Med. J. Cairo Univ., Vol. 81, No.

2, June: 57-64, 2013

www.medicaljournalofcairouniversity.net

Colostomy: Developing Nursing Care Standards for

Patient with Colostomy
1 2
NABEEL M. BHZEH, D.N.Sc. ; SAMIA M. TELEB, D.N.Sc. ; MADIHA A. MAHMOUD,
3
D.N.Sc. and 4
AHMED M. SOLIMAN, M.D.
The Departments of Medical-Surgical Nursing, Faculty of Medicine & Health Sciences, Thamar University, Yemen 1
2,3
Medical-Surgical Nursing, Faculty of Nursing, Assiut University, Egypt and General Surgery, Faculty of Medicine,
4
Assiut University, Egypt

Abstra
ct
Correspondence to: Dr. Nabeel M. Bhzeh, The
Nursing care standards of colostomy are Department of Medical-Surgical Nursing,
significant action to ensure quality of care. The Faculty of Medicine & Health Sciences,
examination of nurses' knowledge and Thamar University, Yemen
practices regarding the nursing care standards
of colostomy has not been conducted before at
Assiut University Hospital. This descriptive
study aimed atestablishing the level of nurses'
knowledge and practice and to examine the
relationship between nurses' knowledge
and practice for developing the nursing care
standards of colostomy. The subjects were
nurses working in the surgical wards of
hospital. The Nurses' Knowl- edge
Questionnaire and Practice checklist were
administered. Data were analyzed by
descriptive statistics and Pearson product-
moment correlation. The findings revealed
that all of nurses (100%) had knowledge about
the standards regarding- colostomy at an
unsatisfactory level (MSD=29.8654
8.34085) with the maximum mean scores
(M=0.8269) and minimum mean scores
(M=2.2308). All of nurses (100%) scored
the actual nurses' practice of the standards
at an unsatisfactory level
(MSD=111.5125.706) with the max-
imum mean scores (M=19.42) and minimum
mean scores (M=2.4615). It was found that
there was a positive weak relationship
between knowledge and practice regarding
nursing care standards of colostomy(r=0.15,
p=.3). It was concluded that nurses'
knowledge and practice in the nursing care
standard of colostomy were unsatisfactory. It
was needed to be improved through
implementation of proposed nursing care
standards of colostomy.
Key Words: A standard is defined as benchmark of
achievement
Which is based on a desired level of excellence.

