Ileostomy and Colostomy Care

Bowel Diversion Methods

• Ileostomies and colostomies are bowel diversion methods.
• Digestion occurs in the duodenum and jejunum after the stomach.
• Bile from the liver helps dissolve fats.
• Dumping syndrome occurs when food moves too fast from the stomach to the intestines, causing diarrhea.

Assessment: Ileostomy or Colostomy

• Assess stoma appearance (color, size, shape).
• Assess skin condition around the stoma.
• Assess stool output (amount, consistency, color).
• Assess for signs of complications (infection, blockage, dehydration).

Normal Stoma Findings

• Stoma is pink to red and moist.
• It may be swollen at first but shrinks in a few weeks.
• Stoma is round or oval, slightly raised.

Normal Output (Stool Consistency)

• Ileostomy (small intestine): Liquid to pasty, frequent output.
• Colostomy (large intestine): More formed stool, depending on location.
• Skin around the stoma is intact without redness or breakdown, slight redness from adhesive is normal.
• Patient reports no significant pain or burning around the stoma.

Abnormal Stoma Findings

• Pale, blue, or black stoma indicates poor blood supply.
• Severe swelling or bleeding is abnormal.
• A sudden decrease or no stool output suggests a possible blockage.
• Watery, high-output ileostomy indicates a risk of dehydration.
• A red, raw, or weepy skin indicates skin irritation from leakage.
• Rashes or breakdown indicate poor fit or allergic reaction.

I&O Documentation and Calculation

Inputs

• IV fluids, GI tube feedings, flushes, and subcutaneous fluids are inputs.
• All fluids and foods liquid at room temperature (e.g., ice cream, Jell-O) are inputs.
• Measure with facility’s standard volumes (e.g., milk carton = 240 mL).
• Small sips of water, liquid medications, and water taken with pills are inputs.

Outputs

• Urine, vomit, diarrhea, wound drainage, suction drainage, and ostomy output are all outputs.
• Measure and record ostomy output separately in mL.
• Use calibrated measuring devices (graduated containers, urine collection devices).
• Estimate output if soaked into bed linens or diapers.
• Note heavy sweating and hyperventilation.

Considerations for lleostomy Patients

• Ileostomy patients are at high risk of dehydration due to frequent liquid stool loss.
• Patients with ostomy output over 1,500 mL/day may need fluid and electrolyte replacement.
• A sudden decrease in output could indicate bowel obstruction.

Nasogastric Tube (NGT) Decompression

• NG tubes remove gas and fluid from the stomach, preventing nausea, vomiting, and aspiration.
• They can be used for bowel obstruction (higher up) and post-op.

Complications of NGT Decompression

• Tube misplacement can cause aspiration pneumonia.
• Mucosal irritation or ulceration and sinusitis or throat irritation can result from prolonged placement.
• Electrolyte imbalances can occur due to excessive gastric drainage.

Nursing Assessment for NGT Decompression

• Monitor tube function.
• Check skin integrity.
• Assess for signs of complications like abdominal distention and nausea.

Confirming NGT Placement

• Methods to confirm NGT placement are radiographic examination, measurement of tube length, measurement of tube marking, measurement of aspirate pH, and monitoring of carbon dioxide.

Gastric Route Feedings Assessment (Normal)

• Patient tolerates feedings without nausea, vomiting, or diarrhea.
• There are no signs of aspiration.
• Residual volumes are within acceptable limits (often <250-500 mL).

Gastric Route Feedings Assessment (Abnormal)

• High gastric residual volumes indicate delayed gastric emptying.
• Nausea, vomiting, or abdominal distension may indicate possible obstruction or intolerance.
• Diarrhea or cramping may indicate formula intolerance or too rapid infusion.
• Aspiration signs indicate risk of pneumonia.

Feeding Tube Documentation

• Document: feeding type, rate, and time given.
• Document: how much the patient tolerated.
• Document: gastric residual volumes (if checked).
• Document: water flushes and intake/output balance.

