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106 Cards in this Set

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Surgical opening into the colon by means of stomas to allow drainage of bowel content.
Colostomy
-Type of Colostomy-Semi liquid stool consistency Increased fluid requirements
Needs appliance & skin barriers, Can't be irrigated
Ascending Colostomy
What are the indications for Ascending colostomy surgery ?
Perforating diverticulitis in lower colon.
Trauma
Inoperable tumors of colon
Rectum or pelvis
rectovaginal fistula
Type of Colostomy-Semi formed stool consistency, possibly increased fluid requirement, uncommon bowel regulation, requires appliance and skin barrier, cant irrigate
Transverse Colostomy
Indication for surgery may also be performed in children who are born with imperforate anus
Transverse Colostomy
Formed stools, no change in fluid requirements, bowel regulation possible with irrigations and/or diet
Need for appliances and barriers dependent on regulation
Decending & Sigmoid colostomy
Opening from the ileum or small intestines through the abdominal wall. By passes the entire large intestines
Ileostomy
Stool is liquid to semi liquid consistency and contains proteolytic enzymes
Increased fluid requirements
No bowel regulation or irrigation.
Requires wearing appliance and skin barrier
Ileostomy
Indications for Ileostomy Surgery
Ulcerative colitis
Crohns disease
Trauma
Cancer
Birth Defect
Familial polyposis
Closure of the colostomy is anticipated. Temporary large stoma where bowel is brought to abdominal surface and opening created in anterior wall of bowel to provide fecal diversion.
One stomas with proximal(Drains Stool) and distal (drains mucous) opening and an intact posterior wall that seperates the two openings. It is sutured to the abdominal wall and held in place with a plastic rod for 7-10 days
Loop Stoma
Proximal stoma is for ?
Draining stool
Distal stoma is for?
draining mucus
One Stoma formed from the proximal end of the bowel with the portion of the gi tract either removed or sewn closed and left in the abdominal cavity
Hartmanns pouch
Bowel is surgically severed and two ends are brought out onto the abdomen as two seperate stomas. Proximal end is the functional stoma. distal end is the nonfuctional stoma called a mucus fistula.
Intended to be temporary diversion in cases where resection is required die to perforation or necrosis
Double Barrel Stoma
The colon is removed and ileum is anastomased or connected to an intact anal sphincter.
Ileoanal Pull through
Internal pouch created from ileum. End of pouch sewn or anastomosed to the anus. Surgery is done in several stages and patient may have temporary colostomy 6-12 weeks until ileal pouch is healed
Ileoanal Reservior
Internal pouch created from a segment of the ileum part of the pouch is brought out low onto the abdomen as the external stoma. A one way nipple valve allows fecal contents to drain when catheter is intermittently inserted in the stoma, no external collecting device is required.
Kock Pouch
Immediately after this surgery a drainage catheter is left in place for 2-4 weeks. The catheter is irrigated with 20 ml of NS every 3-4 hours. Pt is taught to catheterize intermittently with 28Fr catheter
Kock Pouch
Kegal exercises will
help them stregthen the pevic floor and provide muscle control for continence

-Ileoanal reservoirs
Special considerations for pts who have ileoanal reservoirs
kegel exercises
mucus discharge from rectum
Frequent Stools
eliminate foods known to increase bowel activity
Increase fiber decrease sugar
may need metamucil
Antdiarrhea agents
Shouldnt respond to every urge to defecate to help increase pouch capacity
What is the nurses postoperative management of patient with Colostomy
-Focus on assessing the stoma.
-Protecting the skin
-Selecting the pouch
-Patient being able to adapt psychologically to body changes.
What characteristics should nurse observe postoperative for the patient with a colostomy
Type of Stoma
Color
Size
Location of stoma
Peristomal Skin
What is the normal Color of the mucosa?
Rose to brick red
What does a pale stoma indicate?
Anemia
A stoma that indicates inadequate blood supply or excessive tension would show signs of ?
blanching, dark red or purple
What would a black stoma indicate?
