Fecal Diversions: Postoperative Care of Ileostomy and Colostomy

FECAL DIVERSIONS: POSTOPERATIVE CARE OF ILEOSTOMY AND
COLOSTOMY
Within the past 50 years major advances have occurred in ostomy surgery, including continent diversions such as the
Kock pouch and the ileoanal reservoir. However, each year in the United States, 00,000 people still undergo surgery to
create ostomies. !hese so"called incontinent diversions are the primary #ocus o# this plan o# care.
$n 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. %t is usually done when the entire colon, rectum, and anus must
&e removed, in which case the ileostomy is permanent. $ temporary ileostomy is done to provide complete &owel rest
in conditions such as chronic colitis and in some trauma cases.
$ colostomy is a diversion o# the e##luent o# the colon and may &e temporary or permanent. $scending, transverse,
and sigmoid colostomies may &e per#ormed. !ransverse colostomy is usually temporary. $ sigmoid colostomy is the
most common permanent stoma, usually per#ormed #or cancer treatment.
CARE SETTING
%npatient acute care surgical unit.
RELATED CONCERNS
'ancer
(luid and electrolyte im&alances, see )urse 'are *lan '+",-.
%n#lammatory &owel disease/ ulcerative colitis, regional enteritis
*sychosocial aspects o# care
Surgical intervention
!otal nutritional support/ parenteral0enteral #eeding
Patient Assessment Database
+ata depend on the underlying pro&lem, duration, and severity 1e.g., o&struction, per#oration, in#lammation, congenital
de#ects2.
TEACHING/LEARNING
Discharge pan DRG projected mean length of inpatient stay: 9.4 days
c!nsi"erati!ns:$ssistance with dietary concerns, management o# ostomy, and ac3uisition o# supplies may &e
re3uired
Refer to section at end of plan for postdischarge considerations.
NURSING PRIORITIES
. $ssist patient0S- in psychosocial adjustment.
4. *revent complications.
5. Support independence in sel#"care.
6. *rovide in#ormation a&out procedure0prognosis, treatment needs, potential complications, and community resources.
DISCHARGE GOALS
. $djusting to perceived0actual changes.
4. 'omplications prevented0minimi7ed.
5. Sel#"care needs met &y sel#0with assistance depending on speci#ic situation.
6. *rocedure0prognosis, therapeutic regimen, potential complications understood and sources o# support identi#ied.
5. *lan in place to meet needs a#ter discharge.
N#RSIN$ DIA$NOSIS: S%in Integrit&' ris% (!r impaire"
Ris% (act!rs ma& inc)"e
$&sence o# sphincter at stoma
'haracter0#low o# e##luent and #latus #rom stoma
,eaction to product0chemicals8 improper #itting0care o# appliance0skin
P!ssib& e*i"ence" b&
9)ot applica&le8 presence o# signs and symptoms esta&lishes an actual diagnosis.:
DESIRED O#TCOMES+EVAL#ATION CRITERIA,PATIENT -ILL:
.!/e Eiminati!n 0NOC1
.aintain skin integrity around stoma.
%denti#y individual risk #actors.
+emonstrate &ehaviors0techni3ues to promote healing0prevent skin &reakdown.
ACTIONS/INTERVENTIONS
Ost!m& Care 0NIC1
In"epen"ent
%nspect stoma0peristomal skin area with each pouch change.
)ote irritation, &ruises 1dark, &luish color2, rashes.
RATIONALE
.onitors healing process0e##ectiveness o# appliances and
identi#ies areas o# concern, need #or #urther
evaluation0intervention. ;arly identi#ication o# stomal
necrosis0ischemia or #ungal in#ection 1#rom changes in
normal &owel #lora2 provides #or timely interventions to
prevent serious complications. Stoma should &e red and
moist. Ulcerated areas on stoma may &e #rom a pouch
opening that is too small or a #aceplate that cuts into stoma.
%n patients with an ileostomy, the e##luent is rich in
en7ymes, increasing the likelihood o# skin irritation. %n
patient with a colostomy, skin care is not as great a concern
&ecause the en7ymes are no longer present in the e##luent.
.aintaining a clean0dry area helps prevent skin &reakdown.
'lean with warm water and pat dry. Use soap only i# area is
covered with sticky stool. %# paste has collected on the skin,
let it dry, then peel it o##.
.easure stoma periodically, e.g., at least weekly #or #irst <
wk, then once a month #or < mo. .easure &oth width and
length o# stoma.
=eri#y that opening on adhesive &acking o# pouch is at least
>< to
>? in 14@5 mm2 larger than the &ase o# the stoma,

with ade3uate adhesiveness le#t to apply pouch.
