Title: The Patient with an Ostomy
1Chapter 26
- The Patient with an Ostomy
2Learning Objectives
- List the indications for ostomy surgery to divert
urine or - feces.
- Describe nursing interventions to prepare the
patient for - ostomy surgery.
- Explain the types of procedures used for fecal
diversion. - Assist in developing a nursing process to plan
care for - the patient with each of the following types of
fecal - diversion ileostomy, continent ileostomy,
ileoanal reservoir, - and colostomy.
- Explain the types of procedures done for urinary
- diversion.
- Assist in developing a nursing care plan for the
patient - with each of the following types of urinary
diversion ureterostomy, - ileal conduit, and continent internal reservoir.
- Discuss content to be included in teaching
patients to - learn to live with ostomies.
3The Ostomy Patient
- Ostomy
- Surgical creation of artificial opening into a
body cavity - Stoma
- The site of the opening on the skin
- Ostomies in the digestive tract
- Gastrostomy, jejunostomy, duodenostomy,
ileostomy, or colostomy - Ostomies in the urinary tract
- Ureterostomy, ileal or colonic conduit,
cystostomy, vesicostomy, and continent internal
reservoir
4Indications and Preparation for Ostomy Surgery
- Temporary ostomy
- May be indicated after surgery or trauma or when
there is severe inflammation or infection - Bypasses the affected portion of the bowel or
urinary tract, giving it time to heal - Permanent ostomy
- Necessitated by cancer of the bladder or colon or
severe inflammatory bowel disease
5Nursing Care of the Patient Having Ostomy Surgery
6Assessment
- Determine expectations, understanding of the
procedure, information desired, and fears - Health history reason for the procedure
- The medical history documents other acute and
chronic conditions that will require management
before and after surgery - Note drug therapy and allergies
7Interventions
- Anxiety
- Help the patient identify his or her concerns
- Appearance, job, or family life disruptions
- Encourage patients to talk and use coping
strategies that have been effective in the past - Reduce anxiety before teaching
8Interventions
- Deficient Knowledge
- Basic ostomy care should be taught before surgery
- Patients responses and questions should guide
you as to how much detail is appropriate - Preoperative teaching usually requires repetition
and reinforcement after surgery - An important resource is a volunteer from the
American Cancer Society or the United Ostomy
Association
9Fecal Diversion
- Ileostomy
- An opening in the ileum
- Necessary when entire colon must be bypassed or
removed - Require colon bypass congenital defects, cancer,
inflammatory bowel disease, bowel trauma, and
familial conditions such as multiple polyposis
10Fecal Diversion
- Ileostomy
- Procedure
- A surgical incision is made in the abdomen
- A loop or the end of the ileum is brought out
through a second abdominal incision - Edges of the loop or the end of the ileal segment
are everted and sutured to the abdominal skin to
create a stoma - Loops may be supported with a device, such as a
rod or bridge, instead of being sutured to the
skin
11Postoperative Nursing Care of the Patient with
an Ileostomy
12Assessment
- Health history
- Document significant symptoms such as pain,
anorexia, nausea, vomiting, weakness, thirst, and
muscle cramps - Determine what stressors the patient perceives,
usual coping strategies, and sources of support - Assess understanding of ileostomy care
13Assessment
- Physical examination
- Observe patients general status
- Level of consciousness, orientation, posture, and
expression - Vital signs and weight compare with preoperative
findings - Skin color, warmth, and turgor
- Inspect oral tissues for moisture
- Observe respiratory effort, and auscultate breath
sounds - Assess the abdomen for distention and bowel
sounds - Inspect the stoma for color and bleeding
- Inspect the base of the stoma for redness, skin
breakdown, and purulent drainage - Note the characteristics of draining fluid or
fecal matter
14Interventions
- Risk for Deficient Fluid Volume
- Administer intravenous fluids as ordered
carefully monitor hydration status - Keep accurate intake and output records
- Measure output from all sources, including urine,
gastric contents, and fecal drainage - Closely monitor serum electrolytes, and be alert
for signs and symptoms of imbalances - Changes in mental status (confusion, anxiety),
changes in neuromuscular status (twitching,
trembling, weakness), poor tissue turgor, edema,
and dry mucous membranes
15Interventions