Introduct
ion
COLOSTOMY is defined as an
artificial opening of the colon onto
the abdominal surface. It may
originate from: The sigmoid colon, the
descending colon, the transverse
colon or the ascending colon
 A colostomy is named according to
where in the bowel it is formed: It
may be an ascending, transverse,
descending, or sigmoid colostomy. The
type of effluent is dependent on the
location of the bowel used. The type of
effluent in cecostomy (ascending
colostomy) is liquid to mushy and foul
odor. The type of effluent in right
transverse co- lostomy is mushy to
semiformed. The type of effluent in
left transverse colostomy is semiformed
and soft. The type of effluent in
descending or sigmoid colostomy is
soft to hard formed [2].
Hatton, [31 stated that stomas
involving the bowel are most common
with an estimated 50,000 people in the
UK with a colostomy each year. In the
last year (from 1 /1 /2011- 1 /1 /2012),
approxi- mately 71 cases carried out
colostomy at General Surgery
Department of Assiut University
Hospital (Assiut University Hospital
Record, 2011-2012).
57
Basic competency for all acute
care nurses providing care and
educational support for the new post
operative ostomy patient should
include the following: Stoma
assessment, pouch fitting, pouch
emptying, access to resources and
supplies, and basic problem-solving
skills [4].
Priorities for nursing care
include preparing the patient
physically for surgery; providing
infor- mation about post operative
care, including stoma care and
supporting the patient and family
emo- tionally. Patients undergoing
surgery for a tempo- rary colostomy
may express fears and concerns
similar to those of a person with a
permanent stoma. All members of
the health care team, in- cluding
the wound ostomy and continence
nurse (WOCN), should be available
for assistance and support. The
nurse's role is to assess the patient's
anxiety level and coping mechanisms
and suggest
58
Nabeel M. Bhzeh, et al. 58
Colostomy: Developing Nursing Care Standards for Patient
methods for reducing anxiety, such as issues about the impact on sexuality
deep breath- ing exercises and 1121.
visualizing a successful recovery
from surgery [5]. An educational need identified by
patients with an ostomy includes;
Monitoring and managing complications: stoma care skills, counseling, diet,
After the client returns from surgery, obtaining supplies and management
assessments include taking vital of com- plications McMullen, et al.,
signs, checking dressings, and [13] and Lewis, et al., [14] stated that;
moni- toring nasogastric tubes and IV home health care team for patient
infusions. Review the client's chart
for the type of colostomy and the
location of the stoma. If an
abdomin operineal resection was
performed, check the drain or packing
in the perineal area and note the
characteristics of the drainage. Also,
check the surgical dressing
frequently in the early post
operative period and observe the
characteristics of the stoma. Monitor
urine output and the volume of
suctioned gastric secretions. If urine
output is markedly decreased or
less than 500m1/day, inform the
physician im- mediately [6].
The nurse assesses the abdomen
for returning peristalsis and
assesses the initial stool character-
istics [7].
Colostomy irrigation: Colostomy
irrigation is a type of bowel
management. Before the wide-
spread use of disposable, odor-proof
ostomy equip- ment, nearly all
clients with colostomies used
irrigation for control of bowel
movements [8].
Maintaining optimal nutrition: A
complete nutritional assessment is
important for the patient with a
colostomy. The patient avoids foods
that cause excessive odor and gas,
including foods in the cabbage
family, eggs, asparagus, fish, beans,
and high-cellulose products such as
peanuts [9].
During the postoperative period, a
stoma should have a red, moist, shiny
appearance. Any deviation would
warrant an immediate physician
consultation. Protrusion of the stoma
should be assessed and documented
in the clinical record as flush,
budded, or long. Flush stomas open
below skin level and increase the
risk of peristomal skin irritation due
to inadequate appliance seal [10].
Sexual concerns regarding stoma
formation are often psychosocial in
origin, especially in terms of body
image 1111. Nurses should discuss
changes in body image with
patients, and how any issues can be
dealt with, as this can bring to light
 59
Nabeel M. Bhzeh, et al. 59
Colostomy: Developing Nursing Care Standards for Patient
education and discharge planning study could be helpful for nurses in
include the com- bined efforts of the planning and implementing nursing
physician, nurse, WOC nurse, social care standards for such group of
worker, and dietitian. patients.
Subjects and Methods
A nursing care standard is also
defined as a descriptive statement Research design: Descriptive research
of desired quality against which is design was utilized in this study.
evaluate nursing care. It is a
guideline, a path to safe conduct Setting: The study was conducted at
and an aid to professional General
performance [15]. Surgical Department of Assiut
The aim of the study: University Hospital.
The aim of the present study is
developing nursing care standards Sample: A sample of convenience
for patient with colostomy. including all nurses (60 nurses) both
maleand female working in selected
Research questions:
area.
To fulfill the aim of the study, the following Tools:
research question was formulated: Tool (I): Interview questionnaire sheet: It
What is the level of current was designed by the researcher
knowledge and practice of nurses based on current and international
regarding patient with colostomy? literature to assess nurses' knowledge
regarding patient with colostomy
Significance of the study: and it consists of two parts:
In recent years, increased Part 1: Sociodemographic
number of cases of cancer colon and characteristics of nurses: Including
thus have increased colostomy. age, sex, marital status, academic
Candidate observed that the patients qualification and duration of
with colostomy needed a special experience.
nursing care to improve the pa- Part 2: Assessment of nurses'
tients' outcome. This study will be knowledge: It includes definition of
