ATI Module Ostomy Care

What are the 2 important functions of skin barriers when it comes to ostomys?

It protects the skin from stoma output, and it attaches the pouch to the body.

What is An alternative to the standard ileostomy?

Kock's continent ileostomy

lengthening of a stoma due to the bowel telescoping out through the stoma

stomal prolapse

forceful exhalation against a closed glottis, which involves contraction of the abdominal muscles to propel feces out of the body

valsalva maneuver

What is 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.

How should I 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.

Describe 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.

what are common manifestations of ileostomy food blockage?

abdominal cramping, nausea, vomiting, swelling of the stoma, and no ileostomy output for at least 6 hours

What can be done 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.

stripping of superficial skin surface

denudation

What should patients do when an ileostomy food blockage occurs?

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.

What should patients understand about catheters in urostomy management?

1) 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. 2) 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.

To prevent dehydration and blockage, about _____________________ of water per day is typically recommended because fluid loss from an ileostomy may be as high as ______________________ per day.

10 to 12 glasses 1,000 to 2,000 mL

What strategies should I 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.

Describe two-piece systems

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.

Where may a colostomy be placed?

Ascending colon (right abdomen) Transverse colon (mid-abdomen) Descending colon (left upper abdomen)

What is an important difference between colostomy's and ileostomy's?

Because the ileum contains digestive enzymes and acids that cause skin irritation, extra care is required to keep waste materials from contacting the abdominal surface. Initially, stool output may be as high as 1,000 to 2,000 mL per day, putting some patients at risk for dehydration.

What are the different types of ostomy pouching systems?

Closed end pouches drainable pouches one-piece systems two-piece systems

Describe closed end pouches

Closed-end pouches are designed for one-time use and may meet the needs of a patient who irrigates. 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. When the pouch is full, it is removed from the skin barrier and discarded in an appropriate receptacle.

When should I 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

What 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.

What are the 3 different colostomy types that can be formed from the gastrointestinal tract?

End colostomy Loop colostomy Double barrel colostomy

What basic teaching should be provided for patients with an ileostomy?

Gradually, most patients can resume a regular, balanced diet. It is essential for patients to chew their food thoroughly to help it pass through the narrow ileum. They may need to avoid high-fiber foods for the first 6 to 8 weeks after surgery to avoid blockage. Review those foods as well as those that cause intestinal gas with these patients. Advise them to take enteric-coated pills or tablets with caution and to observe for undissolved medication in the ileostomy pouch.

describe one-piece systems

One-piece systems with an attached skin barrier are available. They are available in cut-to-fit and pre-cut types.

What factors should I 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.

describe the output of a Descending colon (left upper abdomen) colostomy

The output is semi-formed because more water is absorbed while fecal material is in the ascending and transverse colon.

describe the output of an Ascending colon (right abdomen) colostomy

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

What is the stoma?

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

What basic teaching should be provided for patients with an urostomy?

There are no dietary restrictions after the placement of a urostomy; however, some foods can cause odor To avoid infection and to maintain urinary function, patients should consume plenty of fluid each day (unless fluid is restricted). Keep in mind that pouches constructed from bowel, such as an ileal conduit, can increase the risk of electrolyte imbalance with the potential for metabolic acidosis.

describe the output of a Sigmoid colon (left lower abdomen) colostomy

This 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.

describe the output of a Transverse colon (mid-abdomen) colostomy

This location is used for a temporary ostomy, with the stoma constructed as a loop. Output is liquid to semi-formed.

When is Kock's continent ileostomy sometimes used?

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.

What color should a stoma be?

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.

Describe 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

What is an ileostomy?

a surgical opening created in the ileum to bypass the entire large intestine. A procedure used to treat colon cancer and ulcerative colitis, total proctocolectomy, involves surgical removal of the entire colon, rectum, and anus, with closure of the anus, resulting in the need for stool diversion. As part of the total proctocolectomy procedure, the end of the terminal ileum is brought out through the abdominal wall, forming a permanent ileostomy

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.

inflammation of the skin resulting from contact with an allergen

allergic contact dermatitis

formation of a connection between two usually distinct structures or portions of a structure

anastomosis

Over time, fluid loss due to an ileostomy should decrease as what happens??

as the ileum adapts to take over some functions of the large intestine, including water and sodium absorption

how should a skin barrier or ostomy pouch fit?

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.

surgical creation of an opening from the beginning of the large intestine to the abdominal wall

cecostomy

ability of the skin barrier to maintain its integrity when exposed to moisture

cohesion

surgically created opening (stoma) from the colon (large intestine) to the abdominal wall to allow stool to pass out of the body

colostomy

What are the 3 primary types of ostomy surgery?

colostomy ileostomy urostomy

describe 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.

passageway

conduit

What are some indications for ostomy surgery?

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

What are the different types of skin barriers?

cut-to-fit, pre-cut, and moldable.

excision or resection of the bladder

cystectomy

rim used for attachment to another object, such as an ostomy pouch attaching to a skin barrier

flange

Patients with an ileostomy are at higher risk for what? Why?

fluid and electrolyte imbalances due to shorter transit time through the bowel, decreased absorption of fluid and nutrients, and a higher volume of effluent.

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

Describe moldable skin barriers

have a pliable stoma opening that can be molded to provide a snug fit around the stoma.

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

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

The stoma of an ileostomy is typically located where?

in the right lower quadrant

inflammation of the skin resulting from contact with an irritating substance

irritant dermatitis

How is an indiana continent reservoir formed?

it 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.

internal pouch created from the distal segment of the ileum to serve as a reservoir for stool or urine

kock pouch

softening or dissolution of tissue after lengthy exposure to fluid

maceration

separation of the stoma from the peristomal skin

mucocutneous separation, also called mucocutaneous detachment

What are risk factors that predispose patients to peristomal skin complications?

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.

What is a uretoerostomy?

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.

pulling in of the skin around a stoma when the stoma is drawn inward below skin level

peristomal retraction

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 should a stoma look like?

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.

referring to the portion of the large intestine between the descending colon and the rectum

sigmoid

mechanical disruption of the epidermis, as can be caused by adhesives when an ostomy appliance is removed

skin stripping

degree of protrusion of a stoma from the skin

stomal height

pulling back of a stoma below skin level

stomal retraction

narrowing of the lumen of the stoma

stomal stenosis

device on a urostomy pouch that permits drainage of the contents

tap

Ostomy's may be ________________ or ________________.

temporary or permanent

Describe an end colostomy

the damaged section of the bowel is removed and the working end is brought through the abdomen to the skin surface. When a colostomy is intended to be permanent, an end stoma is typically created. A temporary colostomy may be performed to allow bowel rest or healing, such as following tumor resection. 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

How do bowel movements work after an ileostomy is placed?

the patient has no voluntary control of bowel movements

A continent internal ileal reservoir or continent ileal bladder conduit (Kock's pouch) is formed how?

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.

What should we 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. A healthy stoma appears pink 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.

As a nurse, what is important to know 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

Describe 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

describe cut-to-fit skin barriers

typically used for the first 6 to 8 weeks following surgery, a time period when the stoma changes in size and shape. 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. 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.

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

faceplate or barrier designed to protect the peristomal skin from the stoma output and to which the pouch is attached

wafer