32 Urinary diversions
Overview/pathophysiology
Health care setting
Nursing diagnosis:
Anxiety
Desired Outcome: Before surgery, patient communicates fears and concerns, relates attainment of increased psychologic and physical comfort, and exhibits a coping demeanor.
| ASSESSMENT/INTERVENTIONS | RATIONALES |
|---|---|
| Assess patient’s perception of his or her impending surgery and resulting body function changes. Listen actively. | This assessment provides an opportunity for patient to express anxieties about the upcoming surgery and for the nurse to evaluate the response. For example, “You seem very concerned about next week’s surgery.” Anger, denial, withdrawal, and demanding behaviors may be coping responses. |
| Acknowledge patient’s concerns. | This will help focus attention on anxieties and concerns so that they can be dealt with. |
| Provide brief, basic information regarding physiology of the procedure and equipment that will be used after surgery, including tubes and drains. | Knowledge is one of the best means of decreasing anxiety. |
| Show patient pouches that will be used after surgery. Assure patient that the pouch usually cannot be seen through clothing and that it is odor resistant. | Patient may worry that others will be able to see and smell the pouch. |
| For patient about to undergo a continent urostomy procedure of Kock or Indiana pouch, explain that a pouching system may be needed for a short time after surgery. Reassure patient that teaching about accessing the continent urostomy will be done in the surgeon’s office or by the home care nurse. | This intervention likely will decrease anxiety by reassuring patient that he or she will be taught necessary skills. |
| Discuss postsurgical activities of daily living with patient. | This information decreases anxiety that such activities of daily living (ADLs) as showers, baths, and swimming can continue and that diet is not affected after the early postoperative period. |
| As appropriate, ask patient what information has been relayed by the surgeon about sexual implications of the surgery. | Patient may be very anxious about sexual implications of this surgery but afraid to ask. Asking this question will help establish an open relationship between patient and nurse. For example, some men undergoing radical cystectomy with urinary diversion may become impotent, but recent surgical advances have enabled preservation of potency for others. The pelvic plexus, which innervates the corpora cavernosa (allowing penile erection), may be damaged permanently as a result of autonomic nerve damage. However, sensation and orgasm are mediated by the pudendal nerve (sensorimotor) and are not affected. |
| Arrange for a visit by the enterostomal therapy (ET) nurse during the preoperative period. Collaborate with surgeon, ET nurse, and patient to identify and mark the most appropriate site for the stoma. | Showing patient the actual spot for placement may help alleviate anxiety by reinforcing that impact on lifestyle and body image will be minimal. |
Nursing diagnosis:
Impaired urinary elimination
Desired Outcome: Patient’s urinary output is 30 mL/hr or greater; urine is clear and straw-colored with normal, characteristic odor.
| ASSESSMENT/INTERVENTIONS | RATIONALES |
|---|---|
| Assess intake and output, and record total amount of urine output from urinary diversion for the first 24 hr postoperatively. Differentiate and record separately amounts from all drains, stents, and catheters. Notify health care provider of an output less than 60 mL during a 2-hr period. | This assessment checks for discrepancies between intake and output. In the presence of adequate intake a decreased output can signal a ureteral obstruction, a leak in one of the anastomotic sites, or impending renal failure. |
Intestinal conduit: Urine is drained via the stoma. Patient also may have ureteral stents and/or conduit catheter/stent in the early postoperative period to stabilize ureterointestinal anastomoses and maintain drainage from the conduit during early postoperative edema. Continent urinary diversions or reservoirs: The Kock urostomy usually has a reservoir catheter and also may have ureteral stents. The Indiana (ileocecal) reservoir usually has ureteral stents exiting from the stoma, through which most of the urine drains, and may have a reservoir catheter exiting from a stab wound, which serves as an overflow catheter. The neobladder has a urethral catheter in place that will drain urine, which initially will be light red to pink in color with mucus but should clear in 24-48 hr. This catheter generally remains in place for 21 days to ensure adequate healing of the anastomosis. | |
| Also assess for flank pain, costovertebral angle (CVA) tenderness, nausea, vomiting, and anuria. | These are other indicators of ureteral obstruction. |
| Monitor functioning of ureteral stents. | Ureteral stents, which exit from the stoma into the pouch, maintain ureteral patency and assist in healing of the anastomosis. Stents may become blocked with mucus, but as long as urine is draining adequately around the stent and the volume of output is adequate, this is not a problem. Right stents usually are cut at a 90-degree angle, and left stents are cut at a 45-degree angle. Each usually produces approximately the same amount of urine, although the amount produced by each is not important as long as each drains adequately and total drainage from all sources is 30 mL/hr or greater. Urine is usually red to pink for the first 24-48 hr and becomes straw-colored by the third postoperative day. Absent or lessening amounts of urine may indicate a blocked stent or problems with the ureter. |
| Monitor functioning of stoma catheters. | Expect output from stoma catheter to include pink or light red urine with mucus and small red clots for the first 24 hr. Urine should become amber colored with occasional clots within 3 postoperative days. Mucus production will continue but should decrease in volume. In continent urinary diversions, a catheter is placed in the reservoir to prevent distention and promote healing of suture lines. This new reservoir (i.e., resected intestine) exudes large amounts of mucus, necessitating catheter irrigation with 30-50 mL of normal saline, which is instilled gently and allowed to empty via gravity. |
| Monitor functioning of drains. | Any urinary diversion may have Penrose drains or closed drainage systems in place to facilitate healing of the ureterointestinal anastomosis. Drainage from these systems may be light red to pink for the first 24 hr and then lighten to amber and decrease in amount. Excessive lymph fluid and urine can be removed via these drains to reduce pressure on anastomotic suture lines. In a continent urinary diversion, an increase in drainage after amounts have been low might signal an anastomotic leak, which necessitates notification of health care provider. |
| Monitor drainage from Foley catheter or urethral drain (if present). Note color, consistency, and volume of drainage, which may be red to pink with mucus. | Patients who have had a cystectomy may have a urethral drain, whereas those with a partial cystectomy will have an indwelling catheter in place. |
| Report sudden increase or decrease in drainage to health care provider. | A sudden increase would occur with hemorrhage; a sudden decrease can signal blockage that can lead to infection or, with partial cystectomy, hydronephrosis. |
| Encourage an intake of at least 2-3 L/day in the nonrestricted patient. | Increased hydration keeps the urinary tract well irrigated and helps prevent infection that could be caused by urinary stasis. |
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