The Patient with an Ostomy

The Patient with an Ostomy
Chapter 26 The Patient with an Ostomy Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Copyright © 2016 by Saunders, an imprint of Elsevier Inc.
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 The gastrostomy is used for long-term feedings. Jejunostomies, duodenostomies, ileostomies, and colostomies are created to drain fecal matter from the intestines. What are examples of stomas in the urinary tract? Ostomies of the urinary tract drain urine from the kidney, ureters, or bladder. Ostomies are sometimes described as means of urinary or fecal diversion. Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

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 What is an enterostomal therapist (ET)? The exact placement of the stoma is very important. Two factors must be considered: secure pouch placement and ease of self-care. Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

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 Why would a mark be placed on the patient’s abdomen before surgery? Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

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 Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Interventions (cont.) Deficient knowledge Basic ostomy care should be taught before surgery Patient’s responses and questions should guide the nurse 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 Volunteers are people with ostomies who have been trained to counsel other patients about adjustment to their ostomies. Why is it a good idea to have a volunteer counsel the patient? Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

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 The ileum is the distal portion of the small intestine that empties into the large intestine. What is multiple polyposis? Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Fecal Diversion (cont.)
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 Digestive secretions quickly begin to drain from the stoma. A pouch is applied that collects fecal drainage to keep it from contaminating the surgical incision and to protect surrounding skin. What is a Kock pouch? Types of colostomies. Single-barreled (end) colostomies are usually permanent. Double-barreled colostomies are usually temporary and stomas may be adjacent or several inches apart. Loop colostomies are temporary and are formed by bringing a loop of colon through the abdominal wall and supporting it with a plastic brace. Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

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 What should the functional assessment reveal? Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Assessment (cont.) Physical examination Observe patient’s 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 When healed, the stoma should be rose red, somewhat darker than the color of the oral mucosa. What would a very pale, bluish, or black stoma indicate? Swelling of the stoma is expected initially, after which it shrinks over a period of 6 to 8 weeks. A small amount of bleeding around the base of a new stoma is not unusual. Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

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 The loss of fluids and electrolytes through nasogastric suction and the passage of liquid stool can lead to deficient fluid volume and electrolyte imbalances. When the patient resumes oral intake, advise a daily fluid intake of 2 to 3 liters. During hot weather or illness, additional fluids may be required. What can the loss of bicarbonate in ileostomy drainage cause? Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Interventions (cont.) 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 Why is it important to keep fecal material off of the skin? A good pouch is one that protects the skin, contains wastes and gas, is odor-proof, permits freedom of movement, provides security for the patient, and is not noticeable. Patients whose barriers quickly erode and those with very convex stomas can obtain special barriers to maintain good fit. Supplies needed to pouch an ostomy may include a pouch with an attached or separate skin barrier, a pouch closure device, skin barrier, paste, and adhesive remover. Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Interventions (cont.) 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 The patient who has an ileostomy is no longer able to control the passage of fecal matter and must learn to manage bowel elimination in a new way. Inability to control odor associated with passage of gas through the stoma is another concern for the patient with an intestinal ostomy. What may cause increased odor? Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Interventions (cont.) 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 Patients may feel unattractive or fear rejection by their partner. What problems may occur in men if there is nerve damage associated with perineal surgery? Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Interventions (cont.) 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 Some patients adjust more easily than others to an ostomy. What is the first step in accepting a stoma? Encourage but do not force patients to participate in the care. Patients also have a grief response to this type of surgery. Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

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 What patients may not be candidates for the continent ileostomy? During surgery, a catheter is placed through the stoma into the pouch and sutured in place. The catheter is connected to low intermittent suction to keep the pouch empty. This prevents stress on the suture lines while the pouch heals. Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

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 Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

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 The catheter is removed after several days, and the pouch is drained at intervals. How much can the pouch hold initially? Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Interventions (cont.) 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 Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Interventions (cont.) 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 Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

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 Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Ileoanal Reservoir (cont.)
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 Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

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 Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Interventions (cont.) 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 Initially, the patient may have as many as 20 stools a day. After a week, the number of stools decreases to 8 to 10 daily. How many stools should be expected by 6 months? The patient learns through trial and error how his or her body handles specific foods. Caffeine and fresh fruits and vegetables tend to cause loose, frequent stools. Pasta, boiled rice, and low-fat cheese tend to produce thicker stools Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Interventions (cont.) 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 Sometimes a stricture or narrowing develops at the site where the ileum is joined to the rectum. When is a stricture most likely to occur? Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

