Nancy Barrett, RN

Ileal loop

For patients having surgery to create a new elimination route, much of the nursing care focuses on the task of car- ing for a stoma. Yet my experience as an enterostomal therapist has shown that this task, although immediate, may have the least impact on the patient’s rehabilitative process.

Such surgery makes radical changes in the patient’s body. In an ileal loop urinary diversion, the ureters are con- nected to a conduit formed from a short segment taken from the terminal ileum. This segment is brought through the abdominal wall as a stoma to allow drainage of urine. But such surgery also radically affects how the patient views himself and his personal worth. For this reason, effective nursing care must also include helping the patient cope with changes in his self-image.

A person’s self-image and body image develop and change throughout his life. The age at which an ileal loop urinary diversion is performed will influence the emotional effects the procedure will have.

Consider how a person’s view of self develops: Our first strong identifica- tions are made in infancy. Cues the

and body image

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Nancy Barrett, R N , ET, is a nurse practitioner and enterostornal therapist at Yale-New Haven Hospital, New Haven, Conn. She is a graduate of Waterbury (Conn) Hospital School of Nursing.

baby receives during cuddling, holding, and feeding build a basic sense of trust and are the first steps in identity forma- tion.

As knowledge increases and emo- tional development continues, a sense of being a separate person begins. During this toddler age, self-esteem and posi- tive self-regard are also learned. The child builds into his identity the ability to do things for himself. Physical dif- ferences in the sexes are visible during this formative period. Learning the sexual role is emphasized by parents and others.

Throughout childhood, knowledge, trust, and respect grow. School starts, and social interaction is learned. If the child’s respect and esteem are damaged in these early years and he cannot ex- pect certain responses from others, he may never learn to care for school or social companionship.

The child’s body grows with great speed, which causes his self-image and body image to readjust continuously. Adolescence is a period of identity crisis when the child is testing his boundaries. The adolescent is not sure of his own wholeness. Peer power is strong, and the adolescent sees his body and self- image as others judge him. In a gradual process, the adolescent learns to cherish and guard his identity.

In adulthood, a person’s self-concept gives added stability, discipline, and tol- erance. There is less need for testing

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he patient has T a shocked awareness he will be different.

reality. Through establishment of a re- lationship with a mate or a significant other, an environment is created in which faith and trust can be placed.

With advanced age comes more fre- quent reassessment of self-image and body image. Although self-respect and dignity have been attained, there is a confrontation with the fears of loneli- ness, dependency, and death. As the possibility of physical crisis grows, it is easy for a person’s body image and self- image to become reduced or confused.

No matter what age at which ileal loop surgery is performed, a patient will go through certain adjustment*stages. These include shock, retreat, disorgani- zation, acknowledgement, reorganiza- tion, and resolution. Although these stages may not be clearly defined, the patient must work through them to achieve full recovery.

Using these explanations of identity building as a basis, consider what hap- pens when a patient with documented transitional cell cancer of the bladder is hospitalized for the creation of an ileal loop diversion. The incidence of bladder cancer is highest in the 50- to 70-year- old age group, and it occurs more fre- quently in men than in women. Transi- tional cell carcinoma, the most common form of bladder cancer, may develop anywhere in the urinary collecting sys- tem, as the walls of the kidneys, ureters, and bladder are all lined with transi- tional cells. The neoplasms may be

single or multiple in focus. When they remain in the dome of the bladder, local treatment is often effective, and prog- nosis is good. Treatment may consist of fulgeration of the bladder by cautery or instillation of a chemical agent.

The prognosis is far more serious if the cancer has invaded the bladder muscle and extends into the bladder’s lymphatic and vascular drainage sys- tem or if invasion of the ureteral open- ings or ureters takes place.’ Surgery and radiation therapy may be required.

The first stage of surgical treatment will include creation of an ileal loop di- version for drainage of urine. The sec- ond stage, which will take place during a separate admission, will be removal of the diseased bladder.

