Fundamentals - Practice & Skills, part 24: Constipation, Diarrhea, and Ostomies

by Meris Shuwarger BSN, RN, CEN, TCRN August 16, 2021 Updated: June 16, 2022 9 min read

This article covers constipation, diarrhea, and different types of ostomies. You can follow along with our Fundamentals of Nursing flashcards, which are intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI, and NCLEX.

Constipation

Constipation occurs when bowel movements are difficult or infrequent and ongoing, lasting several weeks or longer.

It is important to treat patients who are constipated, as unresolved constipation can result in fecal impaction, which is when stool becomes stuck in the colon and can’t leave the body. This requires medical treatment.

What are the risk factors for constipation?

The risk factors for constipation include insufficient fluid and fiber intake, physical inactivity, and some medications. People of an older age are also at risk for constipation.

What are the signs and symptoms of constipation?

Signs and symptoms of constipation include decreased stool output or stool that is hard, dry, and possibly lumpy.

Difficulty passing stool is another indication that a patient may be constipated.

Patient teaching for constipation

Patients should increase their fluid intake, which will enter the bowel and soften the stool.

Patients should also increase the fiber in their diet. This promotes peristalsis.

They should also increase their physical activity — increased physical activity promotes peristalsis.

Diarrhea

What are the risk factors for diarrhea?

The risk factors for diarrhea include infections, some medications, food allergies or contamination, and GI dysfunction (e.g., celiac disease). Occasionally, diarrhea is a sign of another disorder, such as inflammatory bowel disease or irritable bowel syndrome.

What are the signs and symptoms of diarrhea?

Signs and symptoms of diarrhea include loose, watery, and possibly more-frequent bowel movements. Also: abdominal cramping and an urgency to defecate.

Diarrhea places the patient at an increased risk for dehydration, or fluid-volume deficit, as the patient is losing too much fluid in the stool. The signs and symptoms of dehydration include an increase in heart and respiratory rates, as well as dry mouth and fatigue. Diarrhea may also result in perineal skin breakdown or excoriation of the skin (lesions), which are caused by too much moisture in the perineal area (the genitals and rectum).

Patient teaching for diarrhea

Patient teaching for diarrhea focuses on resting the bowel. Patients should be advised not to eat anything they do not usually eat, and to avoid food this spicy or otherwise intense.

Patients should increase their fluid and fiber intake, and they should follow the BRAT diet: bananas, rice, applesauce, and toast.

Ostomies

An ostomy is a surgical procedure that reroutes part of the intestine through the abdominal wall, forming a stoma, that is, an opening in the body. Like a tracheostomy — an opening in the neck — an ostomy that relates to bowel elimination is a surgical opening that diverts the normal passage of the bowel.

Types of ostomy

There are two types of ostomy related to bowel elimination, ileostomy and colostomy.

Ileostomy

An ileostomy is created in the ileum of the small intestine.

The output from an ileostomy is loose and watery. This is because elimination occurs before fluid reaches the colon, where it condenses into stool. Output that does not flow all the way down to the colon, then, is watery.

Colostomy

A colostomy is created in the colon or the large intestine. This kind of ostomy may be situated in the ascending, transverse, or descending/sigmoid colon (the lower part of the colon), and the output will vary depending on which ostomy the patient has. The closer the ostomy is to the rectum, the more solid the stool.

  • An ascending (right) colostomy results in liquid or watery stool
  • A transverse colostomy results in semi-solid stool
  • A descending/sigmoid (left) colostomy results in more solid, formed stool

Ostomy nursing care and patient teaching

Patients with ostomies need to take care of their stoma and know the timing and procedures for bag/appliance changes.

Assess the stoma regularly

The stoma (the opening in the skin) should be checked regularly. A normal looking stoma is pink or red and moist. This indicates a good blood supply.

Report a stoma that appears pale or blue immediately to the provider as this could indicate an ischemia (a condition in which the blood flow, and thus oxygen, is restricted or reduced in a part of the body). The patient requires emergency surgery.

When to empty an ostomy bag

Output from the bowel (or intestine or colon) is collected in an ostomy bag. Empty the ostomy bag when it is one-third full.

If the appliance is leaking, change it immediately.

How to “cut the wafer”

The wafer is the part of the device that sticks to the patient’s skin. Patients should learn to measure their stoma. Usually, there is a template card for this purpose. The patient places the template card over the stoma to see which template fits it best. Then, they cut the opening less than or equal to an eighth of an inch wider in diameter. This is to prevent skin damage from contact with any ostomy output, as moisture could lead to skin damage.

Also, it is important to cut the correct size so the device is not too tight, which can lead to ischemia.

How often should the patient change an ostomy appliance

The ostomy appliance should be changed approximately every two weeks for a patient with a colostomy and more frequently for a patient with an ileostomy.

Chew foods thoroughly

Chewing foods thoroughly will make the output easier.

Patients should consume a low-fiber diet for the first 6 – 8 weeks and avoid foods that cause gas or odor.

An important note about nursing care for patients with ostomies

A patient with an ostomy must learn how to take care of themselves from scratch. In addition, a patient dealing with an ostomy bag may find it disorienting or confusing, and this change in their life could have a psychosocial impact as well.

As a wound care or ostomy care nurse, patient care is paramount. Help comfort the patient prior to surgery. Help them identify the best location for their ostomy. Post-surgery, help them connect with resources in their community so they can learn how to care for themselves and how to care for their stoma.

Being a trusted, sympathetic resource for this patient can make a huge difference as they navigate this new situation they find themselves in.


