Nursing Diagnoses Related to Colostomy Care

Several nursing diagnoses may be relevant for patients with a colostomy, including:

1. Impaired Comfort: Related to the surgical incision, as evidenced by:

   • Verbal reports of pain at the incision site.

   • Facial grimacing or guarding behaviors.

   • Elevated pain scores.

   • Difficulty moving or walking.

   • Restlessness or anxiety due to pain.

2. Risk for Impaired Skin Integrity: Related to the presence of the stoma and contact with effluent, as evidenced by:

   • Redness, swelling, or irritation around the stoma.

   • Skin breakdown, such as abrasions or ulcers.

   • Complaints of discomfort or itching.

   • Leakage or drainage from the stoma.

3. Disturbed Body Image: Related to the altered body appearance and function, as evidenced by:

   • Expressing negative feelings or self-consciousness about the stoma.

   • Avoiding social situations.

   • Difficulty looking at or touching the stoma.

   • Statements indicating feelings of being unattractive or different.

4. Deficient Knowledge: Related to stoma care and lack of prior experience, as evidenced by:

   • Frequent questions about stoma care.

   • Incorrect demonstration of care techniques.

   • Expressing anxiety or fear about managing the stoma.

   • Lack of confidence in self-care.

Nursing Considerations in Colostomy Care

Stoma Assessment:

• Color: The stoma should be a healthy pink or red color. A dusky blue color suggests ischemia (inadequate blood supply), while a brown-black color indicates necrosis (tissue death). Assess stoma color at least every 8 hours.

• Edema: Mild to moderate swelling is expected in the first 2-3 weeks post-surgery. Severe swelling could indicate an obstruction, allergic reaction, or gastroenteritis.

• Bleeding: A small amount of oozing when the stoma is touched is normal due to its high vascularity. Moderate to large amounts of bleeding could indicate a bleeding disorder, gastrointestinal bleeding, or other issues.

Skin Protection:

• Hygiene: Cleanse the peristomal skin with mild soap and warm water, then dry it thoroughly before applying a new skin barrier.

• Skin Barriers: Use skin barriers such as petroleum jelly gauze or protective ointments around the stoma to prevent irritation. Ensure the skin under the barrier is regularly assessed for integrity.

Pouch Management:

• Changing Supplies: Provide the patient with necessary supplies for changing the pouch.

• Waterproofing: Pouching systems are waterproof, allowing patients to bathe or swim with them in place. However, patients with colostomies can shower without a pouch, but those with ileostomies should avoid doing so because of their frequent, unpredictable output.

• Selection: Choose a transparent, odor-proof plastic pouch with an appropriate-sized opening that fits snugly around the stoma without touching it. Ensure the pouch has a drainage valve or can be easily changed.

• Emptying and Changing: Empty the pouch when it is 1/3 full to prevent leakage. Record the volume, color, and consistency of the drainage each time the pouch is changed. Observe the skin for irritation.

Dietary Considerations:

• Initial Diet: For the first month, a low-fiber diet is recommended.

• Long-Term Diet: After one month, a regular diet is usually tolerated.

• Ileostomy Diet: Patients with ileostomies need to be cautious of foods that can cause blockage (e.g., popcorn, nuts, certain vegetables, tough meats).

• Hydration: Encourage fluid intake of at least 3 liters per day (unless contraindicated) to prevent dehydration, especially in hot weather or with diarrhea.

Activity:

• Heavy Lifting: Avoid heavy lifting for 6-8 weeks after surgery to prevent hernias.

• Clothing: Loose-fitting clothing is often preferred initially. Avoid tight belts over the stoma.

Patient and Family Education:

• Pouch Management: Teach the patient how to apply, change, and empty the pouch.

• Skin and Stoma Care: Educate on proper skin care, odor control, and stoma assessment.

• Dietary Guidance: Provide information on appropriate foods and the importance of hydration.

• Obtaining Supplies: Provide information on where to obtain ostomy supplies.

• Follow-Up Care: Emphasize the importance of regular follow-up appointments and when to report complications (e.g., changes in stoma appearance or function, fever, diarrhea, skin irritation).

Colostomy Irrigation:

• May be used to regulate bowel movements or treat constipation. It involves instilling lukewarm water (500-1000 ml) into the stoma using a soft catheter. Do not force the catheter if resistance is felt.

Managing Odor and Gas:

• Dietary Modifications: Identify and limit foods that cause excessive odor (e.g., eggs, onions, fish, cabbage, alcohol) or gas (e.g., beans, onions, cabbage, beer, carbonated beverages).

