Elimination, Ostomy and Catheter Care

In depth

The one-page summary above is what the PDF prints. These sections go further.

Stoma complications in more detail

A stoma has no nerve endings, so the client cannot feel it being cut or scraped; a yellow or white line on it can mean a scrape, and nothing is inserted into it unless ordered. Color is the blood supply: pink to dark red and moist is healthy, while dusky, purple, black, gray or pale and dry means ischemia. In a 2020 review (Tsujinaka), necrosis or ischemia occurred in 1.6% to 11% of stomas; superficial necrosis needs no revision, but necrosis below the fascia needs surgery at once, which is why the nurse reports a color change rather than waiting.

MedlinePlus asks clients to call for a stoma that swells more than 1/2 in (about 1 cm) beyond normal, pulls in below the skin, bleeds more than usual, turns purple, black or white, leaks often or fits worse, or has foul-smelling discharge, and for skin around it that is raw, bleeding, pushed out, or has a rash, pus bumps or sores. A colostomy may be temporary (often reversed after about 12 weeks) or permanent and usually sits on the left side of the abdomen.

Ileostomy output, food and medicines

Without the colon, small-bowel contents arrive at the skin before water and sodium are reabsorbed. A new ileostomy puts out about 1,200 mL a day (range 500 to 2,000 mL), settling to about 300 to 700 mL as the bowel adapts. High output is defined as more than 1,000 to 2,000 mL a day and affects about 16% of clients with a new stoma; causes include partial obstruction, abdominal sepsis, C. difficile, prokinetic drugs, and sudden withdrawal of steroids or opioids. Dehydration is a major cause of readmission, and prolonged hyperaldosteronism adds hypokalemia and hypomagnesemia.

Teaching (MedlinePlus): empty the pouch at one-third to one-half full, 5 to 8 times a day; drink 8 to 10 glasses of fluid a day and more in heat; use electrolyte drinks when output is loose and eat salty and potassium-rich foods. Thickening foods include applesauce, rice, bread, potatoes, peanut butter and pudding; loosening ones include fruit juice, raw fruit and vegetables, spicy food, beer and large meals. Liquid medicines may absorb better, enteric-coated tablets may not, and birth control pills may not protect. In established high output, the team may avoid hypotonic drinks such as tea, coffee and fruit juice, restrict fluid intake, replace fluid and electrolytes and use antidiarrheals (Tsujinaka), so the nurse follows the client’s plan rather than simply pushing fluids.

Blockage: sudden cramping, a swollen stoma, nausea or vomiting, and either no output or a sudden gush of very watery output. Home measures are a warm drink, a warm bath, knees-to-chest positions and loosening a tight pouch opening; an empty pouch for more than 4 to 6 hours is reported, and a laxative is not taken.

Ileal conduit

In an ileal conduit the ureters drain into a short segment of ileum brought out as a stoma, so urine flows all the time with no voluntary control, and the bowel lining makes some mucus, which is normal. Blood in the urine is not. Clients are at risk for urinary infection and are taught its signs. The pouch is emptied every 2 to 4 hours or at one-third full and connected to a night drainage bag for sleep (Open RN). The stoma is measured for the first 8 weeks while swelling settles, and pouches are changed from daily to weekly depending on the type; leaking urine harms the skin, so the client does not wait for a leak (MedlinePlus). UOAA suggests 8 to 10 glasses of fluid a day.

Colostomy irrigation step by step

1. Learn it first with a WOC nurse; irrigate at about the same time daily, ideally within an hour after a meal or hot drink.
2. Fill the bag with warm water: 250 mL the first day, 500 mL the second, 750 mL from the third; 1,000 mL if stool passes between irrigations, never more.
3. Hang the bag about 18 in above the stoma and put on the irrigation sleeve.
4. Lubricate the cone, insert it gently in the direction of the bowel, never past its widest point, and hold it 1 to 2 minutes.
5. Release the clamp slowly. Cramping: stop, breathe, rub the abdomen, lower the bag or slow the flow.
6. Returns usually start in 5 to 10 minutes; the whole process takes 1 to 1.5 hours. A regulated client may stay free of output for 24 to 48 hours and wear a cap.

MSK lists diarrhea, a prolapsed stoma, a parastomal hernia, and chemotherapy or radiation as reasons not to irrigate; a client who has finished treatment and has a regular pattern can be reassessed. Irrigation is for formed stool from a descending or sigmoid colostomy, so it is not used for an ileostomy.

Laxatives, enemas and impaction

Impaction is common in older adults on bed rest and can follow barium. Watery mucus or stool leaking around the mass mimics diarrhea, so an antidiarrheal is the wrong move. Merck’s sequence is a tap-water enema, then a small (100 mL) commercial hypertonic enema, then manual disimpaction, which is painful and is preceded by a local anesthetic ointment. Open RN adds mineral oil enemas to soften hard stool. Afterward, fiber, fluids, a daily routine 15 to 45 minutes after breakfast, and laxatives or enemas no more often than every 3 days prevent recurrence. Laxatives are avoided with unexplained acute abdominal pain, obstruction, inflammatory bowel disease or GI bleeding, and red flags (distention, vomiting, blood, weight loss, new severe constipation in an older adult) are reported.

