Essentials Skills - Ostomy Care
3 possible designs for skin barriers
Cut-to-fit; pre-cut; moldable
Indication for pre-cut skin barrier
After stoma has consistent size and shape; useful for patients who lack manual dexterity to cut the barrier
Describe treatment for allergic contact dermatitis of peristomal area
Alter pouching system or skin care procedure to eliminate the irritating product
Initially, what schedule should urostomy patient follow for emptying and caring for their urostomy?
Catheterize stoma and empty pouch every 2 to 3 hours; irrigate pouch in morning and in evening if prescribed
Unless contraindicated, what should urostomy patient do to avoid infection and maintain urinary function?
Consume plenty of fluids
What should patient do if stoma turns dusky, brown, black or very pale?
Contact provider immediately as these findings could indicate compromised circulation
What causes irritant dermatitis of peristomal skin?
Contact with stool or urine, usually from leakage under pouching system or between skin barrier and stoma
Describe typical initial drainage from an ileostomy
Dark green, loose, odorless
High volume ileostomy output puts patient at risk for what conditions?
Dehydration and electrolyte imbalance
What is the use of temporary bilateral ureteral stents?
In case of an ileal conduit, they may be placed to prevent postsurgical edema from obstructing urine output
How should healthy peristomal skin appear?
Just like the skin on the rest of the abdomen
What procedure is an alternative to the standard ileostomy?
Kock's continent ileostomy
______________ skin surrounding an ostomy
Peristomal skin
Describe moldable skin barrier
Pliable stoma opening that can be molded to provide a snug fit around the stoma
Describe drainable pouch
Pouch can be rinsed and reused; drainable urostomy pouches have tap instead of a clip
Why must extra care be taken when emptying an ileostomy?
The ileum contains digestive enzymes and acids that cause skin irritation and must be prevented from contacting the abdominal surface
What causes mucocutaneous separation?
When suture line fails to heal properly
____________ common temporary colostomy surgery that involves leaving the distal portion of the colon in place and oversewn for closure to create a Hartmann's pouch
Hartmann procedure
What is the most common type of urinary diversion?
Ileal conduit
______________ surgical removal of a section at the end of the small bowel (ileum) and relocation as a passageway for urine from the kidneys to the outside of the body through a stoma
Ileal conduit
_____________ surgical opening created in the ileum to bypass the entire large intestine
Ileostomy
How is a continent internal ileal reservoir/continent ileal bladder/Kock's pouch created?
In same way ileal conduit is formed, except nipple valves are formed by intussuscepting tissue backward into the reservoir; pouch is connected to skin and ureters are connected to the pouch
Why are some patients with new ileostomies at risk for dehydration?
Initial stool output may be as high as 1,000 to 2,000 mL per day
What steps should be taken upon entering room before irrigating colostomy?
Introduce yourself; ensure privacy; set up irrigation bag with warmed tap water/prescribed solution; perform hand hygiene; verify client with 2 identifiers; don gloves
Describe treatment for candidiasis of peristomal area
Keep the skin dry
Describe treatment for irritant dermatitis of peristomal area
Clean and dry peristomal skin, use protective skin barrier powder or wipe skin before applying skin barrier, and remeasure stoma to ensure use of correct size pouch and/or skin barrier
____________ is closing device, required for some ostomy pouches
Clip
What characteristics should be checked for in a newly created stoma?
Color, turgor, edema, signs of injury such as bleeding
Describe an end colostomy
Damaged section of bowel is removed and working end is brought through abdomen to skin surface
What instructional strategies should be included when teaching about ostomy management?
