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Ostomies

Description

An ostomy is a surgical procedure that allows intestinal contents to pass from the bowel through an opening in the skin on the abdomen. The opening is called a stoma, and it is created when the intestine is brought through the abdominal wall and sutured to the skin. The intestinal contents then empty through the hole on the surface of the abdomen rather than being eliminated through the anus.

An ostomy is used when the normal elimination route is no longer possible. For example, if the person has colorectal cancer, the diseased portion is removed together with a certain margin of healthy tissue. Sometimes the tumor can be resected, leaving enough healthy tissue to immediately anastomose (reconnect) the two remaining ends of healthy bowel, and no ostomy is necessary. If the tumor involves the rectum and is large enough to necessitate the removal of the anal sphincters, the anus is sutured shut and a permanent ostomy is created.

Types of ostomies

Ostomies are described according to location and type (Fig. 23). An ostomy in the ileum is called an ileostomy and an ostomy in the colon is called a colostomy. The ostomy is further characterized by its anatomic site (e.g., sigmoid or transverse colostomy). The more distal the ostomy, the more the intestinal contents resemble feces that is eliminated from an intact colon and rectum. A comparison of colostomies and ileostomies is shown in Table 95.

Table 95

Comparison of Ileostomy and Colostomy

		Colostomy
Characteristic	Ileostomy	Ascending	Transverse	Sigmoid
Stool consistency	Liquid to semiliquid	Semiliquid	Semiliquid to semiformed	Formed
Fluid requirement	Increased	Increased	Possibly increased	No change
Bowel regulation	No	No	No	Yes (if there is a history of a regular bowel pattern)
Pouch and skin barriers	Yes	Yes	Yes	Dependent on regulation
Irrigation	No	No	No	Possibly every 24-48 hr (if patient meets criteria)
Indications for surgery	Ulcerative colitis, Crohn’s disease, diseased or injured colon, familial polyposis, trauma, cancer	Perforating diverticulum in lower colon, trauma, rectovaginal fistula, inoperable tumors of colon, rectum, or pelvis	Same as for ascending	Cancer of the rectum or rectosigmoidal area, perforating diverticulum, trauma

The major types of ostomies are end stoma, loop, and double-barrel ostomies.

■ An end stoma is created by dividing the bowel and bringing the proximal end as a single stoma. The distal portion of the GI tract is surgically removed, or the distal segment is oversewn and left in the abdominal cavity. If the distal bowel is removed, then the stoma is permanent.

■ A loop stoma is constructed by bringing a loop of bowel to the abdominal surface and then opening the anterior part of the bowel to provide fecal diversion. This results in one stoma with a proximal and distal opening and an intact posterior bowel wall that separates the two openings. A loop stoma is usually temporary.

■ In a double-barrel stoma the bowel is divided, and both the proximal and distal ends are brought through the abdominal wall as two separate stomas. The proximal one is the functioning stoma; the distal, nonfunctioning stoma is referred to as the mucus fistula. The double-barreled stoma is usually temporary.

The procedures used to perform ostomy surgeries are further discussed in Lewis et al.: Medical-Surgical Nursing, ed. 9, pp. 990 to 991.

Nursing management

Preoperative care

Preoperative care that is unique to ostomy surgery includes (1) psychologic preparation for the ostomy; (2) selection of a flat site on the abdomen that allows secure attachment of the collection bag; and (3) selection of a stoma site that will be clearly visible to the patient to facilitate self-care. Psychologic preparation and emotional support are important as the person copes with the change in body image and a loss of control over elimination and its odors.

■ A wound, ostomy, and continence (WOC) nurse should select the site where the ostomy will be positioned and mark the abdomen preoperatively. Stomas placed outside the rectus muscle increase the chance of developing a hernia. A flat site makes it much easier to create a good seal and avoid leakage from the bag.

Postoperative care

Postoperative nursing care includes assessment of the stoma and provision of an appropriate pouching system that protects the skin and contains drainage and odor. The stoma should be dark pink to red. A dusky blue stoma indicates ischemia, and a brown-black stoma indicates necrosis. Assess and document stoma color every 4 hours. Teach the patient that the stoma is mildly to moderately swollen the first 2 to 3 weeks after surgery.

All pouching systems consist of an adhesive skin barrier and a bag or pouch to collect the feces. The skin barrier is a piece of pectin-based or karaya wafer that has a measurable thickness and hydrocolloid adhesive properties.

Patient and caregiver teaching

■ Teach the patient to perform a pouch change, provide appropriate skin care, control odor, care for the stoma, and identify signs and symptoms of complications.

■ Instruct the patient about the importance of fluids and a healthy diet. Provide the names and addresses of United Ostomy Associations of America, and instruct the patient on when to seek health care.

■ Home care and outpatient follow-up by a WOC nurse are highly recommended. Patients should be discharged with written information about their particular ostomy, instructions for pouch changes, a list of supplies and where to purchase them (including names and phone numbers of retailers), and outpatient follow-up appointments with the surgeon and WOC nurse.

■ Emotional support, interventions from skillful WOC nurses, and visits from people who have successfully learned to manage their ostomies will help patients learn to cope with and manage the new stoma.

■ See Table 43-29 for ostomy teaching guidelines, Lewis et al.: Medical-Surgical Nursing, ed. 9, p. 993.

Colostomy care

A colostomy in the ascending and transverse colon has semiliquid stools. Instruct the patient to use a drainable pouch. A colostomy in the sigmoid or descending colon has semiformed or formed stools and sometimes can be regulated by the irrigation method. The patient may or may not wear a drainage pouch. A well-balanced diet and adequate fluid intake are important.

Colostomy irrigations may be used to stimulate emptying of the colon. Regularity is possible only when the stoma is in the distal colon or rectum. If bowel control is achieved, there should be little or no spillage between irrigations, and the patient may need to wear only a pad or cover over the stoma. The procedure for colostomy irrigation is presented in Table 96.

Table 96

Patient and Caregiver Teaching Guide
Colostomy Irrigation

Include the following instructions when teaching the patient and caregiver to perform a colostomy irrigation.

Equipment*