Week 10: Ostomy Care

Question 1

What is an ostomy and what are some of the reasons for having one?

Answer 1

Ostomy- surgically formed opening from an internal structure to the surface of the body
d/t ileal atresia, necrotizing enterocolitis, imperforated anus, IBD, Hirschsprung , cancer one is too but not listed on notes

Question 2

what is the difference between an ileostomy and a colostomy?

Answer 2

Ileum- right side of abdomen
Drains liquid stool

Sigmoid- left lower ab
Formed stool

Question 3

What are two problems with ostomy usage?

Answer 3

Difficult to locate one small enough to contain liquid drainage without leaking
Skin under the appliance becomes irritated

Question 4

How are bowel diversion ostomies classified?

Answer 4

Classified according to:
Their status as permanent or temporary
Their anatomical location
The nature of the construction of the stoma

Question 5

What are the reasons for having a permanent or temporary ostomy ?

Answer 5

Either temp or permanent

Temp: performed for traumatic injury or inflammatory conditions
Allow the portion to rest and heal

Perm: provide means of elimination when the rectum or anus is non-functioning

Question 6

What are the possible locations of an ostomy?

Answer 6

Anatomical location

Ileostomy- liquid fecal drainage
Constant drainage
Contains some digestive enzymes
Clients must wear an appliance continuously and take steps to prevent skin breakdown
Odour is minimal because of less bacteria

Ascending colostomy
Liquid drainage
Digestive enzymes
Increased odour

Transverse colostomy
Malodourous, mushy drainage

Descending colostomy 
Increasingly solid fecal drainage 
Normal formed consistency  
Discharge can be regulated 
May not have to wear appliance all the time 
Odour can be better controlled 

Note: Length of time ostomy in place can also determine consistency of stool, transverse and descending especially . Overtime stool is more formed because the remaining functioning portions of colon tend to compensate by increasing water absorption

Question 7

What is a urinary diversion?

Answer 7

Surgical rerouting of the urine from the kidneys to site other than bladder

Question 8

What is an incontinent urinary diversion?

Answer 8

Incontinent: no control over passage of urine and requires use of external ostomy appliance to contain urine

May or may not involve cystectomy (removal of bladder)

Ureterostomy: both ureters form stomas
Disadvantage: infection prone, too small for appliances, obstruct urine flow

Nephrostomy: urine from kidney to stoma

Vesicostomy: bladder in tact but urethra is damaged
Ureters remain attached to bladder and bladder wall is surgically attached to stomas below navel

Most common diversion is a ileal conduit/ileal loop
Segment of ileum is removed and the intestine ends are reattached One end of the portion creates the pouch and the other end forms the stoma
Ureters are implanted into the ideal pouch
Provides more protection from organisms and easier to fit for appliance
Urine drains continuously

Question 9

What is the most common type of urinary diversion?

Answer 9

Most common diversion is a ileal conduit/ileal loop
Segment of ileum is removed and the intestine ends are reattached One end of the portion creates the pouch and the other end forms the stoma
Ureters are implanted into the ideal pouch
Provides more protection from organisms and easier to fit for appliance
Urine drains continuously

Question 10

What are the disadvantages to a ureterostomy?

Answer 10

Ureterostomy: both ureters form stomas
Disadvantage: infection prone, too small for appliances, obstruct urine flow

Question 11

What is a continent urinary diversion?

Answer 11

Continent: continence mechanism is created by giving control over the passage of urine
Intermittent catherization or strained voiding
Indiana pouch: created by attaching the ureters to a portion of the ileum that is shaped into a reservoir for urine
The client then inserts the catheter through an opening in the ab wall to empty the reservoir
Usually every 4 hrs
Neobladder: replaces a diseased or damaged bladder with a piece of ileum
Making a new bladder
The new bladder is then sutured to the functional urethra, allowing the person to urinate normally

Question 12

What must the nurse assess for a urinary diversion?

Answer 12

Nurse must accurately assess intake, output, note changes in urine color, odour and clarity, stoma condition, surrounding skin

Question 13

patient is at risk for ____ ( urinary diversion)

Answer 13

Pts at risk for skin irritation

Question 14

What does effluent mean?

Answer 14

output from stoma

Question 15

How is the Urostomy or ileal conduit created ?

Answer 15

Urostomy or ileal conduit is created from a portion of intestine that is resected from ileum
One end of the conduit is sutured closed, and the ureters are implanted through the mucosa.
The other end is brought out on the abdominal wall, and a stoma is formed for urine to exit the body.
This ostomy is permanent.

Question 16

What are the changes or trends with ostomies now adays?

