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ULCERATIVE COLITIS

SCENARIO:
You are a nurse working on a surgical unit and take the following report from the registered
nurse in the emergency department. “We are sending you a direct admit with rule out small
bowel obstruction (R/O SBO) and/or food blockage. Dr. N., the gastrointestinal specialist is on
his way in to see the patient. D.S. is a 78-year-old obese man with complaints of sudden onset
of severe abdominal cramping, distention, and nausea and vomiting; he denies passing of flatus
or stool within the past 12 hours. Past medical history includes heart failure, hypertension, colon
cancer, and ulcerative colitis. He underwent a total colectomy 16 years ago and had an
enterocutaneous fistula 12 years ago. Lab samples have been drawn, and the results will be
sent to your floor. We started an IV and placed a Salem Sump nasogastric tube (NGT). His vital
signs are 143/76, 82, respirations 26 and slightly labored, and 101.1° F (38.4° C). He is on his
way up. 

QUESTIONS:
1. Given that D.S. had had a total colectomy, would he have a colostomy or an ileostomy?
Explain your answer.
2. What would you expect to see if D.S.'s ostomy had normal function?
ANSWERS:
1. The patient would have an ileostomy because the entire colon is removed in a
total colectomy so the small intestine would have to be brought the abdomen to create
the stoma. Green-tinged stools from ileostomy
2. I would expect to see if D.S.’s ostomy has normal function if the characteristics of
the fecal is a liquid brown stool draining from the stoma or green unformed stool. While
the color of the stoma should be pink, viable and moist

Case study progress:


After D.S. is settled into his room, the NGT and IV are functioning well, and he receives pain
medication, you begin your admission assessment. His abdomen is extremely large, firm to
touch, with multiple scars and an ileostomy pouching system in his RLQ.

QUESTIONS:
1. What are the more common complications of an ileostomy?
2. D.S.'s past medical history of fistula, combined with the probability of blockage or
obstruction, places him at an increased risk for which problems?
3. As you assess the stoma, you look for signs that it is healthy. Which of these
assessment findings are the characteristics of a healthy stoma? (Select all that apply.)
a. The stoma is cherry-red, dark pink in color.
b. The stoma is pale pink in color.
c.The stoma is moist.
d. The stoma is dry.
e. The stoma is flat against the skin.
4. What stoma changes would you report immediately to the physician?
4. Why are transparent ostomy pouches recommended postoperatively or when patients
are hospitalized?
4. Will the stoma present visual clues of D.S.'s bowel blockage or obstruction?
ANSWERS:
1. Some of the main complications that can occur after an ileostomy operation are
described below:
 Dehydration-You’re an increased risk of becoming dehydrated if you have an
ileostomy because the large intestine, which is either removed or unused if you
have an ileostomy, plays an important role in helping absorb water from food
waste.
 Stoma Problem-irritation and inflammation of the skin around the stoma (stoma
stricture) stoma prolapse, parastomal hernia, stoma retraction, prolapse
 Internal bleeding
 An intestinal blockage due to too much fiber in the patient’s diet
 Cholelithiasis-blockage of the common bile duct to altered absorption of bile
acids
 Damage to the surrounding organs

2. D.S.’s risk factors based on past medical history would definitely increased the
probability of blockage or obstruction, and had a possible risk factors for having a
bladder infections and UTI’s. The obstruction also puts him at risk for a ruptured bowel.

3. CHARACTERISTICS OF A HEALTHY STOMA


 The stoma is cherry-red, dark pink in color
 The stoma is moist.

4. If would immediately report to the physician if the stoma appear pales,bluish or black
which means that a stoma is impaired, if the stoma retracts or separates, if there is an
increased pulse, respirations and temp, rigid abdomen and abdominal pain could be a
sign of infection, if the stoma appears discharging pus, if the stoma seems dry or if it no
longer moist in appearance

5. Transparent ostomy pouches are recommended for post-operative patient because it


clearly emphasize the visualization of new stoma.to monitor stoma visually in assessing
the viability of the stoma

6. Yes, the stoma will present changes if a blockage or obstruction occurs.


Case study progress:
D.S. continues to complain of abdominal pain and cramping and becomes increasingly restless.
You notice that the abdomen behind and around his stoma and pouch appears larger when
compared with the other side of his abdomen.

QUESTIONS:
1. How would you assess for a possible peristomal hernia?
2. Why is a peristomal hernia a problem?
ANSWERS:
1. To assess for a possible peristomal hernia, CT scans or MRI can used to diagnose it or
find the extent of it, patient should be lying flat, their chin should be tucked in which will
show a bulging.
2. Peristomal hernia can be a problem because it makes it harder to irrigate stoma, it is
also prone to susceptibility of skin breakdown when the pouch is removed and if the
surrounding skin can be tightly stretched. Hernias can be difficult to hide under clothes
resulting in shameful body image in some patients. It is also possible for the intestine to
become trapped or twisted in the hernia. This can lead to loss of blood supply, requiring
emergency surgery to prevent permanent bowel damage or perforation.

