Ostomy care

3.1 Lesson Objectives Upon completion of this lesson, you will be able to:

Explain the purpose of a bowel or bladder diversion. Identify types of bowel and bladder diversions.

Explain differences in color and consistency of drainage based on the location of a bowel diversion

Perform ostomy care including removal of drainage bag, assessment of stoma, stoma care, and replacement of new drainage bag. Required Reading: Elkin, Perry, & Potter, (2007). Nursing Interventions & Clinical Skills: 4th Edition. St. Louis, Missouri: Mosby, Inc. Lesson 3: Ostomy Overview (pp. 725-732) Lesson 4: Pouching an Ostomy (pp. 725-732) Patient with an Ostomy Scenario Patient information Name: Pat Peterson Age: 40 years old Gender: Male or Female Weight and Height: Appropriate to Height and Body Build History of present illness: Had a bowel resection done five days ago. At that time a colostomy was place for bowel rest. He has been on a post surgical floor since the surgery. The nurses have been trying to give patient teaching regarding the home care of the ostomy but the patient has not been interested in learning stating that he/she doesnt like the look of the stoma and thinks that it is gross. Past medical history: Chrons Disease for 18 years Medications: Sulfasalazine, MVI, and Prednisone. Acetaminophen PRN. Prerequisite knowledge (Learners should have competencies in these specific areas prior to the scenario) 1. Ostomy Care 2. Patient Education 3. Normal GI anatomy and physiology

Learning objectives (One objective must be related to communication and one related to safety) 1. Demonstrates proper technique for the care of an ostomy including continual assessment and changing the system. 3. Communicates effectively with patient to minimize anxiety. 4. Demonstrates effective patient and family education of how to care for the ostomy at home. 5. Describes and recognizes signs of stoma irritation and communicates to the patient and family when they should call his/her provider. SCHEDULED: MAR: 22222 Peterson, Pat DOB: 03/18/1968 ADM: 1 week ago Sulfasalazine 4g PO BID Multivitamin with iron, 1 tab QD per FT Prednisone Taper PO 20 mg BID today PRN: MAR: 22222 Peterson, Pat DOB: 03/18/1968 ADM: 1 week ago Acetaminophen liquid, 650mg Q4hrs per FT PRN for temperature/pain MD Orders: Titrate Oxygen for SpO2 < 94% Notify MD for: SpO2< 90%, Systolic BP <90 or >150, HR <50 or >110 RR <10 or >30 Temp. >102.0F, Blood in stool, increased abdominal pain, Colostomy output <100cc in 4 hours, emesis. 0600-1500 1500-1900 1900-0600

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3.2 Introduction Certain diseases and/or conditions involving the bowel or bladder require surgical intervention to create an opening into the abdominal wall for fecal or urinary elimination. The creation of a bowel or urinary diversion may be temporary or permanent. A portion of intestinal mucosa or segment of ureter is brought out to the abdominal wall, and a new opening is formed to allow feces or urine to drain. This opening is called an ostomy. The piece of intestine that is brought out onto the client's abdomen is called a stoma. The drainage from the stoma is called effluent. A stoma can cause serious body image changes, particularly if it is permanent. You must help the client to understand that a normal lifestyle is possible with an ostomy. 3.3 Types of Bladder Diversions Two categories of urinary diversions exist:

Incontinent: Clients who have an incontinent diversion are unable to control when the urine exits from their stoma and therefore must wear an external urinary ostomy pouch at all times. Examples include an ileal conduit and ureterostomy.

Continent: Clients who have continent diversions such as the Kock or Indiana pouch do not require an external ostomy pouch over their urinary stoma. They are taught to insert a catheter into their stoma to drain the urine periodically throughout the day. The three-loop S and the two-loop J ileoanal pouches provide continence by using the client's anal sphincter.

3.4 Types of Bowel Diversions An enterostomy is any surgical procedure

that produces an artificial stoma in a portion of intestine through the abdominal wall. Surgical openings may be created in the ileum (ileostomy) or colon (colostomy), with the ends of the intestine brought through the abdominal wall. The location of the ostomy determines the consistency of stool passed or effluent passed. An ileostomy bypasses the entire large intestine, so stools are liquid, frequently contain digestive enzymes, and must be pouched at all times. A colostomy of the transverse colon generally results in a thicker, semi-formed stool. There are various types of colostomy construction:

Loop colostomy: A loop colostomy is usually performed in a medical emergency when closure of the colostomy is anticipated. The loop ostomy has two openings through the one stoma. The proximal end drains stool and the distal portion drains mucus.

