65-year-old woman Ilea Conduit essay
Order ID 53563633773 Type Essay Writer Level Masters Style APA Sources/References 4 Perfect Number of Pages to Order 5-10 Pages Description/Paper Instructions
You are working on a postoperative surgical floor and are assigned to A.T., a 65-year-old woman with a 30-year smoking history who has recently had a radical cystectomy with ileal conduit for invasive bladder cancer.
- You begin your assessment and look at the transparent urostomy pouch covering the ileal conduit. The stomal opening is red and is draining urine with mucus. Is this normal?
Yes, this is normal. A 6- to 8-inch segment of the ileum, with intact mesentery blood supply, is resected from the bowel, the end is folded over on itself like an ankle sock, and it is sewn to an opening made in the abdominal wall. The distal end of the ileal conduit is positioned such that peristalsis will assist transport of urine through the conduit and out of the stoma. The ureters coming from the kidneys are attached to the piece of ileum, resulting in urine draining through the artificial abdominal opening. The stoma is usually located in the RLQ of the abdomen. The segment of bowel still functions as small bowel; that is, it still produces mucus designed to facilitate the movement of stool through the small bowel. The stoma is red, wet, and slippery if it has good circulation and mucus drains out with the urine.
- A nursing student who is working with you asks you to explain the difference between an ileal conduit and an ileostomy. How do you answer?
An ileostomy is created when the physician cuts the ileum away from the cecum and brings the ileum to the surface of the abdomen. The large intestine is no longer available to dehydrate the stool; that means the ileum drains liquid or semiformed stool through the abdominal wall into an external pouch. An ileal conduit is formed when 6 to 8 inches of the ileum is removed from the bowel and brought to the abdominal wall, where an opening is made. The ureters coming from the kidneys are attached to the piece of ileum so that it drains urine through a piece of intestinal conduit through a sur-gically created abdominal opening, called a stoma, which is Latin for “mouth” or “opening.”
- The student replies, “So, eventually, A.T.’s ileal conduit will become continent, and she won’t need to wear a pouch, right?” How do you answer?
There is no continence mechanism in an ileal conduit, so an external bag, also called a pouch or appli-ance, must be worn to collect the urine.
- What is the proper size for an appliance for an ileal conduit?
It is important to wear a properly fitting appliance that fits the stoma snugly with no more than
1⁄16– to 1⁄8-inch clearance around the stoma. Too tight of an appliance can predispose the patient to a pouch seal leak with the wet stoma undermining the protective skin barrier seal. It can also cut off or impede stoma circulation. Too large of an opening in the protective wafer around the stoma can expose surrounding skin to urine, with subsequent skin breakdown.
CASE STUDY PROGRESS
A.T. is quiet and sullen. You ask her if something is wrong, and she confides she is concerned about whether her husband will find her attractive after he sees her “rosebud.”
- What is the underlying problem?
A.T. is experiencing a change in body image. She has lost an organ, and her body has to function differ-ently, and a normally private body function is now very visible. She has to change the way she thinks about herself.
CASE STUDY PROGRESS
You ask A.T. whether she would love her husband or children any less if they had a physical problem that required surgical repair. She quickly tells you, “No, of course not.” You suggest that her family will likely respond the same way to her surgery. You suggest that someone from the ostomate program come and talk to her.
- What is the ostomate program?
Someone of the same gender, with similar ostomy surgery or similar age, who belongs to an ostomy association and has had some training as a visitor can be contacted—usually through a Certified Wound and Ostomy Care Nurse (CWOCN) or the local ostomy association—to visit a new ostomy patient.
- A.T. is well enough to begin self-care but asks you if you will change her pouch because she doesn’t “want to look at it.” Is there anyone on the hospital staff who could help teach A.T. ostomy self-care and offer more support?
Yes, most hospitals have a CWOCN whose function is to teach ostomy self-care with adjunct help from other hospital staff.
CASE STUDY PROGRESS
It is now the fourth postop day, and A.T. is now willing to learn how to change her appliance. She tells you the stoma feels wet, and it has no feeling when she touches it.
- Which statements about the stoma are true? (Select all that apply.)
- “The lining of the stoma is the same type of tissue as the inside of your mouth.” b. “It has touch receptors, just like your skin, and you should have feeling in it.”
- “The color should be a beefy red, and the stoma should feel wet.” d. “Normally, the stoma is dry. Feeling moisture is a problem.”
- “The tissue is tough and rarely bleeds.”
Answers: A, C
The lining of the stoma is the same type of tissue as the inside of your mouth. It has no touch recep-tors, just pressure receptors, so it is numb to the touch, unless the bowel tissue is stretched like when there is a GI blockage. Lack of touch receptors makes the stoma susceptible to injury. The tissue of the stoma might bleed if bumped. The color is normally a beefy red, and it is moist or wet to the touch.