Calculations for Documentation

• Calculate total fluid intake per shift.
• Calculate total output.
• Compare intake vs. output to detect imbalances.

Feeding Tube Assessment

• Confirm placement with an X-ray (initial placement) before using the tube.

Ongoing Checks for Tubes

• Check pH of stomach contents (should be ≤5 for gastric tubes).
• Aspirate gastric contents to confirm placement.
• Never rely on the "air whoosh" method because it is not safe.

Correct Usage & Maintenance of Tube

• Elevate HOB to 30-45° to prevent aspiration.
• Flush with water before and after feedings/medications.
• Monitor for complications, such as blockage, skin irritation, and signs of infection.

Factors Leading to Poor Nutrition

• Physical Factors: Illness, chronic conditions, and medications affect appetite or digestion.
• Psychosocial Factors: Depression, anxiety, social isolation, financial constraints, and lack of access to nutritious food.
• Environmental Factors: Limited access to grocery stores, food deserts, or inadequate food preparation facilities.
• Age-Related Factors: Older adults may experience changes in metabolism, appetite, and taste, leading to inadequate nutrition.

Barriers to Safe Swallowing (Dysphagia)

• Neurological conditions (e.g., stroke, Parkinson's disease) are a barrier.
• Structural issues (e.g., tumors, esophageal narrowing) are a barrier.
• Cognitive issues (e.g., dementia) are a barrier.

Interventions for Dysphagia

• Positioning: Keep the patient upright during meals to reduce the risk of aspiration.
• Diet Modification: Offer thickened liquids and soft foods to make swallowing easier.
• Swallowing Therapy: Refer to a speech therapist for exercises to improve swallowing ability.
• Monitoring: Regularly assess swallowing function and signs of aspiration pneumonia.

Complications Related to Poor Nutrition

• Impaired Immune Function: Malnutrition can weaken the immune system.
• Delayed Wound Healing: Insufficient nutrients can delay recovery.
• Muscle Wasting: Chronic poor nutrition can lead to muscle loss and weakness.
• Organ Dysfunction: Malnutrition can lead to liver/kidney issues.
• Anemia: Lack of iron, folate, or vitamin B12 can cause anemia.

Solutions to Poor Nutrition

Nutritional Support

• Enteral Nutrition (Tube Feeding) is for patients who cannot consume food orally.
• Parenteral Nutrition (IV) is for patients who cannot receive nutrition through the digestive tract.

Dietary Interventions

• Tailor diets to meet individual needs.
• Use meal replacement shakes or supplements if oral intake is insufficient.

Factors Affecting Normal Bowel Function

• Developmental Factors: Different needs for older adults and children.
• Activity and Lifestyle: Lack of movement reduces peristalsis.
• Substances can alter bowel function.
• Dietary Factors: Low fiber/inadequate fluid intake.
• Medications: Opioids, antacids, antidepressants, and anticholinergics slow bowel motility.
• Psychological Factors: Stress, anxiety, and depression affect gut motility.
• Chronic Conditions and Neurologic Disorders: IBS, diabetes, and hypothyroidism can interfere.
• Structural Issues: Obstructions, adhesions, tumors, or anal fissures can impede.
• Pathologic processes can be first sign of illness or disease.
• Surgery and anesthesia.

Digestive System Anatomy and Physiology

• Mouth: Digestion begins with mastication and saliva.
• Esophagus: Food transport to stomach by peristalsis.
• Stomach: Food breakdown via gastric acids/enzymes.
• Small Intestine: Primary nutrient absorption.
• Large Intestine (Colon): Water/electrolyte absorption; chyme to stool.
• Rectum and Anus: Stool storage/expulsion.
• Peristalsis: Contractions moving food; normal elimination.

