Ostomies

Enema Types - Retention

oil introduced into the rectum and sigmoid colon, retained for long periods (30 minutes). Acts to soften the feces and lubricate the rectum and anal canal.

Colostomy Irrigation

to remove formed stool or regulate the timing of bowel movements. Fluid inserted directly into the stoma for descending or sigmoid colostomies. We irrigate to regulate bowel movements. Puts patients on a schedule. Patient can be trained to regulate bowels movements by irrigating until trained. Once trained, patient doesn't have to wear the bag and faceplate all the time.

Reservoir (Ileoanal anastomosis)

joins a section of ileum to create an ileal reservoir. The distal end of the ileum is sutured above the anus.

Ostomy

opening in the abdominal wall for the elimination of feces or urine

Colostomy

opening into the colon (large bowel)

Ileostomy

opening into the ileum (small bowel)

Ureterostomy

opening into the ureter

Bowel Diversion Ostomies

Purpose of bowel and urinary ostomies is to divert and drain fecal and urinary matter. Bowel diversion Ostomies are often classified according to their status as permanent or temporary; their anatomic location; the construction of a stoma (the opening created in the abdominal wall by the "Ostomy"); Colostomies can be temporary or permanent. Temporary colostomies are performed for traumatic injuries or inflammatory conditions. Allows the distal diseased portion of the bowel to rest and heal.

Measures to Promote Bowel Elimination

Administering an enema, Enema - solution introduce into the rectum, reasons - cleanse lower bowel, soften feces, expel flatus, soothe irritated mucous membranes, outline colon during diagnostic X-rays, treat worm and parasite infestations.

Assessment

Assess any tape allergies. Stoma color - should be moist, red or pink, similar in color to mucosal lining of inner cheek. Pale or bluish indicate impaired circulation. Stoma size - most protrude slightly, patients that have just had surgery to give stoma, the stoma will be swollen. Stoma bleeding - slight bleeding when stoma touched is normal. Status of peristomal skin - transient redness after removal of adhesive is normal. Amount and types of feces. Complaints - burning sensation under the faceplate may indicate breakdown. Assess for abdominal discomfort, distention. Assess clients and family members learning needs and emotional status. The clients physical and emotional status and understanding of the need for an Ostomy will affect teaching sessions. Assess for factors that my limit or affect the ability for self care. Hand tremors, visual impairments. Assess hydration and electrolyte balance. Clients with ileostomies may loose large amounts of fluids from the bowel. Always at risk for dehydration.

Common Alterations in Bowel Elimination

Constipation - elimination problem characterized by dry hard stool that is difficult to pass; Fecal Impaction - large hardened mass of stool that interferes with defecation, making it impossible for the client to pass feces voluntarily, have to go in and break up the mass; Flatulence-excessive accumulation of intestinal gas; Diarrhea - urgent passage of watery stool and commonly is accompanied by abdominal cramping, BS will be hyperactive, due strict I&O.

Continent ileostomy

Kock Pouch - creation of internal reservoir for the storage of GI effluent (discharged fecal material or liquid feces) drained every 4-6 hours.

Enema Types - Cleansing

Types - cleansing enemas - tap water, saline, soap solution, hypertonic (can only give 3 hypertonic because it will cause pt to become dehydrated, every solution except for saline is hypotonic fluid - limit to only because can cause fluid overload (Hypervolemia).

Loop colostomy

___ of bowel brought out onto the abdomen; created generally for an emergency; two openings are made; 1. Proximal openings discharges fecal material; 2. distal opening discharge opening discharges only mucus.

Vagal Response

causes BP and pulse to drop, patient can pass out; Perforation of Colon - insert into adult only 3-4 inches, never more than 6 inches. Position patient in lateral side-lying position, never hang bag more than 18 inches above rectum (flows to fast).

