ENTEROSTOMAL THERAPY

“entero”- intestine“stoma” – opening, mouth

SCOPE >provision of acute and rehabilitative

care for people with select disorder of GI, GU and Integument.

ET nurse- plays a pivotal role in the guidance of optimum care for ostomates.

ROLES OF ET NURSE1. Clinician2. Educator 3. Consultant4. Researcher 5. Administrator6. Coordinator7. Change Agent8. Counselor

ET Nurses Activities for Stoma Patients

I. Pre-Op PhaseCounseling

>Emotional Support >ensures accurate knowledge >treatment and discharge planning

Site Selection > Marking / Stoma Siting a. evaluate body positions

II. Pre-Op Phase 1. Selection and Fitting of appliance 2. Counseling III. Post-Discharge Phase 1. encourage for regular follow-up 2. Joining them to Ostomy Association

of the Philippines or any local Ostomy Groups

3. Informing other support services (Stoma Care Clinic) 4. Acts as liaison

Gastrointestinal System

Food enters through the mouth and is broken down by saliva and the act of chewing. It passes through the esophagus until it reaches the stomach.  The stomach uses acids and enzymes to convert food into a semi-liquid state called chyme. The stomach then expels the chyme into the small intestine.  The small intestine is the portal for all nutrients to enter into the bloodstream. Crucial digestive enzymes and hormones secreted from the pancreas, liver, and gallbladder break down the semi-liquid chyme into molecules small enough to be absorbed into the bloodstream.  Any leftover food goes into the large intestine, where it is converted into solid waste with the help of bacteria. Water and salts are extracted from any undigested food. The end-product is expelled through the rectum and anus.

Colon>Greek word “kolon”>runs from the cecum to the rectum.>measures about 5 ft (1.5 m) in

length>Functions: 1. absorbs water from digested food 2. moves the stool through the

rectum

Rectum an eight-inch chamber that connects

the colon to the anus. The rectum:Receives stool from the colon Lets the person know there is stool to be evacuated Holds the stool until evacuation happens

*When anything (gas or stool) comes into the rectum, sensors send a message to the brain. The brain then decides if the rectal contents can be released or not. If

they can, the sphincters relax and the rectum contracts, expelling its contents. If the contents cannot be expelled, the sphincters contract and the rectum accommodates so that the sensation temporarily goes away.

The anus is the last part of the digestive tract. It consists of the muscles that line the pelvis (pelvic floor muscles) and two other muscles called anal sphincters (internal and external). The lining of the upper anus is specialized to detect whether the rectal contents are liquid, gas or solid.

Major Blood Supply

1. Celiac Artery-stomach and 1st portion of small intestine (duodenum)

2. Small Mesenteric Artery (SMA)- small bowel from the ligament of

Treitz up to the transverse colon3. Inferior Mesenteric Artery

(IMA)- from mid-transverse colon up to the

rectum

Specific Functions:

1.) Ascending Colon

Absorbs water

Vitamin K production

Storage of bacteria

2.) Transverse Colon

“the only mobile portion of the colon”

3.) Descending Colon

Solidification of foods, convert to stool

4.) Rectum

Reservoir for stool

Distal portion merges with anus

TUMORS OF THE GIT1. Benign

Adenoma >pre-malignant >most common-colon >Hamartomas >Lipomas2. Malignant

Adenocarcinoma >arising from adenomas >common-colon

RISK FACTORS

Age 60 years old

Polyps

Familial Tendency

Diet

>red meats

>foods high in fat

Irritable Bowel Disease

PROTECTIVE AGENTS

High Fiber NSAIDs and COX2 inhibitor

WARNING SIGNALSChange in bowel habitsBlood in the stool

TUMOR STAGING

STAGE EXTENT OF DISEASE

SURVIVAL AFTER 5 YEARS

I Only portion of bowel wall

75%

II Beyond whole bowel wall

60%

III Lymph nodes 30%

IV Distant organs (liver, organs)

metastasis

5%

Types of Abdominal Stoma

1.) Ileostomy2.) Urostomy

3.) Colostomy*nomenclature depends on locationEx. Cecum-cecostomy Sigmoid-sigmoid colostomy

INDICATIONS

Disease : Cancer Diverticulitis Mega Colon

Congenital: Hirschprung’s Disease Rectal Atresia

Mega ColonTrauma : Stab wounds – “life saving”

Gunshot Impaled Injury

Special Considerations

Use of skin barriers---active enzyme

Increase fluid intake

Chew foods well

Avoid highly fibrous, oily and fatty foods

Medications (depending on physician’s prescription)

TYPES OF COLOSTOMY APPLIANCES

1.) One-Piece SetSingle use / disposableEasy to applyFlexible Conforms well to body contours Available in pre-cut / cut to fit style Wafer and pouch included in one single piece Disadvantage: can cause skin irritation due to frequent changing / removal of wafer

1.) Remove pouch from top to bottom while maintaining gentle pressure on the skin around the stoma with the other hand.

Application of One-Piece System

2.) Clean the peristomal skin with mild soapy water or cleanser. Rinse skin and pat try.

3. Put a finger through the hole in the skin protector to separate the inner surfaces of the pouch. Ensure that the pouch does not adhere together before applying it.

* If you use a drainable pouch, make sure you put the clamp on before applying it.

4. Peel off the paper / plastic backing from the skin protector.

5. Fold the skin protector in half and position the bottom of the skin protector opening around the base of the stoma.

6.) Lightly massage the bottom part of the skin protector and work upwards

7.) Smooth the entire surface of the skin protector, working from the bottom to top, to ensure good adhesion.

