Objectives

Discuss the pre-operative needs of the ostomy patient

Describe the indications for each type of ostomy

Discuss the post-operative needs of the ostomy patient

Describe the specific post operative needs for each type of ostomy

World Ostomy Day October 6th, 2012

Sponsored by the UOAA – a non-profit support organization that is committed to the improvement of the quality of life of people who have or will have an intestinal or urinary diversion.

Faces of Ostomies

Pre-operative Considerations Assessment

Know your patients medical/surgical history

Don’t get caught in the OOPS factor!

Pre-operative Considerations Assessment

Diagnosis

Surgical Procedure Scheduled

Support System

Cultural/Spiritual Issues

Language Barrier

Vision, Hearing, Cognition

Skin Sensitivities and Allergies

Other Physical/Emotional Challenges

Pre-operative Considerations Emotions

All the senses are triggered to respond to the sights, sound, smell, taste and feel of the holding areas and surgical suite.

FEAR

Commonly Asked Questions/Concerns

Will people accept me?

How will I manage my ostomy?

Concerns about hygiene

Concerns about “bad experiences”

How will my ostomy change my life

How will my family and friends react to my ostomy?

Concerns about intimate relationships

Will this surgery save my life?

Stress the Benefits!! An ostomy will impact body image for all facing this

surgery and for many it will impact them negatively.

Empower the patient

Discuss quality of life issues that will give

them meaning dignity and respect

Suspend your own judgments

Listen and express empathy

Stress that ostomy surgery is life saving and can improve quality of life

Pre-operative Considerations Teaching Needs

Explanation and Rational for Surgery

The patient should be able to describe the surgical procedure to include creation of an ostomy with drainage of stool or urine through an abdominal opening.

Explanation and Appearance of Stoma A surgically created opening in the abdomen

A portion of the intestine is brought through the abdominal opening and sewn down to the skin

The opening is often referred to as a stoma

Stoma means mouth

Pre-operative Considerations Teaching Needs

Introduction to pouching system

Basic review of stoma care

ADL’s with an ostomy

Visit with a WOCN!!!!!

Visit with a UOA member (United Ostomy Association) – can reinforce information given by the surgeon and provide real-life experiences of patients with a stoma.

Pre-operative Considerations Teaching Needs – Informed Consent!

Patients undergoing ostomy surgery may experience disruption of nerve pathways since nerves controlling erection and ejaculation pass through peri-rectal and prostatic tissue.

There is much less known

about female sexual function

following ostomy surgery.

Pre-operative Considerations Stoma Site Marking

It has been shown that pre-operative stoma site marking by a WOCN greatly improves the quality of life for the patient.

Difficulties with stomas occur due to incorrect placement resulting in leakage, peristomal skin damage, increased risk of peristomal hernia and stomal prolapse, emotional stress and increased costs.

It takes a team effort (surgeon, patient, WOCN)

Stoma Site Marking is advocated by: The International Ostomy Association

The Wound, Ostomy and Continence Nurses Society

The American Society of Colon & Rectal Surgeons

The American Urological Association

All have submitted joint statements endorsing preoperative stoma site

marking

Stoma Site Marking Location depends on the type of surgery

Should be located within the rectus muscle

Should be below the beltline

Should be located on the flattest surface possible

Should be evaluated in the sitting, lying, standing and bending position

Avoid skin folds, scars, creases, umbilicus, and bony prominences

Must be visible to the patient

Poor Stoma placement can lead to: Pain

Leakage from the pouching system

Peristomal skin irritation

Fitting challenges

Impaired psychological health

X- MARKS THE SPOT!!

•Colostomy – left lower quadrant

•Ileostomy – right lower quadrant

•Urostomy – right lower quadrant

Indications for a Colostomy Can be created from any part of the colon, cecum,

ascending, transverse, descending or sigmoid.

They can be temporary or permanent.

Usually located in the Left Lower Quadrant of the abdomen.

Indications for Colostomy Emergent

Colonic Obstruction

Due to primary cancer of the distal colon or rectum.

Due to complicated diverticular disease with stricture

or abscess.

Trauma of the distal colon with perforation and fecal spillage (gunshot/stab wound, blunt trauma)

Volvulous – Twisting of the bowel causing obstruction and strangulation of the mesentery

Newborns with distal obstruction from Hirschsprungs

disease or imperforate anus

Emergent Colostomy

Indications for Colostomy Elective

Due to low rectal cancers with abdominal peritoneal resection (removal of entire anal sphincter, rectum and sigmoid colon. Ostomy is permanent.

For protection of a low colorectal or coloanal anastomosis, rectovaginal fistula, incontinence, radiation proctitis, perianal sepsis, diversion for pressure ulcer (stage IV).

