Introduction to Medical-Surgical Nursing, 6th ed.
26
Lesson Plans for
The Patient with an Ostomy
CHAPTER LESSON PLANS & OBJECTIVES
Lesson 26.1:
2. Describe nursing interventions to prepare the patient for ostomy surgery.
4. Assist in developing a nursing process to plan care for the patient with each of the following types of
fecal diversion: ileostomy, continent ileostomy, ileoanal reservoir, and colostomy.
Lesson 26.2:
5. Explain the types of procedures done for urinary diversion.
7. Discuss content to be included in teaching patients to learn to live with ostomies.
CHAPTER TEACHING FOCUS
• In this chapter, the student will be introduced to topics related to the ostomy patient, including
indications and preparation for ostomy surgery, and types of fecal and urinary diversion, such as
ileostomy, colostomy, and cutaneous ureterostomy.
2 Chapter 26 The Patient with an Ostomy _______________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
CHAPTER PRETEST
Have the students answer these questions prior to covering this chapter to understand where they stand
in relation to the content.
1) An ostomy is a surgical opening to the outside of the body for the purpose of __________.
a) draining an infection
b) fecal or urinary diversion
c) repairing a prolapse
d) curing incontinence
2) Consistency of the drainage from a colostomy depends on __________.
a) site of the surgery
b) site of the stoma
c) nutritional intake
d) amount of irrigation
3) Preoperative patient education for an ostomy would include __________.
a) choosing comfortable clothing
b) providing favorite foods
c) determining coping strategies and knowledge deficits
d) 15-minute vital signs
4) A nursing intervention that is more appropriate for patients who have had an ostomy performed than
for patients who have undergone general surgery would be __________.
a) nutritional deficit
b) adequate hydration
c) monitoring vital signs
d) disturbed body image
5) Skin breakdown is an ongoing concern in ostomy patients. An important part of applying a pouch
would be the use of __________.
a) tight clothing for pressure
b) a protective barrier or sealant
c) surgical gauze
d) the most expensive appliance available
6) Maintaining accurate intake and output documentation for an ostomy patient is essential because of
__________.
a) increased liquid drainage from the stoma and nasogastric suctioning
b) nutritional deficits
c) decreased oral intake
d) irrigation of the ostomy
7) Odor from an ostomy can be decreased by __________.
a) using a strong air freshener
b) irrigating the ostomy often
c) emptying the pouch frequently
d) eliminating gas-forming foods and cleaning the pouch
8) Meticulous skin care is needed for patients who have an ostomy from urinary diversion surgery
because of __________.
a) increased odor
b) the possibility of urinary tract infections and skin breakdown
c) skin rashes
d) hard-to-fit pouches
Introduction to Medical-Surgical Nursing, 6th ed.
9) The most common urinary diversions are __________.
a) colostomy and ileostomy
b) continent internal reservoirs
c) ureterostomy and ileal conduits
d) Kock pouches
10) Management of an ostomy is best taught by __________.
a) demonstration and gradual self-management
b) patient education instructions on discharge
c) an enteral therapist
d) a volunteer with a colostomy
4 Chapter 26 The Patient with an Ostomy _______________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
Chapter Pretest Answers
CHAPTER BACKGROUND ASSESSMENT
Discuss these questions with your students prior to covering this chapter to understand where they stand
in relation to the content.
Question: What are three nursing interventions and their rationales for postoperative ostomy patients?
Question: What is the difference between temporary and permanent ostomies?
Answer: Temporary ostomies bypass an affected portion of the bowel or urinary tract and allow time for
_______________________________________________________ Chapter 26 The Patient with an Ostomy 5
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 26.1
Instructor Preparation
Textbook Objectives Covered
1. List the indications for ostomy surgery to divert urine or feces.
3. Explain the types of procedures used for fecal diversion.
4. Assist in developing a nursing process to plan care for the patient with each of the following
types of fecal diversion: ileostomy, continent ileostomy, ileoanal reservoir, and colostomy.
Lesson Preparation Checklist
• Prepare lecture from TEACH lecture slides available on Evolve.
• Demonstration
• Guest speaker: enterostomal therapist
• Student performance evaluation of all entry-level skills required for student comprehension of
principles underlying care of the ostomy patient, including:
• Understanding the indications and preparation for ostomy surgery
• Understanding types of fecal diversion, including ileostomy, continent (pouch) ileostomy,
• Assemble materials and supplies needed for each lesson as indicated below.
