The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [210]
Urostomy/ileal conduit function
Urine will dribble from the stoma every 20–30 seconds and it starts draining immediately. Normal output is 1500 mL/24 hours (Cottam 1999), but may be less after periods of reduced fluid intake, for example at night. Urinary stents (fine-bore catheters) may be in place from the ureters past the anastomosis and out of the stoma. They are placed to maintain patency and protect the suturing until primary healing is completed (Black 2000). Stents are left in situ for 7–10 days.
Postoperative stages
Stage I
In theatre, an appropriately sized transparent drainable appliance should be applied, which should be left on for approximately 2 days. For the first 48 hours postoperatively, the stoma should be observed for signs of ischaemia or necrosis and the stoma colour (a pink and healthy appearance indicates a good blood supply), size and stoma output should be noted, as should the presence of any devices, such as ureteric stents or bridge with a loop stoma (Kirkwood 2006).
Table 6.6 recommends the most appropriate bag type to use on each type of stoma and the expected output. The drainable appliance should always be emptied frequently, gas should be allowed to escape and the appliance should not be allowed to get more than half full with effluent. If the appliance becomes too full, leaks may occur and the weight from the effluent or the pressure from gas may cause the appliance to fall off (Black 1997). A leak-proof, odour-resistant well-fitted appliance does much to promote patient confidence at this time (Kirkwood 2006). The first time a bowel stoma acts, the type, appearance, quantity and consistency of the matter passed should be recorded; this includes any flatus that may be passed (Kirkwood 2006).
Table 6.6 Decision tool to use when selecting appropriate bag/pouch
Immediately postoperatively patients would not be expected to perform their own stoma care but would be encouraged to observe the nurse caring for them and discuss it with the nurse. During appliance changes, observations should be made of the following.
Stoma: colour, size and general appearance: oedematous, flush with abdomen, retracted.
Peristomal skin: presence of any erythema, broken areas, rashes.
Stoma/skin margin (mucocutaneous margin): sutures intact, tension on sutures, separation of stoma edge from skin (mucocutaneous separation).
Any abnormalities should be reported to the stoma care nurse and medical staff (Black 2000, Burch 2004, Kirkwood 2006) (Figure 6.17).
Figure 6.17 Observational index. With permission from Dansac Ltd.
Viewing the stoma may be difficult for the patient, who may be very aware of other people’s reaction to it (Price 1990). The patient’s reaction to their stoma should be observed and recorded.
Stage II
As the patient’s condition improves, they should be encouraged to participate in the care of their stoma. A demonstration change of the appliance should be given with a full explanation of the principles of stoma care. This will be followed by further opportunities to discuss any problems or raise new queries. Care procedures should be divided into small successive stages and patients should be given support to work through these stages until they are able to take on the care of their stoma. Provided the patient agrees, it is useful to involve the patient’s partner or close friends or relatives at this stage. Their acceptance of the stoma may encourage the patient and help to restore the patient’s self-esteem (Salter 1995). They may now be ready to discuss appliances and choose the one that they wish to use at home. Preparation for discharge will be discussed (Black 1994, Heywood Jones 1994).
Stage III
Ideally, the patient should now be independent, eating a normal diet, be ready for discharge and should be competent in stoma care. If