The Patient with an Ostomy

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
  
• Patients 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 patients 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 patients 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 patients 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 patients feelings
• Encourage normal grooming and dressing
• Provide opportunities to ask questions or discuss
  how the ostomy might affect sexual function or
  behavior

51
Interventions

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

52
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

53
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

54
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

55
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

56
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

57
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

58
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

59
Ureterosigmoidostomy and Ureteroileosigmoidostomy

• Ureterosigmoidostomy
• 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

60
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

61
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