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Colostomy Nursing Case Study with NCP Pathophysiology

Wednesday, 23 July 2014

colostomy is an opening (stoma) in the abdominal wall that allows for the defection of stool. It's created surgically in response to a GI problem caused by trauma, infection, inflammation, obstruction, malignancy, or a non-functioning bowel. A colostomy may be a temporary measure used to allow the bowel to heal.

Complications
■ Bleeding
■ Obstruction
■ Tissue necrosis



Assessment
Health perception and management

■ History of a GI disorder
■ Abdominal pain or cramping
■ Abdominal mass

Nutrition and metabolism
■ Anorexia
■ Nausea, vomiting
■ Weight loss
■ Poor dietary habits or choices

Elimination
■ Diarrhea, constipation
■ Recent change in bowel habits
■ Bloody stools

Activity and exercise
■ Decreased activity level
■ Weakness and fatigue

Sleep and rest
■ Disrupted sleep patterns

Cognition and perception
■ Denial of a serious problem

Self-perception and self-concept
■ Low self-esteem
■ Fear of a change in body image

Sexuality and reproduction
■ Impaired sexual relationship

Roles and relationships
■ Role as spouse or parent altered due to fear or anger
■ Fear regarding ability to function in the workplace appropriately

Coping and stress management
■ Anger and hostility possibly preceding hopelessness and despair
■ Bouts of depression

Values and beliefs
■ Feeling of being punished for past behavior
■ Religious and personal beliefs possibly affecting treatment

Physical examination

■ Physical examination findings will vary according to the cause of GI dysfunction. General findings that apply to some disorders are listed.

General appearance and nutrition
■ Poor skin turgor
■ Pale

Gastrointestinal
■ Abnormal or absent bowel sounds
■ Abdominal tenderness
■ Palpable abdominal mass
■ Abdominal distention and rigidity
■ Bloody stool

Renal and urinary
■ Decreased urine output

Diagnostic studies
Studies vary according to the patient's condition and the underlying disorder. They may include the following:

■ Complete blood count may reveal low hemoglobin level or hematocrit that indicates a continuing or unreplaced blood loss; it may also reveal an elevated white blood cell count, indicating infection (usually intra‑abdominal).

■ Electrolyte panel detects or rules out electrolyte abnormalities that affect fluid balance (for example, hyponatremia or hypernatremia) and GI tract function (for example, hypokalemia or hyperkalemia).

■ Carcinoembryonic antigen (CEA) levels may be done before and after surgery for comparison; if they're elevated before surgery, effective surgical resection should result in decreased CEA levels.

■ Flat plate or upright abdominal X‑ray may be done before surgery to rule out colon perforation (in a trauma patient) or colon obstruction (in a patient with suspected malignancy); it's done after surgery as needed to differentiate postoperative ileus (visualized as air‑filled loops of bowel) from mechanical obstruction (visualized as air‑fluid levels and dilated proximal bowel).

■ Transrectal ultrasound may be performed before surgery to determine lymph node involvement, tumor depth, and adhesions to adjacent structures.

■ Computed tomography scan of the abdomen may be used before or after surgery to rule out intra‑abdominal abscess or to detect metastatic lesions.

■ Stool guaiac (Hemoccult) test is used as a preliminary study to rule out GI bleeding; positive study requires further workup to rule out malignancy, hemorrhoidal bleeding, inflammatory bowel disease, or upper tract bleeding; a negative study is inconclusive because of the high incidence of false‑negative results.

■ Barium enema with air and contrast rules out diverticular disease and detects filling defects that indicate colon lesions (such as polyps and tumors).

■ Sigmoidoscopy or colonoscopy rules out colon lesions and allows removal of polyps or biopsy of suspicious lesions.
Nursing care plan
Nursing diagnosis
Nursing priorities

Risk for impaired skin integrity related to fecal contamination of the skin
     Provide appropriate skin care.