End colostomy: The end colostomy consists of one stoma formed from the proximal end of the bowel with the distal portion of the GI tract either removed or sewn closed. For many clients, end colostomies are a result of surgical treatment of colorectal cancer.

Double-barrel colostomy: In a double-barrel colostomy, the bowel is surgically severed and the two ends are brought out onto the abdomen. The double-barrel colostomy consists of two distinct stomas. The proximal functioning stoma and the distal nonfunctioning stoma. The distal stoma may excrete mucus. 4.2 Introduction

A pouch is placed over the stoma to collect all effluent and protect the skin from irritating drainage. A pouch with its skin barrier should fit comfortably, cover the skin surface around the stoma, and create a good seal. The skin barrier of a pouching system should be changed every 3 to 5 days. Many types of pouches and skin barriers are available. A clear pouching system allows visualization of the stoma without having to remove the pouch. Some pouches have skin barriers directly preattached and are called one-piece pouching systems. The manufacturer already precuts some of these one-piece pouches to size, whereas others must be custom cut to size for the client's stoma measurement. One-piece pouches are open-ended pouches that can be opened periodically to empty effluent without having to remove the pouch from around the stoma. Other systems are two separate pieces. The pouch is applied to the skin barrier by attaching it to the flange (a plastic ring) on the barrier. Often the skin barrier needs to be custom cut to the client's specific stoma size. For two-piece systems, the skin barrier with flange must be used with the corresponding size pouch that fits that flange from the same manufacturer to prevent leakage. 4.3 Delegation The skill of pouching either a urinary or bowel ostomy, especially a newly established ostomy, is inappropriate to delegate to AP. In some agencies, the care of established enterostomies may be delegated to AP. If the skill of pouching an established enterostomy is delegated, instruct the care provider:

About the appropriate pouch and skin barrier

About the expected amount, color, and consistency of drainage from the enterostomy

To report changes in volume and/or consistency of drainage

AP should be reminded to report changes in the client's stoma and surrounding skin integrity. 4.5 Assessment Before pouching an ostomy, you should:

Auscultate for bowel sounds to verify the presence of peristalsis.

Observe the existing skin barrier and pouch for leakage and length of time in place.

Observe the stoma for color, swelling, trauma, and healing. The stoma should be moist and reddish pink.

Assess the type of stoma. Stomas can be flush with the skin or be a budlike protrusion on the abdomen.

Observe the abdominal contour and abdominal incision (if present).

Observe the effluent from the stoma and document the intake and output. Plan on changing the skin barrier pouch at times of less effluent output. Avoid changing after meals.

Assess for skin irritation and associated leaking of the pouching system.

Assess the abdomen for the best type of pouching system to use. Consider the contour, the presence of scars/incisions, the location, and the type of stoma.

Assess the client's condition for the best type of pouching system to use. For example, clients who have poor dexterity or limited vision may find a onepiece system or a precut pouch and skin barrier more desirable to use.

After skin barrier and pouch removal, assess the skin around the stoma (i.e., peristomal skin).

Determine the client's and family's emotional response and understanding of an ostomy and its care. 4.6 Assessment of Stoma

There are many aspects to consider when assessing your client's stoma:

Number of stomas Stoma location

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In what part of the bowel is the stoma located? Is it near or in a skin fold?

Stoma type
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New or established? Bud or flush?

Stoma shape
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Round or oval? Regular or irregular?

Stoma visibility
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Color? (It would be normal for a stoma of an infant to change in color temporarily to white or purple when the baby is crying.)
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Bleeding?

Stoma construction
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End, loop, or double barrel? Kock pouch?

Stoma drainage
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Continent or incontinent?

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Amount of drainage? Consistency?

