URINARY DIVERSIONS/UROSTOMY (POSTOPERATIVE CARE)

Incontinent urinary diversions: These ostomies require permanent stoma care and external collecting devices.
Ileal conduit: Ureters are anastomosed to a segment of ileum, resected with the blood supply intact (usually 15–20
cm long). The proximal section is closed, and the distal end brought to skin opening to form a stoma (a
passageway, not a storage reservoir).
Colonic conduit: This is a similar procedure using a segment of colon.
Ureterostomy: The ureter(s) is brought directly through the abdominal wall to form its own stoma.
Continent urinary diversions: Continent urinary reservoirs (CURs) have become one of the major options for patients
to improve their quality of life regarding stoma care and the ability to sleep and travel.
Kock reservoir or Indiana (ileocecal) pouch: A section of intestine is used to form a pouch inside the patient’s
abdomen, creating a reservoir that the patient periodically drains by inserting a catheter through the stoma,
thus negating the need for an external collecting device.

CARE SETTING
Inpatient acute surgical unit.

RELATED CONCERNS
Cancer
Peritonitis
Psychosocial aspects of care
Surgical intervention

Patient Assessment Database

Data depend on underlying problem, duration, and severity, e.g., malignant bladder tumor, congenital malformations,
trauma, chronic infections, or intractable incontinence due to injury/disease of other body systems (e.g., multiple
sclerosis). (Refer to appropriate CP.)

TEACHING/LEARNING
Discharge plan DRG projected mean length of inpatient stay: 5.5 days
considerations: May require assistance with management of ostomy and acquisition of supplies.
Refer to section at end of plan for postdischarge considerations.

DIAGNOSTIC STUDIES
Intravenous pyelogram (IVP): Visualizes size/location of kidneys and ureters and rules out presence of tumors
elsewhere in urinary tract.
Cystoscopy with biopsy: Determines tumor location/stage of malignancy. Ultraviolet cystoscopy outlines bladder
lesion.
Bone scan: Determines presence of metastatic disease.
Bilateral pedal lymphangiogram: Determines involvement of pelvic nodes, where bladder tumor easily seeds because
of close proximity.
CT scan: Defines size of tumor mass, degree of pelvic spread.
Urine cystoscopy: Detects tumor cells in urine (for determining presence and type of tumor).
Endoscopy: Evaluates intestines for use as conduit.
Conduitogram: Assesses length and emptying ability of the conduit and presence of stricture, obstruction, reflux,
angulation, calculi, or tumor (may complicate or contraindicate use as a urinary diversion).

NURSING PRIORITIES
1. Prevent complications.
2. Assist patient/SO in physical and psychosocial adjustment.
3. Support independence in self-care.
4. Provide information about procedure/prognosis, treatment needs, potential complications, and resources.

DISCHARGE GOALS
1. Complications prevented/minimized.
2. Adjusting to perceived/actual changes.
3. Self-care needs met by self/with assistance as necessary.
4. Procedure/prognosis, therapeutic regimen, potential complications understood and sources of support identified.
5. Plan in place to meet needs after discharge.

NURSING DIAGNOSIS: Skin Integrity, risk for impaired

Risk factors may include
Absence of sphincter at stoma [actual] with continuous flow of urine
Character/flow of urine from stoma
Reaction to product/chemicals; improper fitting of appliance or removal of adhesive
Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Tissue Integrity: Skin and Mucous Membranes (NOC)
Maintain skin integrity.
Risk Control (NOC)
Identify individual risk factors.
Demonstrate behaviors/techniques to promote healing/prevent skin breakdown.

ACTIONS/INTERVENTIONS RATIONALE
Ostomy Care (NIC)

Independent
Inspect stoma/peristomal skin. Note irritation, bruises Monitors healing process/effectiveness of appliance and
(dark, bluish color), rashes, status of sutures. identifies areas of concern, need for further
evaluation/intervention. Stoma should be pink or reddish,
similar to mucous membranes. Color changes may be
temporary, but persistent changes may require surgical
intervention. Early identification of stomal
necrosis/ischemia or fungal infection provides for timely
interventions to prevent skin necrosis.