Describing each step of the procedure performed, encouraging participation in ostomy care, answering questions, providing resources until patient is comfortable with performing procedure independently
Indication for closed-end pouches
Designed for one-time use and may meet needs of patient who irrigates; recommended for use with sigmoid colostomies
________________ softening or dissolution of tissue after lengthy exposure to fluid
Maceration
Describe steps for colostomy irrigation
Place absorbent pad under pouch to protect gown and bedding; don appropriate PPE per facility policy; carefully remove ostomy pouch; remove any fecal matter from the opening; clean and discard supplies; remove soiled gloves, perform hand hygiene, don clean gloves; secure irrigation sleeve using flange mechanism for a 2-piece pouch system; use cone to direct water into stoma; prime tubing to avoid introducing air into bowel; lubricate cone with water soluble lubricant; insert cone into top opening of irrigation sleeve; insert cone gently into stoma at an angle that matches the bowel; unclamp irrigation tubing and slowly (over 5 to 10 minutes) instill the fluid into the bowel; it may take 45 minutes for bowel to finish elliminating the irrigant and effluent; hold cone in place for 10 seconds after instilling fluid to elliminate spilling of solution; remove cone gently; once the irrigant is elliminated, place the bottom of the irrigation sleeve into the graduated cylinder and remove the clamp; after procedure is complete, remove irrigation sleeve; clean peristomal area; remove gloves, perform hand hygiene, don new gloves; place new pouch; dispose of all supplies appropriately; perform hand hygiene; document procedure, complications and assessments
What self-care actions should ileostomy patient take if food blockage is suspected?
Place moist towels on abdomen; drink hot tea; lie down and assume knee-chest position to relieve intra-abdominal pressure; massage abdominal area to promote peristalsis and fecal elimination; replace pouch with one that has a larger opening if stoma is swollen to avoid mechanical obstruction
What should nurse do if skin irritation, breakdown, rash, or unusual appearance of stoma or peristomal area is noted?
Notify the provider
Describe creation of ureterostemy
One or both ureters are redirected from kidney(s) through abdominal wall to form a stoma
How should nurse manage an ostomy with high-volume effluent?
Particularly with an ileostomy, watery to pasty stool may initially exceed 1,400 mL per day. To prevent dehydration, recommend copious amounts of water and sport drinks containing electrolytes, especially during exercise and in hot weather. Various high-output pouching systems hold a greater volume of effluent, but these are heavy when full. The high volume of enzymes in ileostomy effluent can corrode the skin, making peristomal skin protection a high priority. Extended-wear skin barriers with skin barrier paste help prevent leakage and maceration of the peristomal area. Attaching an ostomy appliance belt to the pouching system may help support the pouch's weight and maintain the skin barrier's seal.
What care should be taken when using an adhesive remover to assist in removing skin barrier?
Patch-test adhesive remover on skin prior to use to avoid irritation or hypersensitivity reactions
Why is external drainage collection device not necessary for a continent internal ileal reservoir/continent ileal bladder/Kock's pouch?
Patient self-catheterizes about every 4 hours to empty the reservoir
Benefit of two-piece pouch system
Permits frequent pouch changes and minimizes skin breakdown
What recommendations should nurse make to ostomy patient regarding exercise?
Remain vigilant of hydration status; engage in regular exercise routine that includes activities that promote cardiovascular and musculoskeletal fitness
What should be used if pouching system regularly leaks in a particular area?
Skin barrier paste or strips to fill in any irregular skin surfaces
What should be done if patient reports cramping or fullness when irrigating the colostomy?
Slow or stop the procedure; have patient take deep breaths until cramping is resolved
____________ surgically created opening, usually referring to one in the abdominal wall
Stoma
Indication for transverse colon/mid-abdomen placement of colostomy
Temporary ostomy with stoma constructed as a loop
______________ narrow tubular duct that transports urine from the kidney to the bladder
Ureter
______________ faceplate or barrier designed to protect the peristomal skin from the stoma output and to which the pouch is attached
Wafer
How frequently should patient measure a new stoma and why?
Weekly for first 8 weeks, to verify opening of pouch is correct size
When should ileostomy pouch be emptied?
When 1/3 to 1/2 full, typically several times a day
When should colostomy pouch be emptied?
When 1/3 to 1/2 full; choose time when bowel is least active such as 2 to 4 hours after a meal, or just before a meal
Describe two-piece pouch system
Pouch and skin barrier are connected with flange mechanism; pouch may be disposable or reusable; may have filter for gas release
Describe one-piece pouching system
Pouch has attached skin barrier; available in cut-to-fit and pre-cut types
_____________ one-piece or two-piece device that includes a skin barrier/wafer and a collection pouch for output; also referred to as an appliance
Pouching system
What conditions can cause change in contours o f abdomen or characteristics of skin, affecting a pouch's fit?
Pregnancy, change in weight, chronic disease
__________________ impaired skin integrity and/or formation of a wound due to prolonged pressure
Pressure ulcer
What is the benefit of routine/scheduled pouch-replacement?