Stoma size

4.7 Stoma Complications

Observe your client for any signs of possible stoma complications:

Bleeding

Necrosis (evidenced by purple or black discoloration in stoma with impaired circulation)

Prolapse Hernia Laceration Irritation Retraction Stenosis

4.9 PlanningUrinary Ostomy Equipment The equipment necessary to pouch a

urinary diversion includes the following:

Clean disposable gloves Underpad, washcloth, towel, and warm water Scissors with pointed end Measuring guide Tissue or toilet paper Gauze pad or tampon New pouch, skin barrier, and adhesive (if required) Urinary drainage bag

4.10 PlanningBowel Ostomy Equipment The equipment necessary to pouch a bowel diversion includes the following:

Pouch: clear, drainable colostomy/ileostomy in correct size for two-piece system or custom cut-to-fit, one-piece type with attached skin barrier

Pouch closure device, such as a clamp

Ostomy measuring guide Adhesive remover (optional) Clean disposable gloves Ostomy deodorant Gauze pads or washcloth Towel or disposable waterproof barrier Basin with warm tap water Scissors Skin barrier such as sealant wipes or wafer Stoma paste or Stomahesive (optional) Tape or ostomy belt

4.12 PlanningExpected Outcomes You should explain the procedure as it is being performed. This lessens the client's anxiety and promotes the client's participation. Expected outcomes after completion of the procedure include:

The client is without discomfort. The stoma is moist and reddish pink. The skin is intact and free of irritation.

The stoma is functioning with a moderate amount of liquid or soft stool and flatus (bowel diversion) or moderate amount of urine (urinary diversion) in the pouch.

The client observes the stoma and participates in ostomy care.

The client asks questions about the procedure and may attempt to assist with changing the pouch. 4.17 Evaluation To determine whether expected outcomes have been met, you should evaluate the following:

Ask if the client feels discomfort around the stoma. This determines the presence of skin irritation.

Note the appearance of the skin around the stoma while the pouch is removed and the skin is cleansed. Reinspect the condition of the skin barrier and adhesive. Inspect the edges of the pouch for "tracking" of effluent under the edges. This may signal a potential leak caused by a skin fold or wrinkle. This determines the condition of tissues and the progress of healing. It also determines the presence of leaks or potential problems.

Auscultate the bowel sounds and observe the characteristics of the stool. This determines the return of peristalsis and bowel elimination.

Observe the client's nonverbal behaviors as the pouch is applied. Ask if the client has any questions about pouching. This may indicate an emotional response to the stoma and a readiness for teaching. It also determines the level of understanding of the procedure. 4.19 Unexpected Outcomes Unexpected Outcome The client's peristomal skin is irritated and/or the client complains of a burning sensation. Intervention

Assess for causes of skin breakdown:

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Undermining of pouch seal by fecal contents Removing pouch too quickly Infection

Remeasure the stoma size. Check whether the selected pouch is correct for the client's stoma size. Obtain a referral for enterostomal therapy. Use a skin barrier for subsequent pouch

Unexpected Outcome

Intervention changes.

Unexpected Outcome The client's stoma appears necrotic as manifested by:

Intervention

Assess the circulation to the stoma. Check whether the selected pouch is correct for the client's stoma size. Determine the presence of excessive edema or excessive tension on the bowel suture line. Notify the physician.

Purple or black color Dry instead of moist texture Bleeding when washed gently Presence of tissue sloughing

Unexpected Outcome The client's skin barrier and pouch leak.

Intervention

Assess whether the client is waiting too long (e.g., if pouch is more than half full of stool) to empty the pouch. Remeasure the stoma and reevaluate the pouch and skin barrier size. Determine whether the client is cutting out the correct size of skin barrier. Evaluate whether the stoma is in a skin fold or whether other irregularities exist. Assess for peristomal hernia. Determine whether a convex disk, skin barrier paste, or other measures are needed to prevent leakage.

Unexpected Outcome The client is unable to perform an ostomy pouching change.

Intervention

Determine whether the client lacks the physical or mental ability to do

Unexpected Outcome

Intervention ostomy self-care.

Eliminate distractions and other factors (e.g., pain) that might interfere with the client's performance of ostomy self-care. Reevaluate the client's understanding of ostomy self-care. Reevaluate the client's problems with self-image, coping skills, and support systems. Obtain information about ostomy support groups in the community.