7. Fecal diversion - stomas: performed because of disease or trauma; may be temporary or permanent.
   1. Types
      1. Temporary - fecal stream rerouted to allow GI tract to heal or to provide outlet for stool when obstructed.
      2. Permanent - intestine cannot be reconnected. Rectum and anal sphincter removed (abdominal perineal resection). Often performed for cancer of the colon and/or rectum.
      3. Continent ileostomy - pouch is created inside the wall of the intestine. The pouch serves as a reservoir similar to a rectum. The pouch is emptied on a regular basis with a small tube.
      4. Ileoanal anastomosis - the large intestine is removed and the small intestine is inserted into the rectum and attached just above the anus. The muscles of the rectum remain intact and the normal route of stool elimination is maintained.
   2. Analysis/nursing diagnosis:
      1. Bowel incontinence related to lack of sphincter in newly formed stoma.
      2. Altered health maintenance related to knowledge of ostomy care.
      3. Body image disturbance related to stoma.
      4. Fear related to medical condition requiring stoma.
      5. Fluid volume deficit related to increased output through stoma.
   3. Nursing care plan/implementation:
      1. Preoperative period:
         1. Goal: prepare bowel for surgery.
            1. Administer neomycin as ordered to reduce colonic bacteria.
            2. Administer cathartics, enemas as ordered to cleanse the bowel of feces.
            3. Administer low-residue or liquid diet as ordered.
         2. Goal: relieve anxiety and assist in adjustment to surgery.
            1. Provide accurate, brief, and reassuring explanations of procedures; allow time for questions.
            2. Have enterostomal nurse visit to discuss ostomy management and placement of stoma appliance.
            3. Offer opportunity for a visit with an Ostomy Association Visitor.
         3. Goal: health teaching.
            1. Determine knowledge of surgery and potential impact.
            2. Begin teaching regarding ostomy.
      2. Postoperative period:
         1. Goal: maintain fluid balance.
            1. Monitor I&O because large volume of fluid is lost through stoma.
            2. Administer IV fluids as ordered.
            3. Monitor losses through NG tube.
         2. Goal: prevent other postoperative complications.
            1. Monitor for signs of intestinal obstruction.
            2. Maintain sterility when changing dressings; avoid fecal contamination of incision.
            3. Observe appearance of stoma: rosy pink, raised.
         3. Goal: initiate ostomy care.
         1. Protect skin around stoma: use commercial preparation to toughen skin and use protective barrier wafer (Stomahesive) or paste (Karaya or substitute) to keep drainage (which can cause excoriation) off the skin.
         2. Keep skin around stoma clean and dry; empty appliance frequently. Check for drainage in appliance at least twice during each shift. If drainage present (diarrhea-type stool):
         1. Unclip bottom of bag.
         2. Drain into bedpan.
         3. Use a squeeze-type bottle filled with warm water to rinse inside of appliance.
         4. Clean clamp, if soiled.
         5. Put a few drops of deodorant in appliance if not odor proof.
         6. Fasten bottom of appliance securely (fold bag over clamp two or three times before closing).
         7. Check for leakage under appliance every 2-4 hr.
         3. Change appliance when drainage leaks around seal, or approximately every 2-3 days. Initially, size of stoma will be large due to edema. Pouch opening should be slightly larger than stoma so it will not constrict. Stoma will need to be measured for each change until swelling subsides to ensure appropriate fit.
            1. Gather equipment: gloves, skin prep packet, colostomy appliance measured to fit stoma properly (use stoma measuring guide), skin barrier, warm water and soap, face cloth/towel, plastic bag for disposal of old equipment.
            2. Remove old appliance carefully, pulling from area with least drainage to area with most drainage.
            3. Wash skin area (not stoma) with soap and water. Be careful not to: irritate skin, put soap on stoma, irritate stoma; do not put anything dry onto stoma. Remember: bowel is very fragile; working near bowel increases peristalsis so that feces and flatulence may be expelled.
            4. Observe skin area for potential breakdown.
            5. Use packet of skin prep on the skin around the stoma. Do not put this solution onto stoma, because it will cause irritation. Allow skin prep solution to dry on skin before applying colostomy appliance.
            6. Apply skin barrier you have measured and cut to size.
            7. Put appliance on so that bottom of appliance is easily accessible for emptying (e.g., if patient is out of bed most of the time, put the bottom facing the feet; if patient is in bed most of the time, have bottom face the side). Picture frame the adhesive portion of the appliance with 1-inch tape.
            8. Put a few drops of deodorant in appliance if not odor proof.
            9. Use clamp to fasten bottom of appliance.
            10. Talk to patient (or communicate in best way possible during and after procedure). This is a very difficult alteration in body image.
            11. Good hand-washing technique.
         4. Use deodorizing drops in appliance and provide adequate room ventilation to decrease odors. Caution: deodorizing drops must be safe for mucous membranes. No pinholes in pouch.
         5. If continent ileostomy, a Kock pouch, has been constructed, the patient does not have to wear an external pouch. The stool is stored intra-abdominally. The patient drains the pouch several times daily, when there is a feeling of fullness, using a catheter. The stoma is flat and on the right side of the abdomen.
         4. Goal: promote psychological comfort.
            1. Support patient and family-accept feelings and behavior.
            2. Recognize that such a procedure may initiate the grieving process.
         5. Goal: health teaching.
            1. Self-care management skills related to ostomy appliance, skin care, and irrigation, if indicated.
            2. Diet: adjustments to control character of feces; avoid foods that increase flatulence.
            3. Signs of complications of infection, obstruction, or electrolyte imbalance.
            4. Community referral for follow-up care.
      