Preventing surprise leakage problems
Two important functions of skin barrier
Protect skin from stoma output; attach pouch to body
What is the best way to treat a mucocutaneous separation?
Protect the area using powder and paste to promote healing, followed by application of a properly fitting skin barrier and pouch
How much fluid should ileostomy patient drink per day to prevent dehydration?
1.5 to 2.5 L, or more if having large amounts of output
When measuring a cut-to-fit skin barrier, the hole should be cut _____ inches wider than the measured tracing to avoid fitting the skin barrier too tightly
1/8 inch
How long can temporary bilateral ureteral stents be left in place?
10 to 21 days post-surgery
What should urostomy patient place around insertion sites and drains to absorb leakage?
4-inch by 4-inch drain dressing
For patients with a continent ileostomy, surgeon may insert what device to provide continuous drainage?
A catheter
What is a Hartmann's pouch?
A common temporary colostomy surgery involving leaving the distal portion of the colon in place, which is oversewn for closure to create pouch
Describe an ileal conduit
A loop of intestinal ileum is separated and used as a conduit for urine; the ureters are attached to the ileal conduit, and the open end is brought out through the abdominal wall to form a stoma; the remaining ileum is reconnected to the rest of the digestive tract
What should nurse recommend for a patient whose stoma changes sizes or if patient has problems with pouching system?
A pouch refitting with a wound ostomy continence nurse
What strategies should nurse use to prevent complications after stoma retraction?
A retracted stoma has pulled back below the level of the skin and appears as a concave defect on the abdomen. For a stoma that is flush or retracted, convexity may improve wafer adherence. A convex wafer presses into the tissue around the stoma, increasing the degree of stomal protrusion and reducing the risk of undermining of stomal output beneath the pouching system. In addition, it provides contouring to fill uneven areas of the skin around the stoma and support the peristomal field.
What is an ostomy?
A surgically created opening in abdominal wall to allow elimination of urine or feces
What is a urostomy?
A urinary diversion that allows urine to exit the body after removal of a diseased or damaged section of the urinary tract
What are common manifestations of food blockage that ileostomy patient should be instructed to watch for and notify clinician if noted?
Abdominal cramping, nausea, vomiting, swelling of stoma, no ileostomy output for at least 6 hours
To what surfaces does skin barrier attach?
Adheres to skin a round stoma and attaches the pouch to the body
____________ is material used to attach two objects or surfaces, such as glue
Adhesives
Though there are no dietary restrictions after placement of a urostomy, patient may want to avoid what foods that can cause odor?
Alcohol, asparagus, dried beans, broccoli, brussels sprouts, cabbage, cauliflower, cheese, eggs, fish, onions
What products should be avoided for cleaning peristomal skin and why?
Alcohol, betadine, or oil based soap; they can interfere with adhesion of skin barrier and could promote skin breakdown
_______________ is inflammation of the skin resulting from contact with an allergen
Allergic contact dermatitis
What is the indication for a transverse loop colostomy?
An emergency procedure to relieve intestinal obstruction or perforation
Describe the Kock's continent ileostomy procedure
An internal pouch is created from distal segment of ileum, which serves as reservoir for stool; a one-way nipple valve is constructed through stomal opening so that eventually the patient can insert a catheter through the stoma and through the one-way valve to drain the fecal contents of the internal pouch
________ of the severed portions of the colon may be delayed for several reasons, including bowel inflammation or tumor location
Anastomosis
______________ is formation of a connection between two usually distinct structures or portions of a structure
Anastomosis
Nurse should instruct colostomy patient to discuss what medications with their surgeon or primary care provider?
Antacids, anti-diarrheals, anti-inflammatory agents, aspirin, laxatives, antibiotics; includes OTC and herbal remedies
Describe steps to drain bladder through urostomy
Apply water-soluble lubricant to catheter tip; remove and discard stoma cover; clean stoma and peristomal area; sitting over toilet, insert catheter into stoma until urine begins to flow; when flow stops, inch catheter closed and remove it
Depending on area of disease and other physical features of patient's abdomen, colostomy is placed in one of what four locations?
Ascending colon (right abdomen); transverse colon (mid-abdomen); descending colon (left upper abdomen); sigmoid colon (left lower abdomen)
What foods should be avoided by colostomy patient in order to avoid malodorous flatus?