Deficient knowledge (colostomy care) related to lack of knowledge

     Provide teaching.


Disturbed body image related to altered method of fecal elimination

     Prevent or minimize alteration in body image.


Sexual dysfunction related to change in body image or damage to autonomic nerves (with rectal resection)
     Provide support and information regarding sexual function.



Other potential nursing diagnoses: Ineffective coping related to lifestyle changes ■ Anxiety related to diagnosis and surgery ■ Acute pain related to the surgical procedure ■ Death anxiety related to the diagnosis and procedure






Risk for impaired skin integrity related to fecal contamination of the skin
EXPECTED OUTCOME
The patient will display peristomal skin free from breakdown.
Suggested NOC Outcomes
Ostomy self-care; Risk control; Tissue integrity: Skin & mucous membranes
NURSING INTERVENTIONS
Intervention type
Intervention
Rationale
Collaborative
Obtain an enterostomal therapy nurse referral. Reinforce teachings as appropriate.


An enterostomal nurse can provide teaching regarding stoma care and evaluate and provide appropriate stoma supplies for optimal function. Accurately matching the pouch system to abdominal contours optimizes the pouch‑to‑skin seal and minimizes leakage.
 Independent
Assess the patient's skin surrounding the stoma with each pouch change. Note redness, excoriation, or a break in skin integrity.
Identification of skin breakdown allows for proper treatment.

 Independent
Use the appropriate principles in preparing and applying the pouch. Utilize appropriate supplies for skin preparation and the correct size of pouch; ensure an appropriate seal.
Good technique provides maximum security and skin protection.


 Independent
Change the pouch routinely every 5 to 7 days and as needed if there's leakage or if the patient complains of peristomal burning or itching.

Routine changes before leaks can occur protect the skin and provide the patient with a sense of control. Burning or itching may indicate fecal contamination of the skin.
 Independent
Teach the patient and family involved in care how to change the pouch and assess the peristomal skin.
Knowledge of these procedures will decrease the chance of complications.

Collaborative
Obtain a home care referral as appropriate.
Reinforcement of teaching and added assessment of techniques following discharge may decrease the chance of complications.

[Additional individualized interventions]

Suggested NIC Interventions
Incision site care; Ostomy care; Skin care: Topical treatments; Skin surveillance

Deficient knowledge (colostomy care) related to lack of knowledge
EXPECTED OUTCOME
The patient will describe colostomy function and appropriate care.
Suggested NOC Outcomes
Knowledge: Treatment regimen
NURSING INTERVENTIONS
Intervention type
Intervention
Rationale
Independent
Establish a teaching plan based on the patient's decision. Base teaching strategies on the patient's learning style, sensory strengths, and physical abilities.
The patient must be able to perform colostomy care before discharge.

Independent
Teach the patient and family involved in care about colostomy irrigation, if appropriate. Discuss the type of irrigation, scheduling, equipment, and expected outcome. Have the patient demonstrate the procedure.

Knowledge of a procedure can help the patient feel more control over his situation.
Working with the equipment will increase the patient's comfort level for use independently.
Independent
Discuss other management options, such as how to empty the pouch, how to establish a bowel routine, whether to wear a pouch continuously or intermittently, and how often to perform irrigation (if appropriate). Encourage verbalization of feelings and concerns. Answer all questions and clear up any misconceptions.
Control over bowel function will help the patient feel more secure and will promote confidence.
Exploring the pros and cons of various options and discussing the patient's concerns and priorities facilitates decision making and increases the patient's sense of self‑control.
Independent
Teach the patient measures to reduce and control flatus.

Inability to control flatus may lead to social embarrassment and self‑deprecation.
Independent
Teach the patient measures for odor control.


Odor control is a major concern of most patients; instruction in odor‑control methods increases feelings of control and confidence and reduces feelings of embarrassment and shame.

