2Alternative Bowel Elimination Bowel diversion-redirection of the contents of the small or large intestine through a surgically created exit in the abdominal wall.Possible reasons for bowel diversion:Cancerous tumorDisease process such as Crohn’s diseaseInfarcted area which the bowel walls become ischemic and dieRuptured diverticulumUlcerative colitisTraumatic abdominal injuryCertain Disease processes and injuries can necessitate that a patient be provided with an alternative form of bowel elimination by surgically creating a bowel diversion. The fecal material or effluent empties into an ostomy appliance, otherwise known as a bag or pouch.
3OstomiesOstomy- surgically created opening into the abdominal wall that serves as an exit site from the bowel or ureter.Ileostomy- surgically created opening from the small intestines to the abdominal wall allowing the passage of feces.,Colostomy-surgically created opening from the large intestines to the abdominal wall allowing for the passage of feces.When the diversion is brought to the outside of the abdominal wall the new opening is called an ostomy and the mouth of the ostomy is called the stoma.The name of the ostomy is determined by the area of the bowel that is brought out through the abdominal wall.If a part of the small intestine, such as the ileum is, it is called an ileostomy.If a part of the large intestine is used, it is called a colostomy. Used
4ColostomyA colostomy stoma will have a single opening, this is a single barreled or end stoma, if the distal colon is permanently removed.Occurs withCancer of descending colonSevere Chron’s diseaseWith Chron’s disease there is an inflammation of the bowel. The colon may need time to heal and rest. In this situation the colon may be completely incised, or cut into two pieces creating to stomas . Picture in book Pg 690 .With Chron’s disease there is an nflamation of the bowel. The colon may need time to heal and rest. In this situation the colon may be completely incised, or cut into two pieces creating to stomas . Picture in book Pg 690 .This is considered a double barrel colostomy. This is usually temporary allows the disease portion of the bowel to rest and heal.Another type of stoma seen in the treatment of inflammatory disease is the loop stoma.Al loop of the bowel usually the transverse colon is brought to the surface of the abdomen. A plastic rod or a bridge is stitched to the abdominal wall to keep outside the body. Stool will be expelled from the primal opening. Ocassionaly stool will seep from the rectum.A temporary colostomy may be done . A temporary colostomy usually
5StomaStoma- portion of the bowel or ureter that is surgically opened and brought out through the abdominal wall.
6UreterostomyUreterostomy- surgical procedure creating an opening from the ureter to the abdominal cavity.In some cases it is not possible to empty the bladder by draining it with a catheter due to obstruction or interruption of the normal urine pathway. A urinary diversion means that the urine is eliminated by an alternative route rather than traveling the bladder.These diversions may be created when there has been trauma to the bladder, or the bladder has been removed, or as a result of cancer of the bladder.One type is an ileal conduit where the ureters are attached to a section of the samll intestine that has been used to create a pouch and stoma. The urine drains continuously through the stoma. The patient will wear an appliance over the stoma to collect urine.One of the greatest Challenges with a urinary with an incontinent urinary diversion is skin care, If the patient has a problem with irritation and or skin breakdown, and enterstomal therapist or nurse may be ale to recommend protective skin wipes and or ostomy powder to help protect the skin.Know the different types of ostomies.
7StomaStoma- portion of the bowel or ureter that is surgically opened and brought out through the abdominal wall.A Healthy Stoma is shiny, moist and red.Pg 691 Figure 30-5
8Ostomy Drainage Type of drainage depends on location of the ostomy: Ileostomy and ascending colon-liquid feces.Transverse colostomy- mushy stool.Descending colon-soft to solid.Know what the stool would be like depending on type of ostomy.
9Kock PouchIs a diversion that uses the terminal portion of the ileum to form an internal pouch, or reservoir, to collect and store the effluent prior to evacuation from the body.A flap is formed that closes the reservoir, preventing leakage onto the skinThe patient inserts a catheter several times a day to drain the reservoir.The type of stoma is considered a continent ostomy since the patient has control over when it is drained.
10Ostomies May be temporary or permanent. Temporary-bowel rest, e.g. Chron’s disease.Permanent-tumor.Temporary may be several weeks to several months.
11Ostomies Temporary- generally located at the transverse colon. Permanent- usually located at the descending colon or sigmoid colon. Permanent because the colon or rectum have to be removed.
12Nursing Care of Ostomies Many hospitals are now utilizing nurses specially trained to provide ostomy care.The not only provide direct care but are consultantsThey provide patient teaching.Recommend appliances and products depending on patients type of ostomy devices/products.
