Colostomy Care
Content
Colostomy care
Clinicalinstructor: Dr: mona gaber
Presented by: Omar ahmed elzoghamy
1
Definition: Formation of an opening into the colon, brought out onto the abdominal wall as a stoma. The opening can be either permanent or temporary. •
Discussion: This procedure is usually performed for lesions in the large intestine caused by cancer, diverticulitis, or obstruction of the large intestine in an area close to the rectum. •
Types of colostomy: 1.
Temporary colostomy: A temporary colostomy is performed
to divert the fecal stream from the distal colon, which may be obstructed by tumor inflammation, or requires being “put-to-test” because of anastomosis or a pouch procedure. A temporary colostomy may be created in the transverse colon or sigmoid colon. 2. Permanent colostomy: A permanent colostomy is performed to treat malignancies of the colon. Other indications may include irrevocable rectal strictures, incontinence of bowel, or inflammatory bowel disease. A permanent colostomy can be fashioned similar to a temporary colostomy but most often is an end colostomy. 2
Position: •
Supine, with arms extended on arm boards.
Incision Site
•
Dependent on the segment of colon to be used.
Packs/ Drapes: • • • •
Laparotomy pack Four folded towels Transverse Lap sheet Minor pack
Instrumentation: • • • •
Major Lap tray Intestinal tray Closing tray Internal surgical staples
Supplies/ Equipments: 3
• • • • • • • • • •
Basin set Blades Needle counter Penrose drain Internal stapling instruments Glass rod and tubing with colostomy pouch Solutions – saline, water Sutures Medications Dressings
Procedure: 1. The abdomen is opened in the usual manner and the segment of colon is mobilized. 2. The colon can be brought out through the main incision, or through an adjacent site from which a disk of skin and subcutaneous tissue has been excised. 3. The underlying rectus fascia muscle and peritoneal layers are incised to accommodate the colon. The appropriate segment is excised between two atraumatic (intestinal) clamps or the internal stapling instrument, which is used to prepare and create the stoma. 4. In a loop colostomy, a rod or bridge may be placed under the colon to avoid retraction. 5. The abdomen is irrigated with warm saline and closed layers in a routine fashion. 6. A colostomy poucj is applied over the stoma. Perioperative Nurisng Considerations: 1. The colostomy pouch may or may not be applied in surgery. 2. A Vaseline gauze may encircle the stoma with a “fluff” type dressing applied. 3. If the institution has an “Ostomy Nurse”, the application of the colostomy pouch may be delayed until the clinical specialist can work with the patient and family.
:Preparing the Patient for Colostomy Care 4
Measuring the Stoma and Applying the Correct Wafer Size: To prevent skin problems and stool leakage from the pouch system, the wafer must fit properly onto the peristomal skin. In order to accomplish this, the opening in the wafer must be 1/8-inch larger than the stoma. Two types of wafers are available. The pre-cut wafer is already cut to the correct size for the opening around the stoma. Usually, this type is recommended once the stoma has stopped changing size (usually 6 to 8 weeks after surgery); it can be of great benefit for a person who is unable to cut the wafer (eg, due to arthritis or poor coordination). To use the pre-cut wafer, the patient or caregiver needs to measure the size of the stoma using the measuring guide found in most commercially prepared wafer products, keeping in mind the opening needs to be 1/8-inch larger than the stoma. The size is selected and applied without making any changes to the wafer. The cut-to-fit wafer needs to be cut to the correct size before use. The person can size the wafer each time a new one is applied, allowing for more accuracy regarding the stoma opening with each application. To use this wafer, the patient needs to determine the size of the stoma using the measuring guide. The selected hole size of the measuring guide is centered on the wafer. The patient or caregiver traces the hole on the wafer in the center of the flange with a marking pen. The wafer is cut along the pen marking as the guide, adjusting for irregular areas of the stoma. Another wafer option is the convex style. If the stoma is flush or retracted, the use of convexity will help achieve a better wafer adherence. The convex wafer presses into the tissue around the stoma, which increases the degree of stomal protrusion and reduces the risk of undermining. Disposable wafers are available with convexity that ranges from shallow to deep. Convex inserts (plastic rings that fit inside the flange of the wafer) are sized according to the stoma assessment.
