Colostomy is an operation in which an artificial opening is made into the colon on the anterior abdominal wall to permit the escape of faeces and flatus. A colostomy is done for the different purposes.
a. To permit escape of faeces and flatus when there is an obstruction of the large bowel or a known lesion that will eventually cause obstruction.
b. To permit healing of the bowel distal to the colostomy opening since it diverts the faecal contents from the affected area.
c. To provide a permanent means of bowel evacuation when the rectum or anus are non functional as a result of disease, birth defect or a traumatic condition.
TYPES OF COLOSTOMY
1. Temporary and Permanent Colostomy
2. Double Barreled Colostomy and End Colostomy
3. Wet Colostomy and Dry Colostomy
CARE OR THE PATIENT WITH COLOSTOMIES
Patient facing the nursing problems
1. Irregular bowel action
Nursing Actions: the patient should be prepared to accept a colostomy. Emotional states especially fear and anxiety cause regular bowel movements.
Wearing a colostomy bag over the stoma, helps to collect the faeces which can be cleaned at a convenient place and time.
Colostomy may be regulated by following a dietary pattern, because the consistency of the stool and presence of gas depends on the types of food digested. Roughage fresh fruits, bulk forming and laxative foods must be eaten judiciously or diarrhea may develop. On the other hand, totally constipating food will cause problems with hard stools. Therefore, the patient should find out what is agreeable and what is disagreeable to him and thereafter regulate his diet.
An attempt may be made to control elimination by irrigations. In this case the irrigation is done daily at the same time to establish the habit.
2. Diarrhea with fluid electrolyte imbalance
Nursing Actions: the patients with colostomy operations are more prone to diarrhea than other patients. Therefore these patients should take care to avoid all those factors which may precipitate an attack of diarrhea.
Patients with wet colostomy are prone to electrolyte imbalance. They should be encouraged to take an adequate amount of fluids daily. When they develop diarrhea, the fluid intake should be increased. They may take plenty fluid in the form of plain water, plain tea etc, as they develop diarrhea.
Do not irrigate colostomy when the patient develops diarrhea, but if the patient has ingested may irritant foods, a colostomy irrigation may help to remove the irritant foods and control diarrhea.
It is best to restrict the intake of solid foods till the bowel motility has returned to normal. Patients with colostomy should eat such foods that are non irritating to the bowels. They should avoid foods as roughage, fruits, laxative foods and bulk forming foods. While eating roughage it should be chewed well.
3. Faecal impaction and obstruction
Nursing Actions: faecal impactions may occur if the patient is having a sigmoid colostomy and it becomes difficult to evacuate the bowel. A dietary regulation may prevent such complication.
Regulation of bowel with irrigations will prevent such problems.
Oil instilled directly into the stoma at bed time or several hours before irrigation will usually help to evacuate the bowel. Be careful to introduce only a small amount (5 to 10 ml) of oil into the stoma or oil will leak after the irrigation.
4. Flatulence formation in the intestine and foul smell on its expulsion.
Nursing Actions: flatulence is an embarrassing problem since the individual has no control over its passage and has no sensation to indicate when it is about to pass. The noise of the passage of gas and the resultant odor can cause the person to avoid social situations. Odor proof disposable bags with charcoal filter discs are available for use.
A satisfactory method of controlling gas is by dietary control. The patient has to avoid foods which may produce gas.
Swallowing air with foods also cause gas formation. The patients are to be instructed to eat the food slowly. They should also chew the food well.
Charcoal and antacids may help to relieve flatulence.
5. Excoriation of the skin.
Nursing Actions: the skin around the stoma may be excoriated due to the frequent expulsion of the liquid stool. The digestive juices which does not get time for reabsorption is present in the liquid stool and will irritate the skin. Therefore the skin should be protected from coming in contact with liquid stools by wearing a colostomy bag which is attached to the abdominal wall by an adhesive substance. The stools collected in the colostomy bag are emptied at frequent intervals through the opening at the bottom of the bag. Removing the adhesive tape and fixing it every now and then can excoriate with skin around the stoma.
A waterproof material cut to fit around the colostomy opening will prevent digestive juices coming in contact with the skin.
A protective ointment such as zinc oxide or petroleum jelly applied around the opening protects the skin from chaffing.
Application of Tr. Benzoin may help to keep up the integrity of the skin.
The patient should not be discharged from the hospital until he is able for caring his colostomy. The patient and his family members should be taught thoroughly about the care of colostomy.
Since the drainage from the colostomy opening may be fairly constant, the skin should be washed with soap and water and the dressings should be changed as often as necessary to prevent the skin irritation.