[Additional individualized interventions]

Suggested NIC Interventions
Teaching: Procedure/treatment

Disturbed body image related to altered method of elimination
EXPECTED OUTCOME
The patient will describe plans for resuming his preoperative lifestyle.
Suggested NOC Outcomes
Body image; Self-esteem
NURSING INTERVENTIONS
Intervention type
Intervention
Rationale
Independent
Teach the patient how to conceal the pouch under clothing; wearing a knit or stretchy layer next to the skin holds the pouch close to the body and helps conceal large or bulky stomas.
The ability to dress normally and look the same as before surgery diminishes alterations in body image and enhances self‑concept.

Independent
Discuss the normal emotional response to colostomy with the patient and his family. Allow them to explore their feelings about the colostomy. Assess the patient's usual coping strategies. Present helpful coping strategies, such as discussing feelings and seeking information.
Discussing the normal emotional response and accepting negative feelings gives the patient and his family permission to explore their feelings. Accepting feelings enhances self‑concept and promotes adaptation. Discussing various coping strategies may provide the patient with new or more effective ways to handle emotions.

Independent
Discuss colostomy management during occupational, social, and sexual activity. Help the patient to role‑play difficult situations such as telling someone about the stoma.
Preparing for such activities increases coping skills and the likelihood that the patient will manage them successfully. Role-playing helps the patient prepare for difficult situations, which increases his sense of control and enhances self‑concept.

Independent
Offer information on the United Ostomy Association; arrange for an ostomy visitor, if the patient wishes.

Contact with others who have ostomies reduces isolation and increases perception of the colostomy as manageable, thus enhancing the patient's sense of control.


[Additional individualized interventions]

Suggested NIC Interventions
Anticipatory guidance; Body image enhancement; Coping enhancement; Grief work facilitation; Self-esteem enhancement; Socialization enhancement

Sexual dysfunction related to change in body image or damage to autonomic nerves (with rectal resection)
EXPECTED OUTCOME
The patient will share his feelings about the stoma with his spouse or partner, describe any alteration in sexual function (if applicable), and describe measures for pouch management during sexual activity (if applicable).
Suggested NOC Outcomes
Anxiety level; Body image; Sexual functioning
NURSING INTERVENTIONS
Intervention type
Intervention
Rationale
Independent
Assess the patient's and significant other's attitudes toward the presence of the colostomy. Encourage verbalization of feelings and concerns.

 Both the patient and spouse (or partner) may have concerns and negative feelings that can affect their sexual relationship. Openness in discussing feelings may help resolve these.
Independent
Teach the patient measures for securing and concealing the pouch during sexual activity.


Securing and concealing the pouch help prevent leakage and allow the encounter to focus on sexuality and sharing rather than on the pouch and stoma.
Independent
For a female with a wide rectal resection, discuss the possible need for artificial lubrication.

For a male with a wide rectal resection, explain potential interference with erection and ejaculation; explain that no loss of sensation or orgasmic potential will occur; explore alternatives to intercourse as indicated; and explain the availability of penile injections, urethral inserts, penile prostheses, and vacuum devices to restore erectile function. Reinforce the importance of intimacy, whether or not it involves intercourse.

Wide rectal resection may damage parasympathetic nerves thought to mediate vaginal lubrication.
Wide rectal resection may damage parasympathetic nerves controlling erection and sympathetic nerves controlling ejaculation. Sensation and orgasm, mediated by the pudendal nerve, remain intact. Intimacy—emotional closeness—is a human need separate from the desire for sexual expression. It can be met in ways other than sexual behavior, such as sharing feelings and affectionate touching. A number of medical and surgical interventions are now available that restore erectile function.

[Additional individualized interventions]


Suggested NIC Interventions
Sexual counseling
Teaching checklist

■ Disease process and its implications
■ Normal stoma characteristics and function
■ Colostomy care
■ Signs and symptoms of complications
■ Normal adaptation process and feelings after colostomy
■ Home care and community resources available
■ Sources of colostomy supplies and reimbursement procedures
■ Follow-up care

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