      
      Colostomy Irrigation*

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      1. Assemble all equipment for irrigation and appliance change.
      2. Remove and discard old pouch.
      3. Clean the peristomal skin.
      4. Apply the irrigating sleeve; place in toilet or bedpan.
      5. Fill container with 500-1000 mL of warm water, never more than 1000 mL. Clear air from tubing. Insert lubricated tubing 2-4 inches into stoma. Do not force. Hold container about 18 inches above stoma. Infuse gently over 7-10 min.
      6. Allow stool to empty into toilet. Evacuation usually occurs in 20-25 min.
      7. If no return after irrigation, ambulate, gently massage abdomen, or give patient a warm drink.
      8. Once complete, remove the sleeve, and follow guidelines for applying appliance.

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      ‘Colostomy irrigation is seldom used with newer colostomies.
      
      
   4. Evaluation/outcome criteria:
   1. Demonstrates self-care skill for independent living.
   2. Makes dietary adjustments.
   3. Ostomy functions well.
   4. Adjusts to alteration in bowel elimination pattern.
   
   
8. Hemorrhoids: enlarged vein/veins in mucous membrane of rectum. Hemorrhoids can be internal or external. Bleeding internal hemorrhoids can be painful and are best treated by rubber band ligation, injection sclerotherapy, infrared coagulation, or surgery (scalpel, cautery, or laser). Laser surgery is usually done as an outpatient and causes minimal discomfort. High-fiber diets can minimize constipation and prevent hemorrhoids.
1. Pathophysiology: venous congestion and interference with venous return from hemorrhoidal veins —> increase in pelvic pressure, swelling, and distortion.
2. Risk factors:
   1. Straining to expel constipated stool.
   2. Pregnancy.
   3. Intra-abdominal or pelvic masses.
   4. Interference with portal circulation.
   5. Prolonged standing or sitting.
   6. History of low-fiber, high-carbohydrate diet, which contributes to constipation.
   7. Family history of hemorrhoids.
   8. Enlarged prostate.
3. Assessment:
   1. Subjective data: discomfort, anal pruritus, pain.
   2. Objective data:
      1. Bleeding, especially on defecation.
      2. Narrowing of stool.
      3. Grapelike clusters around anus (pink, red, or blue).
      4. Diagnostic test:
         1. Visualization for external hemorrhoids.
         2. Digital exam or proctoscopy for internal hemorrhoids.
4. Analysis/nursing diagnosis:
   1. Pain related to defecation.
   2. Constipation related to dietary habits and pain at time of defecation.
   3. Knowledge deficit related to foods to prevent constipation.
5. Nursing care plan/implementation:
   1. Goal: reduce anal discomfort.
      1. Sitz baths, as ordered; perineal care to prevent infection.
      2. Hot or cold compresses as ordered to reduce inflammation and pruritus.
      3. •3 c. Topical medications as ordered:
      4. Anti-inflammatory: hydrocortisone cream (Anusol).
      5. Astringents: witch hazel-impregnated pads.
      6. Topical anesthetics: pramoxine (Procto-Foam)! dibucaine (Nupercainal).
      7. •3d. Bulk laxatives: psyllium (Metamucil), Konsyl, polycarbophil (FiberCon).
   2. Goal: prevent complications related to surgery.
   1. Encourage postoperative ambulation.
   2. Pain relief until packing removed.
   3. Monitor for bleeding, infection, pulmonary emboli, phlebitis.
   4. Facilitate bowel evacuation: stool softeners, laxatives, suppositories, oil enemas as ordered.
   5. Monitor for syncope/vertigo during first postoperative bowel movement.
   6. Diet:
   1. Low residue (postoperative)—until healing has begun.
   2. High fiber to prevent constipation after healing.
   7. Increase fluid intake.
   3. Goal: health teaching—methods to avoid constipation.
6. Evaluation/outcome criteria:
1. No complications.
2. Patient has bowel movement.
3. Incorporates knowledge of correct foods into lifestyle.