NURSING PROCESS: THE PATIENT UNDERGOING URINARY DIVERSION SURGERY
The following are key preoperative nursing assessment concerns:
· Cardiopulmonary function assessments are performed be-cause patients undergoing cystectomy (excision of the uri-nary bladder) are often older people who may not be able to tolerate a lengthy, complex surgical procedure.
· A nutritional status assessment is important because of pos-sible poor nutritional intake related to underlying health problems.
· Learning needs are assessed to evaluate the patient’s and the family’s understanding of the procedure and the changes in physical structure and function that result from the surgery. The patient’s self-concept and self-esteem are assessed, in addition to methods for coping with stress and loss. The pa-tient’s mental status, manual dexterity and coordination, and preferred method of learning are noted because they will affect postoperative self-care.
Based on the assessment data, the preoperative nursing diagnoses for the patient undergoing urinary diversion surgery may include the following:
· Anxiety related to anticipated losses associated with the sur-gical procedure
· Imbalanced nutrition, less than body requirements related to inadequate nutritional intake
· Deficient knowledge about the surgical procedure and post-operative care
The major goals for the patient may include relief of anxiety, im-proved preoperative nutritional status, and increased knowledge about the surgical procedure, expected outcomes, and post-operative care.
The threat of cancer and removal of the bladder create fears related to body image and security. The patient faces problems in adapt-ing to an external appliance, a stoma, a surgical incision, and al-tered toileting habits. The male patient must also adapt to sexual impotency. (A penile implant is considered if the patient is a can-didate for the procedure.) Women also fear altered appearance, body image, and self-esteem. A supportive approach, both physi-cal and psychosocial, is needed and includes assessing the patient’s self-concept and manner of coping with stress and loss; helping the patient to identify ways to maintain his or her lifestyle and in-dependence with as few changes as possible; and encouraging the patient to express fears and anxieties about the ramifications of the upcoming surgery. A visitor from the Ostomy Visitation Program of the American Cancer Society can provide emotional support and make adaptation easier both before and after surgery.
In addition to cleansing the bowel to minimize fecal stasis, decom-press the bowel, and minimize postoperative ileus, a low-residue diet is prescribed and antibiotic medications are administered to re-duce pathogenic flora in the bowel and to reduce the risk of infec-tion. Because the patient undergoing a urinary diversion procedure for cancer may be severely malnourished due to the tumor, radia-tion enteritis, and anorexia, enteral or parenteral nutrition may be prescribed to promote healing. Adequate preoperative hydration is imperative to ensure urine flow during surgery and to prevent hypovolemia during the prolonged surgical procedure.
An enterostomal therapist is invaluable in preoperative teaching and in planning postoperative care. Explanations of the surgical procedure, the appearance of the stoma, the rationale for preoper-ative bowel preparation, the reasons for wearing a collection device, and the anticipated effects of the surgery on sexual functioning are part of patient teaching. The placement of the stoma site is planned preoperatively with the patient standing, sitting, or lying down to locate the stoma away from bony prominences, skin creases, and fat folds. The stoma should also be placed away from old scars, the umbilicus, and the belt line.
For ease of self-care, the patient must be able to see and reach the site comfortably. The site is marked with indelible ink so that it can be located easily during surgery. The patient is assessed for allergies or sensitivity to tape or adhesives. (Patch testing of cer-tain appliances may be necessary before the ostomy equipment is selected. This is particularly important if the patient may be or is allergic to latex.) It may be helpful to have the patient practice wearing an appliance partially filled with water before surgery (Krupski & Theodorescu, 2001).
To measure the effectiveness of care, the nurse evaluates the pre-operative patient’s anxiety level and nutritional status as well as his or her knowledge and expectations of surgery.