Assessing the Stoma and Peristomal Skin: The stoma and peristomal skin need to be assessed for abnormalities and treated according to the findings. Assessment of these areas should note the following: Color and turgor of the stoma: . The stoma should be red and moist. A pale pink may indicate low hemoglobin and a dark red may indicate bruising, or ischemia (especially immediate post-op) (see 5
* Stomal height: A stoma that is at or below skin level can cause pouching problems because a good seal from the wafer is more difficult to obtain. Stool coming out of the stoma opening has a greater chance of going under the wafer, which can result in skin irritation and leakage. This stoma style would be appropriate for a convex wafer (see above). * Location of the stoma: . Proximity of the incision, waistline, abdominal folds or creases, and boney prominences to the stoma will be factors when pouching is performed. * Post-op assessment of the mucutaneous suture
line:. Any separation at the suture line or any allergic reaction to the suture material should be noted. * Intact and healthy peristomal skin:. Skin damage such as erythema, maceration, denudation, rash, ulceration, or blisters should not be evident.2 If signs of a fungal infection (a red rash and sometimes "weepy" area) are noted, treatment may be necessary. Antifungal powders should only be used if candidiasis has been diagnosed. The powder is sprinkled sparingly over the area before applying the wafer. The wafer may need to be changed sooner than the recommended time of 5 to 7 days to assess the area
Selecting the Pouching System: Different pouching system options need to be considered based on the person's stoma, peristomal skin, and preference. Several options are available (see Figure 3). The one-piece pouch system (the adhesive backing and pouch are connected and cannot be removed from each other) offers some people a sense of security because the components do not come apart. This also offers a more 6
flexible backing that can be an advantage to the person who has a peristomal hernia or abdominal fold near the stoma. One-piece systems also may have a convex wafer built into the system. The two-piece pouch system (the wafer and pouch are separate) allows the pouch to be easily removed for emptying or to view the stoma for problems. Other options include filtered and non-filtered systems. The filter is located at the top of the pouch and allows flatus to pass through a charcoal layer so gas may be vented without an odor. This is helpful for some people who have excess problems with flatus. The nonfiltered system does not offer this feature. Non-disposable pouch systems are also available in a degree of convexity. These are heavier and more durable because of the material used in the construction. Whatever system of convexity is used, the stoma needs to be measured and correct size determined with the 1/8-inch clearance around the stoma to prevent stomal damage.
7
Refrance: Brunnar of Medical Surgical Nursing 10 edition http://emedicine.medscape.com/
8
Clinicalinstructor: Dr: mona gaber
Presented by: Omar ahmed elzoghamy
1
Definition: Formation of an opening into the colon, brought out onto the abdominal wall as a stoma. The opening can be either permanent or temporary. •
Discussion: This procedure is usually performed for lesions in the large intestine caused by cancer, diverticulitis, or obstruction of the large intestine in an area close to the rectum. •
Types of colostomy: 1.
Temporary colostomy: A temporary colostomy is performed
to divert the fecal stream from the distal colon, which may be obstructed by tumor inflammation, or requires being “put-to-test” because of anastomosis or a pouch procedure. A temporary colostomy may be created in the transverse colon or sigmoid colon. 2. Permanent colostomy: A permanent colostomy is performed to treat malignancies of the colon. Other indications may include irrevocable rectal strictures, incontinence of bowel, or inflammatory bowel disease. A permanent colostomy can be fashioned similar to a temporary colostomy but most often is an end colostomy. 2
Position: •
Supine, with arms extended on arm boards.
Incision Site
•
Dependent on the segment of colon to be used.
Packs/ Drapes: • • • •
Laparotomy pack Four folded towels Transverse Lap sheet Minor pack
Instrumentation: • • • •
Major Lap tray Intestinal tray Closing tray Internal surgical staples
Supplies/ Equipments: 3
• • • • • • • • • •
Basin set Blades Needle counter Penrose drain Internal stapling instruments Glass rod and tubing with colostomy pouch Solutions – saline, water Sutures Medications Dressings
Procedure: 1. The abdomen is opened in the usual manner and the segment of colon is mobilized. 2. The colon can be brought out through the main incision, or through an adjacent site from which a disk of skin and subcutaneous tissue has been excised. 3. The underlying rectus fascia muscle and peritoneal layers are incised to accommodate the colon. The appropriate segment is excised between two atraumatic (intestinal) clamps or the internal stapling instrument, which is used to prepare and create the stoma. 4. In a loop colostomy, a rod or bridge may be placed under the colon to avoid retraction. 5. The abdomen is irrigated with warm saline and closed layers in a routine fashion. 6. A colostomy poucj is applied over the stoma. Perioperative Nurisng Considerations: 1. The colostomy pouch may or may not be applied in surgery. 2. A Vaseline gauze may encircle the stoma with a “fluff” type dressing applied. 3. If the institution has an “Ostomy Nurse”, the application of the colostomy pouch may be delayed until the clinical specialist can work with the patient and family.
