VSPM MADHURIBAI DESHMUKH INSTITUTE OF NURSING

EDUCATION, NAGPUR.

SEMINAR

ON

MANAGEMENT OF STOMA, CATHETER AND TUBES

SUBJECT: CHILD HEALTH NURSING

SUBMITTED TO:
MRS.ANAGHA KHERKAR
ASSOCIATE PROFESSOR
VSPM MDINE, NAGPUR

SUBMITTED BY:
MISS.ELISHIBA P. MIRE
MSc. NURSING 1ST YEAR
VSPM MDINE, NAGPUR

DATE OF SUBMISSION:
GENERAL OBJECTIVE

At the end of seminar students will able to gain in-depth knowledge regarding management of
stoma, catheter and tubes.

SPECIFIC OBJECTIVE

At the end of seminar students will able to: -

EXPLAIN MANAGEMENT OF STOMA

 Explain colostomy
 Define colostomy
 Enumerate types of colostomy
 Enlist the indications of colostomy
 List down the complications of colostomy

 Explain Ileostomy
 Define ileostomy
 Enlist the indications of ileostomy

 Explain Urostomy
 Define Urostomy
 Enlist the indications of urostomy

 Enumerate complications of stoma

 Explain stoma care

MANAGEMENT OF CATHETER
 Definition of catheter
 Enumerate the types of catheter
 Enlist the indications of catheterization
 Explain the management of catheterization
 Enlist the complications of catheterization and it’s management

MANAGEMENT OF TUBES
 Definition of tubes
 Types of tubes
 Indications of tubes
 Complications of tubes
 Care and management of tubes
MANAGEMENT OF STOMA

INTRODUCTION

Stoma is a Greek word meaning ‘mouth’ or ‘opening’.

A stoma is an opening in abdomen that allows to exist body, rather than going through digestive
system. They are when part of bowels or bladder either need to heal or to be removed.

There are three main types of stoma

1. Colostomy

2. Ileostomy and

3. Urostomy

1. COLOSTOMY

A colostomy is an artificial opening made in the large bowel to divert faeces and
flatus to exterior, where it can be collected in an external appliance.

Depending on the purpose for which the diversion has been necessary, a colostomy may be:

1) Temporary or 2) Permanent

TYPES OF COLOSTOMY

1. Loop colostomy

This type of colostomy is usually used in emergencies and is a temporary and large stoma. A
loop of the bowel is pulled out onto the abdomen he held in place with an external device. The
bowel is then sutured to the abdomen and two opening are created in the one stoma: one for stool
and other for mucus.
 a. Transverse colostomy
b. Sigmoid colostomy

2. End colostomy

A stoma is created from one end of the bowel. The other portion of the bowel is either
removed or shut.

3. Double barrel colostomy

The bowel is severed(cut) and both ends are brought out onto abdomen. Only the proximal
stoma is functioning.

 Both ends of bowel are brought out.

 The proximal stoma (colostomy) diverts faces
 The distal stoma- mucous fistula
 Indications - trauma, tumours or inflammation
 Temporary or permanent

Advantage:

Ensures that the distal segment (colon, rectum) is completely defunction (absolute rest).

INDICATIONS FOR COLOSTOMY

1. A section of the colon has been removed, e.g. due to colon cancer requiring a total mesorectal
excision, diverticulitis, injury etc., so that it is no longer possible for faeces to exit via the anus.

2. Faecal incontinence

3. Inflammatory bowel disease

4. Obstruction (blockage)

5. Cancer
6. Injury

7. Birth defects

COMPLICATIONS OF COLOSTOMIES

There are five structural complications of colostomy

1. Retraction

2. Stenosis

3. Prolapse

4. Obstruction

5. Herniation

2. ILEOSTOMY

An ileostomy is a stoma constructed by bringing the end or loop of small intestine (the ileum)
out onto the surface of the skin, or the surgical procedure which creates this opening.

INDICATIONS:

1. Ulcerative colitis

2. Crohn’s disease

3. Familial polypsis

4. Cancer
3. UROSTOMY

A urostomy is a surgical procedure that creates a stoma (artificial opening) for the urinary
system. A urostomy is made to available for urinary diversion in cases where drainage of urine
through the bladder and urethra is not possible.

INDICATIONS

1. After cystectomy

2. Bladder cancer

3. Severe kidney disease

4. Accidental damage or injury to the urinary tract

5. Congenital defects that causes urine to back up into the kidney

COMPLICATIONS OF STOMA

1. Skin irritation.

This is a common problem that’s caused by the adhesive on ostomy appliance. Try using a
different appliance or changing the adhesive use.