Necrosis
How often should a stoma be assessed ?
Every 8 hours and color should be documented
It is normal to have mild edema post op of stoma for?
The first 5-7 days
WHat may severe edema of the stoma indicate?
obstruction of the stoma, allergic reaction to food or gastroenteritis.
When the nurse touches the stomal mucous and a small amount of blood oozes from it, Is this normal? Why?
stomal mucosa is so vascular so this is a normal expectation.
When is the first pouching system applied?
in surgery
After surgery when is does the stoma start to function?
What is the consistency like?
2-4 days post op
At first stomal drainage
As peristalsis returns after surgery, flatus and fecal drainage returns usually?
2-4 days
What does the nurse need to observe and document for a patient with a stoma
Volume
color
consistency
Intake and Output
Are there any eating restrictions for the patient with a colostomy?
No
Are there any eating restrictions for the patient with a ileostomy?
Yes it is important for some foods to e avoided to prevent an intestinal blockage
What kind of foods should a patient with an ileostomy avoid
stringy high fiber foods
-Celery
-Coconut
-Corn
-Coleslaw
-Citrus Fruits
-peas
-popcorn
-spinach
-dried fruits
-nuts
-pinnapple
-seeds
-fruit and vegs skins
What helpful tips can you provide to a patient with an ileostomy?
-Encourage pt. to eat at regular intervals
-Chew food well
-Drink adequate fluids
-Avoid overeating
-Avoid excessive weight gain
The opening of the pouch should be how much larger than the stoma
1/8 inch larger
When should the patient empty the pouch
When the pouch is 1/3 full
After emptying the pouch what else is necessary to do?
Cleanse the pouch from top to bottom with a squeeze hand bottle filled with water.
(1 piece unit)
2 piece unit can be snapped off washed and snapped back on
When should the entire pouch unit be changed?
every 4-7 days both (1 or 2 units) depending on the seal
Patients with permenant descending Colostomy will
-wear drainable pouch at all times
Candidates for this option are assessed for past bowel habits and frequency of stools, location of colostomy, age, independence,dexterity, general health and personal preference.
Colostomy Irrigation- to establish regularity and relieve constipation
Why is ileostomy care so different from colostomy care?
The drainage from the ileostomy contains proteolytic enzymes that literally digest the skin. That is why skin care is so important for the patient with a ileostomy
Why is ileostomy care so different from colostomy care?
The drainage from the ileostomy contains proteolytic enzymes that literally digest the skin. That is why skin care is so important for the patient with a ileostomy
The drainage of the ileostomy is ? Color?
liquid in consistency, constant and extremely irritating to the skin
Color- is dark green initally and progresses to yellowish brown when patient begins to eat
Its important to watch what type of labs with patients with ileostomy?
Fluid electrolytes balance
-K+
-Na+
-Fluid Deficits
Fecal output for ileostomy care can range from what in the beginning ? to what as it regulates?
Fecal output can range from 1000-1500ml/24hrs.
decreases slighty within 10-15 days to an average of about 800ml per day
Encourage the patient to drink how much fluid? more around what time of year ?
1-2 liters of fluid per day
more if they have diarrhea and in the summer when they are perspiring.
- Encourage to drink fluids rich in electrolytes
Ileostomy Care
-Begin on a low roughage diet
-Chew food completely
-Avod stringy, fiber foods ro prevent blockage
Type of stoma that bleed easily when touched ?
ileal stoma
How to protect the skin and stoma of a ileostomy patient
-Pouch with skin protective barrier.
-adhesive backing
-pouch with opening no more than 1/8 inch larger than the stoma
-Empty pouch when 1/3 full
-Change immediately if it has begun to leak.
If the terminal ileum is removed what may your patient need?
Vitamine B12 injections every 3 months
What kind of meds are not recommended for a patient with an ileostomy Why? what is perferred?
Enteric Coated, time release meds or hard tablets may not be absorbed.