Clean with water and pat dry (or use hair dryer on cool Maintaining a clean/dry area helps prevent skin
setting). breakdown.

Handle stoma gently to prevent irritation. Mucosa has good blood supply and bleeds easily with
rubbing or trauma.

Measure stoma periodically, e.g., each appliance change As postoperative edema resolves (during first 6 wk), size
for first 6 wk, then monthly times six. of appliance must be altered to ensure proper fit so that
urine is collected as it flows from the stoma and contact
with the skin is prevented.

Apply effective sealant barrier, e.g., Skin Prep or similar Protects skin from pouch adhesive, enhances
product. adhesiveness of pouch, and facilitates removal of pouch
when necessary.
ACTIONS/INTERVENTIONS RATIONALE
Ostomy Care (NIC)

Independent
Make sure opening for adhesive backing of pouch is at Prevents trauma to the stoma tissue and protects the
least 1⁄16 in larger than the base of the stoma (Wound, peristomal skin. Adequate adhesive area is important to
Ostomy and Continence Nursing Society [WOCN] maintain a seal. Note: Too tight a fit may cause stomal
standard), with adequate adhesiveness left to apply pouch. edema or stenosis.

Use a transparent, odor-proof drainable pouch. Keep A transparent appliance during first 4–6 wk allows easy
gauze square/wick over stoma while cleansing area, and observation of stoma and stents (when used) without
have patient cough or strain before applying pouch. necessity of removing pouch and irritating skin. Covering
stoma prevents urine from wetting the peristomal area
during pouch changes. Coughing empties distal portion of
conduit, followed by a brief pause in drainage to facilitate
application of pouch.

Avoid use of karaya-type appliances. Will not protect skin because urine melts karaya.

Apply waterproof tape around pouch edges if desired. Reinforces anchoring.

Connect collecting pouch to continuous bedside drainage May be needed during times when rate of urine formation
system, when necessary. is increased, e.g., while IV fluids are administered.
Weight of the urine can cause pouch to pull loose/leak
when pouch becomes more than half full.

Cleanse ostomy pouch on a routine basis, using vinegar Frequent pouch changes are irritating to the skin and
solution. should be avoided. Emptying and rinsing the pouch with
vinegar not only removes bacteria but also deodorizes the
pouch.

Change pouch every 3–5 days or as needed for leakage. Prevents tissue irritation/destruction associated with
Remove appliance gently while supporting skin. Use “pulling” pouch off.
adhesive removers as indicated and wash off completely.

Investigate reports of burning/itching around stoma. Suggests peristomal irritation or possibly Candida
infections, both requiring intervention. Note: Continuous
exposure of skin to urine can cause hyperplasia around
stoma, affecting pouch fit and increasing risk of infection.

Evaluate adhesive product and appliance fit on ongoing Provides opportunity for problem solving. Determines
basis. need for further intervention.

Monitor for distension of lower abdomen (with ileal Intestinal distension can cause tension on new suture lines
conduit); assess bowel sounds. with possibility of rupture.
ACTIONS/INTERVENTIONS RATIONALE
Ostomy Care (NIC)

Collaborative
Consult with enterostomal nurse. Helpful in problem solving and choosing products
appropriate for patient needs, considering stoma
characteristics, patient’s physical/mental status, and
financial resources. In the presence of persistent or
recurring problems, the ostomy nurse has a wider range of
knowledge and resources. Note: WOCN standards
mandate that patient be capable of changing an ostomy
appliance before discharge, or receive home care until
such time as patient or caregivers are competent.

Apply antifungal spray or powder, as indicated. Assists in healing if peristomal irritation is caused by
fungal infection. Note: These products can have potent
side effects and should be used sparingly.
Creams/ointments are to be avoided, because they
interfere with adhesion of the appliance.