Asparagus, beans, cabbage, eggs, fish, garlic, onions, some spices, beer, broccoli, brussels sprouts, carbonated drinks, cauliflower, corn, cucumbers, dairy products, dried beans, mushrooms, onions, peas, radishes
How can ostomy patient prevent skin problems from occurring?
Assess peristomal skin regularly, ensure skin barrier and pouching system are correct size and fit, mange output and pouch leakage
Following urostomy surgery, what is minimum output that must be maintained to prevent hydronephrosis and possible renal damage?
At least 30 mL per hour
Describe steps for replacing an ostomy pouching system
Begin at one corner and slowly pull off old skin barrier while gently pushing down on skin; if using adhesive remover spot test it on skin to check for irritation or hypersensitivity reaction; dispose of pouch in designated recepticle; cleanse stoma and peristomal skin gently with warm water and a wash cloth or gauze pads or per facility policy; remove any remaining adhesive with warm water and mild soap; dry peristomal skin by patting gently with gauze or soft cloth; remove gloves, perform hand hygiene, don clean gloves; inspect color and turgor of stoma; inspect peristomal skin; use commercially prepared measuring guide in the pouching system kit; trace selected size opening onto back of pouching system; cut hole 1/8 inch wider than stoma to allow for expansion of functioning stoma; be sure skin is dry; remove backing from skin barrier; center hole over stoma; apply pressure evenly by pressing finger on backing, going around stoma to help it adhere to the skin; connect pouch to skin barrier by pressing it onto ring until it snaps into place; dispose of waste materials appropriately; perform hand hygiene; encourage patient to stay still for 5 minutes to ensure adherence; document procedure and assessments
Describe proper removal of skin barrier
Begin with one corner of barrier and slowly pull off remaining adhesive; don't rip or tear off of body; remove it gently while supporting underlying skin and use adhesive remover wipe if appropriate
When does teaching about ostomy management occur?
Begins in preoperative period and continues after surgery
What is the normal shape of a stoma?
Can be round, oval or irregular; either protruding, flush with skin or retracted
What are the risks of an ill-fitting skin barrier or ostomy pouch?
Can cause ulceration or bleeding
______________ is surgical creation of an opening from the beginning of the large intestine (cecum) to the abdominal wall
Cecostomy
Types of peristomal complications
Chemical, mechanical, infectious, immunologic, disease-related
_____________ is ability of the skin barrier to maintain its integrity when exposed to moisture
Cohesion
Indication for ileostomy
Colon cancer, ulcerative colitis, total proctocolectomy;
_______________ is surgically created opening (stoma) from the colon (large intestine) to the abdominal wall to allow stool to pass out of the body
Colostomy
When should nurse consider colostomy irrigation?
Colostomy irrigation helps some patients avoid fecal discharge for about 24 hours. Although not required to maintain bowel function, it can be used to improve the regularity of bowel movements and thereby improve quality of life. Candidates for colostomy irrigation include those who have: a descending or sigmoid colostomy; a history of regular bowel habits prior to surgery; the desire to learn and perform the procedure; manual dexterity and visual acuity; access to running water and bathroom facilities; the ability to perform the procedure on a regular schedule; no signs of stomal prolapse or peristomal hernia
Three primary types of ostomy surgery
Colostomy; ileostomy; urostomy
What type of ostomy pouch could be used to control odor and enhance patient's confidence?
Commercially made pouch with a charcoal filter
What is the drawback of the Kock's pouch?
Complication rate is usually higher than with a traditional ileostomy
_________ is a passageway
Conduit
Generally, what is a colostomy?
Created from end of large intestine to divert waste from digestive system
What type of skin barrier is usually used for the first 6 to 8 weeks following surgery, and why?
Cut-to-fit, because stoma changes size and shape during this period
__________________ is an excision or resection of the bladder
Cystectomy
______________ is stripping of superficial skin surface
Denudation
What are indications for ostomy surgery?
Disorder or injury that keeps urinary or GI system from functioning properly; including congenital anomalies; bladder, colon and rectal cancer; inflammatory bowel diseases (Crohn's and ulcerative colitis); inherited disorders such as familial adenomatous polyposis; obstruction of ureter; stab or gunshot wounds to abdomen
What instructions for irrigation should be given to patient with double-barrel or loop colostomy?
