Optimal Care Plan for a Patient with an Ileostomy
The optimal care plan for a patient with an ileostomy should focus on preventing dehydration, managing output, providing proper nutritional support, and preventing complications through a structured approach to stoma care and patient education.
Fluid and Electrolyte Management
- Maintain adequate hydration with 2200-4000 mL/day of oral fluid intake 1
- Use balanced crystalloid solutions (e.g., lactated Ringer's) rather than normal saline for IV fluid therapy when needed 1
- Monitor electrolytes closely, especially magnesium, to prevent imbalances 1
- Implement a tracking system for intake and output to prevent dehydration, which is the most common cause of readmission 2
- Educate patients on signs of dehydration (dark urine, dry mouth, dizziness, increased thirst)
Nutritional Management
- Begin with low-fiber, low-fat diet initially to reduce output volume 3
- Gradually introduce new foods one at a time to identify those that cause increased output or other symptoms 3
- Recommend white starchy carbohydrates to thicken stoma output 3
- Avoid foods that may cause blockage (nuts, seeds, corn, mushrooms, raw vegetables with skins)
- Avoid or limit alcohol and caffeinated beverages as they may increase output 3
- For patients with high-output ileostomies (>1500 mL/day):
- Consider oral rehydration solutions with sodium and glucose
- Implement small, frequent meals
- Use enteral nutrition if oral intake is inadequate for >7 days 4
Medication Management
- Use loperamide to reduce ileostomy output volume 5
- Avoid or minimize opioids as they can worsen ileus 1
- Consider alternative pain management with acetaminophen/paracetamol and NSAIDs if not contraindicated 1
- Avoid extended-release or enteric-coated medications as they may not be properly absorbed 6
- Consider prokinetic agents like metoclopramide for upper GI motility if needed 1
Stoma Care
- Establish a regular schedule for changing the ostomy appliance (typically every 3-5 days)
- Teach proper technique for measuring and cutting the stoma opening to prevent leakage and skin irritation
- Implement daily inspection of peristomal skin for signs of irritation or breakdown
- Use protective skin barriers to prevent contact between effluent and skin
- Empty the pouch when it is 1/3 to 1/2 full to prevent leakage and skin damage
Complication Prevention and Management
For paralytic ileus:
For high-output ileostomy:
- Separate fluid intake from meals by 30-60 minutes
- Consider antimotility agents (loperamide)
- Monitor for signs of dehydration and electrolyte imbalances
For peristomal skin complications:
- Ensure proper appliance fit
- Use protective skin barriers
- Consult wound/ostomy nurse for persistent issues
Patient Education and Support
- Begin education preoperatively when possible 2
- Use standardized teaching materials throughout the perioperative process 2
- Engage patients directly in ostomy management with stepwise progression 2
- Provide discharge supplies including flow sheets for tracking intake/output 2
- Arrange for visiting nurse services after discharge 2
- Connect patients with ostomy support groups
Follow-up Care
- Schedule regular follow-up appointments to monitor adaptation
- Assess for nutritional deficiencies, especially vitamin B12, which is absorbed in the terminal ileum
- Evaluate for long-term complications such as stomal stenosis, prolapse, or hernia
- Provide ongoing education and support as needed
Special Considerations
- For temporary ileostomies, discuss timeline and preparation for reversal
- For permanent ileostomies, focus on long-term adaptation strategies
- Consider psychological support to address body image concerns and quality of life
This comprehensive approach has been shown to virtually eliminate readmissions for dehydration in new ostomates 2 and should be implemented as standard practice for all patients with ileostomies.