Chapter 26 Homework One End The Ileal Segment Sutured Closed

16 Chapter 26  The Patient with an Ostomy _______________________________________________________

Introduction to Medical-Surgical Nursing, 6th ed.

LESSON 26.1

3

DISCUSS

• Discuss the procedure for an ileostomy.

• Divide the class into four groups. Have each

group prepare a presentation about one type

of ostomy, using drawings of bowel

involvement, stoma placement, and type of

• Discuss the procedure for a continent (pouch)

ileostomy.

• Divide the class into two groups. Have each

group recommend ways for a nurse to

• Discuss the procedure for an ileoanal

reservoir. What are some of the

complications that can result?

• Discuss the procedure for a colostomy.

What are the indications for the two types of

colostomies?

• Divide the class into four groups, and

present each group with one of the following

ostomy complications:

• Skin irritation

• Stenosis

• Prolapse or hernia

• Odor

POST AND COMMENT

• Post the following discussion topic online

and have students comment. Ask the class

to identify three major complications

following ileoanal reservoir surgery. Write

these on the board. Then ask for volunteers

_______________________________________________________ Chapter 26 The Patient with an Ostomy 17

Introduction to Medical-Surgical Nursing, 6th ed.

LESSON 26.1

4

DISCUSS

• Discuss postoperative nursing care of the

patient with an ileostomy. What are some of

the interventions that might be necessary?

• Divide the class into small groups, and

provide each group with a mannequin with a

• Invite an enterostomal therapist to speak to

the class about the nurse’s role in caring for

patients with ostomies. Have the speaker

address ostomy care and common problems

encountered. Ask the speaker to bring

several types of ostomy supplies and

discuss their use.

• Discuss postoperative nursing care of the

patient with an ileoanal reservoir. What are

some of the interventions that might be

necessary?

• Divide the class into small groups. Have

each group refer to the Nursing Diagnoses,

Goals, and Outcome Criteria: Ileoanal

• Discuss Nursing Care Plan: The Patient with

a Colostomy. What are some of the

interventions that might be necessary?

• Divide the class into four groups, and assign

a colostomy location to each group. Have

each group identify the reason,

POST AND COMMENT

• Post the following discussion topic online

and have students comment. Describe

postoperative nursing care of the patient

with a continent ileostomy. What are some

of the interventions that might be

18 Chapter 26  The Patient with an Ostomy _______________________________________________________

Introduction to Medical-Surgical Nursing, 6th ed.

LESSON 26.1

Critical Thinking Question

A patient is 3 days postoperative after an ileostomy for Crohn’s disease. While caring for the

patient’s stoma, the nurse notices that the patient will not look at the stoma or display any

interest in caring for it. How should the nurse proceed?

Discussion Guidelines: Denial, grieving, anxiety, and fear are common in patients who have

ostomies. Strategies such as leading questions to encourage discussion will help the patient vent

Instructor Notes/Student Feedback

_______________________________________________________ Chapter 26 The Patient with an Ostomy 19

Introduction to Medical-Surgical Nursing, 6th ed.

LESSON 26.2

Textbook Objectives Covered

5. Explain the types of procedures done for urinary diversion.

6. Assist in developing a nursing care plan for the patient with each of the following types of

urinary diversion: ureterostomy, ileal conduit, and continent internal reservoir.

7. Discuss content to be included in teaching patients to learn to live with ostomies.

Lesson Preparation Checklist

• Prepare lecture from TEACH lecture slides available on Evolve.

• Student performance evaluation of all entry-level skills required for student comprehension of

principles underlying care of the ostomy patient, including:

• Understanding the indications and preparation for ostomy surgery

Materials and Supplies

• computer and PowerPoint

projector

Key Terms

• anastomosis (p. 416)

• colostomy (p. 424)

• continent (p. 421)

• ileostomy (p. 416)

• nephrostomy (p. 433)

• ostomy (p. 414)

• prolapse (p. 424)

• stoma (p. 414)

• ureterostomy (p. 429)

• vesicostomy (p. 433)

Assignments 2 hours

5

READ – Textbook (pp. 427-428)

REVIEW

• Figure 26-6: Types of urinary diversion (p. 428)

• Figure 26-7: Procedure for applying pouch (p. 431)

ANSWER – Study Guide

• Part ID: 1-3 (pp. 151-152)

6

READ – Textbook (pp. 428-430)

ANSWER – Text

ANSWER – Study Guide

• Part IIE: 13, 14 (p. 153)

20 Chapter 26  The Patient with an Ostomy _______________________________________________________

Introduction to Medical-Surgical Nursing, 6th ed.

LESSON 26.2

7

READ – Textbook (pp. 430-432)

REVIEW

• Table 26-1: Problems associated with urinary stomas (p. 432)

ANSWER – Text

• Review Questions for the NCLEX Examination: 10 (p. 434)

ANSWER – Study Guide

• Part IB: 1-12 9 (p. 150)

50-Minute Lesson Plan

Lecture Outline 20 minutes

5

Slide 31

Interventions

• Ineffective therapeutic regimen management

• Irrigations

• No longer routinely recommended

• Many patients have regular bowel movements without irrigation

• Unlikely to establish control if the patient has diarrhea when under stress, has had

TALKING POINTS:

• What key points should be remembered when irrigating a colostomy?