Use a transparent, odor"proo# draina&le pouch.
$s postoperative edema resolves 1during #irst < wk2, the
stoma shrinks and si7e o# appliance must &e altered to
ensure proper #it so that e##luent is collected as it #lows #rom
the ostomy and contact with the skin is prevented.
*revents trauma to the stoma tissue and protects the
peristomal skin. $de3uate adhesive area prevents the skin
&arrier wa#er #rom &eing too tight. Note: !oo tight a #it may
cause stomal edema or stenosis.
$ transparent appliance during #irst 6@< wk allows easy
o&servation o# stoma without necessity o# removing
pouch0irritating skin.
Ost!m& Care 0NIC1
In"epen"ent
$pply appropriate skin &arrier, e.g., hydrocolloid wa#er,
karaya gun, eAtended"wear skin &arrier, or similar products.
RATIONALE
;mpty, irrigate, and cleanse ostomy pouch on a routine
&asis, using appropriate e3uipment.
Support surrounding skin when gently removing appliance.
$pply adhesive removers as indicated, then wash
thoroughly.
%nvestigate reports o# &urning0itching0&listering around
stoma.
;valuate adhesive product and appliance #it on ongoing
&asis.
C!ab!rati*e
'onsult with certi#ied wound, ostomy, continence nurse.
*rotects skin #rom pouch adhesive, enhances adhesiveness
o# pouch, and #acilitates removal o# pouch when necessary.
Note: Sigmoid colostomy may not re3uire use o# a skin
&arrier once stool &ecomes #ormed and elimination is
regulated through irrigation.
(re3uent pouch changes are irritating to the skin and should
&e avoided. ;mptying and rinsing the pouch with the proper
solution not only removes &acteria and odor"causing stool
and #latus &ut also deodori7es the pouch.
*revents tissue irritation0destruction associated with
BpullingC pouch o##.
%ndicative o# e##luent leakage with peristomal irritation, or
possi&ly Candida in#ection, re3uiring intervention.
*rovides opportunity #or pro&lem solving. +etermines need
#or #urther intervention.
Help#ul in choosing products appropriate #or patientDs
particular reha&ilitation needs, including type o# ostomy,
$pply corticosteroid aerosol spray and prescri&ed anti#ungal
powder as indicated.
physical0mental status, a&ilities to handle sel#"care, and
#inancial resources.
$ssists in healing i# peristomal irritation persists0#ungal
in#ection develops. Note: !hese products can have potent
side e##ects and should &e used sparingly.
N#RSIN$ DIA$NOSIS: .!"& Image' "ist)rbe"
Ma& be reate" t!
Eiophysical/ presence o# stoma8 loss o# control o# &owel elimination
*sychosocial/ altered &ody structure
+isease process and associated treatment regimen, e.g., cancer, colitis
=er&ali7ation o# change in &ody image, #ear o# rejection0reaction o# others, and negative #eelings a&out &ody
$ctual change in structure and0or #unction 1ostomy2
)ot touching0looking at stoma, re#usal to participate in care
.!"& Image 0NOC1
=er&ali7e acceptance o# sel# in situation, incorporating change into sel#"concept without negating sel#"esteem.
+emonstrate &eginning acceptance &y viewing0touching stoma and participating in sel#"care.
=er&ali7e #eelings a&out stoma0illness8 &egin to deal constructively with situation.
.!"& Image Enhancement 0NIC1
In"epen"ent
$scertain whether support and counseling were initiated
when the possi&ility and0or necessity o# ostomy was #irst
discussed.
RATIONALE
;ncourage patient0S- to ver&ali7e #eelings regarding the
ostomy. $cknowledge normality o# #eelings o# anger,
depression, and grie# over loss. +iscuss daily Bups and
downsC that can occur.
,eview reason #or surgery and #uture eApectations.
)ote &ehaviors o# withdrawal, increased dependency,
manipulation, or noninvolvement in care.
*rovide opportunities #or patient0S- to view and touch
stoma, using the moment to point out positive signs o#
healing, normal appearance, and so #orth. ,emind patient
that it will take time to adjust, &oth physically and
emotionally.
*rovides in#ormation a&out patientDs0S-Ds level o#
knowledge and anAiety a&out individual situation.
Helps patient reali7e that #eelings are not unusual and that
#eeling guilty a&out them is not necessary0help#ul. *atient
needs to recogni7e #eelings &e#ore they can &e dealt with
e##ectively.