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 The location of the colostomy affects the characteristics of the fecal drainage: the closer to the rectum, the more formed the stool. What is the expected consistency of drainage from a transverse colostomy? Descending or sigmoid colostomy? Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Colostomy (cont.) 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 What is a double-barreled colostomy? When it is necessary to remove a large part of the colon or the rectum, a permanent colostomy is made. The main long-term complications of colostomy are prolapse and stenosis. Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Question 1 Which of the following is NOT true about fecal diversion? The closer the ostomy is to the rectum, the more formed the fecal matter will be. An end stoma is constructed from the proximal end of the resected portion of bowel. A double-barreled stoma has two stomas, but they are no longer attached. The fecal mass becomes more liquid as it moves toward the rectum. Correct answer: D Rationale: The colon absorbs water from the fecal mass as it moves toward the rectum so that it becomes progressively more solid. Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Question 2 Which of the following statements is INCORRECT about ostomies? A bluish or black stoma has impaired circulation and must be reported to the registered nurse or the physician immediately. Ileostomy patients are usually not given timed-release capsules or enteric-coated tablets because they are likely to be eliminated before they can dissolve and be absorbed. A new intestinal stoma should be pale red; when healed, it should be rose red. Swelling of the stoma is expected initially, after which it shrinks over a period of 6 to 8 weeks. Correct answer: A Rationale: A very pale, bluish, or black stoma has impaired circulation and MUST be reported to the registered nurse or the physician immediately. Prompt surgical intervention is needed to restore circulation and prevent tissue necrosis. Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

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 enterostomal therapist (ET) may perform them initially while teaching patient or significant other What key points should be remembered when irrigating a colostomy? Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Interventions (cont.) Risk for injury Assess for indications of colostomy complications Prolapsed stoma Obstruction Although a prolapsed stoma may look frightening, it is not usually serious. Why would surgery be needed for a prolapsed stoma or an obstruction? Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

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 Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Urinary Diversion: Cutaneous Ureterostomy (cont.)
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 Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Assessment Health history Assess for flank or abdominal pain, fatigue, malaise, and chills Determine patient’s response to the ostomy, knowledge of it, and readiness to learn Determine the reason for ureterostomy as well as pertinent medical history, drug profile, and allergies Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Assessment (cont.) Physical examination Assess patient’s 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 Is blood in the urine normal? Ureterostomy drainage should not contain mucus. Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

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 Why should Karaya products not be used for urinary drainage? Belts can be worn with some appliances to hold them in place. Some pouches can be connected to a leg bag for urine collection. Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Interventions (cont.) 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 Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Interventions (cont.) Risk for injury If urine does not flow readily, suspect obstruction and notify the registered nurse or the surgeon immediately Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Interventions (cont.) Disturbed body image Demonstrate acceptance of the patient and care for the stoma in a matter-of-fact manner Express understanding of patient’s feelings Encourage normal grooming and dressing Provide opportunities to ask questions or discuss how the ostomy might affect sexual function or behavior Adjustment to a stoma can be very difficult. The patient may be afraid of what issues? Patients with ostomies commonly experience grief in response to the loss of normal function and perceived disfigurement. The change in body image may affect the patient’s sexuality. Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Interventions (cont.) Self-care deficit Teaching plan should include Ostomy care Pouches Diet Fluids Activity Sexuality Complications Resources From the early postoperative period, try to help the patient learn independent ostomy care. How soon can normal activities be resumed? Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

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 Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Ileal Conduit (cont.) 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 Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

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 Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

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 What is an ileum neobladder? Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Continent Internal Reservoirs (cont.)
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 What are some complications of the continent pouches? Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Continent Internal Reservoirs (cont.)
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 Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

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 Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

Ureterosigmoidostomy and Ureteroileosigmoidostomy
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 Neither procedure provides continence, and both present problems with kidney infections and urinary calculi (stones). What deficits may the patient be at risk of having with either of these procedures? Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

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 Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

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 Copyright © 2016 by Saunders, an imprint of Elsevier Inc.

The Patient with an Ostomy

Similar presentations

Presentation on theme: "The Patient with an Ostomy"— Presentation transcript:

Similar presentations

About project

Feedback

Log in

Auth with social network:

The Patient with an Ostomy

Similar presentations

Presentation on theme: "The Patient with an Ostomy"— Presentation transcript:

Similar presentations

About project

Feedback