Ostomy care ATI
The surgically-created opening in the skin of the abdomen is called a
stoma. A stoma is the communicating end of the bladder or bowel that is brought to the surface of the abdomen. The location of the stoma depends upon the location of the patient's beltline, the location of any scars and skin folds, where the damage is, and the type of ostomy surgery performed. The stoma should be shiny, wet, and red in color, similar to the mucous membranes of the mouth. A stoma can be round, oval, or irregular in shape, and either protruding, flush with the skin, or retracted.
The swelling
subsides with time, gradually shrinking over the first few months. It is important to measure the stoma periodically to ensure that the size of the pouching system is appropriate. Once the stoma has a consistent size and shape, less frequent measurement is indicat
An ostomy is an opening
surgically created in the abdominal wall to allow for the elimination of urine or feces.
Documentation:
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
After surgery,
1. a newly created stoma is swollen and enlarged. As part of the patient's postoperative care, check it often for color, turgor, edema, and signs of injury such as bleeding. 2. Typically, a stoma is pink to red. Report any stoma that turns pale, dark red, purple, brown, or black to the surgeon immediately as its blood supply may be compromised. The swelling subsides with time, gradually shrinking over the first few months. It is important to measure the stoma periodically to ensure that the size of the pouching system is appropriate. Once the stoma has a consistent size and shape, less frequent measurement is indicated.
Teach patients to recognize the signs and symptoms of food blockage and to know when to contact their provider. Common manifestations
1. abdominal cramping, 2. nausea, 3. vomiting 4. swelling of the stoma, and no ileostomy output for at least 6 hours. 5. When these develop, patients should place moist towels on the abdomen, drink hot tea, lie down and assume a knee-chest position to relieve intra-abdominal pressure, and/or massage the abdominal area to promote peristalsis and fecal elimination. Also, if the stoma is swollen, they might have to replace the pouch with one that has a larger opening to avoid mechanical obstruction. The United Ostomy Associations of America (UOAA) has information available regarding the signs and symptoms of blockage and what to do to relieve blockage (available at www.uoaa.org).
Preventing skin problems is a key aspect of ostomy care and entails
1. assessing the peristomal skin regularly 2. ensuring that the skin barrier and pouching system are the correct size and fit 3. and managing output and pouch leakage.
When the skin barrier has to be removed, b
1. begin with one corner of the barrier and slowly pull off the remaining adhesive. 2. Do not rip or tear the skin barrier off the body; instead, remove it gently while supporting the underlying skin. 3. Use an adhesive remover wipe to make removal easier and to ensure a clean skin surface before attaching the next skin barrier. 3. However, because some products may irritate the skin or produce hypersensitivity reactions, it is best to first patch-test the adhesive remover on the patient's skin prior to use.
The risks of dehydration and hyponatremia increase during hot weather due to fluid losses through perspiration. Tell patients to
1. drink at least 1.5 to 2.5 L of fluids per day. When active during hot weather or having large amounts of output, patients should consume extra fluid, potassium, and sodium (unless contraindicated). Patients may initially follow a low-residue diet. To prevent food blockage, they should avoid high-fiber or difficult-to-digest foods such as popcorn, nuts, corn, celery, fresh tomatoes, figs, strawberries, blackberries, and caraway seeds.
Closed-end pouches Closed-end pouches are designed For
1. for one-time use and may meet the needs of a patient who irrigates. 2. Some closed-end pouches come with a filter designed to reduce odor and gas buildup. This type of pouch has no drain or clip, and it is recommended for use with sigmoid colostomies. 3. When the pouch is full, it is removed from the skin barrier and discarded in an appropriate receptacle.
Instruct patients to notify their clinician for any of the following:
1. increased pain in the abdomen or the incision; fever, redness, or drainage of the incision; or irritation, redness, or breakdown of the peristomal skin 2. change in bowel habits, such as diarrhea or constipation 3. skin irritation unrelieved by a properly fitting pouching 4. system problems obtaining a good seal of the wafer or 5. skin barrier a hernia or bulge around the stoma 6. narrowing of the stoma lumen 7. separation of the stoma from the abdominal surface lacerations or cuts in the stoma
Treatment
1. patients should place moist towels on the abdomen, drink hot tea, lie down and assume a knee-chest position to relieve intra-abdominal pressure, and/or massage the abdominal area to promote peristalsis and fecal elimination. Also, if the stoma is swollen, they might have to replace the pouch with one that has a larger opening to avoid mechanical obstruction.