*atient may #ind it easier to accept0deal with an ostomy
done to correct chronic0long"term disease than #or traumatic
injury, even i# ostomy is only temporary. $lso, patient who
will &e undergoing a second procedure 1to convert ostomy
to a continent or anal reservoir2 may possi&ly encounter less
severe sel#"image pro&lems &ecause &ody #unction
eventually will &e Bmore normal.C
Suggestive o# pro&lems in adjustment that may re3uire
#urther evaluation and more eAtensive therapy.
$lthough integration o# stoma into &ody image can take
months or even years, looking at the stoma and hearing
comments 1made in a normal, matter"o#"#act manner2 can
help patient with this acceptance. !ouching stoma reassures
patient0S- that it is not #ragile and that slight movements o#
stoma actually re#lect normal peristalsis.
%ndependence in sel#"care helps improve sel#"con#idence
and acceptance o# situation.
*rovide opportunity #or patient to deal with ostomy through
participation in sel#"care.
*lan0schedule care activities with patient.
.aintain positive approach during care activities, avoiding
eApressions o# disdain or revulsion. +o not take angry
eApressions o# patient0S- personally.
$scertain patientDs desire to visit with a person with an
ostomy. .ake arrangements #or visit, i# desired.
*romotes sense o# control and gives message that patient
can handle situation, enhancing sel#"concept.
$ssists patient0S- to accept &ody changes and #eel all right
a&out sel#. $nger is most o#ten directed at the situation and
lack o# control individual has over what has happened
1powerlessness2, not with the individual caregiver.
$ person who is living with an ostomy can &e a good
support system0role model. Helps rein#orce teaching 1shared
eAperiences2 and #acilitates acceptance o# change as patient
reali7es Bli#e does go onC and can &e relatively normal.
N#RSIN$ DIA$NOSIS: Pain' ac)te
Ma& be reate" t!
*hysical #actors/ e.g., disruption o# skin0tissues 1incisions0drains2
Eiological/ activity o# disease process 1cancer, trauma2
*sychological #actors/ e.g., #ear, anAiety
,eports o# pain, sel#"#ocusing
Fuarding0distraction &ehaviors, restlessness
$utonomic responses, e.g., changes in vital signs
Pain Le*e 0NOC1
=er&ali7e that pain is relieved0controlled.
+isplay relie# o# pain, a&le to sleep0rest appropriately.
Pain C!ntr! 0NOC1
+emonstrate use o# relaAation skills and general com#ort measures as indicated #or individual situation.
Pain Management 0NIC1
In"epen"ent
$ssess pain, noting location, characteristics, intensity 10@0
scale2.
;ncourage patient to ver&ali7e concerns. $ctive"listen these
concerns, and provide support &y acceptance, remaining
RATIONALE
Helps evaluate degree o# discom#ort and e##ectiveness o#
analgesia or may reveal developing complications. Eecause
a&dominal pain usually su&sides gradually &y the third or
#ourth postoperative day, continued or increasing pain may
re#lect delayed healing or peristomal skin irritation.
Note:*ain in anal area associated with a&dominal"perineal
resection may persist #or months.
,eduction o# anAiety0#ear can promote relaAation0com#ort.
with patient, and giving appropriate in#ormation.
*rovide com#ort measures, e.g., mouth care, &ack ru&,
repositioning 1use proper support measures as needed2.
$ssure patient that position change will not injure stoma.
;ncourage use o# relaAation techni3ues, e.g., guided
imagery, visuali7ation. *rovide diversional activities.
$ssist with ,-. eAercises and encourage early am&ulation.
$void prolonged sitting position.
%nvestigate and report a&dominal muscle rigidity,
involuntary guarding, and re&ound tenderness.
*revents drying o# oral mucosa and associated discom#ort.
,educes muscle tension, promotes relaAation, and may
enhance coping a&ilities.
Helps patient rest more e##ectively and re#ocuses attention,
there&y reducing pain and discom#ort.
,educes muscle0joint sti##ness. $m&ulation returns organs to
normal position and promotes return o# usual level o#
#unctioning. Note: *resence o# edema, packing, and drains 1i#
perineal resection has &een done2 increases discom#ort and
creates a sense o# needing to de#ecate. $m&ulation and
#re3uent position changes reduce perineal pressure.
Suggestive o# peritoneal in#lammation, which re3uires
prompt medical intervention.
Pain Management 0NIC1
C!ab!rati*e
$dminister medication as indicated, e.g., narcotics,
analgesics, patient"controlled analgesia 1*'$2.
RATIONALE
*rovide sit7 &aths.
$pply0monitor e##ects o# transcutaneous electrical nerve
stimulator 1!;)S2 unit.
,elieves pain, enhances com#ort, and promotes rest. *'$
may &e more &ene#icial, especially #ollowing anal"perineal
repair.
,elieves local discom#ort, reduces edema, and promotes
healing o# perineal wound.
