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NUTR 468 Clinical > Ostomy Care > Flashcards

Ostomy Care Flashcards

1
Q

Indications for ostomy

A
  • Cancer - Colon & Rectal Cancers (most common)
  • Diverticulitis
  • Perforated bowel
  • Bowel obstruction
  • Crohn’s disease
  • Ulcerative colitis
  • Birth defects/Congenital Conditions
  • Accidental injury/Trauma
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2
Q

What is an Ostomy?

A

An ostomy is an artificial opening of the body, created by surgery
* In the case of most ostomies, this refers to the connection of a portion of bowel to the outside of the body (also called a stoma) for the purpose of waste excretion

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3
Q

What are the most common types of ostomies?

A
  • ileostomy
  • colostomy
  • Urostomy or Ileal Conduit
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4
Q

Ileostomy

A

connection of the small bowel to the exterior of the body
* To remove or bypass the entire colon and rectum, or to protect a distal colorectal, coloanal, or ileoanal anastomosis
* Can be constructed either as a diverting loop stoma or end stoma, with or without a continent reservoir

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5
Q

colostomy

A

connection of the large bowel to the exterior of the body
* To bypass or remove the distal colon, rectum, or anus and it is either inadvisable or not feasible to restore gastrointestinal continuity
* If the sphincter mechanisms are removed, the colostomy is permanent
* As with ileostomies, colostomies may be created in a loop or end fashion

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6
Q

Urostomy or Ileal Conduit

A

diversion of urine to the exterior of the body

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7
Q

What are small bowel surgeries?

A
  • Small bowel repair
  • Small bowel resection: duodenectomy, jejunectomy, ileectomy
  • Lysis of adhesion: adhesiolysis
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8
Q

what are colon surgeries?

A
  • right hemicolectomy: part of or all right side (ascending) colon is removed. The remaining colon is then reconnected to the SI
  • left hemicolectomy: part of or all left side (descending) colon is removed. The remaining colon is then reconnected to the rectum
  • sigmoid colectomy: part or all of the sigmoid colon is removed. the descending colon is then reattached to the rectum
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9
Q

What are rectal surgeries?

A
  • low anterior resection: The sigmoid colon and a portion of the rectum are removed, descending colon is reattached to the remaining rectum
  • abdominal perineal resection: part or all of the sigmoid colon and the entire rectum and anus are removed. A colostomy is then performed
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10
Q

Types of stomas

A
  • end stoma
  • loop stoma
  • double barrel stoma
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11
Q

Intestinal Sites of Nutrient Absorption

A
  • Ileum: absorption of vitamin B12 and bile acids
  • Colon: absorption of water and electrolytes (sodium, potassium)
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12
Q

Postoperative nutrition

A
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13
Q

What is reccomended in a low fibre diet?

A
  • Choose lower fibre foods
  • Avoid higher fibre foods
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14
Q

Soluble vs. insoluble fibre

A

Soluble Fibre
* Water soluble
* Thickens stool → good for high output ostomies
* Safe for new ostomies

Insoluble Fibre
* Water insoluble / stays in same form
* Bulks stool
* Increases risk of obstruction

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15
Q

Long term nutrition with ostomy

A
  • After 6-8 weeks most people can return to “normal” intake (a regular fibre diet, no restrictions)
  • Some people will find that some foods are more difficult for them to tolerate / may cause symptoms like gas/odor, bloating, looser output, etc.
  • still important to achieve adequate fluid intake to prevent dehydration
  • Bowel adaptation may or may not occur, and often takes several months
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16
Q

How does food tolerations change with ostomy?

A
  • They may or may not have the same food intolerances as before their ostomy
  • Encourage food journaling to determine what exact foods, amounts and types of preparation methods are triggering
  • It is common for people to continue to avoid very high insoluble fibre foods for risk or concern of obstruction
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17
Q

Indications for micronutrient supplementation with ileostomy

A
  • Vitamin B12 supplementation is indicated if > 60 cm of the ileum is resected
  • Fat soluble vitamin supplementation is indicated if > 100 cm of the ileum is resected and steatorrhea occurs
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18
Q

Indications for micronutrient supplementation with colostomy

A

No specific recommendations if functioning well

19
Q

Indications for micronutrient supplementation with hight output ostomy

A

Electrolyte replacement, Magnesium, Zinc & Selenium due to large losses

20
Q

Micronutrient reccomendation for all ostomy patients

A

Can be helpful for all ostomy patients to take a chewable or liquid multivitamin daily at minimum during the healing period, or longer based on their overall nutrition status and intake
* NEVER recommend gummy multivitamins

21
Q

Managing gas, bloating and smell

A

All these things are normal and okay
* There are no specific foods that cause gas/bloating and/or odor for everyone; these things are highly individualized
* Recommending people avoid foods initially can be harmful by needlessly limiting their options
* Try food journaling if noticing increased gas/bloating or smell with certain foods before eliminating any

22
Q

What things do impact gas, bloating and smell?

A
  • Eating quickly
  • Chewing gum
  • Drinking with a straw or from a bottle
  • Carbonated beverages
23
Q

How is ostomy output determined?

