Med-Surg Chp 48

Chapter 48: Caring for Clients With Ostomies

Author: Lisa Kolber MSN, RN, CCRN, PHN
Publication: Wolters Kluwer Health | Lippincott Williams & Wilkins
Edition: 13/E

Student Learning Objectives

  1. Differentiate between ileostomy and colostomy.

  2. Explain how stool is excreted from three types of ileostomies.

  3. Describe the two-part procedure needed to create an ileoanal reservoir.

  4. Discuss various types of colostomies.

  5. Explain ways that clients with descending or sigmoid colostomies may regulate bowel elimination.

  6. Discuss preoperative nursing care of a client undergoing ostomy surgery.

  7. List complications associated with ostomy surgery.

  8. Discuss postoperative nursing management of a client with an ileostomy and colostomy.

  9. Describe the components used to apply and collect stool from an intestinal ostomy.

  10. Cite reasons for changing an ostomy appliance.

  11. Summarize how to change an ostomy appliance.

Ileostomy Overview

  • Ileostomies are primarily indicated in cases of chronic inflammatory bowel disease and cancer.

  • They can be temporary or permanent.

  • An ostomy is an opening between an internal body structure and the skin.

  • There are three types of ileostomies:
      - Standard (Brooke or conventional) Ileostomy
      - Continent Ileostomy
      - Ileoanal Reservoir (J-Pouch or pelvic pouch)

Standard or Brooke Ileostomy

  • Involves surgical removal of the entire colon or rectum through total colectomy, or the colon may be temporarily bypassed.

  • The terminal end of the ileum is externalized through the right lower quadrant (RLQ) of the abdomen, located slightly below the umbilicus.

  • Stool and gas are continually released; the stool typically appears liquid, mushy, or pasty, containing digestive enzymes and acids.

Continent Ileostomy / Abdominal Pouch (Kock pouch)

  • Similar to the standard ileostomy but creates an internal reservoir for storage of gastrointestinal (GI) effluent (discharged fecal material or liquid feces).

  • Reservoir sufficiently stores effluent for several hours, allowing the client to remove it with a catheter, thereby eliminating the need for an external appliance.

  • Provides some control to the patient, and gauze packing is applied by the surgeon to the perineal area from which the lower intestine was removed, remaining for 1 week.

Ileoanal Reservoir / J-Pouch / Pelvic Pouch

  • Also referred to as ileoanal anastomosis; this procedure aims to maintain bowel continence.

  • Performed in two stages:
      - First Stage: creation of a temporary ileostomy and formation of an ileum pouch connected to the anal cuff.
      - Second Stage: occurs 2-3 months later; it involves the closure of the temporary ileostomy and anastomosis of the two sections of ileum.

  • Control of bowel movements is achieved as edema subsides and the anal sphincter strengthens.

  • The procedure preserves innervation to male genitalia, reducing likelihood of bladder dysfunction, erectile dysfunction, or infertility.

Preoperative Care for Ileostomy

Surgical Management

  • The primary provider explains the procedure's purpose, benefits, and potential risks to the patient, including:
      - Possible bladder and sexual dysfunction due to parasympathetic nerve injury.
      - Recommendation for males to collect and store sperm due to potential infertility.
      - Slightly diminished fertility in women.

  • Description of stoma appearance and function, marking the surgical site.

Preoperative Preparations

  • Preparing for surgery includes bowel cleansing via dietary restrictions, laxatives, antibiotic prophylaxis, and IV antibiotics.

  • Steroid prescriptions must be tapered (never abruptly stopped) to avoid adrenal crisis, particularly for patients on prednisone.

  • Preoperative “stress dose” of IV steroids administered for patients on long-term steroids to prevent adrenal crisis.

  • Type and crossmatching done prior to surgery.

  • Discontinuation of immunosuppressive agents 3-4 weeks before the procedure and stopping aspirin 1 week before surgery.

Nursing Process for Clients Before Ileostomy Surgery

Assessment

  1. Obtain comprehensive medical, allergy, diet, and drug histories.

  2. Closely monitor patients on corticosteroids for adrenal insufficiency symptoms (weakness, lethargy, hypotension, nausea, vomiting) during dosage tapering.