• Diarrhea: Avoid foods that may worsen diarrhea (e.g., alcohol, spinach, green beans, coffee, spicy foods, raw fruits).

Psychosocial Adaptation:

• Emotional Support: Provide emotional support and encourage the patient to express their feelings about the colostomy.

• Gradual Acceptance: Encourage the patient to gradually participate in their stoma care, but do not force them before they are ready.

• Cleanliness and Odor Control: Maintain a clean and odor-free environment to minimize the patient’s distress.

• Social and Sexual Concerns: Address concerns about social interactions, clothing, sexual activity, sleep, and body image. Encourage open communication with partners and provide resources for support.

• Pregnancy: Reassure patients that pregnancy is possible with a colostomy, but the number of pregnancies may need to be limited.

Nursing Care Guidelines

• Gentle and Professional Approach: Treat the patient with empathy and maintain a professional demeanor.

• Regular Stoma Assessment: Monitor the stoma for any changes in color, size, or appearance.

• Maintain Cleanliness: Change soiled appliances, dressings, or linens promptly.

• Monitor for Undissolved Medications: Check for undissolved medications in the ileostomy pouch, as this may indicate absorption problems.

• Skin Protection: Apply skin barriers and provide appropriate skin care around the stoma.

• Careful Cleaning: Cleanse the healed stoma with mild soap and water. Avoid alcohol, and discontinue soap if irritation occurs. Consult a healthcare provider if redness or yeast-like growth appears.

• Patient Education: Teach the patient how to manage their ostomy independently, including appliance changes and what to monitor and report.

• Emotional Support: Allow the patient to express their feelings, answer questions, and address misconceptions.

Abnormal and Danger Signs in a Stoma

• Unusual Noises: Report any abnormal sounds emanating from the stoma.

• Excessive Bleeding: Report any significant bleeding from the stoma.

• Color Changes: Report darkening (indicating stenosis or compromised blood supply) or bleaching/extreme lightening (indicating poor circulation).

• Stoma Drying: The stoma should remain moist; report any signs of drying.

• Signs of Infection: Report any redness, swelling, or discharge around the stoma.

• Stoma Edema: Report any swelling, which could indicate an obstruction or other complication.

Routine Observations

• Appliance Fit: Ensure the appliance fits correctly to prevent leakage and maintain circulation.

• Daily Weight: Monitor the patient’s weight for fluctuations that may indicate fluid or nutritional imbalances.

• Electrolyte Balance: Regularly review blood test results to monitor electrolyte levels.

• Stool Assessment: Record the amount and characteristics of stool to identify any changes or problems.

• Vital Signs: Monitor vital signs regularly to detect early signs of complications

Complications of Colostomy

Complications associated with a colostomy can be broadly categorized as follows:

1. Surgical Complications:

• Wound Infection: Bacterial contamination of the surgical wound, potentially causing pain, inflammation, and delayed healing.

• Hemorrhage: Bleeding from the surgical site, requiring medical intervention.

• Parastomal Hernia: Protrusion of abdominal contents through a weakness in the abdominal wall near the stoma.

2. Stoma-Related Complications:

• Stenosis: Narrowing of the stoma opening, potentially obstructing stool passage.

• Prolapse: Protrusion of the stoma beyond the desired level, which can cause discomfort and pouching difficulties.

• Retraction: Sinking or receding of the stoma below the skin surface, making pouch application challenging.

• Necrosis: Tissue death of the stoma, often due to inadequate blood supply, requiring urgent surgical intervention.

3. Skin Issues:

• Irritation and Breakdown: Skin irritation, inflammation, and potential ulceration around the stoma (peristomal skin) due to prolonged contact with fecal matter.

• Infection: Bacterial or fungal infections of the peristomal skin.

4. Other Complications

• Bleeding: While some minor bleeding from the stoma is normal, excessive bleeding may indicate a problem like trauma or infection.

• Obstruction: Blockage of the colostomy, hindering the passage of stool.

5. Fluid and Electrolyte Imbalance:

• Dehydration: Increased risk of fluid loss through the stoma, particularly with high-output stomas.

• Electrolyte Imbalance: Potential loss of electrolytes, especially with significant fluid loss.

6. Psychosocial and Nutritional Issues:

• Psychosocial Impact: Potential for body image issues, anxiety, and depression related to living with a stoma.

• Nutritional Deficiencies: Possible impaired nutrient absorption, leading to deficiencies.