'utaneous stimulation may &e used to &lock transmission o#
pain stimulus.
N#RSIN$ DIA$NOSIS: S%in+Tiss)e Integrit&' impaire"
Ma& be reate" t!
%nvasion o# &ody structure 1e.g., perineal resection2
Stasis o# secretions0drainage
$ltered circulation, edema8 malnutrition
+isruption o# skin0tissue/ presence o# incision and sutures, drains
-!)n" 2eaing: Primar& Intenti!n 0NOC1
$chieve timely wound healing #ree o# signs o# in#ection.
-!)n" Care 0NIC1
In"epen"ent
-&serve wounds, note characteristics o# drainage.
RATIONALE
'hange dressings as needed using aseptic techni3ue.
;ncourage side"lying position with head elevated. $void
prolonged sitting.
*ostoperative hemorrhage is most likely to occur during
#irst 6? hr, whereas in#ection may develop at any time.
+epending on type o# wound closure 1e.g., #irst or second
intention2, complete healing may take <"? mo.
Garge amounts o# serous drainage re3uire that dressings &e
changed #re3uently to reduce skin irritation and potential #or
in#ection.
*romotes drainage #rom perineal wound0drains, reducing
risk o# pooling. *rolonged sitting increases perineal
pressure, reducing circulation to wound, and may delay
healing.
-!)n" Care 0NIC1
C!ab!rati*e
%rrigate wound as indicated, using normal saline 1)S2,
diluted hydrogen peroAide, or anti&iotic solution.
*rovide sit7 &aths.
RATIONALE
.ay &e re3uired to treat preoperative
in#lammation0in#ection or intraoperative contamination.
*romotes cleanliness and #acilitates healing, especially a#ter
packing is removed 1usually day 5@52.
N#RSIN$ DIA$NOSIS: F)i" V!)me' ris% (!r "e(icient
;Acessive losses through normal routes, e.g., preoperative emesis and diarrhea8 high"volume ileostomy output
Gosses through a&normal routes, e.g., )F0intestinal tu&e, perineal wound drainage tu&es
.edically restricted intake
$ltered a&sorption o# #luid, e.g., loss o# colon #unction
Hypermeta&olic states, e.g., in#lammation, healing process
2&"rati!n 0NOC1
.aintain ade3uate hydration as evidenced &y moist mucous mem&ranes, good skin turgor and capillary re#ill,
sta&le vital signs, and individually appropriate urinary output.
F)i"+Eectr!&te Management 0NIC1
In"epen"ent
.onitor intake and output 1%H-2 care#ully, measure li3uid
stool. Weigh regularly.
.onitor vital signs, noting postural hypotension,
tachycardia. ;valuate skin turgor, capillary re#ill, and
mucous mem&ranes.
Gimit intake o# ice chips during period o# gastric intu&ation.
C!ab!rati*e
RATIONALE
*rovides direct indicators o# #luid &alance. Freatest #luid
losses occur with ileostomy, &ut they generally do not
eAceed 500@?00 mG0day.
,e#lects hydration status0possi&le need #or increased #luid
replacement.
%ce chips can stimulate gastric secretions and wash out
electrolytes.
.onitor la&oratory results, e.g., Hct and electrolytes.
$dminister %= #luid and electrolytes as indicated. +etects homeostasis or im&alance, and aids in determining
replacement needs.
.ay &e necessary to maintain ade3uate tissue
per#usion0organ #unction.
N#RSIN$ DIA$NOSIS: N)triti!n: imbaance"' ris% (!r ess than b!"& re3)irements
*rolonged anoreAia0altered intake preoperatively
Hypermeta&olic state 1preoperative in#lammatory disease8 healing process2
*resence o# diarrhea0altered a&sorption
,estriction o# &ulk and residue"containing #oods
Possibly evidenced by
N)triti!na Stat)s 0NOC1
.aintain weight0demonstrate progressive weight gain toward goal with normali7ation o# la&oratory values and &e
#ree o# signs o# malnutrition.
*lan diet to meet nutritional needs0limit F% distur&ances.
N)triti!n Therap& 0NIC1
In"epen"ent
-&tain a thorough nutritional assessment.
RATIONALE
$uscultate &owel sounds.
,esume solid #oods slowly.
%denti#y odor"causing #oods 1e.g., ca&&age, #ish, &eans2 and
temporarily restrict #rom diet. Fradually reintroduce one
#ood at a time.
,ecommend patient increase use o# yogurt, &uttermilk, and
acidophilus preparations.
Suggest patient with ileostomy limit prunes, dates, stewed
apricots, straw&erries, grapes, &ananas, ca&&age #amily,
&eans, and avoid #oods high in cellulose, e.g., peanuts.