Materials and Supplies
• computer and PowerPoint
projector
Key Terms
• anastomosis (p. 416)
• colostomy (p. 424)
• ileostomy (p. 416)
• stoma (p. 414)
• ureterostomy (p. 429)
Student Preparation
Assignments 2 hours
1
READ – Textbook (pp. 414-429)
ANSWER – Text
• Review Questions for the NCLEX Examination: 1, 2 (p. 433)
ANSWER – Study Guide
• Part IIE: 16 (p. 153)
2
READ – Textbook (pp. 415-430)
ANSWER – Study Guide
• Part IIE: 2-5, 17, 18 (p. 152)
6 Chapter 26 The Patient with an Ostomy _______________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 26.1
3
READ – Textbook (pp. 415-418)
REVIEW
• Figure 26-1: Types of colostomies (p. 416)
• Figure 26-2: Continent ileostomy (p. 417)
ANSWER – Study Guide
• Part IC: 1-4 (p. 151)
• Part IIE: 1 (p. 152)
4
READ – Textbook (pp. 418-427)
REVIEW
• Box 26-1: Postoperative Assessment of the Patient with an Ostomy (p. 418)
• Nursing Care Plan 26-1: Patient with a Colostomy (p. 426)
ANSWER – Study Guide
• Part IA: 1-10 (p. 149)
• Part IB: 13 (p. 150)
• Part IC: 5, 6 (p. 151)
_______________________________________________________ Chapter 26 The Patient with an Ostomy 7
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 26.1
Lecture Outline 20 minutes
Slide 1
Chapter 26
The Patient with an Ostomy
1
Slide 2
The Ostomy Patient
• Ostomy
• Surgical creation of artificial opening into a body cavity
• Stoma
• The site of the opening on the skin
• Ostomies in the digestive tract
TALKING POINTS:
• The gastrostomy is used for long-term feedings.
• Jejunostomies, duodenostomies, ileostomies, and colostomies are created to drain fecal
matter from the intestines.
Slide 3
Indications and Preparation for Ostomy Surgery
• Temporary ostomy
• May be indicated after surgery or trauma or when there is severe inflammation or
infection
• Bypasses the affected portion of the bowel or urinary tract, giving it time to heal
• Permanent ostomy
• Necessitated by cancer of the bladder or colon or severe inflammatory bowel disease
TALKING POINTS:
• What is an enterostomal therapist (ET)?
• The exact placement of the stoma is very important.
• Two factors must be considered: secure pouch placement and ease of self-care.
2
Assessment
• Determine expectations, understanding of the procedure, information desired, and fears
TALKING POINTS:
• Why would a mark be placed on the patient’s abdomen before surgery?
8 Chapter 26 The Patient with an Ostomy _______________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 26.1
Slide 5
Interventions
• Anxiety
• Help the patient identify his or her concerns
• Appearance, job, or family life disruptions
• Encourage patients to talk and use coping strategies that have been effective in the
past
• Reduce anxiety before teaching
3
Interventions (cont.)
• Deficient knowledge
• Basic ostomy care should be taught before surgery
TALKING POINTS:
• Volunteers are people with ostomies who have been trained to counsel other patients
about adjustment to their ostomies.
• Why is it a good idea to have a volunteer counsel the patient?
Slide 7
Fecal Diversion
• Ileostomy
• An opening in the ileum
• Necessary when entire colon must be bypassed or removed
TALKING POINTS:
• The ileum is the distal portion of the small intestine that empties into the large intestine.
• What is multiple polyposis?
4
Slide 8
Fecal Diversion (cont.)
• Ileostomy
• Procedure
• A surgical incision is made in the abdomen
• A loop or the end of the ileum is brought out through a second abdominal incision
TALKING POINTS:
• Digestive secretions quickly begin to drain from the stoma.
• A pouch is applied that collects fecal drainage to keep it from contaminating the surgical
incision and to protect surrounding skin.
• What is a Kock pouch?
• Types of colostomies. Single-barreled (end) colostomies are usually permanent. Double-
_______________________________________________________ Chapter 26 The Patient with an Ostomy 9
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 26.1
Slide 9
Assessment
• Health history
• Document significant symptoms such as pain, anorexia, nausea, vomiting, weakness,
TALKING POINTS:
• What should the functional assessment reveal?
Slide 10
Assessment (cont.)
• Physical examination
• Observe patient’s general status
• Level of consciousness, orientation, posture, and expression
• Vital signs and weight; compare with preoperative findings
• Skin color, warmth, and turgor
• Inspect oral tissues for moisture
TALKING POINTS:
• When healed, the stoma should be rose red, somewhat darker than the color of the oral
mucosa.
