2. CARE OF COLOSTOMIES
▪ Definition
▪ Indications
▪ Types of colostomies
▪ Care of colostomies
▪ Complications of colostomy
Definition
-Colostomy refers to surgical bringing out, through the
abdominal wall, a portion of the large intestine to carry out
stool.
Indications for colostomies
1. Decompress an obstructed colon
2. Evacuation of stool when the distal colon or rectum is
removed like in colorectal cancer
3.To divert the fecal stream in preparation for resection of
an inflammatory, obstructive, or perforated lesion or
following traumatic injury;
4. To protect a distal anastomosis following resection.
Types of colostomy
Classification by function
Temporary colostomies - created to divert stool from
injured or diseased portions of the large intestine, allowing
rest and healing before closure of colostomy and
anastomosis of the colon is done
Permanent colostomies are performed when the distal
bowel (bowel at the farthest distance) must be removed or
is blocked and inoperable.
Classification by nature of stoma
Loop colostomy
-This colostomy is created by bringing a loop of bowel
through an incision in the abdominal wall.
-The loop is held in place outside the abdomen by a plastic
rod slipped beneath it.
-An incision is made in the loop to allow the passage of
stool through the loop colostomy.
-The supporting rod is removed approximately 7-10 days
after surgery, when healing has occurred that will prevent
the loop of bowel from retracting into the abdomen.
A loop colostomy is most often performed for creation of
a temporary stoma to divert stool away from an area of
intestine that has been blocked or ruptured.
Terminal or end colostomy (Hartman's colostomy)
-The colon is divided and the proximal end is brought out
(functional part) while the distal end closed and left intra
abdominal (dysfunctional part)
-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.
-An end colostomy is usually a permanent ostomy,
resulting from trauma, cancer or another pathological
condition
Double barred colostomy
(Also Divided colostomy /Paul-Mickulicz colostomy )
Involves the creation of two separate stomas on the
abdominal wall by exteriorizing both ends of the divided
colon.
The proximal stoma is the functional end that is
connected to the upper gastrointestinal tract and will
drain stool. The distal stoma, connected to the rectum
and also called a mucous fistula, drains small amounts
of mucus material. This is most often a temporary
colostomy performed to rest an area of bowel, and to be
later closed.
Care of colostomies
Immediate post operative
General
1.Monitor vital signs every 15 minutes until patient is
awake then 30 minutes until patient gets to the ward then
every 4 hours
2. IV fluids (NS and Dextrose) at least 500mls every 6
hours
3.Continue prophylactic antibiotics
4. Analgesia- 1mg/kg of pethidine then introduce IM
NSAIDs as decrease pethidine dose.
5.Keep patient nil per oral
6. Keep input and output chart thus keep NG tube, and
urethral catheter.
Stoma management.
1.The patient is instructed how to support the operative
site during deep breathing and coughing
2. The stoma is observed for color and amount of wound
drainage. Initially, the colostomy will drain bloody
mucus.
3. Fluids and electrolytes are infused intravenously until
the patient's diet is can gradually be resumed, beginning
with liquids with the return of bowel sounds.
Usually within 72 hours, passage of gas and stool
through the stoma begins. Initially the stool is liquid,
gradually thickening as the patient begins to take solid
foods.
The patient is usually out of bed in 8–24 hours after
surgery and discharged in 2–4 days.
4. Counseling
All patients should be counseled about colostomy before
surgery and counseling and education continued after the
surgery both within the ward and even after discharge.
The counseling should also include the spouse and the
family members to ensure support of the patient and to
continue his usual lifestyle.
5.Education
During the hospital stay, the patient and his or her
caregivers will be educated on how to care for the
colostomy.
i)-Determination of appropriate pouching supplies
ii)Proper application of the pouch on the stoma to avoid
leakage
ii)Schedule of how often to change the pouch
iii) Regular assessment and meticulous care of the skin.
iv) diet changes
v)counseling on regular activities and work
3. Continued care of colostomy after discharge
1.Skin care
-Frequent Cleaning of the area around the stoma with soap
and water and adequate drying.
-The skin around the stoma may be protected by
application of water repellants as zinc oxide and Vaseline.
-To make sure that the colostomy bag fits snugly around
the stoma to avoid leakage to the surrounding skin
2.Control of odor
-Well managed colostomy should not have disturbing odor.
This should be achieved by.
-Prompt changing of the colostomy bags to avoid filling
with effluent and leakage.
-Avoid diet with spices causes’ bad odor.
-Cleaning the skin around the stoma
-General hygiene of the body
-Use of deodorants incase all this fails.
3.Diet
-Patient is encouraged to take a balanced diet and to
increase his fluid intake because of loss of water through
the effluents.
-Avoid spices in food which give the effluents bad smell.
-Avoid food with lots of roughage as vegetables which
increases the amounts of effluent discharged.
4.Lifestyle
As much as possible, Patient should continue with the
normal lifestyle.
-Should continue with his work or employment as normal.
-Should continue to have normal sexual function without
hindrance
However, few modifications
Bathing – You can shower or bathe with the pouch on or
off.
Swimming – Use waterproof tape around the stoma
Lifting – Heavy lifting should be avoided and if previous
job involved this then should change job.
5.Colostomy bags
Patient should be able to get regular supply of affordable
colostomy bags for continued use.
6.Social support
Patient should be supported by the family thus the
importance counseling spouse and family.
Should be linked to colostomy society and associations for
social support and continued education
7.Know when to consult a doctor
-Change in stoma color, swelling or bleeding.
-Skin irritation, redness, or rash around stoma.
-Change in color, amount or appearance of stool.
-Vomiting, abdominal swelling, or cramping with fever
Complications of colostomy
1.Gangrene of stomal tissue
Caused by inadequate blood supply, this complication is
usually visible 12–24 hours after the operation and may
require additional surgery.
2.Stomal Stenosis
(Narrowing at the opening of the stoma). Often
associated with infection around the stoma or scarring.
Mild stenosis can be removed under local anesthesia.
Severe stenosis may require surgery for reshaping the
stoma.
3.Stomal Retraction
-Stoma is flush with the abdomen surface or has moved
below it. Caused by insufficient stomal length, this
complication may be managed by use of special
pouching supplies.
-Elective revision of the stoma is also an option.
4.Stomal Prolapse
-Stoma increases length above the surface of the
abdomen).
-Most often results from an overly large opening in the
abdominal wall or inadequate fixation of the bowel to
the abdominal wall.
-Surgical correction is required when blood supply is
compromised.
5.Parastomal hernia
-Bowel causing bulge in the abdominal wall next to the
stoma. This is due to placement of the stoma where the
abdominal wall is weak or creation of an overly large
opening in the abdominal wall. The use of an ostomy
support belt and special pouching supplies may be
adequate. If severe, the defect in the abdominal wall
should be repaired and the stoma moved to another
location
6. Parastomal abscess formation
Others
7.Infection/sepsis
8.Skin irritation around the stoma
9.Feccal impaction
10.Diarrhhea.
11.Psychological
NB Location of colostomy Consider:
-The contour of abdomen
-The belt line should be placed away from it.
-Away from bony prominences
-Placed in the descending colon-if possible. Semi-solid
discharge reduce the water loss.
