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NURS 522 > nurs 522 postoperative care of patient with fecal urinary diversion > Flashcards

nurs 522 postoperative care of patient with fecal urinary diversion Flashcards

1
Q

Ileal Conduit

A

RLQ
Due to invasive bladder cancer, neurogenic bladder, refractory interstitial cystitis
Proximal end of small bowel closed, distal end creates stoma, ureters inserted into sewn end of conduit

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2
Q

Sigmoid Conduit

A

LLQ
Pre-existing small bowel disease, damage to small bowel 2nd to pelvic radiation
Proximal end of small bowel closed, distal end creates stoma, ureters into tense muscular is of sigmoid conduit = antireflux
Stents from renal pelvis to 4” beyond stoma opening
Not a reservoir

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3
Q

Ileal / Sigmoid Conduit Management

A

Urine samples taken from stents

Clean w/ white vinegar daily

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4
Q

Vesicostomy

A

Above pubic bone
Due to spina bifida (myelomeningocele), Prune Belly Syndrome, bladder exstrophy
Temporary
Bladder sutured to ABD skin as flush stoma
Urethra may or may not be closed off
Use wicking diaper

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5
Q

Ureterostomy

A

Uncommon
At anatomic location of ureter: btwn last rib and iliac crest (posterior)
2nd to megaureter
R, L, B/L ureters sutured to skin surface
May become retracted or stenotic

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6
Q

Uretero-sigmoidostomy

A

No stoma
2nd to bladder exstrophy in newborns or bladder cancer
Ureters implanted into sigmoid colon
Urine mixes w/ feces, expelled via anus

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7
Q

Indiana Pouch (Cutaneous Continent Diversion)

A

RLQ
Bladder cancer, neurogenic bladder, colon cancer
ABD reservoir from distal ileum and ascending colon
Stoma w/ FLAP valve = 0 reflux
Urine stored in reservoir/emptied w/ catheter
600 - 1000 mL capacity

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8
Q

Kock Pouch

A 
RLQ
Bladder cancer, neurogenic bladder
ABD reservoir from distal ileum and ascending colon
Stoma w/ NIPPLE valve = 0 reflux
Continence mechanism 2nd nipple valve
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9
Q

Roy Adaptation Model

A

People as adaptive systems w/ biological and physical processes used to adjust
Level of adaptation affect’s ability to respond + or - to situation

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10
Q

Orem’s Self-Care Theory

A

Meeting self-care needs of pt while assisting to develop self-care behaviors
Wholly compensatory, Partly compensatory, Supportive Education System

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11
Q

PLISSIT Model

A 
Permission (Giving permission)
Limited Information (provide and understand limited info)
Specific Suggestions (beyond WOC scope)
Intensive Therapy (beyond WOC scope)
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12
Q

Indications for Urinary Diversion

A

Bladder removed or bypassed
Temp. if urologic procedures
Perm. if removal of bladder
Most common for transitional cell cancer of bladder
Less common for neurogenic bladder, prostate cancer, interstitial cystitis, radiation cystitis, exenteration 2nd to rectal or cervical cancer

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13
Q

Urine eliminated via: urethra

A

Orthotopic neobladder

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14
Q

Urine eliminated via: continent catheter stoma on skin

A

Indiana pouch
Mitrofanoff
Kock pouch

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15
Q

Urine eliminated via: incontinent stoma on skin

A

Ileal or colon conduit
Urostomies
Vesicostomy

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16
Q

Cystectomy

A

Removal of bladder

Radical cystectomy if lymph node dissection

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17
Q

Bladder Cancer

A

Transitional cell (urothelial) carcinoma #1
3:1 male to female ratio
Diagnosis by resection of tumor
Gross hematuria, urgency/freq/pain w/ urination

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18
Q

Bladder Cancer Management

A
  • grade/noninvasive: chemo

+ grade/recurrent/invasive: Radical cystectomy

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19
Q

Bladder Cancer Risks

A

Smoking, paint and dye chemicals, chronic indwelling cath

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20
Q

Radical Cystectomy

A

Males: Bladder, prostate, pelvic lymph removed
Female: Bladder, uterus, fallopian tubes, ovaries, and anterior vagina

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21
Q

Ileal Conduit

A

Incontinent
Proximal small intestine closed, ureters implanted, distal end to skin
Bladder CA, urinary fistula, neurogenic bladder, refractory cystitis, inability to manage continent reservoir
(+)Simple, - complications
(-)Prior radiation, obesity, renal deterioration, pouching system required

