1Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Chapter 26

The Patient with an Ostomy

2Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Learning Objectives

• List the indications for ostomy surgery to divert urine orfeces.

• Describe nursing interventions to prepare the patient forostomy surgery.

• Explain the types of procedures used for fecal diversion.• Assist in developing a nursing process to plan care for

the patient with each of the following types of fecaldiversion: ileostomy, continent ileostomy, ileoanal reservoir,and colostomy.

• Explain the types of procedures done for urinarydiversion.

• Assist in developing a nursing care plan for the patientwith each of the following types of urinary diversion: ureterostomy,ileal conduit, and continent internal reservoir.

• Discuss content to be included in teaching patients tolearn to live with ostomies.

3Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

The Ostomy Patient

• Ostomy• Surgical creation of artificial opening into a body

cavity

• Stoma• The site of the opening on the skin

• Ostomies in the digestive tract • Gastrostomy, jejunostomy, duodenostomy,

ileostomy, or colostomy

• Ostomies in the urinary tract • Ureterostomy, ileal or colonic conduit, cystostomy,

vesicostomy, and continent internal reservoir

4Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Indications and Preparation for Ostomy Surgery

• Temporary ostomy • May be indicated after surgery or trauma or when

there is severe inflammation or infection • Bypasses the affected portion of the bowel or

urinary tract, giving it time to heal

• Permanent ostomy • Necessitated by cancer of the bladder or colon or

severe inflammatory bowel disease

5Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Nursing Care of the Patient Having Ostomy Surgery

6Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Assessment

• Determine expectations, understanding of the procedure, information desired, and fears

• Health history: reason for the procedure • The medical history documents other acute

and chronic conditions that will require management before and after surgery

• Note drug therapy and allergies

7Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Interventions

• Anxiety• Help the patient identify his or her concerns

• Appearance, job, or family life disruptions

• Encourage patients to talk and use coping strategies that have been effective in the past

• Reduce anxiety before teaching

8Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Interventions

• Deficient Knowledge• Basic ostomy care should be taught before surgery • Patient’s responses and questions should guide you

as to how much detail is appropriate • Preoperative teaching usually requires repetition

and reinforcement after surgery• An important resource is a volunteer from the

American Cancer Society or the United Ostomy Association

9Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Fecal Diversion

• Ileostomy• An opening in the ileum• Necessary when entire colon must be bypassed or

removed • Require colon bypass: congenital defects, cancer,

inflammatory bowel disease, bowel trauma, and familial conditions such as multiple polyposis

10Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Fecal Diversion

• Ileostomy• Procedure

• A surgical incision is made in the abdomen• A loop or the end of the ileum is brought out through a

second abdominal incision • Edges of the loop or the end of the ileal segment are

everted and sutured to the abdominal skin to create a stoma

• Loops may be supported with a device, such as a rod or bridge, instead of being sutured to the skin

11Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Postoperative Nursing Care of the Patient with an Ileostomy

12Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Assessment

• Health history• Document significant symptoms such as pain,

anorexia, nausea, vomiting, weakness, thirst, and muscle cramps

• Determine what stressors the patient perceives, usual coping strategies, and sources of support

• Assess understanding of ileostomy care

13Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Assessment

• Physical examination• Observe patient’s general status

• Level of consciousness, orientation, posture, and expression

• Vital signs and weight; compare with preoperative findings • Skin color, warmth, and turgor • Inspect oral tissues for moisture • Observe respiratory effort, and auscultate breath sounds • Assess the abdomen for distention and bowel sounds • Inspect the stoma for color and bleeding• Inspect the base of the stoma for redness, skin breakdown,

and purulent drainage• Note the characteristics of draining fluid or fecal matter

14Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Interventions

• Risk for Deficient Fluid Volume • Administer intravenous fluids as ordered; carefully monitor

hydration status • Keep accurate intake and output records • Measure output from all sources, including urine, gastric

contents, and fecal drainage • Closely monitor serum electrolytes, and be alert for signs and

symptoms of imbalances• Changes in mental status (confusion, anxiety), changes in

neuromuscular status (twitching, trembling, weakness), poor tissue turgor, edema, and dry mucous membranes

15Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Interventions

• Impaired Skin Integrity• Check the pouch hourly at first to detect leakage • When pouch emptied or changed, prevent fecal

matter from contaminating the primary incision • Clean skin around the stoma gently but thoroughly• Maintain protective barrier to prevent skin

breakdown • A plastic pouch is used to collect fecal drainage• Remove the appliance for thorough cleansing of the

skin surrounding the stoma every 3 to 5 days

16Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Figure 26-1

17Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Interventions

• Disturbed Body Image• Assure patient that odor is normal when the pouch

is being changed or emptied, but that it can be controlled at other times

• Advise to delete and reintroduce various foods to find those that are most troublesome

• Rinsing with a vinegar solution neutralizes odors that cling to the pouch

• Odor-proof pouches and commercial pouch deodorizers are available

18Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Interventions

• Sexual Dysfunction and/or Ineffective Sexuality Patterns• Encourage patients to ask questions about how the

ostomy might affect sexual function or behavior• Practical suggestions may help resume sexual

activity• Pouch should be emptied and taped down before

intercourse • Covers available to conceal the appliance and its contents • The partner wearing the pouch should experiment with

positions that are most comfortable• Female patients should know that ostomy surgery does not

interfere with pregnancy or delivery

19Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Interventions

• Ineffective Therapeutic Regimen Management• After surgery, some teaching should be included

every time stoma care is done • At first, you may simply tell patient what is being done and

why • Then encourage patient to take over more and more of the

procedure • Have patient demonstrate and practice as much as

possible before discharge

20Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Continent (Pouch) Ileostomy

• Internal pouch created from loop of ileum for storing fecal matter

• Advantage: patient does not have continuous drainage and so does not have to wear a pouch

• Procedure• A loop of the ileum is sutured together and then opened • A portion of the distal end of the ileum is inverted within itself

to create a nipple valve • The valve prevents fluid leakage from the pouch

• The looped section then closed, leaving a pouch capable of expanding and storing fecal matter

• The distal end of the ileum is brought through the abdominal wall and sutured into place to create a stoma

21Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Figure 26-2

22Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Postoperative Nursing Care of the Patient with a Continent Ileostomy

23Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Assessment

• Essentially the same as that of the patient with an ileostomy

• Assess for continuous drainage because obstruction of the catheter may occur

• Absence of drainage or patient complaints of a feeling of fullness in the pouch suggest obstruction

• Drainage bloody at first, then brownish

24Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Interventions

• Risk for Injury• Patient given only intravenous fluids to allow the

bowel to heal and peristalsis to resume• For the first 2 weeks, the pouch is drained every 3

to 4 hours • Next 2 weeks: interval is every 5 hours • Eventually the patient will need to drain the pouch

only 2 to 4 times a day

25Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Interventions

• Deficient Knowledge• Draining the continent ileostomy

• Have the patient sit or lie down for the procedure• Gather lubricant, #28 catheter, drape, basin, irrigating

syringe, irrigating solution, gauze dressing• Lubricate catheter and insert it gently into the stoma• Resistance will be felt when the catheter reaches the

nipple valve (approximately 2 inches past the stoma)• Instruct patient to bear down, then roll the catheter

between your fingers and advance it into the pouch• When catheter in the pouch, gas and fecal matter begin to

drain • Drainage continues for approximately 10 minutes and

produces a total volume of 50 to 200 mL

26Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Interventions

• Draining the continent ileostomy• If the drainage is too thick, instill 30 mL of normal saline as

ordered; gently aspirate • Do not do this unless necessary because it may cause dislocation

of the nipple

• When drainage stops, quickly remove the catheter• Place gauze dressing over the stoma to absorb

secretions• Measure, describe, and discard the drainage• Show patient how to perform procedure as soon as

possible• Patient should wear a medical alert bracelet stating

he or she has a continent diversion that must be drained

27Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Ileoanal Reservoir

• Fecal matter is stored and then eliminated through the rectum

• Procedure• First stage

• Colon is removed and an internal pouch that is created from the ileum is attached to the anorectal canal

• Temporary ileostomy made to allow the reservoir to heal

• Second stage• Approximately 2 months later, barium radiographs are

taken to be sure that the reservoir is intact • If the reservoir does not leak, the ileostomy is closed

28Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Figure 26-3

29Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Ileoanal Reservoir

• Complications• Obstruction

• Scar tissue or strictures may cause obstruction • Signs and symptoms: abdominal distention, nausea and vomiting,

decreased bowel sounds, change in bowel pattern

• Peritonitis• If fecal matter leaks through the suture lines of the reservoir into

abdominal cavity, abscesses or peritonitis can develop • Signs and symptoms: increased pulse, respirations, and

temperature; rigid abdomen and abdominal pain; and elevated white blood cell count

• Inflammation• Manifested by bloody diarrhea, anorexia, and pain

30Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Postoperative Nursing Care of the Patient with an Ileoanal Reservoir

31Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Assessment

• Same as for the patient with an ileostomy • In addition, assess for rectal drainage and

condition of the perianal skin

32Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Interventions

• Risk for Impaired Skin Integrity • Skin around the ileostomy stoma and in the perianal

area needs special care • Until reservoir is well healed, liquid discharge may

be expelled without warning • Thorough, gentle cleansing and protective creams

help prevent skin breakdown

33Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Interventions

• Bowel Incontinence• Perineal pads to prevent soiling of clothing• Teach perineal muscle-strengthening exercises• Drugs prescribed to decrease the frequency of

stools and to make them less watery • Advise to avoid fatty foods at first

34Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Interventions

• Risk for Injury• Assess for signs and symptoms of bowel

obstruction, peritonitis, and inflammation• If obstruction occurs, give intravenous fluids and

nothing by mouth • Nasogastric tube inserted to decompress the bowel • If obstruction is caused by adhesions (scar tissue), surgery

may be necessary to release the restriction

35Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Colostomy

• Opening in the colon through which fecal matter is eliminated

• Procedure• Bringing a loop or an end of the intestine through

the abdominal wall and creating a stoma for the passage of fecal matter

• Location of the stoma depends on the portion of the intestine removed

• Classified by location in the colon: ascending, transverse, descending, and sigmoid colostomies

36Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Colostomy

• Temporary colostomy• Allows healing of the intestine after surgery or in

certain disease states

• Permanent colostomy • Removal of a large part of colon or the rectum

required

37Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Postoperative Nursing Care of the Patient with a Colostomy

38Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Interventions

• Ineffective Therapeutic Regimen Management• Irrigations

• No longer routinely recommended• Many patients have regular bowel movements without

irrigation • Unlikely to establish control if the patient has diarrhea

when under stress, has had radiotherapy, has a poor prognosis, or has a history of inflammatory bowel disease

• Complications: perforated bowel; fluid and electrolyte imbalances; cramping, nausea, and dizziness

• If irrigations are indicated, you or the ET may perform them initially while teaching patient or significant other

39Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Interventions

• Risk for Injury• Assess for indications of colostomy complications

• Prolapsed stoma • Obstruction

40Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Urinary Diversion: Cutaneous Ureterostomy

• One or both ureters are brought out through an opening in the abdomen or flank

• Often the two ureters are joined surgically so that only one stoma is needed

• Sometimes a stoma is created from each ureter

• Much smaller than an intestinal stoma• Urine drains from the stoma continuously

• Pouch needed to collect the urine and protect the skin

41Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Urinary Diversion: Cutaneous Ureterostomy

• Complications• Stenosis

• Narrowing of the opening that interferes with the flow of urine

• If the obstruction is not relieved, urine backs up in the kidney and may cause hydronephrosis

• Urinary tract infections

42Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Postoperative Nursing Care of the Patient with a Cutaneous

Ureterostomy

43Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Assessment

• Health history• Assess for flank or abdominal pain, fatigue, malaise,

and chills • Determine patient’s response to the ostomy,

knowledge of it, and readiness to learn • Determine the reason for ureterostomy as well as

pertinent past medical history, drug profile, and allergies

44Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Assessment

• Physical examination• Assess patient’s general state • Take vital signs and compare with preoperative

readings• Observe respiratory effort and auscultate breath

sounds. Assess the abdomen for distention and bowel sounds

• Inspect the stoma • Document amount, appearance, and odor of the

urine

45Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Interventions

• Impaired Skin Integrity• Apply an appliance to collect urine drainage• Use skin barrier around the stoma • Pouch is usually cleaned once or twice daily • Changed every 4 to 6 days or when it leaks

because frequent changes are irritating to the surrounding skin

46Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Figure 26-1

47Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Figure 26-6

48Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Interventions

• Risk for Infection• The stoma serves as a portal for pathogens to enter

the urinary tract, causing infection• Avoid introducing organisms to the area• Yeast infections can develop; characterized by a

skin rash surrounding the stoma • Treat with nystatin powder applied under the skin barrier

49Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Interventions

• Risk for Injury• If urine does not flow readily, suspect obstruction

and notify the registered nurse or the surgeon immediately

50Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Interventions

• Disturbed Body Image• Demonstrate acceptance of the patient and care for

the stoma in a matter-of-fact manner • Express understanding of patient’s feelings • Encourage normal grooming and dressing • Provide opportunities to ask questions or discuss

how the ostomy might affect sexual function or behavior

51Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Interventions

• Self-Care Deficit• Teaching plan should include

• Ostomy care• Pouches• Diet• Fluids• Activity• Sexuality• Complications• Resources

52Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Ileal Conduit

• Procedure• Urinary drainage system made from portion of small

intestine• A 6- to 8-inch segment of ileum is first removed • The remaining ends of the ileum are then

anastomosed (joined) to restore bowel function• The ureters are cut from the bladder and attached to

the ileal segment at an angle to prevent reflux • One end of the ileal segment is sutured closed. The

other end is brought through an abdominal incision and sutured to create a stoma for urine drainage

53Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Ileal Conduit

• Complications• Leakage of the anastomosed ureters and intestinal

segments• Ureteral obstruction• Separation of the stoma from surrounding skin • Wound infection• Necrosis of the stoma• Paralytic ileus • Crystal formation and calculi• Stoma retraction, prolapse, or hernia

54Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Postoperative Nursing Care of the Patient with an Ileal Conduit

• Basically same as for patient with an ileostomy• A few special points to make about the ileal conduit

• Patient will have a nasogastric tube attached to suction to prevent abdominal distention and stress on the resected portion of the ileum while it heals

• Allowed nothing by mouth and is given intravenous fluids until bowel sounds return

• Ureteral catheter or stent may be in place to drain urine• Attach the pouch to a collection device during the night

55Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Continent Internal Reservoirs

• Allows for the storage and controlled drainage of urine

• Ileum neobladder• Eliminates the need for a stoma • Internal urinary reservoir constructed using a

resected segment of the colon that is attached to the urethra

• Urine drains into the reservoir and is eliminated through the urethra

56Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Continent Internal Reservoirs

• Kock pouch • Constructed with a segment of ileum• Ureters implanted in one side of the ileum segment• Nipple valve is constructed from the other side and

attached to the skin, where a stoma is created • Valve prevents urine from flowing from the reservoir• Catheter drains reservoir at 4- to 6-hour intervals

57Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Continent Internal Reservoirs

• Indiana pouch • Similar to the Kock pouch except that it is made of a

portion of the terminal ileum and the ascending colon

• The reservoir is larger than that of the Kock pouch

58Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Postoperative Nursing Care of the Patient with a Kock or Indiana Pouch

• May have Penrose drain to remove fluid from operative site and clear tube in place for continuous urine drainage

• Irrigations may be ordered to remove clots and mucus • When the tube is removed, the pouch may be drained every

2 to 3 hours at first • Later, may need to drain the pouch only every 4 to 6 hours

during the day and once during the night • If pouch functions properly, the patient does not have to

wear an external appliance • Gauze dressing over stoma to absorb mucus drainage • Advise medical alert bracelet: identifies presence of a

continent device that needs intubation to drain

59Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Ureterosigmoidostomy and Ureteroileosigmoidostomy

• Ureterosigmoidostomy• The ureters are implanted into the sigmoid colon • Urine drains into the colon and is eliminated through

the rectum

• Ureteroileosigmoidostomy• A segment of the ileum is anastomosed to the sigmoid and

the ureters implanted into that part of the ileum

60Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Vesicostomy

• Vesicostomy or cystostomy • An opening into the urinary bladder • Some are drained continuously through a catheter,

others have a nipple valve and are drained at intervals

61Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.

Nephrostomy

• Diverts urine directly from the kidney through a tube that exits through the skin

• May be used as a temporary or permanent method of urinary diversion