Bowel Diversion: Ostomies

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Bowel Diversion Ostomies

• NURS 108
• ECC
• Majuvy L. Sulse MSN, RN, CCRN

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Bowel Diversion

• Stoma-temporary or permanent artificial opening
  in the abdominal wall
• Ileostomy-opening in Ileum
• Colostomy-opening in colon

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Bowel Diversion
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Types of Colostomy Reconstruction

• Loop colostomy-
• usually temporary large stomas
• Common site-Transverse colon
• Loop of bowel is pulled out and an external
  device (plastic rod, rubber catheter or bridge)
  is placed to keep the bowel from slipping back
• loop has 2 openings through 1 stoma
• Distal- rains mucus
• Proximal drains stools
• External device is removed within 7-10 days

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Types of Colostomy Reconstruction

• End colostomy
• The functioning end of the intestine (the section
  of bowel that remains connected to the upper
  gastrointestinal tract) is brought out onto the
  surface of the abdomen, forming the stoma by
  cuffing the intestine back on itself and suturing
  the end to the skin
• The surface of the stoma is actually the lining
  of the intestine, usually appearing moist and
  pink.
• The distal portion of bowel (now connected only
  to the rectum) may be removed, or sutured closed
  and left in the abdomen.
• An end colostomy is usually a permanent ostomy,
  resulting from trauma, cancer or another
  pathological condition.

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Types of Colostomy Reconstruction

• Double Barrel Colostomy
• colostomy involves the creation of two separate
  stomas on the abdominal wall.
• proximal (nearest) stoma is the functional end
  that is connected to the upper gastrointestinal
  tract and will drain stool.
• distal stoma, connected to the rectum and also
  called a mucous fistula, drains small amounts of
  mucus material.
• most often a temporary colostomy performed to
  rest an area of bowel, and to be later closed.

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Total proctocolectomy with permanent
ileostomy

• Total proctocolectomy with permanent ileostomy
• Removal of colon, rectum and anus with closure of
  anus.
• End of terminal ileum is brought out through the
  abdominal to form an ostomy

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Ileostomy
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Ileostomy

• Possible complications include
• skin irritation caused by leakage of digestive
  fluids onto the skin around the stoma Irritation
  is the most common complication of ileostomies
• diarrhea
• the development of abscesses
• gallstones or stones in the urinary tract
• inflammation of the ileum
• odors can often be prevented by a change in diet
• intestinal obstruction
• a section of the bowel pushing out of the body
  (prolapse)

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Total proctocolectomy with continent ileostomy

• Total proctocolectomy with continent ileostomy
• The Kock pouch is a variation of the basic
  ileostomy and is named for its Swedish inventor.
• In the Kock technique, the surgeon forms a pouch
  inside the abdominal cavity behind the stoma that
  collects the fecal material.
• The stoma is shaped into a valve to prevent fluid
  from leaking onto the patient's abdomen.
• The patient then empties the pouch several times
  daily by inserting a tube (catheter) through the
  valve.
• The Kock technique is sometimes called a
  continent ileostomy because the fluid is
  contained inside the abdomen.
• When the patient returns to his room, attach the
  drainage catheter emerging from the ileostomy to
  continuous gravity drainage

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Kock Pouch
A thin tube is inserted into the stoma to drain
the contents a few times a day.
A one-way nipple valve sitting flush with the
skin, stops the stool from coming out at all
other times.
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Complications from Kock Pouch

• Pouchitis
• Increased stool frequency
• Urgency
• hematochezia
• abdominal cramping
• Fever
• Malaise and pelvic pain
• treat with Flagyl (metronidazole)
• Fistula development
• Nipple valve extrusion

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Ileostomy

• Patient education
• Ileostomy patients must learn to watch their
  fluid and salt intake.
• greater risk of becoming dehydrated in hot
  weather, from exercise, or from diarrhea.
• In some cases they may need extra bananas or
  orange juice in the diet to keep up the level of
  potassium in the blood.

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Ileostomy

• Patient education includes social concerns as
  well as physical self-care.
• Many ileostomy patients are worried about the
  effects of the operation on their close
  relationships and employment.
• find out about self-help and support groups.
• The ET can also evaluate the patient's emotional
  reactions to the ostomy.

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Ileoanal Reservoir (IAR)

• The IAR requires complete removal of the colon,
  leaving all of the small intestine and about two
  inches of the rectum
• The lining of the rectum, called the mucosa, is
  then removed (stripped), leaving the muscle of
  the rectum and the underlying anal sphincter
  muscles intact. An ileal J pouch is then formed,
  using the last 12 inches of the small bowel
  (ileum).
• A surgical stapling instrument is used to create
  the pouch. The end of the pouch is then "pulled
  through" the pelvis and sewn to the anus.

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Ileoanal Reservoir (IAR)

• A temporary ileostomy about 12 inches upstream
  from the pouch is made. This is constructed to
  divert stool until the suture lines in the
  reservoir have healed and the patient has
  recovered from the operation. This results in all
  stool going into the ileostomy bag on your right
  lower abdomen so that the ileal pouch can heal.
• When the pouch to anus connection has healed,
  usually about two months, the ileostomy is
  closed, resulting in bowel movements from your
  anus.

