Seminar #6: Ostomy/Rectal Meds/Enema Flashcards
1
Q
What are the types of ostomies?
A
- colostomy (LI brought thru abdo wall; ascending rare, transverse/descending more common)
- cecumstomy
- ileostomy (ileum brought through abdo wall)
- urostomy (for urine; ileal conduit - 15-20cm segment of ileum converted into conduit & ureters anastomosed to one end)
2
Q
Colostomy - indications
emergency / temporary / permanent?
A
emergency/temporary:
- bowel obstruction
- abdominal trauma
- perforated diverticulum
permanent/temporary:
- obstructing colorectal cancer
3
Q
What types of drainage are there with a colostomy?
A
- semi-liquid to pasty
- semi-formed or formed stools
4
Q
Bowel Surgery: Bowerl Resection
A
diseased/damaged seciton of bowel removed
- doesn’t necessarily result in creation of an ostomy (may be possible to rejoin bowel) –> anastomosis
5
Q
What is an end ostomy?
A
- single stoma to drain fecal matter
- can be in small/large intestine
6
Q
What is a Hartman’s procedure?
Types of Ostomy Surgeries
A
- distal portion of bowel left in place
- may be reversed at a later time
stage 1: creation of ostomy
stage 2: reversal of ostomy
7
Q
What is a loop ostomy?
A
bowel not completely cut through - a loop of bowel brought to the skin
- usually temporary
8
Q
what is a loop ostomy with bridge?
A
- right after surgery, pt will have bridge/rod to prevent stoma from slipping back into abdomen
- rod usually removed after 3-7 days
9
Q
what is a loop colostomy?
A
- mature loop ostomy
- bridge removed
- 2 openings
- proximal drains stool, distal drains mucous (mucous fistula)
10
Q
What is a double-barrel stoma?
A
- similar to loop ostomy, but bowel has been cut into 2 sections
11
Q
Colostomy: Assessment of Stoma
A
- should be pink/red; vascular, bleeds easily
- first 72h post-op necrosis most likely to occur
- incr swelling 4-6 weeks after surgery
12
Q
Colostomy: Assessment of peri-stomal skin
A
- protecting skin + stoma from trauma & effluent
- choice of pouching systems + skin protection products
13
Q
Colostomy: Nursing Care
A
- empty when 1/3 full or full of gas to prevent leaking
- changing pouching system q3-5 days
- depends on stools/pouching system used
- either before breakfast or 1-2h after meal (when bowel less active)
- may establish bowel control with irrigation
- provide pt teaching on self-care
- assist pt to adapt psychologically to altered body + body image
14
Q
Diet for Colostomy
A
most of intestine remains intake
- don’t need to make major changes to diet
- continue to eat a nutritious diet
- continue to include fibre in diet
- avoid gas producing foods if it’s a problem, e.g., broccoli, cabbage, beans, legumes
hydration:
- incr fluid intake –> the more the bowel is removed, the more fluid patient should intake
15
Q
ileostomy: indications
A
- temporary, e.g., to protect distal anastomosis in post-op low anterior resection
- permanent: UC + Crohn’s disease
- types of drainage:
- post-op: 1200-1800 ml/day bilious output
- later it averages 800 ml/day
16
Q
Ileostomy: Assessment
A
- I/O
- fluid/electrolyte balance
- dehydration = common problem
17
Q
Ileostomy: Assessment of Stoma
A
- should be pink/red; vascular, bleeds easily
- first 72h post-op necrosis most likely to occur
- incr swelling 4-6 weeks after surgery
18
Q
Ileostomy: assessment of peri-stomal skin
A
- protecting skin + stoma from trauma
- stool from ileostomy extremely irritating to skin (if leaking = change daily)
- choice of pouching system + skin protection products
19
Q
Ileostomy Nursing Care
A
- same as colostomy
- detailed I/O to assess for dehydration
- pt teaching abt diet + fluid intake
- pt teaching on care of skin + appliance changes
20
Q
Ileostomy: Diet considerations
A
- low residue diet initially - limit high fat dairy and meats, raw veggies, corn, things w/ lots of seeds, popcorn
- insoluble fibre-containing foods introduced slowly (too much –> bowel obstruction). avoid celery, bran
- gas prod foods: peas, beans, legumes, veggies in cabbage family, eggs, beer, carbonated drink
goal = return to normal nutritious diet
hydration:
- incr fluid intake to replace lost fluids (2-3L/day)
- monitor electrolytes imbalances (sodium + potassium).