• What would a very pale, bluish, or black stoma indicate?
• A small amount of bleeding around the base of a new stoma is not unusual.
Slide 11
Interventions
• Risk for deficient fluid volume
• Administer intravenous fluids as ordered; carefully monitor hydration status
• Keep accurate intake and output records
• Measure output from all sources, including urine, gastric contents, and fecal drainage
TALKING POINTS:
• The loss of fluids and electrolytes through nasogastric suction and the passage of liquid
stool can lead to deficient fluid volume and electrolyte imbalances.
• When the patient resumes oral intake, advise a daily fluid intake of 2 to 3 liters. During hot
weather or illness, additional fluids may be required.
• What can the loss of bicarbonate in ileostomy drainage cause?
10 Chapter 26 The Patient with an Ostomy _______________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 26.1
Slide 12
Interventions (cont.)
• Impaired skin integrity
• Check the pouch hourly at first to detect leakage
• When pouch emptied or changed, prevent fecal matter from contaminating the
primary incision
• Clean skin around the stoma gently but thoroughly
TALKING POINTS:
• Why is it important to keep fecal material off of the skin?
• A good pouch is one that protects the skin, contains wastes and gas, is odor-proof,
permits freedom of movement, provides security for the patient, and is not noticeable.
Slide 13
Interventions (cont.)
• Disturbed body image
• Assure patient that odor is normal when the pouch is being changed or emptied, but
that it can be controlled at other times
TALKING POINTS:
• The patient who has an ileostomy is no longer able to control the passage of fecal matter
and must learn to manage bowel elimination in a new way.
• Inability to control odor associated with passage of gas through the stoma is another
concern for the patient with an intestinal ostomy.
• What may cause increased odor?
_______________________________________________________ Chapter 26 The Patient with an Ostomy 11
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 26.1
3
Slide 14
Interventions (cont.)
• Sexual dysfunction and/or Ineffective sexuality patterns
• Encourage patients to ask questions about how the ostomy might affect sexual
function or behavior
• Practical suggestions may help resume sexual activity
TALKING POINTS:
• Patients may feel unattractive or fear rejection by their partner.
• What problems may occur in men if there is nerve damage associated with perineal
surgery?
Slide 15
Interventions (cont.)
• Ineffective therapeutic regimen management
• After surgery, some teaching should be included every time stoma care is done
• At first, you may simply tell patient what is being done and why
TALKING POINTS:
• Some patients adjust more easily than others to an ostomy.
• What is the first step in accepting a stoma?
4
Slide 16
Continent (Pouch) Ileostomy
• Internal pouch created from loop of ileum for storing fecal matter
• Advantage: patient does not have continuous drainage and so does not have to wear a
pouch
• Procedure
• A loop of the ileum is sutured together and then opened
• A portion of the distal end of the ileum is inverted within itself to create a nipple valve
• The valve prevents fluid leakage from the pouch
TALKING POINTS:
• What patients may not be candidates for the continent ileostomy?
• During surgery, a catheter is placed through the stoma into the pouch and sutured in
place.
• The catheter is connected to low intermittent suction to keep the pouch empty.
• This prevents stress on the suture lines while the pouch heals.
12 Chapter 26 The Patient with an Ostomy _______________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 26.1
Slide 17
Assessment
• Essentially the same as that of the patient with an ileostomy
• Assess for continuous drainage because obstruction of the catheter may occur
• Absence of drainage or patient complaints of a feeling of fullness in the pouch suggest
obstruction
• Drainage bloody at first, then brownish
Slide 18
Interventions
• Risk for injury
• Patient given only intravenous fluids to allow the bowel to heal and peristalsis to
resume
• Eventually the patient will need to drain the pouch only 2 to 4 times a day
TALKING POINTS:
• The catheter is removed after several days, and the pouch is drained at intervals.
• How much can the pouch hold initially?
3
Slide 19
Interventions (cont.)
• Deficient knowledge
• Draining the continent ileostomy
• Have the patient sit or lie down for the procedure
• Gather lubricant, #28 catheter, drape, basin, irrigating syringe, irrigating solution,
gauze dressing
• Lubricate catheter and insert it gently into the stoma
• Resistance will be felt when the catheter reaches the nipple valve (approximately
2 inches past the stoma)
Slide 20
Interventions (cont.)
