Colostomy

Colostomy surgery is often a frightening prospect for most people. But it can dramatically improve a person's quality-of-life, especially in cases of serious disease.

Types of Colostomies

There are several different types of colostomies including ascending, transverse, and descending.

Ascending. This colostomy has an opening created from the ascending colon, and is found on the right abdomen. Because the stoma is created from the first section of the colon, stool is more liquid and contains digestive enzymes that irritate the skin. This type of colostomy surgery is the least common.

Transverse. This surgery may have one or two openings in the upper abdomen, middle, or right side that are created from the transverse colon. If there are two openings in the stoma, (called a double–barrel colostomy) one is used to pass stool and the other, mucus. The stool has passed through the ascending colon, so it tends to be liquid to semi-formed.

Descending or sigmoid. In this surgery, the descending or sigmoid colon is used to create a stoma, typically on the left lower abdomen. This is the most common type of colostomy surgery and generally produces stool that is semi-formed to well-formed because it has passed through the ascending and transverse colon.

 

Types of products are used for colostomies

Pouch: There are a variety of sizes and styles of colostomy pouches. Pouches are lightweight and odor-proof. Pouches have a special covering that prevents the pouch from sticking to the body. Some pouches also have charcoal filters which release gas slowly and help to decrease gas odor. The following is general information about types of colostomy pouches:

Open-ended pouch: This type of pouch allows you to open the bottom of the pouch to drain the output. The open end is usually closed with a clamp. The open-ended pouch is usually used by people with ascending or transverse colostomies. The output from these colostomies is looser and is unpredictable (does not drain at regular times).
Close-ended pouch: This type of pouch is removed and thrown away when the pouch is filled. Close-ended pouches are usually used by people with a descending or sigmoid colostomy. The output from these types of colostomies is firm and does not need to be drained .
One-piece: A one-piece pouch contains the pouch and adhesive skin barrier together as one unit. The adhesive skin barrier is the part of the pouch system that is placed around the stoma and attached to skin. When the pouch is removed and replaced with a new one, the new pouch must be reattached to the skin.
Two-piece: The two-piece pouch has two parts: an adhesive flange and pouch. The adhesive flange stays in place while the pouch is removed and new pouch is attached to the flange. The pouch does not need to be reattached to the skin each time. The two-piece system can be helpful for patients with sensitive skin.
Pre-cut or cut-to-fit pouches: Some pouches have pre-cut holes so you do not have to cut the opening yourself. Other pouches can be cut to fit the size and shape of your stoma. Cut-to-fit pouches are especially useful right after your surgery because your stoma decreases in size for about eight weeks.

Stoma covers and caps: Stoma caps or covers can be placed on the stoma when the stoma is not active (draining). People with descending or sigmoid colostomies who irrigate may use stoma covers or caps. The cover or cap is attached to the skin in the same way as a pouch.

Before Colostomy Surgery

A patient before colostomy surgery may have lots of fears and concerns. Thus, it is useful to inform and educate the patient as well as the significant others about the expectations, necessary preparations and resources during the pre colostomy phase.  

 

Physical Preparation
        Physical preparation for surgery may involve building the patient's stamina several days before the surgery and cleansing the colon the day prior to the procedure.

 

Pre-Colostomy Diet

        If the client's condition permits, the nurse may recommend a diet high in calories, protein, carbohydrates and in low residue to provide adequate nutrition and minimize cramping by increasing peristatsis. Some good sources of these essential nutrients are fats, meats and pasta or rice.

 

Bowel Preparation before Colostomy

         A day or two before the surgery, the surgeon usually orders a bowel prep to cleanse the colon. You can expect enemas and 8-hour (or more) fasting to be advised. Usually, the nurse will walk the patient through this and it is very important to follow the instructions very carefully so as not to postpone the surgical procedure.

 Colostomy care

How to empty the pouch

• Empty the pouch when it is one-third to one-half full. Do not wait until the pouch is completely full because this could put pressure on the seal, causing a leak. The pouch may also detach, causing all of the pouch contents to spill.
• Place toilet paper into the toilet to reduce splash back and noise.
• Take the end of the pouch and hold it up. Remove the clamp (if the pouch has a clamp system).
• You may need to make a cuff at the end of the pouch to keep it from getting soiled.
• Drain the pouch by squeezing the pouch contents into the toilet.
• Clean the cuffed end of the pouch with toilet paper or a moist paper towel. You may also rinse the pouch but it is not necessary. Make sure and keep the end of the pouch clean.
• Undo the cuff at the end of the pouch. Replace the clamp or close the end of the pouch according to your caregiver's instructions.
  