- Impaired Skin Integrity
- Check the pouch hourly at first to detect leakage
- When pouch emptied or changed, prevent fecal
matter from contaminating the primary incision - Clean skin around the stoma gently but thoroughly
- Maintain protective barrier to prevent skin
breakdown - A plastic pouch is used to collect fecal drainage
- Remove the appliance for thorough cleansing of
the skin surrounding the stoma every 3 to 5 days
16Figure 26-1
17Interventions
- Disturbed Body Image
- Assure patient that odor is normal when the pouch
is being changed or emptied, but that it can be
controlled at other times - Advise to delete and reintroduce various foods to
find those that are most troublesome - Rinsing with a vinegar solution neutralizes odors
that cling to the pouch - Odor-proof pouches and commercial pouch
deodorizers are available
18Interventions
- Sexual Dysfunction and/or Ineffective Sexuality
Patterns - Encourage patients to ask questions about how the
ostomy might affect sexual function or behavior - Practical suggestions may help resume sexual
activity - Pouch should be emptied and taped down before
intercourse - Covers available to conceal the appliance and its
contents - The partner wearing the pouch should experiment
with positions that are most comfortable - Female patients should know that ostomy surgery
does not interfere with pregnancy or delivery
19Interventions
- Ineffective Therapeutic Regimen Management
- After surgery, some teaching should be included
every time stoma care is done - At first, you may simply tell patient what is
being done and why - Then encourage patient to take over more and more
of the procedure - Have patient demonstrate and practice as much as
possible before discharge
20Continent (Pouch) Ileostomy
- Internal pouch created from loop of ileum for
storing fecal matter - Advantage patient does not have continuous
drainage and so does not have to wear a pouch - Procedure
- A loop of the ileum is sutured together and then
opened - A portion of the distal end of the ileum is
inverted within itself to create a nipple valve - The valve prevents fluid leakage from the pouch
- The looped section then closed, leaving a pouch
capable of expanding and storing fecal matter - The distal end of the ileum is brought through
the abdominal wall and sutured into place to
create a stoma
21Figure 26-2
22Postoperative Nursing Care of the Patient with a
Continent Ileostomy
23Assessment
- Essentially the same as that of the patient with
an ileostomy - Assess for continuous drainage because
obstruction of the catheter may occur - Absence of drainage or patient complaints of a
feeling of fullness in the pouch suggest
obstruction - Drainage bloody at first, then brownish
24Interventions
- Risk for Injury
- Patient given only intravenous fluids to allow
the bowel to heal and peristalsis to resume - For the first 2 weeks, the pouch is drained every
3 to 4 hours - Next 2 weeks interval is every 5 hours
- Eventually the patient will need to drain the
pouch only 2 to 4 times a day
25Interventions
- Deficient Knowledge
- Draining the continent ileostomy
- Have the patient sit or lie down for the
procedure - Gather lubricant, 28 catheter, drape, basin,
irrigating syringe, irrigating solution, gauze
dressing - Lubricate catheter and insert it gently into the
stoma - Resistance will be felt when the catheter reaches
the nipple valve (approximately 2 inches past the
stoma) - Instruct patient to bear down, then roll the
catheter between your fingers and advance it into
the pouch - When catheter in the pouch, gas and fecal matter
begin to drain - Drainage continues for approximately 10 minutes
and produces a total volume of 50 to 200 mL
26Interventions
- Draining the continent ileostomy
- If the drainage is too thick, instill 30 mL of
normal saline as ordered gently aspirate - Do not do this unless necessary because it may
cause dislocation of the nipple - When drainage stops, quickly remove the catheter
- Place gauze dressing over the stoma to absorb
secretions - Measure, describe, and discard the drainage
- Show patient how to perform procedure as soon as
possible - Patient should wear a medical alert bracelet
stating he or she has a continent diversion that
must be drained
27Ileoanal Reservoir
- Fecal matter is stored and then eliminated
through the rectum - Procedure
- First stage
- Colon is removed and an internal pouch that is
created from the ileum is attached to the
anorectal canal - Temporary ileostomy made to allow the reservoir
to heal - Second stage
- Approximately 2 months later, barium radiographs
