med surge

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med surge
2010-07-29 00:22:57

ch 48
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  1. ostomies
    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
  2. ileostomy
    • 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
  3. ostomy appliance
    • 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
  4. pharmacologic consideration
    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
  5. preoperative period
    • 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
  6. nursing process
    preoperavtive assessment
    • 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
  7. postoperative period
    • 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
  8. recovery from ileostomy
    • 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
  9. continent ileostomy (kock puoch)
    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
  10. ileoanal reserboir (anastomosis)
    • 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
  11. colostomy
    • 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)
  12. loop colostomy
    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)
  13. regulating bowel elimaination
    • 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
  14. nutrition of pt w/ ostomy
    • 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