Distal bowel carries no fecal contents and does not need to be irrigated; if use irrigation at all, they should only irrigate the proximal stoma
What considerations should patient make when showering with the pouch off?
Do this on a pouch-replacement day; apply clean system once skin is patted dry
What should patient do after bathing with the pouch on?
Dry skin barrier and pouching system before dressing
What is the most common cause of peristomal skin disorders?
Effluent leakagevonto skin due to ill-fitting appliance, peristonal hernia, poor adhesive adherence or surgical complications
What increased risks result from urostomy pouches constructed from bowel, such as an ileal conduit?
Electrolyte imbalance with potential for metabolic acidosis
How does patient care for a Kock's pouch?
Empty it several times a day and cover stoma with protective dressing or a stoma cap
What recommendations should nurse make to ostomy patient regarding sexuality?
Encourage sharing feelings with partners about sensitivities or embarrassment about change in body image; avoid friction or irritation of stoma and peristomal skin; patient may feel more secure if empty pouch first, wear smaller pouch, or cover pouch with specially designed underwear, lingerie or pouch covers
When colostomy is intended to be permanent, what type of colostomy is performed?
End colostomy
3 types of colostomies
End colostomy; loop colostomy; double barrel colostomy
What medications should be taken only with precaution in ileostomy patients, and what should they watch for?
Enteric coated pills or tablets; observe for undissolved medication in ileostomy pouch
After initial postoperative period for patient with urostomy, how often should they catheterize?
Every 4 hours while awake o r m ore often if they sense fullness
What causes allergic contact dermatitis of peristomal skin?
Exposure to materials and chemical compounds that irritate the skin on contact (tape, soap, skin barriers, adhesives, powders, pastes, pouch material)
Unless contraindicated, what should ileostomy patient who is active during hot weather or having large amounts of output consume?
Extra fluid, potassium and sodium
What are the signs and symptoms of dehydration or electrolyte imbalance that ileostomy patient should be instructed to recognize?
Extreme thirst; dry skin and oral mucous membranes; decreased urine output; weakness; fatigue; headache; dizziness; muscle cramps; abdominal cramps; nausea; vomiting; shortness of breath; orthostatic hypotension
T/F. Transverse loop colostomies are usually permanent.
False, they are typically temporary
T/F. Colostomy patients have a higher incidence of skin problems than ileostomy patients
False. Ileostomy patients are more prone to skin problems than colostomy patients
T/F. Patients with ileal conduits should not be discharged with drains still intact in the surgical openings.
False. They may be discharged with drains intact and should be taught to care for them during time before their removal
Though patients with colostomy may not need any dietary adjustments, they should be aware of foods that cause what symptoms?
Fecal odors, gas, thick or loose stools
How is leakage and reflux prevented in a continent internal ileal reservoir/continent ileal bladder/Kock's pouch?
Filling pressure closes the valves
__________________ is an ostomy output collection bag that incorporates an odor filtration apparatus
Filtered pouch
_________________ is a rim used for attachment to another object, such as an ostomy pouch attaching to a skin barrier
Flange
______________ gas or air generated in the stomach and/or intestines and expelled via the anus or an intestinal ostomy
Flatus
How long can most disposable drainable pouch systems be used?
For 2 to 7 days, or some may last even longer; should be changed immediately if leak develops
Typical output of colostomy placed in sigmoid colon (left lower abdomen)
Formed
Describe creation of an Indiana continent urinary reservoir
Formed from cecum and a portion of ileum; stoma is continent and flush with skin; patient self-catheterizes to empty the reservoir
Describe normal flow of contents from stomach to large intestine
From stomach to duodenum, jejunum, ileum, then large intestine
Describe typical eventual drainage from an ileostomy
Gradually thickens and becomes yellow to brown
___________________- substance that forms a gel as fluid is absorbed and is used in some ostomy products to absorb perspiration and other metabolic secretions while preventing fungal and bacterial invasion
Hydrocolloids
____________- enlargement of the kidneys as urine collects in the renal pelvis and kidney tissue
Hydronephrosis
____________ abnormal increase in the volume of a tissue or organ
Hyperplasia
What is the indication for skin barrier powder?
If skin is moist or eroded, to remove excess moisture to avoid interference with adhesive
What is an IPAA?