NURSING DIAGNOSIS: Body Image, disturbed

May be related to
Biophysical: presence of stoma; loss of control of urine elimination
Psychosocial: altered body structure
Disease process and associated treatment regimen, e.g., cancer
Possibly evidenced by
Verbalization of change in body image, fear of rejection/reaction of others, and negative feelings about body
Actual change in structure and/or function (ostomy)
Not touching/looking at stoma, refusal to participate in care
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Body Image (NOC)
Demonstrate beginning acceptance by viewing/touching stoma and participating in self-care.
Verbalize feelings about stoma/illness; begin to deal constructively with situation.
Verbalize acceptance of self in situation, incorporating change into self-concept without negating self-esteem.

ACTIONS/INTERVENTIONS RATIONALE
Body Image Enhancement (NIC)

Independent
Review reason for surgery and future expectations. Patient may find it easier to accept/deal with an ostomy
done for chronic/long-term disease (e.g., intractable
incontinence, infections) than for traumatic injury.
ACTIONS/INTERVENTIONS RATIONALE
Body Image Enhancement (NIC)

Independent
Ascertain whether counseling was initiated when the Provides information about patient’s/SO’s level of
possibility and/or necessity of urinary diversion was first knowledge about individual situation and process of
discussed. acceptance.

Answer all questions concerning urostomy and its Establishes rapport and conveys interest/concern of
function. caregiver. Provides additional information for patient to
consider.

Encourage patient/SO to verbalize feelings. Acknowledge Provides opportunity to deal with issues/misconceptions.
normality of feelings of anger, depression, and grief over Helps patient/SO to realize that feelings experienced are
loss. Discuss daily “ups and downs” that can occur after not unusual and that feeling guilty for them is not
discharge. necessary/helpful. Patient needs to recognize feelings
before they can be dealt with effectively.

Note behaviors of withdrawal, increased dependency, Suggestive of problems in adjustment that may require
manipulation, or noninvolvement in care. further evaluation and more extensive therapy. May
reflect grief response to loss of body part/function and
worry over acceptance by others and fear of further
disability/loss of life from cancer.

Provide opportunities for patient/SO to view and touch Although integration of stoma into body image can take
stoma, using the moment to point out positive signs of months or even years, looking at the stoma and hearing
healing, normal appearance, and so forth. comments (made in a normal, matter-of-fact manner) can
help patient with this acceptance. Touching stoma
reassures patient/SO that it is not fragile and that slight
movements of stoma actually reflect normal peristalsis.

Provide opportunity for patient to deal with ostomy Independence in self-care helps improve self-esteem. In
through participation in self-care. the case of a continent diversion, patient needs the
energy, ability, and time to intubate the stoma four times
a day.
Maintain positive approach during care activities,
avoiding expressions of disdain or revulsion. Do not take Assists patient/SO to accept body changes and feel all
patient’s angry expressions personally. right about self. Anger is most often directed at the
situation and lack of control individual has over what has
happened (powerlessness), not the individual caregiver.
Plan/schedule care activities with patient.
Promotes sense of control and gives message that patient
can handle this situation, enhancing self-esteem.
Discuss possibility of contacting ostomy/urostomy visitor
and make arrangements for visit if desired. Can provide a good support system. Helps reinforce
teaching (shared experiences) and facilitates acceptance
of change as patient realizes “life does go on” and can be
relatively normal.
ACTIONS/INTERVENTIONS RATIONALE
Body Image Enhancement (NIC)

Independent
Discuss sexual functioning, medications that promote Patient may experience anticipatory anxiety, fear of
erection, and penile implant, if applicable, and alternative failure in relation to sex after surgery, usually because of
ways for sexual pleasuring. (Refer to ND: Sexual ignorance, lack of knowledge. Surgery that removes the
Dysfunction, risk for.) bladder and prostate (removed with the bladder) may
disrupt parasympathetic nerve fibers that control erection
in men, although newer techniques are available that may
be used in individual cases to preserve nerve function.