- A.T. asks you, “How will I know when to empty it? What about at night? Do I have to get up at night to empty this little pouch?” How do you answer her?
The pouch, or appliance, should have a spout and needs to be emptied when it is one-third to one-half full. Some appliances are closed with a clip that will need to be removed to empty the pouch. Others might have a self-sealing opening. The weight of the collected urine will pull the appliance off of the skin and break the seal, if the pouch overfills. At night, the pouch is connected to a 2-L gravity drainage bag so the person can sleep without interruption.
- What other topics need to be addressed when doing teaching regarding an ileal conduit?
- Because the stoma is subject to injury, it is important to avoid heavy contact sports (e.g., football, wrestling) and avoid placing a seat belt directly across the stoma. It is also important to inspect the stoma regularly for viability—it should be wet and beefy red.
- The drainage pouch sitting next to the abdominal skin frequently causes the skin to perspire and feel sticky. Commercially available pouch covers look attractive, help absorb perspiration, and camouflage the urostomy pouch. Some appliances have a built-in pouch cover that comes preattached.
- The stoma will shrink over a period of 1 year. It can also change in size with a change in weight such as with a growth spurt or pregnancy.
- Hot water locks in odors, so use tepid water to rinse the pouch if reusing. It is also recommended that a pouch be labeled “shower pouch” or “bath pouch” so that, if appliances are reused, only one or a select number is exposed to the hot water used for bathing.
- It is possible to take a bath or a shower or go swimming with an ileal conduit. It is recommended that the patient wear a pouch to protect others from free-flowing urine.
- It is important for a person with an ileal conduit to remain hydrated. This keeps the conduit flushed and prevents dehydration and electrolyte imbalance.
- The most common infection a person with an ileal conduit experiences is a peristomal yeast infection.
- Male patients who have a wide resection for cancer (e.g., radical cystoprostatectomy) are likely to become impotent postop. Generally, the prostate is prophylactically removed, and the perineal nerve is almost always disturbed. If interested in potency, the patient might be able to undergo surgical correction (e.g., penile prosthesis surgery). Encourage the patient to discuss this with a physician if this is an issue.
CASE STUDY PROGRESS
A.T.’s urine looks cloudy, and another nurse suggests that you send a specimen from her pouch to the lab for analysis. Her urine does not smell foul, and she has no fever or flank pain.
- Should you follow through on this suggestion? Why or why not?
- Although cloudy urine can be an indication of a UTI, there is a difference between cloudy urine and clear urine that has mucus in it. Remember, the ileal conduit is formed from small bowel tissue that still produces mucus; mucus production is normal in the urine of an ileal conduit patient.
- Urine removed from a nonsterile, clean bag that has been worn for urine collection (similar to a leg bag or night drain bag) will likely grow bacteria because of bacterial colonization in the collection bag. It might not represent a true bacterial infection.
- What are the signs and symptoms of a urinary tract infection (UTI) in a patient with an ileal conduit?
S/S of a UTI include foul-smelling urine, blood in the urine, fever or chills, and flank pain as well as pos-sible mental status changes and elevated serum WBCs.
- T. asks you, “How will they collect a urine specimen when it just dribbles out all the time?” How will you answer her?
The procedure for collecting urine through an ileal conduit is to catheterize gently using a 14 to 16 Fr through the stoma, using sterile technique. Care is needed to prevent trauma to the stoma or conduit; some facilities might specify that this is done only by someone with specialized training. Never force anything into the stoma because perforation can occur as a result of the lack of pressure receptors in the mucosal tissue used to fashion the conduit.
- As you make rounds, you notice that A.T.’s pouch has sprung a urine leak and she has placed a washcloth over the pouch to absorb the urine. She asks you for tape to attach the washcloth to the bag. How will you respond to her request?
Gently tell her that her pouch needs to be changed because urine next to the skin can cause skin break-down. Urine exposure, even over a period of 24 hours or less, can cause skin breakdown that will make it more difficult to achieve an intact pouch seal.
A.T. eventually masters the pouch application and is discharged to home. She returns to the urology clinic in 6 months for a follow-up visit. She has lost 24 pounds and is seen with a smaller stoma surrounded by a half-inch ring of wartlike skin. The nurse explains to A.T. that her stoma has shrunk, and the bag no longer fits properly; alkaline urine washing over unprotected skin from too large an appliance opening causes a skin reaction that can either appear smooth or wartlike. The wartlike skin buildup is referred to as hyper-keratotic, hyperplastic, epitheliomatous hyperplasia, metaplasia, or acanthosis.
- What can be done once a hyperkeratotic lesion forms around a stoma?
Usually covering the skin for protection will cause the proud skin to recede. However, you can call the CWOCN or physician to examine the ostomy for any cancerous growths that might require a surgical biopsy.
CASE STUDY OUTCOME
A.T. mastered her ileal conduit and became a popular ostomate.
RUBRIC
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