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Timby/Smith: IntroductoryMedical-Surgical Nursing, 10/e

Chapter 48: Caring for Clients withOstomies

Ileostomy

•Ostomy

–Opening between internal body structure andskin

–Types: Ileostomy—distal small intestine;Colostomy—colon

–Stoma: Opening—exterior abdominal surface

–Causes: Inflammatory bowel disorder; Ruptureof intestine; Irreversible obstruction;Compromised blood supply to intestine;Cancerous tumor

Question

Is the following statement true or false?

A colostomy is a surgically-created opening betweenthe small intestine and the skin.

Answer

False.

A colostomy is a surgically-created opening betweenthe colon and the skin. An ileostomy is asurgically-created opening between the smallintestine and the skin. An ostomy is an openingbetween internal body structure and skin.

Ileostomy

•Conventional: Removal—colon and rectum

•Matured stoma: Process;healing; Smoothperistomal area

•Fecal material: Liquid;Digestive enzymes

•Appliance; Ostomate

•Karaya gum: Protectsskin; Promotes adhesion

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The Ostomy Appliance

•Disposable

•Temporary:Immediate postopphase

•Reusable equipment

•Disposableequipment: Replacedaily with bathing

Figure 48-2The ostomy appliance

Ileostomy: Preoperative Period

•Surgical Management

–Interventions by physician

•Surgery: Purpose; Benefits; Risks

•Stoma: Appearance; Function; Mark site

–Enterostomal therapists; Enterostomal therapynurses

–Wound, Ostomy, and Continent Nurses(WOCNs): Collaborate with surgeon and client’seducational needs

–Identify risks from total colectomy: Bladder andsexual dysfunction

Ileostomy: Preoperative Period

•Surgical Management (Cont’d)

–Sexual dysfunction: Collect and store sperm;Slightly diminished fertility in women

–Cleansing of bowel: Dietary restrictions—combination with laxative or lavage agents;Antibiotic prophylaxis; IV antibiotics

–Taper and discontinue prednisone: Avoidnegative effects on tissue healing

–Preoperative “stress dose” of IV steroid: Preventadrenal crisis

Ileostomy: Preoperative Period

•Surgical Management (Cont’d)

–Discontinue immunosuppressive agents

•Prevent negative effects on tissue healing

•Discontinue

•Aspirin-containing compounds to minimizerisk of bleeding

•Obtain

•Blood samples, type, and cross-match forreplacement of losses

Question

Is the following statement true or false?

Discontinuing the use of aspirin before surgerydecreases the likelihood of excessive bleeding.

Answer

True.

Discontinuing the use of aspirin before surgerydecreases the likelihood of excessive bleeding asaspirin side effects include anticoagulant properties.

Nursing Process: PreoperativeIleostomy Care

•Assessment

•Diagnosis

•Planning

•Implementation

•Evaluation of Expected Outcomes

Ileostomy: Postoperative Period

•Surgical Management

–Rectal pack: Absorbs drainage; Promotesgradual healing; 5 to 7 days

–Irrigations: Promote healing; Nasogastric tube—gastrointestinal decompression

–IV fluids: Maintain fluid, electrolyte, andnutritional balances

–Antibiotic therapy; Analgesics

–Monitor: Wound healing

–Manage complications: Intestinal obstruction;Serious complication

Ileostomy: Postoperative Period

•Surgical Management (Cont’d)

–Stoma: Bleeding; Impaired blood supply;Stenosis; Prolapse; Excessive protrusion

–Prolapse or protrusion of ileostomy

–Edema: Obstruction; Restricts stomal bloodsupply

–Stomal necrosis: If prolapse not managedpromptly and skillfully

Nursing Process: The Client RecoveringFrom Ileostomy Surgery

•Assessment

•Diagnosis

•Planning

•Implementation

•Evaluation of Expected Outcomes

Continent Ileostomy (Kock Pouch)

•An internal reservoir for the storage of GIeffluent

•Surgical Management

–Reservoir is formed with a portion of terminalileum; nipple valve

–Temporary catheter insertion

–Perineal area pack: Remains for 1 week

Question

Is the following statement true or false?