Expected patient outcomes may include:
1) Exhibits reduced anxiety about surgery and expected losses
a) Verbalizes fears with health care team and family
b) Expresses positive attitude about outcome of surgery
2) Exhibits adequate nutritional status
a) Maintains adequate intake before surgery
b) Maintains body weight
c) States rationale for enteral or parenteral nutrition if needed
d) Exhibits normal skin turgor, moist mucous membranes, adequate urine output, and absence of excessive thirst
3) Demonstrates knowledge about the surgical procedure and postoperative course
a) Identifies limitations expected after surgery
b) Discusses expected immediate postoperative environ-ment (tubes, machines, nursing surveillance)
c) Practices deep breathing, coughing, and foot exercises
The role of the nurse in the immediate postoperative period is to prevent complications and to assess the patient carefully for any signs and symptoms of complications. The catheters and any drainage devices are monitored closely. Urine volume, patency of the drainage system, and color of the drainage are assessed. A sud-den decrease in urine volume or increase in drainage is reported promptly to the physician because these may indicate obstruction of the urinary tract, inadequate blood volume, or bleeding. In ad-dition, the patient’s needs for pain control are assessed (Colwell, Goldberg & Cramel, 2001).
Based on the assessment data, the major postoperative nursing di-agnoses for the patient following urinary diversion surgery may include the following:
· Risk for impaired skin integrity related to problems in man-aging the urine collection appliance
· Acute pain related to surgical incision
· Disturbed body image related to urinary diversion
· Potential for sexual dysfunction related to structural and physiologic alterations
· Deficient knowledge about management of urinary function
Potential complications may include the following:
· Peritonitis due to disruption of anastomosis
· Stomal ischemia and necrosis due to compromised blood supply to stoma
· Stoma retraction and separation of mucocutaneous border due to tension or trauma
The major goals for the patient may include maintaining peri-stomal skin integrity, relieving pain, increasing self-esteem, de-veloping appropriate coping mechanisms to accept and deal with altered urinary function and sexuality, increasing knowledge about management of urinary function, and preventing poten-tial complications (Krupski & Theodorescu, 2001; O’Shea, 2001).
Postoperative management focuses on monitoring urinary func-tion, preventing postoperative complications (infection and sep-sis, respiratory complications, fluid and electrolyte imbalances, fistula formation, and urine leakage), and promoting patient comfort. Catheters or drainage systems are observed, and urine output is monitored carefully. A nasogastric tube is inserted dur-ing surgery to decompress the GI tract and to relieve pressure on the intestinal anastomosis. It is usually kept in place for several days after surgery. As soon as bowel function resumes, as indi-cated by bowel sounds, the passage of flatus, and a soft abdomen, oral fluids are permitted. Until that time, intravenous fluids and electrolytes are administered. The patient is assisted to ambulate as soon as possible to prevent complications of immobility.
Strategies to promote skin integrity begin with reducing and con-trolling those factors that increase the patient’s risk for poor nu-trition and poor healing. As indicated previously, meticulous skin care and management of the drainage system are provided by the nurse until the patient can manage them and is comfortable doing so. Care is taken to keep the drainage system intact to pro-tect the skin from exposure to drainage. Supplies must be readily available to manage the drainage in the immediate postoperative period. Consistency in implementing the skin care program throughout the postoperative period will result in maintenance of skin integrity and patient comfort. Additionally, maintenance of skin integrity around the stoma will enable the patient and family to adjust more easily to the alterations in urinary function and will help them to learn skin care techniques.
Analgesic medications are administered liberally postoperatively to relieve pain and promote comfort, thereby allowing the patient to turn, cough, and do deep-breathing exercises. Patient-controlled analgesia and administration of analgesic agents regularly around the clock are two options that may be used to ensure adequate pain relief. A pain-intensity scale is used to evaluate the adequacy of the medication and the approach to pain management.
The patient’s ability to cope with the changes associated with the surgery depends to some degree on his or her body image and self-esteem before the surgery and the support and reaction of others. Allowing the patient to express concerns and anxious feelings can help, especially in adjusting to the changes in toileting habits. The nurse can also help improve the patient’s self-concept by teaching the skills needed to be independent in managing the urinary drainage devices. Education about ostomy care is conducted in a private setting to encourage the patient to ask questions without fear of embarrassment. Explaining why the nurse must wear gloves when performing ostomy care can prevent the patient from mis-interpreting the use of gloves as a sign of aversion to the stoma.
