Bowel Diversion
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Stoma-temporary
or permanent
artificial opening in
the abdominal wall
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Ileostomy-opening
in Ileum
Colostomy-opening
in colon
Bowel Diversion
Types of Colostomy Reconstruction
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Loop colostomy
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usually temporary large stomas
Common site-Transverse colon
Loop of bowel is pulled out and
an external device (plastic rod,
rubber catheter or bridge) is
placed to keep the bowel from
slipping back
loop has 2 openings through 1
stoma
Distal- rains mucus
Proximal drains stools
External device is removed
within 7-10 days
Types of Colostomy Reconstruction
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End colostomy
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The functioning end of the intestine
(the section of bowel that remains
connected to the upper gastrointestinal
tract) is brought out onto the surface of
the abdomen, forming the stoma by
cuffing the intestine back on itself and
suturing the end to the skin
The surface of the stoma is actually the
lining of the intestine, usually
appearing moist and pink.
The distal portion of bowel (now
connected only to the rectum) may be
removed, or sutured closed and left in
the abdomen.
An end colostomy is usually a
permanent ostomy, resulting from
trauma, cancer or another pathological
condition.
Types of Colostomy Reconstruction
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Double Barrel
Colostomy
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colostomy involves the creation
of two separate stomas on the
abdominal wall.
proximal (nearest) stoma is
the functional end that is
connected to the upper
gastrointestinal tract and will
drain stool.
distal stoma, connected to the
rectum and also called a
mucous fistula, drains small
amounts of mucus material.
most often a temporary
colostomy performed to rest an
area of bowel, and to be later
closed.
Total proctocolectomy with permanent ileostomy
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Total proctocolectomy with
permanent ileostomy
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Removal of colon, rectum and
anus with closure of anus.
End of terminal ileum is
brought out through the
abdominal to form an ostomy
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Ileostomy
Ileostomy
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Possible complications include:
skin irritation caused by leakage of digestive fluids onto the
skin around the stoma; Irritation is the most common
complication of ileostomies
diarrhea
the development of abscesses
gallstones or stones in the urinary tract
inflammation of the ileum
odors can often be prevented by a change in diet
intestinal obstruction
a section of the bowel pushing out of the body (prolapse)
Total proctocolectomy with
continent ileostomy
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Total proctocolectomy with continent ileostomy
The Kock pouch is a variation of the basic ileostomy and is
named for its Swedish inventor.
In the Kock technique, the surgeon forms a pouch inside the
abdominal cavity behind the stoma that collects the fecal
material.
The stoma is shaped into a valve to prevent fluid from
leaking onto the patient's abdomen.
The patient then empties the pouch several times daily by
inserting a tube (catheter) through the valve.
The Kock technique is sometimes called a continent ileostomy
because the fluid is contained inside the abdomen.
When the patient returns to his room, attach the drainage
catheter emerging from the ileostomy to continuous gravity
drainage
Kock Pouch
A thin tube
is inserted
into the
stoma to
drain the
contents a
few times a
day.
A one-way
nipple valve
sitting flush
with the skin,
stops the stool
from coming
out at all other
times.
Complications from Kock Pouch
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Pouchitis
 Increased stool frequency
 Urgency
 hematochezia
 abdominal cramping
 Fever
 Malaise and pelvic pain
 *treat with Flagyl (metronidazole)
Fistula development
Nipple valve extrusion
Ileostomy
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Patient education
Ileostomy patients must learn to watch their fluid
and salt intake.
 greater risk of becoming dehydrated in hot
weather, from exercise, or from diarrhea.
 In some cases they may need extra bananas
or orange juice in the diet to keep up the level
of potassium in the blood.
Ileostomy
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Patient education includes social concerns as well
as physical self-care.
 Many ileostomy patients are worried about the
effects of the operation on their close
relationships and employment.
 find out about self-help and support groups.
 The ET can also evaluate the patient's
emotional reactions to the ostomy.
Ileoanal Reservoir (IAR)
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The IAR requires complete removal of the colon, leaving
all of the small intestine and about two inches of the
rectum
The lining of the rectum, called the mucosa, is then
removed (stripped), leaving the muscle of the rectum and
the underlying anal sphincter muscles intact. An ileal J
pouch is then formed, using the last 12 inches of the
small bowel (ileum).
A surgical stapling instrument is used to create the
pouch. The end of the pouch is then "pulled through" the
pelvis and sewn to the anus.
Ileoanal Reservoir (IAR)
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A temporary ileostomy about 12 inches upstream
from the pouch is made. This is constructed to
divert stool until the suture lines in the reservoir
have healed and the patient has recovered from
the operation. This results in all stool going into
the ileostomy bag on your right lower abdomen
so that the ileal pouch can heal.
When the pouch to anus connection has healed,
usually about two months, the ileostomy is
closed, resulting in bowel movements from your
anus.