2.) Two-Piece Set

Security

Easy access to stoma

Minimized skin stripping

Economical-wafer can remain on body for 3-4 days

Application of Two-Piece System

1.) Remove used pouch. Grasp the pouch tab (depending on product manufacturing) gently and pull from top to bottom.

2.) Gently peel off the flange / wafer. Press down gently on the adjacent skin with one hand while you peel off the flange / wafer.

3.) Clean the peristomal area with mild soapy water or cleanser. Rinse and pat dry.

4.) Trace your stoma size using the transparent cover from the package.

* Use the traced plastic cover.

5.) Use the cut out plastic cover to trace the stoma size onto the white paper backing on the flange / wafer.

* Cut the skin protector using a pair of curved scissor.

6.) Peel the paper / plastic backing from the center of the flange and place it over the stoma.

7.) Lightly massage the skin protector with your finger to ensure good adhesion around the stoma. In most cases there should only be a little or no exposed skin between your stoma and the skin protector.

8.) If present, remove the outer paper / plastic backing from the flange. Adhere it onto the skin ensuring that there are no creases.

9.) Open the flange lock by moving the lever upward without forcing. This is only a small movement.

10.) To fit the plastic ring, press pouch and flange together starting at the bottom. Run fingers around the bottom. Run fingers around the coupling system / ring from bottom to top: when a slight click is heard the pouch is securely positioned.

11.) Push the lever down to lock the system.

12.) A gentle tug downward on the pouch will confirm that the pouch is safely locked in place.

ComplicationsFolliculitis

Redness at the base of the hair follicle around peristomal skin.Causes:

Hair follicle is removed aggressively by adhesive, causing irritation and infection.Treatment:

> Regularly shave the peristomal area.

Product Skin Allergy

Obvious outline of skin barrier around stoma with signs of redness, soreness, itching, etc.

Causes: Allergic reaction Treatment: Change of appliance/

product

.

Redness, soreness, rash, weeping area,

blister, bleeding, ulceration….etc

Causes: Poorly sighted Leakage, allergies,

infection radiation, skin stripping

Treatment: Identify cause

ProlapseIntestine is pushed outwards through the stoma. The exposed mucous membrane is more inclined to bleeding.

Causes: Weight gain Overstraining of peritonuem Insufficient fixation of stomaTreatment: Use a larger appliance to

contain to contain the stoma. For severe cases, consult your

surgeon for further treatment.

HerniaAbdominal wall protudes in the area of a stoma- “weak point” of the abdominal walls.

Causes: Overstraining of peritoneumTreatment: Strenous physical

exercise/work should be avoided.

For severe cases, consult your surgeon for further treatment.

Retraction

The stoma retracts below the skin level

Causes: Weight gain Insufficient fixation of

stoma TraumaTreatment: Use appliance with

convexity For severe cases, consult

your surgeon for further tratment.

Guide to Documenting

Stoma Shape: Round, Oblong Color: Red, pinkish, bluish, black Surface: Moist, Bloody, dull, dry, cracked

Peristomal Area Smooth, intact, blistered, ulcerated, excoriated

Drainage / Stool Consistency: Formed, watery, semi-formed, mucoid Odor: Non-odorous, malodorous, pungent Color: Brownish, greenish, yellow, black

A stoma is not a hindrance. > Most people can enjoy a healthy sex life and

have babies. > Regular Exercise to maintain body fitness and

health. * Avoid sports that might injure the stoma and

sports that put too much stress on the abdominal muscles.

-what to avoid: weight lifting, rowing -what is encouraged: swimming, cycling, hiking,

skiing. > When health is restored, think of returning back

to work. > You can wear anything you like.

Benefits of active lifestyle

1. Helps body recover faster

2. Helps reduce excessive weight and maintain healthy body weight.

3. Helps to gain confidence and maintain a positive attitude.

4. Helps to keep you healthy and feeling good.

Usually, a specific diet is not required. General rules of a well-

balanced diet will apply.Check first with your surgeon when can normal diet be resumed. Try different foods in small portions if you suspect they have caused problems.Avoid foods that may cause diarrhe, constipation, gas and odor.Check with surgeon / stomal therapy regarding medications.

*Take regular meals *Eat dietary fibers (colostomates)*Drink plenty of water*Eat a balanced diet*Restric alcohol beveragesAvoid fatty foods.

Dietary Guide for Ostomates

Foods that increase odor

asparagus, broccoli, cabbage, cauliflower, beans, eggs, fish, onions, spices

Foods that increase gas

beans, beer / carbonated soda, broccoli, cabbage, cauliflower, corn, cucumbers, mushrooms, peas, radish

Dietary Guide for Ostomates

Foods that thicken stool applesauce, bananas, cheese, boiled milk,

marshmallows, pasta, peanut butter, pretzels, rice, bread, toast, yogurtFoods that may loosen stool

green beans, beer, broccoli, fresh fruits, grape juice raw vegetables, prunes / prune juice, spicy foods, fried foods, chocolate, spinach, leafy green vegetables

Dietary Guide for Ostomates

High fiber foods that may cause blockages

dried nuts, grape fruit, nuts, corn, raisins, celery, popcorn, coconut, seeds, coleslaw, Chinese vegetables, oranges

Where to get help?

Stoma Care Team

Adrianne Gonzaga, RN- Head / Trainor

Rhyan Hitalla, RN- In patient Coordinator

John Frondoso, RN- Home Care Coordinator

*Call the Supervisor-on-duty for referrals and problems that may arise in stoma patients