Flashcards in WEEK 11 Deck (47):
What is a urinary diversion?
When is it done?
= surgical rerouting urine from kidneys to site other than bladder
• Usually done when bladder tumour necessitates cystectomy, managing pelvic malignancy, birth defects, strictures, trauma to ureters + urethra, neuogenic bladder, chronic infection + intractable interstitual cystitis
1) Cutaneous urinary diversion (incontinent)
2) Continent urinary diversion (portion of intestine makes reservoir)
Removal of the bladder?
What is an incontinent urinary diversion?
• No control over passage of urine – requires ostomy bag
• Examples: ureterostomy, nephrostomy, vesicostomy, ileal conduits
Vesicostomy = ?
urine diverted from kidneys to stoma (see figure 42.20 p. 1342)
used when bladder intact but cannot void through ureter (d/d neurogenic bladder or obstruction); ureters connected to bladder still + bladder wall attached to opening in skin below navel
Most common type of urinary diversion?
Describe this kind.
ILEAL CONDUIT: aka ilieal loop
o Segment of ileum removed + intestinal ends anastamosed; one end of removed section closed with sutures, other end creates stoma in abdominal wall; ureters implanted in this pouch and urine drains from here
• Loop of sigmoid colon can also be used
• Ileostomy bag collects urine
oEasier to fit pouch than ureterostomy + mucosal layer in intestine helps protect from bacteria
WHat are continent diversions?
• Pt control through either intermittent catheterization of internal reservoir (Indiana pouch) or strained voiding (neobladder)
From med surg:
o (urinary reservoir made from intestine which has sm reservoir that has sm stoma, a catheter is inserted to empty the urine from the ppouch 4-6x daily)
o Orthotopic neobladder (uses intestinal pouch to replace the bladder which is in same place as orig bladder was→an void normally. The pt will have freq incontinence and needs bladder training schedule
1)Describe an indiana pouch
1)ureters attached to ileum shaped into reservoir pouch – catheter put through abdominal wall to empty (q4hrs)
2)piece of ileum replaces diseased or damaged bladder; sutured to urethra allowing person to urinate regularly
What kind of nursing assessments need to be done with urinary diversions?
• Assess I/O
• Changes in urine colour, odor, clarity? – mucous sheds common for those with ileal diversion
• Condition of stoma + surrounding skin
• Need right fit! Compromise to skin integrity if not d/t irritation
• Coping – sexual + body image issues
Changing urinary diversion pouch similar to bowel diversion except.... (2 ways, one pertains to immediately after sx)
o Empty continually → dry gauze placed under stoma during change to catch urine
o Immed after sx, may have ureteralstents present + protruding from stoma – remain 10-14 days
What is an ostomy?
How are bowel diversion ostomies classified?
• Ostomy = sx constructed artificial excretory opening
• Named according to anatomical loc
• Classified according to temporary/permanent + nature of construction of the stoma
SToma = ?
opening created in abdominal wall by ostomy
When are temporary + permanent bowel ostomies used?
• Temporary – for traumatic injuries or inflm conditions of bowel; allow distal section rest
• Permanent – for nonfunctional rectum or anus as result of birth defect or disease (ex: CA)
How does it work?
What risk does it pose?
How is odour?
drains from distal end of SI; liquid fecal drainage, constant + cannot be regulated; contains enzymes so more risk of skin breakdown; odour minimal (less bacteria)
o Ascending colostomy very similar except odour is issue (can have deodorant in appliance)
transverse + descending colostomy
How does these differ in terms of fecal matter?
o Transverse = malodorous mushy drainage, usually no control
o Descending = more formed
Advantages of this?
usually fully formed stool, frequency can be regulated…don’t have to wear applicance at all times + odour controlled
Overall: • Location influences character of drainage – farther = more formed and more control over frequency
Will stool characteristics from a colostomy ever change?
• If in place for longer, colon will begin to compensate + stool becomes more formed
Which type of ostomy is particularly irritating the skin?