Transverse colostomy

colostomy empties from ___ colon - produces a malodorous mushy drainage (some of the liquid has been reabsorbed)

Bowel Elimination

defecation bowel elimination; peristalsis-rhythmic contractions of intestinal smooth muscle that facilitate defecation; valsalva maneuver (bearing down) - closing the glottis and contracting the pelvic and abdominal muscles

Assessment - Elimination Patterns

different for everyone; Stool characteristics - Consistency - soft, formed, Abnormal - liquid or semiliquid, watery, unformed, very hard and dry, Shape - longer curved shape, cylindrical - Abnormal - balls, clumps, or broken off chunks, flat or ribbon-like, pencil-like, Color - yellow in infants, light brown to dark brown in others - Abnormal - bright red blood, black, coffee-grounds appearance, pale, white, gray, or clay-color, Presence of Infection - absence of pus, mucous, fat - Abnormal - presence of pus, excessive mucus, foamy, of floating on water, Presence of parasites - absence of parasites - Abnormal - presence of worms or eggs, Odor - slight odor - Abnormal - foul odor, strongly odiferous, blood or old-blood smell, metallic smell; If stool is liquid, must measure and put on I&O chart.

Sigmoidostomy

empties from the ___ colon - stools are of normal or formed consistancy; frequency of D/C can be regulated; may not have to wear an appliance at all times.

ascending colostomy

empties from the ____ colon- drainage is liquid and cannot be regulated; digestive enzymes are present; odor is a problem; control with deodorant inside the appliance.

Ileostomy

empties from the distal end of the small intestine - produces liquid fecal drainage; drainage is constant and cannot be regulated; contain some digestive enzymes which are damaging to the skin; odor is minimal because fewer bacteria are present; client must wear an appliance continuously and take precautions to prevent skin breakdown.

Enema Types - Return Flow (harris flush, siphone enema)

inserted into rectum, lower the bag and fluid comes back out, done to eliminate gas.

Single Barrel Colostomy

only one stoma from the end of the proximal portion of the bowel - ileostomy - distal end resected or closed off.

Contraindications

rectal surgery, rectal bleeding, ulcerative colitis chrohn's, rectal fissures (opening in anus), or rectal cancer

Stoma and Skin Care

the fecal material from a colostomy or ileostomy is irritating to the Peristomal skin, Ileal effleunt contains digestive enzymes. Assess the Peristomal skin for irritation each time the appliance is changed, Irritation and breakdown need to be treated immediately. Peristomal care- prevent breakdown. Wash stoma and surrounding area with mild soap and water and pat dry. Barrier substances such as Karaya can be applied around the stoma. Ostomy Appliance - consists of a pouch for collecting stool and a faceplate, or disk, that attaches to the abdomen. The stoma protrudes through an opening in the center of the appliance. Faceplate remains in place 3 to 5 days unless it becomes loose or causes skin discomfort. All appliances have a pouch to collect the effluent (outlet at the bottom for easy emptying). Should be emptied when it is 1/3 to 1/2 full. Temporary, disposable pouches are made of transparent plastic and have pell off adhesive square in which a hole the size of the stoma is cut 1/8 to 1/4 inches larger than the stoma. Permanent pouches may be clear or opaque rubber or vinyl and have a solid ring faceplate that fits around the stoma - once swelling has dissolved. Odor control is essential to self-esteem. Intact appliance will contain the odor, Should be rinsed thoroughly when emptied - Some newer bags cannot be rinsed because it affects the integrity of the bag. Disposable appliance can be applied for up to 7 days. Remove pouch and skin barrier twice a week to clean and inspect skin. If Peristomal skin is erythematous - remove and change system every 48 to 72 hours. If breakdown - should be changed every 24 - 48 hours to allow appropriate treatment.

Double Barreled colostomy

two separate stomas created; 1. Proximal or functional stoma - fecal drainage coming from it; 2. Distal or resting stoma - only mucus drains from it.

Enema Types - Medicating

usually to decrease irritation in the bowel.