NUR 142: SKILL 35-2

1. NUR 142: SKILL 35-2 POUCHING A UROSTOMY

2. INTRODUCTION: POUCHING A UROSTOMY: • Because urine flows continuously from an incontinent urinary diversion, placement of the pouch is more challenging than with the fecal diversion. • In the immediate postoperative period urinary stents extend out from the stoma. • A surgeon places the stents to prevent stenosis of the ureters at the site where the ureters are attached to the conduit. • The stents will be removed during the hospital stay or at the first postoperative visit with the surgeon. • The stoma is normally red and moist. It is made from a portion of the intestinal tract, usually the ileum. • It should protrude above the skin. • An ileal conduit is usually located in the right lower quadrant. • While the patient is in bed, the pouch may be connected to a bedside drainage bag to decrease the need for frequent emptying.

3. ASSESSMENT: • 1. Perform hand hygiene. • 2. Observe existing skin barrier and pouch for leakage and length of time in place. Pouch should be changed every 3 to 7 days, NOT DAILY. If urine is leaking under wafer, change pouch. • 3. Observe urine in pouch or bedside drainage bag. Empty pouch if it is more than one-third to one-half full by opening valve and draining it into container for measurement. • 4. Observe stoma for color, swelling, presence of sutures, trauma, and healing of peri-stomal skin. Assess type of stoma. Remove and dispose of gloves. • 5. Explore patient’s attitude toward learning self-care and identify others who will be helping patient after leaving the hospital.

4. PLANNING: • 1. Expected outcomes following completion of the procedure: • Stoma is moist, reddish-pink with stents protruding from it. Peri-stomal skin is free of irritation and intact. Sutures are intact. • Urine drains freely from stents or stoma. Urine is yellow with mucus shreds and is without foul odor. Urine may be pink or contain small blood clots after surgery. Volume of output is within acceptable limits (>30 mL/hr). • Patient and family caregiver observe stoma and procedural steps. • Patient asks questions about the procedure and may help with pouch change. • 2. Explain procedure to the patient; encourage their interactions and questions. • 3. Assemble equipment and close room curtains or door. – This optimizes privacy.

5. IMPLEMENTATION: • 1. Identify the patient using two identifiers. • 2. Position patient in semi-reclining or spine position. If possible provide patient a mirror for observation. • 3. Perform hand hygiene and apply clean gloves. • 4. Place a towel or disposable waterproof barrier under patient and across patient’s lower abdomen. • 5. Remove used pouch and skin barrier gently by pushing skin away from barrier. If stents are present, pull pouch gently around them and lay towel underneath. Empty pouch and measure output. Dispose of pouch in appropriate receptacle. • 6. Place rolled gauze at stoma opening. Maintain gauze at the stoma opening continuously during pouch measurement and change. • 7. While keeping rolled gauze in contact with the stoma, cleanse peri-stomal skin gently with warm tap water using wash clot; do not scrub skin. If you touch the stoma, minor bleeding is normal. Pat skin dry.

6. IMPLEMENTATION – CONT’D • 8. Measure Stoma (see SKILL 35-1, step 7). Be sure that opening is at least 1/8 inch larger than the stoma to avoid pressure on stoma. Expect size of stoma to change for first 4 to 6 weeks after surgery. • 9. Trace pattern on pouch backing or skin barrier (see SKILL 35-1, step 8). • 10. Cut opening in the pouch. • 11. Remove protective backing from adhesive surface. Remove rolled gauze from stoma. • 12. Apply pouch. Press adhesive barrier firmly into place around the stoma and outside of the edges. Have the patient hold their hand over the pouch 1 to 2 minutes to apply heat to secure the seal. • 13. Use adapter provided with pouches to connect pouch to bedside urinary bag. Keep tubing below level of the bag. • 14. Remove drape from the patient. Remove gloves and perform hand hygiene.

7. EVALUATION: • 1. Observe appearance of the stoma, peri-stomal skin, and suture line during pouch change. • This determines the condition of the stoma and peri-stomal skin and progress of wound healing. • 2. Evaluate character and volume of urinary drainage. • Determines if stoma and/or stents are patent. Character of urine reveals degree of concentration and alterations in renal function. • 3. Observe patient’s and family caregiver’s willingness to view stoma and ask questions about the procedure. • Determines level of adjustment and understanding of stoma care and pouch application.

8. UNEXPECTED OUTCOMES: • 1. Skin around the stoma is irritated, blistered, or bleeding, or a rash is noted as a result of chronic exposure to urine. • Check stoma size and opening in skin barrier. Re-size skin barrier opening if necessary. • Remove pouch more carefully • Consult ostomy care nurse • 2. No urine output for several hours, or output is less than 30 mL/hr. Urine has a foul odor. • Increase fluid intake • Notify health care provider • Obtain urine specimen for culture and sensitivity as ordered. • 3. Patient and family caregiver are unable to observe stoma, ask questions or participate in care. • Consult ostomy care nurse • Allow patient to express their feelings • Encourage family support

9. RECORDING & REPORTING: • Record type of pouch, time of change, condition and appearance of stoma and peri-stomal skin, and character of urine. • Record urinary output on intake and output form. • Record patient’s and family caregiver reaction to stoma and level of participation. • Report abnormalities in stoma or peri-stomal skin and absence of urinary output to nurse in charge or health care provider.

10. THIS IS THE END OF THE SKILL • Your book has not provided a video for this skill. • I looked on you tube, but was unable to find one that I was happy with. • While you are more than welcome to view this power-point presentation, you will not pass this skill if you don’t go and practice it in the nursing skills lab!