Seminar 6 Flashcards
for RNs to insert a flexi-seal rectal device, the nurse first needs a
physician order
what is a colostomy
(transverse/descending are most common)
when the colon (large intestine) is brought through the abdominal wall
(ascending colostomy is rare)
when is a cecumstomy seen
it is rare, seen in spina bifida
what is a ileostomy
when the ileum is brought through the abdominal wall
what is a urostomy
it is for urine,
ileal conduit (15-20 cm segment of the ilueim is converted in a conduit and ureters are anastomosed to one end)
what are indications for a colostomy
emerg/temp
- bowel obstruction
-abd. trauma
- perforated diverticulum
Perm/temp
- obstructing colorectal cancer
what types of drainage can come from a colostomy
semi-liquid to pasty, semi formed or formed
what is a bowel resection
diseased/damaged section of the bowel is removed. Does not necessarily result in creation of an ostomy (may be possible to rejoin the bowel)= anastomosis!
What is hartmans procedure
distal portion of bowel left in place.
(may be reversed at a later time)
Stage 1: creation of ostomy
Stage 2: reversal of ostomy
healthy bowel tissue is stitched to abdomen (colostomy)
what is a loop ostomy
bowel is not completely cut through - a loop of bowel is brought to the skin
usually temporary
what is a loop ostomy with bridge, how long is bridge left in place?
- right after surgery the patient will have a bridge (or rod) to prevent the stoma from slipping back into the abdomen.
- the rod is removed after 3-7 days
what does the proximal opening on and loop stoma drain, what about the distal
proximal: drains stool
distal: drains mucous (called a mucous fistula)
what is a double barrel stoma?
Similar to a loop ostomy but the bowel has been cut into two sections. They can be close together or separated.
What should a health stoma look like
pink, or red, vascular, bleeds easily.
when is post-op necrosis most likely to occur for a new stoma
first 72 hours
how long will a stoma be swollen after surgery
4-6 weeks
what role does the nurse play in ensuring health peri-stomal skin
- protect the skin and stoma from trauma and effluent.
- choice of pouching systems and skin protection products.
when should the nurse empty a ostomy bag
1/3 full or full or gas to prevent leakage
how often is the ostomy pouching system changed
q3-5days
- depends on pouching system.
- either before breakfast or 1-2 hours after a meal (less active)
what does a diet look like for a person with a colostomy
most of intestine is intact so people do not need to make major changes,
- eat nutritious diet,
- continue to eat fiber
- avoid gas producing foods (broccoli, beans, cabbage, legumes)
- increase fluid intake!!!! (more bowel removed, more fluid you should consume)
indications for a ileostomy
temporary: protect distal anastomosis in post-op anterior resectino
permanent: UC or crohns
what type of drainage will a ileostomy produce
post-op: 1200-1800 ml/day bilious output
later it averages 800 mL / day
what is a common problem with ileostomy
dehydration
(watch I+O, and fluid/lytes balance)
what diet should patients with a ileostomy be taught to eat
low residue diet intially, than introduce insoluble fiber-containing food slowly
What can happen if a patient with a ileostomy consumes too much fiber
bowel obstruction
how much fluids should a person with a ileostomy consume a day
2-3 L/day, monitor lyte imbalance. (sodium and potassium) may need to increase intake
what are some considerations that the nurse can teach a patient with a ileostomy/ colostomy
- chew food well
- avoid straws
- avoid chewing gum
- use a pouch with a filter/charcoal or deodorizer (releases gas but no odor)
- ascending and transvere colostomies have strong odor (needs control)
- avoid foods that cause odor (fish, eggs, onions, garlic, cheese, fried foods, asparagus)
indications for a urostomy
cancer, neurogenic bladder, congential anomalies, strictures, trauma to bladder, chronic infections with decreased renal function
type of drainage from a urostomy
urine, mucous
what will urostomies have post surgery and for how long
stents, for 3-5 days. considered sterile as goes to kidneys
what should a urostomy look like
pink or red
what are patients at a increased risk for and why
UTI due to stasis in the urinary diversion
how often should a urostomy pouch be changed
2-7 days (when less active)
fitted 7-10 days after surgery for permanent appliance
regarding stoma height, what should be reported to the NSWOC nurse
if stoma is flush or recessed
what should the nurse do if they notice stoma is necrosis
report to NSWOC and surgeon, this is not normal!!! Stoma should be pink or red
what should the nurse do if they notice a stoma prolapse
-reduce swelling, use support garments, use a large pouch.
Ensure good circulation
What should be done if the nurse notices mucocutaneous separation
this is when the stoma becomes detaching from the incision site, report ot NSWOC and manage with wound care principles.
What causes irritant dermatitis of a peri-stoma skin
caused by leakage of stool or urine on the skin, consult NSWOC,
how do you prevent and manage irritant dermatitis of a stoma
change the pouch system before it leaks, clean and dry skin well.
Apply stomadhesive power on raw edges
what should the nurse recognize and do if the notice contact dermatitis/ allergy to a stoma
recognize this is caused by sensitivity to products being used, report to NSWOC nurse who will get different product. Than treat excoriated area to promote healing
What is folliculitis in regards to a stoma
inflammation of the hair follicle, presents as bumpy, red rash.
Usually due to a staph infection or due to shaving rather than clipping hair, or when removing ostomy appliance
what is a candida albican infection of a stoma
yeast infection, reddened, moist, tender area.