NURSING DIAGNOSIS: Pain, acute

May be related to
Physical factors, e.g., disruption of skin/tissues (incisions/drains)
Biological: activity of disease process (cancer, trauma)
Psychological factors, e.g., fear, anxiety
Possibly evidenced by
Reports of pain
Guarding/distraction behaviors, restlessness
Self-focusing
Autonomic responses, e.g., changes in vital signs
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Pain Level (NOC)
Verbalize relief/control of pain.
Appear relaxed, able to sleep/rest appropriately.
Pain Control (NOC)
Perform general comfort measures.

ACTIONS/INTERVENTIONS RATIONALE
Pain Management (NIC)

Independent
Assess pain, noting location, characteristics, intensity(0– Helps evaluate degree of discomfort and effectiveness of
10 scale). analgesia or may reveal developing complications, e.g.,
because abdominal pain usually subsides gradually by the
third or fourth postoperative day, continued or increasing
pain may reflect delayed healing, peristomal skin
irritation, infection, intestinal obstruction.
ACTIONS/INTERVENTIONS RATIONALE
Pain Management (NIC)

Independent
Auscultate bowel sounds; note passage of flatus. Indicates reestablishment of bowel function. Lack of
return of bowel sounds/function within 72 hr may indicate
presence of complication, e.g., peritonitis, hypokalemia,
mechanical obstruction.

Note urine flow and characteristics. Decreased flow may reflect urinary retention (due to
edema) with increased pressure in upper urinary tract or
leakage into peritoneal cavity (failure of anastomosis).
Cloudy urine may be normal (presence of mucus) or
indicate infectious process.

Encourage patient to verbalize concerns. Active-listen Reduction of anxiety/fear can promote relaxation and
these concerns and provide support by acceptance, comfort.
remaining with patient and giving appropriate
information.

Provide comfort measures, e.g., back rub, Reduces muscle tension, promotes relaxation, and may
repositioning(using body support measures as needed). enhance coping abilities.
Assure patient that position change will not injure stoma.

Encourage use of relaxation techniques, e.g., guided Helps patient rest more effectively and refocuses
imagery, visualization, diversional activities. attention, which may enhance coping ability, reducing
pain and discomfort.

Assist with ROM exercises and encourage early Reduces muscle/joint stiffness. Ambulation returns
ambulation. organs to normal position and promotes return of
peristalsis/passage of flatus and feelings of general well-
being.

Investigate and report abdominal muscle rigidity, Suggestive of peritoneal inflammation, requiring prompt
involuntary guarding, and rebound tenderness. medical intervention.

Collaborative

Administer medications as indicated, e.g., narcotics, Relieves pain, enhances comfort, and promotes rest. PCA
analgesics; patient-controlled analgesia (PCA). may be more beneficial than intermittent analgesia,
especially following radical resection.

Provide sitz baths, if indicated. Relieves local discomfort, reduces edema, and promotes
healing of perineal wound associated with radical
procedure.

Apply/monitor effects of transcutaneous electrical nerve Cutaneous stimulation may be used to block transmission
stimulator (TENS) unit. of pain stimulus.

Maintain patency of NG tube. Decompresses stomach/intestines; prevents abdominal

distension when intestinal function is impaired.
 NURSING DIAGNOSIS: Infection, risk for
Risk factors may include
Inadequate primary defenses (e.g., break in skin/incision; reflux of urine into urinary tract)
Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Immune Status (NOC)
Achieve timely wound healing, be free of purulent drainage or erythema, and be afebrile.
Knowledge: Infection Control (NOC)
Verbalize understanding of individual causative/risk factors.
Demonstrate techniques, lifestyle changes to reduce risk.

