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Urinary diversion - PowerPoint PPT Presentation


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Urinary diversion. Introduction. Diversion of urinary pathway from its natural path Types: Temporary Permanent. Indications of permanent urinary diversion. When the bladder has to be removed

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Presentation Transcript
introduction
Introduction
  • Diversion of urinary pathway from its natural path
  • Types:
    • Temporary
    • Permanent
indications of permanent urinary diversion
Indications of permanent urinary diversion
  • When the bladder has to be removed
  • When the sphincters of the bladder & the detrusor muscle have been damaged or have lost their normal neurological control
  • When there is irremovable obstruction in the bladder & distal to that
  • Ectopic vesicae
  • Incurable vesico- vagina fistula
temporary urinary diversion
Temporary urinary diversion
  • Suprapubic cystostomy
  • Pyelostomy or nephrostomy or urethrostomy (with indwelling catheters)
slide6

A nephrostomy is a surgical procedure by which a tube, stent, or catheter is inserted through the skin and into the kidney.

permanent urinary diversion
Permanent urinary diversion
  • Uretero - sigmoidostomy
  • Ileal conduit
  • Colon conduit
  • Ileocaecaecal segment
  • Lowsley’s operation
types of urinary diversions
Types of urinary diversions

Cutaneous urinary diversions

  • Ileal conduit (ileal loop)
  • A 12 cm loop of ileum led out through abdominal wall
  • Stents used
  • The space at cystectomy site drained by a drainage system
  • After surgery a skin barrier and a transparent disposable urinary drainage bag
  • Constantly drains
complications of ileal conduit
Complications of ileal conduit
  • Wound infection
  • Wound dehiscence
  • Urinary leakage
  • Ureteral obstruction
  • Small bowel obstruction
  • Ileus
  • Stomal gangrene
  • Narrowing of the stoma
  • Pyelonephritis
  • Renal calculi
uretero sigmoidostomy
Uretero- sigmoidostomy
  • Complications:
    • Reflux of urine
    • Hyperchloraemic acidosis
    • Renal infection
    • Stricture formation
continent urinary diversions
Continent Urinary Diversions
  • Continent Ileal Urinary Reservoir

Indiana Pouch

  • Most common continent urinary diversion
  • Periodically catheterized

Koch Pouch

Charleston Pouch

Ureterosigmoidostomy

  • Voiding occurs from rectum
slide20
Potential complications
  • Peritonitis due to disruption of anastomosis
  • Stomal ischaemia and necrosis due to compromised blood supply to stoma
  • Stoma retraction and separation of mucocutaneous border due to tension or trauma
nursing process the patient undergoing urinary diversion surgery
Nursing process : The patient undergoing urinary diversion surgery

Preoperative assessment :

  • Cardiopulmonary assessment
  • Nutritional assessment
  • Learning capcity assessment

Preoperative nursing diagnosis

  • Anxiety
  • Knowledge deficit

Preoperative planning and goals

  • Relief of anxiety
  • Ensuring adequate nutrition
  • Explaining surgery and its effects
nursing management
Nursing Management
  • In the immediate postoperative period urine volumes are monitered hourly
  • An output below 30 ml/h dehydration or obstruction
  • Promote urine output – a catheter may be inserted through urinary conduit
  • Provide stoma and skin care – consult with enterostomal therapist
  • Skin care specialist consulted
  • Stoma looked for color – dark purplish –blood supply compromised
  • Skin inspected for irritation
  • Bleeding
  • Wound infections
slide26
Postoperative nursing interventions
  • Monitor urinary function
  • Prevent complications

infection, sepsis, respiratory, complications, fluid and electrolyte imbalances, fistula formation.

  • Ryle’s tube aspiration
  • Ambulate quickly
  • Maintain peristomal integrity
  • Relieve pain
  • Improve body image
  • Exploring sexuality issues
  • Treat peritonitis
  • Look for stomal ischaemia and necrosis
  • Look for stomal retraction and separation
slide27
Neomycin, kanamycin
  • Immediately after operation – catheter in rectum – to prevent reflux into ureters and infection of the newly formed ureteric opening into the intestines
  • Monitoring fluid and electrolytes : intestinal mucosa absorb urine water and electrolytes; diarrhoea due to potassium and magnesium; maintain the balance. Pt advised to empty the rectum every 2 hours to ↓ build up of pressure and thereby the absorption of urinary salts
  • Retrain the rectum – special sphincteric exercises – learn the differentiate between the need to defaecate and the need to urinate
slide28
Promoting dietary measures – avoid chewing gum, smoking.
  • Salt intake restricted to prevent hyperchloremic acidosis. Potassium increased to make up for potassium lost in acidosis
  • Monitoring and managing potential complications : - pyelonephritis due to reflux of bacteria from rectum – long term antibiotics – late complication due to irritation - adenocarcinoma
managing ostomy appliance
Managing ostomy appliance
  • Empty the pouch when 1/3 full to prevent weight pulling down
  • A small amount of urine is left to prevent collapse of the bag against itself
  • The collecting bottle and tubing is rinsed with cold water daily and once in a week with a 3:1 solution of water and white vinegar
  • Continuing care – look for metastases
slide30
Look for leakage of urine from the appliance
  • Urine pH is kept below 6.5 by administration of ascorbic acid
  • Appliance to be fitted properly to prevent skin from getting irritated by urine
  • If the urine is foul smelling C&S done
  • Ileal conduit – mucosa – mucus produced – urine gets mixed with mucus – patient encouraged to take lot of fluid to wash out the mucus.
  • Appliances : reusable or disposable
  • Skin barrier used to protect skin from urine
promoting home and community care
Promoting home and community care
  • Teach patients self care
  • Control odour : food that gives odour to urine avoided e.g. Cheese, eggs
  • Deodorizers or dilute white vinegar introduced into the drainage bag
  • Ascorbic – acidifies – suppresses odour
  • Aspirin introduced into bag to deodorize may cause ulceration of the stoma
slide32
Home and community care
  • Teaching self care
  • Continuing care
future aspects
Future aspects
  • More than 40 variants of continent diversion, no single best technique
  • Which bowel segment ?
  • Which continent technique ?
  • Which anti-reflux technique ?

Only long term follow up can answer these questions