Ileal pouch anal anastomosis
When can the bridge formed in a loop colostomy be removed?
In 7 to 10 days
What indications would require a patient with a new ostomy to notify their clinician?
Increased pain in abdomen or incision; fever, redness, drainage of incision; irritation, redness, breakdown of peristomal skin; change in bowel habits such as diarrhea or constipation; skin irritation unrelieved by properly fitting pouching system; problems obtaining a good seal of the wafer or skin barrier; hernia o r bulge around stoma; narrowing of stoma lumen; separation of stoma from abdominal surface; lacerations o r cuts in the stoma
Why is patient with ostomy at risk for being unaware of potential or actual damage to the stoma?
Intestinal mucosa is relatively free of nerve endings so patient won't feel pressure
What is a restorative proctolectomy with IPAA?
Involves connecting ileum to a "new" rectum (or anal pouch, also made out of a portion of ileum
_________________ inflammation of the skin resulting from contact with an irritating substance
Irritant dermatitis
Describe candidiasis of peristomal area
Itchy, bumpy, reddened skin
______________ internal pouch created from the distal segment of the ileum to serve as a reservoir for stool or urine
Kock pouch
What causes candidiasis of peristomal skin?
Leakage, perspiration, antibiotic therapy, broken skin
What dietary considerations should be made for colostomy patient with large amounts of effluent?
Limit insoluble fiber; may need to add foods that thicken stool such as applesauce, bananas, cheese, pasta, and rice
Typical output of colostomy placed in transverse colon (mid-abdomen)
Liquid to semi-formed
Typical output of colostomy placed in ascending colon (right abdomen)
Liquid to semi-liquid; very irritating to surrounding skin
What determines location of stoma?
Location of patient's beltline; location of scars and skin folds, where damage is, and type of ostomy surgery performed
Describe a loop colostomy
Loop of bowel is brought through abdomen to skin surface and temporarily supported by a plastic bridge or rod; a communicating wall remains between proximal and distal bowel; two openings through one stoma - proximal end drains stool while distal portion drains mucus
To prevent food blockage, ileostomy patients may initially follow what diet?
Low-residue - avoid high-fiber or difficult-to-digest foods such as popcorn, nuts, corn, celery, fresh tomatoes, figs, strawberries, blackberries, and caraway seeds
________________ blood seeping through the opening (lumen) of a stoma
Luminal bleeding
What is the benefit of using an adhesive remover to help remove skin barrier?
Makes removal easier and ensures clean skin surface before attaching next skin barrier
Why does diabetes mellitus increase risk for mucocutaneous separation?
Microvascular changes that cause delayed or poor wound healing
What type of cleansing agent should be used on peristomal skin?
Mild, pH-balanced soap or no soap at all and just water
_____________________ separation of the stoma from the peristomal skin; also called mucocutaneous detachment
Mucocutaneous separation
Describe proper fitting of pouching system
Must fit so skin at base of stoma is covered, but not so it constricts or exerts pressure on the stoma
Describe closed-end pouches
No drain or clip; may come with filter to reduce odor and gas buildup; when full, it's removed from skin barrier and discarded in an appropriate receptacle
What should nurse do if urine drainage from a new urostomy is slightly cloudy with no odor?
Nothing, this is normal due to mucus intestinal mucosa produces. Urine is very cloudy with a foul odor, could be sign of infection
What should patient do if stoma turns red, moist and protrudes from abdominal wall 3/4 of an inch?
Nothing. This is normal.
What should patient with temporary diverting colostomy do if they feel an urge do defecate through the rectum or have rectal drainage?
Nothing. This is normal.
Risk factors that predispose patient to peristomal skin complications
Obesity; wound complications adjacent to or in peristomal field; poorly located or constructed stoma; stoma complications including retraction and hernia; any factor that increases likelihood of inadequate adherence or fitting of pouching system increasing risk of leakage
What is the indication for a Kock's pouch?
Occasionally created to treat ulcerative colitis and may be option for patients who do not wish to wear an external pouch over the stoma
How is urine removed from a urostomy?