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22
Q

Colon Conduit

A

Incontinent
Colon closed, ureters implanted, distal end to skin
Bladder CA, urinary fistula, neurogenic bladder, refractory cystitis, inability to manage continent reservoir, small bowel disease, pelvic radiation
(+) - risk of stomal stenosis
(-) Renal deterioration, pouching system, large stoma

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23
Q

Orthotopic Neobladder

A

ContinentIleum used, ureters implanted, distal connected to urethra to allow voiding
Bladder CA, urinary fistula, neurogenic bladder, refractory cystitis
Cancer-free urethra/functional sphincter needed
(+) Improved cosmesis, 0 stoma, void via urethra
(-) Renal deterioration incomplete emptying, incontinence possible

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24
Q

Indiana Pouch

A

Continent
Ileocecal used, ureters implanted, ileocecal valve used for continence, Catheterization via ABD wall stoma
Bladder CA, urinary fistula, neurogenic bladder, refractory cystitis
(+) 0 pouch, small stoma
(-) Renal deterioration, pt capable of self-cath, inability to cath is emergency

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25
Neurogenic Bladder
Impairment of central and peripheral nervous system 2nd to stroke, MS, SCI, DM, post-surgical injury s/s: incontinence, retention, + pressure storage of urine Urinary diversion last resort
26
Radiation Cystitis
Radiation induced damage to bladder and sphincter s/s: incontinence, bleeding, pain w. bladder filling Ileal conduit
27
Interstitial Cystitis
s/s: pelvic/bladder pain, urgency, frequency, nocturia Ulcerations, petechial hemorrhages on xray If refractory: urinary diversion Pain not cured by surgery
28
Suprapubic catheter
Change Q4 weeks If strictures or failed reconstruction Some pt have urinary diversion to avoid indwelling cath
29
Pouchitis
``` Urine changes (odor, color, hematuria, mucous), pain, fever, malaise, difficult catheterizations tx: antibiotics, irrigation ```
30
Hyperchloremic metabolic acidosis w/ hypokalemia
2nd to prolonged urine contact w/ mucosa Na/Cl reabsorbed via bowel wall Bicarb/K lost
31
Prune Belly Syndrome
Absence, deficiency, hypoplasia of ABD musculature Co-existing disorders: hypotonic bladder and dilated ureters s/s: prune-like ABD skin tx: Prevent UTI, vesicostomy, ureterostomy, pyelostomy, continent urinary diversion
32
Mitrofanoff Continent Diversion
Allows bladder drainage if voiding/self-cath not possible 0 pouch or indwelling cath Creates channel into bladder for self-cath Made from appendix or small bowel, 1 end tunneled into bladder wall to create valve, other end passes into ABD wall for stoma RLQ For spina bifida, prune belly, exstrophy of bladder, neurogenic bladder
33
Myelomeningocele
Open neural tube defect, spina bifida s/s: depend on location, hydrocephalus, bladder/bowel dysfunction tx: bladder decompression w/ intermittent cath, vesicostomy, continent urinary diverson, anticholinergics
34
Neurogenic Bladder
At or below micturition center (S2-S4) SCI or myelomeningocele= flaccid or atonic bladder Pyelonephritis (kidney infections)
35
Neurogenic Bladder: Surgical Interventions
1. Ileal or sigmoid conduit w/o removal of bladder or urethra 2. Continent ABD reservoir (Indiana pouch, Mitrofanoff) If bladder not removed, annual cystoscopy due to production of mucus
36
Bladder Exstrophy
Bladder and urethra didn't close in utero = bladder mucosa open in lower ABD w/ anorectal/genital malformations, pelvic bone separation tx: closure of bladder, temp ureteral stents and suprapubic urinary drainage, reconstruction of abnormalities
37
Ureterosigmoidostomy
Ureters implanted into sigmoid colon 0 stomaUrine and stool mix and passed through anus Option if bladder exstrophy Complications: metabolic abnormalities, ureteral obstruction, pyelonephritis, colon/rectal cancer
38
Posterior Urethral Valves
Newborn males Folds of tissue obstruct urine flows/s: ABD mass, recurring UTI tx: Urinary tract decompression w. vesicostomy, ureterostomy, pyelostomy, resection or ablation of valves
39
Solid skin barrier
