Timby/Smith: Introductory Medical-Surgical Nursing, 10/e

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. The Ostomy Appliance • Disposable • Temporary: Immediate postop phase • Reusable equipment • Disposable equipment: Replace daily with bathing Figure 48-2The 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