2. Dehydration

Having a lot of waste exist through stoma can lead to dehydration. In most cases, rehydrate by
drinking more fluids, but severe cases might require hospitalization.

3. Leakage

If stoma appliance doesn’t fit properly, it can leak. If this happens probably need a new appliance
that fits better.
4. Parastomal hernia

This is a frequent complication that happens when intestine starts to press outward through the
opening. These are very common and often go away on their own. However, in some cases may
need surgery to repair it.

5. Necrosis

Necrosis refers to tissue death, which happens when blood flow to stoma is reduced or cut off.
When this happens, it’s usually within the first few days after surgery

STOMA CARE

Initial care

 Follow the steps below to promote wound healing.

 Observe colour of the stoma. Observe and document stoma for perfusion, bleeding, skin
integrity and signs of infection or prolapse every 4-6 hours.
 Measure stoma output. Notify medical staff if there is >30-49mls/kg/day stoma output.
 Ensure the skin surrounding the stoma is protected from excoriating effects of enzymes
 Check stoma with cares 4 to 6 hourly for wound ooze, bleeding (small spots of blood
common with cleaning) and bowel motion. Clean with warm sterile saline until wound
suture line healed then warm sterile water can be used.

POST OPERATIVELY

 Measures stoma and cut a hole in the flange of the Hollister New born appliance to fit
over the stoma, apply then put new born pouch onto skin barrier. This should be done
immediately post operatively for protection of skin and stoma. The stoma can be viewed
through the clear pouch or the pouch or the pouch can be removed from the flange if the
stoma needs to be viewed more closely.
  In the first week post op the stoma will decrease in size as the swelling resolves, therefore
the size of the hole cut in the flange will need re-measuring (when new pouch applied).

STABILISING THE STOMA

 Follow the steps below to ensure stoma is stabilised.

 Stoma pouch must be changed every 3-4 days, or as soon as it leaks.

 Check flange and pouch with cares, ensure flange is not leaking, if the flange is stained
underneath then it has leaked and needs to be changed. Pouch needs to be emptied when
1/3 full of bowel motion or gas as it will lift the flange.

 To change pouch if leaking.

 Gather equipment: gloves, bowl, warm water (no soap), gauze, cotton buds, appropriate
sized bag and clip, scissors, flange backing for size.

 Carefully removes old pouch from the top edge downloads, clean skin with warm water,
dry well; assess skin for any signs of excoriation. Assess stoma for any changes in
colour, sizes or excessive bleeding.

 If skin is looking red, use the cavilon no sting barrier film and allow to dry.

 Cut hole in flange to fit the size and shape of stoma, the flange needs to fit over the stoma
with a gap of approximately 2mm from edge of stoma to flange. If the flange is too close
to the stoma will cause the flange to lift. If the flange is not close enough to the stoma
then the surrounding skin could become excoriated.

 Warm flange between hands for approximately one minute. Apply flange and apply
pressure to the flange for one minute and press down all edges. Check the flange is well
attached and apply pouch. Close end of pouch with clip provided.
Pre-closure of stoma- Distal End Wash Out

 Follow the steps below when doing a distal end washout.

 A contrast study may be requested prior to closure of the stoma, as per individual surgeon
orders.

 Ensure that warmed 0.9% sodium chloride 10ml/kg used.

 With a size 8 feeding tube lubricated with KY jelly, intubate the stoma the stoma 1-2 cm
or until there is resistance.

 Flush saline through with a syringe using minimal pressure.

 Fluid coming out through the rectum must be clear pre-operative.

 
MANAGEMENT OF CATHETER

CATHETERS

INTRODUCTION

A catheter is a thin tube made from medical grade materials serving a broad range of
functions. Catheters are medical devices that can be inserted in the body to treat diseases or
performed a surgical procedure.

Catheters can be inserted into body cavity, duct, or vessels. Functionally, they allow
drainage, administration of fluids or gases, access by surgical instruments, and also perform a
wide variety of other tasks depending on the type of catheters.

In the first week post op the stoma will decrease in size as the swelling resolves, therefore the
size of the hole cut in the flange will need re-measuring (when new pouch applied).

TYPES OF CATHETERS

Urinary catheters

A urinary catheter is used to drain the urinary bladder when it cannot be emptied normally.

