Medical Surgical Nursing Chapter 54

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Medical Surgical Nursing Chapter 54

• Caring for Clients With Ostomies

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TERMS Table 54-1

• Ostomy an opening between an internal structure
  the skin
• Ileostomy an opening from the distal small
  intestine
• Colostomy an opening from the colon

• Stoma an opening on the exterior surface of the
  abdomen
• Ostomate a person with an ileostomy or
  colostomy
• Ostomies may be temporary or permanent

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ILEOSTOMY

• Conventional stoma located in the lower abd,
  stool is liquid or mushy contains digestive
  enzymes always incontinent
• Continent stoma located in the lower abd,
  liquid stool with continence attainable
• Appliance - the collection device worn over the
  stoma

• Preop explain the expected outcome, where the
  stoma will be, what is involved in its care,
  risks for bladder sexual dysfunction see
  nursing process
• Postop rectal packing, NGT care, antibiotics,
  pain mgmt, watch closely for s/s intestinal
  obstruction see nursing process

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STOMAS

• See characteristics of healthy or unhealthy stoma
  table 54-2
• See changing an ostomy appliance nursing
  guidelines 54-1

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CONTINENT ILEOSTOMY(Koch Pouch)

• An internal reservoir is created for the storage
  of GI effluent, fig 54-3
• Temporary catheter inserted during surgery
• Post op catheter may be connected to suction to
  allow healing
• Nurse checks the ileal catheter frequently for
  signs of obstruction irrigate with normal saline
  prn
• Empty reservoir every 2-4 hrs initially
• After about 6 months it may be emptied 3-4 x
  daily
• Teaching plan

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ILEOANAL RESERVOIR(Ileoanal anastamosis)

• Maintains bowel continence on pts with chronic
  ulcerative colitis fig 54-4
• Done in 2 stages
• 1st stage creates temporary ileostomy
• in 2-3 months temporary ileostomy closed the
  2 sections of ileum are sutured back together
• fecal material then expelled through the anus
• Client and family teaching 54-2

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COLOSTOMY

• An opening in the large bowel created by bringing
  a section of the large intestine out to the abd
  and making a stoma
• Indications cancer, ulcerative colitis,
  multiple polyps, traumatic injury
• May be temporary or permanent

• See fig 54-5, various colostomies
• Depending on where the colostomy is formed may be
  regulated by irrigations so the person would not
  always wear an appliance
• Irrigations nsy guidelines 54- 2, box 54-3 54-4

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TYPES

• Single barrel colostomy a single stoma through
  which stool passes
• Double barrel colostomy has two openings or
  stomas usually temporary may need
  irrigations-make sure MD indicates on chart which
  is the proximal distal end

• Loop colostomy when a loop of the bowel is
  lifted through the abd then opened 24-72 hrs
  later at the bedside. This allows for initial
  healing of the incision without danger of
  contamination. Prepare the pt cover clothing,
  odor, have ostomy pouch ready

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NURSING MANAGEMENT

• Similar to care of the ileostomy client
• Routine post op care, check dressings, packing in
  the rectum, check to see when the packing is to
  be removed

• Assess appearance of the stoma, s/s of
  intestinal obstruction such as an increase in
  pain, abd tenderness or distention, urine op,
  appearance amt of suctioned gastric contents
  see nursing process
• Client family teaching 54-3

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GENERAL NUTRITIONAL CONSIDERATIONS

• A low fiber diet may be prescribed for 6-8 weeks
  after ostomy surgery
• 1-2 quarts of fluid are needed to replace liquids
  lost from decreased water reabsorption from the
  bowel
• Give list of foods that may produce odorous gas
• Parenteral injections of vitamin B12 may be
  needed for those who have lost most or all of the
  ileum

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GENERAL PHARMACOLOGIC CONSIDERATIONS

• Some medications such as vitamins, antibiotics,
  antituberculosis drugs may cause particularly
  strong odors that cling to the appliance.
• Clients with an ileostomy should avoid
  enteric-coated products modified-release drugs.
  They may be passed through without being
  absorbed

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GENERAL GERONTOLOGIC CONSIDERATIONS

• Teach ostomy care as appropriate for the clients
  age prior understanding
• Teach another person how to perform ostomy care
  in case the client temporarily cannot assume
  responsibility for this task
• Older adults with chronic disorders such as poor
  vision arthritis may have problems with proper
  care of their ostomy
• Ostomates are particularly vulnerable to
  emotional distress, including loss of
  self-esteem, poor body image, increased anxiety
• Never assume that an older adult is not concerned
  about the effects of the ostomy on sexuality