Promoting Regular Bowel Habits

• Promote regular bowel habits by focusing on timing, positioning, privacy, nutrition, and exercise.
• Encourage toileting at the patient’s usual time to support timing. Education is important.
• Sitting upright to support positioning.
• A dietary analysis supports nutrition. A fluid intake of 2,000 to 3,000 mL/day is important.
• Exercise improves GI motility to support exercise.

Preventing and Treating Constipation

• Constipation means dry, hard stool and infrequent or incomplete passage.
• This is due to decreased gastric motility and increased fluid absorption.
• Patients on bedrest, those taking constipating meds, those with CNS issues or reduced intake are at risk for constipation.
• A combination of high-fiber foods and a fluid intake of 2,000-3,000 mL/day and exercise can reduce constipation.

Types of Laxatives

• Bulk-forming: Absorbs water, softens stool; for long-term use.
• Osmotic: Draws water into intestines.
• Stimulant: Irritates intestines; not for daily use.
• Saline-osmotic: Draws water into intestines. Caution for kidney problems.
• Stool softeners keep stool soft .
• Laxatives are only to be used when needed.

Preventing and Treating Diarrhea

• Diarrhea means Passing three or more stools per day or having loose, watery stools.
• Dehydration or electrolyte loss are risks.
• Focus on eliminating the cause, replacing fluids, and treating symptoms.
• Teaching includes nutrition, medications, and food safety.

Interventions for Diarrhea

• Oral rehydration solutions (ORS) help replace lost fluids/electrolytes for hydration.
• A bland diet is useful for dietary modifications.
• Loperamide medications may be used to reduce diarrhea using anti-diarrheal medications.

Bowel Obstruction (Ileus) vs. Constipation

Bowel Obstruction

• A mechanical or functional obstruction.
• Causes: abdominal distention, cramping pain, vomiting, inability to pass stool/gas, dehydration.
• Imaging required for assessment. Auscultation may reveal absent bowel sounds.
• Treatment: surgical intervention or conservative management.
• The complications of bowel obstruction can be bowel perforation, peritonitis, and shock.

Constipation

• Causes: slow-moving bowel, lifestyle factors, medication, or conditions.
• Symptoms: infrequent/difficult stool, abdominal discomfort, bloating.
• Assessment: physical exam, stool pattern assessment, review of diet and meds.
• Treatment: lifestyle changes, laxatives, or stool softeners.

Key Differences

• Cause: Bowel obstruction has physical blockage/dysfunction; constipation is related to bowel movement/stool production.
• Symptoms: Obstruction has severe pain, vomiting, and inability to pass gas/stool; constipation has infrequent movements and mild discomfort.
• Management: Obstruction requires surgery/medical management; constipation requires lifestyle changes/medications.

Urostomy or Ileal Conduit

• An ileal conduit (urostomy) is an incontinent cutaneous urinary diversion.
• A resection of the small intestine occurs with transplantation of the ureters to the isolated segment of small bowel
• This separate section is brought to the abdominal wall with surgery, which creates a stoma on the body surface for urine excretion.

Rationale for a Urostomy/Ileal Conduit

• It occurs when the bladder must be removed/bypassed.
• The goal is continuous urinary drainage through a surgical stoma.
• Because the diversion is incontinent a pouching system is necessary.

Assessment for a Urostomy/Ileal Conduit (Normal vs. Abnormal)

Normal

• Stoma should protrude about 1-3 cm above skin level.
• It should be dark pink/red and moist.
• There should be minimal bleeding and secure edges.
• Stoma should protrude ½-1 inch post 6-8 weeks when it stabilizes.
• Peristomal skin should be intact and there should be no odors.
• Consistent flow of urine is typical.
• Appliance should be well-sealed, with no leakage and emptied regularly.

