Ostomy and Enteral Feeding PDF

# Ostomy Care ## General Postoperative Ostomy Information ### Follow-up Care - Clients should follow up regularly with the surgeon and wound, ostomy and continence nurse. - Clients will want to know when they can resume their usual activities. - Most clients can resume their usual activities with...

# Ostomy Care ## General Postoperative Ostomy Information ### Follow-up Care - Clients should follow up regularly with the surgeon and wound, ostomy and continence nurse. - Clients will want to know when they can resume their usual activities. - Most clients can resume their usual activities with minimal restrictions after the stoma has healed adequately. - Give them specific information about exercise and sexual activity and make sure it matches what their provider has prescribed or recommended. ### Exercise - Ostomy clients should be advised to remain vigilant of their hydration status during strenuous physical activity. - Clients should engage in a regular exercise routine that includes activities that promote cardiovascular and musculoskeletal fitness. ### Sexuality - Clients should expect to feel sensitive about the change in body image. - Encourage them to share feelings with their partners and to respond to any concerns. - Irritation of the stoma and peristomal skin due to friction should be avoided. - Clients may feel more secure about engaging in sexual activity if they empty the pouch first, wear a smaller pouch, or cover the pouch with specifically designed underwear, lingerie, or pouch covers. ## Urostomy Management - Teach clients and families about stoma and urinary diversion care, including: - Odor management - Skin care - Adequate fluid intake - Pouch application and leakage prevention - Self-catheterization for clients who have continent reservoirs - Signs of infection and obstruction - Teach clients how to evaluate the character and color of their urine and to report any skin alterations under their skin barrier that may be a sign of leakage or the need for an extended-wear skin barrier. ## Ileostomy Management - To prevent food blockage, clients should avoid high-fiber foods and those that cause intestinal gas. - Advise clients to take enteric-coated pills or tablets with caution and to observe for undissolved medication in the ileostomy pouch. - Drainage from an ileostomy is typically dark green, loose, and odorless. - Instruct clients to empty the pouch when it is one-third to one-half full, which may require draining several times a day. - Effluent from the ileostomy contains enzymes and bile salts that can irritate the skin. - Advise the use of a skin barrier and prompt attention to any indications of pouch leakage. - Teach clients to recognize the manifestations of food blockage and to know when to contact their provider. - Common manifestations are abdominal cramping, nausea, vomiting, swelling of the stoma, and no ileostomy output for at least 6 hours. - When these develop, clients should lie down and assume a knee-chest position to relieve intra-abdominal pressure, and/or massage the abdominal area to promote peristalsis and fecal elimination. - If the stoma is swollen, they might have to replace the pouch with one that has a larger opening to avoid mechanical obstruction. - The United Ostomy Associations of America has information available online regarding the manifestations of blockage and what to do to relieve blockage. - High-volume ileostomy output can put clients at risk for fluid and electrolyte imbalances. They need to recognize the manifestations of dehydration or electrolyte imbalance. ## Colostomy Management - Clients who have a colostomy need information about their options for management, including: - Use of drainable or closed-end pouches - Irrigation - Dietary management - Review strategies for managing diarrhea and constipation. - Clients who have a temporary diverting colostomy need to know that they might feel an urge to defecate through the rectum or have rectal drainage. - Clients who have a double-barrel or loop colostomy should be aware that the distal bowel carries no fecal contents. - Review the various options for pouching systems so clients can choose a system that fits their lifestyle. - The use of a commercially made pouch with a charcoal filter provides odor control and may enhance confidence. - Clients who have a colostomy might not need any dietary adjustments, although they should be aware of foods that cause fecal odors and gas and those that thicken or loosen stools. ## Ileostomy - An ileostomy is a surgical opening created in the ileum to bypass the entire large intestine. - The stoma of an ileostomy is typically located in the right lower quadrant. - A restorative proctocolectomy with ileal pouch anal anastomosis (IPAA) involves connecting the ileum to a new rectum (or anal pouch), also made out of a portion of ileum. - It is the procedure of choice in cases where the rectum can be preserved, allowing the client to retain anal sphincter control of bowel movements. - The client will have a temporary loop ileostomy to divert stool while this new anal pouch heals, followed by closure of the ostomy a few months later. - An alternative to the standard ileostomy is Kock's continent ileostomy. - During the procedure, an internal pouch is created from the distal segment of the ileum, which serves as a reservoir for stool. - During surgery, a one-way nipple valve is constructed through the stomal opening so that eventually the client can insert a catheter through the stoma and through the one-way valve to drain the fecal contents of the internal pouch. - This type of ostomy is occasionally created to treat ulcerative