Ostomy Care Flashcards
Indications for ostomy
- Cancer - Colon & Rectal Cancers (most common)
- Diverticulitis
- Perforated bowel
- Bowel obstruction
- Crohn’s disease
- Ulcerative colitis
- Birth defects/Congenital Conditions
- Accidental injury/Trauma
What is an Ostomy?
An ostomy is an artificial opening of the body, created by surgery
* In the case of most ostomies, this refers to the connection of a portion of bowel to the outside of the body (also called a stoma) for the purpose of waste excretion
What are the most common types of ostomies?
- ileostomy
- colostomy
- Urostomy or Ileal Conduit
Ileostomy
connection of the small bowel to the exterior of the body
* To remove or bypass the entire colon and rectum, or to protect a distal colorectal, coloanal, or ileoanal anastomosis
* Can be constructed either as a diverting loop stoma or end stoma, with or without a continent reservoir
colostomy
connection of the large bowel to the exterior of the body
* To bypass or remove the distal colon, rectum, or anus and it is either inadvisable or not feasible to restore gastrointestinal continuity
* If the sphincter mechanisms are removed, the colostomy is permanent
* As with ileostomies, colostomies may be created in a loop or end fashion
Urostomy or Ileal Conduit
diversion of urine to the exterior of the body
What are small bowel surgeries?
- Small bowel repair
- Small bowel resection: duodenectomy, jejunectomy, ileectomy
- Lysis of adhesion: adhesiolysis
what are colon surgeries?
- right hemicolectomy: part of or all right side (ascending) colon is removed. The remaining colon is then reconnected to the SI
- left hemicolectomy: part of or all left side (descending) colon is removed. The remaining colon is then reconnected to the rectum
- sigmoid colectomy: part or all of the sigmoid colon is removed. the descending colon is then reattached to the rectum
What are rectal surgeries?
- low anterior resection: The sigmoid colon and a portion of the rectum are removed, descending colon is reattached to the remaining rectum
- abdominal perineal resection: part or all of the sigmoid colon and the entire rectum and anus are removed. A colostomy is then performed
Types of stomas
- end stoma
- loop stoma
- double barrel stoma
Intestinal Sites of Nutrient Absorption
- Ileum: absorption of vitamin B12 and bile acids
- Colon: absorption of water and electrolytes (sodium, potassium)
Postoperative nutrition
What is reccomended in a low fibre diet?
- Choose lower fibre foods
- Avoid higher fibre foods
Soluble vs. insoluble fibre
Soluble Fibre
* Water soluble
* Thickens stool → good for high output ostomies
* Safe for new ostomies
Insoluble Fibre
* Water insoluble / stays in same form
* Bulks stool
* Increases risk of obstruction
Long term nutrition with ostomy
- After 6-8 weeks most people can return to “normal” intake (a regular fibre diet, no restrictions)
- Some people will find that some foods are more difficult for them to tolerate / may cause symptoms like gas/odor, bloating, looser output, etc.
- still important to achieve adequate fluid intake to prevent dehydration
- Bowel adaptation may or may not occur, and often takes several months
How does food tolerations change with ostomy?
- They may or may not have the same food intolerances as before their ostomy
- Encourage food journaling to determine what exact foods, amounts and types of preparation methods are triggering
- It is common for people to continue to avoid very high insoluble fibre foods for risk or concern of obstruction
Indications for micronutrient supplementation with ileostomy
- Vitamin B12 supplementation is indicated if > 60 cm of the ileum is resected
- Fat soluble vitamin supplementation is indicated if > 100 cm of the ileum is resected and steatorrhea occurs
Indications for micronutrient supplementation with colostomy
No specific recommendations if functioning well
Indications for micronutrient supplementation with hight output ostomy
Electrolyte replacement, Magnesium, Zinc & Selenium due to large losses
Micronutrient reccomendation for all ostomy patients
Can be helpful for all ostomy patients to take a chewable or liquid multivitamin daily at minimum during the healing period, or longer based on their overall nutrition status and intake
* NEVER recommend gummy multivitamins
Managing gas, bloating and smell
All these things are normal and okay
* There are no specific foods that cause gas/bloating and/or odor for everyone; these things are highly individualized
* Recommending people avoid foods initially can be harmful by needlessly limiting their options
* Try food journaling if noticing increased gas/bloating or smell with certain foods before eliminating any
What things do impact gas, bloating and smell?
- Eating quickly
- Chewing gum
- Drinking with a straw or from a bottle
- Carbonated beverages
How is ostomy output determined?
