med surge

ostomy: opening between internal structure & skin

ileostomy: opening of distal sm. intestine

colostomy: opening from colon

stoma: fecal exits, opening of exterior abd. surface

most are created b/c of inflammatory bowel disorder that doesnt respond to med. tx or complications like rupture part of intestine, irreversable obstruction, compromised blood supply, cancerous tumor

• removal of rectum & colon
• R lower quad of abd. under umbilicus, near rectus muscle

matured stoma: cut end everted & sutured to skin, stoma releases stool & gas

fecal material is liquid or mushy & contains digestive enzyme

• matured stoma can permit fast application of appliance
• freq. emtying
• has bag, faceplate/disk(sticks 2 skin), by adhesive, adhesive powder, paste or wafer
• karaya gum- turns like gel when contact moisture, protects skin, pulled/shaped, good for corrected ill-fitting appliances, fits snuggly w/o injury to stoma

disposable/temp: used right after surgury b/c it could change shape/size from swelling

reusable: better pouch w/ "O" ring, pouch clamps @ bottom, fastened to belt, use guaze under pouch to reduce skin irritation

disposable replaced daily w/ bath

vit., antibiotic, & antiTB, cause strong odor to appliance (list of meds given to pt)

avoid enteric-coated & modified release drugs b/c they pass thru w/o absortion, when changing bag check 4 undissolved & therefore unabsorbed cap., doesnt mean that pt hasnt recieved full effect of med

slow-K (potassium chloride) leaves "ghost" of wax coating, but doent mean med not absorbed

pt w/ ileostomy may need monthly vit.12 injections or intranasal b/c of interferance w/ vit absorption

• DR.:
• reason 4 surgery, benefits, risk
• discribes appearance & function of stoma, where it will be placed, & itz care
• ensures itz away from bony prominence, skin creases, scars, but around rectus abd. muscle, unobstructed, & visible to pt.
• identifies risk of bladder/sexual dysfunction (pt may want to save sperm)
• may lower fertility in women
• prophylactic antibiotic med may be needed, prednisone tapered/dcbefore surgery to avoid neg. effect of tissue healing
• peroperative stress dose given IV when pt has been on steriod >6mon. to reduce adrenal crises which can be fatal (withdrawal)
• D/C immunosupressive agent 3-4wk before surgery
• D/C asprin 1wk before
• blood taken before surgery, & noted

• enterstomal therapy nurse/ therapist, or wound, ostomy, continance nurse (WOCN):
• assist w/ marking stoma site, & talks to surgeon about placement & pt educational need
• bowel prep, diet restrictions w/ combination of laxative/lavage

• medical, allergy, drug hx (steriods), if on them monitor 4 adrenal crises (lethargy, weakness, hypotension, nausea, vomiting
• inspect skin in abd. auscultate bowel sounds, bowel prep
• v/s including wt
• labs 4 blood cell count & eletrolyte levels
• ask about any diet & antibiotic therapy done or that they were asked to do
• refere to resources before surgery to eases their anxiety
• procedure explanation aloowing ?s
• asess for good coping skills, encourage pt to discuss feeling about procedure
• tell pt that staff will be there when they first touch & see stoma
• enterostomal therapist:
• gives ostomy care instructions, & answer any questions pt may have

• rectum packed w/ gauze 4 drainage & healing, removed in 5-7days, then irrigation ordered
• nasogastric tube 4 GI decomposition until normal mobility
• fluid, electrolyte, nutritional balance maintained w/ IV fluids until oral nourishment possible
• antibiotic therapy continous
• analgesic given 4 pain
• monitor wound healing

• possible complication:
• intestinal obstruction- serious from intestine left, poorly chewed food/bolus, Dr irrigates stoma, if bowel twisted/strangulated surgery may b needed
• bleeding
• impaired blood supply
• stenosis/prolapse/protussion of stoma- common, if moderate(1-2in)- no tx needed
• if edema occurs could lead to necrosis, once prolapse occurs likely to reoccur

• review med. record (type of surgery, & any problems
• v/s including pain
• inspect dressing (bleeding, infection)
• monitor fluid & blood infusion
• check function of gastric function suction
• measure i/o
• inspect collection appliance, drains, packing, tube

• inter:
• instruction of bag placement
• adapting to new diet
• recog. drug affect bowel elimination
• sexual dysfunction
• pain managment
• demonstrate safe removal of pouch including cleansing area w/ warm water & mild soap
• teach how to apply skin barrier
• instruct fit/secure pouch (leave 1/8in by appliance), press adhesive for 30sec, stay still for 5min, allow sm. amount of air to be trapped in pouch(lower tension), make pin-holes punctures @ upper edge (so gas could escape)
• demonstrate emptying
• assess fluid balance, skin turgur, & tongue
• check for potassium & sodium (acidosis, cardiac arrhythmias)
• instruct on sexual disfunction, differant position