A

The type and volume of output is determined by the location of the stoma relative to the ileocecal valve

24
Q

Output with ileostomy & ascending colostomy

A
  • Output is more liquid consistency due to reduced water absorption
  • Ostomy requires emptying several times per day
  • Output contains some degree of digestive enzymes that can be irritating to the skin/mucosa
25
Q

Output with descending & sigmoid colostomy

A
  • Output is more formed (stool)
  • Output amount varies → may empty ostomy bag several times or not at all in a day
  • Output does not contain digestive enzymes
26
Q

Expected ostomy output over 24 hrs for ileostomy

A

1200 mL (mature 600-800 mL)
* contains significant amounts of Na and K
* Increased risk of dehydration, especially during episodes of increased output

27
Q

Expected ostomy output over 24 hrs for colostomy

A

200-600 mL
* Can go a day or so without any output (constipation possible)

28
Q

What is high output defined as?

A

> 1000-1500 mL
* most common in ileostomies, shortly after surgery (~1200 mL expected)
* can become a complication if persists long term

29
Q

What contributes to loose outputs?

A
  • Spicy foods: least amount of evidence to support
  • Caffeine: reduces intestinal transit time + diuretic effect
  • Very high fat foods: when missing part of the ileum, increased risk of steatorrhea
  • Very high sugar foods: draws water into the bowel
  • Alcohol: can have laxative effect + diuretic effects
  • Sugar alcohols: draws water into the bowel
30
Q

Signs of dehydration

A
  • dry mouth
  • dry skin
  • headaches
  • thirst
  • dizziness
  • muscle cramping
  • nausea
  • low blood pressure
  • low or dark urine output
31
Q

What is critically high ostomy output?

A

> 2000 mL daily
* Require hospitalization for IV hydration until output improves or a long- term outpatient IV therapy plan can be established

32
Q

What populations are at risk for high ostomy output?

A
  • Extensive surgical resection (< 200 cm residual bowel, short bowel syndrome)
  • More proximal location of the stoma (higher in the GI tract, ex ileostomy)
  • Intra-abdominal sepsis or infection enteritis
  • Partial or intermittent bowel obstruction
  • Recurrent disease in the remaining bowel (ex Crohn’s)
  • Sudden discontinuation of medications (ex steroids, opioids → constipating)
  • Use of prokinetic medications (ex metoclopramide → stimulate gut movement)
  • Bacterial overgrowth or enteric pathogens
33
Q

Nutrition for high output ostomy

A
34
Q

Fibre for high ostomy output

A
  • Soluble fiber can thicken output → it does not decrease stool volume or enhance absorption
  • Dietary sources: oatmeal, barley, lentils, psyllium (Metamucil), applesauce, smooth peanut butter, fruits and vegetables with the skin/peel removed
  • Fiber bulking agents may be effective. Can often make patients feel full = difficulty meeting nutritional needs
35
Q

Oral rehydration solutions

A

Oral rehydration solutions are Isotonic
* Promote absorption of water by being similar in solute concentration to the bowel
* Fluid with modest amounts of sugar and salts (Na, K) to promote hydration
* Does not decrease stool volume

36
Q

What do hypertonic fluids do?

A

pull water into small bowel to dilute higher osmolarity fluids = increasing stool volume
* Milk, popsicles, fruit juice, soda, broth, ONS

37
Q

What do hypotonic fluids do?

A

fluids pull sodium into the small bowel to increase osmolarity of the fluid = increasing stool volume
* Na never travels alone, always brings water along
* Water, tea, coffee, sugar free drinks

38
Q

Recipes for oral rehydration solutions

A

Limit regular fluids to < 500 mL daily

Sports drinks are NOT isotonic + need adjustments to be considered ORS
* Regular Gatorade is hypertonic: 1 1⁄2 cups Gatorade + 2 1⁄2 cups water + 1⁄2 tsp salt
* G2 is hypotonic: 4 cups G2 + 1⁄2 tsp salt

Juice recipe example
* 3⁄4 cup 100% juice + 3 1⁄4 cup water + 1⁄2 - 3⁄4 tsp salt

Soup recipe example
* 4 cups water + 1 dry bouillon cube + 1⁄4 tsp salt + 2 tbsp sugar

39
Q

Drugs?

A
  • Anti-diarrheals: loperamide, Lomotil, codeine
  • Fibre supplements (Metamucil): not effective without a colon
  • Cholestyramine: for bile acid induced high output ostomy (following terminal ileum resection)
  • Anti-secretory: pantoprazole, omeprazole, ranitidine, octreotide (somatostatin)
40
Q

What should be monitored daily in thr hospital for hydration status?

A

Monitor electrolytes (Na, Cl, K), Mg, Phos, Creatinine, Urea daily
* Avoid enteral electrolyte replacement to prevent worsening outputs

41
Q

When is PN used?

A
  • Preferred method if unable to achieve adequate PO intake
  • Often require increased fluid and electrolyte provision (Na, Cl, K, etc.) due to increased losses
42
Q

When is EN used?

A
  • Okay to use polymeric and fibre containing formulas
  • Osmolarity can be an issue
  • Formulas are often hyperosmolar
  • Isotonic: Isosource Fibre 1.0 HP, Peptamen w/ Prebiotics
  • Close to isotonic: Isosource 1.0 HP, Peptamen Intense
  • In high output, may need ORS via tube → exchange water flushes for “ORS” flushes
43
Q

Nutrition with ostomy reversal

A

Following an ostomy reversal, there are no specific dietary restrictions
* A patient’s bowel habits will be heavily impacted by the amount and health of bowel added back after the reversal
* Patients who maintain limited colon length following an ostomy reversal may experience looser bowel movements and/or chronic diarrhea postop (reccommendations to follow high output ostomy diet)

NUTR 468 Clinical (34 decks)

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