the first study in this geographical colostomy, types, and causes, function
location which will help nurses to of colon, location of sigmoid and
improve safe, high quality nursing descend- ing colon, types of
care further- more, result of this colostomy pouch, optimal
nutrition, complications, nursing care and instruc-
tions of colostomy patient.
Tool (II): Observation checklist sheet: It was
designed by the researcher after reviewing of
literature to assess nurses' practice. It will include
two parts:
Part 1: General nursing care for colostomy
designed to include (8) goals related nursing activ-
ities: (a) General abdominal surgery wound care
of stoma. (b) Managing skin and stoma (emptying
and cleaning). (c) Caring the mucus fistula of loop
colostomy. (d) Changing the pouch. (e) Irrigation
of colostomy. (f) Attainment of fluid balance. (g)
Monitoring vital signs. (h) Assessing bowel sound.
Part 2: Instructions given to patient by nurses.
It includes (5) goals related instructions: Informa-
tion about signs and symptoms should be reported,
maintaining optimal nutrition, supporting positive
self image, decreased anxiety level and attainment
of satisfactory sexual performance
Scoring system:
For interview questionnaire: Each right answer
was given one score and zero for wrong answer,
the total scores was (87), those who obtained less
than 60% were considered having unsatisfactory
knowledge level, equal or more than 60% were
considered having satisfactory.
For observation checklist: Each right answer
was given two score (done correctly), one score
(done incorrectly), and Zero if not done. The scores
for each items are summed to create a total score
338, those who obtained less than 60% were con-
sidered having unsatisfactory level, equal or more
than 60% were considered having satisfactory.
Methods:
The study was executed on two phases:
Phase (1): Preparatory phase:
In this phase, the study tools were formulated
after review of literature. Validity of tools was
done by 5 experts. By the end of this phase, a pilot
study was carried out on 10% of sample to test the
feasibility of the study and applicability of the
tools, and the time needed to complete the tool
was 15 minutes. After pilot study, the tool was
used.
Phase (2): Implementation phase:
The data collection was carried out from 23
February until 23 May 2012, the researcher intro-
duced himself to initiate line of communication,
oral permission for voluntary participation was
obtained from nurses, the purpose, steps and ben-
efits of study were explained to nurses, confiden-
tiality and anonymity of data was ensured, the
knowledge of each nurse involved in the study was
assessed by questionnaire sheet through semi struc-
tured interview and the observation checklist was
carried out by the researcher while the nurses were
on duty during morning.
Data analysis:
The statistical analysis was carried out using
SPSS 16.0. The collected data were tabulated and
analyzed by using frequency distribution, percent-
age, mean, range and standard deviation. The level
of significance was considered at 5% level (p .
05). t-test was used to determine the differences
between the knowledge and practice in relation to
sociode- mographic characteristics of nurses.
Pearson- moment product correlation coefficient
was used to find out the relationship between total
knowledge and practice.
Results
Frequency distribution of socio demographic
characteristics of nurses showed that, most of the
subjects were females (75%). Age was less than
40 years in most subjects with percentage (69.2%)
and MeanSD (32.449.798). The majority of the
subjects were married (90.4%). Most of the subjects
had completed a diploma of nursing (88.5%). The
most period of working experiences in surgical
wards of (92.3%) of nurses was more than 3 years
with MeanSD (11.336.92).
Table (1) shows that total nurse's knowledge
score with MeanSD=29.86548.3408 also the
result showed that total practice score with
MeanSD=111.5125.706).
Table (2) shows that all of nurses had an unsat-
isfactory level of knowledge and practice
regarding to the standards regarding colostomy.
Table (1): Total mean score of nurses'
knowledge and practice regarding
nursing care standards for patient
with
colostomy.
Allotted score
MeanSD Total knowledge score
87.00 29.86548.34085
Total practice score 338
111.5125.706
Table (2): Frequency distribution of the level
of total nurses' knowledge and
practice regarding nursing care
standards for patient with
colostomy.
Percentage
Level
Total knowledge level 100 Total practice level 100
Unsatisfactory Unsatisfactory
 Table (3) shows that nurses had knowledge Table (4): Total and subtotal mean score of
regarding definition of colostomy at high percent- Nurses' practice
age of score with MeanSD=.8269.38200 and scores regarding colostomy care.
had low knowledge score regarding potential com- Nurses' practice
Ite No=5
plication of colostomy with MeanSD=2.2308 ms 2
1.13094. Allotted score
MeanSD
Wound care of stoma 40
10.0000.79212
Table (3): Total and subtotal mean score of
nurses' knowledge regarding Managing skin and stoma 36
colostomy care. 13.50005.8994
Nurses' knowledge Care of mucosa fistula 16
scores 7.13463.5204
Changing the pouch 42
15.73087.5980
Ite No=5 Irrigating the colostomy 34
ms 2 19.42318.5390
Allotted Attainment of fluid balance 6
MeanSD 1.51922.1281
score
score Monitoring vital signs 72
34.23084.2914
Definition of colostomy 1.00 . Assess the 20 0000
8269.38200 abdomen
including bowel
Anatomy of colon 1.00 . sounds 18
4615.50338 2.11543.3703
Instructions
about
Physiology of colon 4.00 symptoms and
1.2500.96761 signs should be 32
reported 2.46153.3282
Types of colostomy 4.00 .
8077.92965 Maintaining
optimal 8
Causes of colostomy 4.00 nutrition
1.84622.0521
1.9231.90415 Supporting
positive self
Nursing care of colostomy 4.00 . image 8
9038.35753 1.8846.92150
Reduction of
Types of colostomy pouch 47.00 anxiety
17.13464.88707 related to the
loss 6
Optimal nutrition 4.00 of bowel 1.42311.6490
1.3846.84375 control
Attainment of
Potential complications 9.00 satisfactory
2.23081.13094
Instruction 9.00 sexual performance
should be 2.9423.99830 related to altered
given to body image
patient