:Preparing the Patient for Colostomy Care 4
Measuring the Stoma and Applying the Correct Wafer Size: To prevent skin problems and stool leakage from the pouch system, the wafer must fit properly onto the peristomal skin. In order to accomplish this, the opening in the wafer must be 1/8-inch larger than the stoma. Two types of wafers are available. The pre-cut wafer is already cut to the correct size for the opening around the stoma. Usually, this type is recommended once the stoma has stopped changing size (usually 6 to 8 weeks after surgery); it can be of great benefit for a person who is unable to cut the wafer (eg, due to arthritis or poor coordination). To use the pre-cut wafer, the patient or caregiver needs to measure the size of the stoma using the measuring guide found in most commercially prepared wafer products, keeping in mind the opening needs to be 1/8-inch larger than the stoma. The size is selected and applied without making any changes to the wafer. The cut-to-fit wafer needs to be cut to the correct size before use. The person can size the wafer each time a new one is applied, allowing for more accuracy regarding the stoma opening with each application. To use this wafer, the patient needs to determine the size of the stoma using the measuring guide. The selected hole size of the measuring guide is centered on the wafer. The patient or caregiver traces the hole on the wafer in the center of the flange with a marking pen. The wafer is cut along the pen marking as the guide, adjusting for irregular areas of the stoma. Another wafer option is the convex style. If the stoma is flush or retracted, the use of convexity will help achieve a better wafer adherence. The convex wafer presses into the tissue around the stoma, which increases the degree of stomal protrusion and reduces the risk of undermining. Disposable wafers are available with convexity that ranges from shallow to deep. Convex inserts (plastic rings that fit inside the flange of the wafer) are sized according to the stoma assessment.
Assessing the Stoma and Peristomal Skin: The stoma and peristomal skin need to be assessed for abnormalities and treated according to the findings. Assessment of these areas should note the following: Color and turgor of the stoma: . The stoma should be red and moist. A pale pink may indicate low hemoglobin and a dark red may indicate bruising, or ischemia (especially immediate post-op) (see 5
* Stomal height: A stoma that is at or below skin level can cause pouching problems because a good seal from the wafer is more difficult to obtain. Stool coming out of the stoma opening has a greater chance of going under the wafer, which can result in skin irritation and leakage. This stoma style would be appropriate for a convex wafer (see above). * Location of the stoma: . Proximity of the incision, waistline, abdominal folds or creases, and boney prominences to the stoma will be factors when pouching is performed. * Post-op assessment of the mucutaneous suture
line:. Any separation at the suture line or any allergic reaction to the suture material should be noted. * Intact and healthy peristomal skin:. Skin damage such as erythema, maceration, denudation, rash, ulceration, or blisters should not be evident.2 If signs of a fungal infection (a red rash and sometimes "weepy" area) are noted, treatment may be necessary. Antifungal powders should only be used if candidiasis has been diagnosed. The powder is sprinkled sparingly over the area before applying the wafer. The wafer may need to be changed sooner than the recommended time of 5 to 7 days to assess the area
Selecting the Pouching System: Different pouching system options need to be considered based on the person's stoma, peristomal skin, and preference. Several options are available (see Figure 3). The one-piece pouch system (the adhesive backing and pouch are connected and cannot be removed from each other) offers some people a sense of security because the components do not come apart. This also offers a more 6
flexible backing that can be an advantage to the person who has a peristomal hernia or abdominal fold near the stoma. One-piece systems also may have a convex wafer built into the system. The two-piece pouch system (the wafer and pouch are separate) allows the pouch to be easily removed for emptying or to view the stoma for problems. Other options include filtered and non-filtered systems. The filter is located at the top of the pouch and allows flatus to pass through a charcoal layer so gas may be vented without an odor. This is helpful for some people who have excess problems with flatus. The nonfiltered system does not offer this feature. Non-disposable pouch systems are also available in a degree of convexity. These are heavier and more durable because of the material used in the construction. Whatever system of convexity is used, the stoma needs to be measured and correct size determined with the 1/8-inch clearance around the stoma to prevent stomal damage.
7
Refrance: Brunnar of Medical Surgical Nursing 10 edition http://emedicine.medscape.com/
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