• Geri alet:
• may also get poor vision & arthritis, cant change pouch, skin care, irrigating stoma, refer to resourses that could help

internal reservoir for GI effluent(liquid material), holds it 4 several hr until removed w/ cath

• reservoir formed w/ portion of terminal ilium; nipple valve
• perineal area pack:remains for 1wk

• nurse management:
• reinforce packing; check dressing/drainage, connect cath 2 low suction, check 4 obstruction
• note drainage (color, amount, size of stoma), drainage stabilizes in 10-14days
• irrigate cath PRN (normal saline)
• keep skin clean, change gauze, monitor output, q 6-8hr
• empty reservior q 2-4hr, after 6mon. empty q 2-4xwkly

• maintain bowel continance
• pt w/ ulcerative colitis disease doent effect anorectal sphincter
• preserves innervation of male genitalia
• bladder & erectile dysfunction unlikely
• infertility

• surgical management:
• 1st stage- temp. ileostomy; cont. d/c of mucus from anus
• freq. d/c of fecal material, watery d/c

• 2nd stage:
• 2-3mon later, close temp. ileostomy, reunite 2 section of ileum (anastomosis)
• fecalmaterial expelled, controlled anal sphincture

• nurse:
• preoperavtive same as ileostomy
• postoperative-1st stage:observation of anal area for drainage (tube in presacral area)
• , use squirt bottlo
• postopative-2nd stage- drainage-anal area operative site, instruct pt to clean anus w/ warm/soapy water, dry area well
• instruct: perform perineal exercise/ bowel incontinance, keep area clean

• opening in lrg bowel
• cancerous lesion, ulcerative inflammatory process, multiple polyposis, injury 2 bowel

• types:
• temp & perm
• sigmoid colostomy-solid feces
• descending- feces semi-mushy
• ascending- fluid feces
• transverse- feces mushy
• reg. irrigation control sigmoid & desceding colostomy reducing need 4 appliance

• single barrel colostomy:
• single stoma, diseased part removed, segmantal resection- distal end enclosed 4 later reconnection
• abdominoperneal resection- tumor in lower 3rd of sigmoid
• site pack & left for 1wk, then irrigation done

• double barrel colostomy:
• temp. treats acute diverticulitis, chronic constipation
• dr identifies proximal & distal stoma, nurse copies on nursing care plan(4 checking bowel function & irrigation)
• interval before reestablishing:16mon or longer
• when diseased part removed or healed bowel is reconnected & functions normally

• proximal- opening where feces comes out
• distal- connected to rectum (gas & mucus production)

loop of bowel thr abd. & supported by glass rod or plastic butterfly device

• after 24-48hr after surgery, stoma done, posterior wall left intact & leads 2 opening to bowel
• b/c of delaying opening the healing process occurs w/o danger of infection/comtamination, no nerves (lacks pain receptors)
• protect bed & pt clothes when loop opened
• prepare pt 4 pugnunt odor of feces
• pouch used initially 4 flow of feces

• nursing management:
• preoperative same as ileostomy
• anxiety high RT cause of ileostomy/colostomy (cancer)

• to reduce having 2 irrigate:
• insert soppository, like glycerin or basicodyl into stoma, upto 7 days or more may b needed b4 reg. elimination pattern established
• movements may occur 3-4 xdaily, but q day may decrease till 1-2 movements daily

• other methods:
• drinkin prum or fruit juice
• eating fiber foods & dryed fruits
• preforming mild exercise
• using stool softner, mineral oil, or milk of magnesia

• fiber restricted ostomy 2 prevent irritation & slow transit till healed
• then sm. amount of food w/ fiber till complete tolerance
• foods not tolerated may b reintroduce wk/mon later
• most resume noraml diet w/i 6wk after surgey
• primary nutrition concerns after fluids & electrolytes 8-10cups of fluid recommended daily
• reassure that fluids dont lead 2 watery stool but are excreted as urine
• fluid restriction shoudnt b used 2 control liquid feces
• sodium & potassium req. increase b/c of losses
• eatin sm. freq. meals recommended
• pt should take sm. bites & chew thoughly
• foods that may recrease odor- buttermilk, parsely, yogurt, kefir, cranberry juice
• odor causing foods- dry peas & beans, fish, eggs, onion, garlic, veggies from cabbage family, asparagus, alcohol
• banana flakes, apple sauces, pasta, potatoes, smooth peanut butter, & cheese may help thicken stool
• b/c they may cause obstuction, nuts, corn, cabbage, coconut, dry fruit, unpeeled apple & grapes should b avoided

• colostomy pt:
• eventually high fibef diet improves consistancy & regularity (increase gradually)

• ileostomy pt:
• lactose intolerance may occur
• limit liquid w/ meals if output high
• oral rehydration formulas, like gatorade