are taken to be sure that the reservoir is intact
- If the reservoir does not leak, the ileostomy is
closed
28Figure 26-3
29Ileoanal Reservoir
- Complications
- Obstruction
- Scar tissue or strictures may cause obstruction
- Signs and symptoms abdominal distention, nausea
and vomiting, decreased bowel sounds, change in
bowel pattern - Peritonitis
- If fecal matter leaks through the suture lines of
the reservoir into abdominal cavity, abscesses or
peritonitis can develop - Signs and symptoms increased pulse,
respirations, and temperature rigid abdomen and
abdominal pain and elevated white blood cell
count - Inflammation
- Manifested by bloody diarrhea, anorexia, and pain
30Postoperative Nursing Care of the Patient with
an Ileoanal Reservoir
31Assessment
- Same as for the patient with an ileostomy
- In addition, assess for rectal drainage and
condition of the perianal skin
32Interventions
- Risk for Impaired Skin Integrity
- Skin around the ileostomy stoma and in the
perianal area needs special care - Until reservoir is well healed, liquid discharge
may be expelled without warning - Thorough, gentle cleansing and protective creams
help prevent skin breakdown
33Interventions
- Bowel Incontinence
- Perineal pads to prevent soiling of clothing
- Teach perineal muscle-strengthening exercises
- Drugs prescribed to decrease the frequency of
stools and to make them less watery - Advise to avoid fatty foods at first
34Interventions
- Risk for Injury
- Assess for signs and symptoms of bowel
obstruction, peritonitis, and inflammation - If obstruction occurs, give intravenous fluids
and nothing by mouth - Nasogastric tube inserted to decompress the bowel
- If obstruction is caused by adhesions (scar
tissue), surgery may be necessary to release the
restriction
35Colostomy
- Opening in the colon through which fecal matter
is eliminated - Procedure
- Bringing a loop or an end of the intestine
through the abdominal wall and creating a stoma
for the passage of fecal matter - Location of the stoma depends on the portion of
the intestine removed - Classified by location in the colon ascending,
transverse, descending, and sigmoid colostomies
36Colostomy
- Temporary colostomy
- Allows healing of the intestine after surgery or
in certain disease states - Permanent colostomy
- Removal of a large part of colon or the rectum
required
37Postoperative Nursing Care of the Patient with a
Colostomy
38Interventions
- Ineffective Therapeutic Regimen Management
- Irrigations
- No longer routinely recommended
- Many patients have regular bowel movements
without irrigation - Unlikely to establish control if the patient has
diarrhea when under stress, has had radiotherapy,
has a poor prognosis, or has a history of
inflammatory bowel disease - Complications perforated bowel fluid and
electrolyte imbalances cramping, nausea, and
dizziness - If irrigations are indicated, you or the ET may
perform them initially while teaching patient or
significant other
39Interventions
- Risk for Injury
- Assess for indications of colostomy complications
- Prolapsed stoma
- Obstruction
40Urinary Diversion Cutaneous Ureterostomy
- One or both ureters are brought out through an
opening in the abdomen or flank - Often the two ureters are joined surgically so
that only one stoma is needed - Sometimes a stoma is created from each ureter
- Much smaller than an intestinal stoma
- Urine drains from the stoma continuously
- Pouch needed to collect the urine and protect the
skin
41Urinary Diversion Cutaneous Ureterostomy
- Complications
- Stenosis
- Narrowing of the opening that interferes with the
flow of urine - If the obstruction is not relieved, urine backs
up in the kidney and may cause hydronephrosis - Urinary tract infections
42Postoperative Nursing Care of the Patient with a
Cutaneous Ureterostomy
43Assessment
- Health history
- Assess for flank or abdominal pain, fatigue,
malaise, and chills - Determine patients response to the ostomy,
knowledge of it, and readiness to learn - Determine the reason for ureterostomy as well as
pertinent past medical history, drug profile, and
allergies
44Assessment
- Physical examination
- Assess patients general state
- Take vital signs and compare with preoperative
readings - Observe respiratory effort and auscultate breath
sounds. Assess the abdomen for distention and
bowel sounds - Inspect the stoma
- Document amount, appearance, and odor of the urine
45Interventions
- Impaired Skin Integrity
- Apply an appliance to collect urine drainage
- Use skin barrier around the stoma
- Pouch is usually cleaned once or twice daily
- Changed every 4 to 6 days or when it leaks