+iscuss mechanics o# swallowed air as a #actor in the
#ormation o# #latus and some ways patient can eAercise
control.
%denti#ies de#iciencies0needs to aid in choice o#
interventions.
,eturn o# intestinal #unction indicates readiness to resume
oral intake.
,educes incidence o# a&dominal cramps, nausea.
Sensitivity to certain #oods is not uncommon #ollowing
intestinal surgery. *atient can eAperiment with #ood several
times &e#ore determining whether it is creating a pro&lem.
.ay help prevent gas and decrease odor #ormation.
!hese products increase ileal e##luent. +igestion o# cellulose
re3uires colon &acteria that are no longer present.
+rinking through a straw, snoring, anAiety, smoking, ill"
#itting dentures, and gulping down #ood increase the
production o# #latus. !oo much #latus not only necessitates
C!ab!rati*e
'onsult with dietitian.
#re3uent emptying, &ut also can cause leakage #rom too
much pressure within the pouch.
Help#ul in assessing patientDs nutritional needs in light o#
changes in digestion and intestinal #unction, including
a&sorption o# vitamins0minerals.
N)triti!n Therap& 0NIC1
C!ab!rati*e
$dvance diet #rom li3uids to low"residue #ood when oral
intake is resumed.
$dminister enteral0parenteral #eedings when indicated.
RATIONALE
Gow"residue diet may &e maintained during #irst <@? wk to
provide ade3uate time #or intestinal healing.
%n the presence o# severe de&ilitation0intolerance o# oral
intake, parenteral or enteral #eedings may &e given to supply
needed components #or healing and prevention o# cata&olic
state.
N#RSIN$ DIA$NOSIS: Seep Pattern' "ist)rbe"
Ma& be reate" t!
;Aternal #actors/ necessity o# ostomy care, eAcessive #latus0ostomy e##luent
%nternal #actors/ psychological stress, #ear o# leakage o# pouch0injury to stoma
=er&ali7ations o# interrupted sleep, not #eeling well rested
'hanges in &ehavior, e.g., irrita&ility, listlessness0lethargy
Seep 0NOC1
Sleep0rest &etween distur&ances.
,eport increased sense o# well"&eing and #eeling rested.
Seep Enhancement 0NIC1
In"epen"ent
;Aplain necessity to monitor intestinal #unction in early
postoperative period.
*rovide ade3uate pouching system. ;mpty pouch &e#ore
retiring and, i# necessary, on a preagreed schedule.
Get patient know that stoma will not &e injured when
sleeping.
,estrict intake o# ca##eine"containing #oods0#luids.
Support continuation o# usual &edtime rituals.
RATIONALE
*atient is more apt to &e tolerant o# distur&ances &y sta## i#
he or she understands the reasons #or0importance o# care.
;Acessive #latus0e##luent can occur despite interventions.
;mptying on a regular schedule minimi7es threat o# leakage.
*atient will &e a&le to rest &etter i# #eeling secure a&out
stoma and ostomy #unction.
'a##eine may delay patientDs #alling asleep and inter#ere
with ,;. 1rapid eye movement2 sleep, resulting in patient
not #eeling well rested.
*romotes relaAation and readiness #or sleep.
Seep Enhancement 0NIC1
C!ab!rati*e
+etermine cause o# eAcessive #latus or e##luent, e.g., con#er
with dietitian regarding restriction o# #oods i# diet"related.
$dminister analgesics, sedatives at &edtime as indicated.
RATIONALE
%denti#ication o# cause ena&les institution o# corrective
measures that may promote sleep0rest.
*ain can inter#ere with patientDs a&ility to #all0remain asleep.
!imely medication can enhance rest0sleep during initial
postoperative period. Note: *ain pathways in the &rain lie
near the sleep center and may contri&ute to wake#ulness.
N#RSIN$ DIA$NOSIS: C!nstipati!n+Diarrhea' ris% (!r
*lacement o# ostomy in descending or sigmoid colon
%nade3uate diet0#luid intake
.!/e Eiminati!n 0NOC1
;sta&lish an elimination pattern suita&le to physical needs and li#estyle with e##luent o# appropriate amount and
consistency.
ACTIONS/INTERVENTIONS RATIONALE
.!/e Management 0NIC1
In"epen"ent
$scertain patientDs previous &owel ha&its and li#estyle.
%nvestigate delayed onset0a&sence o# e##luent. $uscultate
&owel sounds.
%n#orm patient with an ileostomy that initially the e##luent is
li3uid. %# constipation occurs, it should &e reported to
enterostomal nurse or physician.