. In the case of an ileal conduit,
1. temporary bilateral ureteral stents may be placed to prevent postsurgical edema from obstructing urine output. 2. These stents may be left in place for 10 to 21 days after surgery. 3. A skin barrier and clear ostomy pouch is applied to the stoma so that the stents drain into the bag; this allows for easy assessment of stent patency, urine output, and stoma condition. Be aware that the reabsorption of electrolytes from reservoirs created by portions of the bowel can cause electrolyte imbalances and metabolic acidosis. 4. The constant drainage of urine can pose a problem when you measure, refit, or replace the pouching system of a urostomy. To keep this from disrupting the procedure, use a piece of rolled, cotton-free gauze to wick urine from the stoma. Gently dab the wick on the surface of the stoma to absorb urine while you prepare the patient's skin and apply the ostomy pouch.
With an end colostomy, t
1. the damaged section of the bowel is removed and the working end is brought through the abdomen to the skin surface. 2. When a colostomy is intended to be permanent, an end stoma is typically created. 3. A temporary colostomy may be performed to allow bowel rest or healing, such as following tumor resection.
Make sure patients understand that
1. they can reuse a catheter for up to a month if they clean it after each use with warm soap and water 2. rinse it thoroughly, and allow it to dry on a clean towel. 3. They should store the clean catheter in a resealable plastic bag and discard it if it becomes discolored or cracked.
Cut-to-fit barriers are
1. typically used for the first 6 to 8 weeks following surgery, a time period when the stoma changes in size and shape. 2. The stoma is first measured using a measuring guide, and the selected size is traced onto the paper backing of the skin barrier's adhesive side. 3. The opening of the skin barrier is then cut to accommodate the stoma size and shape. Typically, the hole is cut 1/8 inch wider than the measured tracing to avoid fitting the skin barrier too tightly.
Since an ill-fitting skin barrier or ostomy pouch can cause ulceration or bleeding, be sure that the opening of the appliance is
1/16 to 1/8 inch (0.15 to 0.3 centimeters) larger than the diameter of the stoma to prevent constriction.
issue edema and bleeding can interfere with urinary output from the stoma. It is essential to maintain the patient's urine output at
30 mL per hour or more to prevent hydronephrosis and possible renal damag
Patients may be the first to recognize changes in the peristomal area;
the skin may be itchy, burning, or painful.
For patients with a continent ileostomy,
the surgeon may insert a catheter to provide continuous drainage. Regular irrigation of an indwelling drainage tube may be indicated
Following urostomy surgery,
tissue edema and bleeding can interfere with urinary output from the stoma. It is essential to maintain the patient's urine output at 30 mL per hour or more to prevent hydronephrosis and possible renal damage. Assess the color and consistency of the urine. Urine may be cloudy due to the mucus the intestinal mucosa produces, but excessive cloudiness and a foul odor are signs of infection.
With a urostomy,
urine will flow as it is produced because the patient has no voluntary control over urine flow. An external pouching system or collection device contains the urine. Urostomy pouches have a drainage tap on the bottom for emptying them repeatedly throughout the day.
Urostomy
A urostomy is a urinary diversion that allows urine to exit the body after removal of a diseased or damaged section of the urinary tract. When the entire bladder must be removed, an ileal conduit can be created. For this type of surgery, 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. This is the most common type of urinary diversion.
Ostomy surgery is performed
when a disorder or an injury keeps the urinary or gastrointestinal system from functioning properly.
Instruct patients to empty the pouch
when it is one third to one half full, which may require drainage several times a day. Effluent from the ileostomy contains enzymes and bile salts that can irritate the skin. Advise the use of a skin barrier and prompt attention to any signs of pouch leakage.
mucocutaneous separation can occur
when the suture line fails to heal properly. Candidiasis, dermatitis, and stripping injuries can develop at any time.
Replacing an Ostomy
• Perform hand hygiene; Don clean gloves • Identify patient using two identifiers, explain procedure and answer any patient questions. • Observe skin barrier and pouch for leakage and length of time in place. • Place towel or waterproof barrier under patient.
After the drains are removed, make sure patients know how to empty the pouch and to establish a schedule. Initially they should catheterize the stoma, empty the pouch every 2 to 3 hours, and irrigate the pouch in the morning and in the evening (if prescribed). Later, they can catheterize every 4 hours while awake or more often if they sense fullness. Make sure patients understand that they can reuse a catheter 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. They should store the clean catheter in a resealable plastic bag and discard it if it becomes discolored or cracked.
