ATI Skills Module: Ostomy Care

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

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.

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

With an end colostomy,

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.

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

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.

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.

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.

COnduit

Passageway

Verify Order

Patient record and need for procedure Identify, Gather, and Prepare Equipment and Supplies

Colostomy management

Patients with a colostomy need information about their options for management, including the use of drainable or closed-end pouches, irrigation, and dietary management. Review strategies for managing diarrhea and constipation with them. Patients with a temporary diverting colostomy need to know that they might feel an urge to defecate through the rectum or have rectal drainage.

A nurse is providing preoperative teaching for an older adult patient who has diverticulitis and is scheduled for a creation of a double barrel colostomy in the sigmoid colon. Which of the following instructions should the nurse include in the teaching? Irrigate both stomas periodically to promote drainage Tape a dry gauze pad over the distal stoma to collect drainage Change the proximal stroma's appliance every other day Expect liquid to drain from both stomas

Tape a dry gauze pad over the distal stoma to collect drainage The distal stoma (also called a mucous fistula) secretes mucus; it does not drain feces. A dry gauze is usually sufficient. With a double barrel colostomy, irrigation might not be necessary at all. If it is, it would only apply to one stoma, not both. Ostomy appliances remain in place for up to 7 days and do not need to be replaced every other day.

Ascending colon (right abdomen).

The output is typically liquid to semi-liquid and is very irritating to the surrounding skin.

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

Teach patients with a new stoma the techniques to use for

cleansing, signs and symptoms of stoma or peristomal skin complications, and application and management of the pouching system.

• Pouching an Ostomy

(towel or waterproof barrier, washcloths, warm water, adhesive remover, measuring device, marker/pen, scissors, skin barrier, pouch system)

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.

Cystectomy

excision or resection of the bladder

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.

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.

A healthy stoma appears ________ or red and moist, and should protrude about ¾ inch (2 cm) from the abdominal wall. Teach patients to report any stoma that turns dusky, brown, black, or very pale to the provider immediately as these findings indicate compromised circulation. Make sure they understand the type of cleansing agent to use on the peristomal skin, typically a mild, pH-balanced soap or no soap at all and just water. Using other products such as alcohol, povidone-iodine (Betadine), or oil-based soap can interfere with the adhesion of the skin barrier and could promote skin breakdown.

pink

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.

Later, they can catheterize every

Later, they can catheterize every 4 hours while awake or more often if they sense fullness.

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

Yeast Infection

Causes:Leakage, perspiration, antibiotic therapy or broken skin description: itchy, bumpy, reddened skin. treatment- Keep the skin dry.

A nurse is teaching a patient how to apply an extended wear skin barrier. Which of the following strategies should the nurse instruct the patient to use for maximal adherence? Use an oil based lotion on the peristromal area Apply the skin barrier while the skin is slightly moise Leave the residue from the previous appliance on the skin Press gently around the barrier for 1 to 2 minutes

Press gently around the barrier for 1 to 2 minutes The pressure sensitive tackifiers and heat sensitive polymers of the skin barrier require adequate pressure and warmth (from the fingers) to ensure adherence.

While the nurse is teaching a patient how to replace her ostomy pouching system, the patient reports that removing the skin barrier is sometimes painful. Which of the following should the nurse suggest? Lift up on both sides of the skin barrier simultaneously. Release one corner of the barrier and pull it quickly over the stoma Push the skin away from the barrier while removing it Gently roll the barrier end over end across the stoma

Push the skin away from the barrier while removing it Pushing the skin away from the barrier helps prevent skin stripping, which can be painful and make the skin sensitive to adhesive. If the patient is having difficulty with the initial release of the barrier, it may help if she starts in one corner and gently pulls across the stoma while pushing the skin away from the barrier. Lifting the skin from both sides at once will pull directly on the dermis and possibly traumatize the skin. Rolling the skin barrier end over end will pull directly on the dermis and possibly traumatize the skin.

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).

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.

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.

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.

Emphasize the need to measure the stoma weekly over the first weeks following surgery to verify that the opening of the pouch is the correct size.

8

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.

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.

