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Chapter 26
The Patient with an
Ostomy
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Learning Objectives
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List the indications for ostomy surgery to divert urine or
feces.
Describe nursing interventions to prepare the patient for
ostomy surgery.
Explain the types of procedures used for fecal diversion.
Assist in developing a nursing process to plan care for
the patient with each of the following types of fecal
diversion: ileostomy, continent ileostomy, ileoanal reservoir,
and colostomy.
Explain the types of procedures done for urinary
diversion.
Assist in developing a nursing care plan for the patient
with each of the following types of urinary diversion: ureterostomy,
ileal conduit, and continent internal reservoir.
Discuss content to be included in teaching patients to
learn to live with ostomies.
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The Ostomy Patient
• Ostomy
• Surgical creation of artificial opening into a body
cavity
• Stoma
• The site of the opening on the skin
• Ostomies in the digestive tract
• Gastrostomy, jejunostomy, duodenostomy, ileostomy,
or colostomy
• Ostomies in the urinary tract
• Ureterostomy, ileal or colonic conduit, cystostomy,
vesicostomy, and continent internal reservoir
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Indications and Preparation for
Ostomy Surgery
• Temporary ostomy
• May be indicated after surgery or trauma or when
there is severe inflammation or infection
• Bypasses the affected portion of the bowel or
urinary tract, giving it time to heal
• Permanent ostomy
• Necessitated by cancer of the bladder or colon or
severe inflammatory bowel disease
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Nursing Care of the Patient
Having Ostomy Surgery
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Assessment
• Determine expectations, understanding of the
procedure, information desired, and fears
• Health history: reason for the procedure
• The medical history documents other acute
and chronic conditions that will require
management before and after surgery
• Note drug therapy and allergies
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Interventions
• Anxiety
• Help the patient identify his or her concerns
• Appearance, job, or family life disruptions
• Encourage patients to talk and use coping
strategies that have been effective in the past
• Reduce anxiety before teaching
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Interventions
• Deficient Knowledge
• Basic ostomy care should be taught before surgery
• Patient’s responses and questions should guide you
as to how much detail is appropriate
• Preoperative teaching usually requires repetition
and reinforcement after surgery
• An important resource is a volunteer from the
American Cancer Society or the United Ostomy
Association
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Fecal Diversion
• Ileostomy
• An opening in the ileum
• Necessary when entire colon must be bypassed or
removed
• Require colon bypass: congenital defects, cancer,
inflammatory bowel disease, bowel trauma, and
familial conditions such as multiple polyposis
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Fecal Diversion
• Ileostomy
• Procedure
• A surgical incision is made in the abdomen
• A loop or the end of the ileum is brought out through a
second abdominal incision
• Edges of the loop or the end of the ileal segment are
everted and sutured to the abdominal skin to create a
stoma
• Loops may be supported with a device, such as a rod or
bridge, instead of being sutured to the skin
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Postoperative Nursing Care of the
Patient with an Ileostomy
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Assessment
• Health history
• Document significant symptoms such as pain,
anorexia, nausea, vomiting, weakness, thirst, and
muscle cramps
• Determine what stressors the patient perceives,
usual coping strategies, and sources of support
• Assess understanding of ileostomy care
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Assessment
• Physical examination
• Observe patient’s general status
• Level of consciousness, orientation, posture, and expression
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Vital signs and weight; compare with preoperative findings
Skin color, warmth, and turgor
Inspect oral tissues for moisture
Observe respiratory effort, and auscultate breath sounds
Assess the abdomen for distention and bowel sounds
Inspect the stoma for color and bleeding
Inspect the base of the stoma for redness, skin breakdown,
and purulent drainage
• Note the characteristics of draining fluid or fecal matter
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Interventions
• Risk for Deficient Fluid Volume
• Administer intravenous fluids as ordered; carefully monitor
hydration status
• Keep accurate intake and output records
• Measure output from all sources, including urine, gastric
contents, and fecal drainage
• Closely monitor serum electrolytes, and be alert for signs and
symptoms of imbalances
• Changes in mental status (confusion, anxiety), changes in
neuromuscular status (twitching, trembling, weakness), poor
tissue turgor, edema, and dry mucous membranes
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Interventions
• Impaired Skin Integrity