6

Slide 32

Interventions (cont.)

• Risk for injury

• Assess for indications of colostomy complications

• Prolapsed stoma

• Obstruction

TALKING POINTS:

• Although a prolapsed stoma may look frightening, it is not usually serious.

• Why would surgery be needed for a prolapsed stoma or an obstruction?

Urinary Diversion: Cutaneous Ureterostomy

• One or both ureters are brought out through an opening in the abdomen or flank

_______________________________________________________ Chapter 26 The Patient with an Ostomy 21

Introduction to Medical-Surgical Nursing, 6th ed.

LESSON 26.2

Slide 34

Urinary Diversion: Cutaneous Ureterostomy (cont.)

• Complications

• Stenosis

• Narrowing of the opening that interferes with the flow of urine

• If the obstruction is not relieved, urine backs up in the kidney and may cause

hydronephrosis

• Urinary tract infections

Assessment

• Health history

Slide 36

Assessment (cont.)

• Physical examination

• Assess patient’s general state

• Take vital signs and compare with preoperative readings

• Observe respiratory effort and auscultate breath sounds.

TALKING POINTS:

• Is blood in the urine normal?

• Ureterostomy drainage should not contain mucus.

Slide 37

Interventions

• Impaired skin integrity

• Apply an appliance to collect urine drainage

• Use skin barrier around the stoma

TALKING POINTS:

• Why should Karaya products not be used for urinary drainage?

• Belts can be worn with some appliances to hold them in place.

• Some pouches can be connected to a leg bag for urine collection.

Slide 38

Interventions (cont.)

• Risk for infection

• The stoma serves as a portal for pathogens to enter the urinary tract, causing

22 Chapter 26  The Patient with an Ostomy _______________________________________________________

Introduction to Medical-Surgical Nursing, 6th ed.

LESSON 26.2

Slide 39

Interventions (cont.)

• Risk for injury

• If urine does not flow readily, suspect obstruction and notify the registered nurse or

the surgeon immediately

5

Slide 40

Interventions (cont.)

• Disturbed body image

• Demonstrate acceptance of the patient and care for the stoma in a matter–of–fact

manner

TALKING POINTS:

• Adjustment to a stoma can be very difficult.

• The patient may be afraid of what issues?

• Patients with ostomies commonly experience grief in response to the loss of normal

function and perceived disfigurement.

• The change in body image may affect the patient’s sexuality.

Slide 41

Interventions (cont.)

• Self-care deficit

• Teaching plan should include

• Ostomy care

• Pouches

• Diet

• Resources

TALKING POINTS:

• From the early postoperative period, try to help the patient learn independent ostomy

care.

• How soon can normal activities be resumed?

6

Slide 42

Ileal Conduit

• Procedure

• Urinary drainage system made from portion of small intestine

• A 6- to 8-inch segment of ileum is first removed

_______________________________________________________ Chapter 26 The Patient with an Ostomy 23

Introduction to Medical-Surgical Nursing, 6th ed.

LESSON 26.2

5

Slide 43

• Stoma retraction, prolapse, or hernia

Ileal Conduit (cont.)

• Complications

• Leakage of the anastomosed ureters and intestinal segments

• Ureteral obstruction

• Separation of the stoma from surrounding skin

6

Slide 44

• Attach the pouch to a collection device during the night

Postoperative Nursing Care of the Patient with an Ileal Conduit

• Basically same as for patient with an ileostomy

• A few special points to make about the ileal conduit

• Patient will have a nasogastric tube attached to suction to prevent abdominal

Continent Internal Reservoirs

• Allows for the storage and controlled drainage of urine

• Ileum neobladder

TALKING POINTS:

• What is an ileum neobladder?

Slide 46

Continent Internal Reservoirs (cont.)

• Kock pouch

• Constructed with a segment of ileum

• Ureters implanted in one side of the ileum segment

TALKING POINTS:

• What are some complications of the continent pouches?

5

Slide 47

Continent Internal Reservoirs (cont.)

• Indiana pouch

• Similar to the Kock pouch except that it is made of a portion of the terminal ileum and

the ascending colon

• The reservoir is larger than that of the Kock pouch

24 Chapter 26  The Patient with an Ostomy _______________________________________________________

Introduction to Medical-Surgical Nursing, 6th ed.

LESSON 26.2

Slide 48

Postoperative Nursing Care of the Patient with a Kock or Indiana Pouch

• May have Penrose drain to remove fluid from operative site and clear tube in place for

continuous urine drainage

intubation to drain

Slide 49

Ureterosigmoidostomy and Ureteroileosigmoidostomy

• Ureterosigmoidostomy

• The ureters are implanted into the sigmoid colon

• Urine drains into the colon and is eliminated through the rectum

TALKING POINTS:

• Neither procedure provides continence, and both present problems with kidney infections

and urinary calculi (stones).