Total knowledge 87.00 Total practice 338

29.86548.34085 111.5125.706

physiology of colon at satisfactory level.

Generally the results show that all nurses had
Fig. (1) Illustrate frequency and percentage of
total knowledge regarding nurs- ing care standards
nurses' knowledge regarding colostomy care. The
of colostomy at unsatisfactory level.
results show that 82.7% of nurses had knowledge
regarding the definition of colostomy at
satisfactory level but the minimum number of Table (4) shows that nurses had practice regard-
7.7% of nurses had knowledge regarding the ing irrigating the colon through colostomy at high
score (MeanSD=19.42318.5390). In addition to
the result showed that nurses had practice
regarding optimal nutrition at low score
(MeanSD=2.4615
3.3282). The result showed that nurses had zero
percentage in assessment of bowel sound because
it is not applicable to nurses.
Fig. (2) Illustrate frequency and percentage of
nurses' practice regarding colostomy care. The
results show that; (13.5%) of nurses had practice
regarding the Attainment of fluid balance at satis-
factory level but the minimum number of (1.9%)
of nurses had practice regarding the Monitoring
vital signs at satisfactory level. Generally the result
show that all nurses had practice regarding nursing
care standards of colostomy at unsatisfactory level.
Table (5) shows that there was positive weak
relationship between knowledge and practice re-
garding nursing care standards of colostomy and
not significant (r=0.15, p=.3).
Table (5): Relationship between total
knowledge and total practice
regarding nursing care standards of
colos- tomy.
Total knowledge score Total practice
Pearson correlation (r- score .149
Significance (p-value) .292
N 52
 10
0
90
80
70
60
50
40
30
20
10
0

Fig. (1): Frequency and percentage distribution of nurses' knowledge regarding

colostomy.

10
0
9
0
8
0
7
0
6
0
5
0
40
3
0
20
1
0 Fig. (2): Frequency and percentage distribution of nurses' practice regarding
0 colostomy.

Discussi settings to improve the patients'

on outcome
[16].

The aim of the present study is

developing nursing care standards
for patient with colostomy at Assiut
University Hospital.

