out of bed most of the time, put the bottom facing the feet; if patient is in bed most of the time, have bottom face the side). Picture frame the adhesive portion of the appliance with 1-inch tape.
            1. Put a few drops of deodorant in appliance if not odor proof.
            2. Use clamp to fasten bottom of appliance.
            3. Talk to patient (or communicate in best way possible during and after procedure). This is a very difficult alteration in body image.
            4. Good hand-washing technique.
          1. Use deodorizing drops in appliance and provide adequate room ventilation to decrease odors. Caution: deodorizing drops must be safe for mucous membranes. No pinholes in pouch.
          2. If continent ileostomy, a Kock pouch, has been constructed, the patient does not have to wear an external pouch. The stool is stored intra-abdominally. The patient drains the pouch several times daily, when there is a feeling of fullness, using a catheter. The stoma is flat and on the right side of the abdomen.
      1. Goal: promote psychological comfort.
        1. Support patient and family - accept feelings and behavior.
        2. Recognize that such a procedure may initiate the grieving process.
      2. Goal: health teaching.
        1. Self-care management skills related to ostomy appliance, skin care, and irrigation, if indicated (Table 7-29).
        2. Diet: adjustments to control character of feces; avoid foods that increase flatulence.

TABLE 7-29 ►Colostomy Irrigation
  1. Assemble all equipment for irrigation and appliance change.
  2. Remove and discard old pouch.
  3. Clean the peristomal skin.
  4. Apply the irrigating sleeve; place in toilet or bedpan.
  5. Fill container with 500-1000 ml of warm water, never more than 1000 ml. Clear air from tubing. Insert lubricated tubing 2-4 inches into stoma. Do not force. Hold container about 18 inches above stoma. Infuse gently over 7-10 min.
  6. Allow stool to empty into toilet. Evacuation usually occurs in 20-25 min.
  7. If no return after irrigation, ambulate, gently massage abdomen, or give patient a warm drink.
  8. Once complete, remove the sleeve, and follow guidelines for applying appliance.
Colostomy irrigation is seldom used with newer colostomies.
        1. Signs of complications of infection, obstruction, or electrolyte imbalance.
        2. Community referral for follow-up care.
    1. Evaluation/outcome criteria:
      1. Demonstrates self-care skill for independent living.
      2. Makes dietary adjustments.
      3. Ostomy functions well.
      4. Adjusts to alteration in bowel elimination pattern.

  1. Hemorrhoids: enlarged vein/veins in mucous membrane of rectum. Hemorrhoids can be internal or external. Bleeding internal hemorrhoids can be painful and are best treated by rubber band ligation, injection sclerotherapy, infrared coagulation, or surgery (scalpel, cautery, or laser). Laser surgery is usually done as an outpatient and causes minimal discomfort. High-fiber diets can minimize constipation and prevent hemorrhoids.
    1. Pathophysiology: venous congestion and interference with venous return from hemorrhoidal veins —> increase in pelvic pressure, swelling, and distortion.
    2. Risk factors:
      1. Straining to expel constipated stool.
      2. Pregnancy.
      3. Intra-abdominal or pelvic masses.
      4. Interference with portal circulation.
      5. Prolonged standing or sitting.
      6. History of low-fiber, high-carbohydrate diet, which contributes to constipation.
      7. Family history of hemorrhoids.
      8. Enlarged prostate.
    3. Assessment:
      1. Subjective data: discomfort, anal pruritus, pain.
      2. Objective data:
        1. Bleeding, especially on defecation.
        2. Narrowing of stool.
        3. Grapelike clusters around anus (pink, red, or blue).
        4. Diagnostic test:
          1. Visualization for external hemorrhoids.
          2. Digital exam or proctoscopy for internal hemorrhoids.
    4. Analysis/nursing diagnosis:
      1. Pain related to defecation.
      2. Constipation related to dietary habits and pain at time of defecation.
      3. Knowledge deficit related to foods to prevent constipation.
    5. Nursing care plan/implementation:
      1. Goal: reduce anal discomfort.
        1. Sitz baths, as ordered; perineal care to prevent infection.
        2. Hot or cold compresses as ordered to reduce inflammation and pruritus.