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Ileoanal Reservoir
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Comparison of colostomies Ileostomy
Ascending Transverse Sigmoid Ileostomy
Stool consistency Semi liquid Semiliquid-semiformed Formed Liquid to semiliquid
Fluid requirement Increased Probably increased No change increased
Bowel regulation No Uncommon Yes if with regular pattern No
Pouch skin barriers yes yes Dependent on regulation yes
irrigation no no Possible q 24-48 hrs no
Indications for surgery Diverticulitis, trauma, CA of colon, rectum or pelvis Same as ascending Ca of rectum or rectosigmoid area, diverticulitis Crohns, ulcerative colitis, trauma, CA
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Effects of food on stoma output
ODOR Producing
Diarrhea causing Alcohol, beer, cabbage family,
spinach, green beans, coffee, spicy foods, raw
fruits
Eggs, garlic, onions, fish, asparagus, cabbage,
broccoli, alcohol
Potential for obstruction in Ileostomy Nuts,
raisins, popcorn, seeds, raw vegetables, celery,
corn
Gas Forming Beans, onions, cabbage beer,
carbonated beverages, sprouts, Strong cheese
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NURSING MANAGEMENT

• Pre-operative preparation
• Psychological preparation
• Ability to perform self care
• Identify support systems
• Visit by ET
• Bowel preparation-decrease post op infection
• Osmotic lavages, cathartics, enemas
• Antibiotics-neomycin erythromycin

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NURSING MANAGEMENT

• Post-operative-
• Patient adaptation-ADLs in 6-8 weeks, no heavy
  lifting, psychological support, identify coping
  mechanism
• Colostomy care
• Assess stoma and surrounding skin
• Pink stoma-healthy pale- anemic dusky
  blue-necrotic
• Mild to moderate swelling- till 2-3 weeks is
  normal moderate to severe swelling-obstruction
  of stoma
• Small amount of oozing-normal moderate to large
  bleeding-coagulation problem or or GI bleed

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NURSING MANAGEMENT

• Colostomy care
• Assess stoma and surrounding skin
• Wash stoma with mild soap water
• Use of skin barrier
• Use of pouch-leave ¼ of skin around the stoma
• Colostomy irrigations
• Regulate bowel function-stimulate the bowel to
  function at specific time everyday or every other
  day
• Treat constipation
• Prepare for surgery

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Colostomy Irrigation

• Use lukewarm water as irrigant(500-1000 ml) just
  enough to distend but not cause cramping
• Ensure comfortable position-sit up on chair or
  toilet bowl
• Hang container on hook or IV pole (18-24 in)
  above stoma
• Apply irrigating sleeve and place end in toilet
  bowl
• Lubricate stoma cone and insert gently into the
  stoma
• Allow irrigation solution to flow steadily for
  5-10 minutes stop the flow if cramping occurs

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Colostomy Irrigation

• Clamp the tubing and remove irrigating cone when
  desired amount has been delivered or when patient
  senses colonic distention
• Allow 30-45 minutes for the solution and feces to
  be expelled.
• Cleanse, rinse and dry peristomal skin well and
  replace the colostomy drainage pouch

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Nursing Diagnosis/Interventions

• Risk for skin integrity related to irritation
  from fecal drainage and peristomal area,
  irritation from appliance and lack of knowledge
  of skin care
• Skin assessment, use mild soap water to cleanse
  area, use of skin barrier and application of well
  fitting pouch

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Nursing Diagnosis/Interventions

• Disturbed body image related to presence of
  ostomy and malodor
• Assess attitude towards ostomy
• Allow expression of feelings and assist in
  adjustment process (grief)
• Prepare patient to do owm stoma and appliance
  care to increase independnce and enhance
  self-esteem/image
• Encourage attendance in support classes or groups
• Use of measures to control odors
• Odor proof pouch, pouch deodorants, avoid foods
  that increases odor

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Nursing Diagnosis/Interventions

• Imbalanced nutrition less than body requirements
  related to decreased appetite and lack of
  knowledge of appropriate foods
• Assess nutritional intake
• Introduce foods one at a time
• Provide list of foods for reference
• Risk for fluid volume deficit related to excess
  fluid loss from ileostomy or diarrhea or
  inadequate fluid intake
• Assess for signs symptoms of fluid
  electrolyte imbalance
• I/O, encourage fluids-3000ml/day
• Monitor electrolytes

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Nursing Diagnosis/Interventions

• Ineffective sexuality patterns related to
  perceived loss of sexual appeal and accidental
  seepage of fecal materials during sexual activity
• Assess patients attitude and impact of the ostomy
  on the sexual functioning-fear of rejection
  (encourage open communication)
• Encourage support groups to share concerns and
  solutions
• Encourage use of perfumes or fragrance to combat
  odors