Guidelines for Care of the Patient With a Urinary Diversion
Keep the patient as free of odors as possible. If the patient has an external appliance, empty the appliance frequently.
Inspect the patient's stoma regularly. It should ideally protrude about 1 to 3 cm above skin level and be dark pink to red in color and moist (Berti-Hearn & Elliott, 2019; Stelton, 2019). A pale stoma may indicate anemia, and a dark or purple-blue stoma may reflect compromised circulation or ischemia. Bleeding around the stoma and its stem should be minimal. The edges of the stoma should appear secure to the surrounding skin (Stelton, 2019). The pulling away of the stoma from the peristomal skin is called mucocutaneous separation or stoma dehiscence (Stelton, 2019) and occurs more often in patients who are at risk for impaired healing, including patients with diabetes, poor nutritional status or who received high-dose steroid therapy or chemotherapy before surgery (Butler, 2009). Notify the health care team promptly if bleeding persists or is excessive, if color changes occur in the stoma, or if it appears the stoma is separating from the peristomal skin (Stelton, 2019).
Note the size of the stoma, which usually stabilizes within 6 to 8 weeks (Stelton, 2019). Most stomas protrude 0.5 to 1 inch from the abdominal surface and may initially appear swollen and edematous. After 6 weeks, the edema usually subsides. If an abdominal dressing is in place at the incision site after surgery, check it frequently for drainage and bleeding.
Keep the skin around the stoma site (peristomal area) clean and dry. If care is not taken to protect the skin around the stoma, irritation or infection may occur. Assess the peristomal (around the stoma) skin; peristomal skin should be intact and appear consistent with that of the rest of the abdomen, without pain or discomfort (Burch, 2018). In patients with light skin tones, the peristomal skin should not be reddened; in patients with darker skin tones, the skin should not have darker discolorations (Stelton, 2019). A leaking or ill-fitted stoma appliance will cause moisture-associated skin damage (Berti-Hearn & Elliott, 2019) (refer to the discussion earlier in the chapter). Candida or yeast infections can also occur around the stoma if the area is not kept dry.
Measure the patient's fluid intake and output. Careful monitoring of the patient's urinary output is necessary to monitor fluid balance.
Monitor the return of intestinal function and peristalsis. Initially after surgery, peristalsis is inhibited. Remember, the patient had a bowel resection as part of the urinary diversion procedure.
Monitor for mucus in the urine from an ileal conduit, which is a normal finding (Berti-Hearn & Elliott, 2019). The isolated segment of small intestine continues to produce mucus as part of its normal functioning.
Explain each aspect of care to the patient and explain what their role will be when they begin self-care. Patient teaching is one of the most important aspects of ostomy care and should include family members/caregivers, when appropriate. Teaching can begin before surgery so that the patient has adequate time to absorb the information.
Encourage the patient to participate in care and to look at the stoma. Patients normally experience emotional depression during the early postoperative period. Help the patient to cope by listening, explaining, and being available and supportive. A visit from a representative of the local ostomy support group may be helpful. Patients usually begin to accept their altered body image when they are willing to look at the stoma, make neutral or positive statements concerning the ostomy, and express interest in learning self-care.