Chapter 11: Ostomy care
An ostomy is named according to the part of intestine used to construct it. A colostomy is the creation of a stoma from part of the colon (large bowel), where the intestine is brought through the abdominal wall and attached to the skin, diverting normal intestinal fecal matter through the stoma instead of the anus. An ileostomy is created from the ileum (small bowel), which is brought through the abdominal wall and used to create a stoma. A urostomy or ileal conduit is a stoma created using a piece of the intestine to divert urine to the outside of the body. The ureters are sewn to a piece of the intestine that is made into a small conduit. The conduit emerges from the abdominal wall as a stoma.
These surgeries are performed on patients with diseases such as cancer of the bowel or bladder, inflammatory bowel diseases (such as colitis or Crohn’s), or perforation of the colon. Emergencies that may require an ostomy include diverticulitis, bowel rupture, trauma, necrotic bowel, or radiation complications. An ostomy may be permanent or temporary, depending on the reason for the surgery. Other types of ostomies are called jejunostomy, double-barrel ostomy, and loop ostomy (Perry et al., 2018).
Pouching Systems (Ostomy Appliances)
Individuals with colostomies, ileostomies, or urostomies have no control over the activity of their ostomy. Persons with ostomies must wear a pouching system. The pouching system must be completely sealed to prevent leaking of the effluent and to protect the surrounding peristomal skin. The disposable pouching systems can be either a one-piece or a two-piece system consisting of a pouch (plastic bag) and a flange (skin barrier) that sit against the patient’s skin. Most flanges are flat. Sometimes a stoma that is flat or retracted can be protruded with the use of a convex flange making it easier to direct the drainage into the pouch. The pouch has an open end to allow effluent to be drained, and is closed according to the manufacturer’s design—usually a plastic clip or Velcro strip. Urostomy pouches have a spout type of drainage hole to allow urine to be drained.
Different manufacturers make different types of pouching systems each designed to meet the needs of the client. Step 2 in Checklist 89 shows ostomy supplies including a flange, an ostomy bag, and a one-piece system (Perry et al., 2018; United Ostomy Association of America, 2017). The flange is cut to fit around the stoma in a way that avoids pressure or irritation on the stoma while covering the peristomal skin or a moldable flange can be used to achieve the same result (see Figure 10.18).
Ostomy pouching systems are chosen based on type of stoma (ileostomy, colostomy, urostomy), stoma characteristics (flat, raised, recessed), stoma location, patient abilities (to cut a flange and to operate the opening / closing of the pouch), skin folds, and patient preference. Pouching systems generally last from four to seven days. Ileosotmies and urostomies generally require more frequent flange changes due to the weight of the effluent and the impact of the weight on the flange’s ability to remain adhered to the patient. The pouch must be changed if it is leaking, if there is excessive skin exposure between the stoma and the edge of the flange (particularly for ileostomies because this stool contains enzymes that break down skin), or if the patient complains of itching or burning under the flange. Patients with established ostomies can swim and participate in most activities of daily life. In terms of showering, pouching systems can remain on or off and will depend on the patient’s preference and activity of the ostomy. All patients are expected to participate in all aspects of their ostomy care; if they cannot, a caregiver may be involved in the teaching (Perry et al., 2018).
Depending on the patient, a surgical procedure may be performed to create an internal pouch to collect feces or urine, which eliminates the need for an external pouch. A continent ileostomy is made from part of the ileum and is flushed a number of times each day to clean out the effluent (Koch pouch) (Oxford Radcliff Hospitals, 2013). An ileoanal ostomy is a pouch created above the anal sphincter and is also created from a portion of the ileum (Birmingham Bowel Clinic, 2011). Two types of internal urinary diversions may be created from part of the intestine. The first is an orthotopic neobladder, where a bladder is created and placed in the body at a normal bladder position; over time, with continence training, the patient can learn to void normally. The second type is a continent urinary reservoir, where a pouch is created from part of the intestine, and a catheter is inserted a number of times during the day to remove the urine (Perry et al., 2018; United Ostomy Association of America, 2017).
Physical and Emotional Assessment and Care
Patients may have co-morbidities that affect their ability to manage their ostomy care. Conditions such as arthritis, vision changes, Parkinson’s disease, or post-stroke complications may hinder a patient’s coordination and fine motor skills needed for ostomy management. In addition, the emotional burden of coping with an ostomy may be devastating for some people and may affect their self-esteem, body image, quality of life, and ability to be intimate. It is common for a person with an ostomy to struggle with body image and altered body function. The nurse’s attitude and non-verbal responses around ostomy care can help to normalize the situation and play a significant role in helping the patient adjust to new patterns of elimination. An important element of nursing care includes care both inside and outside the acute care setting. This includes ensuring the patient has the appropriate referrals to a wound / ostomy nurse and a social worker and information about support groups, possibly including online support groups (Perry et al., 2018).
