colostomy types , indications management and care

colostomy types , preparation of patient, post operative care

1. Colostomy and ileostomy care

2. Ostomy An ostomy is a surgically created opening on the abdomen that allows the discharge of body waste when the normal elimination route is no longer possible. The outermost part that is visible is a stoma. The stoma is the result of the large or small bowel being brought to the outside of the abdomen and sutured in place. When a stoma is created as a fecal diversion, feces will drain through the stoma instead of the anus

3. Indications Ileostomy Intestinal obstruction due to benign and malignant disease Perforation peritonitis Ulcerative colitis, or Crohn's disease Mesenteric ischemia. Colostomy   Intestinal obstruction with associated inflammation Diverticulitis Carcinoma colon,rectum

4. Types Ostomies are named according to their location and type. An ostomy in the ileum is an ileostomy. An ostomy in the colon is a colostomy.

5. Ostomies may be temporary or permanent. Permanent ostomies may be continent or traditional.

6. Permanent colostomy Continent ileostomies Koch pouch Barnett Continent Ileal Reservoir( use 40 to 45 cm of the terminal ileum to fashion an internal pouch, nipple valve, and abdominal stoma) Traditional ostomies End stoma Double barreled stoma Loop ostomy .

7. End Stoma An end stoma is made by dividing the bowel and bringing out the proximal end as a single stoma, making a colostomy or ileostomy. The distal part of the GI tract is surgically removed or the distal segment is oversewn and left in the abdominal cavity with its mesentery intact. If the distal bowel is removed, the stoma is permanent. When the distal bowel is oversewn and not removed, the procedure is called a Hartmann’s pouch

8. Loop Stoma A loop stoma is made by bringing a loop of bowel to the abdominal surface and then opening the anterior wall of the bowel to provide fecal diversion. This results in 1 stoma with a proximal opening for feces and a distal opening for mucus drainage from the distal colon. A plastic rod holds the loop of bowel in place for 7 to 10 days after surgery to prevent it from slipping back into the abdominal cavity.

9. Loop stoma

10. Double- Barreled Stoma To create a double-barreled stoma,the bowel is divided and both the proximal and distal ends are brought through the abdominal wall as 2 separate stomas . The proximal stoma is the functioning stoma. The distal, nonfunctioning stoma is a mucus fistula. A double-barreled stoma is usually temporary.

11. Ileoanal Pouch Anastomosis For clients who need to have colectomy for treatment of ulcerative colitis Colon is removed, pouch is created from the end of small intestine and attached to the anus. Pouch provides collection of waste material , similar to rectum. Stool is evacuated by anus. When ileal pouch is created temporary ileostomy to allow anastomosis to heal.

12. Kock continent ileostomy Created in small intestine Detubularising its cylindrical shape and creating spherical reservoir. The pouch has a continent stoma, nipple type of valve that is drained with external catheter which is placed intermittently on stoma. Used in treatment of ulcerative colitis

13. Preoperative Care Selection of a flat site on the abdomen that allows secure attachment of collection bag Selection of stoma site that will clearly visible to the patient Criteria for selection of site include it should lie within the rectus muscle is a flat crease-free surface Stoma placed outside rectus muscle increase the chance of developing hernia.

14. Bowel preparation : Empty the intestine before surgery to decrease chance of infection caused by bacteria in feces. Psychologic preparation and emotional support are particularly important as the person begins to cope with potential changes in body image and elimination. The patient and caregiver should understand the extent of surgery planned. It is normal for the patient and caregiver to have questions concerning the procedures. Provide the patient opportunities to share concerns and questions.

15. Providing Postoperative Care Pain management during the immediate postoperative period. Monitor the patient for complications Leakage from the site of the anastomosis Prolapse of the stoma Perforation, stoma retraction, Fecal impaction Skin irritation Pulmonary complications associated with abdominal surgery.

16. Assess the abdomen for returning peristalsis and assesses the initial stool characteristics. Help patients with a colostomy out of bed on the first postoperative day and encourage them to begin participating in managing the colostomy

17. Managing nutrition The diet is individualized as long as it is well balanced and does not cause diarrhea or constipation. The return to normal diet is rapid. A complete nutritional assessment is important for patients with a colostomy. The patient avoids foods that cause excessive odor and gas, including foods in the cabbage family, eggs, fish, beans, and high-cellulose products such as peanuts. Determine whether the elimination of specific foods is causing any nutritional deficiency. Help the patient identify any foods or fluids that may be causing diarrhea, such as fruits, high-fiber foods, soda, coffee, tea, or carbonated beverages. For constipation, prune or apple juice or a mild laxative is effective. Encourage fluid intake of at least 2 L of fluid per day

18. Providing Wound Care Frequently examine the abdominal dressing during the first 24 hours after surgery to detect signs of hemorrhage. It is important to help the patient splint the abdominal incision during coughing and deep breathing to lessen tension on the edges of the incision. Monitor temperature, pulse, and respiratory rate for elevations, which may indicate an infectious process. If the patient has a colostomy, the stoma is examined for swelling (slight edema from surgical manipulation is normal), color (a healthy stoma is pink or red), discharge (a small amount of oozing is normal), and bleeding (an abnormal sign).

19. Irrigating The Colostomy A stoma does not have voluntary muscular control and may empty at irregular intervals. Regulating the passage of fecal material is achieved by irrigating the colostomy or allowing the bowel to evacuate naturally without irrigations. The choice often depends on the individual and the type of the colostomy. By irrigating the stoma at a regular time, there is less gas and retention of the irrigant . The time for irrigating the colostomy should be consistent with the schedule the person will follow after leaving the hospital

20. Supporting A Positive Body Image The patient is encouraged to verbalize feelings and concerns about altered body image and to discuss the surgery and the stoma (if one was created). A supportive environment and a supportive attitude on the nurse’s part are crucial in promoting the patient’s adaptation to the changes brought about by the surgery.

21. Assess the wound regularly and record bleeding, excess drainage, and unusual odor. Monitor for edema, erythema, and drainage around the suture line, as well as fever and a high WBC count. Observe the skin around any drains for signs of inflammation. Keep the area around the drain clean and dry.

22. If an ostomy is present, assess the stoma and place a clear pouching system that protects the skin and contains drainage and odor. The stoma should be rosy pink to red and mildly swollen A dusky blue stoma indicates ischemia; a brown-black stoma indicates necrosis. Assess and document stoma color every 4 hours and ensure that there is no excess bleeding. Report any sustained color changes or bleeding to the HCP. Edema will resolve over the first 6 weeks.

23. Complications Delayed wound healing Hemorrhage Fistulas Infections

24. The colostomy starts functioning when peristalsis returns. Record the volume, color, and consistency of the drainage. When a colostomy is done on a colon that was not cleaned out before surgery, stool will drain when peristalsis returns. If the bowel was cleansed preoperatively, it will not begin producing stool until a few days after the patient is eating again

25. Excessive amounts of gas are common during the first 2 weeks. Because this can be distressing to patients, assure them this is temporary

26. In the first 24 to 48 hours after surgery, the amount of drainage from an ileostomy may be negligible. When peristalsis returns, ileostomy output may be as high as 1500 to 1800 mL/24 hr. If the small bowel is shortened by surgery, drainage may be greater.

27. After intraoperative manipulation of the anal canal, transient incontinence of mucus may occur. Have the patient start Kegel exercises about 4 weeks after surgery to strengthen the pelvic floor and sphincter muscles Perianal skin care is important to protect the epidermis from mucous drainage and maceration. Teach the patient to gently clean the skin with a mild cleanser, rinse well, and dry thoroughly.