6. Psychological problems such as insignificance and loneliness, feeling of fear and shame, withdrawal and depression.
Nursing Actions: preoperative instructions about colostomy and how it will be managed will be important for the patient to adjust with a colostomy. They should know that the colostomy. They should know that the colostomy need not alter their life, but its care will become a routine part of their daily activity.
They may given chances to talk with someone who has a colostomy and has learned to manage elimination and overcome fears. Such conversations will be reassuring and informative. On the contrary a conversation with a maladjusted person will have an adverse effect.
Constant encouragement and teaching in the care of the colostomy will create confidence in the patient. Once a patient masters to carry his self care, he can adjust to his problems. A well adjusted person can lead a completely normal life and even take part in the activities.
Fearing of soiling the dress during travel can be avoided by irrigating the bowel before the onset of long journeys and wearing a colostomy bag of good capacity. The patient should be instructed to carry extra linen to change in case of accidental soiling.
With love, patience understanding and with good hygienic practices, both from the side of the patient and other family members, they enjoy a normal life socially, vocationally, recreationally and sexually.
7. Stricture of the stoma.
Nursing Actions: stricture occur when the rectus muscle of the abdominal wall tend to close over the artificial opening. Passage of a formed stool is an indication that the colostomy is functioning well. Some physicians may teach their patients to dilate the stoma with gloved finger before the each irrigation.
Purpose of Colostomy Irrigations
1. To establish regularity of evacuation.
2. To cleanse the intestinal tract of gas, mucus and faeces.
3. To prevent excoriation of the skin around the stoma.
4. To remove any irritant foods ingested by the patient.
5. To teach the patient and his relatives the care of the colostomy.
Solutions used for Irrigation
1. Normal saline
2. Plain water
3. Soapy water ( as in enema)
1. Explain the steps of procedure to the patient and encourage him to co-operate in the procedure.
2. In the immediate post operative period, the nurse carries out the procedure herself. But as soon the patient become ambulatory, the nurse help the patient to carry out the procedure.
3. Use 500 to 100 ml of irrigating solution at the temperature of 37.8 to 40.6 degree celcius. The time taken for irrigation should be reduced to prevent the patient developing fatigue.
4. Use a soft catheter. Always lubricate the catheter with a water soluble jelly and not with Vaseline.
5. Do not insert a catheter more than 4 inches.
6. As far as possible avoid colostomy irrigations. Do not irrigate more than once a day.
7. When irrigations are done, choose a time convenient for the patient. It should fit in the routine of the patient.
8. Do not irrigate if there is diarrhea e.g., in gastroenteritis.
9. Never use force to introduce the catheter into the stoma. Force exerted may cause perforation of the gut. If any resistance is encountered, some solution should be instilled to distend the bowel ahead of the tube and thus ease its insertion.
10. In the immediate post-operative period, ‘aseptic techniques’ are used as there is a surgical wound that is to be healed. Later on a ‘clean technique’ is sufficient.
11. Since the faecal contents are highly contaminated with bacteria, care should be taken to keep the discharges away from the surgical wound (incision).
12. The height of the irrigating can should not be more than 12 to 18 inches above the colostomy opening or it should not be raised above the shoulder level if the patient is sitting. The rate of flow and force of fluid depends upon the height. If the fluid is introduced rapidly it may cause abdominal cramps. It may also be lost in the transverse colon and may spurt after 12 to 24 hours.
13. Avoid introducing air into the colon by:
a. Expelling the air form the tubing.
b. Removing froth from the solution.
c. By not allowing the fluid to run completely out of the tube.
14. Before introducing the fluid into the colon, make sure which is the proximal and distal loop of the colon. It is the proximal loop that is to be irrigated. To distinguish the proximal and distal loop, watch for the expulsion of the faeces or consult the doctor. The distal end is irrigated only when directed by the doctor as a preliminary measure to next surgical step.
15. Wet colostomies are never irrigated, because of the danger of forcing the contaminated material into the ureters causing infections.
16. If the patient complaints of cramps during colostomy irrigation, reduce the force of fluid either by clamping the tube or by lowering the irrigating can.
NURSES RESPONSIBILITY IN THE COLOSTOMY IRRIGATION
1. Check the name, bed number and other identification of the patient.
2. Check the diagnosis and the purpose of irrigation.
3. Check the type of colostomy done. Make sure of the proximal and distal loop of the colon.
4. Check the patient’s ability for self care.
5. Check the doctor’s orders for specific instructions and the precautions, if any, regarding the colostomy irrigations movement of the patient etc.
6. Check the understanding of the patient to follow instructions.
7. Check the articles available in the patient’s unit.
Colostomy Irrigation – Care, Purpose, Responsibility, Preparation and After Care of Patient. – A Detailed Nursing Guide Procedure.