• Check the pouch hourly at first to detect leakage
• When pouch emptied or changed, prevent fecal
matter from contaminating the primary incision
• Clean skin around the stoma gently but thoroughly
• Maintain protective barrier to prevent skin
breakdown
• A plastic pouch is used to collect fecal drainage
• Remove the appliance for thorough cleansing of the
skin surrounding the stoma every 3 to 5 days
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Figure 26-1
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Interventions
• Disturbed Body Image
• Assure patient that odor is normal when the pouch
is being changed or emptied, but that it can be
controlled at other times
• Advise to delete and reintroduce various foods to
find those that are most troublesome
• Rinsing with a vinegar solution neutralizes odors
that cling to the pouch
• Odor-proof pouches and commercial pouch
deodorizers are available
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Interventions
• Sexual Dysfunction and/or Ineffective Sexuality
Patterns
• Encourage patients to ask questions about how the
ostomy might affect sexual function or behavior
• Practical suggestions may help resume sexual
activity
• Pouch should be emptied and taped down before
intercourse
• Covers available to conceal the appliance and its contents
• The partner wearing the pouch should experiment with
positions that are most comfortable
• Female patients should know that ostomy surgery does not
interfere with pregnancy or delivery
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Interventions
• Ineffective Therapeutic Regimen Management
• After surgery, some teaching should be included
every time stoma care is done
• At first, you may simply tell patient what is being done and
why
• Then encourage patient to take over more and more of the
procedure
• Have patient demonstrate and practice as much as
possible before discharge
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Continent (Pouch) Ileostomy
• Internal pouch created from loop of ileum for storing
fecal matter
• Advantage: patient does not have continuous drainage
and so does not have to wear a pouch
• Procedure
• A loop of the ileum is sutured together and then opened
• A portion of the distal end of the ileum is inverted within itself to
create a nipple valve
• The valve prevents fluid leakage from the pouch
• The looped section then closed, leaving a pouch capable of
expanding and storing fecal matter
• The distal end of the ileum is brought through the abdominal
wall and sutured into place to create a stoma
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Figure 26-2
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Postoperative Nursing Care of the
Patient with a Continent Ileostomy
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Assessment
• Essentially the same as that of the patient with
an ileostomy
• Assess for continuous drainage because
obstruction of the catheter may occur
• Absence of drainage or patient complaints of a
feeling of fullness in the pouch suggest
obstruction
• Drainage bloody at first, then brownish
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Interventions
• Risk for Injury
• Patient given only intravenous fluids to allow the
bowel to heal and peristalsis to resume
• For the first 2 weeks, the pouch is drained every 3
to 4 hours
• Next 2 weeks: interval is every 5 hours
• Eventually the patient will need to drain the pouch
only 2 to 4 times a day
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Interventions
• Deficient Knowledge
• Draining the continent ileostomy
• Have the patient sit or lie down for the procedure
• Gather lubricant, #28 catheter, drape, basin, irrigating
syringe, irrigating solution, gauze dressing
• Lubricate catheter and insert it gently into the stoma
• Resistance will be felt when the catheter reaches the
nipple valve (approximately 2 inches past the stoma)
• Instruct patient to bear down, then roll the catheter
between your fingers and advance it into the pouch
• When catheter in the pouch, gas and fecal matter begin to
drain
• Drainage continues for approximately 10 minutes and
produces a total volume of 50 to 200 mL
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Interventions
• Draining the continent ileostomy
• If the drainage is too thick, instill 30 mL of normal saline as
ordered; gently aspirate
• Do not do this unless necessary because it may cause dislocation
of the nipple
• When drainage stops, quickly remove the catheter
• Place gauze dressing over the stoma to absorb
secretions
• Measure, describe, and discard the drainage
• Show patient how to perform procedure as soon as
possible
• Patient should wear a medical alert bracelet stating
he or she has a continent diversion that must be
drained
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Ileoanal Reservoir
• Fecal matter is stored and then eliminated
through the rectum
• Procedure
• First stage
• Colon is removed and an internal pouch that is created
from the ileum is attached to the anorectal canal
• Temporary ileostomy made to allow the reservoir to heal
• Second stage
• Approximately 2 months later, barium radiographs are
taken to be sure that the reservoir is intact
• If the reservoir does not leak, the ileostomy is closed
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Figure 26-3
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Ileoanal Reservoir
• Complications
• Obstruction