A nurse is replacing the ostomy appliance for a patient whose newly created colostomy is functioning. After removing the pouch, which of the following should the nurse do first? Measure the stroma Cover the stroma with gauze Remove the backing on the skin barrier Cleanse the stoma and the peristomal skin

Cleanse the stoma and the peristomal skin To facilitate the nurse's assessment of the stoma and the peristomal skin, the nurse must remove any effluent adhering to the area.

A nurse is obtaining a health history from a young adult patient who has a colostomy. The patient reports frequent episodes of loose stools over the last month, but has no signs of infection or bowel obstruction. He reports that his concerns about leakage have limited social activities. Which of the following should the nurse recommend? Consume foods that are low in fiber content Take an ounce of mineral oil twice a day Add buttermilk and cranberry juice to the diet Increase water intake to 3 to 3.5 L per day

Consume foods that are low in fiber content Foods low in fiber help thicken the stool; examples include rice, noodles, white bread, cream cheese, lean meats, fish, and poultry. Mineral oil produces laxative action by lubricating the stool and reducing water absorption from the stool. This will not relieve diarrhea. Buttermilk and cranberry juice can help control oder, but they do not relieve diarrhea.

A nurse is teaching a patient with a new ileostomy about incorporating preventive strategies at home. To prevent excoriation and breakdown of the peristomal skin, the nurse should instruct the patient to Apply hydrocortisone cream to the skin when changing the appliance Empty the pouch when it is no more than half full Wash the peristomal skin frequently with deodorizing soap and water Choose a time shortly after a meal for replacing the pouch

Empty the pouch when it is no more than half full Waiting until the pouch is more than half full increases the risk of leakage. Ileostomy effluent is irritating to peristomal skin, so patients should replace the pouch when it is one third to one half full. Patients should avoid the use of soap, especially oil or lotion based soaps. They leave a residue that can interfere with pouch adhesion and increase the risk of leakage. They should cleanse the skin and warm tap water. For times when soap is essential and if their provider allows it, they should only use a mild, pH balanced soap.

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.

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.

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

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.

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.

Loop colostomy

Usually performed in a medical emergency. Temporary large stomas constructed in the transverse colon. Surgeon pulls a loop of bowl onto the abdomen supported by a device such a a plastic rod, bridge, or rubber catheter temporarily placed under the bowel loop to keep it from slipping back. Two openings: proximal end drains stool, whereas the distal portion drains mucus. Within 7 to 10 days the surgeon removes the external supporting device

A patient who has bladder cancer tells the nurse that, of the various urinary diversion options the surgeon presented, she prefers one that will allow her to have some control over urinary elimination. The nurse should explain the option that will allow that is a Kock's pouch an ileal conduit a cutaneous ureterostomy a nephrostomy

a Kock's pouch This is a continent ileal bladder conduit that does not require an external drainage collection device because the patient self-catheterizes every 2 to 4 hours to remove urine. The device will control the patient desires. An ileal conduit is a passageway for urine to flow from the kidneys to the outside of the body. With this type of diversion, urine flows as it is produces, so the patient will not be able to control it. A cutaneous ureterostomy allows urine to flow from a ureteral opening to the outside of the body. Urine flows through the stoma as it is produces, so the patient will not be able to control it. A nephrostomy allows urine to flow from the kidney to the outside of the body. Urine flows through the stoma as it is produced, so the patient will not be able to control it.

A nurse is providing preoperative teaching for a patient who has colon cancer. The surgeon informed the patient that his entire large intestine and rectum will be removed. The nurse should explain the type of ostomy he will have is a cecostomy a loop colostomy an ileostomy a decending colostomy

an ileostomy After removing the entire large intestine and the rectum, the surgeon will create an ileostomy to divert feces from the small intestine to the abdominal surgace and into an ostomy pouch. A cecostomy is a surgical opening created in the cecum, the first section of the large intestine, with an opening to the abdominal wall for diversion of feces. This is not possible if the entire large intestine is removed. A loop colostomy involves a large and usually temporary stoma the surgeon creates by pulling a loop of intestine onto the abdominal wall and creating two openings in the loop. This is not possible if the entire large intestine is removed. A descending colostomy is created when the surgeon removes a portion of the descending colon and uses the remaining section to create a stoma on the outer surface of the abdomen. This is not possible if the entire large intestine is removed.

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

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.

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.

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.

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. .

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.

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

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.

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.