Stomas involving the bowel are

most common with an estimated
50,000 people in the UK with a
colostomy each year. Stoma therapy
nurses deliver specialized nursing
care in both hospital and com- munity
 A standard of care is one approach
to the chal- lenges experienced by
the health care delivery system has
been the move toward
standardization of care. Nursing
standards have been developed by
the profession in an attempt to
describe what nurses do and what
nurses are accountable for in
practice. They provide a guide to
the knowledge, skills, judgments
and attitudes that are needed to
practice safely [17,18].
Based on the results of the
present study, the majority of the
nurses their ages ranged from 20-
40 years, married, female, have
diploma of nursing
and their experiences more than 3 years, this
finding in the line with study by Abd Al-Magid
(2011) "entitled nursing care standards for cancer
patients undergoing chemotherapy of Assiut
University Hospital" reported the majority of
nurses aged from 20-40 years, female, have
diploma in nursing and their experience more than
3 years. Also the result supported finding
[19,20].
The findings revealed that total knowledge
regarding nursing care standards of colostomy was
at unsatisfactory level. The reasons might be due
to the background of the subjects. The majority of
the nurses had gained a diploma in nursing
(88.5%). Only (11.5%) of nurses with Bachelor of
Science in Nursing. Previous study found that
education has a significant impact on the
knowledge and competencies of the nurse
clinician, as it does for all health care providers.
Nurses with Bachelor of Science in Nursing
(BSN) degrees are well- prepared to meet the
demands placed on today's nurse. BSN nurses
are prized for their skills in critical thinking,
leadership, case management, and health
promotion, and for their ability to prac- tice across
a variety of inpatient and outpatient settings
[21].
In addition, the nurses had not been specialized
in enterstomal therapist (ET) the ostomy care.
Previous study shows that the nursing role of
caring for ostomy patients has evolved from the
bedside nurse to an enterstomal therapist (ET) or
a nurse clinical specialist with ostomy care
experience. Routine practice calls for staff nurses
and physi- cians to refer patients with a new
ostomy or patients with stoma problems to these
specialists. The responsibility for successful
outcomes typically falls on these specialized
nurses [22]. Another study in the United States
[23] Peirce, Tiffany, Kinsey and Link, (2008)
have shown that patients who were cared for by
wound ostomy continence (WOC) nurses (also
known as Enterostomal Therapy Nurses or ETs)
had better outcomes in terms of healing rates
and/or costs of care compared to patients cared
for by non WOC/ET nurses. Therefore, these
factors may affect the unsatisfactory level of knowl-
edge in this group of subjects [23,24].
The findings showed that the working experi-
ence in the surgical wards of 92.3% subjects was
more than 3 years. Although it has been proposed
that more working experience could increase
knowledge in that area, the findings in this study
is not compatible with that proposed. The staff
nurses who had experience period over three years
in providing care had lower knowledge than other
staff that had experience period less than three
years. Because the nurse may not know all aspects
of nursing care for colostomy even do they have
some working experiences. Similar to previous
study, it was found that a lower level of knowledge
among nurses with many years of working experi-
ence was due to a lack of current educational status
[25]. Another study also reported that;
knowledge could be acquired through basic and
continuing education, training, personal
experience, or in- service training [26].
Moreover, the results indicated that forty three
subjects (82.7%) had satisfactory level about the
definition of colostomy. Only five subjects (9.6%)
understood the types of colostomy. Also the result
indicated that fourteen subjects (26.9) had satisfac-
tory level about the causes of colostomy. Only four
of the nurses (7.7%) recognize the physiology of
colon but twenty four of nurses (46.2%) identified
anatomy of colon.
Finally the result indicated that six subjects
(11.5%) had satisfactory level about the optimal
nutrition but all nurses does not have satisfactory
knowledge level regarding complications of colos-
tomy, nursing care of colostomy and instruction
should be given to patients. This result indicated
that nurses had unsatisfactory knowledge in these
areas. Most of nurses give wrong answer about the
nursing care of colostomy, they believe that the
irrigation of colostomy has been done before sur-
gery, in obstruction or as needed by doctor. Rosdahl
(2012) stated that; colostomy irrigation is a type
of bowel management. Before the widespread use
of disposable, odor-proof ostomy equipment,