Ileoanal Reservoir
Comparison of colostomies & Ileostomy
Ascending
Transverse
Sigmoid
Ileostomy
Stool
consistency
Semi liquid
Semiliquidsemiformed
Formed
Liquid to
semiliquid
Fluid
requirement
Increased
Probably
increased
No change
increased
Bowel
regulation
No
Uncommon
Yes if with
regular
pattern
No
Pouch &
yes
skin barriers
yes
Dependent
on
regulation
yes
irrigation
no
no
Possible q
24-48 hrs
no
Indications
for surgery
Diverticulitis, Same as
trauma, CA
ascending
of colon,
rectum or
pelvis
Ca of rectum
or
rectosigmoid
area,
diverticulitis
Crohn’s,
ulcerative
colitis,
trauma, CA
Effects of food on stoma output
ODOR Producing
Diarrhea causing
Eggs, garlic,
onions, fish,
asparagus,
cabbage, broccoli,
alcohol
Alcohol, beer, cabbage
family, spinach, green
beans, coffee, spicy
foods, raw fruits
Gas Forming
Beans, onions,
cabbage beer,
carbonated
beverages,
sprouts, Strong
cheese
Potential for
obstruction in
Ileostomy
Nuts, raisins, popcorn,
seeds, raw vegetables,
celery, corn
NURSING MANAGEMENT
Pre-operative preparation
 Psychological preparation
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Ability to perform self care
Identify support systems
Visit by ET
 Bowel preparation-decrease post op
infection
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Osmotic lavages, cathartics, enemas
Antibiotics-neomycin & erythromycin
NURSING MANAGEMENT
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Post-operative
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Patient adaptation-ADL’s in 6-8 weeks, no heavy lifting,
psychological support, identify coping mechanism
Colostomy care
 Assess stoma and surrounding skin
 Pink stoma-healthy; pale- anemic; dusky bluenecrotic
 Mild to moderate swelling- till 2-3 weeks is
normal; moderate to severe swelling-obstruction
of stoma
 Small amount of oozing-normal; moderate to
large bleeding-coagulation problem or or GI bleed
NURSING MANAGEMENT
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Colostomy care
 Assess stoma and surrounding skin
 Wash stoma with mild soap & water
 Use of skin barrier
 Use of pouch-leave ¼ of skin around the
stoma
 Colostomy irrigations
 Regulate bowel function-stimulate the
bowel to function at specific time
everyday or every other day
 Treat constipation
 Prepare for surgery
Colostomy Irrigation
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Use lukewarm water as irrigant(500-1000 ml) just
enough to distend but not cause cramping
Ensure comfortable position-sit up on chair or
toilet bowl
Hang container on hook or IV pole (18-24 in)
above stoma
Apply irrigating sleeve and place end in toilet bowl
Lubricate stoma cone and insert gently into the
stoma
Allow irrigation solution to flow steadily for 5-10
minutes: stop the flow if cramping occurs
Colostomy Irrigation
 Clamp
the tubing and remove
irrigating cone when desired amount
has been delivered or when patient
senses colonic distention
 Allow 30-45 minutes for the solution
and feces to be expelled.
 Cleanse, rinse and dry peristomal
skin well and replace the colostomy
drainage pouch
Nursing Diagnosis/Interventions
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Risk for skin integrity related to irritation from fecal drainage
and peristomal area, irritation from appliance and lack of
knowledge of skin care
 Skin assessment, use mild soap & water to cleanse area,
use of skin barrier and application of well fitting pouch
Nursing Diagnosis/Interventions
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Disturbed body image related to presence of ostomy and
malodor
 Assess attitude towards ostomy
 Allow expression of feelings and assist in adjustment
process (grief)
 Prepare patient to do owm stoma and appliance care to
increase independnce and enhance self-esteem/image
 Encourage attendance in support classes or groups
 Use of measures to control odors
 Odor proof pouch, pouch deodorants, avoid foods that
increases odor
Nursing Diagnosis/Interventions
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Imbalanced nutrition less than body requirements related to
decreased appetite and lack of knowledge of appropriate foods
 Assess nutritional intake
 Introduce foods one at a time
 Provide list of foods for reference
Risk for fluid volume deficit related to excess fluid loss from
ileostomy or diarrhea or inadequate fluid intake
 Assess for signs & symptoms of fluid & electrolyte
imbalance
 I/O, encourage fluids-3000ml/day
 Monitor electrolytes
Nursing Diagnosis/Interventions
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Ineffective sexuality patterns related to perceived loss of
sexual appeal and accidental seepage of fecal materials during
sexual activity
 Assess patients attitude and impact of the ostomy on the
sexual functioning-fear of rejection (encourage open
communication)
 Encourage support groups to share concerns and solutions
 Encourage use of perfumes or fragrance to combat odors