Week 6 - Ostomies, Rectul Tubes, Rectal Meds, Enemas Flashcards
A physician’s order is required for RNs or LPNs to insert what?
Flexi-seal device (rectal tube) into appropriate patient
What are the different types of ostomies?
- colostomy
- ascending colostomy
- cecumstomy
- Ileostomy
- urostomy
in regards to the different types of ostomies describe a colostomy
- transverse/ descending more common
- colon (large intestine) brought through abdominal wall
in regards to the different types of ostomies describe a ascending colostmoy
rare
in regards to the different types of ostomies describe a cecumstomy
rare/ seen in spina bifida
in regards to the different types of ostomies describe an ileostomy
when the ileum is brought through the abdominal wall
in regards to the different types of ostomies describe a urostomy
- 15-20cm segment of ileum converted into conduit
- ureteres anastomosed to one end
What are the indications for a colostomy?
emergency/ temporary
- bowel obstruction
- abdominal trauma
- perforated diverticulum
permanent
- obstructing colorectal cancer
What are the types of drainage in regards to colostomy
- semi-liquid to pasty
- semi-formed or formed stool
in regards to nursing care describe the assessment of the stoma
- should be pink/ red, vascular, bleeds easily
- first 72hrs post-op necrosis likely occurs
what is included in the nursing care for a colostomy?
- assessment of stoma
- assessment of peri-stomal skin
- protecting the skin and stoma from trauma and effluent
- empty when 1/3 full or full of gas to prevent leaking
- change pushing system
- provide patient teaching on self-care
- assist patient to adapt psychologically to changed body
- documentation
in regards to nursing care describe protecting the skin and stoma from trauma and affluent
choice of pouching systems and skin protection products
in regards to nursing care describe changing the pouching system
- depends on stools/ pouching system used (every 3-5 days)
- either before breakfast or 1-2hrs after
- establish bowel control with irrigation
describe the diet for people with a colostomy
- do not need to make major changes to diet
- continue to eat nutritious diet
- continue to include fibre in diet
describe hydration for people with a colostomy
- increase fluid intake
- more bowel removed more fluid should be taken in
What are the indications for an ileostomy?
temporary
- protect distal anastomosis in post-op low anterior resection
permanent
- ulcerative colitis
- Crohn’s disease
What are the types of drainage in regards to an ileostomy?
- post-op 1200-1800ml/day bilious output
- later average 800ml/day
describe nursing care for ileostomies
- assessment of intake/output and fluid/ electrolyte balance
- assessment of stoma
- assessment of peri-stomal skin
- protect skin/ stoma from trauma
- empty pouch when 1/3 full
- change pouch system
- patient teaching on self-care
- assist patient to adapt psychologically to changed body
- documentation
in regards to nursing care for an ileostomy describe the assessment of the stoma
- should be pink/red, vascular, bleeds easily
- first 72hrs post-op necrosis most likely to occur
- increased swelling 4-6 weeks after surgery
in regards to nursing care for an ileostomy describe protecting the skin and stoma from trauma, effluent
- stool from ileostomy extremely irritating to skin
- choice of pouching system/ skin protection products
in regards to nursing care for an ileostomy describe changing the pouching system
- drainable pouch usually changed every 3-5 days
- either before breakfast or 1-2hrs after
describe a diet for people with an ileostomy
food does not pass through large intestine
- low residue diet initially
- insoluble fibre-containing foods introduced slowly
- increase intake of high potassium foods
- goal to return to a normal pre-surgical, nutritious diet
describe hydration for people with an ileostomy
- increase fluid intake to replace lost fluids (2-3L/day)
What are some foods to avoid, reduce or eat with caution for people with an ileostomy?
- popcorn
- nuts and seeds
- corn
- bran
- celery
- sausage casing
- drink plenty of fluids if eating these
How do people with ileostomies minimize gas?
- cut down on certain foods
- chew food well
- avoid drinking from straw
- avoid chewing gum
- use pouch with filter
in regards to cutting down gas for people with ileostomies what foods should they cut down on?
- peas
- beans
- legumes
- veggies in cabbage family (broccoli, cauliflower, Brussel sprouts)
- eggs
- beer/ carbonated drinks
How do you minimize odors for people with a colostomy?
