Perianesthesia Nurses Ostomy Talk
Post on 22-Dec-2015
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Objectives
Discuss the pre-operative needs of the ostomy patient
Describe the indications for each type of ostomy
Discuss the post-operative needs of the ostomy patient
Describe the specific post operative needs for each type of ostomy
World Ostomy Day October 6th, 2012
Sponsored by the UOAA – a non-profit support organization that is committed to the improvement of the quality of life of people who have or will have an intestinal or urinary diversion.
Faces of Ostomies
Pre-operative Considerations Assessment
Know your patients medical/surgical history
Don’t get caught in the OOPS factor!
Pre-operative Considerations Assessment
Diagnosis
Surgical Procedure Scheduled
Support System
Cultural/Spiritual Issues
Language Barrier
Vision, Hearing, Cognition
Skin Sensitivities and Allergies
Other Physical/Emotional Challenges
Pre-operative Considerations Emotions
All the senses are triggered to respond to the sights, sound, smell, taste and feel of the holding areas and surgical suite.
FEAR
Commonly Asked Questions/Concerns
Will people accept me?
How will I manage my ostomy?
Concerns about hygiene
Concerns about “bad experiences”
How will my ostomy change my life
How will my family and friends react to my ostomy?
Concerns about intimate relationships
Will this surgery save my life?
Stress the Benefits!! An ostomy will impact body image for all facing this
surgery and for many it will impact them negatively.
Empower the patient
Discuss quality of life issues that will give
them meaning dignity and respect
Suspend your own judgments
Listen and express empathy
Stress that ostomy surgery is life saving and can improve quality of life
Pre-operative Considerations Teaching Needs
Explanation and Rational for Surgery
The patient should be able to describe the surgical procedure to include creation of an ostomy with drainage of stool or urine through an abdominal opening.
Explanation and Appearance of Stoma A surgically created opening in the abdomen
A portion of the intestine is brought through the abdominal opening and sewn down to the skin
The opening is often referred to as a stoma
Stoma means mouth
Pre-operative Considerations Teaching Needs
Introduction to pouching system
Basic review of stoma care
ADL’s with an ostomy
Visit with a WOCN!!!!!
Visit with a UOA member (United Ostomy Association) – can reinforce information given by the surgeon and provide real-life experiences of patients with a stoma.
Pre-operative Considerations Teaching Needs – Informed Consent!
Patients undergoing ostomy surgery may experience disruption of nerve pathways since nerves controlling erection and ejaculation pass through peri-rectal and prostatic tissue.
There is much less known
about female sexual function
following ostomy surgery.
Pre-operative Considerations Stoma Site Marking
It has been shown that pre-operative stoma site marking by a WOCN greatly improves the quality of life for the patient.
Difficulties with stomas occur due to incorrect placement resulting in leakage, peristomal skin damage, increased risk of peristomal hernia and stomal prolapse, emotional stress and increased costs.
It takes a team effort (surgeon, patient, WOCN)
Stoma Site Marking is advocated by: The International Ostomy Association
The Wound, Ostomy and Continence Nurses Society
The American Society of Colon & Rectal Surgeons
The American Urological Association
All have submitted joint statements endorsing preoperative stoma site
marking
Stoma Site Marking Location depends on the type of surgery
Should be located within the rectus muscle
Should be below the beltline
Should be located on the flattest surface possible
Should be evaluated in the sitting, lying, standing and bending position
Avoid skin folds, scars, creases, umbilicus, and bony prominences
Must be visible to the patient
Poor Stoma placement can lead to: Pain
Leakage from the pouching system
Peristomal skin irritation
Fitting challenges
Impaired psychological health
X- MARKS THE SPOT!!
•Colostomy – left lower quadrant
•Ileostomy – right lower quadrant
•Urostomy – right lower quadrant
Indications for a Colostomy Can be created from any part of the colon, cecum,
ascending, transverse, descending or sigmoid.
They can be temporary or permanent.
Usually located in the Left Lower Quadrant of the abdomen.
Indications for Colostomy Emergent
Colonic Obstruction
Due to primary cancer of the distal colon or rectum.
Due to complicated diverticular disease with stricture
or abscess.
Trauma of the distal colon with perforation and fecal spillage (gunshot/stab wound, blunt trauma)
Volvulous – Twisting of the bowel causing obstruction and strangulation of the mesentery
Newborns with distal obstruction from Hirschsprungs
disease or imperforate anus
Emergent Colostomy
Indications for Colostomy Elective
Due to low rectal cancers with abdominal peritoneal resection (removal of entire anal sphincter, rectum and sigmoid colon. Ostomy is permanent.
