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HOME  NURSING CARE PLANS  GASTROINTESTINAL CARE PLANS  10 ILEOSTOMY AND COLOSTOMY NURSING

CARE PLANS
 NURSING CARE PLANS
 GASTROINTESTINAL CARE PLANS
 SURGERY AND PERIOPERATIVE CARE PLANS

10 Ileostomy and Colostomy

Nursing Care Plans
By
 Matt Vera, BSN, R.N.
 -
Last Updated on June 2, 2019
 ADVERTISEMENTS

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:

1. Risk for Impaired Skin Integrity

2. Disturbed Body Image
3. Acute Pain
4. Impaired Skin Integrity
5. Deficient Fluid Volume
6. Risk for Imbalanced Nutrition: Less Than Body Requirements
7. Risk for Sexual Dysfunction
8. Disturbed Sleep Pattern
9. Risk for Constipation or Diarrhea
10. Deficient Knowledge

11. Other Nursing Care Plans

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1 - Risk for Impaired Skin Integrity

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Risk for Impaired Skin Integrity

Nursing Diagnosis

 Risk for Impaired Skin Integrity

Risk factors may include

 Absence of sphincter at the stoma

 Character/flow of effluent and flatus from the stoma
 Reaction to product/chemicals; improper fitting/care of appliance/skin
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 maintain skin integrity around the stoma.

 Client will identify individual risk factors.
 Client will demonstrate behaviors/techniques to promote healing/prevent
skin breakdown.
Nursing Interventions Rationale

Monitors the healing process and effectiveness of

Inspect stoma and peristomal skin area with each
pouch change. Note irritation, bruises (dark, bluish
color), rashes
appliances and identifies areas of concern, need for
further evaluation and intervention. Early
identification of stomal necrosis or ischemia or
fungal infection (from changes in normal bowel
flora) provides for timely interventions to prevent
serious complications. Stoma should be red and
moist. Ulcerated areas on stoma may be from a
pouch opening that is too small or a faceplate that
cuts into stoma. In patients with an ileostomy, the
effluent is rich in enzymes, increasing the
likelihood of skin irritation. In patient with a
colostomy, skin care is not as great a concern
because the enzymes are no longer present in the
effluent.

Clean with warm water and pat dry. Use soap only
Maintaining a clean and dry area helps prevent skin
if area is covered with sticky stool. If paste has
breakdown.
collected on the skin, let it dry, then peel it off.

As postoperative edema resolves (during first 6

Measure stoma periodically: at least weekly for wk), the stoma shrinks and size of appliance must
first 6 wk, then once a month for 6 mo. Measure be altered to ensure proper fit so that effluent is
both width and length of stoma. collected as it flows from the ostomy and contact
with the skin is prevented.

Verify that opening on adhesive backing of the Prevents trauma to the stoma tissue and protects the
pouch is at least 1⁄16 to 1⁄8 in (2–3 mm) larger than peristomal skin. Adequate adhesive area prevents
 Nursing Interventions Rationale

the skin barrier wafer from being too

the base of the stoma, with adequate adhesiveness
tight. Note: Too tight a fit may cause stomal edema
left to apply pouch.
or stenosis.

A transparent appliance during first 4–6 wk allows

Use a transparent, odor-proof drainable pouch. easy observation of stoma without necessity of
removing pouch/irritating skin.

Protects skin from pouch adhesive, enhances

adhesiveness of pouch, and facilitates removal of
Apply appropriate skin barrier: hydrocolloid wafer,
pouch when necessary. Note: Sigmoid colostomy
karaya gun, extended-wear skin barrier, or similar
may not require use of a skin barrier once stool
products.
becomes formed and elimination is regulated
through irrigation.

Frequent pouch changes are irritating to the skin

and should be avoided. Emptying and rinsing the
Empty, irrigate, and cleanse ostomy pouch on a
pouch with the proper solution not only removes
routine basis, using appropriate equipment.
bacteria and odor-causing stool and flatus but also
deodorizes the pouch.

Support surrounding skin when gently removing

Prevents tissue irritation or destruction associated
appliance. Apply adhesive removers as indicated,
with “pulling” pouch off.
then wash thoroughly.

Indicative of effluent leakage with peristomal

Investigate reports of burning, itching, or blistering
irritation, or possibly Candida infection, requiring
around stoma.
intervention.

Evaluate adhesive product and appliance fit on Provides opportunity for problem solving.
ongoing basis. Determines need for further intervention.

Helpful in choosing products appropriate for

Consult with certified wound, ostomy, patient’s particular rehabilitation needs, including
continence nurse. type of ostomy, physical/mental status, abilities to
handle self-care, and financial resources.

Apply corticosteroid aerosol spray and Assists in healing if peristomal irritation persists
prescribed antifungal powder as indicated. and/or fungal infection develops. Note: These
products can have potent side effects and should be
 Nursing Interventions Rationale

used sparingly.

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1 - Risk for Impaired Skin Integrity

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See Also
You may also like the following posts and care plans:

 Nursing Care Plan: The Ultimate Guide and Database  – the ultimate
database of nursing care plans for different diseases and conditions! Get the
complete list!
 Nursing Diagnosis: The Complete Guide and List – archive of different
nursing diagnoses with their definition, related factors, goals and nursing
interventions with rationale.
Gastrointestinal Care Plans

Care plans covering the disorders of the gastrointestinal and digestive system:

 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
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 TAGS

 ACUTE PAIN

 CONSTIPATION

 DEFICIENT FLUID VOLUME

 DIARRHEA

 DISTURBED BODY IMAGE

 DISTURBED SLEEP PATTERN

 IMBALANCED NUTRITION

 IMPAIRED SKIN INTEGRITY

 KNOWLEDGE DEFICIT

 RISK FOR IMPAIRED SKIN INTEGRITY

 SEXUAL DYSFUNCTION

Matt Vera, BSN, R.N.

Matt Vera is a registered nurse with a bachelor of science in nursing since 2009 and is currently working as a
full-time writer and editor for Nurseslabs. During his time as a student, he knows how frustrating it is to cram
on difficult nursing topics. Finding help online is nearly impossible. His situation drove his passion for helping
student nurses by creating content and lectures that are easy to digest. Knowing how valuable nurses are in
delivering quality healthcare but limited in number, he wants to educate and inspire nursing students. As a
nurse educator since 2010, his goal in Nurseslabs is to simplify the learning process, break down complicated
topics, help motivate learners, and look for unique ways of assisting students in mastering core nursing
concepts effectively.

4 COMMENTS

1. FinFin June 17, 2012 At 4:48 AM

 Thank you for these nursing care plans! They’re great!

Reply

2. RN May 21, 2014 At 9:17 PM

Readiness for enhanced learning (if they are willing to learn)

Reply

3. Dickson Aruasa June 15, 2014 At 12:40 PM

Thank you for this informative site!

Reply

4. SURESH KUMAR March 13, 2019 At 1:04 PM

Thank you for the Nursing process its very helpfull.

Reply

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