NURSING MANAGEMENT OF THE PATIENT REQUIRING AN ILEOSTOMY
Some patients with IBD eventually require permanent fecal di-version with creation of an ileostomy to manage symptoms and to treat or prevent complications. The Plan of Nursing Care 38-1 summarizes care for the patient requiring an ostomy.
A period of preparation with intensive replacement of fluid, blood, and protein is necessary before surgery is performed. Anti-biotics may be prescribed. If the patient has been taking corti-costeroids, they will be continued during the surgical phase to prevent steroid-induced adrenal insufficiency. Usually, the patient is given a low-residue diet, provided in frequent, small feedings. All other preoperative measures are similar to those for general abdominal surgery. The abdomen is marked for the proper place-ment of the stoma by the surgeon or the enterostomal therapist. Care is taken to ensure that the ostomy stoma is conveniently placed–usually in the right lower quadrant about 2 inches below the waist, in an area away from previous scars, bony prominence, skin folds, or fistulas.
The patient must have a thorough understanding of the surgery to be performed and what to expect after surgery. Infor-mation about an ileostomy is presented to the patient by means of written materials, models, and discussion. Preoperative teach-ing includes management of drainage from the stoma, the nature of drainage, and the need for nasogastric intubation, parenteral fluids, and possibly perineal packing.
General abdominal surgery wound care is required. The nurse observes the stoma for color and size. It should be pink to bright red and shiny. For the traditional ileostomy, a tempo-rary plastic bag with adhesive facing is placed over the ileostomy and firmly pressed onto surrounding skin. The nurse monitors the ileostomy for fecal drainage, which should begin about 72 hours after surgery. The drainage is a continuous liq-uid from the small intestine because the stoma does not have a controlling sphincter. The contents drain into the plastic bag and are thus kept from coming into contact with the skin. They are collected and measured when the bag becomes full. If a continent ileal reservoir was created, as described for the Kock pouch, continuous drainage is provided by an indwelling reservoir catheter for 2 to 3 weeks after surgery. This allows the suture lines to heal.
As with other patients undergoing abdominal surgery, the nurse encourages those with an ileostomy to engage in early am-bulation. It is important to administer prescribed pain medica-tions as required.
Because these patients lose much fluid in the early post-operative period, an accurate record of fluid intake, urinary output, and fecal discharge is necessary to help gauge the fluid needs of the patient. There may be 1000 to 2000 mL of fluid lost each day in addition to expected fluid loss through urine, perspiration, respiration, and other sources. With this loss, sodium and potassium are depleted. The nurse monitors labo-ratory values and administers electrolyte replacements as pre-scribed. Intravenous fluids are administered to replace fluid losses for 4 to 5 days.
Nasogastric suction is also a part of immediate postoperative care, with the tube requiring frequent irrigation, as prescribed. The purpose of nasogastric suction is to prevent a buildup of gas-tric contents. After the tube is removed, the nurse offers sips of clear liquids and gradually progresses the diet. It is important to immediately report nausea and abdominal distention, which may indicate obstruction.
By the end of the first week, rectal packing is removed. Because this procedure may be uncomfortable, the nurse may administer an analgesic an hour before it is performed. After the packing is removed, the perineum is irrigated two or three times daily until full healing takes place.
The patient understandably may think that everyone is aware of the ileostomy and may view the stoma as a mutilation compared with other abdominal incisions that heal and are hidden.
Because there is loss of a body part and a major change in anatomy, the patient often goes through the various phases of grieving—shock, disbelief, denial, rejection, anger, and restitution. Nursing sup-port through these phases is important, and understanding of the patient’s emotional outlook in each instance should determine the approach taken. For example, teaching may be ineffective until the patient is ready to learn. Concern about body image may lead to questions related to family relationships, sexual function, and for women, the ability to become pregnant and to deliver a baby normally. Patients need to know that someone understands and cares about them. A calm, nonjudgmental attitude exhibited by the nurse aids in gaining the patient’s confidence. It is impor-tant to recognize the dependency needs of these patients. Their prolonged illness can make them irritable, anxious, and depressed. The nurse can coordinate patient care through meetings attended by consultants such as the physician, psychologist, psy-chiatrist, social worker, enterostomal therapist, and dietitian. The team approach is important in facilitating the often complex care of this patient.
Conversely, a surgical procedure to create an ileostomy can produce dramatic positive changes in patients who have suffered from IBD for several years. After the continuous discomfort of the disease has decreased and patients learn how to take care of the ileostomy, they often develop a more positive outlook. Until they progress to this phase, an empathetic and tolerant approach by the nurse plays an important part in recovery. The sooner the patient masters the physical care of the ileostomy, the sooner he or she will psychologically accept it.
The support of other ostomates is also helpful. The United Ostomy Association is dedicated to the rehabilitation of osto-mates. This organization gives patients useful information about living with an ostomy through an educational program of litera-ture, lectures, and exhibits. Local associations offer visiting ser-vices by qualified members who provide hope and rehabilitation services to new ostomy patients. Hospitals and other health care agencies may have an enterostomal therapy nurse on staff who can serve as a valuable resource person for the ileostomy patient.
The patient with a traditional ileostomy cannot establish regular bowel habits because the contents of the ileum are fluid and are discharged continuously. The patient must wear a pouch at all times. Stomal size and pouch size vary initially; the stoma should be rechecked 3 weeks after surgery, when the edema has subsided. The final size and type of appliance is selected in 3 months, after the patient’s weight has stabilized, and the stoma shrinks to a sta-ble shape.