For protection of a low colorectal or coloanal anastomosis, rectovaginal fistula, incontinence, radiation proctitis, perianal sepsis, diversion for pressure ulcer (stage IV).
Atonic bowel (congenital or acquired).
Indications for Ileostomy Can be temporary or permanent
Usually located in the right upper or lower quadrant of the abdomen
Indications for Ileostomy Emergent
Conditions requiring small bowel or proximal colon resection, in which the integrity of a primary anastomosis would be compromised
Diffuse bowel injury from radiation or Crohn’s disease
Hemorrhage, ischemia, perforation, sepsis
Infants – necrotizing enterocolitis
Indications for Ileostomy Elective
Rectal cancers
Inflammatory bowel disease (chronic ulcerative colitis, Crohn’s disease
**** A total colectomy cures ulcerative colitis, does not cure Crohn’s disease
Familial Polyposis – requires removal of the rectum and entire colon
Elective Ileostomy
Creation of a Stoma – End Stoma
Creation of a Stoma – Hartmann’s Pouch
Creation of a Stoma - Loop •Usually temporary •Quicker surgery
Creation of a Stoma – Double Barrel The bowel is divided (resected) – proximal end is
brought out as a functioning stoma and distal end is brought out as a “mucous fistula”.
Pre-operative Bowel Prep for Existing Colostomy
Need to know who many bowel segments does the patient have?
Which segment is to be prepped?
How to access the segment?
How long is the segment?
Proximal segment (mouth to anus: oral laxatives, liquid diet, irrigations through stoma)
Distal segment (Hartmann’s pouch, distal stoma to anus) use rectal suppositories, rectal enemas, or irritations of distal limb of loop or distal stoma.
Indications for Urostomy (Ileal Conduit). Permanent surgical procedures
Stoma usually located in the right upper or lower quadrant of the abdomen
Indications for Urostomy Invasive Bladder Cancer
Congenital abnormalities (bladder extrophy)
Chronic urinary incontinence (interstitial/radiation cystitis)
Trauma
Hostile Neurogenic Bladder
Intraoperative Events
Significantly impact postoperative outcomes and complication rates
Most at risk are ostomies created in response to trauma (blunt and penetrating)
Rupture of the large or small intestine
Spillage of fecal contents
Septic shock
Atypical location of stoma
Intraoperative Events High volume blood loss - leads to hypotension and
hypo perfusion. Requires crystalloid resuscitation and transfusion of blood products to prevent ischemia and necrosis of the stoma.
Operative insults may lead to electrolyte imbalances and a systemic inflammatory response which in extreme cases can progress to organ failure.
Intraoperative Events Technical Factors:
The surgeons ability to mobilize and deliver the intestine through the abdominal wall influences stomal maturation.
The amount of subcutaneous tissue through which the bowel must pass
The integrity of the abdominal wall
The patients wound healing potential
The presence of associated diseases
Stomal Assessment – In a Perfect World!!
•Red •Moist •Round •Protruding (budded) •Mucocutaneous stitches intact •In the rectus abdominus muscle •In the patient’s line of vision •Away from belt or clothing lines •Not in a wrinkle or fold
Post-operative Stomal Assessment Keen assessment skills, early recognition of
signs and symptoms of a complication, and prompt intervention are crucial to maintaining a viable stoma and a successful surgical outcomes.
Post Operative Considerations Stoma Assessment
Anatomic location and type of stoma
Assessment of loop catheter (loop colostomy,
loop ileostomy)
Assessment of stomal stents (ileal conduit)
Stoma viability (moist, bright red)
Height of stoma (budded, flush, retracted, prolapsed)
Location of stomal opening
Output (24-72 hours colostomy, 24-48 hours ileostomy, immediate for urostomy).
Transparent pouch permits visualization of stoma
Stomas gone bad!!
Stomal Complications Mucocutaneous Separation
Occurs when stomal tissue detaches from the surrounding peristomal skin
Excessive tension on stoma
Superficial infection
Diabetes Mellitus
Regular use of steroids
Malnutrition
Stomal Complications- Prolapse Telescoping of the intestine through the stoma
Insufficient attachment of the bowel to the abdominal wall
Insufficient fascial support
Increased abdominal pressure
(crying, coughing)
Stomal Complications - Retraction Disappearance of normal stomal protrusion in line
with or below skin level.
Problems with surgical construction of the ostomy resulting in mesenteric tension or inadequate stomal length.
Can be associated with a distended
and edematous abdominal wall
Stomal Complication - Stenosis Impairment of effluent drainage due to narrowing or
contraction of the stomal tissue at the level of the skin or fascia
May be related to surgical construction techniques
Excessive scar formation
Irradiation of bowel segment
Peristomal sepsis
****Patient will have explosive or narrow stools with loud flatus. The urostomy patient will experience flank pain and decreased output.