Spinal cord injury: bowel and bladder

After spinal cord injury, the client cannot rely on the urge, so the bowel is trained by timing: sit on the toilet or commode 20 to 30 minutes after eating, give the suppository and gentle stimulation as taught, and allow 15 to 45 minutes. Stool softeners or laxatives are used until stools are soft, then tapered once the pattern has been stable for about a month (MedlinePlus). For the bladder, CDC prefers intermittent catheterization to an indwelling catheter for clients with bladder-emptying problems and suggests it after spinal cord injury; outside the hospital, clean technique is acceptable, and catheterization at regular intervals prevents overdistension. A full bladder or rectum, pressure injury or tight clothing below the level of the injury can each trigger autonomic dysreflexia; the client may have dangerously high blood pressure with few symptoms.

Urinary incontinence and retention

Pelvic floor exercises: find the muscles by stopping the stream or holding back gas, squeeze for a count of 3 and relax for 3, build to 10 to 15 repetitions, at least 3 times a day lying, sitting and standing; improvement takes 3 to 6 weeks. The bladder scan is done after voiding with the client supine, the probe about 1 in above the pubic bone, and the male setting chosen for a female client who has had a hysterectomy.

Catheter insertion, removal and CAUTI

CDC lists the inappropriate uses as plainly as the indications: a catheter is not a substitute for nursing care of incontinence, not a way to get a urine sample from someone who can void, and not left in after surgery without a reason (remove within 24 hours when possible). External catheters suit cooperative men without retention, and female external wicking devices are an option. Routine antiseptic lubricant, periurethral antiseptic, bladder irrigation, antimicrobials in the bag and clamping before removal are all unnecessary; a catheter and bag are changed for infection, obstruction or a broken closed system, not on a schedule. If the closed system is broken, the catheter and bag are replaced aseptically.

Drainage bags are emptied at one-half to two-thirds full so they do not pull on the urethra; leg bags are smaller and emptied more often. A coudé tip is kept pointing up for a man with an enlarged prostate. After removal, the nurse records the time and the first void, encourages fluids, warns that mild burning with the first void is expected, and scans or catheterizes for retention (Open RN 21.6). At home, clients clean the tubing from the body outward and call for no drainage, leakage around the catheter, fever, flank pain, blood or grit in the urine.

Specimens: small samples come from the needleless sampling port with a sterile syringe after disinfecting it; if the tubing is empty, clamp below the port for 10 to 15 minutes, take 10 to 30 mL, and unclamp. Larger non-culture volumes may be taken aseptically from the bag, never a culture. CDC does not recommend screening catheterized clients for bacteriuria, which is nearly universal in long-term catheters.

Incontinence-associated dermatitis versus pressure injury

Incontinence-associated dermatitis is chemical and physical irritation of the skin by urine or stool: redness and swelling, sometimes blisters, erosion or a secondary infection, spread diffusely over the perineum, buttocks and folds with blurred edges. A pressure injury starts as non-blanchable redness of intact skin over a bony prominence. The two are often confused, and incontinence raises pressure injury risk. The Cochrane review found that soap and water performed poorly, that a no-rinse cleanser may work better, and that leave-on moisturizers or skin protectants beat no product, while no single brand proved better than another. Common barriers include zinc oxide and dimethicone.

Peritoneal dialysis basics

Dialysate runs into the abdomen through a cuffed catheter, dwells while the peritoneum filters waste and fluid, and drains out. In continuous ambulatory PD, the client does at least 4 exchanges a day of about 30 to 40 minutes each, with dwells of 4 to 6 hours or more; in automated PD a cycler does 3 to 5 exchanges overnight (NIDDK). Merck notes catheters are usually left about 2 weeks after placement before use. Peritonitis brings abdominal pain and tenderness, cloudy effluent, fever and nausea; it is diagnosed by 2 of 3 findings (clinical picture, effluent white cells over 100/mcL with more than half neutrophils, positive culture), and antibiotics start before cultures return. Exit-site infection shows tenderness, crusting, redness and drainage. Dextrose absorption causes weight gain, and the abdominal wall is prone to hernias at the navel, exit site and groin.

Exam pearls

• A dusky or dry stoma is the one to report; a red, swollen, slightly bleeding new stoma is expected.
• Ileostomy: liquid output, dehydration risk, chew fibrous food well, no irrigation, ask about enteric-coated drugs.
• Liquid stool after days without a bowel movement is overflow around an impaction until proven otherwise.
• Bowel program: same time daily after a meal; never wait for the urge; headache during bowel care at T6 or above means stop and sit up.
• Least invasive first: privacy and running water, then a bladder scan, then intermittent catheterization, and an indwelling catheter last.
• Catheter not draining: tubing and bag first. Specimen: port, never bag. Bag: below the bladder, never on the floor.
• Cloudy PD effluent with pain means peritonitis: culture and antibiotics.