Key Takeaways
- A healthy stoma is pink/red and moist; a pale, dusky, or black stoma indicates ischemia and requires immediate surgical consultation
- Ileostomies produce liquid stool and increase risk for dehydration and electrolyte imbalances; colostomies produce more formed stool
- Constipation prevention: increase fiber (25-30g/day), fluids (2-3L/day), and physical activity
- Colostomy location affects output: ascending = liquid, transverse = semi-formed, descending/sigmoid = formed
- Ostomy pouches should be emptied when 1/3 to 1/2 full and changed every 3-7 days or when seal loosens
Last updated: January 2026
Bowel Elimination and Ostomy Care
Bowel elimination is a fundamental human need. The nurse must understand normal patterns, common problems, and the specialized care required for patients with ostomies.
Normal Bowel Function
Normal bowel pattern varies widely—from three times daily to three times weekly. The key is what's normal for the individual patient.
Characteristics of Normal Stool
| Characteristic | Normal | Abnormal |
|---|---|---|
| Color | Brown | Black (melena), red (hematochezia), clay-colored (biliary obstruction) |
| Consistency | Soft, formed | Hard (constipation), liquid (diarrhea), mucus-filled |
| Frequency | 3x/day to 3x/week | Significant change from baseline |
| Odor | Characteristic fecal odor | Extremely foul (C. diff, GI bleed) |
Constipation
Constipation is infrequent, difficult passage of hard, dry stool.
Causes
| Category | Examples |
|---|---|
| Dietary | Low fiber, inadequate fluids |
| Activity | Immobility, sedentary lifestyle |
| Medications | Opioids, anticholinergics, iron supplements, calcium |
| Conditions | Hypothyroidism, neurological disorders, obstruction |
| Behavioral | Ignoring urge to defecate, lack of privacy |
Nursing Interventions
| Intervention | Rationale |
|---|---|
| Increase fiber intake (25-30 g/day) | Adds bulk to stool, promotes peristalsis |
| Increase fluid intake (2-3 L/day) | Softens stool |
| Encourage physical activity | Stimulates peristalsis |
| Establish regular toileting routine | Uses gastrocolic reflex (30 min after meals) |
| Provide privacy | Promotes relaxation of sphincter |
| Position on toilet/commode | Sitting position uses gravity |
Laxatives and Stool Softeners
| Type | Examples | Mechanism | Onset |
|---|---|---|---|
| Bulk-forming | Psyllium (Metamucil) | Absorbs water, increases bulk | 12-72 hours |
| Stool softener | Docusate (Colace) | Allows water into stool | 24-72 hours |
| Osmotic | Polyethylene glycol (MiraLAX) | Draws water into bowel | 24-48 hours |
| Stimulant | Bisacodyl (Dulcolax), Senna | Irritates bowel, increases motility | 6-12 hours |
| Enema | Fleet, tap water | Mechanical stimulation | Minutes |
Diarrhea
Diarrhea is frequent passage of loose, watery stool.
Causes
- Infection: Viral, bacterial (C. difficile, Salmonella), parasitic
- Medications: Antibiotics, laxatives, chemotherapy
- Diet: Food intolerance, excessive fiber
- Disease: Inflammatory bowel disease, malabsorption
- Tube feeding: Rate too fast, contamination
Nursing Interventions
- Assess for dehydration (vital signs, skin turgor, urine output)
- Replace fluids and electrolytes
- Monitor and record frequency and characteristics
- Protect perianal skin (barrier cream, gentle cleansing)
- Identify and treat cause (stool culture, C. diff testing)
- Contact precautions if infectious cause suspected
C. difficile Precautions
C. difficile requires contact precautions and hand washing with soap and water (alcohol-based sanitizers do not kill spores).
Ostomies
An ostomy is a surgically created opening from an internal organ to the body surface. Bowel ostomies divert stool to an external pouch.