,eview dietary pattern and amount0type o# #luid intake.
$ssists in #ormulation o# a timely0e##ective irrigating
schedule #or patient with a colostomy, i# appropriate.
*ostoperative paralytic0adynamic ileus usually resolves
within 6?@I4 hr, and ileostomy should &egin draining within
4@46 hr. +elay may indicate persistent ileus or stomal
o&struction, which may occur postoperatively &ecause o#
edema, improperly #itting pouch 1too tight2, prolapse, or
stenosis o# the stoma.
$lthough the small intestine eventually &egins to take on
water"a&sor&ing #unctions to permit a more semisolid, pasty
discharge, constipation may indicate an o&struction.
$&sence o# stool re3uires emergency medical attention.
$de3uate intake o# #i&er and roughage provides &ulk, and
#luid is an important #actor in determining the consistency
o# the stool.
.!/e Management 0NIC1
In"epen"ent
,eview physiology o# the colon and discuss irrigation
management o# sigmoid ostomy, i# appropriate.
RATIONALE
+emonstrate use o# irrigation e3uipment per institution
policy or under guidance o# physician or certi#ied wound,
ostomy, continence nurse.
%nstruct patient in the use o# closed"end pouch or a patch,
dressing0Eand"$id when irrigation is success#ul and the
sigmoid colostomy e##luent &ecomes more managea&le,
with stool eApelled every 46 hr.
%nvolve patient in care o# the ostomy on an increasing &asis.
C!ab!rati*e
%nstruct in use o# !;)S unit i# indicated.
!his knowledge helps patient understand individual care
needs.
%rrigations may &e done on a daily &asis i# appropriate,
although there are di##ering views on this practice. .any
&elieve cleaning the &owel on a regular &asis is help#ul.
-thers &elieve that this inter#eres with normal #unctioning.
1.ost authorities agree that occasional irrigation is use#ul
#or emptying the &owel to avoid leakage when special
events are planned.2
;na&les patient to #eel more com#orta&le socially and is less
eApensive than regular ostomy pouches.
,eha&ilitation can &e #acilitated &y encouraging patient
independence and control.
;lectrical stimulation has &een used in some patients to
stimulate peristalsis and relieve postoperative ileus.
N#RSIN$ DIA$NOSIS: Se4)a D&s()ncti!n' ris% (!r
$ltered &ody structure0#unction8 radical resection0treatment procedures
=ulnera&ility0psychological concern a&out response o# S-
+isruption o# seAual response pattern, e.g., erectile di##iculty
Se4)a F)ncti!ning 0NOC1
=er&ali7e understanding o# relationship o# physical condition to seAual pro&lems.
%denti#y satis#ying0accepta&le seAual practices and eAplore alternative methods.
,esume seAual relationship as appropriate.
Se4)a C!)nseing 0NIC1
In"epen"ent
+etermine patientDs0S-Ds seAual relationship &e#ore the
disease and0or surgery and whether they anticipate pro&lems
related to presence o# ostomy.
,eview with patient0S- seAual #unctioning in relation to
own situation.
,ein#orce in#ormation given &y the physician. ;ncourage
3uestions. *rovide additional in#ormation as needed.
RATIONALE
%denti#ies #uture eApectations and desires. .utilation and loss o#
privacy0control o# a &odily #unction can a##ect patientDs view o#
personal seAuality. When coupled with the #ear o# rejection &y
S-, the desired level o# intimacy can &e greatly impaired.
SeAual needs are very &asic, and patient will &e reha&ilitated
more success#ully when a satis#ying seAual relationship is
continued0developed as desired.
Understanding i# nerve damage has altered normal seAual
#unctioning 1e.g., erection2 helps patient0S- to understand
the need #or eAploring alternative methods o# satis#action.
,eiteration o# data previously given assists patient0S- to
hear and process the knowledge again, moving toward
acceptance o# individual limitations0restrictions and
prognosis 1e.g., that it may take up to 4 yr to regain potency
a#ter a radical procedure or that a penile prosthesis may &e
necessary2.
Knowing what to eApect in progress o# recovery helps
patient avoid per#ormance anAiety0reduce risk o# B#ailure.C
%# the couple is willing to try new ideas, this can assist with
adjustment and may help to achieve seAual #ul#illment.
+isguising ostomy appliance may aid in reducing #eelings
o# sel#"consciousness, em&arrassment during speci#ically
+iscuss likelihood o# resumption o# seAual activity in
approAimately < wk a#ter discharge, &eginning slowly and
progressing 1e.g., cuddling0caressing until &oth partners are
com#orta&le with &ody image0#unction changes2. %nclude
alternative methods o# stimulation as appropriate.