The location and length of the stoma are significant in the man-agement of the ileostomy by the patient. The surgeon positions the stoma as close to the midline as possible and at a location where even an obese patient with a protruding abdomen can care for it easily. Usually, the ileostomy stoma is about 2.5 cm (1 in) long, which makes it convenient for the attachment of an appliance.
Skin excoriation around the stoma can be a persistent problem. Peristomal skin integrity may be compromised by several factors, such as an allergic reaction to the ostomy appliance, skin barrier, or paste; chemical irritation from the effluent; mechanical injury from the removal of the appliance; and possible infection. If irri-tation and yeast growth occur, nystatin powder (Mycostatin) is dusted lightly on the peristomal skin.
A regular schedule for changing the pouch before leakage occurs must be established for those with a traditional ileostomy. The patient can be taught to change the pouch in a manner similar to that described in Chart 38-4.
The amount of time a person can keep the appliance sealed to the body surface depends on the location of the stoma and on body structure. The usual wearing time is 5 to 7 days. The appli-ance is emptied every 4 to 6 hours or at the same time the patient empties the bladder. An emptying spout at the bottom of the ap-pliance is closed with a special clip made for this purpose.
Most pouches are disposable and odor-proof. Foods such as spinach and parsley act as deodorizers in the intestinal tract; foods that cause odors include cabbage, onions, and fish. Bismuth sub-carbonate tablets, which may be prescribed and taken by mouth three or four times each day, are effective in reducing odor. A stool thickener, such as diphenoxylate (Lomotil), can also be prescribed and taken orally to assist in odor control.
For a continent ileostomy (ie, Kock pouch), the nurse teaches the patient to drain the pouch, as described in Chart 38-5. A catheter is inserted into the reservoir to drain the fluid. The length of time between drainage periods is gradually increased until the reservoir needs to be drained only every 4 to 6 hours and irrigated once each day. A pouch is not necessary; instead, most patients wear a small dressing over the opening.
When the fecal discharge is thick, water can be injected through the catheter to loosen and soften it. The consistency of the effluent is affected by food intake. At first, drainage is only 60 to 80 mL, but as time goes on, the amount increases significantly. The internal Kock pouch stretches, eventually accommodating 500 to 1000 mL. The patient learns to use the sensation of pressure in the pouch as a gauge to determine how often the pouch should be drained.
A low-residue diet is followed for the first 6 to 8 weeks. Strained fruits and vegetables are given. These foods are important sources of vitamins A and C. Later, there are few dietary restrictions, ex-cept for avoiding foods that are high in fiber or hard-to-digest kernels, such as celery, popcorn, corn, poppy seeds, caraway seeds, and coconut. Foods are reintroduced one at a time. The nurse assesses the patient’s tolerance for these foods and reminds him or her to chew food thoroughly.
Fluids may be a problem during the summer, when fluid lost through perspiration adds to the fluid loss through the ileostomy. Fluids such as Gatorade are helpful in maintaining the electrolyte balance. If the fecal discharge is too watery, fibrous foods (eg, whole-grain cereals, fresh fruit skins, beans, corn, nuts) are re-stricted. If the effluent is excessively dry, salt intake is increased. Increased intake of water or fluid does not increase the effluent, because excess water is excreted in the urine.
Monitoring for complications is an ongoing activity for the pa-tient with an ileostomy. Minor complications occur in about 40% of patients who have an ileostomy; less than 20% of the compli-cations require surgical intervention (Kirsner & Shorter, 2000).
Common complications include skin irritation, diarrhea, stomal stenosis, urinary calculi, and cholelithiasis. Peristomal skin irritation, the most common complication of an ileostomy, re-sults from leakage of effluent. A pouch that does not fit well is often the cause. The nurse or an enterostomal therapist adjusts the pouch and skin barriers are applied. Diarrhea, manifested by very irritating effluent that rapidly fills the pouch (every hour or sooner), can quickly lead to dehydration and electrolyte losses. Supplemental water, sodium, and potassium are administered to prevent hypovolemia and hypokalemia. Antidiarrheal agents are administered. Stenosis is caused by circular scar tissue that forms at the stoma site. The scar tissue must be surgically released. Uri-nary calculi occur in about 10% of ileostomy patients because of dehydration from decreased fluid intake. Intense lower abdominal pain that radiates to the legs, hematuria, and signs of dehydration indicate that the urine should be strained. Fluid intake is en-couraged. Sometimes, small stones are passed during urination; otherwise, treatment is necessary to crush or remove the calculi.
Cholelithiasis (ie, gallstones) occurs three times more com-monly in patients with an ileostomy than in the general population because of changes in the absorption of bile acids that occur post-operatively. Spasm of the gallbladder causes severe upper right abdominal pain that can radiate to the back and right shoulder.
The spouse and family should be familiar with the adjustment that will be necessary when the patient returns home. They need to know why it is necessary for the patient to occupy the bathroom for 10 minutes or more at certain times of the day and why cer-tain equipment is needed. Their understanding is necessary to reduce tension; a relaxed patient tends to have fewer problems. Vis-its from an enterostomal therapy nurse may be arranged to ensure that the patient is progressing as expected and to provide additional guidance and teaching as needed.
The patient needs to know the commercial name of the pouch to be used so that he or she can obtain a ready supply and should have information about obtaining other supplies. The names and contact information of the local enterostomal therapy nurse and local self-help groups are often helpful. Any special restrictions on driving or working also need to be reviewed. The nurse teaches the patient about common postoperative complications and how to recognize and report them (Chart 38-6).
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