 

What is irrigation?

People with descending or sigmoid colostomies may be able to irrigate their colostomies on a regular basis. Irrigating the stoma means putting a fluid into the stoma to empty the bowel. This may also be called an enema. Irrigation allows a person to have timed bowel movements. Irrigation can allow a person to be free from stool output for about 24 to 48 hours. Once stool output is regular, a stoma cap can be used between irrigations instead of using a drainable pouch. The stoma cap will absorb mucus and deodorize and vent gas.
Talk to your caregiver about whether irrigation is right for you. Irrigation may be right for you if you had regular bowel movements before the colostomy. You should also be physically able to perform the irrigation procedure. It is also important to have a lifestyle that will allow regular irrigation. For example, you should have a daily schedule in which you can schedule enough time to regularly irrigate. You should also be free from certain colostomy problems. People with problems such as a prolapse or a hernia should not irrigate. Irrigation could make a prolapse worse or create a hole in the bowel. Irrigation could also cause leakage of stools between irrigations or make it hard to control bowel movements.

 

How do I irrigate my colostomy?

Ask a specially trained caregiver such as an ostomy nurse how to properly irrigate your colostomy. Below are some general steps for irrigation:

• You will need a plastic irrigating container with a long tube and a cone to introduce water into the colostomy. You will also need an irrigation sleeve that will direct the output into the toilet. You will need an adjustable belt to attach the irrigation sleeve and a tail closure for the end of the sleeve.
• Choose the same time each day when you will not be interrupted to irrigate your colostomy.
• Fill the irrigating container with about 16 to 50 ounces (500 to 1500 mL) of lukewarm water. The water should not be cold or hot. The amount of water each person needs to put in the irrigating container varies. Ask your caregiver how much water you will need to irrigate. Hang the irrigation container at a height in which the bottom of the container is level with your shoulder. Sit up straight on the toilet or on a chair next to the toilet.
• Take the adjustable belt and attach it to the irrigation sleeve. Place the belt around your waist and place the sleeve over your stoma. Place the end of the irrigation sleeve into the toilet bowel.
• Release air bubbles from the tubing on the plastic irrigating container by releasing the clamp. Allow a small amount of water to be released into the sleeve. Clamp the tubing again.
• Moisten the end of the cone with water or lubricate it with water-soluble lubricant.
• Place the tip of the cone about three inches deep into the stoma. Make sure there is a snug fit but do not place the cone too deeply or forcefully into the stoma. Release the clamp on the tubing again and allow the water to flow into the stoma. The water must go in slowly and takes about five to ten minutes. Keep the cone in place for another 10 seconds.
• Remove the cone from the stoma. Allow the output to drain into the irrigation sleeve for about 10 to 15 minutes. Dry the end of the irrigation sleeve. Clip the bottom of the sleeve to the top with a clasp or close the end of the sleeve with the tail closure. You may move around for about 30 to 45 minutes until all the water and stool has drained. Drain the output from the sleeve into the toilet. Clean the area around the stoma with mild soap and water and pat dry.

 

What are some problems that can happen with a stoma?

Most stoma problems happen during the first year after surgery.

• Stoma retraction: Retraction happens when the height of the stoma goes down to the skin level or below the skin level. Retraction may happen soon after surgery because the colon does not become active soon enough. Retraction may also happen because of weight gain. The pouching system must be changed to match the change in stoma shape.
• Peristomal hernia: Peristomal hernias occur when part of the bowel (colon) bulges into the area around the stoma. Hernias are most obvious during times when there is pressure on the abdomen. For example, the hernia may be more obvious when sitting, coughing, or straining. Hernias may make it difficult to create a proper pouch seal or to irrigate. The hernia may be managed with a hernia belt. Changes may also need to be made to the pouching system to create a proper seal. Surgery may also be done in some people.
• Prolapse: A prolapse means the bowel becomes longer and protrudes out of the stoma and above the abdomen surface. The stomal prolapse may be caused by increased abdominal pressure. Surgery may be done to fix the prolapse in some people.
• Stenosis: A stenosis is a narrowing or tightening of the stoma at or below the skin level. The stenosis may be mild or severe. A mild stenosis can cause noise as stool and gas is passed. Severe stenosis can cause obstruction (blockage) of stool. If the stoma is mild, a caregiver may enlarge it by stretching it with his finger. If the stenosis is severe, surgery is usually needed.

 

What types of foods can I eat after a colostomy?