Abnormal

• Pale pink stoma indicates anemia.
• Dark or purple-blue stoma indicates compromised circulation.
• Excessive bleeding is abnormal.
• Peristomal skin: Redness, erosion, irritation, rash can mean leakage, infection, or yeast overgrowth.
• Abnormal Urine: absent output, cloudy or foul-smelling urine, excessive mucus.
• Frequent leakage or poor fit indicate the appliance has issues.

Input (I)

• Refers to fluid intake including oral fluids, intravenous fluids, and any other fluids the patient consumes.

Output (O)

• Refers to the amount of urine produced.
• It is collected in the urostomy pouch.
• It is recorded regularly to monitor the patient’s renal function, hydration status, and overall fluid balance.
• Frequency should be every shift or every few hours.
• Total output is added to the patient’s I & O chart.
• Volume of urine output is measured using markings on the urostomy pouch.
• Volume is calculated to track whether the patient is maintaining adequate fluid balance.
• Discrepancies in I & O can indicate potential issues with renal function or hydration.

Normal Urinary Elimination

• Measure and record total volume (mL/hour, mL/day).
• Note urine color, clarity, and odor.
• Identify method of collection.
• Assess for signs of abnormal elimination.

Assessment Expectations Based on History

• Kidney Disease: May show decreased output, proteinuria, hematuria.

• Diabetes: Polyuria, glucose/ketones in urine.

• Heart Failure: Fluid retention --> decreased urine output.

• Post-Surgical Patients: Anesthesia may cause urinary retention.

• Catheterization may be required.

• There is a risk for infection or kidney complications.

Influences from Food, Drug, and Fluid Intake

• Alcohol is a diuretic, foods high in water increase urine output, foods high in sodium cause sodium and water reabsorption/retention

Medications Influence on Urination

• Anticoagulants may cause hematuria.
• Diuretics can lighten urine color to pale yellow.
• Phenazopyridine can cause orange or orange-red urine.
• Antidepressant amitriptyline/B-complex vitamins can turn urine green or blue-green.
• Levodopa and injectable iron compounds can lead to brown or black urine.

Problems Affecting Appropriate Urinary Elimination

Urinary Elimination Anatomy and Physiology

• Kidneys: Filter waste and regulate fluids/electrolytes.
• Ureters: Transport urine to the bladder.
• Bladder: Stores urine until elimination.
• Urethra: Facilitates urine excretion.

Common Disorders Affecting Urinary Elimination

• Urinary Retention (incomplete emptying)
• Urinary Incontinence (loss of bladder control)
• UTIs (bacterial infections from improper hygiene/catheter use/retention)
• Kidney Disease (affects filtration and urine production)

Solutions to Promote Appropriate Urinary Elimination Patterns

Nursing Care

• Supports voiding habits by education, encouraging schedule, privacy, hygiene, and location. Also education on voiding as urges occur.
• Educate on fluid intake (six to eight 8-oz glasses of liquid daily).
• Strengthen muscle tone with pelvic floor muscle training (PFMT) where possible. Instruct patients to contact the pelvic floor muscles for 5 to 10 seconds and to relax them for 10 seconds.
• Stimulating urination, resolving urinary retention, and assisting with toileting.

Interventions to Resolve Incontinence

• Stress Incontinence: Kegel exercises, weight management.
• Urge Incontinence: Bladder training, anticholinergic medications.
• Overflow Incontinence: Catheterization if severe retention.
• Functional Incontinence: Environmental modifications.

Care of Urinary Catheters & Types

Urinary Catheters

• Intermittent (straight) catheters: Drains the bladder for short periods. This should be a consideration before indwelling catheterization to reduce CAUTIs. This is preferred for patients with urinary retention and bladder-emptying dysfunctions.
• Indwelling (Foley) Catheter: Continuous bladder drainage for urinary retention, post-surgical patients, or critically ill individuals
• Suprapubic Catheter: Surgically inserted into the bladder through the abdominal wall for long-term catheterization when urethral catheterization is not possible

