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The Patient with an Ostomy

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Title: The Patient with an Ostomy


1
Chapter 26
  • The Patient with an Ostomy

2
Learning 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.

3
The 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

4
Indications 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

5
Nursing Care of the Patient Having Ostomy Surgery
6
Assessment
  • 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

7
Interventions
  • 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

8
Interventions
  • 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

9
Fecal 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

10
Fecal 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

11
Postoperative Nursing Care of the Patient with
an Ileostomy
12
Assessment
  • 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

13
Assessment
  • 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

14
Interventions
  • 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

15
Interventions
  • 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

16
Figure 26-1
17
Interventions
  • 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

18
Interventions
  • 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

19
Interventions
  • 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

20
Continent (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

21
Figure 26-2
22
Postoperative Nursing Care of the Patient with a
Continent Ileostomy
23
Assessment
  • 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

24
Interventions
  • 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

25
Interventions
  • 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

26
Interventions
  • 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

27
Ileoanal 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

28
Figure 26-3
29
Ileoanal 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

30
Postoperative Nursing Care of the Patient with
an Ileoanal Reservoir
31
Assessment
  • Same as for the patient with an ileostomy
  • In addition, assess for rectal drainage and
    condition of the perianal skin

32
Interventions
  • 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

33
Interventions
  • 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

34
Interventions
  • 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

35
Colostomy
  • 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

36
Colostomy
  • 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

37
Postoperative Nursing Care of the Patient with a
Colostomy
38
Interventions
  • 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

39
Interventions
  • Risk for Injury
  • Assess for indications of colostomy complications
  • Prolapsed stoma
  • Obstruction

40
Urinary 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

41
Urinary 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

42
Postoperative Nursing Care of the Patient with a
Cutaneous Ureterostomy
43
Assessment
  • 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

44
Assessment
  • 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

45
Interventions
  • 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

46
Figure 26-1
47
Figure 26-6
48
Interventions
  • 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

49
Interventions
  • Risk for Injury
  • If urine does not flow readily, suspect
    obstruction and notify the registered nurse or
    the surgeon immediately

50
Interventions
  • 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

51
Interventions
  • Self-Care Deficit
  • Teaching plan should include
  • Ostomy care
  • Pouches
  • Diet
  • Fluids
  • Activity
  • Sexuality
  • Complications
  • Resources

52
Ileal 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

53
Ileal 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

54
Postoperative 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

55
Continent 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

56
Continent 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

57
Continent 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

58
Postoperative 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

59
Ureterosigmoidostomy 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

60
Vesicostomy
  • 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

61
Nephrostomy
  • 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
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