ACTIONS/INTERVENTIONS RATIONALE
Infection Protection (NIC)

Independent
Empty ostomy pouch when it becomes one-third full, Reduces risk of urinary reflux and maintains integrity of
once IV fluids and continuous pouch drainage have been appliance seal if pouch does not have an antireflux valve.
discontinued.

Document urine characteristics, and note whether changes Cloudy odorous urine indicates infection (possibly
are associated with reports of flank pain. pyelonephritis); however, urine normally contains mucus
after a conduit procedure.

Test urine pH with Nitrazine paper (use fresh specimen, Urine is normally acidic, which discourages bacterial
not from pouch); notify physician if greater than 6.5. growth/UTIs. Note: Presence of alkaline urine also
creates favorable environment for stone formation in
presence of hypercalciuria.

Report sudden cessation of urethral drainage. Constant drainage usually subsides within 10 days;
however, abrupt cessation may indicate plugging and lead
to abscess formation.

Note red rash around stoma. Rash is most commonly caused by yeast. Urine leakage
or allergy to appliance or products may also cause red,
irritated areas.

Inspect incision line around stoma. Observe and Provides baseline/comparative reference. Complications
document wound drainage, signs of incisional may include interrupted anastomosis of intestine/bowel or
inflammation, systemic indicators of sepsis. ureteral conduit, with leakage of bowel contents into
abdomen or urine into peritoneal cavity.

Change dressings as indicated when used. Moist dressings act as a wick to the wound and provide
media for bacterial growth.

Assess skin-fold areas in groin, perineum, under arms and Use of antibiotics and trapping of moisture in skin-fold
breasts. areas increases risk of Candida infections.
ACTIONS/INTERVENTIONS RATIONALE
Infection Protection (NIC)

Independent
Monitor vital signs. An elevated temperature suggests incisional infection or
UTI and/or respiratory complications.

Auscultate breath sounds. Patient is at high risk for development of respiratory

complications because of length of time under anesthesia.
Often this patient is older and may already have a
compromised immune system. Also, painful abdominal
incisions cause patient to breathe more shallowly than
normal and to limit coughing effort. Accumulation of
secretions in respiratorytract predisposes to atelectasis
and infections.
Collaborative

Use pouch with antireflux valve, if available. Prevents backflow of urine into stoma, reducing risk of
infection.

Obtain specimens of exudates, urine, sputum, blood as Identifies source of infection/most effective treatment.
indicated. Infected urine may cause pyelonephritis. Note: Urine
specimen must be obtained from the conduit because the
pouch is considered contaminated.

Administer medications as indicated, e.g.:

Cephalosporins, e.g., cefoxitin (Mefoxin), cefazolin Given to treat identified infection or may be given
(Ancef); prophylactically, especially with history of recurrent
pyelonephritis.

Antifungal powder; Used to treat yeast infections around stoma.

Ascorbic acid/vitamin C. Given to acidify urine, reduce bacterial growth/risk of

infection. Note: Large doses of vitamin C can impair GI
absorption of vitamin B12, potentiating pernicious anemia.

Assist with injection of IV methylene blue. Dye appearing in wound drainage signifies urine leakage
into peritoneal cavity and need for surgical repair.
 NURSING DIAGNOSIS: Urinary Elimination, impaired
May be related to
Surgical diversion; tissue trauma, postoperative edema
Possibly evidenced by
Loss of continence
Changes in amount, character of urine; urinary retention
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Urinary Elimination (NOC)
Display continuous flow of urine, with output adequate for individual situation.

ACTIONS/INTERVENTIONS RATIONALE
Urinary Elimination Management (NIC)

Independent
Note presence of stents/ureteral catheters. Label “right” Use of stents/ureteral catheters assists in healing of
and “left” and observe urine flow through each. anastomosis by keeping it urine-free. It is necessary to
verify that both kidneys/ureters are functional.