- may need to incr intake of high K+ & Na+ foods –> consult MRP/dietician
21
Q
Considerations for people with colostomy/ileostomy
A
- chew food well
- avoid drinking straws
- avoid chewing gum
- use pouch with filter/charcoal or deodorizer (releases gas from bag, but not the odor)
- ascending + transverse colostomies have strong odor requiring control
- ileostomies have less odor bc fewer bacteria present
- avoid foods that cause odors: fish, eggs, onions, garlic, asparagus, cheese, fried foods
22
Q
urostomy: indications
A
- bladder cancer
- neurogenic bladder
- congenital anomalies
- strictures
- trauma to bladder
- chronic infections w/ decreased renal function
22
Q
what type of drainage does ursotomy have?
A
urine, mucous
23
Q
what are the types of urostomy?
A
most common = ileal conduit, where one end of segment of ileum is attached to the ureters and the other end is used to make the stoma
24
What are the different urinary diversion surgeries?
- urostomy (ileal conduit) --> after surgery, pts will have stents for 5-7 days. are considered sterile as they go up into the ureters
- cutaneous ureters
- nephrostomy
25
Urostomy nursing care: assessment of stoma + peri-stomal skin
stoma: red, pink
peri-stomal skin: requires meticulous care due to irritating urine
26
Urostomy care: fluids
- I/O measurement
- incr fluid intake to keep urine dilute and minimize formation of kidney stones
27
urostomy: how to minimize odor
- empty frequently, change pouch every few days
- cleanse night drainage bag with soap and water, then vinegar/water, and hang dry
28
Urostomy nursing care
- frequent emptying of pouch to prevent leaking
- changing pouching system q2-7 days when less active, fitted 7-10 days after surgery for permanent appliance
- providing pt education on self-care
- incr risk of UTI d/t stasis in urinary diversion
- no diet consideration required
- documentation
29
Post-op approach for new ostomy pts
- important to convey acceptance of pt + ostomy
- careful w/ facial expressions; drainage can smell very foul
- allow pt to get used to change to body
- encourage pt to look at stoma + get used to touching it
30
immediate post-op ostomy care
first few days, ostomy emptied while pt in bed
- more risk for spills
- position bag to side (not up and down while pt ambulating)
- rinse pouch with warm water
- clean edges well before closing
- immediately after post-op, pt will be on reduced diet/NPO, but as peristalsis returns, diet will advance
- normally don't need TPN/tube feeds
31
Stoma complications: Stoma necrosis
- stoma should be pink or red
- if not, refer immediately to NSWOC nurse + notify surgeon
32
Stoma complications: Stoma Prolapse
- if circulation good, may be managed by ET/NSWOC nurse
- reduce swelling
- use of support garments
- use of larger pouch
- if circulation compromised, may require surgery
33
Stoma complications: Mucocutaneous Separation
- notice areas of separation at 2-3 o'clock, where stoma is detaching from incision site
- usually managed by NSWOC nurse, using principles of wound care (e.g., may involve packing, etc)
34
stoma complications: irritant dermatitis
- caused by leakage of stool / urine on the skin
- consult ET/NSWOC nurse
- prevention: change pouching system before it leaks
- managemet: clean + dry skin well; apply stomadhesive powder on raw areas
35
stoma complications: contact dermatitis/allergy
| what is this?
- sensitivity/allergy to one of the products (e.g., skin barrier, tape, powders, adhesives, etc)
- consult NSWOC nurse -- there are many products made out of different materials
- treat excoriated area to promote healing
35
stoma complications: candida albicans infection
- yeast infection
- reddened, moist, tender
- may have patchy white areas
- treat with antifungal medication like powder or Nystatin
35
Stoma complications: folliculitis
| what is this?
inflammation of hair follicles - presents as bumpy, red rash
- usually d/t staph infection
- often d/t shaving (rather than clipping) hair - or when removing ostomy appliance pulls hair out
36
stoma complications: stenosis
- narrowing of stoma / intestinal lumen
- may result in bowel obstruction
- minor stenosis may be managed w/ low-residue diet + incr fluids
- serious stenosis requires surgery
36
stoma complications: retracted stoma in skin crease
| what do you do?
- consult w/ ET nurse
- may need to use stoma paste/barrier strips
- may need a convex skin barrier and stoma belt
37
Hernia: what is it and how to treat?
= loop of intestine protrudes thru abdominal wall
- conservative treatment = support
- hernia belt can be applied to provide support
- surgery: if blood supply is compromised
38
what are the types of ostomy appliances?
