* There are many available types of colostomy irrigation sets available from commercial firms. Reasonably efficient substitutes may be improvised.

Irrigation Procedure

The irrigation can should be hung approximately 18 inches above the colostomy stoma. It should not be raised higher because this will increase the pressure on the colon. If the patient should have severe abdominal cramps when the irrigator is placed at this height, it should be lowered.

Lubricate or moisten the catheter, expel the air from the tubing, and insert catheter gently into the stoma, 3 to 4 inches. If the catheter is difficult to insert, allow the water to continue to flow, while gently but firmly inserting the catheter into the stoma. If resistance is encountered remove the catheter and stop the irrigation. Normally the catheter will insert easily. Allow the solution to run in slowly, never more than 500 cc's at a time. Do not allow the irrigating can to completely empty at any time; refill as necessary. If the patient complains of cramps shut off the flow of solution and wait until his discomfort subsides before resuming the irrigation.

If an irrigation set is used, the returns will be expelled around the catheter and down the rubber or plastic sheath into the toilet. Periodically it may be necessary to clamp off the catheter and remove it to allow the returns to be more easily expelled. (See diagram A).

If the patient does not have a closed irrigation set, he may use the open method and collect the returns in a large emesis basis held tightly against the abdomen under the stoma.

Either the closed or open method of colostomy irrigation may be adapted to the patient who is confined to bed. (See diagrams B and C.)

The colostomy irrigation should be continued until the prescribed amount of solution is used up or the returns are clear.

The procedure for irrigating a double-barrel colostomy is the same for cleansing the proximal loop of the bowel (the upper portion). The lower loop (the distal loop) will be cleansed when and as ordered by the physician. Some returns from the distal loop will come through the rectum. Therefore a bed patient will have to be placed on a bedpan.

After the irrigation has been completed, the skin around the stoma should be cleansed with mild soap and water unless something else has been specified by the physician. Sometimes special ointments are ordered to protect or heal the skin. These measures aid in preventing excoriation and irritation. The stoma should be covered with a small gauze pad or soft cloth. Plastic material or waxed paper held in place by scotch tape are sometimes used to cover the dressing. An elastic belt, two-way stretch or soft girdle can be worn to keep the dressings in place. The dressing should be changed as often as necessary. Cleanliness helps to prevent odors.

Collection bags or other such devices should be discouraged except for patients with incurable disease for whom the establishment of bowel control is impossible. Patients become dependent upon the collection bag and control of the colostomy may be delayed or not established. Moreover, regardless of how well they are cleaned, the rubber bags usually retail a fecal odor. If a collection bag is ordered an effort should be made to obtain the disposable type and thus minimize the odor problem.

A. CLOSED IRRIGATION FOR AMBULATORY PATIENT

Diagram A

B. CLOSED IRRIGATION FOR BED PATIENT

Diagram B c

C. OPEN IRRIGATION FOR BED PATIENT

Diagram C

Many patients with colostomies need much encouragement to continue their former pattern of living. Information about the colostomy clubs that have been organized in various places throughout the country may stimulate some patients to attend. This often helps the patient to realize that many other people who have colostomies are able to work and resume their social activities.

Diet

The diet immediately following a colostomy tends to be more liberal than heretofore when highly restricted diets were the usual practice. There is, however, a great deal of variation in the diet regimen depending upon the attending physician. Foods high in cellulose and fiber tend to be restricted, but more emphasis is being placed on experimenting with small amounts of foods to determine those which the patient can tolerate. Some patients find it necessary to eliminate strong flavored vegetables or rough foods but others seem to tolerate them very well. The patient should be instructed to eliminate those which cause difficulty. Some patients tend to be too self-restricting and may need encouragement to try new foods and to retry those foods which caused difficulty in early convalescence. During the period of limited selection, care must be taken to see that the nutrient intake is adequate. (See appendix II for a low residue diet which may be used during the convalescent period.)

In recommending foods, consideration should be given to the individual's likes and dislikes, and the amount of money he has to spend.

Perineal Resection

When the perineum has been resected and left open, the area takes a long time to heal. This must be kept clean to facilitate healing and prevent infection. The physician may order sitz baths once or twice daily to promote healing, and this may be the only treatment required. If the wound does not heal or if a discharge occurs a daily sterile irrigation may be ordered. This will require sterile irrigating equipment and sterile dressings and it will be necessary for the nurse to teach the family how to prepare and handle them.

Perineal Care

If an irrigation is ordered it may be done either by means of a sterile irrigating can with tubing and a hard-rubber-douche tip or with a sterile, rubber-tipped syringe and sterile bowl for the solution.

1. Procedure using irrigating can-remove the dressing and drape the patient; place a protective pad and the bedpan under the patient; cleanse the area surrounding the wound with soap and water; carefully insert the douche tip and let the solution flow in a steady but gentle stream; dry the skin surrounding the wound and apply the dressings and binder.

2. Procedure using syringe-remove the dressings and drape the patient; turn the patient on his side; place protective pad under him; irrigate the wound with a sterile syringe with a rubber tip or with a sterile syringe and catheter; a curved basin held below the wound is used for the return flow; dry the skin carefully and apply the dressings and binder.

Caution must be exercised in inserting the douche tip or catheter; tissues can be easily damaged and the healing process retarded.

Sterile dressings are applied to the area after each sitz bath and/or irrigation and the patient must be assisted as needed in learning to apply them.

The perineum remains sensitive for a long time and it may be difficult for the patient to sit comfortably. However, he must be encouraged to learn to sit without the aid of a rubber ring or soft pillows. Followup visits to determine what the patient needs and to give support to both the patient and the family should be part of the plan for nursing service.