PREPARATION OF ARTICLES
1. Irrigating can with tubing, clamp and catheter.
Purpose: act as a reservoir.
2. I.V. stand.
Purpose: to hang the irrigator at a desired height and the patient will have a control over the whole equipment.
3. A jug with solution at the temperature of 37.8 to 40.6 degree celcius.
4. Water soluble jelly.
Purpose: to lubricate the catheter.
5. Clean cotton swabs or rag pieces.
Purpose: to clean skin around stoma.
6. Kidney tray and paper bag.
Purpose: to receive the wastes.
7. Dressings, protective ointments etc. as necessary.
Purpose: to protect the skin from excoriation.
8. Mackintosh or waterproof sheet.
Purpose: to direct the return flow into the toilet.
9. Clean linen as necessary.
Purpose: to change after irrigation.
10. Bucket with disinfecting solution.
Purpose: to receive the soiled linen.
Preparation of the Patient and the Environment
1. Explain the procedure to the patient and tell him how he can co-operate.
2. Make the patient sit on a chair in the bathroom. A rubber sheet placed on the lap of the patient can be used as a trough leading into the toilet to receive the return flow.
3. Provide privacy. Remove the undergarments to prevent soiling by the excreta. An old sheet or cloth may be given to the patient to wear until the irrigation is over.
4. A bath blanket may be kept around the shoulder to prevent chills.
5. Ask the patient to observe every step, so that he learns the care of the colostomy. It is desirable to have a family member be present to learn the procedure.
6. It is desirable to have some reading material or radio nearby to provide pleasure and diversion of the patient while waiting for the return flow.
7. Arrange articles conveniently for the nurse and the patient.
Steps of Procedure
1. Wash hands
Reason: to prevent cross infection
2. Fill the irrigating can with the solution and hang it at a required height.
Reason: rate of flow and force of the fluid depends upon the height of the reservoir.
3. Expel the air from the tubing and clamp it. Remove the froth if any, from the solution.
Reason: air introduced into the colon causes discomfort to the patient.
4. Untie the colostomy bag and remove the dressings, (not of the incision) if any, and discard them into the kidney tray.
Reason: the dressings over the incision are not removed for fear of infection of incision. It needs a sterile technique.
5. Clean the skin around the stoma with clean cotton swabs or rag pieces or wash the area with soap and water.
Reason: to prevent faecal matter into the colon along with the catheter.
6. Introduce the catheter through the teat and the tip of the catheter is lubricated with water soluble jelly. Lubricant is used sparingly.
Reason: lubrication of the catheter prevents friction. The lubricant should not clog the eye of catheter.
7. Pour some solution over stoma.
Reason: to test the temperature tolerance of the patient.
8. Introduce catheter into the stoma about 4 inches. Do not use any force.
Reason: all precautions are taken to prevent perforation of gut.
9. Allow the solution to run in slowly, involving about 20 minutes.
Reason: rapid distension of the colon can cause abdominal clamps.
10. Clamp the tube before the entry of entire fluid.
Reason: to prevent introduction of air into the colon.
11. Remove the catheter from stoma. Disconnect it from the tubing and place it in the kidney tray.
Reason: the catheter is highly contaminated.
12. Wait for the return flow. Divert the attention of patient by providing him reading material or radio. The patient may be asked to move from side to side and forward.
Reason: activity hastens the bowel movements.
After Care of the Patient and the Articles
1. When return flow is complete, remove the mackintosh. Clean the skin around the colostomy opening and dry the skin thoroughly.
2. Apply the clean dressing or a clean colostomy bag over the stoma to receive any drainage that may leak out.
3. After making sure that the patient is thoroughly clean, help him to wear his clean dresses.
4. Help the patient to get into his bed. Change the dressing of incision using aseptic technique. Make him comfortable. Tidy up the unit.
5. Take all articles to the utility room. Clean all equipments immediately. Rinse them first in cold water then with warm soapy water. Dry and store them in a convenient place for the next use.
6. Patients are instructed for the care and cleaning of the colostomy bags to prolong its life and keep it free of odors. Cleaning with soap or detergent with water and exposing it to fresh air is sufficient. However it may still may necessary to deodorize the bag with liquid deodorizers available in the market.
7. Chart the procedure in the patient’s record with date and time. Specify the amount and the kind of solution used, the participation of the patient in the procedure, abnormalities, if any, noted during the procedure etc. record the condition of the skin around the stoma. Report immediately any redness/excoriation of the skin noted and the immediate steps taken to prevent further damage.
AUTHOR : DAVID NEGI