- avoid foods that cause odor
- pouch deodorizers
- charcoal filters in pouch
What foods should people with ileostomies avoid if they are trying to minimize odours?
- fish
- eggs
- onions
- garlic
- asparagus
- cheese
- fried foods
What are the indications for a urostomy?
- cancer of the bladder
- neurogenic bladder
- congenital anomalies
- strictures
- trauma to bladder
- chronic infection with decreased renal function
in regards to urostomies describe the type of drainage that would come out
- urine
- mucous
what is the most common type of urostomy?
ileal conduit
describe the ileal conduit
one end of segment of ileum attached to ureters and other end used to make stoma
describe the nursing care for a patient with a urostomy
- assessment of stoma
- assessment of peri-stomal skin
- frequent emptying of pouch
- changing pouch system
- provide patient teaching on self-care
- assist patient to adapt psychologically to changed body
- documentation
in regards to nursing care for a patient with a urostomy describe changing the pouching system
- usually every 2-7days
- before fluids in am or 2hrs after fluids
- fitted 7-10 days after surgery for permanent appliance
describe the diet/ hydration for a person with a urostomy
- no dietary restrictions
- increase fluid intake to keep urine dilute/ minimize formation of kidney stones
- 2-3L/ day recommended
What are people with a urostomy at an increased risk for?
urinary tract infection due to stasis in urinary diversion
How do you minimize the order for a client with a urostomy?
- change pouch regularly
- change pouch if leaking
- keep tap on bottom of pouch clean/ dry
- drink 2-3L/day
- cleanse night drainage bag
For people with a urostomy what do they use to clean their night drainage bag?
- soap
- water
- vinegar/ water
- hang to dry
What do you need to document each time a pouch is changed for an ostomy?
- volume, color, consistency of drainage
- condition of peristomal skin
- stoma size
- stoma shape
- stoma colour
- stoma height
- products used and any accessories
- presence of stents, catheters, rods, bridges
- pre and post-op patient teaching
What are the different types of ostomy surgeries?
- bowel resection
- Hartman’s resection
- loop ostomy
- double barrel stoma
- urostomy
in regards to the different types of ostomy surgeries describe a bowel resection
- diseased/ damaged section of bowel removed
- does not necessarily result in creation of ostomy
describe the creation of an end ostomy
- single stoma to drain fecal matter
- can be in small or large intestine
in regards to the different types of ostomy surgeries describe a Hartmann’s 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
in regards to the different types of ostomy surgeries describe a loop ostomy
- bowel is not completely cut through a loop of of bowel is brought to skin
- temporary
in regards to the different types of ostomy surgeries describe a loop ostomy with a bridge
- right after surgery patient will have bridge/ rod to prevent stoma from slipping back into abdomen
- rod usually removed after 3-7 days
in regards to the different types of ostomy surgeries describe a loop colostomy
- mature loop ostomy bridge removed
2 openings
- proximal drains stool
- distal drains mucous
in regards to the different types of ostomy surgeries describe a double-barrel stoma
- similar to loop ostomy
- bowel has been cut into 2 sections
post-op urostomy surgery how Long will a patient usually have stents for?
5-7 days
what are some post approaches to new ostomy patients nurses should be aware of?
- very important to convey acceptance of patient/ ostomy
- be careful with expression
- be aware drainage may smell really bad
describe immediate postop care for clients with an ostomy
- first few days ostomy emptied while patient in bed
- more risk for spills
- position ostomy bag to side
- rinse pouch with warm water
- clean edges well before closing
What is the nutrition after surgery for patients with an ostomy?
- patient on reduced diet (NPO) as peristalsis returns diet will be advanced
- patients do not normally need TPN or tube feeds
What are the different stoma complications that can arise?