Patients who experience altered sexual function as a result of the surgical procedure may mourn for this loss. Encouraging the patient and partner to share their feelings about this loss with each other and acknowledging the importance of sexual function and expression may encourage the patient and partner to seek sexual counseling and to explore alternative ways of expressing sexual-ity. A visit from another “ostomate” who is functioning fully in society and family life may also assist the patient and family in recognizing that full recovery is possible.
Complications are not unusual because of the complexity of the surgery, the underlying reason (cancer, trauma) for the urinary diversion procedure, and the patient’s frequently less-than-optimal nutritional status. Complications may include the usual post-operative complications (eg, respiratory problems, such as atelec-tasis, fluid and electrolyte imbalances) as well as breakdown of the anastomoses, sepsis, fistula formation, fecal or urine leakage, and skin irritation. If these occur, the patient will remain hospitalized for an extended length of time and will probably require parenteral nutrition, GI decompression by means of nasogastric suction, and further surgery. The goals of management are to establish drainage, provide adequate nutrition for healing to occur, and prevent sepsis.
Peritonitis can occur postoperatively if urine leaks at the anasto-mosis. Signs and symptoms include abdominal pain and disten-tion, muscle rigidity with guarding, nausea and vomiting, paralytic ileus (absence of bowel sounds), fever, and leukocytosis.
Urine output must be monitored closely because a sudden de-crease in amount with a corresponding increase in drainage from the incision or drains may indicate urine leakage. In addition, the urine drainage device is observed for leakage. The pouch is changed if a leak is observed. Small leaks in the anastomosis may seal them-selves, but surgery may be needed for larger leaks.
Vital signs (blood pressure, pulse and respiratory rates, temper-ature) are monitored. Changes in vital signs, as well as increasing pain, nausea and vomiting, and abdominal distention, are reported to the physician and may indicate peritonitis.
The stoma is monitored because stomal ischemia and necrosis can result from tension on the mesentery blood vessels, twisting of the bowel segment (conduit) during surgery, or arterial insufficiency. The new stoma must be inspected at least every 4 hours to assess the adequacy of its blood supply. The stoma should be red or pink. If the blood supply to the stoma is compromised, the color changes to purple, brown, or black. These changes are reported immediately to the physician. The physician or enterostomal therapist may insert a small, lubricated tube into the stoma and shine a flashlight into the lumen of the tube to assess for super-ficial ischemia or necrosis. A necrotic stoma requires surgical intervention. If the ischemia is superficial, the dusky stoma is observed and may slough its outer layer in several days.
Stoma retraction and separation of the mucocutaneous border can occur as a result of trauma or tension on the internal bowel segment used for creation of the stoma. In addition, mucocuta-neous separation can occur if the stoma does not heal as a result of accumulation of urine on the stoma and mucocutaneous bor-der. Using a collection drainage pouch with an antireflux valve is helpful because the valve prevents urine from pooling on the stoma and mucocutaneous border. Meticulous skin care to keep the area around the stoma clean and dry promotes healing. If a separation of the mucocutaneous border occurs, surgery is not usually needed. The separated area is protected by applying karaya powder, stoma adhesive paste, and a properly fitted skin barrier and pouch. By protecting the separation, healing is promoted. If the stoma retracts into the peritoneum, surgical intervention is mandatory.
If surgery is needed to manage these complications, the nurse provides explanations to the patient and family. The need for ad-ditional surgery is usually perceived as a setback by the patient and family. Emotional support of the patient and family is pro-vided along with physical preparation of the patient for surgery.
A major postoperative objective is to assist the patient to achieve the highest level of independence and self-care possible. The primary nurse and enterostomal therapist work closely with the patient and family to instruct and assist them in all phases of managing the ostomy. Adequate supplies and complete instruc-tion are necessary to enable the patient and a family member to develop competence and confidence in their skills. Written and verbal instructions are provided, and the patient is encouraged to contact the nurse or physician with follow-up questions. Follow-up telephone calls from the nurse to the patient and family after discharge may provide added support and provide another op-portunity to answer their questions. Follow-up visits and re-inforcement of correct skin care and appliance management techniques also promote skin integrity. Specific techniques for managing the appliance are described in Chart 45-15.