Record urinary output; investigate sudden Sudden decrease in urine flow may indicate
reduction/cessation of urine flow. obstruction/dysfunction (e.g., blockage by edema or
mucus) or dehydration. Note: Reduced urinary output
(not related to hypovolemia) associated with abdominal
distension, fever, and clear/watery discharge from
incision suggests urinary fistula, also requiring prompt
intervention.

Observe and record color of urine. Note hematuria and/or Urine may be slightly pink, which should clear up in 2–3
bleeding from stoma. days. Rubbing/washing stoma may cause temporary
oozing because of vascular nature of tissues. Continued
bleeding, frank blood in the pouch, or oozing around the
base of stoma requires medical evaluation/intervention.

Position tubing and drainage pouch so that it allows Blocked drainage allows pressure to build within urinary
unimpeded flow of urine. Monitor/protect placement of tract, risking anastomosis leakage and damage to renal
stents. parenchyma. Note: Stents inserted to maintain patency of
ureters during period of postoperative edema may be
inadvertently dislodged, compromising urine flow.

Demonstrate self-catheterization techniques and reservoir Patients with continent diversions do not require an
irrigations as appropriate. external collection device. Periodic catheterization
empties the internal reservoir and reduces risk of injury
from overdistension. Daily irrigations remove
accumulated mucus from the reservoir. Note: Patients
with Kock pouches connected to the urethra are instructed
to void every 2 hr during the day and every 3 hr during
the night. This is done by bearing down and applying
hand pressure on the lower abdomen to aid in emptying
the reservoir.
ACTIONS/INTERVENTIONS RATIONALE
Urinary Elimination Management (NIC)

Independent
Encourage increased fluids and maintain accurate intake. Maintains hydration and good urine flow.

Monitor vital signs. Assess peripheral pulses, skin turgor, Indicators of fluid balance. Reflects level of hydration
capillary refill, and oral mucosa. Weigh daily. and effectiveness of fluid replacement therapy.

Collaborative

Administer IV fluids as indicated. Assists in maintaining hydration/adequate circulating

volume and urinary flow.

Monitor electrolytes, ABGs, calcium. Impaired renal function in patient with intestinal conduit
increases risk of severe electrolyte and/or acid-base
problems, e.g., hyperchloremic acidosis. Elevated
calcium levels increase risk of crystal/stone formation,
affecting both urinary flow and tissue integrity.

Prepare for diagnostic testing, procedures as indicated. Retrograde ileogram may be done to evaluate patency of
conduit; nephrostomy tube or stents may be inserted to
maintain urine flow until edema/obstruction is resolved.

NURSING DIAGNOSIS: Sexual Dysfunction, risk for

Risk factors may include
Altered body structure/function; radical resection/treatment procedures
Vulnerability/psychological concern about response of SO
Disruption of sexual response pattern, e.g., erection difficulty
Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Sexual Functioning (NOC)
Verbalize understanding of relationship of physical condition to sexual problems.
Identify satisfying/acceptable sexual practices and explore alternative methods.
Resume sexual relationship as appropriate.
ACTIONS/INTERVENTIONS RATIONALE
Sexual Counseling (NIC)

Independent
Ascertain patient’s/SO’s sexual relationship before the Mutilation and loss of privacy/control of a bodily
disease and/or surgery. Identify future expectations and function can affect patient’s view of personal sexuality.
desires. When coupled with the fear of rejection by SO, the
desired level of intimacy can be greatly impaired. Sexual
needs are very basic, and patient will be rehabilitated
more successfully when a satisfying sexual relationship is
continued/developed.

Review with patient/SO anatomy and physiology of Understanding normal physiology helps patient/SO
sexual functioning in relation to own situation. understand the mechanisms of nerve damage and need for
exploring alternative methods of satisfaction.

Reinforce information given by the physician. Encourage Reiteration of previously given information assists
questions. Provide additional information as needed. patient/SO to hear and process the knowledge again,
moving toward acceptance of individual
limitations/restrictions and prognosis (e.g., that it may
take up to 2 yr to regain potency after a radical procedure
or that a penile prosthesis may be necessary).