A Kock pouch is used to facilitate a continenturostomy.

Answer

False.

A Kock pouch is used to facilitate a continentileostomy.

Continent Ileostomy (Kock Pouch)

•Nursing Management

–Reinforce perineal packing; Check abdominaldressing—drainage; Connect stomal catheter tolow, intermittent suction; Check ileal catheter—obstruction

–Note drainage: Color, amount; Observe stomasize and color

–Administer irrigations of ileal catheter-salinesolution: Routine; As-needed

–Keep skin clean around stoma; Change gauzedressing; Monitor ileal output

–Empty reservoir; Teaching plan

Ileoanal Reservoir

•Ileoanal Anastomosis

–Maintain bowelcontinence

–Clients: Ulcerativecolitis; Disease doesnot affect anorectalsphincter

–Preserves innervationof male genitalia

–Bladder and erectiledysfunction unlikely

–Infertility

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Ileoanal Reservoir

•Surgical Management

–First stage

•Temporary ileostomy; Continuous dischargeof mucus from anus

•Frequent discharge of fecal material fromileostomy; Uncontrollable watery discharge

–Second stage

•2 to 3 months later; Closes temporaryileostomy; Reunites two sections of ileum;Anastomosis

•Fecal material is expelled; Control; Strongeranal sphincter

Ileoanal Reservoir

•Nursing Management

–Assessment

•Preoperative: Same as ileostomy

•Postoperative—first stage: Observations; Analarea for drainage; Drain or drainage tube inpresacral area

•Postoperative—second stage: Drainage—analarea and operative sites

•Instruct: Perform perineal exercises—bowelincontinence; Keep perianal area clean

Ileoanal Reservoir

•Nursing Management

–Assessment (Cont’d)

•Postoperative

•After first-stage ileoanal surgery: Teachclient to use a squirt bottle

•After second-stage repair: Instruct theclient to cleanse anus with warm, soapywater

•Emphasize to dry the area well

Colostomy

•Opening: Large bowel

•Indications: Cancerous lesion; Ulcerativeinflammatory process; Multiple polyposis; Injury tobowel

•Types

–Temporary, permanent: Ascending;Transverse; Descending; Sigmoid

Question

Is the following statement true or false?

A colostomy can be either temporary or permanent.

Answer

True.

A colostomy can be either temporary or permanent.It is also referred to by its placement.

Colostomy

Various colostomies

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Colostomy

•Types

–Regular irrigations: Controls sigmoid anddescending colostomy

–Appearance: Single-barrel; Double-barrel; Loop

•Surgical Management

–Single-barrel: Single stoma; Segmentalresection; Abdominoperineal resection—tumorsin lower third of sigmoid

–Double-barrel: Stoma—proximal and distal;Duplicate medical record diagram—nursing careplan to assess bowel function and irrigationsrequired

Colostomy

•Surgical Management

–Temporary; Treats disorder—acute diverticulitis;Chronic constipation

–Inflammatory bowel disease

–Interval before reestablishing: 16 months orlonger

–Loop colostomy

•Loop of bowel: Lifted; Supported—glass rodor plastic butterfly device

•Opening of intestinal loop and bowel: Lackspain receptors

Colostomy

•Surgical Management

–Loop colostomy

•Protect bed and client’s clothing when loopcolostomy is opened

•Prepare client for pungent odor of fecalmaterial; Temporary ostomy pouch—receivesflow of liquid feces

•Nursing Management

–Preoperative: Same as ileostomy

–Anxiety related to cause for ileostomy orcolostomy (cancer)

Nursing Process: Postoperatively

•Assessment

•Diagnosis

•Planning

•Implementation

•Evaluation of Expected Outcomes

End of Presentation