The patient is encouraged to participate in decisions regard-ing the type of collecting appliance and the time of day to change the appliance. The patient is assisted and encouraged to look at and touch the stoma early to overcome any fears. The patient and family need to know the characteristics of a normal stoma, as follows:
· Pink and moist, like the inside of the mouth
· Insensitive to pain because it has no nerve endings
· Vascular and may bleed when cleaned
Additionally, if a segment of the GI tract was used to create the urinary diversion, mucus may be visible in the urine. By learn-ing what is normal, the patient and family become familiar with what signs and symptoms they should report to the physician or nurse and what problems they can handle themselves.
Information provided to the patient and the extent of in-volvement in self-care are determined by the patient’s physical re-covery and ability to accept and acquire the knowledge and skill needed for independence. Verbal and written instructions are provided, and the patient is given the opportunity to practice and demonstrate the knowledge and skills needed to manage urinary drainage.
Follow-up care is essential to determine how the patient has adapted to the body image changes and lifestyle adjustments. Vis-its from a home care nurse are important to assess the patient’s adaptation to the home setting and management of the ostomy. Teaching and reinforcement may assist the patient and family to cope with altered urinary function. It is also necessary to assess for long-term complications that may occur, such as pouch leakage or rupture, stone formation, stomal stenosis, deterioration in renal function, or incontinence (Baker, 2001).
The following procedures are recommended for patients with
continent urinary diversion: pouch-o-gram (x-rays taken after
radioactive agent is instilled into the pouch) between 3 and
6 months, 9 and 12 months, 24 months, then every other year; renal function tests (BUN, serum creatinine) 1 month, 3 months, 6 months, then twice yearly; and pouchoscopy (endoscopic exam-ination of the pouch) every year starting 5 to 7 years after surgery (Colwell, Goldberg & Cramel, 2001). The patient who has had surgery for carcinoma should have a yearly physical examination and chest x-ray to assess for metastases. In addition, the patient and family are reminded of the importance of participating in health promotion activities and recommended health screening.
Long-term monitoring for anemia is performed to identify vi-tamin B deficiency, which may occur when a significant portion of the terminal ileum is removed. This may take several years to develop and can be treated with vitamin B injections. The patient and family are informed of the United Ostomy Association and any local ostomy support groups to provide ongoing support, assistance, and education.
Expected patient outcomes may include:
1) Maintains skin integrity
a) Maintains intact peristomal skin and demonstrates skill in managing drainage system and appliance
b) Reports absence of pain or discomfort in peristomal area
c) States actions to take if skin excoriation occurs
2) Exhibits increased knowledge about managing urinary function
a) Participates in managing urinary system and skin care
b) Verbally describes anatomic alteration due to surgery
c) Revises daily routine to accommodate urinary drainage management
d) Identifies potential problems, reportable signs and symptoms, and subsequent measures to take
3) Exhibits improved self-concept as evidenced by the fol-lowing:
a) Voices acceptance of urinary diversion, stoma, and appliance
b) Demonstrates increasingly independent self-care, in-cluding hygiene and grooming
c) States acceptance of support and assistance from family members, health care providers, and other ostomates
4) Copes with sexuality issues
a) Verbalizes concern about possible alterations in sexual-ity and sexual function
b) Reports discussion of sexual concerns with partner and appropriate counselor
5) Demonstrates knowledge needed for self-care
a) Performs self-care and proficient management of uri-nary diversion and appliance
b) Asks questions relevant to self-management and pre-vention of complications
c) Identifies signs and symptoms needing care from physi-cian or other health care providers
6) Absence of complications as evidenced by the following:
a) Reports absence of pain or tenderness in abdomen
b) Has temperature within normal range
c) Reports no urine leakage from incision or drains
d) Has urine output within desired volume limits
e) Maintains stoma that is red or pink, moist, and appro-priately “budded”
f) Has intact and healed stomal border