Atonic bowel (congenital or acquired).

Indications for Ileostomy Can be temporary or permanent

Usually located in the right upper or lower quadrant of the abdomen

Indications for Ileostomy Emergent

Conditions requiring small bowel or proximal colon resection, in which the integrity of a primary anastomosis would be compromised

Diffuse bowel injury from radiation or Crohn’s disease

Hemorrhage, ischemia, perforation, sepsis

Infants – necrotizing enterocolitis

Indications for Ileostomy Elective

Rectal cancers

Inflammatory bowel disease (chronic ulcerative colitis, Crohn’s disease

**** A total colectomy cures ulcerative colitis, does not cure Crohn’s disease

Familial Polyposis – requires removal of the rectum and entire colon

Elective Ileostomy

Creation of a Stoma – End Stoma

Creation of a Stoma – Hartmann’s Pouch

Creation of a Stoma - Loop •Usually temporary •Quicker surgery

Creation of a Stoma – Double Barrel The bowel is divided (resected) – proximal end is

brought out as a functioning stoma and distal end is brought out as a “mucous fistula”.

Pre-operative Bowel Prep for Existing Colostomy

Need to know who many bowel segments does the patient have?

Which segment is to be prepped?

How to access the segment?

How long is the segment?

Proximal segment (mouth to anus: oral laxatives, liquid diet, irrigations through stoma)

Distal segment (Hartmann’s pouch, distal stoma to anus) use rectal suppositories, rectal enemas, or irritations of distal limb of loop or distal stoma.

Indications for Urostomy (Ileal Conduit). Permanent surgical procedures

Stoma usually located in the right upper or lower quadrant of the abdomen

Indications for Urostomy Invasive Bladder Cancer

Congenital abnormalities (bladder extrophy)

Chronic urinary incontinence (interstitial/radiation cystitis)

Trauma

Hostile Neurogenic Bladder

Intraoperative Events

Significantly impact postoperative outcomes and complication rates

Most at risk are ostomies created in response to trauma (blunt and penetrating)

Rupture of the large or small intestine

Spillage of fecal contents

Septic shock

Atypical location of stoma

Intraoperative Events High volume blood loss - leads to hypotension and

hypo perfusion. Requires crystalloid resuscitation and transfusion of blood products to prevent ischemia and necrosis of the stoma.

Operative insults may lead to electrolyte imbalances and a systemic inflammatory response which in extreme cases can progress to organ failure.

Intraoperative Events Technical Factors:

The surgeons ability to mobilize and deliver the intestine through the abdominal wall influences stomal maturation.

The amount of subcutaneous tissue through which the bowel must pass

The integrity of the abdominal wall

The patients wound healing potential

The presence of associated diseases

Stomal Assessment – In a Perfect World!!

•Red •Moist •Round •Protruding (budded) •Mucocutaneous stitches intact •In the rectus abdominus muscle •In the patient’s line of vision •Away from belt or clothing lines •Not in a wrinkle or fold

Post-operative Stomal Assessment Keen assessment skills, early recognition of

signs and symptoms of a complication, and prompt intervention are crucial to maintaining a viable stoma and a successful surgical outcomes.

Post Operative Considerations Stoma Assessment

Anatomic location and type of stoma

Assessment of loop catheter (loop colostomy,

loop ileostomy)

Assessment of stomal stents (ileal conduit)

Stoma viability (moist, bright red)

Height of stoma (budded, flush, retracted, prolapsed)

Location of stomal opening

Output (24-72 hours colostomy, 24-48 hours ileostomy, immediate for urostomy).

Transparent pouch permits visualization of stoma

Stomas gone bad!!

Stomal Complications Mucocutaneous Separation

Occurs when stomal tissue detaches from the surrounding peristomal skin

Excessive tension on stoma

Superficial infection

Diabetes Mellitus

Regular use of steroids

Malnutrition

Stomal Complications- Prolapse Telescoping of the intestine through the stoma

Insufficient attachment of the bowel to the abdominal wall

Insufficient fascial support

Increased abdominal pressure

(crying, coughing)

Stomal Complications - Retraction Disappearance of normal stomal protrusion in line

with or below skin level.

Problems with surgical construction of the ostomy resulting in mesenteric tension or inadequate stomal length.

Can be associated with a distended

and edematous abdominal wall

Stomal Complication - Stenosis Impairment of effluent drainage due to narrowing or

contraction of the stomal tissue at the level of the skin or fascia

May be related to surgical construction techniques

Excessive scar formation

Irradiation of bowel segment

Peristomal sepsis

****Patient will have explosive or narrow stools with loud flatus. The urostomy patient will experience flank pain and decreased output.