- bag w/ attached flange
- bag with detachable flange
- moldable opening vs cutable opening
- reusable vs disposable
- closed-ended pouch: used for sigmoid colostomies, where stool is well-formed and pt may have 1 bm/day
39
what are the different ostomy/stoma products?
different products can be used to help primarily with achieving a good seal to prevent leaks + for maintaining / healing skin integrity:
- stomadhesive powder: keeps skin dry + adhered
- stoma paste: used to fill in gaps + creases
- barrier strips + rings: to fill in gaps
- ostomy belt to hold it in place
40
steps to emptying the ostomy
1. empty
2. rinse
3. clean edges
4. close
41
What is a stoma cap?
- can only be used for people who have formed bowel movements at specific times of day (e.g., sigmoid colostomy)
- can be used when bathing, swimming, or during intimacy
42
what is the purpose of ostomy irrigation?
- goal = "train" bowel to empty @ same time every day
- habituation of bowel takes 3-6 weeks
- not all pts can be managed w/ irrigations (an ostomy nurse will help assess if this is an approrpiate management technique)
42
Heights of edemas
high: 30-45 cm above anus
regular: 30 cm above anus
low: 7.5 above anus
43
Carminative enema
| indications?
e.g., Mg, glycerin, h2o
- to stimulate peristalsis + expel flatus (60-80mL solution instilled)
44
cleansing enema
| indications + solutions?
promotes complete evacuation of rectum by stimulating peristalsis with large volumes of fluid
- hypertonic: saline sodium phosphate - fleet, retain 5-10 minutes
- hypotonic: tap h2o (retain 15-20 min)
- isotonic: NS; safest (retain 15-20 min)
- soap suds: castile soap + tap h2o (retain 10-15 min); usually warmed solution (adult 500-1000 mL)
45
oil retention enema
| indication?
- lubricates the rectum + colon
- feces absorbs oil + becomes softer and easier to pass
46
medication enema
| indications?
- antibiotic: reduce bacteria in bowel, e.g., b4 surgery
- anthelminitic: kills worms, parasites
- kayexalate: reduce dangerously high serum K+ levels
47
return flow enema
| indication?
to expel flatus + relieve abdominal distension
- 100-200 mL fluid in/out of rectum/colon repeated 5-6x
48
What are the potential enema complications?
- mucosal irritation
- puncture of colon
- dehydration
- fluid electrolyte imbalance (e.g., hyponatremia)
- circulatory overload
- decreased bowel /sphincter tone with overuse
49
what position for enema / laxative suppositories?
position patient on left side, right knee flexed
50
laxative suppositories: action + indication
indication: constipation
action:
- softening feces, "stool softener"
- stimulating nerve endings in rectal muscosa
- releases co2 to distend rectum (sodium bicarb)
51
what is manual disimpaction?
- for fecal impaction, which is an acute complication of chronic + untreated constipation
- digital removal of fecal impaction involves breaking up fecal mass digitally + removing it in portions
- sometimes done for pts w/ some deficit in sensation/evacuation of bowels (e.g., paralysis)
52
Bowel protocol: indications
- to prevent opioid-induced constipation
- to manage constipation where dietary measures have failed, or previous laxative treatment unsatisfactory
prevention = key
53
bowel protocol: contraindications
- ileostomy
- blood in stool / rectum
- absence of bowel sounds
- complete bowel obstruction
- diarrhea
- if abdominal / rectal mass of unknown origin palpated
- impaction if present, clear impaction prior to initiating protocol
54
rectal tubes: indications + goals
indications: to divert + contain liquid stool
goals:
- decr incidence of skin breakdown
- reduce risk of infection
- protect wounds
- improve pt comfort
- maintain pt dignity
55
rectal tube: complications
- rectal trauma/ hemorrhaging
- rectal ulceration secondary to pressure necrosis
56
contraindications for rectal tube
- lower large bowel, rectal, anal surgery within last year
- rectal / anal injury, severe hemorrhoids or strictures or stenosis
- fecal impaction
- pediatric pt
- suspected/confirmed rectal mucosa impairment/rectal or anal tumour
- any sensitivity or allergy to components within the kit
57
criteria for insertion of rectal tube
- all options for diarrhea considered
- fecal incontinence bag/appliance use has been attempted and unsuccessful
- 3 episdores of fecal incontinence of liquid stool in 12h period, or presence of skin breakdown/presence of surgical site or dressing
- liquid / semi-liquid stool anticipated for period > 36h
- pt not mobile