  3. Conduct a physical assessment focusing on:
       - Inspection of the abdomen's skin
       - Auscultation of bowel sounds
       - Recording vital signs and weight.
       - Reviewing preoperative lab results for blood cell counts and serum electrolytes.

  4. Document dietary modifications and antibiotic therapies as indicated.

Community Resources and Education

  • Referral to community resources enhances the patient’s postoperative quality of life, with additional educational support from organizations like the Crohn's & Colitis Foundation of America.

  • The involvement of a Wound, Ostomy, and Continence (WOC) nurse may help facilitate ostomy education, alleviating preoperative anxiety.

  • Preoperative intimacy and coping skills considerations for clients and partnerships should be encouraged.

Evaluation of Expected Outcomes

Assessment confirms that the patient demonstrates understanding of preoperative expectations, surgical details, and creates avenues for coping through education.

Postoperative Nursing Management

Standard or Brooke Ileostomy

  1. Manage rectal packing to absorb drainage and promote healing (removed after 5-7 days).

  2. Monitor and manage nasogastric tube (NGT) for gastric decompression, and maintain IV fluids to uphold fluid, electrolyte, and nutritional balances.

  3. Administer antibiotic therapy and analgesics as needed.

  4. Monitor healing of the wound and manage complications such as intestinal obstruction.

Continent Ileostomy Management

  1. Reinforce perineal packing and monitor the abdominal dressing.

  2. Connect the stomal catheter if ordered to low intermittent suction.

  3. Aim to prevent tension on healing suture lines and carefully check for signs of obstruction associated with the ileal catheter (e.g., lack of fecal drainage, fullness in pouch area, leakage).

  4. Monitor color and size of the stoma, maintain peri-stomal skin cleanliness, and evaluate ileal output closely.

Ileoanal Reservoir Management

  1. Similar initial nursing measures as with standard ileostomy, with additional care for the anal area for drainage.

  2. Educate the client regarding perineal exercises (akin to Kegels) that rehabilitate anal sphincter control.

  3. Use thorough cleansing protocols to maintain hygiene.

Components for Ostomy Management

  • Disposable and Reusable Equipment:
      - An ostomy appliance may be disposable or reusable, changing daily as required postoperatively.

Assessment and Managing Complications

Protection of Peristomal Skin

  • Teach clients how to keep peristomal skin intact by demonstrating gentle cleaning techniques, and using appropriate skin barriers or protective measures.

Managing Infection Risks

  • Provide thorough instructions on changing the ostomy pouch to minimize infection risk involving fecal contamination of the surgical wound. Lowering the risk of contamination and ensuring appropriate care should be a priority.

Personal Care and Coping Strategies

  • Guide clients in employing appropriate emotional support and coping strategies to enhance their adaptation to living with an ostomy. Utilizing available support networks is encouraged.

Nutrition for Clients with an Ostomy

General Nutrition Notes

  • Initially restrict fiber and prioritize fluid intake post-surgery while reintroducing high-fiber foods gradually.

  • Maintain adequate hydration (8-10 cups daily) and monitor for signs of nutrient deficiencies following complications of ileostomy surgery.

Colostomy Nutrition

  • Gradually transition into high-fiber diets for improved stool consistency.

Ileostomy Nutrition

  • Note potential for lactose intolerance and recommend electrolyte maintenance via rehydration solutions.

Client and Family Teaching Postoperatively

  1. Stoma Care: Assess for size and color variations in the stoma as normal reactions; identify causes that could affect its appearance.

  2. Diet Recommendations: Maintain a regular diet and avoid gas-producing foods while also keeping hydrated to manage constipation or diarrhea.

  3. Stoma Maintenance: Ensure proper irrigation schedules and adherence to dietary modifications.

Changing an Ostomy Appliance

Guidelines for Changing an Appliance

  1. Preparation: Gather necessary materials and ensure privacy.

  2. Emptying the Pouch: Conduct changes at the optimal time for fewer issues.

  3. Technique for Removal: Use proper methods to prevent skin irritation from removal.

  4. Cleaning and Application: Clean the skin properly before replacing the appliance with measured care for alignment to reduce leakage risk.

Conclusion

  • Ensure continuous education and support for patients undergoing ostomy surgery to promote effective postoperative coping and adaptation. Regular assessments of stoma health and nutritional needs are vital to successful ostomy management.