Specific Needs – Colostomy Pre-operative

Assure informed consent and address patient’s concerns

Explain that a colostomy does not change the ability to digest and absorb nutrients; no change in diet required

Causes loss of ability to control elimination or stool and gas

Will need to wear an odor proof pouch

Patient with existing colostomy may have had a bowel prep pre-op.

Specific Assessment – Colostomy Post-Operative

Stoma viability (color, turgor, hydration)

Mucocutaneous suture line

(approximated vs. separated)

Presence of loop catheter

Stomal edema – stoma will shrink for

the next six weeks

Ileus is normal for first several days post op

Focus on emotional support of patient and family

Specific Needs – Ileostomy Pre-operative

Discuss rational for surgery and obtain informed consent

Discuss impact of surgery on bowel function: Will maintain ability to digest and absorb nutrients if the proximal small bowel is normal.

Will lose function of the colon and rectum

May have some dietary restrictions

Provide emotional support

Specific Assessment – Ileostomy Post - Operative

Stoma viability

Mucocutaneous suture line

Stomal edema and presence of loop catheter

Bowel function: stool produced 12-24 hours post- op, color will be dark green, viscous and odorless

Initially will have high volume of liquid output (>1000 cc/day). Bowel will gradually adapt

Accurate I&O’s crucial

High risk for peristomal skin breakdown

Specific Needs – Ileostomy Post-operative

High fiber foods may cause stomal blockage

Will need 10-12 glasses of fluid each day

Medication concerns: large pills, enteric coated pills, sustained-release medications

Never give a laxative!!!!!!

Specific Needs – Urostomy Pre-operative

Assure informed consent

(Male patient undergoing cystoprostatectomy – must discuss potential alteration in sexual function with patient to assure informed consent).

Explain procedure in lay terms and provide a simple diagram

Assure patient that bowel function will be undisturbed. May need to explain the reason for bowel prep

Show patient a pouch with a spout

Urostomy pouches

Specific Assessment – Urostomy Post-operative

Stomal Assessment

Some Hematuria and mucous is normal, should be transparent in color

Expect output from stents and stoma - flow will be continuous. Stents are threaded all the way up the ureter into the renal pelvis (bilateral) and sutured to the ureter with absorbable sutures. Stay in 7-10 days.

Stents – support the ureterointestinal anastomosis and prevent obstruction. They should not be irrigated.

Ileal conduit with stents

Specific Assessment – Urostomy Post-operative

Monitor patient for bowel sounds, N/G output, distention, nausea. Usual post up ileus 3-4 days

Make sure attachment device for attaching pouch to bed side drainage bag is compatible

Monitor for anastomotic breakdown (reduced output through stents & stoma and increased output through surgical drains and/or increased abdominal growth).

A few words…….. Continent Urinary Diversions – should have a Foley in

the internal pouch during surgery and recovery and remove as soon as the patient can resume care. Use 14-16 Fr.

Orthotopic Neobladder – Can be catheterized as you would a “normal” bladder. Use 14-16 Fr.

What I wish I had known Voices from Ostomates

Don’t sugarcoat

Be as realistic as you can

You are not alone

Provide compassionate honesty

Faces of Ostomy

Ulcerative colitis/colo rectal cancer/ileostomy

Marathon runner

Faces of Ostomy

Colo/rectal cancer stage III - colostomy

Patient advocate/surfer

Faces of Ostomy

Ulcerative colitis/colon cancer/ileostomy

Gastronaut ostomy puppet

Patient advocate

Faces of Ostomy

Crohn’s disease/ileostomy

Model

Newlywed

Patient advocate

Faces of Ostomy

Rhabdomyosarcoma of the Bladder/ileal conduit

Famous Ostomies!! Pope John Paul II

The Queen mother of England

Napoleon Bonaparte

Fred Astaire

Red Skelton

Ed Sullivan

Tip O’Neil

William Powell

Ostomy Companies www.hollister.cm - Hollister

www.convatec.com-

www.coloplast.com – Coloplast

www.nu-hope.com – Nu-hope

Ostomy buddy dolls

Resources www.wocn.org – Wound, Ostomy and Continence

Nurses Society

www.ostomy.org United Ostomy Associations of America, Inc

www.raleighuoa.org– Triangle Ostomy Association – Meets the first Tuesday of every month at 7:30 pm at Rex Hospital.

www.greatcomebacks.com – Great Comebacks – Inspiring stories of people living with ostomies

www.inspire.com – Hosts an online support group for patients with ostomies

Thanks for all of your hard work!!