Patient has no voluntary control over urine flow; external pouch system or collection device contains the urine; urostomy pouches have a drainage tap on bottom for emptying them repeatedly throughout the day
______________ pulling in of the skin around a stoma when the stoma is drawn inward below skin level
Peristomal retraction
Describe steps for draining an ostomy pouch
Place absorbant pad under pouch to protect gown and bedding; tilt bottom of pouch upward and remove closure clamp; if fecal material is thick, fold ends of pouch over to make cleaning easier; place end of pouch into graduated cylinder; with a 2-piece flange system you can unsnap pouch to drain it but opening is preferable if effluent is draining continually; clean end of pouch before replacing clip; perform hand hygiene; document procedure including color, consistency and amount of effluent; perform hand hygiene; don gloves; dispose of waste materials appropriately
Indication for drainable pouches
Recommended for use with ascending or transverse colostomy, ileostomy, and urostomy
Describe irritant dermatitis of peristomal area
Reddened, moist, painful skin
Describe allergic contact dermatitis of peristomal area
Redness and irritation in area covered or treated with the product
_______________ adjusting a pouching system to accommodate changes in stoma size or to address other stomal or peristomal issues
Refitting
If patient reports burning, itching,or purulent drainage around stoma, what should nurse do?
Remove pouching system and notify provider
________________ storage place; in the case of an IPAA or Kock's pouch, an internal reservoir is surgically created
Reservoir
What procedure is indicated when entire large colon must be removed, but rectum can be preserved, and why?
Restorative proctolectomy with IPAA; it allows patient to retain anal sphincter control of bowel movements
Where is stoma typically placed for an ileostomy?
Right lower quadrant
Typical output of colostomy placed in descending colon (left upper abdomen)
Semi-formed because more water is absorbed while fecal material is in ascending and transverse colon
Describe appearance of a healthy stoma
Shiny, wet, red in color, similar to mucous membranes of mouth; protrudes about 3/4 inch from abdominal wall
Why are ileostomy patients at higher risk for fluid and electrolyte imbalances?
Shorter transit time through bowel, decreased absorption of fluid and nutrients; higher volume of effluent
_______________ referring to the portion of the large intestine between the descending colon and the rectum
Sigmoid
Which location is used for a permanent colostomy, particularly for cancer of the rectum?
Sigmoid colon/left lower abdomen
How can best pouch fit be maintained?
Size and shape of stoma should be determined using a measuring guide, traced onto paper backing o f skin barrier's adhesive side, and opening of skin barrier cut to accommodate stoma size and shape
______________ faceplate designed to protect the peristomal skin from the stoma output and to which the pouch is attached
Skin barriers
What skin preparation should be made prior to skin barrier application?
Skin should be dry; if skin is not intact, use appropriate skin treatment or protection product before applying pouch
___________ mechanical disruption of the epidermis, as can be caused by adhesives when an ostomy appliance is removed
Skin stripping
What factors should nurse consider when selecting an appropriate solid skin barrier for a patient with an ostomy?
Solid skin barriers contain several ingredients that help them adhere to the skin's surface: polymers, heat-sensitive ingredients that fill in the creases and crevices of the skin's surface to promote adhesion & hydrocolloids (carboxymethylcellulose, pectin, gelatin), which absorb perspiration and other metabolic secretions while preventing fungal and bacterial invasion; The cohesion, or ability of the skin barrier to maintain its integrity when exposed to moisture, varies with each product. Extended-wear skin barriers, for example, are more cohesive than standard wear adhesives and are designed for ostomies with watery or high-volume effluent. The product's cohesion is a factor in how well it protects the skin, maintains a seal around the stoma, and withstands moisture. However, it also determines how much residue remains on the skin after its removal. A skin barrier with high cohesion may leave residue that requires solvents to remove it. Your assessment of the individual's skin surface and integrity, amount of perspiration, characteristics of the effluent, and the personal preferences can help you find the appropriate barrier.
What should patient and family be taught about urostomy management?
Stoma care, odor management, skin care, adequate fluid intake, pouch application and leakage prevention, self-catheterization for patients with continent reservoirs, signs of infection and obstruction, how to evaluate character and color of urine, to report skin alterations under skin barrier
______________ degree of protrusion of a stoma from the skin
Stomal height
_____________ lengthening of a stoma due to the bowel telescoping out through the stoma
Stomal prolapse
____________ pulling back of a stoma below skin level
Stomal retraction
_________________ narrowing of the lumen of the stoma
Stomal stenosis
How would nurse treat stomal retraction into peritoneum?