Protects from effluent Integrated into most pouching systems Apply gentle pressure to apply
40
Stoma paste
``` Fills in uneven areas Prevents effluent passing under seal Contains alcohol Use as caulk Touch with moist fingers only ```
41
Stoma powder
Absorbs moisture Provides surface to apply pouch Too much may cause seal failure Sprinkle liberally and brush off excess
42
Stoma ring
``` Enhances seal Provides soft convexity to flat system Improves seal 0 alcohol May be too high to allow effluent to flow into pouch ```
43
Stoma strip
Enhance seal as second barrier Small pieces may fill in uneven areas Requires manual dexterity Will not cause irritation
44
Elastic barrier strips
Enhance seal on outer edge of pouching system | May help if peristomal skin shifts (ex. hernia)
45
Stoma liquid
Protect skin from stripping Seals skin barrier to enhance seal May have alcohol Allow to dry prior to applying pouch
46
Temporary fecal diversions
Hartmann's pouch and loop ileostomy/colostomy | Allows bowel to heal
47
Hartmann's pouch
Resection of bowel, closure of fecal stump, end colostomy Done in emergency Stool/mucus per anus Temporary
48
Loop stoma
Loop of bowel through ABD wall w/ opening 4 stool | Mucous fistula to - chance of dehiscence
49
Colostomy irrigation
If left sided colostomy- pouch changes + flatulence Goal: stool-free, pt can wear stoma cap
50
Colostomy irrigation: indications/complications
Descending/sigmoid colon have - peristalsis, can hold stool longer, formed stool Non-return of fluid, vasovagal response, ABD cramping 0 use if stenosis, hernia, prolapse, Crohn's disease
51
Colostomy odor and flatus
Oral deodorizers = green/black stool | Buttermilk, parsley, cranberry juice, yogurt
52
Foods that cause gas
``` Asparagus Beans Beer Cabbage Carbonated drinks Hard boiled eggs Fish Melon Milk Onions Spicy foods ```
53
Ostomy and Constipation
Rare w/ ileostomy due to storage capacity Mild: + fluid/fiber/exercise Stool softeners if taking pain meds
54
Ostomy and Diarrhea
Causes: osmotic, mechanical, secretory, pharmacological + banana, cheese, applesauce, marshmallow, rice, pasta, tapioca
55
Ileostomy
Colon/rectum may be removed = - absorption = dehydration/obstruction +Na intake: broth, canned veg, tomato juice +K intake: Banana, potato, peppers, chicken, beef, spinach
56
Ileostomy Obstruction
Partial: distention, cramps/pain, stoma edema, watery oupout tx: warm bath, heating pad, lie on rt, massage, knee-chest Complete: -BM, N/V, stoma edematx: NPO, go to ED
57
Ileal lavage
If obstruction not resolved | Insert cath into stoma, instill 10-20 mL saline (repeat)
58
Ileostomy and medications
0 enteric-coated or sustained-release if + output or short bowel Suboptimal drug absorption
59
Ileal Conduit
= hyperchloremic metabolic acidosis/malabsorption Urinary calculi possible Crystals on skin = urinary alkalosis 0 specific diet: + fluids, unsweetened cranberry juice (unless on warfarin)
60
Ileal Conduit and Stents
Maintain patency Allow ureteral/conduit anastamosis to healIn place 7-10 days Not emergent if fall out
61
Assessment of Incision
Palpate for healing ridge, temp, oozing | Space btwn incision and stoma 4 pouching
62
Stoma measuring
Changes size 6-8 weeks post-surgery
63
Urostomy output
1500-2000/24 hrs
64
Acidic urine
Resists UTI | Dilute urine = acidic
65
Convexity
Moves downward around base of stoma Causes stoma to protrude May cause separation of mucocutaneous junction
66
Soft ABD muscle tone
Firm barrier
67
Firm ABD muscle tone
Soft/flexible barrier
68
Ostomy belt
Used only if stoma at belt line Pouching system needs belt tabs Binder may be used if stoma not at belt line
69
Partial Blockage Management
``` Grape juice Warm bath No solid foods Peristomal massage Roll back and forth Ileostomy lavage ER if full blockage ```
70
Ileostomy management
Monitor for dehydration Obstruction B12 supplements
71
Ileal Conduit
Keep urine dilute for acidity w/ cranberry juice | Hyperchloremic metabolic acidosis
72
Pouch-o-gram
Scheduled prior to takedown | Dye study to ensure suture lines healed

NURS 522 (3 decks)

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