NURSING DIAGNOSIS: Knowledge deficit

regarding the surgical procedure, hospital routines associated with the surgery, physical preparation for the bowel diversion, sensations that normally occur following surgery and anesthesia, expected appearance and function of the ileostomy, and postoperative care and management of the ileostomy.

Desired Outcome
The client will verbalize an understanding of the surgical procedure, preoperative care, and postoperative sensations and care.
Nursing Actions and Selected Purposes/Rationales
  1. Refer to Standardized Preoperative Care Plan, Diagnosis 4, actions a.1-4, for information to include in preoperative teaching.
  2. Provide additional information regarding specific preoperative care and postoperative sensations and care for clients having a bowel diversion with ileostomy:
    1. explain the preoperative bowel preparation (e.g. low-residue or clear liquid diet, cleansing enemas, laxatives, antimicrobial therapy)
    2. if proctocolectomy is planned, inform client that:
      1. a perineal wound drain will be present after surgery
      2. occasional feelings of pressure in the perineal area are expected after surgery and that these will subside as edema decreases
    3. if a continent ileostomy is planned, inform client that:
      1. a catheter will be inserted into the reservoir during surgery and will extend from the stoma and drain into an external collection device; stress that this is a temporary measure (usually for 2-4 weeks) to keep the reservoir from becoming distended while the suture lines are healing
      2. the reservoir will need to be irrigated periodically (especially in the early postoperative period) to remove mucus that accumulates in the reservoir (the bowel used to construct the reservoir initially secretes quite a bit of mucus)
      3. following removal of the stomal catheter, a catheter will be inserted into the stoma at regularly scheduled intervals to drain the reservoir and an external collection device will not be needed.
  3. Allow time for questions and clarification of information provided.
Desired Outcome
The client will demonstrate the ability to perform activities designed to prevent postoperative complications.
Nursing Actions and Selected Purposes/Rationales
  1. Refer to Standardized Preoperative Care Plan, Diagnosis 4, action b, for instructions on ways to prevent postoperative complications.
Desired Outcome
The client will verbalize an understanding of the appearance, function, and management of the ileostomy.
Nursing Actions and Selected Purposes/Rationales
  1. Arrange for a visit with an ET nurse if available.
  2. Reinforce information provided by physician and/or ET nurse about the appearance and function of the ileostomy:
    1. the stoma will be medium pink to red in color and moist (similar in appearance to healthy oral mucous membrane)
    2. the stoma will shrink in size as edema resolves during the first 6 weeks after surgery (final stoma height is usually 1.5-2.5 cm [about 1/2-1 inch] from the skin surface)
    3. slight bleeding of the stoma is expected when it is wiped with tissue
    4. for the first day or two after surgery, the stoma will drain a small amount of clear to white, blood-tinged fluid containing some mucus; after a few days, the color of the drainage will change to green and then light to medium brown as the diet progresses
    5. when the ileostomy begins to function (usually 2-3 days after surgery), the drainage will be watery and high-volume (up to 1-2 liters/day) but within a couple of weeks the amount will begin to decrease (expected amount of output after 2-3 months is 500-800 ml/day) and develop a thicker, paste-like consistency.
  3. Provide basic information about peristomal skin care, ways to control intestinal gas and odor of the effluent, products the client will be using after surgery, and irrigation and drainage of the reservoir (if a continent ileostomy is planned).
  4. Provide visual aids and allow client to handle ileostomy appliances that will be used in the immediate postoperative period. Provide a pouch clamp so that client can practice putting it on and taking it off of an empty pouch.
  5. Encourage client to try wearing a pouch system partially filled with water in order to experience how it feels and to determine if the planned stoma site will be adequate for successful adhesion of the pouch.
  6. Allow time for questions and clarification of information provided.