because frequent changes are irritating to the
surrounding skin
46Figure 26-1
47Figure 26-6
48Interventions
- Risk for Infection
- The stoma serves as a portal for pathogens to
enter the urinary tract, causing infection - Avoid introducing organisms to the area
- Yeast infections can develop characterized by a
skin rash surrounding the stoma - Treat with nystatin powder applied under the skin
barrier
49Interventions
- Risk for Injury
- If urine does not flow readily, suspect
obstruction and notify the registered nurse or
the surgeon immediately
50Interventions
- Disturbed Body Image
- Demonstrate acceptance of the patient and care
for the stoma in a matter-of-fact manner - Express understanding of patients feelings
- Encourage normal grooming and dressing
- Provide opportunities to ask questions or discuss
how the ostomy might affect sexual function or
behavior
51Interventions
- Self-Care Deficit
- Teaching plan should include
- Ostomy care
- Pouches
- Diet
- Fluids
- Activity
- Sexuality
- Complications
- Resources
52Ileal Conduit
- Procedure
- Urinary drainage system made from portion of
small intestine - A 6- to 8-inch segment of ileum is first removed
- The remaining ends of the ileum are then
anastomosed (joined) to restore bowel function - The ureters are cut from the bladder and attached
to the ileal segment at an angle to prevent
reflux - One end of the ileal segment is sutured closed.
The other end is brought through an abdominal
incision and sutured to create a stoma for urine
drainage
53Ileal Conduit
- Complications
- Leakage of the anastomosed ureters and intestinal
segments - Ureteral obstruction
- Separation of the stoma from surrounding skin
- Wound infection
- Necrosis of the stoma
- Paralytic ileus
- Crystal formation and calculi
- Stoma retraction, prolapse, or hernia
54Postoperative Nursing Care of the Patient with an
Ileal Conduit
- Basically same as for patient with an ileostomy
- A few special points to make about the ileal
conduit - Patient will have a nasogastric tube attached to
suction to prevent abdominal distention and
stress on the resected portion of the ileum while
it heals - Allowed nothing by mouth and is given intravenous
fluids until bowel sounds return - Ureteral catheter or stent may be in place to
drain urine - Attach the pouch to a collection device during
the night
55Continent Internal Reservoirs
- Allows for the storage and controlled drainage of
urine - Ileum neobladder
- Eliminates the need for a stoma
- Internal urinary reservoir constructed using a
resected segment of the colon that is attached to
the urethra - Urine drains into the reservoir and is eliminated
through the urethra
56Continent Internal Reservoirs
- Kock pouch
- Constructed with a segment of ileum
- Ureters implanted in one side of the ileum
segment - Nipple valve is constructed from the other side
and attached to the skin, where a stoma is
created - Valve prevents urine from flowing from the
reservoir - Catheter drains reservoir at 4- to 6-hour
intervals
57Continent Internal Reservoirs
- Indiana pouch
- Similar to the Kock pouch except that it is made
of a portion of the terminal ileum and the
ascending colon - The reservoir is larger than that of the Kock
pouch
58Postoperative Nursing Care of the Patient with a
Kock or Indiana Pouch
- May have Penrose drain to remove fluid from
operative site and clear tube in place for
continuous urine drainage - Irrigations may be ordered to remove clots and
mucus - When the tube is removed, the pouch may be
drained every 2 to 3 hours at first - Later, may need to drain the pouch only every 4
to 6 hours during the day and once during the
night - If pouch functions properly, the patient does not
have to wear an external appliance - Gauze dressing over stoma to absorb mucus
drainage - Advise medical alert bracelet identifies
presence of a continent device that needs
intubation to drain
59Ureterosigmoidostomy and Ureteroileosigmoidostomy
- Ureterosigmoidostomy
- The ureters are implanted into the sigmoid colon
- Urine drains into the colon and is eliminated
through the rectum - Ureteroileosigmoidostomy
- A segment of the ileum is anastomosed to the
sigmoid and the ureters implanted into that part
of the ileum
60Vesicostomy
- Vesicostomy or cystostomy
- An opening into the urinary bladder
- Some are drained continuously through a catheter,
others have a nipple valve and are drained at
intervals
61Nephrostomy
- Diverts urine directly from the kidney through a
tube that exits through the skin - May be used as a temporary or permanent method of
urinary diversion