During the initial preoperative phase, impact of the impending surgery be- gins. The patient has a shocked aware- ness that he will be a different person, unlike all the other persons he knows. After the first disbelief passes, it is often replaced by grim fear and an over- whelming sorrow that the surgery must take place. Loss of control over this part of his life has been unthinkable, and now the future is uncertain. The patient has usually been physically comfort- able, except perhaps for increased fre- quency of urination, dysuria, and blad- der irritability. Meanwhile, his food is taken away and strangers are subject- ing him to examinations, intravenous infusion, and enemas. The patient may

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withdraw and think he is starting on a downward path toward death. The feel- ing of aloneness can be so strong that the patient thinks no one can empathize with him.

Knowing that many patients feel this way, the OR nurse’s preoperative care plan, in conjunction with that of the unit nurse and enterostomal therapist, might include:

0 encouraging the patient to state fears of rejection, loss of control, and the risk of surgery

0 talking with the patient about his feelings concerning changes in body image and self-concept

0 providing clear, honest, and direct answers to the patient’s questions

0 strengthening the patient’s family through preoperative teaching, if it is desired

0 spending extra time with the pa- tient

0 giving simple, detailed expla- nations about the stoma and its ap- pearance, location, and care

0 emphasizing the concept that the patient will have the ability to take care of the stoma assuring that if pressures seem unmanageable, the patient can turn to the nursing staff for help.

Intraoperative phase. After the pre- medicated patient arrives in the operat- ing room, his identity, level of con- sciousness, and medical record are checked, and he is placed in the supine position. The circulating nurse assures the patient by standing nearby or touch- ing the patient as general endotracheal anesthesia is given. A catheter is in- serted to empty the bladder and is then withdrawn. A nasogastric tube is intro- duced, and the circulator applies a grounding device and checks the pa- tient’s position. A surgical skin prepa- ration is performed on the entire abdo- men, and the patient is draped, expos- ing the surgical site.

A left paramedian incision is made, extending from just above the umbilicus to the symphysis. Underlying sub- cutaneous tissue is incised down to the rectus fascia, and bleeders are clamped and coagulated. The left rectus fascia and the rectus muscles are retracted laterally; the posterior rectus sheath and peritoneum are then opened. An exploration of the abdomen is done to check for spread of the cancer from the urinary bladder to the stomach, duodenum, gall bladder, paraaortic nodes, and peritoneum.

After the small bowel has been packed away, the right ureter is iden- tified and dissected down deep into the pelvis. Next, the left colon is mobilized, and the left ureter is similarly iden- tified and dissected. The distal ends of the ureters are tied off, and a small por- tion is sent to pathology for frozen sec- tion diagnosis.

A suitable segment of terminal ileum is selected for the ileal conduit. The ap- pendix may be removed. The scrub nurse provides a fiberoptic light for ob- servation of good vascular supply to the segment of ileum. When observation is complete, a 4 to 6 in piece of ileum is freed, turned and drawn up, and stabilized under the remaining ileum. The interrupted bowel is repaired with an end-to-end anastomosis.

The ureters are retrieved and brought through tunnels created retroperito- neally. Small openings are made in the ileal segment so the ureters, spatulated slightly, can be sewn to the conduit in an end-to-side manner. Stents a re placed with one end located upward to- ward the kidney and the other end exit- ing at the distal end of the ileal conduit. Later the stents will be sutured to the mature stoma so they cannot slip out. A Penrose drain is placed with the proxi- mal end near the anastomosis in case leakage occurs.

The stoma is created at the site

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erioperative care often P determines the patient’s perception of his. new stoma.

marked preoperatively in the right lower quadrant by excising a circular layer of skin, making an opening in the underlying muscle and peritoneum, and bringing the conduit out through this opening. The piece of ileum is everted and sewn to the skin, thus creating a stoma. The abdomen is then closed in layers. To preserve skin integrity, the stoma and surrounding area are cov- ered with a skin protector and a one- piece disposable pouch tha t can be drained by a valve from the bottom.

The type of care that nurses give dur- ing this perioperative period often de- termines the patient’s perception of his new stoma. The way the nurse perceives the stoma may be the way the patient will perceive it from then on.

