1. The Patient with an Ostomy
Chapter 26
The Patient with an Ostomy

2. The Ostomy Patient Ostomy Stoma Ostomies in the digestive tract
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

3. 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

4. Nursing Care of the Patient Having Ostomy Surgery

5. 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

6. 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

7. 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

8. 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

9. 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

10. Postoperative Nursing Care of the Patient with an Ileostomy

11. 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

12. 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

13. 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

14. 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

15. Figure 26-1

16. 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

17. 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

18. 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

19. 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

20. Figure 26-2

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

22. 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

23. 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

24. 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

25. 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

26. 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

27. Figure 26-3

28. Ileoanal Reservoir Complications Obstruction Peritonitis Inflammation
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

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

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

31. 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

32. 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

33. 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

34. 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

35. Colostomy Temporary colostomy Permanent 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

36. Postoperative Nursing Care of the Patient with a Colostomy

37. 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

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

39. 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

40. 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

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

42. 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

43. 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

44. 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

45. Figure 26-1

46. Figure 26-6

47. 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

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

49. 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

50. Interventions Self-Care Deficit Teaching plan should include
Ostomy care
Pouches
Diet
Fluids
Activity
Sexuality
Complications
Resources

51. Ileal Conduit Procedure
Urinary drainage system made from portion of small intestine
A 6- to 8-inch segment of ileum is first removed
The remaining ends of the ileum are then anastomosed (joined) to restore bowel function
The ureters are cut from the bladder and attached to the ileal segment at an angle to prevent reflux
One end of the ileal segment is sutured closed. The other end is brought through an abdominal incision and sutured to create a stoma for urine drainage

52. Ileal Conduit Complications
Leakage of the anastomosed ureters and intestinal segments
Ureteral obstruction
Separation of the stoma from surrounding skin
Wound infection
Necrosis of the stoma
Paralytic ileus
Crystal formation and calculi
Stoma retraction, prolapse, or hernia

53. Postoperative Nursing Care of the Patient with an Ileal Conduit
Basically same as for patient with an ileostomy
A few special points to make about the ileal conduit
Patient will have a nasogastric tube attached to suction to prevent abdominal distention and stress on the resected portion of the ileum while it heals
Allowed nothing by mouth and is given intravenous fluids until bowel sounds return
Ureteral catheter or stent may be in place to drain urine
Attach the pouch to a collection device during the night

54. Continent Internal Reservoirs
Allows for the storage and controlled drainage of urine
Ileum neobladder
Eliminates the need for a stoma
Internal urinary reservoir constructed using a resected segment of the colon that is attached to the urethra
Urine drains into the reservoir and is eliminated through the urethra

55. Continent Internal Reservoirs
Kock pouch
Constructed with a segment of ileum
Ureters implanted in one side of the ileum segment
Nipple valve is constructed from the other side and attached to the skin, where a stoma is created
Valve prevents urine from flowing from the reservoir
Catheter drains reservoir at 4- to 6-hour intervals

56. Continent Internal Reservoirs
Indiana pouch
Similar to the Kock pouch except that it is made of a portion of the terminal ileum and the ascending colon
The reservoir is larger than that of the Kock pouch

57. Postoperative Nursing Care of the Patient with a Kock or Indiana Pouch
May have Penrose drain to remove fluid from operative site and clear tube in place for continuous urine drainage
Irrigations may be ordered to remove clots and mucus
When the tube is removed, the pouch may be drained every 2 to 3 hours at first
Later, may need to drain the pouch only every 4 to 6 hours during the day and once during the night
If pouch functions properly, the patient does not have to wear an external appliance
Gauze dressing over stoma to absorb mucus drainage
Advise medical alert bracelet: identifies presence of a continent device that needs intubation to drain

58. Ureterosigmoidostomy and Ureteroileosigmoidostomy
The ureters are implanted into the sigmoid colon
Urine drains into the colon and is eliminated through the rectum
Ureteroileosigmoidostomy
A segment of the ileum is anastomosed to the sigmoid and the ureters implanted into that part of the ileum

59. Vesicostomy Vesicostomy or cystostomy
An opening into the urinary bladder
Some are drained continuously through a catheter, others have a nipple valve and are drained at intervals

60. Nephrostomy
Diverts urine directly from the kidney through a tube that exits through the skin
May be used as a temporary or permanent method of urinary diversion