After the drains are removed, make sure patients know how to empty the pouch and to establish a schedule. Initially they should catheterize the stoma, empty the pouch every 2 to 3 hours, and irrigate the pouch in the morning and in the evening (if prescribed). Later, they can catheterize every 4 hours while awake or more often if they sense fullness. Make sure patients understand that they can reuse a catheter 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. They should store the clean catheter in a resealable plastic bag and discard it if it becomes discolored or cracked.
Allergic Contact Dermatitis
Causes- exposure to the material and chemical compound that irritates the skin on contact( tape, soap, skin barrier, adhesive, powders, pastes, pouch material) Description- Redness and irritation in the area covered or treated with the product. Treatment - Alter pouching system or skin care procedure, eliminate the irritating product.
Yeast Infection
Causes:Leakage, perspiration, antibiotic therapy or broken skin description: itchy, bumpy, reddened skin. treatment- Keep the skin dry.
Follow-up care Patients should follow up regularly with the surgeon and the wound ostomy continence nurse. Patients will want to know when they can resume their usual activities. Most can do so with minimal restrictions after the stoma has healed adequately. It is important to give them specific information about exercise and sexual activity and to make sure it matches what their provider has prescribed or recommended for them.
Exercise. Ostomy patients should be advised to remain vigilant of their hydration status during strenuous physical activity. Patients should engage in a regular exercise routine that includes activities that promote cardiovascular and musculoskeletal fitness. Sexuality. It is important for patients to expect to feel sensitive about the change in body image. Encourage them to share feelings with their partners and to respond to any concerns. Irritation of the stoma and peristomal skin due to friction should be avoided. Patients may feel more secure about engaging in sexual activity if they empty the pouch first, wear a smaller pouch, or cover the pouch with specially designed underwear, lingerie, or pouch covers.
Apply Principles of Aseptic Practice
Hand hygiene, personal protective equipment Communicate Effectively Privacy, patient identification, patient teaching Perform Steps
Patient Care
Instructional strategies include describing each step of the procedure performed, encouraging participation in ostomy care, answering questions, and providing resources until patients are comfortable with performing the procedure independently.
Skin barriers A skin barrier adheres to the skin around the stoma and performs two important functions:
It protects the skin from stoma output, and it attaches the pouch to the body. There are various types of skin barriers with specific indications based on the type of ostomy. For example, a "regular wear" skin barrier may not be best for a patient with high stomal output; this person may want an "extended wear" barrier. Skin barriers also come in different designs: cut-to-fit, pre-cut, and moldable.
Later, they can catheterize every
Later, they can catheterize every 4 hours while awake or more often if they sense fullness.
One-piece systems
One-piece systems with an attached skin barrier are available. They are available in cut-to-fit and pre-cut types. Two-piece system
COnduit
Passageway
Verify Order
Patient record and need for procedure Identify, Gather, and Prepare Equipment and Supplies
Drainable pouches
Some drainable pouches can be rinsed and reused. They are recommended for use with an ascending or transverse colostomy, an ileostomy, and a urostomy. Drainable urostomy pouches have a tap instead of a clip.
Descending colon (left upper abdomen).
The output is semi-formed because more water is absorbed while fecal material is in the ascending and transverse colon.
Ascending colon (right abdomen).
The output is typically liquid to semi-liquid and is very irritating to the surrounding skin.
the complication rate associated with a continent ileostomy is usually higher than with a traditional ileostomy. .
The patient empties the pouch several times a day and the stoma is covered with a protective dressing or a stoma cap.
Review the various options for pouching systems so patients can choose a system that fits their lifestyle.
The use of a commercially made pouch with a charcoal filter provides odor control and may enhance confidence. Patients with a colostomy might not need any dietary adjustments, although they should be aware of foods that cause fecal odors and gas and those that thicken or loosen stools
With a double-barrel colostomy,
Two separate stomas are created. Both ends of the bowel are brought through the abdomen to the skin surface as two separate sections. Typically the distal colon is not removed but bypassed. The proximal stoma, which is functional, diverts feces to the abdominal wall. The distal stoma, or mucous fistula, expels mucus from the distal colon.
r this type of surgery,
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. This is the most common type of urinary diversion.
With a loop colostomy,
a loop of the bowel is brought through the abdomen to the skin surface and temporarily supported by a plastic bridge or rod. A transverse loop colostomy is typically created as an emergency procedure to relieve an intestinal obstruction or perforation. A communicating wall remains between the proximal and the distal bowel. It has two openings through the one stoma - the proximal end drains stool while the distal portion drains mucus. The bridge can be removed in 7 to 10 days. Transverse loop colostomies are typically temporary.
