Ostomy care

1. Ostomy care Patty Maloney MSN Ed, RN

2. Alternative Bowel Elimination • Bowel diversion-redirection of the contents of the small or large intestine through a surgically created exit in the abdominal wall. • Possible reasons for bowel diversion: • Cancerous tumor • Disease process such as Crohn’s disease • Infarcted area which the bowel walls become ischemic and die • Ruptured diverticulum • Ulcerative colitis • Traumatic abdominal injury

3. Ostomies • Ostomy- surgically created opening into the abdominal wall that serves as an exit site from the bowel or ureter. • Ileostomy- surgically created opening from the small intestines to the abdominal wall allowing the passage of feces. • Colostomy-surgically created opening from the large intestines to the abdominal wall allowing for the passage of feces.

4. Ureterostomy • Ureterostomy-surgical procedure creating an opening from the ureter to the abdominal cavity.

5. Stoma • Stoma- portion of the bowel or ureter that is surgically opened and brought out through the abdominal wall.

6. Ostomy Drainage • Type of drainage depends on location of the ostomy: • Ileostomy and ascending colon-liquid feces. • Transverse colostomy-mushy stool. • Descending colon-soft to solid.

7. Ureterostomy Ureterostomy- drains urine.

8. Ostomies • May be temporary or permanent. • Temporary-bowel rest, eg. Chron’s disease. • Permanent-tumor. • Temporary may be several weeks to several months.

9. Ostomies • Temporary-generally located at the transverse colon. • Permanent-usually located at the descending colon or sigmoid colon. Permanent because the colon or rectum have to be removed.

10. Ostomy Appliances • Many types of appliances/pouches available. • One piece-one unit bag attached to wire. • Two piece- wafer is separated from pouch. • Wafers- some precut and some must be custom fit.

11. Ostomy Appliances • Sealant or paste- create a seal. • Closure- clip or clamp.

12. Ostomy Care • Wash hands. • Don gloves. • Remove old appliance. • Note effulent (drainage)-color, amount, and odor. • Drain effulent into commode. • Discard old appliance into biohazard bag.

13. Ostomy Care • Assessing initial post-op stoma: • initially post-op stoma will be edematous and may have small amount of bleeding. • Monitor for post-op complications: • Excessive bleeding. • Stoma dark in color or blanched due to lack of blood supply. • Drying of stoma. Signs of infection. • May take 4-6 weeks to determine stoma size.

14. Ostomy Care • Stoma assessment: • Stoma should be pink to red and moist. • Assess for cuts, ulcerations, or any abnormal findings. • Assess skin around stoma. • Note any redness or irritation.

15. Challenges • Skin breakdown is a major challenge due to the enzymes in the stool. • Excoriation-chemical injury of the skin due to the enzymes.

16. Nursing Implications • Wash stoma and skin around stoma with soap and water and pat dry. • Apply skin barrier substance (karaya powder, skin prep). • Enterostomal therapist-nurse who specializes in care of ostomies.

17. Application of appliance • Application depends on the type of appliance used. • Pre-cut-appropriate size is chosen and then applied. • Custom fit- • use an ostomy guide to cut the opening on the wafer 1/16 to 1/8 larger than stoma. • key is to fit appliance around the stoma without touching stoma or exposing surrounding skin.

18. Applying Appliance • One piece system- use skin sealant. • Two piece system- use paste. • Appliance chosen depends on the type of ostomy, stoma shape, location of stoma. (Trial and error) • May reinforce appliance with non-allergic paper tape in picture frame. • May wear an ostomy belt. • Roll end of pouch upward once and apply clip/clamp. • Be sure clam is snug.

19. Assessment of Ostomy • GI assessment of patient. • Assess bowel sounds in all 4 quadrants. • Assess effulent from ostomy. • Empty pouch when 1/3-1/2 full. • Assess abdomen. • Report any abnormal findings immediately. • Bowel sounds and activity by day 3.

20. Ostomy Care • Management of ostomy: • Ostomy should be pink & moist. • Skin should be clean, dry, & intact. • Assess for s/s of redness or irritation. • New appliances should adhere to skin without wrinkles or gaps.

21. Colostomy Irrigation • Requires Dr. order. • Procedure: • Remove appliance. • Place irrigation sleeve over stoma. • Instill lubricated cone into stoma. • Insert catheter into cone. • Instill 500cc-1000cc tap water or saline . • Start with 500cc over 5-10 minutes.

22. Colostomy Irrigation

23. Urinary Diversion • Surgical opening on the abdomen or ostomy through which urine is eliminaed. • Types: Continent and incontinent. • Continent diversion-internal pouch or reservoir created from a segment of the bowel. • Patient performs self catheterization every 4-6 hours. • No appliance used.

24. Continent Urinary Diversion

25. Incontinent Urinary Diversion • AKA-ileal conduit. • Ureter is transplanted into a closed off portion of the ileum with an opening to the outer abdomen creating a stoma. • Ureterostomy- • 1 or 2 ureters are brought to the abdominal wall and a stoma is formed. • Requires a pouch or appliance because of continuing urinary drainage.

26. Urinary Diversion Nursing Implications: • Increased chance of skin breakdown due to continuous drainage. • Change appliance bag frequently due to weight of urine. • Place a tampon in stoma to absorb urine while cleaning. • Peristomal skin is difficult to keep free from breakdown due to ammonia in urine. • Use of skin barrier or topical antibiotics or steroids.