Slide 50

Vesicostomy

• Vesicostomy or cystostomy

• An opening into the urinary bladder

• Some are drained continuously through a catheter, others have a nipple valve and are

drained at intervals

Nephrostomy

• Diverts urine directly from the kidney through a tube that exits through the skin

_______________________________________________________ Chapter 26 The Patient with an Ostomy 25

Introduction to Medical-Surgical Nursing, 6th ed.

LESSON 26.2

Activities

Classroom Choose from below to make 30 minutes

Online

5

DISCUSS

• Divide the class into four groups. Have each

group describe one type of urinary diversion,

providing drawings and methods of care for

that particular type. Examples would be

cutaneous ureterostomy, ileal conduit, colon

• Ask the class to identify complications

following ileal conduit surgery. Write these

on the board. Then ask for volunteers to

write the cause and signs and symptoms for

each complication. Discuss related nursing

care for each complication.

• Discuss the procedure for continent internal

reservoirs. What are some of the

complications that can result?

• Ask the class to identify complications

following Kock and Indiana pouch

• Discuss Nutrition Considerations (p. 423).

• Divide the class into pairs. Assign each pair

one of the urinary diversion procedures

POST AND COMMENT

• Post the following discussion topic online

and have students comment. Describe the

procedure for cutaneous ureterostomy.

Create a table that outlines some of the

complications that can result.

26 Chapter 26  The Patient with an Ostomy _______________________________________________________

Introduction to Medical-Surgical Nursing, 6th ed.

LESSON 26.2

6

DISCUSS

• Discuss postoperative nursing care of the

patient with a cutaneous ureterostomy. What

are some of the interventions that might be

necessary?

• Discuss Table 26-1 (p. 432). What are some

of the interventions that might be

necessary?

• Divide the class into small groups. Have

each group refer to the Nursing Diagnoses,

Goals, and Outcome Criteria: Cutaneous

Ureterostomy (p. 430) and discuss two

POST AND COMMENT

• Post the following discussion topic online

and have students comment. Discuss

postoperative nursing care of the patient

with an ileal conduit. What are some of the

interventions that might be necessary?

7

DISCUSS

• Discuss content that should be included in

the education of patients after ostomy

surgery.

• Divide the class into two groups. Have each

group present a discharge scenario with

ostomy teaching. Examples would be a

POST AND COMMENT

• Post the following discussion topic online

and have students comment. Create a

patient teaching plan for the patient who has

a new colostomy.

_______________________________________________________ Chapter 26 The Patient with an Ostomy 27

Introduction to Medical-Surgical Nursing, 6th ed.

LESSON 26.2

Critical Thinking Question

While examining a patient’s ureterostomy stoma, the nurse notices that the skin around the

stoma is reddened, irritated, and painful. When asked how he was caring for it at home, the

patient correctly answers questions regarding what he has been taught, but the nurse

suspects he is not following through with proper care. How should the nurse intervene?

Discussion Guidelines: Good skin care is essential in caring for a stoma. Fecal matter, urine, and

the adhesives used to attach the pouch can be very irritating to the skin. The nurse needs to have

Instructor Notes/Student Feedback

28 Chapter 26  The Patient with an Ostomy _______________________________________________________

Introduction to Medical-Surgical Nursing, 6th ed.

26

Assessments for

The Patient with an Ostomy

CHAPTER OBJECTIVES

Lesson 26.1:

2. Describe nursing interventions to prepare the patient for ostomy surgery.

4. Assist in developing a nursing process to plan care for the patient with each of the following types of

fecal diversion: ileostomy, continent ileostomy, ileoanal reservoir, and colostomy.

Lesson 26.2:

5. Explain the types of procedures done for urinary diversion.

7. Discuss content to be included in teaching patients to learn to live with ostomies.

Assessments by Lesson & Objective

Lesson 26.1

1

Study Guide

• Part IIE: 16 (p. 153)

Evolve Student Resources

• NCLEX Review: 7

Study Guide

Evolve Instructor Resources

• Test Bank: 7

3

Study Guide

• Part IC: 1-4 (p. 151)

• Part IIE: 1 (p. 152)

Evolve Instructor Resources

• Test Bank: 1, 8, 15, 19, 29, 30

Evolve Student Resources

• NCLEX Review: 2, 3, 4

4

Study Guide

• Part IB: 13 (p. 150)

Evolve Instructor Resources

• Test Bank: 2-5, 13, 22, 23, 25-28

Evolve Student Resources

• NCLEX Review: 1, 5, 8, 10

• Prioritization: 1-5

_______________________________________________________ Chapter 26 The Patient with an Ostomy 29

Introduction to Medical-Surgical Nursing, 6th ed.

Assessments by Lesson & Objective

5

Study Guide

• Part ID: 1-3 (pp. 151-152)

6

Study Guide

• Part IIE: 13, 14 (p. 153)

Evolve Instructor Resources

• Test Bank: 12, 15, 16, 21, 25

7

Study Guide

• Part IB: 1-12 9 (p. 150)

Instructor’s Notes/Student Feedback