1. Bowel Diversion
Stoma-temporary or permanent artificial opening in the abdominal wall
Ileostomy-opening in Ileum
Colostomy-opening in colon

2. Bowel Diversion

3. Types of Colostomy Reconstruction
Loop colostomy-
usually temporary large stomas
Common site-Transverse colon
Loop of bowel is pulled out and an external device (plastic rod, rubber catheter or bridge) is placed to keep the bowel from slipping back
loop has 2 openings through 1 stoma
Distal- rains mucus
Proximal drains stools
External device is removed within 7-10 days

4. Types of Colostomy Reconstruction
End colostomy
The functioning end of the intestine (the section of bowel that remains connected to the upper gastrointestinal tract) is brought out onto the surface of the abdomen, forming the stoma by cuffing the intestine back on itself and suturing the end to the skin
The surface of the stoma is actually the lining of the intestine, usually appearing moist and pink.
The distal portion of bowel (now connected only to the rectum) may be removed, or sutured closed and left in the abdomen.
An end colostomy is usually a permanent ostomy, resulting from trauma, cancer or another pathological condition.

5. Types of Colostomy Reconstruction
Double Barrel Colostomy
colostomy involves the creation of two separate stomas on the abdominal wall.
proximal (nearest) stoma is the functional end that is connected to the upper gastrointestinal tract and will drain stool.
distal stoma, connected to the rectum and also called a mucous fistula, drains small amounts of mucus material.
most often a temporary colostomy performed to rest an area of bowel, and to be later closed.

6. Total proctocolectomy with permanent ileostomy
Removal of colon, rectum and anus with closure of anus.
End of terminal ileum is brought out through the abdominal to form an ostomy

7. Ileostomy

8. Ileostomy Possible complications include:
skin irritation caused by leakage of digestive fluids onto the skin around the stoma; Irritation is the most common complication of ileostomies
diarrhea
the development of abscesses
gallstones or stones in the urinary tract
inflammation of the ileum
odors can often be prevented by a change in diet
intestinal obstruction
a section of the bowel pushing out of the body (prolapse)

9. Total proctocolectomy with continent ileostomy
The Kock pouch is a variation of the basic ileostomy and is named for its Swedish inventor.
In the Kock technique, the surgeon forms a pouch inside the abdominal cavity behind the stoma that collects the fecal material.
The stoma is shaped into a valve to prevent fluid from leaking onto the patient's abdomen.
The patient then empties the pouch several times daily by inserting a tube (catheter) through the valve.
The Kock technique is sometimes called a continent ileostomy because the fluid is contained inside the abdomen.
When the patient returns to his room, attach the drainage catheter emerging from the ileostomy to continuous gravity drainage

10. Kock Pouch
A thin tube is inserted into the stoma to drain the contents a few times a day.
A one-way nipple valve sitting flush with the skin, stops the stool from coming out at all other times.

11. Complications from Kock Pouch
Pouchitis
Increased stool frequency
Urgency
hematochezia
abdominal cramping
Fever
Malaise and pelvic pain
*treat with Flagyl (metronidazole)
Fistula development
Nipple valve extrusion

12. Ileostomy Patient education
Ileostomy patients must learn to watch their fluid and salt intake.
greater risk of becoming dehydrated in hot weather, from exercise, or from diarrhea.
In some cases they may need extra bananas or orange juice in the diet to keep up the level of potassium in the blood.

13. Ileostomy
Patient education includes social concerns as well as physical self-care.
Many ileostomy patients are worried about the effects of the operation on their close relationships and employment.
find out about self-help and support groups.
The ET can also evaluate the patient's emotional reactions to the ostomy.

14. Ileoanal Reservoir (IAR)
The IAR requires complete removal of the colon, leaving all of the small intestine and about two inches of the rectum
The lining of the rectum, called the mucosa, is then removed (stripped), leaving the muscle of the rectum and the underlying anal sphincter muscles intact. An ileal J pouch is then formed, using the last 12 inches of the small bowel (ileum).
A surgical stapling instrument is used to create the pouch. The end of the pouch is then "pulled through" the pelvis and sewn to the anus.

15. Ileoanal Reservoir (IAR)
A temporary ileostomy about 12 inches upstream from the pouch is made. This is constructed to divert stool until the suture lines in the reservoir have healed and the patient has recovered from the operation. This results in all stool going into the ileostomy bag on your right lower abdomen so that the ileal pouch can heal.
When the pouch to anus connection has healed, usually about two months, the ileostomy is closed, resulting in bowel movements from your anus.