Assessments and Interventions to Prevent & Promote Continence

Assessment

• Include pt hx taking factors such as medication, fluid intake, and conditions.
• Include a voiding diary, records frequency, volume, and timing

Interventions

• Behavioral interventions: Kegel exercises, bladder training, voiding, and biofeedback.
• Pharmacologic Treatments: Medications help manage type of incontinence.
• External Devices: Catheters/collection for those who need management
• Surgical Interventions: reserved for the severe cases

Incontinence-Associated Problems (CAUTI)

• CAUTIs are a significant risk connected with indwelling catheters

Assessment

Monitor fever, chills, dysuria, or urine appearance.

Risk Factors

• Prolonged use of urinary catheters increases the risk for CAUTI.
• Assess the need for ongoing catheterization.

Interventions for CAUTI

Catheter Care

• Promotes technique for insertion/maintenance.
• Crucial to securing the catheter, and preventing backflow,
• Catheter removal, the catheter should only be used when necessary & the shortest time

Aseptic Technique

Follow aseptic protocols.

Hydration

Adequate fluid intake prevents infection.

Urinary Incontinence Problems

Incontinence-associated dermatitis:

• Damage to skin.
• Regular skin checks, cleansing and dried.

UTIs:

• Incontinence can lead to UTIs.
• Tx includes antibiotics.

Pressure ulcers:

• Increased risk of pressure ulcers.
• Regular repositioning and provide help to protect.

Evaluation of Hydration Status through Intake and Output (I&O)

Assessment:

• I&O monitoring: Keep data collected (urine, vomit, sweat) so the patient's system can work.
• Output: Typically a normal output is 30 mL per hour to signal whether a patient needs care.
• Signs of Dehydration: Include a dry mouth, dark urine, and lower skin quality

Interventions

Ensure adequate fluid intake to encourage the body to hydrate

Enteral/Parenteral Medication Administration (Excluding IVs)

• Reviewing the correct administration

Terminology

Term Enteral Medication:

• Giving meds to the GI including through multiple routes. Parenteral Meds:
• Giving meds to the body through multiple injections.

Safe Medication Adiminstration

Follow correct guidelines with 3 checks and 5 rights, including dosage

Types of Medication Orders

• Standing Order: Carried out until cancelled
• PRN Order: Only given when the patient needs it
• One-Time Order: Administered once at a certain time
• STAT Order: Adminsitered immediately and urgent
• Now Order: Administered quickly but not STAT
• On-Call Order: Given to the department before procedures

Variations in Supply/Route

Routes, each absorbed at their own rate:

• Enternal
• Sublingual
• Buccal
• Transdermal
• Enternal Tube
• Intramuscular
• Subcutaneous
• Intradermal

Componets of the Order

• Drug labels
• Med name
• Generic name
• Strength
• Expiration Date
• Lot Number
• Instructions

Factors of Absoprtion

• Route of adminsitration
• Blood Flow
• Conditions with Acidic enviornments
• Food reactions
• Suface Area
• Kidney funciton
• Liver funciton

Factors on Effective Med Administration

ADR is when a medication causes harmful effects:

• Allergic reaction is when the body rejects an allergy.
• Chrionic Illnesses affect the ways meds react.
• Age changes reactions.
• Absorption differs.
• Wrong Dose differs with conditions

Following procedures with correct timing is of high importance.

• Avoid:
• Drug interactions
• Food Interactions
• Allergies

Drug Label Checks

• Be sure to clarify with a provider if unclear
• Make sure correct patients get the medicine
• Use all drug labels Chart meds correctly with their correct use

Documentation

• Chart meds quickly and make sure data follows parameters with the help of nurses and label information.
• List all reasons including data that go into adminitration

Medication Error Handling

1. Involve people
2. Doc the error and chart
3. File an incident report.
4. Monitor the patients in case of any changes

Parenteral Medication Administration

(Excluding the IV route).

• Includes steps in injections and guidelines for each type