;ncourage dialogue &etween partners. Suggest wearing
pouch cover, !"shirt, shortie nightgown, or underwear
seAual activity.
Stress awareness o# #actors that might &e distracting 1e.g.,
unpleasant odors and pouch leakage2. ;ncourage use o#
sense o# humor.
*ro&lem"solve alternative positions #or coitus.
+iscuss0role"play possi&le interactions or approaches when
dealing with new seAual partners.
*rovide &irth control in#ormation as appropriate and stress
that impotence does not necessarily mean patient is sterile.
C!ab!rati*e
designed #or seAual contact.
*romotes resolution o# solva&le pro&lems. Gaughter can
help individuals deal more e##ectively with di##icult
situation, promote positive seAual eAperience.
.inimi7ing awkwardness o# appliance and physical
discom#ort can enhance satis#action.
,ehearsal is help#ul in dealing with actual situations when
they arise, preventing sel#"consciousness a&out Bdi##erentC
&ody image.
'on#usion may eAist that can lead to an unwanted
pregnancy.
Sharing o# how these pro&lems have &een resolved &y others
can &e help#ul and reduce sense o# isolation.
%# pro&lems persist longer than several months a#ter surgery,
a trained therapist may &e re3uired to #acilitate
communication &etween patient and S-.
$rrange meeting with an ostomy visitor i# appropriate.
,e#er to counseling0seA therapy as indicated.
N#RSIN$ DIA$NOSIS: 5n!/e"ge' "e(icient 6Learning Nee"7 regar"ing c!n"iti!n' pr!gn!sis'
treatment' se(8care' an" "ischarge nee"s
Ma& be reate" t!
Gack o# eAposure0recall in#ormation misinterpretation
Un#amiliarity with in#ormation resources
Juestions8 statement o# misconception0misin#ormation
%naccurate #ollow"through o# instruction0per#ormance o# ostomy care
%nappropriate or eAaggerated &ehaviors 1e.g., hostile, agitated, apathetic, withdrawal2
5n!/e"ge: Disease Pr!cess 0NOC1
=er&ali7e understanding o# condition0disease process, prognosis, and potential complications.
5n!/e"ge: Treatment Regimen 0NOC1
=er&ali7e understanding o# therapeutic needs.
'orrectly per#orm necessary procedures, eAplain reasons #or the action.
%nitiate necessary li#estyle changes.
Learning Faciitati!n 0NIC1
In"epen"ent
;valuate patientDs emotional, cognitive, and physical
capa&ilities.
%nclude written0picture 1photo, video, %nternet2 learning
RATIONALE
!hese #actors a##ect patientDs a&ility to master care"tasks and
willingness to assume responsi&ility #or ostomy care.
resources.
Teaching: Disease Pr!cess 0NIC1
,eview anatomy, physiology, and implications o# surgical
intervention. +iscuss #uture eApectations, including
anticipated changes in character o# e##luent.
%nstruct patient0S- in stomal care. $llot time #or return
demonstrations and provide positive #eed&ack #or e##orts.
,ecommend increased #luid intake during warm weather
months.
+iscuss possi&le need to decrease salt intake.
*rovides re#erences #or o&taining support, e3uipment, and
additional in#ormation a#ter discharge to support patient
e##orts #or independence in sel#"care.
*rovides knowledge &ase #rom which patient can make
in#ormed choices, and o##ers an opportunity to clari#y
misconceptions regarding individual situation. 1!emporary
ileostomy may &e converted to ileoanal reservoir at a #uture
date8 ileostomy and ascending colostomy cannot &e
regulated &y diet, irrigations, or medications.2
*romotes positive management and reduces risk o#
improper ostomy care0development o# complications.
Goss o# normal colon #unction o# conserving water and
electrolytes can lead to dehydration and constipation.
Salt can increase ileal output, potentiating risk o#
dehydration and increasing #re3uency o# ostomy care
needs0patientDs inconvenience.
In"epen"ent
%denti#y symptoms o# electrolyte depletion, e.g., anoreAia,
a&dominal muscle cramps, #eelings o# #aintness or BcoldC in
arms0legs, general #atigue0weakness, &loating, decreased
sensations in arms0legs.
+iscuss need #or periodic evaluation0administration o#
supplemental vitamins and minerals as appropriate.
Stress importance o# chewing #ood well, ade3uate intake o#
#luids with0#ollowing meals, only moderate use o# high"#i&er
#oods, avoidance o# cellulose.
,eview #oods that are0may &e a source o# #latus 1e.g.,
car&onated drinks, &eer, &eans, ca&&age #amily, onions, #ish,
and highly seasoned #oods2 or odor 1e.g., onions, ca&&age
#amily, eggs, #ish, and &eans2.