16. Ileoanal Reservoir

17. Comparison of colostomies & Ileostomy
Ascending
Transverse
Sigmoid
Ileostomy
Stool consistency
Semi liquid
Semiliquid-semiformed
Formed
Liquid to semiliquid
Fluid requirement
Increased
Probably
increased
No change
Bowel regulation No
Uncommon
Yes if with regular pattern
Pouch & skin barriers
yes
Dependent on regulation
irrigation no
Possible q hrs
Indications for surgery
Diverticulitis, trauma, CA of colon,
rectum or pelvis
Same as ascending
Ca of rectum or rectosigmoid area,
diverticulitis
Crohn’s, ulcerative colitis, trauma, CA

18. Effects of food on stoma output
ODOR Producing
Diarrhea causing
Alcohol, beer, cabbage family, spinach, green beans, coffee, spicy foods, raw fruits
Eggs, garlic, onions, fish, asparagus, cabbage, broccoli, alcohol
Potential for obstruction in Ileostomy
Nuts, raisins, popcorn, seeds, raw vegetables, celery, corn
Gas Forming
Beans, onions, cabbage beer, carbonated beverages, sprouts, Strong cheese

19. NURSING MANAGEMENT Pre-operative preparation Psychological preparation
Ability to perform self care
Identify support systems
Visit by ET
Bowel preparation-decrease post op infection
Osmotic lavages, cathartics, enemas
Antibiotics-neomycin & erythromycin

20. NURSING MANAGEMENT Post-operative-
Patient adaptation-ADL’s in 6-8 weeks, no heavy lifting, psychological support, identify coping mechanism
Colostomy care
Assess stoma and surrounding skin
Pink stoma-healthy; pale- anemic; dusky blue-necrotic
Mild to moderate swelling- till 2-3 weeks is normal; moderate to severe swelling-obstruction of stoma
Small amount of oozing-normal; moderate to large bleeding-coagulation problem or or GI bleed

21. NURSING MANAGEMENT Colostomy care Assess stoma and surrounding skin
Wash stoma with mild soap & water
Use of skin barrier
Use of pouch-leave ¼ of skin around the stoma
Colostomy irrigations
Regulate bowel function-stimulate the bowel to function at specific time everyday or every other day
Treat constipation
Prepare for surgery

22. Colostomy Irrigation
Use lukewarm water as irrigant( ml) just enough to distend but not cause cramping
Ensure comfortable position-sit up on chair or toilet bowl
Hang container on hook or IV pole (18-24 in) above stoma
Apply irrigating sleeve and place end in toilet bowl
Lubricate stoma cone and insert gently into the stoma
Allow irrigation solution to flow steadily for 5-10 minutes: stop the flow if cramping occurs

23. Colostomy Irrigation
Clamp the tubing and remove irrigating cone when desired amount has been delivered or when patient senses colonic distention
Allow minutes for the solution and feces to be expelled.
Cleanse, rinse and dry peristomal skin well and replace the colostomy drainage pouch

25. Nursing Diagnosis/Interventions
Risk for skin integrity related to irritation from fecal drainage and peristomal area, irritation from appliance and lack of knowledge of skin care
Skin assessment, use mild soap & water to cleanse area, use of skin barrier and application of well fitting pouch

26. Nursing Diagnosis/Interventions
Disturbed body image related to presence of ostomy and malodor
Assess attitude towards ostomy
Allow expression of feelings and assist in adjustment process (grief)
Prepare patient to do owm stoma and appliance care to increase independnce and enhance self-esteem/image
Encourage attendance in support classes or groups
Use of measures to control odors
Odor proof pouch, pouch deodorants, avoid foods that increases odor

27. Nursing Diagnosis/Interventions
Imbalanced nutrition less than body requirements related to decreased appetite and lack of knowledge of appropriate foods
Assess nutritional intake
Introduce foods one at a time
Provide list of foods for reference
Risk for fluid volume deficit related to excess fluid loss from ileostomy or diarrhea or inadequate fluid intake
Assess for signs & symptoms of fluid & electrolyte imbalance
I/O, encourage fluids-3000ml/day
Monitor electrolytes

28. Nursing Diagnosis/Interventions
Ineffective sexuality patterns related to perceived loss of sexual appeal and accidental seepage of fecal materials during sexual activity
Assess patients attitude and impact of the ostomy on the sexual functioning-fear of rejection (encourage open communication)
Encourage support groups to share concerns and solutions
Encourage use of perfumes or fragrance to combat odors