The different types of urinary catheters:

1. Indwelling catheter (also called a Foley catheter)

An indwelling catheter is a catheter stays inside the body for a longer period, and there are two
types. A urethral indwelling catheter is catheter inserted through the urethra into the bladder,
while a suprapubic indwelling catheter is inserted through the stomach directly into the bladder.

AGE SIZE (FR)

 Newborn 5-6 Fr

Toddlers to age 12 5-10 Fr

Women 12-14 Fr

Men 14-18 Fr

Clot retention 20-22 Fr

Suprapubic 16-20 Fr

2. Intermittent catheter

An intermittent catheter is inserted into urethra on demand to empty the bladder and then
removed again as soon as the bladder is empty.

3. Non-hydrophilic catheters vs. hydrophilic catheters

There are two major types of intermittent urinary catheter: Non- hydrophilic catheters, which are
uncoated catheters, and hydrophilic intermittent catheter which are coated with a slippery surface
to make insertion and withdrawal easy.

4. External catheters (Condom catheter)

A external catheter is a catheter placed outside the body. It’s typically necessary for men who
don’t have urinary retention problems but have serious functional or mental disabilities, such as
dementia.

 INDICATIONS FOR URINARY CATHETERIZATION:

 Short-term indwelling catheterization

  Collection of sterile urine sample.
 Provide relief of discomfort from bladder distension.
 Decompression of the bladder.
 Measure residual urine.
 Management of patients with spinal cord injury, neuromuscular degeneration, or
incompetent bladders.
 Long-term indwelling catheterization
 Post-surgery and in critically ill patients to monitor urinary output.
 Prevention of urethral obstruction from blood clots with continuous or intermittent
bladder irrigations.
 Instillation of medication into the bladder.
 Surgical procedures involving pelvic or abdominal surgery repair of the bladder, urethra,
and surrounding structures.
 Urinary obstruction (e.g. enlarged prostate), acute urinary retention.
 Intermittent catheterization
 Refractory bladder outlet obstruction and neurogenic bladder with urinary retention.
 Prolonged and chronic urinary retention.
 To promote healing of perineal ulcers where urine may cause further skin breakdown.
 Male external catheterization
 Overactive bladder incontinence without post void residual urine (PVR) in men.
 Incontinence in men- day and/or night loss of urine with or without urge, but without
PVR.
 Urological problems in men with some neuromuscular syndromes
 Complex orthopaedic surgery of the pelvis in men with a normal voiding pattern

Intravenous catheter

These helps to give medicine or fluids straight into bloodstream. There are three kinds:
 a) Peripheral venous catheter (16 Gauge, 18 Gauge, 20 Gauge, 22 Gauge, 24Gauge)

The most common type of intravenous catheter is designed for peripheral access. This is the IV
line commonly put into the hand or forearm when a patient is admitted to the hospital. It is short,
approximately ¾ to 1 inch long, and is inserted into the vein

INDICATIONS

 Repeated blood sampling

 IV administration of fluids and medications
 IV administration of chemotherapeutic agents
 IV administration of blood or blood products

b) Midline peripheral catheter

Another type of IV catheter is called a midline, which is defined as a catheter that is from 3-to 10
inches long, and inserted by a trained nurse in the arm near the inside of the elbow.

c) Peripheral inserted central catheter

A peripheral inserted central catheter, or PICC, is a flexible catheter that is put into the elbow
vein much like the midline catheter. The difference is that this catheter is longer and guided into
vena cava, which leads into the heart.

INDICATIONS

 Patient with limited peripheral access

 Long-term IV medication administration (antibiotics)

 Continuous administration of vesicants or drugs that irritate peripheral veins

 Blood product infusion

 Frequent blood drawn

 Patient with coagulation disorders  

10. Central venous catheter

Central venous catheters as those that are inserted by the physician through a vein in the neck,
upper chest or anterior chest, with the tip in the vena cava of the heart.

INDICATIONS

 Volume resuscitation

 Emergency venous access

 Nutritional support

 Administration of caustic medications (eg. Vasopressor)

 CVP monitoring

 Introduction of transvenous pacing wire

 Haemodialysis

11. A Swan-Ganz catheter is a special type of catheter placed into the pulmonary artery for
measuring pressure in the heart.