- ischemia/ necrosis
- stoma prolapse
- mucocutaneous separation
- irritant dermatitis
- contact dermatitis/ allergy
- folliculitis
- Candida albicans infection
- stenosis
- retracted stoma in skin crease
in regards to the different stoma complications, describe ischemia/ necrosis
- stoma should be pink/ red
- refer immediately to ET nurse and notify surgeon
in regards to the different stoma complications, describe stoma prolapse
if circulation good may be managed by ET nurse
- reduce swelling
- use of support garments
- use of larger pouch
circulation compromised may require surgery
in regards to the different stoma complications, describe mucocutaneous separation
- areas of separation at 2-3 o’clock
- managed by ET nurse using principles of wound care
in regards to the different stoma complications, describe irritant dermatitis
- caused by leakage of stool/ urine on skin
- consult ET nurse
- prevention > change pouching system before leaking
- management > clean/ dry skin well, apply stomadhesive powder on raw areas
in regards to the different stoma complications, describe contact dermatitis/ allergy
- sensitivity/ allergy to one of the products
- consult ET nurse
- treat excoriated area to promote healing
in regards to the different stoma complications, describe folliculitis
- inflammation of hair follicles
- due to staph infection, shaving hair, removing ostomy appliance pulls hair out
in regards to the different stoma complications, describe candida albicans infection
- yeast infection
- reddened, moist, tender
- patchy white areas
- treat with anti fungal medication
describe anti fungal powder
- need doctor order
- initiated by ET nurse
- sprinkled on skin
in regards to the different stoma complications, describe stenosis
- narrowing of stoma/ intestinal lumen
- may result in bowel obstruction
- minor stenosis managed with low-residue diet/ increased fluids
- serious stenosis requires surgery
in regards to the different stoma complications, describe retracted stoma in skin crease
- consult ET nurse
- may need stoma paste or barrier strips
- may need convex skin barrier/ stoma belt
What are the different types of ostomy appliances?
- bag c attached flange
- bag c detachable flange
- moldable opening vs. cutable opening
- reusable
describe drainable two-piece ostomy pouches
- low profile
- after surgery don’t want to push to hard so low pressure adapters used
when do you not need to wear a low pressure adapter anymore?
after stoma healed
what can a drainable one-piece ostomy pouch come with?
- pre-sized holes
- cut-to-fit holes
- moldable holes
when is a closed-ended pouch used?
- sigmoid colostomies
- stool well formed
- person only have 1 bowel movement per day or less
how can closed-ended pouches also come?
- 2-piece system
- only pouch removed and discarded each time
What are the steps in emptying an ostomy?
- empty
- rinse
- clean edges
- close
describe urostomy appliances
- have all same options as colostomy bags
- have urine drain at bottom
whats something nifty about urostomy appliances that you can do at night?
- hook up to straight drainage system like catheter
- may need an adapter
describe stomadhesive powder
- not medication/ no prescription needed
- any RN can use
- helps keep skin dry/ keep pouching system well adhered to skin
describe stoma paste
- used to fill gaps/ creases
- get a good seal/ protect skin
- not everyone needs paste
describe barrier strips and rings
- like stoma paste
- used to fill in gaps/ creases
describe a hernia
- loop of intestine protrudes through the abdominal wall
- conservative treatment = support
- surgery if blood supply is compromised
describe a hernia belt
- applies support around stoma
- skin barrier wafer of ostomy pouch goes on first then hernia belt
- pouch snaps on the skin barrier wafer outside belt
when can stoma caps be used?
- people who have formed bowel movements at specific times
- bathing
- swimming
- sex
What is the goal of ostomy irrigation?
- train bowel to empty at the same time every day
are there any restrictions with colostomies and medications?
- fewer restrictions since part of large intestine remains
what are the restrictions in regards to medications for ileostomies?
- avoid enteric coated tablets/ extended release meds
- take liquid medication or crush tablets
- observe for incompletely dissolved pills
why might lomotil or loperamide be used when someone has an ostomy?
used to slow peristalsis
why might psyllium or other fibre products be used when someone has an ostomy?
helps manage high output from ileostomies
What hight are high, regular and low enemas hung?
high - 30-45cm above anus
regular - 30cm above anus
low - 7.5cm above anus
what does a cleansing enema promote?
complete evacuation of rectum by stimulating peristalsis with large volumes of fluid
what are the different types of cleansing enemas?
- hypertonic
- hypotonic
- isotonic
- soap suds
- usually warmed sollution
how much solution should be put in an adult in regards to cleansing enemas?
750-1000mL
in regards to cleansing enemas what are the different hypertonic solutions that can be used?
- saline
- sodium phosphate
in regards to cleansing enemas what are the different hypotonic solutions that can be used?
- tap water
in regards to cleansing enemas what are the different isotonic solutions that can be used?
normal saline (safest)
in regards to cleansing enemas what are the different soap suds solutions that can be used?