%denti#y #oods associated with diarrhea, such as green &eans,
&roccoli, highly seasoned #oods.
,ecommend #oods used to manage constipation 1e.g., &ran,
celery, raw #ruits2, and discuss importance o# increased #luid
intake.
+iscuss resumption o# presurgery level o# activity. Suggest
emptying the ostomy appliance &e#ore leaving home and
carrying a #anny pack with #resh supplies. ,ecommend
resources #or o&taining attractive appliances and decorative
cummer&unds as appropriate.
!alk a&out the possi&ility o# sleep distur&ance, anoreAia,
loss o# interest in usual activities.
;Aplain necessity o# noti#ying healthcare providers and
pharmacists o# type o# ostomy and avoidance o# sustained"
release medications.
RATIONALE
Goss o# colon #unction altering #luid0electrolyte a&sorption
may result in sodium0potassium de#icits re3uiring dietary
correction with #oods0#luids high in sodium 1e.g., &ouillon,
Fatorade2 or potassium 1e.g., orange juice, prunes,
tomatoes, &ananas, Fatorade2.
+epending on portion and amount o# &owel resected, lack o#
a&sorption may cause de#iciencies.
,educes risk o# &owel o&struction, especially in patient with
ileostomy.
!hese #oods may &e restricted or eliminated, &ased on
individual reaction, #or &etter ostomy control, or it may &e
necessary to empty the pouch more #re3uently i# they are
ingested.
*romotes more even e##luent and &etter control o#
evacuations.
*roper management can prevent0minimi7e pro&lems o#
constipation.
With a little planning, patient should &e a&le to manage
same degree o# activity as previously enjoyed and in some
cases increase activity level. $ cummer&und can provide
&oth physical and psychological support when patient is
involved in activities such as tennis and swimming.
BHomecoming depressionC may occur, lasting #or months
a#ter surgery, re3uiring patience0support and ongoing
evaluation as patient adjusts to living with a stoma.
'ounsel patient concerning medication use and pro&lems
associated with altered &owel #unction. ,e#er to pharmacist
#or teaching0advice as appropriate.
+iscuss e##ect o# medications on e##luent, i.e., changes in
color, odor, consistency o# stool, and need to o&serve #or
drug residue indicating incomplete a&sorption.
*resence o# ostomy may alter rate0eAtent o# a&sorption o#
oral medications and increase risk o# drug"related
complications, e.g., diarrhea0constipation or peristomal
eAcoriation. Gi3uid, chewa&le, or injecta&le #orms o#
medication are pre#erred #or patients with ileostomy to
maAimi7e a&sorption o# drug.
*atient with an ostomy has two key pro&lems/ altered
disintegration and a&sorption o# oral drugs and unusual or
pronounced adverse e##ects. Some o# the medications that these
patients may respond to di##erently include laAatives,
salicylates, H4 receptor antagonists, anti&iotics, and diuretics.
Understanding decreases anAiety regarding intestinal
#unction and enhances independence in sel#"care.
In"epen"ent
Stress necessity o# close monitoring o# chronic health
conditions re3uiring routine oral medications.
%denti#y community resources, e.g., United -stomy
$ssociation, the 'rohnDs and 'olitis (oundation o# $merica,
-stomy ,eha&ilitation *rogram, local ostomy support
group, certi#ied wound, ostomy, continence nurse, visiting
nurse, pharmacy0medical supply house.
RATIONALE
.onitoring o# clinical symptoms and serum &lood levels is
indicated &ecause o# altered drug a&sorption re3uiring
periodic dosage adjustments.
'ontinued support a#ter discharge is essential to #acilitate
the recovery process and patientDs independence in care.
'erti#ied wound, ostomy, continence nurse can &e very
help#ul in solving appliance pro&lems, identi#ying
alternatives to meet individual patient needs.
POTENTIAL CONSIDERATIONS (!!/ing ac)te h!spitai9ati!n 0"epen"ent
!n patient:s age' ph&sica c!n"iti!n+presence !( c!mpicati!ns'
pers!na res!)rces' an" i(e resp!nsibiities1
Skin %ntegrity, risk #or impairedKa&sence o# sphincter at stoma, character0#low o# e##luent and #latus #rom stoma.
'oping, ine##ectiveKsituational crises, vulnera&ility.
Social %nteraction, impairedKsel#"concept distur&ance, concern #or loss o# control o# &odily #unctions.

Fecal Diversions: Postoperative Care of Ileostomy and Colostomy

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FECAL DIVERSIONS: POSTOPERATIVE CARE OF ILEOSTOMY AND

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