Liquid or chewable meds are perferred
Patients that have had a ileostomy need what since the colon absorption and synthesis are eliminated?
Vitamin A, D, E, & K
If you patient with an ileostomy develps a food blockage what tips may you encourage?
-Get into a knee-chest position and gently massage the area below the stoma
-Try a warm tub bath to help relax abdominal muscles
- Remove pouch and replace it with one tha has a larger opening
-May take fluids only as long as not vomiting and passing some stool.
-If vomiting and not passing stool take nothing by mouth and contact MD
Patient teaching for stomas
Patients readiness to learn
-assist with emptying, cleaning, and changing pouch
WHat happens if the patient isnt ready or willing to learn or hasnt progressed ?
The nurse must teach a caregiver how to change the pouch and manage the care of the pouch until the patient is ready to learn
When is the pouch change best performed?
Before eating because the stoma is less active
What is the ideal change of the appliance (pouch)
5-7 days but if it leaks it must be changed immediately
It is abnormal for the pouch to smell?
Yes, The pouch is order proof plastic but if the bag isnt cleaned correctly or if leak has developed
What can a patient do to eliminate odor besides effective cleaning management?
There are products on the market to eliminate odors
-drops that can be put in bag while changing or cleaning.
-Neutralizing sprays when the pouch is changed
-bags with built in charcoal filters
Tablets that patients can take by mouth to eliminate the odor
-Activated Charcoal
-Chlorophyllin Copper
-Bismuth Subgallate
Reason For Urinary diversion.
-Removal of bladder from cancer
-Neurogenic bladder
-congenital anomalies strictures
-Trauma to the bladder
-chronic infections with deteriorateion of renal function
Types of Urinary Diversions
Incontinent
1. Ileal conduit
2. Cutaneous ureterostomy
3. Nephrostomy
Ureters are implanted into a segment of the ileum that has been resected. Ureters are anastomosed into one end of the conduit and the other end if brought out through the abdominal wall to form a stoma.
No valve or voluntary control
Ileal conduit
Advantages and Disadvantages of Ileal Conduit
A- Good urine flow with few physiologic alterations

D- Surgical procedure is complex and Must wear an external collecting device
Must care for stoma and drainage bag
Uterers are excised from the bladder and brought through the abdominal wall to form stoma
Cutaneous Ureterostomy
Advantages and Disadvantages of Cutaneous Ureterostomy
A- Not considered major surgery

D-External collecting device must be worn
Possible of stricture or stenosis of small stoma
Catheter is inserted into the pelvis of the kidney. May be done to one or both kidneys and may be temporary or permanent. Most freq done in advanced disease as a pallative measure.
Nephrostomy
Advantages and Disadvantages of Nephrostomy
A- No need for major surgery

D- High risk of renal infection. Predisposition to calculus formation from catheter.
Catheter should be clamped and remain open
is the connection of two structures
anastomosis
Loops of intestines are anastoosed together and then connected to the abdomen via stomal segment. Ureters are attached to the pouch above the valve which prevent reflux of urine to the kidneys,
A second valve is placed in the intestinal segment leading to the stoma
Continent Diversions
Koch pouch
Ureters are anastomsed to the colon portion of the reservoir in a manner to prevent reflux. The ileocecal valve is used to provide continenceand the section of ileum that extends from the intestinal reservoir to the skin is made narrower to prevent urine leakage
Indiana Pouch
What type of Diversions are the stoma usually flush with skin and placed lower on the abdomen then the ileal conduit stoma
Continent Urinary Diversion
A patient that will need to self catheterize themselves will need to
Self catheterize every 4-6 hours
need to irrigate the internal reservoir to remoce mucus,
but will not have to wear an external device.
It is abnormal for the pouch to smell?