Specific Needs – Colostomy Pre-operative
Assure informed consent and address patient’s concerns
Explain that a colostomy does not change the ability to digest and absorb nutrients; no change in diet required
Causes loss of ability to control elimination or stool and gas
Will need to wear an odor proof pouch
Patient with existing colostomy may have had a bowel prep pre-op.
Specific Assessment – Colostomy Post-Operative
Stoma viability (color, turgor, hydration)
Mucocutaneous suture line
(approximated vs. separated)
Presence of loop catheter
Stomal edema – stoma will shrink for
the next six weeks
Ileus is normal for first several days post op
Focus on emotional support of patient and family
Specific Needs – Ileostomy Pre-operative
Discuss rational for surgery and obtain informed consent
Discuss impact of surgery on bowel function: Will maintain ability to digest and absorb nutrients if the proximal small bowel is normal.
Will lose function of the colon and rectum
May have some dietary restrictions
Provide emotional support
Specific Assessment – Ileostomy Post - Operative
Stoma viability
Mucocutaneous suture line
Stomal edema and presence of loop catheter
Bowel function: stool produced 12-24 hours post- op, color will be dark green, viscous and odorless
Initially will have high volume of liquid output (>1000 cc/day). Bowel will gradually adapt
Accurate I&O’s crucial
High risk for peristomal skin breakdown
Specific Needs – Ileostomy Post-operative
High fiber foods may cause stomal blockage
Will need 10-12 glasses of fluid each day
Medication concerns: large pills, enteric coated pills, sustained-release medications
Never give a laxative!!!!!!
Specific Needs – Urostomy Pre-operative
Assure informed consent
(Male patient undergoing cystoprostatectomy – must discuss potential alteration in sexual function with patient to assure informed consent).
Explain procedure in lay terms and provide a simple diagram
Assure patient that bowel function will be undisturbed. May need to explain the reason for bowel prep
Show patient a pouch with a spout
Urostomy pouches
Specific Assessment – Urostomy Post-operative
Stomal Assessment
Some Hematuria and mucous is normal, should be transparent in color
Expect output from stents and stoma - flow will be continuous. Stents are threaded all the way up the ureter into the renal pelvis (bilateral) and sutured to the ureter with absorbable sutures. Stay in 7-10 days.
Stents – support the ureterointestinal anastomosis and prevent obstruction. They should not be irrigated.
Ileal conduit with stents
Specific Assessment – Urostomy Post-operative
Monitor patient for bowel sounds, N/G output, distention, nausea. Usual post up ileus 3-4 days
Make sure attachment device for attaching pouch to bed side drainage bag is compatible
Monitor for anastomotic breakdown (reduced output through stents & stoma and increased output through surgical drains and/or increased abdominal growth).
A few words…….. Continent Urinary Diversions – should have a Foley in
the internal pouch during surgery and recovery and remove as soon as the patient can resume care. Use 14-16 Fr.
Orthotopic Neobladder – Can be catheterized as you would a “normal” bladder. Use 14-16 Fr.
What I wish I had known Voices from Ostomates
Don’t sugarcoat
Be as realistic as you can
You are not alone
Provide compassionate honesty
Faces of Ostomy
Ulcerative colitis/colo rectal cancer/ileostomy
Marathon runner
Faces of Ostomy
Colo/rectal cancer stage III - colostomy
Patient advocate/surfer
Faces of Ostomy
Ulcerative colitis/colon cancer/ileostomy
Gastronaut ostomy puppet
Patient advocate
Faces of Ostomy
Crohn’s disease/ileostomy
Model
Newlywed
Patient advocate
Faces of Ostomy
Rhabdomyosarcoma of the Bladder/ileal conduit
Famous Ostomies!! Pope John Paul II
The Queen mother of England
Napoleon Bonaparte
Fred Astaire
Red Skelton
Ed Sullivan
Tip O’Neil
William Powell
Ostomy Companies www.hollister.cm - Hollister
www.convatec.com-
www.coloplast.com – Coloplast
www.nu-hope.com – Nu-hope
Ostomy buddy dolls
Resources www.wocn.org – Wound, Ostomy and Continence
Nurses Society
www.ostomy.org United Ostomy Associations of America, Inc
www.raleighuoa.org– Triangle Ostomy Association – Meets the first Tuesday of every month at 7:30 pm at Rex Hospital.
www.greatcomebacks.com – Great Comebacks – Inspiring stories of people living with ostomies
www.inspire.com – Hosts an online support group for patients with ostomies
Thanks for all of your hard work!!
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