Types of Intestinal Ostomies
| Type | Location | Stool Consistency | Key Concerns |
|---|---|---|---|
| Ileostomy | Ileum (small intestine) | Liquid, continuous | High-volume output, dehydration, electrolyte loss, skin breakdown |
| Ascending colostomy | Right colon | Liquid to semi-liquid | Similar to ileostomy |
| Transverse colostomy | Mid-colon | Semi-formed | Moderate output |
| Descending colostomy | Left colon | Semi-formed to formed | More predictable |
| Sigmoid colostomy | Sigmoid colon | Formed | Most predictable, may achieve regularity |
Stoma Assessment
A healthy stoma should be:
- Pink to brick red in color
- Moist and shiny
- Slightly raised above skin level
ABNORMAL FINDINGS requiring immediate action:
| Finding | Indicates | Action |
|---|---|---|
| Pale or dusky | Ischemia | Notify surgeon immediately |
| Black/necrotic | Tissue death | Emergency—surgical consultation |
| Dry, dull | Dehydration | Assess fluid status |
| Bleeding (more than slight) | Trauma, complication | Assess cause, may need intervention |
| Prolapse | Stoma protruding excessively | Notify provider |
| Retraction | Stoma sinking below skin | May need revision |
Ostomy Pouch Care
Emptying the Pouch
- Empty when 1/3 to 1/2 full to prevent leakage and weight pulling at seal
- For ileostomy: May need to empty frequently (liquid output)
- For colostomy: Less frequent (formed stool)
Changing the Pouch System
| Component | Change Frequency |
|---|---|
| Pouch (drainable) | Every 3-7 days |
| Skin barrier (wafer) | Every 3-7 days or when seal loosens |
| One-piece system | Every 3-5 days |
Steps for Pouch Change
- Gather supplies
- Remove old pouch gently (adhesive remover helps)
- Clean peristomal skin with warm water (no soap with oils)
- Pat dry completely
- Assess stoma and peristomal skin
- Measure stoma and cut opening 1/8 inch larger than stoma
- Apply skin barrier if using two-piece system
- Apply pouch, press firmly for 30 seconds
- Ensure secure seal
Skin Protection
The effluent (output) from an ileostomy is highly caustic and can cause severe skin breakdown. Protect skin with:
- Properly fitted pouch (opening just slightly larger than stoma)
- Skin barrier paste to fill irregular areas
- Pectin-based powder for denuded skin
- Change pouch promptly when seal leaks
Patient Education: Ostomy Living
Dietary Considerations
Ileostomy:
- Avoid high-fiber foods initially (may cause obstruction)
- Chew food thoroughly
- Stay well-hydrated (risk of dehydration)
- Avoid excessive gas-producing foods
Colostomy:
- Fiber intake may help regulate output
- Identify foods that cause gas or odor
- Stay hydrated
Foods That May Cause Issues
| Effect | Foods |
|---|---|
| Gas | Beans, cabbage, broccoli, carbonated beverages |
| Odor | Fish, eggs, asparagus, garlic, onions |
| Blockage (ileostomy) | Popcorn, nuts, mushrooms, raw vegetables, corn |
Lifestyle Considerations
- Bathing: Can bathe/shower with or without pouch
- Activity: Most activities are safe; avoid contact sports (protect stoma)
- Clothing: Regular clothing; avoid tight waistbands over stoma
- Intimacy: Possible and encouraged; empty pouch beforehand
- Travel: Carry extra supplies; TSA notification cards available
On the Exam
NCLEX tests:
- Stoma assessment: Know normal (pink/red, moist) vs. abnormal (pale, dusky, black = ischemia)
- Output by ostomy type: Ileostomy = liquid; sigmoid colostomy = formed
- Complications: Dehydration with ileostomy, skin breakdown, obstruction
- Patient teaching: Pouch care, dietary modifications, when to seek help
Key Takeaways
- Healthy stoma: Pink/red, moist; ischemic stoma: Pale, dusky, black—notify surgeon immediately
- Ileostomy: Liquid output, high dehydration risk
- Colostomy: Output consistency depends on location (ascending = liquid → sigmoid = formed)
- Constipation prevention: Fiber, fluids, activity
- Empty pouch when 1/3 to 1/2 full; change pouch every 3-7 days
Test Your Knowledge
During a stoma assessment, the nurse notes the stoma appears dusky and dark purple. What is the priority nursing action?
A
B
C
D
Test Your Knowledge
A patient with a new ileostomy is at highest risk for which complication?
A
B
C
D
Test Your Knowledge
Which intervention is most appropriate for a patient experiencing constipation?
A
B
C
D