Yes, The pouch is order proof plastic but if the bag isnt cleaned correctly or if leak has developed
Complications of the Urinary Diversions
-Breakdown of anastomoses in the GI Tract
-Leakage from the ureteroileal or ureterosigmoid anastomosis
-Paralytic Ileus
-Obstruction of Uterers
-Wound infection
-Mucocutaneous seperation
-Stomal necrosis
Pre op care for patients with Urinary diversions
When to teach
-assess ability and readiness to learn before initiating a teaching program, involve patients family in the teaching process
What Pre op care is taught to the client with a continent urinary diversion?
Teach patient who will have a continent diversion how to catherize themselves and irrigate and adhere to a strict schedule
What should the nurse arrange for the patient to meet with for pre op of urinary diversion
Arrange pre op meetings for patient with ET(Enteralstomal Therapy) nurse and with volunteer from Unitied Ostomy Association
Preop the patient will be prepared by..
cleaning out there bowels completely
Patients adjust better to the procedures when ?
When they have been well informed about the surgical procedure, Post operative period and long term management goals.
Stent is placed in Ileal conduit POst op for?
To promote Urinary Drainage
POst op continent urostomy will have what in place?
will have a catheter or stent in stoma (sutured in place) to allow drainage form reservoir.
Post op of a urostomy procedure the patient may have to have what until perstalsis returns
An NG tube.
May also start on clear liquids to advance as tolerated
What may be placed over the stoma after a ileal conduit procedure?
a clear pouch which is placed over the stoma for easily assessing
What should be monitored after a patient comes out of a urostomy procedure. Also what is expected ?
Urine output
Blood in the urine is expected in immediate postop period with gradual clearing
Mucus is present in urine bc it is secreted by the intestines as a result of the irritating effect of the urine
What is encouraged Post op of a urostomy procedure?
High fluid intake to flush the ileal conduit or continent diversion.
This is high risk for patients with urostomies
UTI
What may be the reason as to why stomal or loop stenosis occurs
Urine being retained in the conduit with subsequent electrolyte imbalances
What should the urine level be for a patient that has a urostomy and why?
Strive to keep urine Acidic because alkaline urine promotes encrustation and stone formation
Edema is usually present after an ileal conduit stoma when should the patient start to see it subside and decrease in size
within 7 days edema will subside and stoma will decrease gradually in size over the next 6-8 weeks
who may need special assistance after urostomy procedures?
Elderly and patients with limited dexterity
What typeof information should the nurse provide the patient with postop of a urostomy procedure
Need to know:
-Where to purchase supplies
-Emergency #'s
-Ostomy support groups
-F/U appt. with nurse & MD
Complications with stomas
-Bleeding
-Stenosis
-Prolapse
When teaching ostomy care it is important to teach the patient how important it is to have them
Examine the peristomal skin for any signs of breakdown. Its harder to prevent then it is to heal.
Patients with ostomy should be taugh certain things about being in water
Patient may bathe or shower with or without the pouch
- swimming with pouch in place
Routine skin care for ostomies
Proper method for removal:
-gently peel pouch away from the skin while pressing down on or supporting the skin.
-avoid wiping the area with paper towels or toliet paper that leave a lot of lint behind
Routine cleansing of ostomies
Wash with warm water
soap is likely to leave residue that can cause dermatitis and decrease the adhesiveness of the pouch.
if soap is used be sure to avoid ones with oil and rinse throughly
Patients with ostomies may consider buying this product for when they are away from there home
Tucks - works well or any cleansing wipes that dont contain lanolin or emollients.
This should be done routinely for a patient with an ostomy to prevent pain with pouch removal
-Shaving if peristomal skin is hairy to prevent folliculitis and pain.
Caution your patient not to do what for the first 6-8 weeks after surgery of the ostomy
Lift anything over 10lbs , all other activities are ok
Before your patient is discharged they should beable to ?
-Demonstrate cleaning and changing the pouch
-verbalize where to obtain supplies
-Know how to contact resource person for issues
-know how and when to follow up with physicians
Adaptation to the stoma
gradual process because patient may show grief over the loss of a body part and an alteration in body image.
-Adjustment is indivualized
-Patient are concerned about body image,sexual activity,family,responsibilities and changes in lifestyle.