Answer 16

Changes/trends:
The current trend is to apply a pouch directly to clean dry skin without using skin preparations, paste, or added adhesives unless a patient has a specific problem keeping a pouch intact
The adhesives on the skin barriers are pressure and heat sensitive; thus a patient should apply gentle pressure with the hand over the skin barrier for several minutes to adhere the barrier to the skin
There are new and improved accessory products such as rings or seals for managing abdominal contours that are uneven or peristomal skin that is not intact.
Some pouches have effective gas filters that allow flatus to escape slowly from the pouch through a charcoal filter. This filter absorbs odor and does not allow leakage of liquid effluent through the filter.
All of the ostomy companies now have pouches with integrated closures. A Velcro-like closure eliminates the need for a clip to close the bottom of the pouch. It also requires less manual dexterity to empty the pouch.
A wider selection of products for neonatal and pediatric use

Question 17

What are some differences with neonate ostomies? infant ostomies? why might they need them, etc?

Answer 17

Because most ostomy surgery done on neonates is for emergencies, often no time is available for preoperative selection of stoma site. The surgery is usually done because the neonate has necrotizing enterocolitis (NEC), Hirschsprung’s disease, or congenital disorders.
The stomas are frequently temporary, with closure of the ostomy when the surgical repair has healed and the neonate is medically ready for surgery.
Because infants swallow large amounts of air while sucking, it is normal to expect flatus. Make sure that pouch can accommodate increased amount of flatus after feeding or be prepared to release flatus frequently

• The skin of a preterm infant is not fully developed and is more absorbent than that of a full-term infant. Do not use skin sealants and adhesive removers unless they are approved for preterm-infant use
• As an infant grows in size, so does the stoma. Measure the stoma frequently and make appropriate adjustments in pouching and skin barrier size. Skin barriers for preterm infants must have flexibility to cover the infant’s rounded abdominal contour

Question 18

Why are some reasons children have ostomies?

Answer 18

Children and adolescents may have ostomy surgery for conditions such as cancer, inflammatory bowel disease, and trauma.

Question 19

What are some gerontologic considerations?

Answer 19

Gerontologic
• Evaluate an older adult’s cognitive status for understanding ostomy self-care instructions. Include a family caregiver in the care plan.
• Adapt care approaches for older patients who have impaired manual dexterity or limited vision. If a patient is unable to custom cut the size of the skin barrier, consider having barriers precut by an ostomy equipment supplier or using a precut pouching system.

Question 20

Ostomies- What are some homecare teaching points?

Answer 20

Evaluate home toileting facilities and patients’ ability to position to empty pouch directly into a toilet.
• Patient may shower without covering pouch.
• Patients should avoid storing pouches in extremely hot or cold locations. Temperature affects barrier and adhesive materials.

Question 21

How often should you check the bag (ostomies / childre)

Answer 21

Check bag every 4 hrs

Question 22

How long can the collection bag remain in place (ostomies / children)

Answer 22

Collection bag may stay in place for as long as one week if properly secured

Question 23

How can you reduce the odor (ostomies/ children)

Answer 23

To reduce odor: flush appliance with warm water and soap, use bulb syringe, rinse with clear water

Question 24

What are some complications of NG feeding (mercks manual- see notes week 8-13 for reading list of complications, signs and interventions, but these are similar)

Answer 24

Presence of tube-> Damage to the nose, pharynx, or esophagus- Sinusitis (The tube, particularly if large, can irritate tissues, causing them to erode. Sinus ostia can become blocked).

Blockage of tube lumen->Inadequate feeding
(Thick feedings or pills can block the lumen, particularly of small tubes. Sometimes blockages can be dissolved by instilling a solution of pancreatic enzymes or other commercial products)

Misplacement of a nasogastric tube intracranially –>Brain trauma, infection (A tube may be misplaced intracranially if the cribriform plate is disrupted by severe facial trauma.

Misplacement of a nasogastric or orogastric tube in the tracheobronchial tree –>Pneumonia (Responsive patients immediately cough and gag. Obtunded patients have few immediate symptoms. If misplacement is not recognized, feedings enter the lungs, causing pneumonia)

Dislodgement of a gastrostomy or jejunostomy tube –> Peritonitis (After being dislodged, a tube may be replaced into the peritoneal cavity. If tubes were originally placed using invasive techniques, replacement is more difficult and more likely to cause complications.)

Formula-related –>Intolerance of one of the formula’s main nutrient components –> DiarrheaMOST COMMON, GI discomfort,* nausea, vomiting, mesenteric ischemia (occasionally) (Intolerance occurs in up to 20% of patients and 50% of critically ill patients and is more common with bolus feedings)

Osmotic diarrhea –>Frequent, loose stools (Sorbitol, often contained in liquid drug preparations given through feeding tubes, can exacerbate diarrhea)

Nutrient imbalances –>Electrolyte disturbances, hyperglycemia, volume overload, hyperosmolarity (look at dumping syndrome) (Body weight and blood levels of electrolytes, glucose, magnesium, and phosphate should be frequently monitored (daily during the first week).

Other

Reflux of tube feedings or difficulty with oropharyngeal secretions –>Aspiration (Aspiration may occur even though tubes are placed correctly and the head of the bed is elevated if patients have either of these problems)

*GI discomfort may have other causes, including reduced compliance of the stomach due to shrinkage caused by lack of feeding, distention due to volume of feeding, and decreased gastric emptying due to dysfunction of the pylorus.