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

2. 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

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

4. 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.

5. 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

6. 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

7. 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

8. 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

9. 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

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

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

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

13. 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

14. 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

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

16. 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

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

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

19. 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

20. 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

21. 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

22. 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

23. 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

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

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

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

27. Colostomy
Various colostomies

28. 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

29. 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

30. 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)

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

32. End of Presentation