Figure 10.16 Types of ostomies (fecal related)
An ostomy is named according to the part of intestine used to construct it. A colostomy is the creation of a stoma from part of the colon (large bowel), where the intestine is brought through the abdominal wall and attached to the skin, diverting normal intestinal fecal matter through the stoma instead of the anus. An ileostomy is created from the ileum (small bowel), which is brought through the abdominal wall and used to create a stoma. A urostomy or ileal conduit is a stoma created using a piece of the intestine to divert urine to the outside of the body. The ureters are sewn to a piece of the intestine that is made into a small conduit. The conduit emerges from the abdominal wall as a stoma.
These surgeries are performed on patients with diseases such as cancer of the bowel or bladder, inflammatory bowel diseases (such as colitis or Crohn’s), or perforation of the colon. Emergencies that may require an ostomy include diverticulitis, bowel rupture, trauma, necrotic bowel, or radiation complications. An ostomy may be permanent or temporary, depending on the reason for the surgery. Other types of ostomies are called jejunostomy, double-barrel ostomy, and loop ostomy (Perry et al., 2018).
Pouching Systems (Ostomy Appliances)
Figure 10.17 Application of ostomy appliance
Individuals with colostomies, ileostomies, or urostomies have no control over the activity of their ostomy. Persons with ostomies must wear a pouching system. The pouching system must be completely sealed to prevent leaking of the effluent and to protect the surrounding peristomal skin. The disposable pouching systems can be either a one-piece or a two-piece system consisting of a pouch (plastic bag) and a flange (skin barrier) that sit against the patient’s skin. Most flanges are flat. Sometimes a stoma that is flat or retracted can be protruded with the use of a convex flange making it easier to direct the drainage into the pouch. The pouch has an open end to allow effluent to be drained, and is closed according to the manufacturer’s design—usually a plastic clip or Velcro strip. Urostomy pouches have a spout type of drainage hole to allow urine to be drained.
Different manufacturers make different types of pouching systems each designed to meet the needs of the client. Step 2 in Checklist 89 shows ostomy supplies including a flange, an ostomy bag, and a one-piece system (Perry et al., 2018; United Ostomy Association of America, 2017). The flange is cut to fit around the stoma in a way that avoids pressure or irritation on the stoma while covering the peristomal skin or a moldable flange can be used to achieve the same result (see Figure 10.18).
Figure 10.18 Moldable flange. Note the turtle-necking of the wafer.
Ostomy pouching systems are chosen based on type of stoma (ileostomy, colostomy, urostomy), stoma characteristics (flat, raised, recessed), stoma location, patient abilities (to cut a flange and to operate the opening / closing of the pouch), skin folds, and patient preference. Pouching systems generally last from four to seven days. Ileosotmies and urostomies generally require more frequent flange changes due to the weight of the effluent and the impact of the weight on the flange’s ability to remain adhered to the patient. The pouch must be changed if it is leaking, if there is excessive skin exposure between the stoma and the edge of the flange (particularly for ileostomies because this stool contains enzymes that break down skin), or if the patient complains of itching or burning under the flange. Patients with established ostomies can swim and participate in most activities of daily life. In terms of showering, pouching systems can remain on or off and will depend on the patient’s preference and activity of the ostomy. All patients are expected to participate in all aspects of their ostomy care; if they cannot, a caregiver may be involved in the teaching (Perry et al., 2018).
Depending on the patient, a surgical procedure may be performed to create an internal pouch to collect feces or urine, which eliminates the need for an external pouch. A continent ileostomy is made from part of the ileum and is flushed a number of times each day to clean out the effluent (Koch pouch) (Oxford Radcliff Hospitals, 2013). An ileoanal ostomy is a pouch created above the anal sphincter and is also created from a portion of the ileum (Birmingham Bowel Clinic, 2011). Two types of internal urinary diversions may be created from part of the intestine. The first is an orthotopic neobladder, where a bladder is created and placed in the body at a normal bladder position; over time, with continence training, the patient can learn to void normally. The second type is a continent urinary reservoir, where a pouch is created from part of the intestine, and a catheter is inserted a number of times during the day to remove the urine (Perry et al., 2018; United Ostomy Association of America, 2017).
Physical and Emotional Assessment and Care
Patients may have co-morbidities that affect their ability to manage their ostomy care. Conditions such as arthritis, vision changes, Parkinson’s disease, or post-stroke complications may hinder a patient’s coordination and fine motor skills needed for ostomy management. In addition, the emotional burden of coping with an ostomy may be devastating for some people and may affect their self-esteem, body image, quality of life, and ability to be intimate. It is common for a person with an ostomy to struggle with body image and altered body function. The nurse’s attitude and non-verbal responses around ostomy care can help to normalize the situation and play a significant role in helping the patient adjust to new patterns of elimination. An important element of nursing care includes care both inside and outside the acute care setting. This includes ensuring the patient has the appropriate referrals to a wound / ostomy nurse and a social worker and information about support groups, possibly including online support groups (Perry et al., 2018).
Checklist 89 reviews the steps to changing an ostomy appliance (flange and pouch).
Different manufacturers have patient teaching videos on the web. This is not an endorsement of any particular product but will help inform you and your practice around ostomy care: Convatec Ostomy Care Video Library and Hollister Ostomy Care Resources.
A urostomy is similar to a fecal ostomy, but it is an artificial opening for the urinary system and the passing of urine to the outside of the abdominal wall through an artificially created hole called a stoma. A urostomy is created for the following reasons:
A person with a urostomy has no voluntary control of urine, and a pouching system must be used and emptied regularly. Many patients empty their urostomy bag every two to four hours, or as often as they regularly used the bathroom prior to their surgery. Urostomy pouches (see Figure 10.19) have a drain spot at the distal end, and the pouch should be emptied when one-third full. The pouch may also be attached to a large drainage bag for overnight drainage as an attempt to minimize sleep disturbances associated with having to wake up to attend to a full pouch. People with a urostomy are more at risk for urinary tract infections (UTIs) and should be taught about the signs and symptoms of such infections (Perry et al., 2018).
Figure 10.19 Urostomy pouch. note the different opening (left side of photo)
Changing a urostomy appliance (flange and pouch) is for the most part the same as changing an ileostomy or colostomy appliance. A few considerations specific to a urostomy are outlined in Table 10.6.
Critical Thinking Exercises