What should an ostomy bag do?
What does it consist of?
• Ostomy appliance should protect skin, collect stool + control odour
• Appliance consists of skin barrier + pouch (as one piece or two – two has flange)
Are ostomy bags open or closed?
• Can be closed or drainable – drainable used for those who empty >2 times/day, closed more common for sigmoidoscopy (empty 1-2X/day)
How can the issue of odour be addressed for ostomy?
• Odours very important to pt self esteem – need right appliance to control; some allow odourless gas to pass through filter
• Once pt ambulatory, taught to work with ostomy in bathroom to avoid odours
How often are ostomy bags changed?
• Ostomy pouch applied for up to 7 days, changed before leakage occurs
• Assess skin – if erythema, erosion or ulcerated, change bag q24-48hrs
• More freq changes better is pt has pain or discomfort
• Empties when 1/3 to ½ full
What is colostomy irrigation?
• Similar to enema
• Used only for sigmoid or colostomy
• Purpose: extends bowel enough to stimperitalsis + cause evacuation → once regular evac pattern achieved, don’t have to wear pouch anymore
• Not currently taught routinely to clients
• Up to client to use irrigation or other method to achieve reg daily evac pattern – some prefer to use dietary method (as irrigation can take up to 1h/day)
• Done at same time each day
• For most ppl, 300-500mL enough to stimevac, some up to 1L as fluid often lost during procedure (can use cone on irrigation catheter to help this)
Those who perform colostomy irrigation for long time more prone to?
peristomal hernias, bowel perforation + electrolyte imbalance (with 500mL-1L infusions)
Sx is primary treatment method of colonic + rectal CA
What possible sx procedures are done?
o Segmented resection w anastomosis (remove tumour, portion of bowel on either size, blood vessels + lymph nodes)
o Abdominoperineal resection w permanent sigmoid colostomy – aka Miles resection (remtumour, portion of sigmoid colon, all of rectum and anal sphincter)
o Temporary colostomy followed by segmental reection and anastomosis and subsequent anatomosis of colostomy, allowing initial bowel decompression + bowel prep before resection
o Permanent colonostomy or ileostomy for palliation of unresectable obstructing lesions
o Construction of coloanal reservoir called colonic J pouch → 2 step process: loop ileostomy to diverse intestinal flow, and newly constructed J pouch (made from 6-10cm of colon) reattached to anal stump; then ileostomy reversed + continence preserved
Are urinary diversions done for managing incontinence?
Med surg says only as last resort
What factors must be taken into consideration when choosing if pt should have urinary diversion?
What factors play into pt acceptance?
• Must take into account: age of pt, condition of bladder, body buid, degree of obesity, degree of urethral dilation, status of renal fx, pt learning ability
• Pt acceptance depends on location of position of stoma, whether has watertight seal on skin + pt’s ability to manage the apparatus
How often is bag on ileal conduit urinary diversion changed?
• Once healed, bag remains in place as long as is watertight
Complications of ileal conduit procedure?
wound infection, dehiscence, urinary leakage, ureteral obstruction, hyperchoremic acidosis, SBO, ileus, gangrene of stoma, stenosis of stoma, rehal deterioration d/t chronic reflux, pyelonephritis, renal calculi
Term used for stool coming from ostomy?
Describe a continent internal fecal or urinary pouch.
Is this still done?
How many BM's/day with this menthod?
• Sx to create continent internal fecal or urinary pouches elim the need for an external pouch (the continent ileostomy is a pouch made from segment of ileum and placed under abdm wall w small tract from pouch opening through the skin. The pt inserts lg catheter through this opening to get effluent (this isn’t used much anymore as other options have longer term success rates).
• In ileal pouch anal anastomosis the surgeon creates an internal reservoir from segment of ileum that’s then connected to anal canal above the anal sphincter. Often a temporary ileostomy is done that allows the reservoir to heal
• Pt has approx 4-6BMs per day.
