomal hernia


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Colostomy Care Colostomy Care


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DefinitionDefinition

A A colostomycolostomy is a surgically created is a surgically created opening in the abdominal wall opening in the abdominal wall through which digested food passes. through which digested food passes. It may be temporary or permanent. It may be temporary or permanent. The opening is called a stoma from The opening is called a stoma from the Greek word meaning mouth. the Greek word meaning mouth.


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Stool passes through the stoma into Stool passes through the stoma into a pouch attached to the stoma on a pouch attached to the stoma on the outside of the abdomen. The the outside of the abdomen. The pouch, stoma, and skin surrounding pouch, stoma, and skin surrounding the stoma require care and the stoma require care and maintenance by the patient or maintenance by the patient or caregiver.caregiver.


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PurposePurpose

A pouch is worn over a colostomy to A pouch is worn over a colostomy to collect the stool passed through the collect the stool passed through the stoma. There are a variety of stoma. There are a variety of pouches available for use with a pouches available for use with a colostomy. Over time the patient can colostomy. Over time the patient can determine which pouch type best determine which pouch type best suits his or her needs. suits his or her needs.


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A colostomy pouch is normally A colostomy pouch is normally emptied one or more times daily. The emptied one or more times daily. The pouch itself usually needs to be pouch itself usually needs to be changed every four to six days. The changed every four to six days. The stoma and surrounding skin need to stoma and surrounding skin need to be kept clean and sanitary.be kept clean and sanitary.


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PrecautionsPrecautions

The nurse attending to a colostomy The nurse attending to a colostomy should wash his or her hands before should wash his or her hands before and after the procedure, as well as and after the procedure, as well as wear latex gloves while performing wear latex gloves while performing care.care.


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DescriptionDescription

A pouching system is normally worn A pouching system is normally worn over a colostomy stoma. Pouches over a colostomy stoma. Pouches can be obtained from several can be obtained from several different manufacturers in both different manufacturers in both disposable and reusable varieties. disposable and reusable varieties. The enterostomal therapy ET nurse The enterostomal therapy ET nurse can be an invaluable resource when can be an invaluable resource when helping patients select a pouch helping patients select a pouch system.system.


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Colostomy pouches may be either Colostomy pouches may be either open ended or closed. Open-ended open ended or closed. Open-ended pouches require a clamp for closure. pouches require a clamp for closure. They can be drained simply and They can be drained simply and reused after they are emptied. reused after they are emptied. Closed pouches are sealed at the Closed pouches are sealed at the bottom and are usually used by bottom and are usually used by patients who irrigate their patients who irrigate their colostomies or who have a regular colostomies or who have a regular bowel elimination pattern.bowel elimination pattern.


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Two-piece pouch systems consist of a Two-piece pouch systems consist of a separate flange and pouch. The pouch has separate flange and pouch. The pouch has a closing ring that attaches to a matching a closing ring that attaches to a matching piece on the flange. One-piece systems piece on the flange. One-piece systems have a connected wafer and pouch that do have a connected wafer and pouch that do not separate. The portion of the pouch not separate. The portion of the pouch that is applied to the abdomen is called a that is applied to the abdomen is called a skin barrier wafer. Both two-piece and skin barrier wafer. Both two-piece and one-piece systems can be either closed or one-piece systems can be either closed or open endedopen ended


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Some patients with colostomies can Some patients with colostomies can irrigate their stomas using a irrigate their stomas using a procedure similar to an enema. This procedure similar to an enema. This cleans the stool out of the colon cleans the stool out of the colon through the stoma. A special through the stoma. A special irrigation system is used. Sometimes irrigation system is used. Sometimes a special lubricant is used to prepare a special lubricant is used to prepare for the irrigation. Irrigating often for the irrigation. Irrigating often leads to increased control over the leads to increased control over the timing of bowel movements.timing of bowel movements.


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irrigationirrigation


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Removing the colostomy appliance Removing the colostomy appliance requires gently pushing away the requires gently pushing away the skin surrounding the stoma and skin surrounding the stoma and pulling the appliance downwards. pulling the appliance downwards. Adhesive remover wipes are Adhesive remover wipes are available to help in the removal of available to help in the removal of the wafer. the wafer.


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The bag is then discarded in an The bag is then discarded in an appropriate waste container. The appropriate waste container. The stoma should be cleaned with stoma should be cleaned with lukewarm water and dried with a soft lukewarm water and dried with a soft towel. towel.


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The stoma and surrounding skin The stoma and surrounding skin should be assessed. The stoma should be assessed. The stoma should be pink or red and moist- should be pink or red and moist- looking, and may bleed slightly when looking, and may bleed slightly when cleansed. The stoma normally cleansed. The stoma normally decreases in size slightly during the decreases in size slightly during the first weeks after surgery.first weeks after surgery.


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The opening in the wafer should fit The opening in the wafer should fit snugly around the stoma. An opening snugly around the stoma. An opening that is too large will allow intestinal that is too large will allow intestinal contents to leak onto the skin. contents to leak onto the skin. Measuring guides come with the Measuring guides come with the colostomy wafers so that the hole colostomy wafers so that the hole can be cut to the proper size. Skin can be cut to the proper size. Skin barrier paste can be used to help barrier paste can be used to help create a better seal between the create a better seal between the wafer and the patient's abdomen. wafer and the patient's abdomen.


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Various skin preparation products are Various skin preparation products are also available to help protect the skin also available to help protect the skin under the wafer and around the under the wafer and around the stoma. They also aid in the adhesion stoma. They also aid in the adhesion of the wafer. Using the fingertips, of the wafer. Using the fingertips, gentle pressure should be applied to gentle pressure should be applied to put the wafer in place.put the wafer in place.


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After the application of the barrier, After the application of the barrier, the bag should be applied (if it is a the bag should be applied (if it is a two-piece system). If it is an open two-piece system). If it is an open system, apply a clamp to the bottom system, apply a clamp to the bottom of the new pouch.of the new pouch.


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The nurse should instruct the patient The nurse should instruct the patient and caregiver(s) about the procedure and caregiver(s) about the procedure before it is performed. Many people before it is performed. Many people feel anxious and nervous when first feel anxious and nervous when first dealing with an ostomy. Encourage dealing with an ostomy. Encourage the patient to ask questions, and the patient to ask questions, and explain all steps as they are explain all steps as they are performed.performed.


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AftercareAftercare

The nurse should assess the patient's The nurse should assess the patient's tolerance of the procedure and tolerance of the procedure and response to teaching or education response to teaching or education about the appliance.about the appliance.

Colostomy & Colostomy Care

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