Castile soap and tap water
what are the different types of eneams?
- cleansing
- carminative
- oil retention
- medication
- return flow
in regards to the different types of enemas, describe carminative enemas and provide some examples
- stimulate peristalsis and expel flatus
ex. mg, glycerin, and water
in regards to the different types of enemas, describe oil retention enemas. How Long do they need to be retained for?
- feces absorbs oil and becomes softer and easier to pass
- retained for 30mins-3hrs
in regards to the different types of enemas, what are some examples of medication enemas and what do they kill?
antibiotic - reduces bacteria in bowel
antihelminitic - kills worms, parasites
kayexalate - reduces dangerously high serum potassium levels
in regards to the different types of enemas, describe return flow enemas and describe procedure
- expel flatus and relieve abdominal distension
- 100-200ml fluid in/out of rectum/colon repeated 5-6 times
What are some potential enema complications?
- mucosal irritation
- puncture of the colon
- dehydration
- fluid electrolyte imbalances
- circulatory overload
- decreased bowel/ sphincter tone with overuse
when is a rectal exam needed?
- prior to administering enema for constipation
- nurse needs to check for stool in rectum
describe rectal med suppositories
small torpedo shaped pellets that melt at body temperature
what are some examples of rectal med suppositories? when are they used?
glycerin - stool softener
bisacodyl - stimulant
acetaminophen - fever, mild-mod pain
diphenhydrinate - nausea/vomiting
valtaren - anti-inflammatory
opium and belladonna - bladder spasms
what is the indication for suppositories used as laxative?
constipation
- infrequent/ hard stools
what is the action for suppositories used as laxative?
- soften feces
- stimulate nerve endings in rectal mucosa
- releasing carbon dioxide to distend rectum
what is the administration for suppositories used as laxative?
best results when retained for up to 30mins
what are the potential complications for suppositories used as laxative?
trauma to the anal spinster or rectum
what is the nursing care for suppositories used as laxative?
- position patient on left side
- assist as needed
- documentation
what are the indications for a bowel protocol?
- prevent opioid-induced constipation
- manage constipation where dietary measures have failed
- previous laxative treatment unsatisfactory
what are the contraindications for bowel protocol?
- ileostomy
- blood in stool/ rectum
- absence or bowel sounds
- complete bowel obstruction
- diarrhea
- abdominal/ rectal mass unknown origin palpated
- impaction if present, clear impaction prior to initiating
- if in doubt contact MD
how do you use a bowel protocol?
- complete bowel assessment
- determine level to start at/ document on MAR
- document all bowel medications/ interventions
- subsequent rectal/ abdominal examinations documented
when using a bowel protocol how do you determine the level to start at?
- based on bowel pattern
- time since last BM
- bowel medication use prior to admin
What are the indications for rectal tube use?
divert/ contain liquid stool
What is the goal of rectal tube use?
- decrease incidence of skin breakdown
- reduce risk of infection
- protect wounds
- improve patient comfort
- maintain patient dignity
What is the criteria for inserting a rectal tube?
- all options for diarrhea have been considered
- fecal incontinente bag/ appliance has been attempted
- 3 episodes of fecal incontinence of liquid stool in 12hr period
- liquid/ semi-liquid stool anticipated for +36hrs
- patient not mobile
what are contraindications for a rectal tube use?
- lower large bowel, rectal, anal surgery within 1yr
- rectal/anal injury
- severe hemorrhoids
- fecal impaction
- paediatric patient
- severe rectal/ anal stricture or stenosis
- suspected/ confirmed rectal mucosa impairment
- indwelling, external, internal rectal device
- any need for rectal/ anal procedures
- any sensitivity/ allergy to components with kit
What are potential complications for a rectal tube use?
- rectal trauma/ hemorrhaging
- rectal ulceration secondary to pressure necrosis
in regards to nursing care for a rectal tube describe insertion
- assess for fecal impaction/ adequate sphincter tone
- lubricate/ insert tube well inside rectal vault
- position device along length of patients leg/ bag below level of patient
in regards to nursing care for a rectal tube describe maintenance
- anal skin care
- change bag prn
- irrigate as needed with 60mL tap water through port
in regards to nursing care for a rectal tube describe removal
- deflate balloon and gently pull out
