This NCLEX review will discuss the two types of GI ostomies: colostomies and ileostomy.
As a nursing student, you must be familiar with the different types of GI ostomies, how to provide pre-opt and post-opt care to a patient with an ostomy, and patient teaching.
These type of questions may be found on NCLEX and definitely on nursing lecture exams.
Don’t forget to take the GI ostomy quiz.
You will learn the following from this NCLEX review:
- Definition of Colostomy and Ileostomy
- Reason for a GI ostomy
- Types of Colostomies
- Stools Types based on Ostomy location
- Pre-opt and Post-opt Nursing Care
- Pouching System, Medication and Diet Teaching
NCLEX Review Lecture on Colostomy and Ileostomy
What is a Colostomy and Ileostomy? A surgical opening created on the surface of the abdomen to allow stool (waste) to exit the body rather than through the rectum. A GI ostomy can be created for the small (ileostomy) or large intestine (colostomy).
Reasons for a GI ostomy:
- GI diseases: Crohn’s, ulcerative colitis, diverticulosis, infection, cancer (rectum and colon), injury (trauma to the GI system), congenital defects (obstructions)
*May be permanent (lifetime) or reversible (GI system just needs to heal and then it will be reversed)
Colostomy vs Ileostomy
Colostomy: an opening created to bring the LARGE INTESTINE to the surface of the abdomen (the large intestines are also called the colon).
There are various locations for a colostomy (think back to A & P of the GI system):
Remember the mnemonic: “DATS a Colostomy”
- Double-barrel ostomy: type of transverse colostomy where there is the creation of two stomas which divide the bowel. One stoma is called the proximal and puts out stool while the other stoma is known as the distal and puts out mucus. It is also known as a mucus fistula.
Ileostomy: an opening created to bring the SMALL INTESTINE to the surface of the abdomen, specifically the ileum (which is the last part of the small intestine before it opens into the large intestine).
How does food travel through the body?
Need to know this so you know what type of stool to expect from various ostomies, and the potential complications.
Digestion starts in the mouth….you chew the food (saliva has digestive enzymes that breaks down some of the food) -> then you swallow-> the food travels through your esophagus and this tube uses peristalsis to help the food enter your stomach -> the stomach breaks down the food with the help of gastric acid and it becomes chyme (digested food and gastric acid)
-> “chyme” is released into the duodenum (which is the first part of the small intestine), then flows to jejunum and finally the ileum, which is the last part of the small intestine that enters into the large intestine (while the food flows through the small intestine enzymes and bile breakdown the food even further)-> (CONSISTENCY OF CONTENTS right now is thick liquid…therefore an ileostomy will have liquid stool…as it progresses through the GI tract and gets closer to the rectum it becomes more formed like the stool that would have left the anus ->stool goes through the large intestine (which is going to absorb the water and electrolytes left over)…so the stool starts to have more of a formed look to it)
-> starts at the cecum, then up through the ascending colon to the transverse colon and then down through the descending colon and then into the sigmoid colon to the rectum and excreted.
*Ostomies closer to the end of the GI tract will have similar consistency to normal stool AND the patient has a greater chance of developing bowel continence (where they will learn how to control bowel movements). Hence, patients with DESCENDING and SIGMOID colostomies have the greater chance of bowel continence.
Stool types based on Ostomy location
Ileostomy: will always have liquid stool.
- Note there is an increased risk of dehydration and electrolyte imbalance (because the contents will NOT flow to the colon where water and electrolytes are majorly absorbed…instead it is excreted out). There is also a huge risk for skin break down around the stoma because the small intestine contains digestive and pancreatic enzymes that will break down the skin.
- Ascending: liquid stool
- Transverse: lose to partly formed stool
- Descending/Sigmoid: similar to normal consistency
The stoma isn’t painful to the patient (area around the stoma after surgery may be tender) therefore the patient is at risk for unknown injuries…not painful when you clean.
Pre-opt Nursing Care:
- Educate about what to expect (many patients are scared), how the stoma will look (show them a picture), and where it will be on the abdomen.
- Start teaching them about the pouching system
- MD may prescribe oral antibiotics to reduce bacteria in the colon (which normally lives there) to prevent post-opt infection.
- 2 to 3 days before surgery soft or semi-liquid diet may be ordered
- A cleansing solution and laxative may be ordered to clean the colon and that the patient follows a clear liquid diet prior to surgery (24 hours). Patient may have to be hospitalized due to the profuse diarrhea they will be experiencing and may need an IV solution to maintain hydration.
- NPO day of surgery
Post-opt Nursing Care:
Monitor the electrolytes, sign of dehydration (urinary output) site and stoma:
- After surgery, stoma will be swollen and large, but after a couple months it will shrink to normal size
Ostomies will SHOULD ALWAYS look: pink or red and be moist/shiny.
Notify MD if stoma is: pale pink patient (may have a low hgb and hct), dark red or black could mean compromised circulation to the stoma.
After Surgery Stool:
Ileostomy: drainage is dark green and then turns yellow when patient starts to eat
Colostomy: may pass mucous stool at first….stool will be liquid at first and then progress to what it should look like depending on its location. It can take up to 2 days before stool is produced. A petroleum gauze will be over the stoma to keep the stoma moist, and then a sterile dry dressing until pouching system in place.
Help patient understand the pouch system:
- Empty pouch when 1/3 to 1/2 full
- Change pouch when gut less active (morning before breakfast)
- Change pouching system every 3-5 days
- Keep stoma and skin around stoma clean
- Watching for burning around the skin or leaking (patient needs to be taught how to perform by self and become independent with it)
- Be familiar with the various pouching systems: one piece (skin barrier and pouch are one unit) vs two piece (pouch and skin barrier separate).
NOTE: When applying the pouching system, the skin barrier application is key in preventing skin irritation and stoma constriction. Be sure to measure the stoma and cut the opening of the skin barrier to be 1/8” LARGER than the stoma.
- Stoma irrigation may be ordered by the doctor. This is an enema given through the stoma. Ordered if stoma is not excreting regular amounts of stool OR to teach a patient with a descending or sigmoid colostomy bowel continence.
Medications precautions for patients with an ileostomy:
- NO: Enteric coating medications (don’t dissolve until reaching a specific part of the small intestine) OR Sustained-released medication (releases slowly over a period of time)
Start out slow (1st 6 weeks) with low fiber, small meals throughout the day, monitor hydration and electrolyte status, eat slowly and chew thoroughly and then advance as tolerated.
Patients with an ileostomy need to stay hydrated and consume fluid and electrolyte solutions like Gatorade (remember they are losing a lot of rich fluids that cannot pass through the colon).
Most patients will be able to eat a regular diet eventually, but should avoid foods that caused problem before surgery and MUST keep the following in mind:
Use caution and eat small amounts or completely avoid foods that are not completely digestible:
- Corn, celery, peas, coleslaw, popcorn, nuts and seeds, raisins, skin of fruits, raw mushrooms and pineapple etc,
Gas/Odor causing foods:
Pouch will expand as gas collects in bag (teach patient this and how to “burp” the bag)…there are bags with filters that allow gas to escape while filtering the smell or drops for the bag.
Foods to avoid that cause excessive gas: beans, onions, eggs, broccoli, cabbage, garlic, alcoholic beverages, fish…high fibrous foods
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