nearly all clients with colostomies used
irrigation for control of bowel movements [27].
The findings showed that total practice level
regarding the nursing care standards of colostomy
was at unsatisfactory level. This indicated that
nurses were not providing good nursing care for
patient with colostomy and this may be due to that
all nurses didn't have enough information about it
and the absence of standards of nursing care for
patient with colostomy. Marquis and Huston (2009)
reported that; each organization and profession
must set standards and objectives to guide individ-
uals and practitioners in performing safe and ef-
fective care [28].
In addition, some nursing procedures of colos-
tomy care those were not applicable for nurses as
the nurses were verboten. The current result indi-
cated that all nurses were not performing wound
dressing and assessment of bowelsounds because
it was not applicable for them. It was performed
by physician and the nurses had unsatisfactory
knowledge in these areas. Barbara (2010) stressed
that; the nurse should check the surgical dressing
frequently in the early post operative period and
observe the characteristics of the stoma [29].
And- Pottage (2012) added that, the nurse assesses
the abdomen for returning peristalsis in the
patient with colostomy [30].
Moreover, the present study result indicated
that all nurses didn't perform satisfactory practice
in managing skin and stoma, care of mucosa
fistula, changing the pouch, instruction about
signs and symptoms that should be reported,
maintaining optimal nutrition, reducing anxiety
related to loss of bowel control and attainment
of satisfactory sexual performance related to
altered body image. These result indicated that
nurses lacked practice in these area.
Also the result indicated that seven subjects
(13.5) had performed satisfactorily in attainment
of fluid balance but only four nurses (7.7) satisfac-
tory irrigated the colostomy.
Finally the result indicated that three subjects
(5.8) satisfactory supported positive image of
patient but only one nurses (1.9) satisfactorily
performed the monitoring vital signs Marquis and
Huston [31]. Reported that each organization
and profession must set standards and
objectives to guide individuals and practitioners
in performing safe and effective care. Also not only
must standards exist, but leader and managers also
must see that subordinates know and understand
the standards and employee must be aware that
their performance will be measured in terms of
their ability to meet the established standards.
A weak, positive correlation was found between
knowledge and practice regarding the nursing care
standards of colostomy (r=0.15,p=.3). This signi-
fied that knowledge did not influence practice
regarding the colostomy nursing care standards.
This may be due to that the nurse may had knowl-
edge in some area but are not applicable in their
practice that may affect the scores for practice.
These may not be the actual true scores of nursing
care, but knowledge could be a representative of
true cognitive ability. Therefore, these phenomena
could explain the weak relationship between
knowl- edge and practice of the nursing care
standards of colostomy.
The relationship between knowledge and prac-
tice was found to be inconsistent in the literature
review. One previous study found that there was
a weak negative relationship between knowledge
and practice regarding infection control among
doctors and nurses (r=.01,p=.001) [32].
However, another study found a positive
relationship between knowledge and practice in
the area of infection control (r=0.54,p<.001)
[33]. This matches Bloom's taxonomy. Who
mentioned that practice is posi- tively related to
knowledge. In addition, the nurses' practice
regarding the nursing care standards of
colostomy may also be influenced by other factors.
Conclusion:
Based on the result of present study, it can be
concluded that nurses' knowledge and practice
regarding nursing care of colostomy patient in
general surgical department of Assiut University
Hospital are at an unsatisfactory level and need
training about nursing care standards for patients
with colostomy to improve nurses' knowledge and
practice regarding nursing care of colostomy pa-
tient.
Recommendations:
Based on the finding of this study, the following
recommendations were made:
- Similar study should be done to evaluate the
effect of implementation of the proposed nursing
care standards of colostomy at general surgical
department of Assiut University Hospital gener-
alizable results.
- Continued nursing education and inservice train-
ing ostomy programs at General Surgical Depart-
ment should be held within Assiut University
Hospital and equipped with the necessary educa-
tional tools.
- Replication of study on a larger sample obtained
from different geographical areas in Egypt.
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