• Scar tissue or strictures may cause obstruction
• Signs and symptoms: abdominal distention, nausea and vomiting,
decreased bowel sounds, change in bowel pattern
• Peritonitis
• If fecal matter leaks through the suture lines of the reservoir into
abdominal cavity, abscesses or peritonitis can develop
• Signs and symptoms: increased pulse, respirations, and
temperature; rigid abdomen and abdominal pain; and elevated
white blood cell count
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Inflammation
• Manifested by bloody diarrhea, anorexia, and pain
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Postoperative Nursing Care of the
Patient with an Ileoanal Reservoir
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Assessment
• Same as for the patient with an ileostomy
• In addition, assess for rectal drainage and
condition of the perianal skin
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Interventions
• Risk for Impaired Skin Integrity
• Skin around the ileostomy stoma and in the perianal
area needs special care
• Until reservoir is well healed, liquid discharge may
be expelled without warning
• Thorough, gentle cleansing and protective creams
help prevent skin breakdown
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Interventions
• Bowel Incontinence
• Perineal pads to prevent soiling of clothing
• Teach perineal muscle-strengthening exercises
• Drugs prescribed to decrease the frequency of
stools and to make them less watery
• Advise to avoid fatty foods at first
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Interventions
• Risk for Injury
• Assess for signs and symptoms of bowel
obstruction, peritonitis, and inflammation
• If obstruction occurs, give intravenous fluids and
nothing by mouth
• Nasogastric tube inserted to decompress the bowel
• If obstruction is caused by adhesions (scar tissue), surgery
may be necessary to release the restriction
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Colostomy
• Opening in the colon through which fecal
matter is eliminated
• Procedure
• Bringing a loop or an end of the intestine through
the abdominal wall and creating a stoma for the
passage of fecal matter
• Location of the stoma depends on the portion of the
intestine removed
• Classified by location in the colon: ascending, transverse,
descending, and sigmoid colostomies
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Colostomy
• Temporary colostomy
• Allows healing of the intestine after surgery or in
certain disease states
• Permanent colostomy
• Removal of a large part of colon or the rectum
required
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Postoperative Nursing Care of the
Patient with a Colostomy
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Interventions
• Ineffective Therapeutic Regimen Management
• Irrigations
• No longer routinely recommended
• Many patients have regular bowel movements without
irrigation
• Unlikely to establish control if the patient has diarrhea
when under stress, has had radiotherapy, has a poor
prognosis, or has a history of inflammatory bowel disease
• Complications: perforated bowel; fluid and electrolyte
imbalances; cramping, nausea, and dizziness
• If irrigations are indicated, you or the ET may
perform them initially while teaching patient or
significant other
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Interventions
• Risk for Injury
• Assess for indications of colostomy complications
• Prolapsed stoma
• Obstruction
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Urinary Diversion:
Cutaneous Ureterostomy
• One or both ureters are brought out through an
opening in the abdomen or flank
• Often the two ureters are joined surgically so
that only one stoma is needed
• Sometimes a stoma is created from each
ureter
• Much smaller than an intestinal stoma
• Urine drains from the stoma continuously
• Pouch needed to collect the urine and protect the
skin
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Urinary Diversion:
Cutaneous Ureterostomy
• Complications
• Stenosis
• Narrowing of the opening that interferes with the flow of
urine
• If the obstruction is not relieved, urine backs up in the
kidney and may cause hydronephrosis
• Urinary tract infections
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Postoperative Nursing Care of the
Patient with a Cutaneous
Ureterostomy
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Assessment
• Health history
• Assess for flank or abdominal pain, fatigue, malaise,
and chills
• Determine patient’s response to the ostomy,
knowledge of it, and readiness to learn
• Determine the reason for ureterostomy as well as
pertinent past medical history, drug profile, and
allergies
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Assessment
• Physical examination
• Assess patient’s general state
• Take vital signs and compare with preoperative
readings
• Observe respiratory effort and auscultate breath
sounds. Assess the abdomen for distention and
bowel sounds
• Inspect the stoma
• Document amount, appearance, and odor of the
urine
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Interventions
• Impaired Skin Integrity
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Apply an appliance to collect urine drainage
Use skin barrier around the stoma
Pouch is usually cleaned once or twice daily
Changed every 4 to 6 days or when it leaks
because frequent changes are irritating to the
surrounding skin
