Ostomy and wound care.docx - Ostomy skin and wound care...

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Ostomy, skin, and wound care & surgical asepsis Be very cognizant of hand-washing, sterility during ostomy care o Skin and the excretions from the ostomy are not sterile o Double-gloving to remove if one becomes soiled during stoma care Ostomy – surgically created opening for waste removal o Bowel Colon cancer Bowel disease Diverticulosis rupturing diverticulitis o Can often be reversed after healing Trauma Temporary Reversed after healing Permanent Rectum or anus is completely dysfunctional o Tumor o Mass o Cancer o Urinary Bladder cancer (most common cause) Bladder injury Temporary Permanent Can be continent or incontinent Meet the patient on the illness-wellness continuum o Understand that people are scared to death and meet them with comfort o Don’t stereotype the patient realize your thoughts about stomas do you think they’re gross? Your thoughts impact where the client ends up on the continuum because you affect their care Assess the stoma o Moist o Shiny o Pink If the tissue is not pink, it is losing blood flow and could die o Intact peristomal area o Healthy skin NANDA LABELS o Altered body image o Impaired skin integrity o Bladder incontinence o Fluid volume deficit
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Incontinent = running and running Electrolyte imbalances – watch lab values! o Deficient knowledge o Anxiety Embarrassing – where does a man self-cath in a male restroom? Delegating ostomy care o Can only delegate emptying o Nurse is in charge for assessment of stoma and skin care Assess skin, clean skin, keep it from breaking down Bowel Ostomy Think about the stoma and the viscosity of the waste/odor that is coming out of it o Majority of water reabsorption occurs in descending and sigmoid colon o Will the ostomy be continuously running? Small intestine Small intestine ostomy quality o Gastric juices and enzymes have not been reabsorbed If there is a leak, skin will get burned and infected People can die from these infections Ascending colon ostomy quality o Runny Transverse colon ostomy quality o Runny Descending colon ostomy quality o Best location for permanent ostomy because greatest amount of water is reabsorbed o Can begin to train the bowel to eliminate at a said period of time IV antibiotics decrease intestinal flora and will increase the odor from the ostomy o Consider how the patient feels Types of ostomies o Small intestine Ileum Most common Duodenum Jejunum Urinary Ostomy Urinary diversions o Continent Trained to empty with abdominal muscles Ureterostomy o Incontinent
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Constantly flowing Potential for UTIs Encourage fluids to keep it flowing and pH neutral Skin breakdown potential Nephrostomy o Placed during/after kidney stone, kidney damage Urine drained from renal pelvis of kidney o Attaches to abdominal wall Wounds A wound is any break in the integumentary system
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  • Summer '17
  • o Drainage,  People,  Electrolyte imbalances

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