Colostomy

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Psychic preparation of the patient for the necessity of colostomy is a long first step toward his adjustment to living with an artificial anus. Proper surgical placement of the outlet will ease care of the bowel. Control of fecal consistency and peristaltic rate should ideally produce constipation responsive only to habit or enemata. The object of the enema is to produce an evacuation thorough enough to prevent soiling for a day or two. The object of dietary variations is to produce a manageable volume and consistency of fecal stream. The technique of enemas and choice of diet can be individualized when the underlying principles are understood. Reasons for Performing a Colostomy 

When feces cannot progress naturally from the colon to the anus



When it is more desirable or manageable to divert the feces, as for paraplegics



In any condition where the rectum or anus is nonfunctional because of disease, a birth defect or a traumatic condition.



It is performed to divert the fecal flow away from an area of inflammation or around an operative area

General Procedure for Changing an Ostomy Pouch Assessment 1. Identify the type of ostomy the patient has and its location (Bowel Urinary Diversion) 2. Assess the skin integrity around the stoma and as general appearance 3. Note the amount and character of any fecal material or urine in the pouch 4. Determine whether the patient is being taught self-care at the moment Planning 1. Wash your hands 2. Gather the equipment needed in changing a pouch or dressing 

Cleansing supplies including tissues, warm water, mild soap, wash cloth and a towel



Clean pouch of the type currently being used



Seal or use tape to prevent leakage



Clean belt



Dressing materials



Receptacle for the soiled pouch or dressing (bedpan, paper bag/newspaper for wrapping)



Protective spray



Clean gloves

1. Determine whether the patient is to participate actively 2. Choose the appropriate location in performing the procedure (bathroom/ bedside) Implementation 1. Identify the patient 2. Explain the procedure to the patient 3. Put on clean gloves for infection 4. Assist the patient to the bathroom or provide privacy 5. Remove the soiled dressing 6. Using warm water and a mild soap, cleanse the skin around the stoma thoroughly. Inspect the skin for redness or irritation. 7. Cover the stoma with a tissue to prevent feces or urine from contacting. Change tissues as necessary during the procedure

8. Dry the skin around the stoma carefully, patting gently 9. Apply a skin protective spray if needed 10. Allow the skin to dry thoroughly so the pouch will adhere firmly (a hair dryer on a low setting at least 18 inches from the skin may be used) 11. Remove the tissue from the stoma and apply the clean pouch or dressing 12. Remove gloves and wash hands Evaluation 1. Evaluate using the following criteria 

Pouch or dressing secure



Area clean



Odor free



Patient comfortable



If the patient is being taught the procedure, add the following criteria: 

Patient is able to change pouch using correct technique



Patient verbalizes understanding of key points in care

Documentation 1. Record the following information: 

The amount, color, and consistency of the fecal material or urine in the pouch



The application of the clean pouch and dressing change



The knowledge and ability of the patient t participate in the procedure or ability to change independently. 

Definition



A colostomy is a surgically created opening in the abdominal wall through which digested food passes. It may be temporary or permanent. The opening is called a stoma from the Greek word meaning mouth. Stool passes through the stoma into a pouch attached to the stoma on the outside of the abdomen. The pouch, stoma, and skin surrounding the stoma require care and maintenance by the patient or caregiver.



Purpose



A pouch is worn over a colostomy to collect the stool passed through the stoma. There are a variety of pouches available for use with a colostomy. Over time the patient can determine which pouch type best suits his or her needs. A colostomy pouch is normally emptied one or more times daily. The pouch itself usually needs to be changed every four to six days. The stoma and surrounding skin need to be kept clean and sanitary.



Precautions



The nurse attending to a colostomy should wash his or her hands before and after the procedure, as well as wear latex gloves while performing care.



Description



A pouching system is normally worn over a colostomy stoma. Pouches can be obtained from several different manufacturers in both disposable and reusable varieties. The enterostomal therapy ET nurse can be an invaluable resource when helping patients select a pouch system.



Colostomy pouches may be either open ended or closed. Open-ended pouches require a clamp for closure. They can be drained simply and reused after they are emptied. Closed pouches are sealed at the bottom and are usually used by patients who irrigate their colostomies or who have a regular bowel elimination pattern. Two-

piece pouch systems consist of a separate flange and pouch. The pouch has a closing ring that attaches to a matching piece on the flange. One-piece systems have a connected wafer and pouch that do not separate. The portion of the pouch that is applied to the abdomen is called a skin barrier wafer. Both two-piece and onepiece systems can be either closed or open ended. 

Some patients with colostomies can irrigate their stomas using a procedure similar to an enema. This cleans the stool out of the colon through the stoma. A special irrigation system is used. Sometimes a special lubricant is used to prepare for the irrigation. Irrigating often leads to increased control over the timing of bowel movements.



Removing the colostomy appliance requires gently pushing away the skin surrounding the stoma and pulling the appliance downwards. Adhesive remover wipes are available to help in the removal of the wafer. The bag is then discarded in an appropriate waste container. The stoma should be cleaned with lukewarm water and dried with a soft towel. The stoma and surrounding skin should be assessed. The stoma should be pink or red and moist- looking, and may bleed slightly when cleansed. The stoma normally decreases in size slightly during the first weeks after surgery.



The opening in the wafer should fit snugly around the stoma. An opening that is too large will allow intestinal contents to leak onto the skin. Measuring guides come with the colostomy wafers so that the hole can be cut to the proper size. Skin barrier paste can be used to help create a better seal between the wafer and the patient's abdomen. Various skin preparation products are



also available to help protect the skin under the wafer and around the stoma. They also aid in the adhesion of the wafer. Using the fingertips, gentle pressure should be applied to put the wafer in place.



After the application of the barrier, the bag should be applied (if it is a two-piece system). If it is an open system, apply a clamp to the bottom of the new pouch.



Preparation



The nurse should instruct the patient and caregiver(s) about the procedure before it is performed. Many people feel anxious and nervous when first dealing with an ostomy. Encourage the patient to ask questions, and explain all steps as they are performed.



Aftercare



The nurse should assess the patient's tolerance of the procedure and response to teaching or education about the appliance.



Health care team roles



Although most members of the health care team will come into contact with patients having ostomies, it is the nurse who has the responsibility for providing ostomy care and instructing the patient and/or caregiver how to provide care independently. An enterostomal therapy (ET) nurse is specially educated in all aspects of ostomy care.

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KEY TERMS

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Stoma—Surgically constructed mouth or passage between the intestine and the outside of the patient's body.

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