Timby/Smith: Introductory Medical-Surgical Nursing, 10/e Chapter 48: Caring for Clients with Ostomies

Ileostomy Ostomy Opening between internal body structure and skin Types: Ileostomy—distal small intestine; Colostomy—colon Stoma: Opening—exterior abdominal surface Causes: Inflammatory bowel disorder; Rupture of intestine; Irreversible obstruction; Compromised blood supply to intestine; Cancerous tumor

Question Is the following statement true or false? A colostomy is a surgically-created opening between the small intestine and the skin.

Answer False. A colostomy is a surgically-created opening between the colon and the skin. An ileostomy is a surgically-created opening between the small intestine and the skin. An ostomy is an opening between internal body structure and skin.

Ileostomy Conventional: Removal— colon and rectum Matured stoma: Process; healing; Smooth peristomal area Fecal material: Liquid; Digestive enzymes Appliance; Ostomate Karaya gum: Protects skin; Promotes adhesion

Figure 48-2 The ostomy appliance Disposable Temporary: Immediate postop phase Reusable equipment Disposable equipment: Replace daily with bathing Figure 48-2 The ostomy appliance

Ileostomy: Preoperative Period Surgical Management Interventions by physician Surgery: Purpose; Benefits; Risks Stoma: Appearance; Function; Mark site Enterostomal therapists; Enterostomal therapy nurses Wound, Ostomy, and Continent Nurses (WOCNs): Collaborate with surgeon and client’s educational needs Identify risks from total colectomy: Bladder and sexual dysfunction

Ileostomy: Preoperative Period Surgical Management (Cont’d) Sexual dysfunction: Collect and store sperm; Slightly diminished fertility in women Cleansing of bowel: Dietary restrictions— combination with laxative or lavage agents; Antibiotic prophylaxis; IV antibiotics Taper and discontinue prednisone: Avoid negative effects on tissue healing Preoperative “stress dose” of IV steroid: Prevent adrenal crisis

Ileostomy: Preoperative Period Surgical Management (Cont’d) Discontinue immunosuppressive agents Prevent negative effects on tissue healing Discontinue Aspirin-containing compounds to minimize risk of bleeding Obtain Blood samples, type, and cross-match for replacement of losses

Question Is the following statement true or false? Discontinuing the use of aspirin before surgery decreases the likelihood of excessive bleeding.

Answer True. Discontinuing the use of aspirin before surgery decreases the likelihood of excessive bleeding as aspirin side effects include anticoagulant properties.

Nursing Process: Preoperative Ileostomy Care Assessment Diagnosis Planning Implementation Evaluation of Expected Outcomes

Ileostomy: Postoperative Period Surgical Management Rectal pack: Absorbs drainage; Promotes gradual healing; 5 to 7 days Irrigations: Promote healing; Nasogastric tube— gastrointestinal decompression IV fluids: Maintain fluid, electrolyte, and nutritional balances Antibiotic therapy; Analgesics Monitor: Wound healing Manage complications: Intestinal obstruction; Serious complication

Ileostomy: Postoperative Period Surgical Management (Cont’d) Stoma: Bleeding; Impaired blood supply; Stenosis; Prolapse; Excessive protrusion Prolapse or protrusion of ileostomy Edema: Obstruction; Restricts stomal blood supply Stomal necrosis: If prolapse not managed promptly and skillfully

Nursing Process: The Client Recovering From Ileostomy Surgery Assessment Diagnosis Planning Implementation Evaluation of Expected Outcomes

Continent Ileostomy (Kock Pouch) An internal reservoir for the storage of GI effluent Surgical Management Reservoir is formed with a portion of terminal ileum; nipple valve Temporary catheter insertion Perineal area pack: Remains for 1 week

Question Is the following statement true or false? A Kock pouch is used to facilitate a continent urostomy.

Answer False. A Kock pouch is used to facilitate a continent ileostomy.

Continent Ileostomy (Kock Pouch) Nursing Management Reinforce perineal packing; Check abdominal dressing—drainage; Connect stomal catheter to low, intermittent suction; Check ileal catheter— obstruction Note drainage: Color, amount; Observe stoma size and color Administer irrigations of ileal catheter-saline solution: Routine; As-needed Keep skin clean around stoma; Change gauze dressing; Monitor ileal output Empty reservoir; Teaching plan

Ileoanal Reservoir Ileoanal Anastomosis Maintain bowel continence Clients: Ulcerative colitis; Disease does not affect anorectal sphincter Preserves innervation of male genitalia Bladder and erectile dysfunction unlikely Infertility

Ileoanal Reservoir Surgical Management First stage Temporary ileostomy; Continuous discharge of mucus from anus Frequent discharge of fecal material from ileostomy; Uncontrollable watery discharge Second stage 2 to 3 months later; Closes temporary ileostomy; Reunites two sections of ileum; Anastomosis Fecal material is expelled; Control; Stronger anal sphincter

Ileoanal Reservoir Nursing Management Assessment Preoperative: Same as ileostomy Postoperative—first stage: Observations; Anal area for drainage; Drain or drainage tube in presacral area Postoperative—second stage: Drainage—anal area and operative sites Instruct: Perform perineal exercises—bowel incontinence; Keep perianal area clean

Ileoanal Reservoir Nursing Management Assessment (Cont’d) Postoperative After first-stage ileoanal surgery: Teach client to use a squirt bottle After second-stage repair: Instruct the client to cleanse anus with warm, soapy water Emphasize to dry the area well

Colostomy Opening: Large bowel Indications: Cancerous lesion; Ulcerative inflammatory process; Multiple polyposis; Injury to bowel Types Temporary, permanent: Ascending; Transverse; Descending; Sigmoid

Question Is the following statement true or false? A colostomy can be either temporary or permanent.

Answer True. A colostomy can be either temporary or permanent. It is also referred to by its placement.

Colostomy Various colostomies

Colostomy Types Regular irrigations: Controls sigmoid and descending colostomy Appearance: Single-barrel; Double-barrel; Loop Surgical Management Single-barrel: Single stoma; Segmental resection; Abdominoperineal resection—tumors in lower third of sigmoid Double-barrel: Stoma—proximal and distal; Duplicate medical record diagram—nursing care plan to assess bowel function and irrigations required

Colostomy Surgical Management Temporary; Treats disorder—acute diverticulitis; Chronic constipation Inflammatory bowel disease Interval before reestablishing: 16 months or longer Loop colostomy Loop of bowel: Lifted; Supported—glass rod or plastic butterfly device Opening of intestinal loop and bowel: Lacks pain receptors

Colostomy Surgical Management Loop colostomy Protect bed and client’s clothing when loop colostomy is opened Prepare client for pungent odor of fecal material; Temporary ostomy pouch—receives flow of liquid feces Nursing Management Preoperative: Same as ileostomy Anxiety related to cause for ileostomy or colostomy (cancer)

Nursing Process: Postoperatively Assessment Diagnosis Planning Implementation Evaluation of Expected Outcomes

End of Presentation