May have patchy white areas. Treat with antifungal medication such as a power or nystatin
What is stoma stenosis
narrowing of the stoma or intestinal lumen.
what can a stoma stenosis lead to
bowel obstruction
how are stenosis of a stoma treated
- minor stenosis can be treated with low residue diet and increased fluids.
- serious ones require surgery.
what should the nurse do if they notice a retracted stoma in a skin crease
- notify NSWOC
- may need to use stoma paste or barrier strip
- may need convex skin barrier or stoma belt
What is a hernia with stoma and what is the tmt plan
a loop of intestine protudes through abdominal wall.
- conservation treatment= support
- if blood supply is compromised= surgery
may need hernia belt to provide support
what is stomadhesive powder used for
keeps skin dry and adhered
what is stoma paste used for
used to fill gaps and creases
what are barrier strips and rings used for
to fill gaps
What is a stoma cap?
can only be used for people who have formed BM at specific times of the day (sigmoid colostomy)
- can be used when bathing, swimming, or during intimacy
how long does habituation of the bowel take after surgery
3-6 weeks
what is ostomy irrigation
goal is to train the bowel to empty at the same time every day
not all patients can manage irrigation, NSWOC will determine
how high will a high enema be placed above the anus
30-45 cm
how high will a regular enema be placed above the anus
30 cm
how high will a low enema be placed above the anus
7.5 cm
what is a cleansing enema
promoted complete evacuation of the rectum by stimulating peristalsis with large volume of fluid
how long should a hypertonic (saline sodium phosphate) FLEET enema be retained
5-10 min
how long should a hypotonic (tap water) enema be retained
15-20 minutes
how long should a isotonic (NS) enema be retained
15-20
this is the safest
how long should a soap sud (castile soap and tap water) enema be retained and how much solution is usually required
10-15 mins
with warm solution (500-1000mL)
What is carminative enema (glycerin, Mg and water) and how much solution is intilled
To stimulate peristalsis and expel flatus (60 - 80 mL solution instilled)
What is a oil retention enema
lubricates the rectum and colon, feces absorbs the oil and comes softer and easier to pass
what is a abx enema
reduces bacteria in the bowel (eg before surgery)
what is a antihelminitic enema
kills worms, parasites
what is a kayexalate enema
reduces dangerously high serum potassium levels
what is a return flow enema
(to expel flatus and relieve abdominal distension)
100-200mL fluid in/out of rectum/colon repeated 5-6 times
before giving an enema or supp, the nurse needs to do a
rectal exam
if there is not stool upon rectal exam
enema or supp will probably be unsuccessful in which nurse may decide to do top-down approach and give laxative or stool softner according to bowel protocol
How should patient be positioned when being giving a supp or enema
left side with right knee flexed
what should the nurse tell the patient to do while the nurse administers a admin
to breathe out slowly
if some abdominal cramping and distention normal when giving a enema
yes
what should be documented after enema insertion
amount, colour, consistency, flatus, abd distension, and problems
how long should the pt return enema fluid for cleansing and retention
cleaning : 5-10 mins
retention: up to 30 minutes
best results will be obtained when patient can hold supp for
up to 30 minutes
what is the action of laxative supp
- soften feces (glycerin)
- stimulates nerve endings in the rectal mucosa (bisacodyl)
- releases CO2 to distend rectum (sodium bicarb)
what is fecal impaction
fecal impaction is a common digestive disorder and considered an acute complication of chronic and untreated constipation
what is manual disimpaction
digital removla of fecal impaction involves breaking up fecal mass digitally and removing it in portions
what needs to be monitored during manual disimpaction and why
HR as the vagus nerve is stimulated in the rectum
what is the procedure of manual disimpaction
left side, lube, finger toward umbilicus, break up hard stool with scissor motion, than bent finger in circular motion, than pull out feces.
careful with elders= risk of syncopal
may need anesthesia for some pt
bowel protocol contrainindications
Ileostomy
Blood in stool or rectum
Absence of bowel sounds
Complete bowel obstruction.
Diarrhea.
If abdominal or rectal mass of unknown origin palpated
Impaction if present, clear impaction prior to initiating protocol
If in doubt, contact MD.
indications for bowel protocol
prevent opioid-induced constipation
manage constipation where dietary measures have failed or previous laxative treatment is unsatisfactory
how should the nurse determine what level to use when starting the bowel protocol
bowel pattern, time since LBM, bowel medication use prior to admission
non-pharmacological interventions to facilitate normal bowel routines
- regular toileting
- mobility
- increase fluids
- increase dietary fiber
what are the contraindications for using the IH bowel protocol
ileostomy, if blood is present, absence of bowel sounds, complete bowel obstruction, diarrhea, or rectal mass of unknown origin is palpated
what is the indication for a rectal tube
to divert and contain liquid stool
on the rectal tube, what port is for irrigation and which is for filling the balloon
white: ballon … blue: irrigate
criteria for insertion of a rectal tube
- All options for diarrhea have been considered
Fecal incontinence bag/appliance use has been attempted and unsuccessful. - 3 episodes of fecal incontinence of liquid stool in a 12 hour period, or presence of skin breakdown, or presence of surgical site or dressing.
- Liquid or semi-liquid stool is anticipated for a period longer than 36 hours
- Patient is not mobile
how should the nurse go about inflating the balloon of a rectal tube
with finger still in place, inflat balloon with 45 ml water