Surgical intervention would be required
Describe an ileostomy
Surgical opening created in ileum to bypass entire large intestine; terminal ileum is brought out through the abdominal wall forming a permanent ileostomy
What is a total proctolectomy?
Surgical removal of entire colon, rectum, and anus, with closure of anus, resulting in need for stool diversion
_____________ device on a urostomy pouch that permits drainage of the contents
Tap
What temporary procedure will be performed along with a restorative proctolectomy with IPAA?
Temporary loop ileostomy created to divert stool while new anal pouch heals, followed by closure of ostomy a few months later
Why is leakage from an ileostomy pouch concerning?
The stool contains enzymes and bile salts that can irritate the skin
What is a stoma?
The surgically-created opening in the skin of the abdomen for an ostomy; it's the communicating end of the bladder or bowel t hat is brought to surface of abdomen
Though after initial postoperative period most patients with colostomy can resume a regular diet, what foods should be avoided?
Those more likely to cause loose stools such as chocolate, dried beans, fried foods, highly spiced foods, raw fruits and veggies; foods that are difficult to digest and might cause blockage such as stringy meats, coconut, coleslaw, mushrooms, popcorn, seeds, berries, celery, fresh tomatoes, some shellfish
Following urostomy surgery, what can interfere with urinary output from stoma?
Tissue edema and bleeding
When would a temporary ostomy be used?
To allow for healing and return to normal elimination, such as following tumor resection
Why are ureteral stents drained into an ostomy pouch?
To assess stent patency, urine output and stoma condition
What is a transureteroureterostomy used for?
To connect ureters internally and bring one out through the abdominal wall, preventing need for two collecting devices with a ureterostomy
Why should peristomal skin be kept dry?
To ensure good adhesive seal and reduce risk of candidiasis
Why is it essential for ileostomy patients to chew their food thoroughly?
To help it pass through the narrow lumen
Why is it essential to choose a well-fitted pouching system?
To prevent irritating stool, urine or mucus from contacting the surface of the skin
Describe a double-barrel colostomy
Two stomas are created; both ends of bowel are brought through abdomen to skin surface as two separate sections; distal colon not typically removed but is bypassed; proximal stoma is functional and diverts feces to abdominal wall; distal stoma (or m ucous fistula) expels mucus from distal colon
______________ surgically created ureteral skin opening that diverts urine away from the bladder and out of the body
Ureterostomy
___________________ surgically created opening that diverts urine away from the bladder and out of the body
Urostomy
Patients with a colostomy need information about options for management including what?
Use of drainable or closed-end pouches; irrigation; dietary management; strategies for managing diarrhea and constipation
What should nurse do when changing urostomy drainage bag to cope with constant urine drainage?
Use piece of rolled, cotton-free gauze to wick urine from stoma; gently dab wick on surface of stoma to absorb urine while you prep patient's skin and apply ostomy pouch
_______________ forceful exhalation against a closed glottis, which involves contraction of the abdominal muscles to propel feces out of the body
Valsalva maneuver
Indication for ileal conduit
When entire bladder must be removed
What factors should be considered when choosing a pouching system for an ostomy?
Which system provides best adhesive seal and skin protection, stoma's location and structure, consistency of effluent, availability and cost of supplies, wear time, abdominal shape and firmness, patient dexterity, personal preference
How would colostomy irrigation be performed in the bathroom?
With client sitting on toilet or sitting on chair facing toilet
When would a patient want an extended wear barrier instead of a regular wear barrier?
With high stomal output
Can a urostomy patient reuse a catheter? How should it be cared for?
Yes for up to a month if they clean it after each use with warm soap and water, rinse it thoroughly, and allow it to dry on a clean towel, storing it in a resealable plastic bag and discarding it if it becomes discolored or cracked
What information should be included when documenting ostomy care?
the date and time; assessment findings (bowel sounds, flatus, abdominal distention, tenderness); the characteristics of the stoma and peristomal skin; the appearance of any sutures; the type of skin barrier or accessories used (paste, powder, skin sealant, strips, rings) to prevent or treat complications; the measurement of the stoma; the type of pouching system used, especially if this has changed; any changes in the peristomal skin care procedures or products used; the characteristics and amount of output; any complications of the procedure performed; the patient's level of participation; strategies to promote self-management; the patient's ability to manage the skills required for ostomy care