How do pt's report QOL to change with incontinent or continent urinary diversion
• Pts report same QOL when they have continent vs incontinent stomas/procedure
Evidence based practice on stoma care
• Pouching systems are more effective
• Current trend is application of a pouch directly to clean dry skin without skin prep, paste adhesive until the pt has speicic problem
• Adhesives are P and heat sensitive. Apply gentle P for several kinutes to adhere the barrier to the skin
• Now have Velcro like closure to elim the need for a clip to close the bottom of pouch
What does stoma look like if healthy?
Does it change in size?
What should periosteal skin look like?
o Stoma should be red or pink and moist. Report gray purple or black stoma to the charge nurse or HCP
o In the 4-6wks after sx the stoma will likely dec in size. Meas with each pouch change
o Peristomal skin normally is intact with some reddening. Blisters, rash, rawlike appearance is abn
Why is Cut to fit transparent pouch is preferred when pouching colostomy or ileostomy?
itll cover the peristomal skin without constricting the stoma and allow for visibility of the stoma
How might stoma site be immediately post op and what does this mean in terms of changes?
• Immed postop the stoma may be edematous and abdm distended (resolves after 4-6wks after sx. During this time its nec to revise pouching system to meet changing sie of stoma and body contours)
According to P+P how often should an ostomy pouch be changed?
(Colostomy + ileostomy)
• Pouch should BE CHANGED EVRY 3-7 DAYS for colostomy and 3 TO 5 FOR ILEOSTOMY.
What might repeat leaking from colostomy indicate?
Should you patch a leaking ostomy rather than change it?
• Repeat leaking may indicate need for diff type of pouch.
If leaking change it. Taping or patching it leaves skin exposed to Es rxn
What to note about effluent when emptying ostom bag?
• Note consistency of effluent and record I/O
Observe stoma for what?
TYPE, LOCATION, COLOR, SWELLING, SUTURES?, TRAUMA, HEALING OR IRRITATION OF PERISTOMAL SKIN. Toss gloves
Important consideration for monitoring presence of flatus post-operatively in pt with ostomy?
Flatus indicates return of peristalsis after sx. May not be observable if pouch has gas filter
Procedure for changing ostomy bag?
• Pos pt in semireclining or supine during assessment and pouhing (decs wrinkles→easier apply)
• Gloves on, towel under pt and across lower abdm
• If not done during assesent tae off old pouch and skin barrier gently by pushing the skin away from barrier. Empty and meas if nec
• Clean peristomal skin gently w warm tap water using washcloth, don’t scrub. Pat dry
• When pouching ileostomy put washcloth over stoma (as they leak continuously in some pts)
• Meas stoma (expect size to change for 4-6wks postop)
• Trace pattern of stoma meas on pouch backing or skin barrier
• cut opening on backing THAT IS AT LEAST 1/8 LARGER THAN STOMA TO AVOID P ON IT
• remove protective backing from adhesive and appy over stoma, press firmly into place around stoma and outside edges. Have pt hold hand over pouch to apply heat to secure seal
• close end of pouch w clip or integrated losure
When is bleeding from stoma normal?
If touch stoma minor bleeding is normal
(and I assue freshly post-op as well)
What to do if:
• skin around stoma is irritated, blistered, bleeding, or rash is noted. May be caused by undermining of pouch seal by fecal ontents, allergic rxn or fungal skin eruption
o remove pouch more carefully
o hange more freq r use diff system
o consutl ostomy care nurse
What to do if:
• necrotic stoma is mnft by purple or black color, has dry instead of moist texture, fail to bleed when washed gently or tissue is sloughing
o document appearance
What to do if:
• pt refuses to view stoma or participate n care
o obtain referral for ostomy care nurse
o allow pt to express feelings
o enc family support
Ped's considerations for stoma?
• infants ingest lg amounts of air while feeding and might need to open pouch often to let it out
• don’t use skin stuff on preemies as their skin is v absorptive