Checklist 89 reviews the steps to changing an ostomy appliance (flange and pouch).
- When patients are discharged from an acute care facility, ensure they have referrals to a community / home health nurse; that they are able to empty and change their pouch system independently or with assistance from a caregiver (this includes burping the system of excess flatus) (Ostomy Canada Society, n.d.); that they have spare supplies and know what supplies to get and where to get them (involve social services if finances are a barrier); that they know the signs and symptoms of complications and where to seek help; that they have had the necessary dietitian referral and information, particularly related to ileostomy dietary considerations (Registered Nurses Association of Ontario, 2019); that they know about showering or bathing with an ostomy appliance; that they recognize peristomal skin irritation and know what to do.
A urostomy is similar to a fecal ostomy, but it is an artificial opening for the urinary system and the passing of urine to the outside of the abdominal wall through an artificially created hole called a stoma. A urostomy is created for the following reasons:
- Bladder cancer
- Trauma or surgery
- Painful bladder or overactive bladder
- Congenital abnormalities
- Conversion of continent urinary diversion to incontinent stoma
- Neurological conditions and diseases
- Spinal cord injury
- Chronic inflammation of bladder
- Interstitial cystitis
- Radiation damage
- Inability to manage a continent urinary diversion or a neobladder
A person with a urostomy has no voluntary control of urine, and a pouching system must be used and emptied regularly. Many patients empty their urostomy bag every two to four hours, or as often as they regularly used the bathroom prior to their surgery. Urostomy pouches (see Figure 10.19) have a drain spot at the distal end, and the pouch should be emptied when one-third full. The pouch may also be attached to a large drainage bag for overnight drainage as an attempt to minimize sleep disturbances associated with having to wake up to attend to a full pouch. People with a urostomy are more at risk for urinary tract infections (UTIs) and should be taught about the signs and symptoms of such infections (Perry et al., 2018).
Changing a urostomy appliance (flange and pouch) is for the most part the same as changing an ileostomy or colostomy appliance. A few considerations specific to a urostomy are outlined in Table 10.6.
|Urine flows continually from a urostomy making it a little more challenging to ensure a good seal with the flange.||Because the kidneys continually produce urine, a urostomy continually drips urine. Wet peristomal skin interferes with flange adhesion. Solution: Place a sterile gauze on top of the stoma to absorb urine during cleansing of peristomal skin and flange preparation. Remove it immediately before application of the new flange before urine can wet the peristomal skin.|
|Ureteral Stents that go from the ureter(s) through the stoma opening are placed post-operatively to prevent stricture at the ureter / stoma anastamosis site.
When ureteral stents are present, sterile technique must be used when changing a urostomy appliance. Always follow agency policy.
The stents are usually removed in the hospital by the surgeon or at the first physician visit.
When present, the stents present an extra consideration when changing the flange.
|Ureteral stents facilitate urine drainage from the kidney and the increase the risk for urinary tract infection.
Following principles of asepsis, place the stents on a sterile drape during flange change. This reduces risk of introducing microorganisms into the urinary tract.
Care must be taken to avoid accidental removal of the stents during removal of the old appliance and application of the new.
Feed the stents into the drainage bag through the hole in the flange.
|Like ileostomies, the weight of the effluent impacts the flanges ability to remain adhered to the skin||Change urostomy flanges every 5 days.|
|Urine character from a urostomy / ileal conduit is normally cloudy and can be foul smelling.||Because urine passes through a piece of bowel, the character of the urine will be cloudy from mucous and likely foul smelling from the bacteria that lives in the ileal conduit.|
|Without a bladder, signs and symptoms of urinary tract infection might be different than anticipated||Cloudy, foul smelling urine is no longer a potential symptom of urinary tract infection. Without a bladder, urgency and frequency are no longer possible. Assess for fever, changes to urine character (changes from the new norm), flank pain.
Encourage hydration by drinking at least 2 litres of fluid per day (unless contraindicated).
|Needing to frequently empty a urostomy pouch can interfere with sleep.||Use a nighttime drainage bag attached to the pouch. When using a large urine drainage bag, the anti-reflux valve incorporated into the bag should prevent backup of urine into the urostomy pouch.|
|Data sources: BCIT, 2015; Perry et al., 2018; United Ostomy Association of America, 2017|
Figure 10.17 A medical illustration depicting how to put an ostomy bag on by Bruce Blaus is used under a Creative Commons Attribution-Share Alike 4.0 International license.
Figure 10.18 Ileostomy patient wearing a two-piece ostomy wafer [cropped from original photo] by Eric Polsinelli (VeganOstomy) is used under the CC BY 4.0 license.
Critical Thinking Exercises
- What dietary or medication changes might be considered for a patient who has a new ileostomy and no longer has a small bowel?
- A patient with a new colostomy refuses to look at his stoma or participate in changing the pouching system. What are some suggestions to help your patient adjust to the stoma?