Discuss resumption of sexual activity approximately 6 wk Knowing what to expect in progress of recovery helps
after discharge, beginning slowly and progressing (e.g., patient avoid performance anxiety/reduce risk of
cuddling/caressing until both partners are comfortable “failure.” If the couple is willing to try new ideas, this can
with body image/function changes). Include alternative assist with adjustment and may help achieve sexual
methods of stimulation as appropriate. fulfillment.

Encourage dialogue between patient/SO. Suggest wearing Disguising urostomy appliance may aid in reducing
pouch cover, T-shirt, or shortie nightgown. feelings of self-consciousness, embarrassment during
sexual activity.

Stress awareness of factors that might be distracting (e.g., Promotes resolution of solvable problems.
unpleasant odors and pouch leakage).

Encourage use of sense of humor. Laughter can help individuals deal more effectively with
difficult situation and promote a positive sexual
experience.

Problem-solve alternative positions for coitus. Minimizing awkwardness of appliance and physical
discomfort can enhance satisfaction.

Discuss/role-play possible interactions or approaches Rehearsal helps deal with actual situations when they
when dealing with new sexual partners. arise, preventing self-consciousness about “different”
body image.

Provide birth control information as appropriate and Confusion about impotency and sterility can lead to an
stress that impotence does not mean patient is necessarily unwanted pregnancy.
sterile.
ACTIONS/INTERVENTIONS RATIONALE
Sexual Counseling (NIC)

Collaborative
Arrange meeting with an ostomy visitor if appropriate. Sharing of how these problems have been resolved by
others can be helpful and reduce sense of isolation.

Refer to counseling/sex therapy as indicated. If problems persist longer than several months after
surgery, a trained therapist may be required to facilitate
communication between patient and SO.

NURSING DIAGNOSIS: Knowledge, deficient [Learning Need] regarding condition, prognosis,

treatment, self-care, and discharge needs
May be related to
Lack of exposure/recall; information misinterpretation
Unfamiliarity with information resources
Possibly evidenced by
Questions; statement of misconception/misinformation
Inaccurate follow-through of instruction/performance of urostomy care
Inappropriate or exaggerated behaviors (e.g., hostile, agitated, apathetic, withdrawn)
DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL:
Knowledge: Disease Process (NOC)
Verbalize understanding of condition/disease process, prognosis, and potential complications.
Knowledge: Treatment Regimen (NOC)
Verbalize understanding of therapeutic needs.
Correctly perform necessary procedures, explain reasons for the action.
Initiate necessary lifestyle changes.

ACTIONS/INTERVENTIONS RATIONALE
Teaching: Disease Process (NIC)

Independent
Evaluate patient’s emotional and physical capabilities. These factors affect patient’s ability to master tasks and
willingness to assume responsibility for ostomy care.

Review anatomy, physiology, and implications of Provides knowledge base from which patient can make
surgical intervention. Discuss future expectations. informed choices and an opportunity to clarify
misconceptions regarding individual situation.

Include written/picture resources. Provides references after discharge to support patient

efforts for independence in self-care.
ACTIONS/INTERVENTIONS RATIONALE
Teaching: Disease Process (NIC)

Independent
Instruct patient/SO in stomal care as appropriate. Allot Promotes positive management and reduces risk of
time for return demonstrations and provide positive improper ostomy care.
feedback for efforts.

Ensure that stoma and appliance are odorless, nonleaking. When patient feels confident about urostomy,
energy/attention can be focused on other tasks.

Demonstrate padding to absorb urethral drainage; ask Small amount of leakage may continue for several weeks
patient to report changes in amount, odor, character. after prostate surgery with bladder left in place
(temporary diversion procedure).

Recommend routine clipping/trimming of hair around Hair can be pulled out when the pouch is changed,
stoma to edges of pouch adhesive. causing irritation of hair follicles and increasing risk of
local infection.

