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2. . Urinary diversion to divert urine from the bladder to a new exit siteUsually through a surgically created opening (stoma) in the skin. 3. Indications. Tumour necessitating removal of entire bladderPelvic malignancyBirth defects Strictures Trauma to ureters and urethraNeurogenic bladder Chronic infection causing severe uretral and renal damageIntractable interstitial cystitis and Incontinence.
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1. 1 Urinary Diversions
2. 2 Urinary diversion
to divert urine from the bladder to a new exit site
Usually through a surgically created opening (stoma) in the skin
3. 3 Indications Tumour necessitating removal of entire bladder
Pelvic malignancy
Birth defects
Strictures
Trauma to ureters and urethra
Neurogenic bladder
Chronic infection causing severe uretral and renal damage
Intractable interstitial cystitis and
Incontinence
4. 4 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
5. 5 Complications of ileal conduit Wound infection
Wound dehiscence
Urinary leakage
Ureteral obstruction
Hyperchloremic acidosis
Small bowel obstruction
Ileus
Stomal gangrene
Ureteral obstruction
Narrowing of the stoma
Renal deterioration due to chronic reflux
Pyelonephritis
Renal calculi
6. 6 Cutaneous Ureterostomy…
Stoma – flush with the skin or retraction
Other cutaneous urinary diversions : suprapubic cystostomy, nephrostomy…
7. 7 Cutaneous Ureterostomy…
8. 8 Vesicostomygo to the next
9. 9 Nephrostomy…
10. 10 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
11. 11
12. 12
13. 13 Koch Pouch II
14. 14 ureterosigmoidostomy
15. 15 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
16. 16 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
17. 17 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
Vleeding
Encrustation
Wound infections
18. 18 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
19. 19 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
20. 20 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
21. 21 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
22. 22 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
23. 23 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 drainag bag
Ascorbic – acidifies – suppresses odour
Aspirin introduced into bag to deodorize may cause ulceration of the stoma
24. 24 Home and community care
Teaching self care
Continuing care
25. 25