• Draining the continent ileostomy
• If the drainage is too thick, instill 30 mL of normal saline as ordered; gently aspirate
• Do not do this unless necessary because it may cause dislocation of the nipple
• When drainage stops, quickly remove the catheter
• Place gauze dressing over the stoma to absorb secretions
_______________________________________________________ Chapter 26 The Patient with an Ostomy 13
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 26.1
Slide 21
Ileoanal Reservoir
• Fecal matter is stored and then eliminated through the rectum
• Procedure
• First stage
• Colon is removed and an internal pouch that is created from the ileum is attached
to the anorectal canal
4
Slide 22
Ileoanal Reservoir (cont.)
• Complications
• Obstruction
• Scar tissue or strictures may cause obstruction
• Signs and symptoms: abdominal distention, nausea and vomiting, decreased
bowel sounds, change in bowel pattern
• Peritonitis
• If fecal matter leaks through the suture lines of the reservoir into abdominal cavity,
Slide 23
Assessment
• Same as for the patient with an ileostomy
• In addition, assess for rectal drainage and condition of the perianal skin
Slide 24
Interventions
• Risk for impaired skin integrity
• Skin around the ileostomy stoma and in the perianal area needs special care
• Until reservoir is well-healed, liquid discharge may be expelled without warning
• Thorough, gentle cleansing and protective creams help prevent skin breakdown
3
Interventions (cont.)
• Bowel incontinence
• Perineal pads to prevent soiling of clothing
TALKING POINTS:
• Initially, the patient may have as many as 20 stools a day.
• After a week, the number of stools decreases to 8 to 10 daily.
• How many stools should be expected by 6 months?
14 Chapter 26 The Patient with an Ostomy _______________________________________________________
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 26.1
Slide 26
Interventions (cont.)
• Risk for injury
• Assess for signs and symptoms of bowel obstruction, peritonitis, and inflammation
• If obstruction occurs, give intravenous fluids and nothing by mouth
• Nasogastric tube inserted to decompress the bowel
• If obstruction is caused by adhesions (scar tissue), surgery may be necessary to
release the restriction
TALKING POINTS:
• Sometimes a stricture or narrowing develops at the site where the ileum is joined to the
rectum.
• When is a stricture most likely to occur?
4
Slide 27
Colostomy
• Opening in the colon through which fecal matter is eliminated
• Procedure
• Bringing a loop or an end of the intestine through the abdominal wall and creating a
TALKING POINTS:
• The location of the colostomy affects the characteristics of the fecal drainage: the closer
to the rectum, the more formed the stool.
• What is the expected consistency of drainage from a transverse colostomy? Descending
or sigmoid colostomy?
Slide 28
Colostomy (cont.)
• Temporary colostomy
• Allows healing of the intestine after surgery or in certain disease states
• Permanent colostomy
• Removal of a large part of colon or the rectum required
TALKING POINTS:
• What is a double-barreled colostomy?
Question 1
• Which of the following is NOT true about fecal diversion?
A. The closer the ostomy is to the rectum, the more formed the fecal matter will be.
TALKING POINTS:
• Correct answer: D
• Rationale: The colon absorbs water from the fecal mass as it moves toward the rectum so
that it becomes progressively more solid.
_______________________________________________________ Chapter 26 The Patient with an Ostomy 15
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 26.1
Slide 30
Question 2
• Which of the following statements is INCORRECT about ostomies?
A. A bluish or black stoma has impaired circulation and must be reported to the
registered nurse or the physician immediately.
B. Ileostomy patients are usually not given timed-release capsules or enteric-coated
TALKING POINTS:
• Correct answer: A
• Rationale: A very pale, bluish, or black stoma has impaired circulation and MUST be
reported to the registered nurse or the physician immediately. Prompt surgical intervention
is needed to restore circulation and prevent tissue necrosis.
Activities
Classroom Choose from below to make 30 minutes
Online
1
ASSESS BASELINE
• Have the class complete the Pretest. Collect
their work and use the results to guide how
you teach the class.
DISCUSS
• Discuss the indications and preparation for
ostomy surgery. Why is the exact placement
of the stoma so important?
• Discuss the elements of assessment that
are unique to ostomy surgery.
ASSESS BASELINE
• Post the Pretest and the Background
Assessment online and have your class
complete them. Use the results to guide how
you teach the class.
2
DISCUSS
• Discuss patient teaching before ostomy
surgery. What other resources might be
useful in patient education?
• Ask the class to identify several possible
POST AND COMMENT
• Post the following discussion topic online
and have students comment. Create a
patient teaching plan for the patient with a
colostomy.