The type and volume of output is determined by the location of the stoma relative to the ileocecal valve
Output with ileostomy & ascending colostomy
- Output is more liquid consistency due to reduced water absorption
- Ostomy requires emptying several times per day
- Output contains some degree of digestive enzymes that can be irritating to the skin/mucosa
Output with descending & sigmoid colostomy
- Output is more formed (stool)
- Output amount varies → may empty ostomy bag several times or not at all in a day
- Output does not contain digestive enzymes
Expected ostomy output over 24 hrs for ileostomy
1200 mL (mature 600-800 mL)
* contains significant amounts of Na and K
* Increased risk of dehydration, especially during episodes of increased output
Expected ostomy output over 24 hrs for colostomy
200-600 mL
* Can go a day or so without any output (constipation possible)
What is high output defined as?
> 1000-1500 mL
* most common in ileostomies, shortly after surgery (~1200 mL expected)
* can become a complication if persists long term
What contributes to loose outputs?
- Spicy foods: least amount of evidence to support
- Caffeine: reduces intestinal transit time + diuretic effect
- Very high fat foods: when missing part of the ileum, increased risk of steatorrhea
- Very high sugar foods: draws water into the bowel
- Alcohol: can have laxative effect + diuretic effects
- Sugar alcohols: draws water into the bowel
Signs of dehydration
- dry mouth
- dry skin
- headaches
- thirst
- dizziness
- muscle cramping
- nausea
- low blood pressure
- low or dark urine output
What is critically high ostomy output?
> 2000 mL daily
* Require hospitalization for IV hydration until output improves or a long- term outpatient IV therapy plan can be established
What populations are at risk for high ostomy output?
- Extensive surgical resection (< 200 cm residual bowel, short bowel syndrome)
- More proximal location of the stoma (higher in the GI tract, ex ileostomy)
- Intra-abdominal sepsis or infection enteritis
- Partial or intermittent bowel obstruction
- Recurrent disease in the remaining bowel (ex Crohn’s)
- Sudden discontinuation of medications (ex steroids, opioids → constipating)
- Use of prokinetic medications (ex metoclopramide → stimulate gut movement)
- Bacterial overgrowth or enteric pathogens
Nutrition for high output ostomy
Fibre for high ostomy output
- Soluble fiber can thicken output → it does not decrease stool volume or enhance absorption
- Dietary sources: oatmeal, barley, lentils, psyllium (Metamucil), applesauce, smooth peanut butter, fruits and vegetables with the skin/peel removed
- Fiber bulking agents may be effective. Can often make patients feel full = difficulty meeting nutritional needs
Oral rehydration solutions
Oral rehydration solutions are Isotonic
* Promote absorption of water by being similar in solute concentration to the bowel
* Fluid with modest amounts of sugar and salts (Na, K) to promote hydration
* Does not decrease stool volume
What do hypertonic fluids do?
pull water into small bowel to dilute higher osmolarity fluids = increasing stool volume
* Milk, popsicles, fruit juice, soda, broth, ONS
What do hypotonic fluids do?
fluids pull sodium into the small bowel to increase osmolarity of the fluid = increasing stool volume
* Na never travels alone, always brings water along
* Water, tea, coffee, sugar free drinks
Recipes for oral rehydration solutions
Limit regular fluids to < 500 mL daily
Sports drinks are NOT isotonic + need adjustments to be considered ORS
* Regular Gatorade is hypertonic: 1 1⁄2 cups Gatorade + 2 1⁄2 cups water + 1⁄2 tsp salt
* G2 is hypotonic: 4 cups G2 + 1⁄2 tsp salt
Juice recipe example
* 3⁄4 cup 100% juice + 3 1⁄4 cup water + 1⁄2 - 3⁄4 tsp salt
Soup recipe example
* 4 cups water + 1 dry bouillon cube + 1⁄4 tsp salt + 2 tbsp sugar
Drugs?
- Anti-diarrheals: loperamide, Lomotil, codeine
- Fibre supplements (Metamucil): not effective without a colon
- Cholestyramine: for bile acid induced high output ostomy (following terminal ileum resection)
- Anti-secretory: pantoprazole, omeprazole, ranitidine, octreotide (somatostatin)
What should be monitored daily in thr hospital for hydration status?
Monitor electrolytes (Na, Cl, K), Mg, Phos, Creatinine, Urea daily
* Avoid enteral electrolyte replacement to prevent worsening outputs
When is PN used?
- Preferred method if unable to achieve adequate PO intake
- Often require increased fluid and electrolyte provision (Na, Cl, K, etc.) due to increased losses
When is EN used?
- Okay to use polymeric and fibre containing formulas
- Osmolarity can be an issue
- Formulas are often hyperosmolar
- Isotonic: Isosource Fibre 1.0 HP, Peptamen w/ Prebiotics
- Close to isotonic: Isosource 1.0 HP, Peptamen Intense
- In high output, may need ORS via tube → exchange water flushes for “ORS” flushes
Nutrition with ostomy reversal
Following an ostomy reversal, there are no specific dietary restrictions
* A patient’s bowel habits will be heavily impacted by the amount and health of bowel added back after the reversal
* Patients who maintain limited colon length following an ostomy reversal may experience looser bowel movements and/or chronic diarrhea postop (reccommendations to follow high output ostomy diet)
