OSTOMY CARE Patty Maloney MSN Ed, RN Alternative Bowel Elimination Bowel diversion-redirection of the contents of the small or large intestine through a surgically created exit in the abdominal wall. Possible reasons for bowel diversion: Cancerous tumor Disease process such as Crohn’s disease Infarcted area which the bowel walls become ischemic and die Ruptured diverticulum Ulcerative colitis Traumatic abdominal injury Ostomies Ostomy- surgically created opening into the abdominal wall that serves as an exit site from the bowel or ureter. Ileostomy- surgically created opening from the small intestines to the abdominal wall allowing the passage of feces. Colostomy-surgically created opening from the large intestines to the abdominal wall allowing for the passage of feces. Ureterostomy Ureterostomysurgical procedure creating an opening from the ureter to the abdominal cavity. Stoma Stoma- portion of the bowel or ureter that is surgically opened and brought out through the abdominal wall. Ostomy Drainage Type of drainage depends on location of the ostomy: Ileostomy and ascending colon-liquid feces. Transverse colostomymushy stool. Descending colon-soft to solid. Ureterostomy Ureterostomydrains urine. Ostomies May be temporary or permanent. Temporary-bowel rest, eg. Chron’s disease. Permanent-tumor. Temporary may be several weeks to several months. Ostomies Temporary-generally located at the transverse colon. Permanent-usually located at the descending colon or sigmoid colon. Permanent because the colon or rectum have to be removed. Ostomy Appliances Many types of appliances/pouches available. One piece-one unit bag attached to wire. Two piece- wafer is separated from pouch. Wafers- some precut and some must be custom fit. Ostomy Appliances Sealant or pastecreate a seal. Closure- clip or clamp. Ostomy Care Wash hands. Don gloves. Remove old appliance. Note effulent (drainage)-color, amount, and odor. Drain effulent into commode. Discard old appliance into biohazard bag. Ostomy Care Assessing initial post-op stoma: initially post-op stoma will be edematous and may have small amount of bleeding. Monitor for post-op complications: Excessive bleeding. Stoma dark in color or blanched due to lack of blood supply. Drying of stoma. Signs of infection. May take 4-6 weeks to determine stoma size. Ostomy Care Stoma assessment: Stoma should be pink to red and moist. Assess for cuts, ulcerations, or any abnormal findings. Assess skin around stoma. Note any redness or irritation. Challenges Skin breakdown is a major challenge due to the enzymes in the stool. Excoriation-chemical injury of the skin due to the enzymes. Nursing Implications Wash stoma and skin around stoma with soap and water and pat dry. Apply skin barrier substance (karaya powder, skin prep). Enterostomal therapist-nurse who specializes in care of ostomies. Application of appliance Application depends on the type of appliance used. Pre-cut-appropriate size is chosen and then applied. Custom fituse an ostomy guide to cut the opening on the wafer 1/16 to 1/8 larger than stoma. key is to fit appliance around the stoma without touching stoma or exposing surrounding skin. Applying Appliance One piece system- use skin sealant. Two piece system- use paste. Appliance chosen depends on the type of ostomy, stoma shape, location of stoma. (Trial and error) May reinforce appliance with non-allergic paper tape in picture frame. May wear an ostomy belt. Roll end of pouch upward once and apply clip/clamp. Be sure clam is snug. Assessment of Ostomy GI assessment of patient. Assess bowel sounds in all 4 quadrants. Assess effulent from ostomy. Empty pouch when 1/3-1/2 full. Assess abdomen. Report any abnormal findings immediately. Bowel sounds and activity by day 3. Ostomy Care Management of ostomy: Ostomy should be pink & moist. Skin should be clean, dry, & intact. Assess for s/s of redness or irritation. New appliances should adhere to skin without wrinkles or gaps. Colostomy Irrigation Requires Dr. order. Procedure: Remove appliance. Place irrigation sleeve over stoma. Instill lubricated cone into stoma. Insert catheter into cone. Instill 500cc-1000cc tap water or saline . Start with 500cc over 5-10 minutes. Colostomy Irrigation Urinary Diversion Surgical opening on the abdomen or ostomy through which urine is eliminaed. Types: Continent and incontinent. Continent diversion-internal pouch or reservoir created from a segment of the bowel. Patient performs self catheterization every 4-6 hours. No appliance used. Continent Urinary Diversion Incontinent Urinary Diversion AKA-ileal conduit. Ureter is transplanted into a closed off portion of the ileum with an opening to the outer abdomen creating a stoma. Ureterostomy1 or 2 ureters are brought to the abdominal wall and a stoma is formed. Requires a pouch or appliance because of continuing urinary drainage. Urinary Diversion Nursing Implications: Increased chance of skin breakdown due to continuous drainage. Change appliance bag frequently due to weight of urine. Place a tampon in stoma to absorb urine while cleaning. Peristomal skin is difficult to keep free from breakdown due to ammonia in urine. Use of skin barrier or topical antibiotics or steroids.