• People with colostomies can eat a regular diet. Choose healthy foods from all the food groups. To avoid constipation, eat foods such as oatmeal, whole-grain breads and cereals, fruits and vegetables. There may be some foods that you cannot tolerate very well. If a food gives you cramps or diarrhea, do not include that food in your diet. Try the food again in a few weeks. Eat small portions first and then gradually increase your portion sizes.
• You may want to avoid foods that cause gas and odor. Some foods that may cause gas and odor are vegetables such as broccoli, cabbage, and cauliflower. Other foods include beans, eggs, and fish. You can also reduce gas by eating slowly and not using straws to drink liquids. Foods that may help to control odor and gas in some people are fresh parsley, yogurt and buttermilk.
• Drink at least 8 to 10 (eight ounce) cups of water each day. Follow your caregiver's advice if you must limit the amount of liquids you drink. Healthy liquids for most people to drink are water, juices, and milk. Limit the amount of caffeine you drink, such as coffee, tea, and soda.

 

How can a colostomy fit into my lifestyle?

• Work: You can go back to work when your caregiver says it is OK. You may need special support to prevent a hernia if you work is heavy labor, such as lifting or digging. You may need an ostomy belt over the pouch to keep it in place if you move a lot at your job.
• Exercise: Exercise is very important. Talk to your caregiver about an exercise program once you feel stronger. Together you can plan a program that works for you. It is best to start slowly and do more as you get stronger. Exercising makes the heart stronger, lowers blood pressure, and helps keep you healthy. Your body and mind should feel better after exercising. Walking, jogging, bicycling, and swimming are good exercises. Talk with your caregiver before playing contact sports. You may need to wear a special support or a colostomy cover to protect your stoma. Empty your pouch before playing sports.
• Bathing or swimming: You may take a bath with or without your pouch. You can take a shower or bath with your pouch off. Water will not go into the stoma during a shower or bath. For swimming, you should always wear your pouch. Empty your pouch before getting into the water if you swim. You may want to put waterproof tape strips over the edges of your skin barrier.
• Relationships:
  • You may feel anxious, nervous, or scared when you first start to care for your colostomy. You may not like the way your body looks. You may feel like you are no longer in control of your body. These are normal feelings. Talk to someone close to you or to your caregiver about these feelings.
  • Learning to live with a colostomy may be difficult for both you and your spouse. Together you can find ways to live with this change in your life. It will take time for you to feel better after surgery. If you had an active sex life before colostomy surgery, it can be the same after surgery. You cannot hurt your stoma by having close body contact. Be sure to empty the pouch before having sex.
• Traveling: Always carry extra colostomy supplies and pouches with you when traveling. Take enough supplies for your trip. You may not be able to find what you need while traveling. Contact your local ostomy group or ostomy nurse for help. They may be able to give you a list of ostomy caregivers in the area you are visiting.
  • If you fly, pack your supplies in your carry-on luggage not your checked suitcase because luggage is sometimes lost or delayed.
  • If you drive, do not put your supplies in the trunk or glove compartment. This can cause your supplies to get hot, melt and not stick well. Keep your ostomy supplies in the coolest place in the car.

 
Nursing Considerations
 

Risk for impaired Skin Integrity: risk factors may include absence of sphincter at stoma and chemical irritation from caustic bowel contents, reaction to product/removal of adhesive, and improperly fitting appliance.

Risk for Diarrhea/Constipation: risk factors may include interruption/alteration of normal bowel function (placement of ostomy), changes in dietary/fluid intake, and effects of medication.*

Deficient Knowledge [Learning Need] regarding changes in physiologic function and self care/treatment needs may be related to lack of exposure/recall, information misinterpretation, possibly evidenced by questions, statement of concern, and inaccurate follow-through of instruction/development of preventable complications.

Disturbed Body Image may be related to biophysical changes (presence of stoma; loss of control of bowel elimination) and psychosocial factors (altered body structure, disease process/associated treatment regimen, e.g., cancer, colitis), possibly evidenced by verbalization of change in perception of self, negative feelings about body, fear of rejection/reaction of others, not touching/looking at stoma, and refusal to participate in care.

Impaired Social Interaction may be related to fear of embarrassing situation secondary to altered bowel control with loss of contents, odor, possibly evidenced by reduced participation and verbalized/observed discomfort in social situations.

Risk for Sexual Dysfunction: risk factors may include altered body structure/function, radical resection/treatment procedures, vulnerability/psychologic concern about response of SO(s), and disruption of sexual response pattern (e.g., erection difficulty)

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