colitis and may be an option for clients who do not wish to wear an external pouch over the stoma. - The complication rate associated with a continent ileostomy is usually higher than with a traditional ileostomy. - The client empties the pouch several times a day and the stoma is covered with a protective dressing or a stoma cap. ## Colostomy - Clients can prevent the passage of malodorous flatus by avoiding foods that cause odors. - Beverages and foods that increase intestinal gas include beer, broccoli, Brussels sprouts, cabbage, carbonated drinks, cauliflower, corn, cucumbers, dairy products, dried beans, mushrooms, onions, peas, and radishes. - Advise clients who have a colostomy to speak with their surgeon or primary care provider before using laxatives and enemas due to the potential for fluid and electrolyte imbalance. - Clients should also be instructed to use caution when taking enteric-coated and sustained-release medications. ## Types of Colostomy - **Loop colostomy**: A loop of the bowel is brought through the abdomen to the skin surface and temporarily supported by a plastic bridge or rod. A transverse loop colostomy is typically created as an emergency procedure to relieve an intestinal obstruction or perforation. A communicating wall remains between the proximal and the distal bowel. It has two openings through the one stoma; the proximal end drains stool while the distal portion drains mucus. The bridge can be removed in 7 to 10 days. Transverse loop colostomies are typically temporary. - **Double-barrel colostomy**: Two separate stomas are created. Both ends of the bowel are brought through the abdomen to the skin surface as two separate sections. Typically, the distal colon is not removed but bypassed. The proximal stoma, which is functional, diverts feces to the abdominal wall. The distal stoma, or mucous fistula, expels mucus from the distal colon. ## Location of Colostomy - Depending on the area of disease or injury and other physical features of the client's abdomen, a colostomy is placed in one of four locations. - **Ascending colon (right abdomen)**: The output is typically liquid to semi-liquid and is very irritating to the surrounding skin. - **Transverse colon (mid-abdomen)**: This location is used for a temporary ostomy, with the stoma constructed as a loop. Output is pasty. - **Descending colon (left upper abdomen)**: The output is semi-formed because more water is absorbed while fecal material is in the ascending and transverse colon. - **Sigmoid colon (left lower abdomen)**: This is the location for a permanent colostomy, particularly for cancer of the rectum. The stoma is typically located on the lower left quadrant of the abdomen, and the output is formed. # Enteral Tube Feeding ## Insertion Procedure - **To prepare the tube for insertion**, dip the tip of the tube into a water-based lubricant or in a cup of water to activate the lubricant. Follow facility policies for using lidocaine spray, gel, a nebulizer, or other medications to numb the airway tissues. - **Ask the client to tip their head backward and breathe through the mouth.** - **Insert the tube through the naris towards the back of the throat (the posterior nasopharynx).** After you have passed the tube through the nasopharynx, have the client flex their head toward their chest and swallow as the tube advances. If the client can swallow liquids safely, ask them to take small sips of water. Advance the tube each time the client swallows until you have inserted the predetermined length of tube. - **Check for the position of the tube in the back of the throat with a penlight and a tongue blade.** You should be able to visualize the tube taut against the back of the throat. Observe for any difficulty breathing, coughing, or gagging. - **Assess the client's comfort level.** Temporarily anchor the feeding tube and verify placement by testing gastric aspirate for pH or bilirubin or use a CO₂ level. - **Gastric fluid from a client who has fasted for at least 4 hours usually has a pH range of 1 to 4,** and the fluid will be grassy green, off-white, or tan with the consistency of water. **Intestinal fluid pH is usually 7 or higher,** and since it contains bile it will appear light to golden yellow or brownish green with a syrupy consistency. Clients receiving continuous tube feeding often have a pH of 5 or higher. - **In contrast, respiratory fluid is usually clear with a pH greater than 6.** - If you are unable to obtain fluid after flushing the tube with air, try repositioning the client from side to side. Try multiple flushes with air. Again, it is important to note the color and consistency of the fluid. - Besides checking the pH reading and the color and consistency of the aspirate, **evaluate the client's risk for undetected respiratory placement.** Clients who have a decreased level of consciousness, have poor cough or gag reflexes, are endotracheally intubated or have been recently extubated, are unable to cooperate with the procedure, or are restless or agitated are at greater risk for improper tube placement and require extra precautions. - **Secure the tube at the point of insertion and mark the tube with a permanent marker or tape directly where the tube meets the naris or the mouth.** - **Assist the client to a comfortable position, dispose of used supplies, apply clean gloves, and provide mouth care.** Be sure to document all feeding tube insertion procedures. - **Confirmation of tube placement by x-ray is required.** If using a guidewire, wait to remove the guidewire until after confirmation of the tube placement and do not reinsert it, as it could potentially damage surrounding tissue during reinsertion.