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Figure 26-1
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Figure 26-6
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Interventions
• Risk for Infection
• The stoma serves as a portal for pathogens to enter
the urinary tract, causing infection
• Avoid introducing organisms to the area
• Yeast infections can develop; characterized by a
skin rash surrounding the stoma
• Treat with nystatin powder applied under the skin barrier
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Interventions
• Risk for Injury
• If urine does not flow readily, suspect obstruction
and notify the registered nurse or the surgeon
immediately
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Interventions
• Disturbed Body Image
• Demonstrate acceptance of the patient and care for
the stoma in a matter-of-fact manner
• Express understanding of patient’s feelings
• Encourage normal grooming and dressing
• Provide opportunities to ask questions or discuss
how the ostomy might affect sexual function or
behavior
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Interventions
• Self-Care Deficit
• Teaching plan should include
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Ostomy care
Pouches
Diet
Fluids
Activity
Sexuality
Complications
Resources
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Ileal Conduit
• Procedure
• Urinary drainage system made from portion of small
intestine
• A 6- to 8-inch segment of ileum is first removed
• The remaining ends of the ileum are then
anastomosed (joined) to restore bowel function
• The ureters are cut from the bladder and attached to
the ileal segment at an angle to prevent reflux
• One end of the ileal segment is sutured closed. The
other end is brought through an abdominal incision
and sutured to create a stoma for urine drainage
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Ileal Conduit
• Complications
• Leakage of the anastomosed ureters and intestinal
segments
• Ureteral obstruction
• Separation of the stoma from surrounding skin
• Wound infection
• Necrosis of the stoma
• Paralytic ileus
• Crystal formation and calculi
• Stoma retraction, prolapse, or hernia
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Postoperative Nursing Care of the
Patient with an Ileal Conduit
• Basically same as for patient with an ileostomy
• A few special points to make about the ileal conduit
• Patient will have a nasogastric tube attached to suction to
prevent abdominal distention and stress on the resected
portion of the ileum while it heals
• Allowed nothing by mouth and is given intravenous fluids until
bowel sounds return
• Ureteral catheter or stent may be in place to drain urine
• Attach the pouch to a collection device during the night
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Continent Internal Reservoirs
• Allows for the storage and controlled drainage
of urine
• Ileum neobladder
• Eliminates the need for a stoma
• Internal urinary reservoir constructed using a
resected segment of the colon that is attached to
the urethra
• Urine drains into the reservoir and is eliminated
through the urethra
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Continent Internal Reservoirs
• Kock pouch
• Constructed with a segment of ileum
• Ureters implanted in one side of the ileum segment
• Nipple valve is constructed from the other side and
attached to the skin, where a stoma is created
• Valve prevents urine from flowing from the reservoir
• Catheter drains reservoir at 4- to 6-hour intervals
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Continent Internal Reservoirs
• Indiana pouch
• Similar to the Kock pouch except that it is made of a
portion of the terminal ileum and the ascending
colon
• The reservoir is larger than that of the Kock pouch
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Postoperative Nursing Care of the
Patient with a Kock or Indiana Pouch
• May have Penrose drain to remove fluid from operative site
and clear tube in place for continuous urine drainage
• Irrigations may be ordered to remove clots and mucus
• When the tube is removed, the pouch may be drained
every 2 to 3 hours at first
• Later, may need to drain the pouch only every 4 to 6 hours
during the day and once during the night
• If pouch functions properly, the patient does not have to
wear an external appliance
• Gauze dressing over stoma to absorb mucus drainage
• Advise medical alert bracelet: identifies presence of a
continent device that needs intubation to drain
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Ureterosigmoidostomy and
Ureteroileosigmoidostomy
• Ureterosigmoidostomy
• The ureters are implanted into the sigmoid colon
• Urine drains into the colon and is eliminated through
the rectum
• Ureteroileosigmoidostomy
• A segment of the ileum is anastomosed to the sigmoid and
the ureters implanted into that part of the ileum
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Vesicostomy
• Vesicostomy or cystostomy
• An opening into the urinary bladder
• Some are drained continuously through a catheter,
others have a nipple valve and are drained at
intervals
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Nephrostomy
• Diverts urine directly from the kidney through a
tube that exits through the skin
• May be used as a temporary or permanent
method of urinary diversion
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