Full Transcript

Hi. I'm Meris. And in this video I'm going to be talking to you about constipation, diarrhea, and different types of ostomies. I'm going to be following along with our Fundamentals of Nursing flashcards. These are available on our website, leveluprn.com. And if you already have a set of your own, you can follow along with me, starting on card number 124. Let's get started.

Okay. So first up, we are talking about constipation and diarrhea. Constipation is going to be either decreased stool output or stool that is really hard, dry, maybe lumpy. And it puts your patient at risk for a lot of things. But it's also very painful. One of the things that I want to talk to you about is what do we do about constipation. So big, big, big stuff to know for nursing school and clinical practice is that constipation, the patient teaching is almost always going to be the same. It's to increase fluids, increase fiber in your diet, and increase activity. The more fluid we have, the more we can pull it into the bowel and soften the stool. The more fiber we have, the more we can bulk up the stool and promote peristalsis. And then the more activity we do, the more we promote peristalsis as well. Now, when I have diarrhea, what is my patient education, right? So patient education for diarrhea is going to be to rest the bowel in terms of don't eat anything that's really out of your norm, don't eat anything spicy or really intense. You want to eat things that are going to be like the BRAT diet, so bananas, rice, applesauce, and toast. Because what is your patient at risk for if they have diarrhea? Pause the video, think about it, and then come back.

Your patient with diarrhea is at risk for fluid-volume deficit. They are losing too much fluid in the stool. So we also want them to increase their fluid intake and, shockingly, increase that fiber too, right? The bananas as well. So important things to know about diarrhea is it's not just fluid balance I need to worry about, it's going to be things like excoriation of the skin. So I'm going to have irritated skin, right? I could end up having, actually, impaired skin integrity from diarrhea. So very important to be assessing your patients who have these conditions.

Now, let's talk about ostomies. And if you stay until the end of this video, I'm going to tell you about a personal experience with ostomies. So on card 125, we talk about the different types of ostomies. So an ostomy is a surgically created opening. So a tracheostomy, right, that's in the neck. But when we're talking about ostomies as it relates to bowel elimination, we're talking about surgical openings that somehow divert the normal passage of the bowel. So we have an ileostomy, and as the name would suggest, that's a surgical opening created in the ileum of the small intestine. So that output is going to be very, very liquidy and very frequent because the colon's job, the large intestine, is to remove fluid to condense that stool. So it's important to understand that when we don't make it to the colon, we're going to have really watery output. A colostomy is created in the colon, the large intestine. It can be in the ascending, transverse, descending, and sigmoid colon. So the output is going to vary based on where it is in the colon. The closer we get to the rectum, the more formed the stool is going to be. So in the ascending colon, pretty watery still. In the transverse colon, we're thinking more this is semisolid or pudding-like consistency. And from descending and sigmoid, it's going to be essentially formed stool.

So on card 126 - I want you to really pay attention - this is the nursing considerations and patient education for ostomies. Super-duper important stuff. Lots of red and bold text here, which means it's important to know. So empty the bag-- obviously, I need a collection bag on the outside so that I'm not just emptying my bowels onto my skin. So empty the bag when it is a third full, but change the appliance immediately if it is leaking. Also, the stoma should be-- the stoma is the actual opening itself. The stoma should be red or pink and moist. All of that indicates good blood supply. We are not having any problems there. But if it is pale or cool or dusky or blue, we need to report this finding immediately to the provider. There's nothing you as the nurse can do about it. This patient needs emergency surgery due to the ischemia that is causing these color changes.

All right. Other things to know would just be education on how to cut the wafer. So the wafer is the part of the device that sticks to the patient's skin. You need to educate the patient that they should measure their stoma. Usually, there's a little template card that you can use. You place it over the stoma and see which one fits it best. And then you want to cut the opening less than or equal to about an eighth of an inch wider in diameter. Reason being I don't want to expose too much of my skin because of the risk of skin breakdown from moisture, but I also don't want it to be too tight. Because if the device is too tight, it's going to cause what? Ischemia. So very important patient teaching there. All right. So that is it for constipation, diarrhea, and ostomies.

I hope that review was helpful. If it was, please like this video so that I know that you enjoyed it. If you have a great way to remember something, I'd love to hear in the comments, and I'm sure the others watching this video would too. And be sure to subscribe to the channel so that you are the first to know when our new videos drop. The next video in this series is going to be talking about laxatives, enemas, and fecal-occult-blood testing. Thanks so much, and happy studying.

So I actually had a colostomy for a year. I have a genetic condition called familial Mediterranean fever. And at the time, it was undiagnosed. But I was having a lot of colorectal problems and a lot of colorectal surgeries. So I had a temporary diverting colostomy, a loop colostomy placed in my sigmoid colon. So that was on the left side of my abdomen. I had it there for a year, from the time that I was 24 to 25. And then almost exactly to the day, a year later, I had it reversed, and it was reversed without any problems or complications. I can tell you that as an ostomate - that's what we call someone who has a stoma - and especially as an ostomate who had her colostomy placed very young, it's a huge life change, a huge life change. But the person who made a really big impact in my life was my wound and ostomy care nurse. She came to see me before my surgery. She helped identify the best location for my ostomy. And then she helped connect me with resources in my community to help me learn how to care for myself and how to care for my stoma because you have to learn how to take care of yourself from scratch. It's very disorienting and confusing and has a lot of psychosocial impact as well. So if you are interested in wound care, if you are interested in ostomies, I would very much encourage you to look into this field because that woman-- I don't remember her name, but I can remember her face, and I can remember how she made me feel. Sorry. So very important to have those incredible resources and incredible people in the nursing field, in the nursing profession. And if that is something that you are interested in, I would really encourage you to pursue it.


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