Case study progress:


You note that the ostomy pouch has liquid brown effluent along the lateral edge of the wafer.
You check to see that the pouch is properly attached to the wafer and discover that stool is
indeed leaking from under the barrier. D.S. apologizes for not bringing any supplies with him,
stating, “My ostomy nurse told me to always carry extra supplies for times like this.”
D.S. does not remember what size he needs, but you note he is wearing a 2-piece system with
a plastic ring-flange that attaches to the pouch with a matching ring.

QUESTIONS:
1. How will you determine the correct pouching size and system?
ANSWERS:
1. To determine the correct size for a pouch and system, you measure the size of the
stoma and use a measuring guide. Find the smallest hole on the guide that fits around
the stoma without touching it. After you find that size, you add one eight of an inch
around that. A pattern can be made of the stoma on paper then traced on to the wafer,
then cut to that size.
Case study progress:
You have finished with your general head-to-toe assessment and order the appropriate
pouching products for D.S. You have already taken clean towels, washcloths, and underpads
into his room, along with a hamper to receive dirty, used laundry. You gather scissors, skin-
prep, and adhesive remover to assist with the pouching change.

QUESTIONS:
1. As you return to his room, you review the steps for changing an ostomy pouch. What are
the steps you will need to follow?
ANSWERS:
1. STEPS FOR CHANGING AN OSTOMY POUCH

a. Wash your hands with soap and water. Be sure to wash between your fingers
and under your fingernails. Dry with a clean towel or paper towels.
b. If you have a 2-piece pouch, press gently on the skin around your stoma with 1
hand, and remove the seal with your other hand. (If it is removing the seal, you
can use special pads. Ask your nurse about these)
c. Remove the pouch. Keep the clip. Put the old ostomy pouch in a bag and then
place the bag in the trash.
d. Clean the skin around your stoma with warm soap and water and clean
washcloth or paper towels. Dry with a clean towel.
e. Check the skin:
i. A little bleeding is normal. Your skin should be pink red. Call your doctor
if it is purple, black, or blue.
ii. Wipe around the stoma with special skin wipe. If your skin is a little wet,
sprinkle some of the stoma powder on just the wet or open part.
iii. Lightly pat the special wipe on top of the powder and your skin again.
iv. Let the area air-dry for 1 to 2 minutes.
f. Measure your stoma:
i. Use your measuring card to find the circle size that matches the size of
your stoma. DO NOT touch the card to your skin.
ii. If you have a 2-piece system, trace the circle size onto the back of the
ring seal and cut out this size. Make sure the cut edges are smooth.
g. Attach the pouch:
i. Attach the pouch to the ring seal if you have a 2-piece ostomy system.
ii. Peel the paper off the ring seal.
iii. Squirt the stoma paste around the hole in the seal, or place the special
stoma ring around the opening.
iv. Place the seal evenly around the stoma. Hold it in place for a few
minutes. Try holding a warm washcloth over the seal to help make it
stick to your skin. Hold washcloth or hand there for 10 minutes.
v. If you need them, put cotton balls or special gel packs in your pouch to
keep it from leaking.
vi. Attach the pouch clip or use Velcro to close the pouch.
vii. Wash your hands again with warm soap and water.
Case study progress:
You have gathered all needed supplies, and D.S. is as comfortable as possible. You begin the
pouching change. Using the adhesive remover, with the push-pull method, you gently remove
the wafer. As you lift the wafer, you note that the peristomal skin has severe erythema directly
encircling the stoma. There is denudation (partial-thickness breakdown) at the medial stoma-
skin edge.

QUESTIONS:
1. How should the skin around the stoma look?
2. Generally, there are four different causes of erythema or skin breakdown. Identify two.
3. After you discover the reddened skin, how will you proceed with the ostomy care?
ANSWERS:
1. The skin around the stoma should have a normal appearance and the skin around the
stoma should be intact without irritation, rash, or redness.

2. CAUSES OF ERYTHEMA:

a. Structural characteristics such as stoma type, size, and location on the abdominal
plane can affect the seal of the pouching system, and a poor fit can result in
leakage and consequently irritation of the skin.
b. Flanges, paste, barrier rings, even the plastics of the drainable pouch clips may
cause patients to have burning, redness, and at times weeping. Many times this
allergic reaction leads to leaking and causes further denudement and ulceration.

3 If the skin surrounding the stoma appears to be irritated, red, or there is a rash present,
the nurse would want to apply Stomahesive powder to the affected area under the
ostomy itself. If the patients complains of itchiness and discomfort around the site
among other symptoms similar to that of a yeast infection such as a low grade fever,
the nurse may suggest applying antifungal powder such as 2% Miconazole to the area.
The nurse would provide the patient with clear instructions regarding the application of
the stomahesive powder including making sure the patient washes his hands before
touching the area, makes sure tha area is dry and clean prior to application, and to use
skin prep over the powdered area.

Case Study progress:


The next day, D.S.'s vital signs return to normal, and his abdomen is less distended. The
ileostomy is steadily draining greenish-brown liquid stool. The NGT is removed, and D.S. is
started on sips of clear liquids. When you go to check his ileostomy pouch, D.S. tells you, “I
know I've had this a long time, but I still can't stand to look at this thing. My wife usually helps
me with it, and I hate that.”

QUESTIONS:
1. What will you suggest for D.S. at this time?
ANSWERS:
1. Support group to work through the change in physical appearance as well as how this
change has affected D.S.’s relationship with his wife.