Chapter 26

1. Chapter 26 The Patient with an Ostomy

2. Learning Objectives • List the indications for ostomy surgery to divert urine or feces. • Describe nursing interventions to prepare the patient for ostomy surgery. • Explain the types of procedures used for fecal diversion. • Assist in developing a nursing process to plan care for the patient with each of the following types of fecal diversion: ileostomy, continent ileostomy, ileoanal reservoir, and colostomy. • Explain the types of procedures done for urinary diversion. • Assist in developing a nursing care plan for the patient with each of the following types of urinary diversion: ureterostomy, ileal conduit, and continent internal reservoir. • Discuss content to be included in teaching patients to learn to live with ostomies.

3. 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

4. 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

5. Nursing Care of the Patient Having Ostomy Surgery

6. 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

7. 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

8. Interventions Deficient Knowledge Basic ostomy care should be taught before surgery Patient’s responses and questions should guide you 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

9. 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

10. Fecal Diversion 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

11. Postoperative Nursing Care of the Patient with an Ileostomy

12. 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

13. Assessment 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

14. 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

15. Interventions 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

16. Figure 26-1

17. Interventions 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

18. Interventions 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

19. Interventions 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

20. 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

21. Figure 26-2

22. Postoperative Nursing Care of the Patient with a Continent Ileostomy

23. 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

24. 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

25. Interventions 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

26. Interventions 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

27. 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

28. Figure 26-3

29. Ileoanal Reservoir 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

30. Postoperative Nursing Care of the Patient with an Ileoanal Reservoir

31. Assessment Same as for the patient with an ileostomy In addition, assess for rectal drainage and condition of the perianal skin

32. 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

33. Interventions 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

34. Interventions 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

35. 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

36. Colostomy 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

37. Postoperative Nursing Care of the Patient with a Colostomy

38. 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 ET may perform them initially while teaching patient or significant other

39. Interventions Risk for Injury Assess for indications of colostomy complications Prolapsed stoma Obstruction

40. 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

41. Urinary Diversion: Cutaneous Ureterostomy 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

42. Postoperative Nursing Care of the Patient with a Cutaneous Ureterostomy

43. 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 past medical history, drug profile, and allergies

44. Assessment 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

45. 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

46. Figure 26-1

47. Figure 26-6

48. Interventions 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

49. Interventions Risk for Injury If urine does not flow readily, suspect obstruction and notify the registered nurse or the surgeon immediately

50. Interventions 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