11. Digestive - endocrine pathology

The ostomies

A stoma is a temporary or permanent abouchement viscera to the skin surface in order to permit the release of gut contents, is an artificial communication organ surgically created abdominal wall to supply the natural route of excretion.

The ostomies are classified according to the organ that is affected:

• Digestive: it loses voluntary control of elimination, since the stoma has no sphincter
• Ileostomy: externalization of the ileum through the abdominal wall to permit the release of intestinal contents (liquid stool very irritating to the skin). It is located in the abdomen.
• Colostomy: externalization of the colon through the abdominal wall may be ascending (feces liquid / semi-liquid irritant), transverse (semisolid stool little irritating) and downstream (solid feces non-irritating), depending on the position of the exteriorized colon.
• Urinary: not change the function of the kidneys; deflect the normal course of urine. There are three types: nephrostomy, ureterostomy skin and Bricker

Hygiene and Care of the stoma:

Also on proper care of the stoma, must also maintain a correct hygienic the peristomal area; must be kept clean, dry and well hydrated.

• Removing the remains of effluents that are left in the skin, can be done with a tissue.
• Clean the entire area, including the stoma with soap and water in a circular motion from the outside towards the inside.
• Dry the area well with a towel
• Once clean and dry, replace the device.
• Open bag (which is closed by a clamp, which are collected liquid stool)
• Urostomy (which closes with a drain valve in which urine is collected)
• Closed bag (for solid stool).

Placing/removing to the ostomy bag:

• Placing the ostomy bag:
• Measure the diameter of the stroma to cut the adhesive to proper length to prevent the effluent into contact with the skin.
• If the device having two parts, after the above process, disk placed over the stoma  and then closing the pouch to adapt the lock subsequently
• Removing to the ostomy bag:
• Withdraw slowly, without jerks, just as in the placement, from bottom to top holding with the other hand always the peristomal area.
• Change to the device:
• Opened bags are emptied several times a day and changed every 24 hours.
• At night, there are bags of more capacity
• Colostomy bags are removed when the patient believes are filled; 2-3 times a day

Ostomy complications:

During the first 30 days after surgery, may appear:

• Abscess and infection: onset of inflammation and suppuration of the area.
• Nursing cares: watch the progression of symptoms and administration of prescribed treatment. Change the dressing every 24 hours
• Dehiscence: Separation between the mucosa and the peristomal skin.
• Nursing cares: care for healing every 24 hours
• Allergic dermatitis: skin injury by sensitization of device components.
• Nursing cares: Avoid positioning the device that caused the allergic reaction and try perilesional area with relevant drugs (barrier creams or dressings for healing).
• Edema: thickening of the intestinal mucosa
• Nursing cares: apply compresses with water or cold saline and check the measurement of edema to verify the improvement
• Stenosis: widening to stomal orifice below the extent necessary to ensure adequate evacuation.
• Nursing cares: measure the stoma regularly to watch their reduction, stoma dilation using a lubricant to ensure attachment to the skin and fascia
• Fistula: contamination from the intestinal light and peristomal skin which gives rise to effluent outlet
• Nursing cares: Care of the stoma and peristomal skin using a device to prevent leakage
• Bleeding: blood loss through the stoma from the peristomal area or from the own viscera
• Nursing cares: implementation of local hemostasis; compresses with cold saline and, if necessary, suture the subcutaneous vessels.
• Hernia / eventration: abdominal wall failure that causes the output of the stoma and peristomal skin, resulting in a bulge that appears when the patient stands up.
• Nursing cares: provide fiber diet to avoid constipation. Recommend the abandonment of physical effort and show massages on the abdomen.
• Necrosis: insufficient blood supply to the mucosa of the stoma; becomes black.
• Nursing cares: resect the necrotic area and, if necessary, intervene again
• Ulcers: lesions of the skin or mucosa of the stoma by improper care, skin infections, etc..
• Nursing cares: care to the wound applying cares for the healing by second intention, debridement, silver nitrate, healing dressings and exudate control, etc.. the cure is to be done every 24 hours, watching its evolution well

It is my opinion, it is very important that the patients who carrying a ostomy made the properly carried hygiene to prevent the large number of complications that may develop.

Bibliography

• Contel Segura, J. C; Gené Badía, J; Peya Gascons, M. Atención domiciliaria: organización y práctica. Barcelona: Springer; 1999.
• Fisterra. [Monografía de internet]. [Fecha de consulta 29 de abril de 2013]. Disponible en: http://www.fisterra.com/ayuda-en-consulta/tecnicas-atencion-primaria/manejo-cuidado-estomas-digestivos-urinarios-colostomia-ileostomia-ureterostomia/
• Medline. [Monografía de internet]. [Fecha de consulta 29 de abril de 2013]. Disponible en: http://www.nlm.nih.gov/medlineplus/spanish/ency/patientinstructions/000204.htm