CLINICAL REVIEW
Managing a colostomy or ileostomy
in community nursing practice
Elissa Bradshaw, Brigitte Collins
Elissa Bradshaw is a Stoma Nurse Specialist in Biofeedback at St Marks Hospital, Harrow, Middlesex. Brigitte Collins is the
Lead Nurse in Biofeedback at St Marks Hospital, Harrow, Middlesex
T he word ‘stoma’ is Greek in origin and means
‘mouth’ or opening’ (Black, 2000). A stoma is
a surgically formed opening generally created
for diversion of faeces or urine from the body (Burch,
2008). Nicholls (1996) states that there are two general
indications for creating an intestinal stoma—either when
the surgeon wishes to create a faecal or urinary diversion
to allow bowel to heal and avoid pelvic sepsis, or when
the removal of the anal sphincter mechanism means an
alternative route for voiding waste is required. There are
a wide range of congenital, pathological and traumatic
conditions which necessitate stoma formation—the most
common reasons being bowel cancer of inflammatory
bowel disease (Nicholls, 1996). There are various types
of stoma, surgically formed from sections of bowel such
as the ileostomy, colostomy, urostomy, caecostomy and
jejunostomy—and these are named after the organ from
which they originate (Burch, 2008). For example, the
colostomy is formed from the colon and the ileostomy
from the ileum. The colostomy and ileostomy are the
most common types of stoma and it is the management
of these with regard to diet and appliance choices, which
will be discussed.
Stoma care in the community
There are thought to be around 100 000 ostomates (peo-
ple with stomas) in the UK (Williams and Ebanks, 2003).
Stomas can either be temporary (sometimes referred to as
‘defunctioning’) or permanent, and can be further catago-
rized by how they are made. For example, an end stoma is
ABSTRACT
After stoma formation the patient should be independent with their own
stoma care. However, with emphasis being placed on community nurses
for ongoing aftercare of ostomates: Skingley (2004) has asserted that many
community nurses did not feel confident undertaking stoma care.
This article is ideally placed for the community nurses to obtain a broad
overview of some of the key points pertaining to stoma care. The article
looks at care of ostomates and ileostomates in relation to available
appliances and also discusses dietary recommendations.
KEY WORDS
Ostomates w Stoma care nursing w One and two piece appliances
514
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Email: elissa.bradshaw@nwlh.nhs.uk
made from one single end of bowel which is sutured to the
abdomen. A loop stoma is made from an end of bowel, split
into two, with both sides adhered to the abdominal wall.
Regardless of their specific type and way in which they are
made, any stoma should be warm, pink and moist. They
vary in size and shape, and ideally an ileostomy should have
a spout to allow its liquid output to be more easily managed
(Burch, 2008).
After stoma formation in hospital a patient should ide-
ally be independent with their own stoma care prior to
discharge into the community (Erwin-Toth and Doughty,
1992). However, in the current healthcare climate, the
emphasis is now placed increasingly on primary care for
ongoing aftercare of the patient discharged earlier from
hospital. Skingley (2004) reported that many community
nurses did not feel confident in undertaking stoma care
pointing to the fact that many had been in situations
where the patient required help with stoma care.
Appliances
There are currently a wide range of products available on
prescription to ostomates and new appliances are constant-
ly emerging. There are two basic categories of appliance,
one and two-piece systems. However, it is beyond the
scope of this article to discuss all existing appliances thus, a
brief overview of one and two-piece appliances pertaining
to colostomy and ileostomy will be discussed.
One piece appliance
One-piece appliances are systems in which the adhesive
base plate and bag are manufactured as one component.
The adhesive plate will often have a hydrocolloid skin bar-
rier to protect the skin and/or a hypoallergenic adhesive
to give added security (Williams, 2006). The one-piece
system is flexible, lightweight, and usually has a low pro-
file under clothing. The one-piece appliance requires no
assembly for application and can be applied to the abdo-
men in one step. This is of benefit to individuals who may
have problems with manual dexterity. A one-piece appli-
ance is available in a closed or drainable system.
Two piece appliance
A two-piece appliance is manufactured as two separate
units and has similar properties to that of a one-piece
appliance (Williams, 2006). Two-piece appliances consist
British Journal of Community Nursing Vol 13, No 11
 CLINICAL REVIEW