INDICATIONS

 Cardiogenic shock during supportive therapy

 Discordant right and left ventricular failure
 Severe chronic heart failure requiring inotropic, vasopressor and vasodilators therapy
 Suspected pseudosepsis (high cardiac output, low systemic vascular resistance, elevated
right arterial and pulmonary capillary wedges pressures)

12.  A Quinton catheter is a double or triple lumen, external catheter used for haemodialysis.

COMPLICATIONS

Due to urinary catheter

 1. Infection – This is the most common problem. The catheter may let germs into body,
where they can infect bladder, urethra, or kidneys.

2. Leaks – This may be a sign that catheter is blocked by clotted blood or debris, which is
common with indwelling catheters.

3. Bladder spasms – These can happen if bladder tries to push out the catheter

Related to intravenous catheters

 The catheter might leak.

 The catheter might get twisted

 Clotted blood might block catheter.

 The catheter might come loose from the vein.

 Infection

 A blood clot might from in the vein.

Central venous catheter-

 The catheter might injure the vein.

 Blood might leak out and a bruise or other problems.

 The catheter might cut lung, would make it collapse.

CATHETER MANAGEMENT

 Routine management of urinary catheter

 Catheter size
 Minimizing infection
  Once the decision has been made to use an indwelling urinary catheter, efforts should be
made to minimize problems.
 The catheter should be inserted using sterile technique.
 Every attempt should be made to keep the drainage system closed. Any break in the
catheter-to-collection unit may invite earlier infection.

MANAGEMENT OF COMPLICATIONS

1. Obstruction:

The material that obstructs urinary catheters consists of bacteria, glycocalyx, protein and
precipitated crystals. Methenamine preparations may be beneficial in reducing episodes of
obstruction. Irrigation may prevent repeated obstructions that are not responsive to increase fluid
intake and urine acidification. However obstructed catheters must be removed.

2. Leakage:

Bladder spasm are not uncommon in patients with long-term catheterization. The force generated
by spasms commonly overwhelms the drainage capacity of the catheter, creating leakage around
the catheter. This type of leakage should not be corrected by using a large diameter catheter.
Infection or catheter obstruction, if present, should be treated. Antispasmodics, such as
oxybutynin (Ditropan-2.5 to 5.0 mg four times daily) and flavoxate (Urispas- 100 to 200 mg four
times daily), can be effective in alleviating spasm due to detrusor instability.

3. Colonization Vs Infection

Virtually every patient with chronic catheterization is colonized with bacteriuria within six
weeks. Bacteriuria also occurs within a few months in the majority of patient using clean
intermittent catheterization. Antibiotics prophylaxis simply promotes emergence of antibiotic-
resistance microbes.

MANAGEMENT OF TUBES
TUBES

INTRODUCTION

Tube is a long narrow object similar to a pipe that liquid or gas can move through.

TYPES

1. A Feeding Tube

A feeding tube is a medical device used to provide nutrition to people who cannot obtain
nutrition by mouth, are unable to allow safely, or need nutritional supplementation.

TYPES

 The most common types of tubes include those placed through the nose, including
 Nasogastric (NG) tubes
 Nasoduodenal tube
 Nasojejunal tube
 And those placed directly into the abdomen, such as
 Gastric or gastrostomy tubes
 Gastrojejunal (GJ) or Transjejunal tubes
 Jejunal tubes

INDICATION:

 Less than 50% of necessary nutritional intake received orally for five days

 Coma

 Severe dysphasia

 Low enterocutaneous fistula output

2. Tracheal tube
A tracheal tube is a catheter that is inserted into the trachea for the primary purpose of
establishing and maintaining a patent airway and to ensure the adequate exchange of oxygen and
carbon dioxide.

An endotracheal tube is a specific type of tracheal tube that is nearly always inserted through
the mouth (orotracheal) or nose (nasotracheal).

Age (Inner) diameter (mm)

Preterm 2.5-3.0

0-6 months 3.0-3.5

6-12 months 3.5-4.0

1-3 years 4.0-4.5

4-7 years 5.0-5.5

8-10 years 5.5-6.5

Adult female 7.0-7.5

Adult male 8.0-9.0

A tracheostomy tube is another type of tracheal tube; this 2-3-inch-long (51-76mm) curved
metal or plastic tube may be inserted into a tracheostomy stoma (following a tracheotomy) to
maintain a patent lumen.

