Transcript Ostomy care Chapter 31 - Wilkes

OSTOMY CARE
Nursing I
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
Ostomies
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Ostomy- surgically created opening into the
abdominal wall that serves as an exit site from the
bowel or ureter.
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Ileostomy- surgically created opening from the
small intestines to the abdominal wall allowing the
passage of feces.,
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Colostomy-surgically created opening from the
large intestines to the abdominal wall allowing for
the passage of feces.
Colostomy
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A colostomy stoma will have a single opening, this is a single
barreled or end stoma, if the distal colon is permanently
removed.
Occurs with
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Cancer of descending colon
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Severe Chron’s disease
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With Chron’s disease there is an inflammation of the bowel. The
colon may need time to heal and rest. In this situation the colon
may be completely incised, or cut into two pieces creating to
stomas . Picture in book Pg 690 .
Stoma
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Stoma- portion of
the bowel or ureter
that is surgically
opened and
brought out through
the abdominal wall.
Ureterostomy
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Ureterostomysurgical procedure
creating an opening
from the ureter to
the abdominal
cavity.
Stoma
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Stoma- portion of
the bowel or ureter
that is surgically
opened and brought
out through the
abdominal wall.
A Healthy Stoma is
shiny, moist and red.
Pg 691 Figure 30-5
Ostomy Drainage
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Type of drainage
depends on location of
the ostomy:
Ileostomy and
ascending colon-liquid
feces.
Transverse colostomymushy stool.
Descending colon-soft
to solid.
Kock Pouch
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Is a diversion that uses the terminal portion of the
ileum to form an internal pouch, or reservoir, to
collect and store the effluent prior to evacuation
from the body.
A flap is formed that closes the reservoir,
preventing leakage onto the skin
The patient inserts a catheter several times a day to
drain the reservoir.
The type of stoma is considered a continent ostomy
since the patient has control over when it is drained.
Ostomies
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May be temporary or permanent.
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Temporary-bowel rest, e.g. Chron’s disease.
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Permanent-tumor.
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Temporary may be several weeks to several
months.
Ostomies
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Temporarygenerally located
at the transverse
colon.
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Permanentusually located at
the descending
colon or sigmoid
colon. Permanent
because the colon
or rectum have to
be removed.
Nursing Care of Ostomies
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Many hospitals are now utilizing nurses specially
trained to provide ostomy care.
The not only provide direct care but are consultants
They provide patient teaching.
Recommend appliances and products depending on
patients type of ostomy devices/products.
OstomyAppliances
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Many types of appliances/pouches available.
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One piece-one unit bag attached to an adhesive disc that
applies directly to a patents abdomen after peeling off the
protective backing off the adhesive disc.
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Two piece- wafer is separated from pouch. The bag adheres
to an adhesive disc called a wafer faceplate.
See pg 692 Figure 30-7.
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Wafers- some precut and some must be custom fit. See pg
691 Figure 30-6 Look like a tuperware seal.
Te face plate is changed every 3-5 days and prn.
Ostomy Appliances
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Once the adhesive
begins to loose contact
with the skin, it allows
the effluent to leak
underneath the face
plate, which can create
excoriation of the skin.
If leakage continues
unheeded, infection
and or ulceration can
occur. Sealant or pastecreate a seal.
Closure- clip or clamp.
Ostomy Care
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Wash hands.
Don gloves.
Remove old appliance.
Note effulent (drainage)-color, amount, and
odor.
Drain effulent into commode.
Discard old appliance into biohazard bag.
Ostomy Appliances
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The ostomy bag should be emptied when 1/3 to ½
half full to prevent leakage and odor.
Most bags have a drain on the bottom edge of the
bag that can be opened and emptied.
Some patients prefer to change the bag, others
empty and rinse with cool water, dry and reapply.
Ostomy supplies are expensive
Ostomy Care
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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 shrink 2-3 weeks post surgery. May take 4-6 weeks to
determine stoma size.
Ostomy Care
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Stoma assessment:
Stoma should be pink to
red and moist. Pallor,
cyanosis or dusky color
indicates poor blood
supply. Black indicates
necrosis.
Initially there may be some
edema.
Assess for cuts,
ulcerations, or any
abnormal findings.
Assess skin around stoma.
Note any redness or
irritation.
Challenges
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Excoriation – chemical
injury of the skin due
to the enzymes .
Numerous products are
available Skin
breakdown is a major
challenge due to the
enzymes in the stool.
Nursing Implications
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Wash stoma and skin around stoma with soap
and water and pat dry.
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Apply skin barrier substance (karaya powder,
skin prep).
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Enterostomal therapist-nurse who specializes
in care of ostomies.
Application of appliance
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Application depends on the type of appliance used.
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Pre-cut-appropriate size is chosen and then applied.
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Custom fit-use an ostomy guide to cut the opening on
the wafer 1/16 to 1/8 larger than stoma.
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Key is to fit appliance around the stoma without
touching stoma or exposing surrounding skin.
See skills pg. 703 -704 Skill 30-5
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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.
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Assessment of Ostomy
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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.
Ostomy Care
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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.
Colostomy Irrigation
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Is similar to an enema.
Colostomies may be irrigated to evacuate due to constipation.
May be ordered post op for stomas located in the descending colon.
When irrigating a descending or sigmoid colostomy the goal is to
train the ostomy to evacuate the same time every day.
Requires Dr. order.
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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.
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See Skill 30- 6 pg 705 -706.
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Colostomy Irrigation
Urinary Diversion
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Surgical opening on the abdomen or ostomy
through which urine is eliminated.
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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.
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Continent Urinary Diversion
Incontinent Urinary Diversion
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AKA-ileal conduit.
Ureter is transplanted into a closed off portion of
the ileum with an opening to the outer abdomen
creating a stoma.
Ureterostomy1 or 2 ureters are brought to the abdominal wall
and a stoma is formed.
Requires a pouch or appliance because of
continuing urinary drainage.
Page 725- in text
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.