closed appliance has no opening and the complete appli-

Table 1. Dietary guidelines for ostomates ance is discarded after use and replaced with a new one.
However, should a colostomate require more than two
Foods that may Foods that may cause Foods that produce
appliance changes a day then a two-piece appliance is
Cause obstruction loose stools flatus and odour
more appropriate, as this is less likely to cause skin distur-
Mushrooms Alcoholic drinks Asparagus
bance and is more cost efficient (Burch and Sica, 2007).
Dried fruit Apple juice Apples
Sweetcorn Coffee Beer Drainable appliances
Coconut Dairy Cabbage Drainable appliances are designed to empty the contents
Orange Pith Green leafy veg Broccoli while in use, they are often used for those who have
undergone formation of an ileostomy, where the faecal
Nuts Baked beans Brussel sprouts
output is often loose and the bag may require frequent
Popcorn Liquorice Cauliflower emptying. Drainable bags can also be used as a one or two-
Tough fruit piece system. A one-piece drainable appliance can stay in
and vegetable skins Chocolate Cucumber place for 2–3 days.
Celery Tomatoes Dried peas/ beans Each type of appliance is available in a variety of sizes
Chinese vegetables Prune juice Eggs and lengths to accommodate the quantity of output, short
Peas Spiced foods Fatty foods torsos, clothing, lifestyle, activity, self-care ability, or per-
sonal preference. Additionally the majority of appliances
Sorbitol Onions
are obtainable in clear or opaque. Most appliances have
Turnips activated charcoal filters, which allow flatus to be released
Dairy products and absorb the odour, making them more discreet and
Chewing gum comfortable. There are also a number of accessories avail-
Carbonated drinks able for patients with stomas that are difficult to manage. A
stoma nurse specialist will often be able to give advice on
Garlic
choosing the correct accessories if required.
Fish Using a one or two-piece system will depend on the
Constipation relief Foods that thicken Foods that control odour patient’s needs and a thorough assessment. Certain fac-
output tors need to be considered for the appropriateness of an
Cooked fruits Potatoes Parsley appliance e.g. manual dexterity and vision, lifestyle consid-
Cooked vegetables White rice Cranberry juice erations, skin sensitivities as well as the type of stoma and
Fresh fruits Bananas Yoghurt effluent (Cottam and Porrett, 2005).
There are many types of stoma appliances manufactured
Fruit juice Stewed apples Orange juice
by various companies in the UK. Table 2 gives a brief
Water Smooth peanut
overview of some of the manufacturers and their most
butter bread
commonly used products. However, please note this table
Cream crackers
provides a cursory review only.
Marshmallows
Jelly Babies Diet
Crisps Many patients express concerns with diet following the
formation of a stoma. Patients believe that diet should be
changed completely or restricted to reduce faecal output
of an adhesive baseplate fixed around the stoma and a bag (Williams, 2006; Fulham, 2008).
that can be clipped or adhered securely to the baseplate. There are no set dietary rules for ostomates and each
The baseplate can stay in place for 2–5 days and the bag individual will respond differently. Literature is lacking in
can be replaced when the stoma is active (Black, 1998). objective evidence and is based primarily on individual
A two-piece appliance permits access to the stoma experiences (Floruta, 2001) although, such evidence is
without removing the entire system, thus causing less skin often useful as a guide.
disturbance (Burch and Sica, 2007). Another benefit of the Most patients can be encouraged to follow a normal
two-piece appliance is the option of using interchangeable healthy balanced diet. A balanced diet is one that contains
bags at particular times, such as any sports activities and all the following food types, carbohydrates, fruit and vege-
sexual intercourse (Williams, 2006). Two-piece appliances tables, proteins, dairy products and fats and sugars (Pearson,
are also available as closed or drainable. 2008). However, patients should be aware that certain
aspects of diet can and may be problematic.
Closed appliances
One-piece closed appliances are predominantly suitable Ileostomy
for colostomates with a faecal output that is formed or Ileostomates should be encouraged to take a healthy bal-
firm and require only one or two changes per day. A anced diet. However, complications, such as obstruction,

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 CLINICAL REVIEW

loose output and dehydration can occur (Burch, 2006).