INDICATIONS

 Upper airway obstruction

  Congenital: laryngeal cysts, B/L (Bilateral lower) choanal atresis, tracheoesophageal
fistula, Craniofacial anomalies.
 Infective: Acute epiglottitis
 Removal of secretions and protection of tracheobronchial tree from aspiration
 Respiratory failure
 Prolonged ventilation
 Head and neck surgery
 A tracheal button is a rigid plastic cannula
 A tracheal button is a rigid plastic cannula about 1 inch in length that can be placed into
the tracheostomy after removal of a tracheostomy tube to maintain patency of the lumen.

3. Chest tube

A chest tube (chest drain, thoracic catheter, tube thoracotomy, or intercostal drain) is a flexible
plastic tube that is inserted through the chest wall and into the pleural space or mediastinum. It is
used to remove air (pneumothorax), fluid, pleural effusion, blood, chyle), or pus (empyema)
from the intrathoracic space. It is also known as a Bülau drain or an intercostal catheter.

COMPLICATIONS OF TUBES

 Wound dehiscence
 Infection
 Leakage
 Aspiration
 Bleeding
 Accidental tube removal
 Tube blockage
 Tube fracture
 Tube displacement
 Aspiration pneumonia
  Bleeding
 Gastric mucosa overgrowth

CARE AND MANAGEMENT OF TUBES

 All artificial airways will be stabilized.

 The tracheostomy tube will be secured with Velcro trach ties or cloths ties at either side
of the neck except neurosurgery patients. When changing the ties, the tracheostomy tube
must be held in place to prevent extubation.
 The endotracheal tube will be firmly secure by a Hollister.
 For those patients that have an oral airway, repositioning should be done every 4 hours
with routine ventilator checks.
 For neonatal and pediatric patients, tubes will be repositioned as necessary or re-tapping
the endotracheal is required.
 Except the emergencies, generally physician is the only one who changes the
tracheostomy tube until patient firmly teaching begins. At that times a respiratory
therapist may instruct in changing the tube.
 A patient with oral endotracheal tube may have an oral airway or bite block in place that
should be change at least every 24 hours.
 A ventilator, T- tube, or trach collar will provide constant humidification. Corrugated
tubing should be emptied by disconnecting the tubing and draining into an appropriate
receptacle.
 An extra tracheostomy tube of the same size is to be kept at the bedside at all times. In
paediatric area, a tube of the same size and size down is required to be at the bedside at
all times.
 A study of long-term complications associated with enteral ostomy and their
contributory factors

Umesh Jayarajah, Asuramuni M. P. Samarasekara & Dharmabandhu N. Samarasekera

Background

Complications of ostomy significantly affect the quality of life of ostomates. There is little
evidence on the rate of long-term complications in ostomates, especially from the developing
countries which include Sri Lanka. This study was aimed to describe the long-term
complications of enteral ostomies and their contributory factors.

Methods

A retrospective analysis was carried out on 192 patients who underwent ostomy creation over a
period of 5 years. Data on type of complications, age, sex, type of ostomy, type of surgery and
perioperative care by enteric stoma therapist were gathered. Associations were established using
Chi square test and multiple logistic regression.

Results

Out of 192 patients, only 146 patients presented regularly for follow up. The mean follow up
duration was 28 months (range: 3–183). Around 34.2% developed surgical long-term
complications related to the ostomy. Common complications were prolapse (n = 24, 16.4%), skin
excoriation (n = 22, 15.1%) and parastomal hernia (n = 14, 9.6%). Overall complication rate was
significantly less in loop ostomies (p < 0.05) and defunctioning ostomies (p < 0.05). Skin
excoriation was significantly high in males (p < 0.05) and in ileostomies (p < 0.001). Parastomal
hernia was commoner in end ostomies (p < 0.05). Perioperative care by enteric stoma therapist
reduced the overall and specific complications (p < 0.001).
Conclusion

The overall complication rate in our cohort of patients was 34.2%. The perioperative care of a
stoma therapist may be very effective in preventing complications particularly in a setting with
limited resources.
REFERENCE

1) Sister Cecy Correia. Principles and practice of nursing: Senior nursing procedures. 1st
edition. New Delhi: Jaypee brothers medical publishers (P) Ltd. P-145-148
2) Mary Sulakshini Immanuel. Nursing foundation: Principles and practices. 1st edition.
Hydrabad: Universities press (India) private limited. P-547
3) Potter and Perry. Fundamentals of Nursing. 7th edition. New Delhi: Elsevier publication.
P- 1181-1185
4) I Clement. Basic concepts of nursing procedures. 2nd edition. 2nd edition. New Delhi:
Jaypee Brother Medical Publishers. P- 263