13OstomyAppliances Many types of appliances/pouches available. One piece-one unit bag attached to an adhesive disc that applies directly to a patents abdomen after peeling off the protective backing off the adhesive disc.Two piece- wafer is separated from pouch. The bag adheres to an adhesive disc called a wafer faceplate.See pg 692 Figure 30-7.Wafers- some precut and some must be custom fit. See pg 691 Figure Look like a tuperware seal.Te face plate is changed every 3-5 days and prn.Ostomy appliances come in different sizes. The determine the correct size the stoma must be measured.The stoma size is determined using a stoma device made of card stock.The card has different sizes of holes cut out with a corresponding size.The correct size will fit around the stoma and allow 1/8 to ¼ inch of peristomal skin to show.The appliances also come in different sizes. Once you determine the correct size required to fit as above around the stoma, it will be used to detrmined the correct flange or ostomy bag to use.
14Ostomy AppliancesOnce the adhesive begins to loose contact with the skin, it allows the effluent to leak underneath the face plate, which can create excoriation of the skin.If leakage continues unheeded, infection and or ulceration can occur. Sealant or paste- create a seal.Closure- clip or clamp.O
15Ostomy Care Wash hands. Don gloves. Remove old appliance. Note effulent (drainage)-color, amount, and odor.Drain effulent into commode.Discard old appliance into biohazard bag.
16Ostomy AppliancesThe ostomy bag should be emptied when 1/3 to ½ half full to prevent leakage and odor.Most bags have a drain on the bottom edge of the bag that can be opened and emptied.Some patients prefer to change the bag, others empty and rinse with cool water, dry and reapply.Ostomy supplies are expensive
17Ostomy Care Assessing initial post-op stoma: initially post-op stoma will be edematous and may have small amount of bleeding.Monitor for post-op complications:Excessive bleeding.Stoma dark in color or blanched due to lack of blood supply.Drying of stoma.Signs of infection.May shrink 2-3 weeks post surgery. May take 4-6 weeks to determine stoma size.
18Ostomy Care Stoma assessment: Stoma should be pink to red and moist. Pallor, cyanosis or dusky color indicates poor blood supply. Black indicates necrosis.Initially there may be some edema.Assess for cuts, ulcerations, or any abnormal findings.Assess skin around stoma.Note any redness or irritation.Was a
19ChallengesExcoriation – chemical injury of the skin due to the enzymes .Numerous products are available Skin breakdown is a major challenge due to the enzymes in the stool.
20Nursing ImplicationsWash stoma and skin around stoma with soap and water and pat dry.Apply skin barrier substance (karaya powder, skin prep).Enterostomal therapist-nurse who specializes in care of ostomies.
21Application of appliance Application depends on the type of appliance used.Pre-cut-appropriate size is chosen and then applied.Custom fit-use an ostomy guide to cut the opening on the wafer 1/16 to 1/8 larger than stoma.Key is to fit appliance around the stoma without touching stoma or exposing surrounding skin.See skills pg Skill 30-5
22Applying Appliance One piece system- use skin sealant. Two piece system- use paste.Appliance chosen depends on the type of ostomy, stoma shape, location of stoma.(Trial and error)May reinforce appliance with non-allergic paper tape in picture frame.May wear an ostomy belt.Roll end of pouch upward once and apply clip/clamp.Be sure clam is snug.
23Assessment of Ostomy GI assessment of patient. Assess bowel sounds in all 4 quadrants.Assess effulent from ostomy.Empty pouch when 1/3-1/2 full.Assess abdomen.Report any abnormal findings immediately.Bowel sounds and activity by day 3.
24Ostomy Care Management of ostomy: Ostomy should be pink & moist. Skin should be clean, dry, & intact.Assess for s/s of redness or irritation.New appliances should adhere to skin without wrinkles or gaps.
25Colostomy Irrigation Is similar to an enema. Colostomies may be irrigated to evacuate due to constipation.May be ordered post op for stomas located in the descending colon.When irrigating a descending or sigmoid colostomy the goal is to train the ostomy to evacuate the same time every day.Requires Dr. order.Procedure:Remove appliance.Place irrigation sleeve over stoma.Instill lubricated cone into stoma.Insert catheter into cone.Instill 500cc-1000cc tap water or saline .Start with 500cc over 5-10 minutes.See Skill pg
27Urinary DiversionSurgical opening on the abdomen or ostomy through which urine is eliminated.Types: Continent and incontinent.Continent diversion-internal pouch or reservoir created from a segment of the bowel.Patient performs self catheterization every 4-6 hours.No appliance used.
29Incontinent Urinary Diversion AKA-ileal conduit.Ureter is transplanted into a closed off portion of the ileum with an opening to the outer abdomen creating a stoma.Ureterostomy-1 or 2 ureters are brought to the abdominal wall and a stoma is formed.Requires a pouch or appliance because of continuing urinary drainage.Page 725- in text
30Urinary Diversion Nursing Implications: Increased chance of skin breakdown due to continuous drainage.Change appliance bag frequently due to weight of urine.Place a tampon in stoma to absorb urine while cleaning.Peristomal skin is difficult to keep free from breakdown due to ammonia in urine.Use of skin barrier or topical antibiotics or steroids.