Encourage patients with Kock pouch to lengthen voiding Increases capacity of reservoir to achieve a more normal
interval by 1 hr each week unless discomfort noted. voiding pattern. Presence of discomfort suggests reservoir
is full, necessitating prompt emptying.

Instruct patient in a progressive exercise program to Improves tone of pelvic muscles and the external
include Kegel exercises and stop/start of urinary stream. sphincter to enhance continence when patient voids
through urethra.

Encourage optimal nutrition. Promotes wound healing, increases utilization of energy

to facilitate tissue repair. Anorexia may be present for
several months postoperatively, requiring conscious effort
to meet nutritional needs.

Discuss use of acid-ash diet (e.g., cranberries, prunes, May be useful in acidifying urine to decrease risk of
plums, cereals, rice, peanuts, noodles, cheese, poultry, infection and crystal/stone formation. Products containing
fish); avoidance of salt substitutes, sodium bicarbonate, bicarbonate/calcium potentiate risk of crystal/stone
and antacids; and cautious use of products containing formation affecting both urinary flow and tissue integrity
calcium. Note: Use of sulfa drugs requires alkaline urine for
optimal absorption, so acid-ash diet/vitamin C
supplements should be withheld.

Discuss importance of maintaining normal weight. Changes in weight can affect size of stoma/appliance fit.
Note: Weight loss of 10–20 lb is not uncommon because
of intestinal involvement and anorexia.

Stress necessity of increased fluid intake of at least2–3 Maintains urinary output and promotes acidic urine to
L/day; of cranberry juice or ascorbic acid/vitamin C reduce risk of infection and stone formation. Note:
tablets; avoidance of citrus fruits as indicated. Oranges/citrus fruits make urine alkaline and are
therefore contraindicated. Large doses of vitamin C can
inhibit vitamin B12 absorption, requiring periodic
monitoring of vitamin B12 levels.
ACTIONS/INTERVENTIONS RATIONALE
Teaching: Disease Process (NIC)

Independent
Discuss resumption of presurgery level of activity and Patient should be able to manage same degree of activity
possibility of sleep disturbance, anorexia, loss of interest as previously enjoyed and in some cases increase activity
in usual activities. level except for contact sports. “Homecoming
depression” may occur, lasting for up to 3 mo after
surgery, requiring patience/support and ongoing
evaluation.
Encourage regular activity/exercise program.
Immobility/inactivity increases urinary stasis and calcium
shift out of bones, potentiating risk of stone formation and
resultant urinary obstruction, infection.
Identify signs/symptoms requiring medical evaluation,
e.g., changes in character, amount and flow of urine, Early detection and prompt intervention of developing
unusual drainage from wound; fatigue/muscle weakness, problems such as UTI, stricture, intestinal fistula may
anorexia, abdominal distension, confusion. prevent more serious complications. Urinary electrolytes
(especially chloride) are resorbed in the intestinal conduit,
which leads to compensatory bicarbonate loss, lowered
serum pH (metabolic acidosis), and potassium deficit.
Stress importance of follow-up appointments.
Monitors healing, disease process; provides opportunity
for discussion of appliance fitting problems, generalized
health, and adaptation to condition. Note: Extensive
surgery requires prolonged recuperation for regaining
strength and endurance.
Identify community resources, e.g., United Ostomy
Association and local ostomy support group, enterostomal Continued support after discharge is essential to facilitate
therapist, visiting nurse, pharmacy/medical supply house. the recovery process and patient’s independence in care.
Enterostomal nurse can be very helpful in solving
appliance problems and identifying alternatives to meet
individual patient needs.

POTENTIAL CONSIDERATIONS following acute hospitalization (dependent on patient’s age, physical

condition/presence of complications, personal resources, and life responsibilities)
In addition to postsurgical concerns:
Urinary Elimination, impaired—anatomical diversion.
Self-Esteem, situational low—loss of/altered control of body function.