Foods that are difficult to breakdown and not chewed Table 2. Available stoma products
appropriately can cause an obstruction (Table 1) (Black
2000, Burch 2006). Foods rich in fibre can stimulate great- Company name One-piece Two-piece
er activity in the small intestine and thus can sometimes Coloplast Sensura 1 Easiflex
cause problems with loose output (McKenzie, 2001). This (closed & drainable) (closed & drainable)
can often be rectified by avoiding these foods and replacing Convatec Esteem Esteem Synergy
with low fibre alternatives. (closed & drainable) (closed & drainable)
Without a functioning colon an ileostomate is prone Dansac Nova 1 Nova 2
to losing 50–80mmols of sodium per day (Wood, 1998), (closed & drainable) (closed &drainable)
as a consequence dehydration may occur. This can be Hollister Moderma Flex Tandem
prevented in those patients who have a faecal output of (closed & drainable) (closed & drainable)
less than 1200ml per day by ensuring that fluid intake is Salts Confidence comfort Second nature
1.5–2.0 litres and sodium is replaced by adding the equiva- (closed & drainable) (closed & drainable)
lent of an extra teaspoonful of salt to daily food (Fulham,
2008; Burch, 2007). However, Fulham (2008) highlights
the need for explaining this carefully to ensure compliance, Production of flatus is as a result of swallowed air and
especially as this contradicts current dietary guidelines on colonic bacterial fermentation (Burch, 2007). A reduc-
salt intake. tion or avoidance of certain foods that produce flatus
Rather than follow the lists of foods to avoid the (Table 1) may decrease colonic fermentation and thus
ileostomate is encouraged to try all foods and only decrease the volume of flatus passed.
avoid those that cause frequently undesirable symptoms
(Pearson, 2008). Pearson (2008) also points out that refer- Conclusion
ral to a registered dietitian should be considered should In conclusion, the role of the community nurse in provid-
it be problematical in ascertaining a balanced diet and ing support through the medium of information and edu-
adequate function. cation, is of the utmost importance in facilitating patient
empowerment, in care of all community patients. This
Colostomy is exceptionally important in the care of ostomates in the
Most colostomates in general can eat a normal healthy bal- community. As White (1998) has asserted, early learning of
anced diet that will include all the food types as previously stoma skills can help the patient in adapting psychologically
discussed. However, problems of constipation, diarrhoea to their surgery. Burch (2008) surmises that it is unlikely
and flatus can occur and will be discussed further. that the patient will have time to adapt to the stoma sur-
Patients in continuity (those without stoma’s) and colos- gery while in hospital—and thus as an ongoing process
tomates generally have bowel actions that vary from three of adjustment, the community nurse is ideally placed to
daily to three times weekly (Emmanuel, 2004). Anything
less than three times a week is classed as constipation.
There can be many causes to constipation and a low
residue diet (Collett, 2002) is one aspect. Modifying diet
by increasing fibre (Table 1) and fluid intake can help pre-
vent constipation (Pellatt, 2006; Peate, 2003). Thompson
et al (2003) stress the importance of assessing dietary
fibre and fluid intake and adjusting accordingly prior to
considering laxatives.
Diarrhoea/loose stools can be a result of many caus-
es such as stress, medications, infection and antibiotics
(Bridgewater, 1999). However, diarrhoea can also be related
to diet (Table 1). Patients experiencing diarrhoea may need
to modify diet if certain foods are likely to upset the colos-
tomate (Burch, 2007). This may mean substituting certain
foods for those that may thicken output. Anti-diarrhoeals
such as Loperamide can also be prescribed to reduce gut
transit time and thus thicken faecal output (Porrett and
McGrath, 2005). It should be noted that a colostomate
suffering with diarrhoea should switch to drainable appli-
ances until the diarrhoea subsides, thus preventing repeated
changes and skin disturbance.
District nurses are integral in
A colostomy provides no voluntary control over the supporting ostomates in the community
passage of flatus, which can be a source of embarrassment.

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 CLINICAL REVIEW
give reassurance and support. The author hopes to have
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KEY POINTS
wThere are approximately 100 000 ostomates (people
with stomas) in the United Kingdom.
w In the current healthcare climate emphasis is placed
on the community nurse for care of patients.
wInformation and education is of the utmost importance
in care of all community patients.
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