A restorative proctocolectomy with IPAA (ileal pouch anal anastomosis) involves connecting the ileum to a "new" rectum (or anal pouch),
also made out of a portion of ileum; it is the procedure of choice in cases where the rectum can be preserved, allowing the patient to retain anal sphincter control of bowel movements. The patient will have a temporary loop ileostomy to divert stool while this new anal pouch heals, followed by closure of the ostomy a few months later.
The pouching system must fit so the skin
at the base of the stoma is covered, but not so that it constricts or exerts pressure on the stoma. If the stoma size changes or a patient has problems with the pouching system, recommend a pouch refitting with a wound ostomy continence nurse.
Remove the pouching system if the patient reports
burning or itching beneath it or purulent drainage around the stoma. Notify the provider of any skin irritation, breakdown, rash, or unusual appearance of the stoma or the peristomal area
Moldable skin barriers have a pliable stoma opening that
can be molded to provide a snug fit around the stoma. When the skin barrier is applied, it's important to make sure that the skin is dry to make sure the pouching system stays in place between changes. If the skin is not intact, use an appropriate skin treatment or protection product before applying the pouch.
Irritant Dermatitis:
causes- contact with stool or urine, usually from leakage under the pouching system or between the skin barrier or the stoma. Description: Reddened, moist, Painful skin Treatment: 1. Clean and Dry peristomal skin 2. use a protective barrier powder and wipe the skin before applying the skin barrier and remeasure the stoma to ensure the use of correct size pouch and skin barrier.
Depending on the disorder or injury, the ostomy may be temporary, to allow for healing and a return to normal elimination, or permanent. The three primary types of ostomy surgery are:
colostomy ileostomy urostomy
Pre-cut skin barriers
come in a variety of sizes, so they do not have to be cut. After measuring the stoma with the measuring guide, the appropriate size opening is selected. Typically, the size should be 1/8 larger than the stoma measurement to avoid a constrictive opening. These are used after the stoma has a consistent size and shape and are especially useful for patients who lack the manual dexterity it takes to cut the barrier.
Indications for ostomy surgery include:
congenital anomalies bladder, colon, and rectal cancer inflammatory bowel diseases (Crohn's disease, ulcerative colitis) inherited disorders such as familial adenomatous polyposis obstruction of the ureter stab or gunshot wounds to the abdomen
• Pouching an Ostomy
(towel or waterproof barrier, washcloths, warm water, adhesive remover, measuring device, marker/pen, scissors, skin barrier, pouch system)
Patients with a double-barrel or loop colostomy should be aware that the
distal bowel carries no fecal contents and does not need irrigation. If they use irrigation at all, they should irrigate the proximal stoma only. Review the various options for pouching systems so patients can choose a system that fits their lifestyle. The use of a commercially made pouch with a charcoal filter provides odor control and may enhance confidence.
An Indiana continent urinary reservoir is formed from the cecum and a portion of the ileum
. The created stoma is continent and flush with the skin. The patient self-catheterizes to empty the reservoir. With a ureterostomy, one or both ureters are redirected from the kidney(s) through the abdominal wall to form a stoma. To avoid the need for two collecting devices, a transureteroureterostomy may be performed to connect the ureters internally and bring one out through the abdominal wall. WHen the bladder is nonfunctional.
A continent internal ileal reservoir or continent ileal bladder conduit (Kock's pouch) is created the same way as an ileal conduit is,
except that nipple valves are formed by intussuscepting tissue backward into the reservoir; the pouch is connected to the skin and the ureters are connected to the pouch. Filling pressure closes the valves, thereby preventing leakage and reflux. An external drainage collection device is not necessary because the patient self-catheterizes about every 4 hours.
Cystectomy
excision or resection of the bladder
High-volume ileostomy output can put patients at risk for fluid and electrolyte imbalances. They need to recognize the signs and symptoms of dehydration or electrolyte imbalance, including:
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
A two-piece system permits
frequent pouch changes and also minimizes skin breakdown. The pouch and skin barrier are connected with a flange mechanism. With a two-piece system, the pouch may be disposable or reusable, and it may have a filter for gas release. Choosing a well-fitted pouching system is essential for preventing irritating stool, urine, or mucus from contacting the surface of the skin. To help maintain the best fit, be sure to determine the size and shape of the stoma using a measuring guide.
Sigmoid colon (left lower abdomen). T
his is the location for a permanent colostomy, particularly for cancer of the rectum. The stoma is typically located on the lower left quadrant of the abdomen, and the output is formed.