For five days after surgery, the pa- tient may resist communication. This may be partly because of the routine course of postoperative surgery and partly because of pain, anxiety, and grieving over perceived loss of control, attractiveness, sexuality, or modesty. Many patients manifest signs of depres- sion and do not participate in their care. It is a time of disorganization of the pa- tient’s identity. He may reveal this feel- ing of depersonalization and denial by saying things like: “What choice did I have? I had no choice.”; “I have a pretty strong stomach, but that makes me sick.”; “Maybe I should give up.”; “They won’t want me back at the office with this.”; “My wife will do it, I guess. Why

should I do it?’ Postoperative nursing interventions

can help the patient in adjusting to his new condition. Although primarily the responsibility of the unit nurse, they are also appropriate for OR nurses who are able to return to the unit for a postoper- ative assessment. In addition, some may be useful for the OR nurse in providing preoperative care to patients returning for the second part of a two- stage procedure.

Suggested interventions include: encouraging the patient to initiate communication about the stoma

0 promoting communication about the stoma between the patient and the spouse, parent, or significant other encouraging parental support if the patient is a child or an adolescent confronting discrepancies between what is said or thought by dem- onstrating sensitivity to the pa- tient’s behavioral cues

0 communicating expectations for self-care and self-control providing patient, family, or signif- icant others with informational booklets reinforcing teaching in areas the patient has blocked acknowledging the patient’s reac- tion to the appearance of the stoma by explaining that time and self- confidence in care will allay some negative feelings and will allow

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care to become more commonplace 0 ensuring the patient’s privacy dur-

ing appliance change 0 teaching the patient to take care of

the stoma competently, then giving positive feedback (eg, “Yes, you’re doing a good job.”)

0 supporting adjustment patterns (eg, “You will find a way that is best for you.”) reinvolving a withdrawn patient by demonstrating energy and interest in matters other than stoma care.

Postoperatively, many patients will be concerned about their sexuality. En- courage the patient to talk about his worries, but also respect wishes not to discuss sex. Reassurances about the pa- tient’s sexuality should stress cleanli- ness, emptying the appliance before intercourse, and making sure the appliance is well secured. Counseling can include correcting misinformation and encouraging discussions between the patient and partner about sexual arousal and activity. Some ileal diver- sions and bladder resections will leave male patients surgically impotent. The use of penile implants may be discussed with such patients.

As the patient touches and sees his stoma, he becomes more secure; and as control returns, his fears of rejection and isolation lessen. Methods the pa- tient has used in the past to adapt to change will return and take over. The patient’s identity starts to reorganize, and resolution begins. Some verbal cues heard at this time might be: “It was a terrible operation, but my family cheered me up.”; “The nurse and doctor say I’ll be ok, good as new.”; “My hus- band hugged me anyway.’’ The patient starts to think about caring for the stoma himself and the possibility of going back to work.

Understanding this “resolution phase” will help OR nurses assess the psychosocial condition of ileal conduit

diversion patients about to have a sec- ond procedure for the removal of their diseased bladder. At that time, the OR nurse may be able to assist the enteros- tomal therapist and unit nurses with the following interventions:

teaching the patient how to manage minor episodes of constipation, diarrhea, and skin irritation sur- rounding the stoma teaching the patient what signs and symptoms should be reported promptly to the physician (eg, ab- dominal cramps, repeated vomit- ing, pain, fever)

0 encouraging normal eating pat- terns and discussing any restric- tions referring the patient to the enteros- tomal therapist for reassessment and reevaluation of problems con- cerning atypical stomas suggesting topics of concern (eg, diet, exercise, hygiene, skin care, appliance care, and the patient’s re- turn to usual activities) to the pa- tient to be discussed during the dis- charge planning interview.

Each ostomy patient has an indi- vidual response to body image changes and adaptation to identity threat. Nurs- ing interventions and the manner in which nursing care is delivered makes a difference in the rehabilitation of these patients. 0 Note

1. Nancy Barrett, ”Cancer of the bladder: A case history,” American Journal of Nursing 81 (De- cember 1981) 2192-2195.

Suggested readlng Erickson, Marcene L. Assessment and Manage-

ment of Development Changes in Children. St Louis: C V Mosby, 1976.

Haber, Judith; Leach, Anita; Schudy, Sylvia; Sideleau, Barbara. Comprehensive Psychiatric Nursing. New York: McGraw-Hill, 1978,386-387.

Watson, P G. “Applying rehabilitation concepts in the care of persons with ostomies.“ARNJournal 1 (November-December 1976) 12-14.

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