An alternative to the standard ileostomy
is Kock's continent ileostomy. During the procedure, an internal pouch is created from the distal segment of the ileum, which serves as a reservoir for stool. -During surgery, a one-way nipple valve is constructed through the 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. -This type of ostomy is occasionally created to treat ulcerative colitis and may be an option for patients who do not wish to wear an external pouch over the stoma. However, the complication rate associated with a continent ileostomy is usually higher than with a traditional ileostomy. The patient empties the pouch several times a day and the stoma is covered with a protective dressing or a stoma cap. .
Initial drainage from an ileostomy
is typically dark green, loose, and odorless. Drainage gradually thickens and becomes yellow to brown.
A common temporary colostomy surgery involves
leaving the distal portion of the colon in place, which is oversewn for closure to create what is known as a Hartmann's pouch. Anastomosis of the severed portions of the colon may be delayed for several reasons, including bowel inflammation or tumor location.
Patient should follow a
low-residue diet. To prevent food blockage, they should avoid high-fiber or difficult-to-digest foods such as popcorn, nuts, corn, celery, fresh tomatoes, figs, strawberries, blackberries, and caraway seeds.
Risk factors that predispose patients to peristomal skin complications include
obesity, wound complications adjacent to or in the peristomal field, a poorly located or constructed stoma, and stoma complications, including retraction and hernia. These factors increase the likelihood of inadequate adherence or fitting of the ostomy pouching system, thereby increasing the risk of leakage. Establishing a pouch-replacement schedule and immediately addressing signs of leakage are important steps in peristomal skin protection. Routine pouch-replacement helps prevent surprising leakage problems.
Transverse colon (mid-abdomen). This location is used for a temporary ostomy, with the stoma constructed as a loop. Output is liquid to semi-formed.
output- liquid to semiformed
Report any stoma that turns
pale, dark red, purple, brown, or black to the surgeon immediately as its blood supply may be compromised. The swelling subsides with time, gradually shrinking over the first few months. It is important to measure the stoma periodically to ensure that the size of the pouching system is appropriate. Once the stoma has a consistent size and shape, less frequent measurement is indicat
Steps to drain the bladder through Urostomy?
1. Apply water soluble lubricant at the catheter tip. Remove and discard the stoma cover. Clean the stoma and peristomal area. 2. Sitting over the toilet, insert the catheter into the stoma until urine begins to flow 3. when the flow stops pinch the catheter closed and remove it
Depending on the area of disease or injury and other physical features of the patient's abdomen, a colostomy is placed in one of the following four locations:
1. Ascending colon 2. Transvers colon 3. Descending Colon 4. Sigmoid Colon.
A colostomy is created from the end of the large intestine to divert waste from the digestive system. Three different colostomy types can be formed from the gastrointestinal tract:
1. End ( Hartmans pouch) 2. Loop 3. Double barrel
Intervention for periostomal Skin complication
1. Establishing a pouch-replacement schedule and immediately addressing signs of leakage are important steps in peristomal skin protection. 2. Routine pouch-replacement helps prevent surprising leakage problems. 3. If the skin is moist or eroded, use skin barrier powder to manage the affected areas. Dust the powder over the moist area and remove any excess to avoid interference with the adhesive.
Ostomy pouches are manufactured in an array of shapes and sizes, with various features designed to meet patients' needs for comfort, safety, and ease of application. Pouches may be disposable or reusable, they may be one-piece or two-piece, and the skin barriers may come with the stomal opening pre-cut or require custom cutting for each application. Factors to consider when selecting a pouching system are which system
provides the best adhesive seal and skin protection, the stoma's location and structure, the consistency of effluent, availability and cost of supplies, wear time, abdominal shape and firmness, patient dexterity, and personal preference.
How often should they catheterize the Stoma initially
1. Initially they should catheterize the stoma, 2. empty the pouch every 2 to 3 hours, 3. and irrigate the pouch in the morning and in the evening (if prescribed).
Stoma Inspection
1. Inspect the stoma daily. 2. Cleanse the stoma routinely with warm water according to the facility's policies. 3. The intestinal mucosa is delicate and is relatively free of nerve endings, so the patient won't feel pressure and may be unaware of potential or actual damage to the stoma. 4. Since an ill-fitting skin barrier or ostomy pouch can cause ulceration or bleeding, be sure that the opening of the appliance is 1/16 to 1/8 inch (0.15 to 0.3 centimeters) larger than the diameter of the stoma to prevent constriction.
As part of the total proctocolectomy procedure,
1. The end of the terminal ileum is brought out through the abdominal wall, forming a permanent ileostomy. 2. After this type of ileostomy surgery, the patient has no voluntary control of bowel movements. 3. The stoma of an ileostomy is typically located in the right lower quadrant.
