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Promoting Outcomes for Patients with Spinal Cord Impairments and Ostomies.

Mr. W., a patient with incomplete C 5-6 quadriplegia, presented on the medical-surgical unit with multiple concerns related to his loop colostomy. His colostomy was constructed 2 years prior due to a large ischial pressure ulcer which became infected with repeated fecal contamination. Like so many patients with temporary colostomies for this purpose, however, he elected to retain the ostomy as opposed to having it "taken down" when the ulcer healed. Mr. W. represents a growing number of persons with spinal cord impairment (SCI) who have ostomies resulting from surgical interventions for elective and nonelective conditions.

Despite the ethical considerations and risks of mortality and morbidity subsequent to surgery, elective ostomies are performed on SCI patients to manage quality-of-life issues as well as medical considerations (see Table 1). Medical indications have become more prevalent in the past 2 decades, as individuals with SCI live longer and are therefore as likely as able-bodied persons to have diversions due to cancer and other conditions.

Table 1. Ostomy Indications for Patients with SCI

Quality-of-Life Considerations

* Time required to perform the bowel care procedure resulting in complete bowel evacuation, a time commitment often exceeding 2 hours 3 to 4 times a week.

* Aesthetics of bowel management.

* Emotional impact of the bowel care routine on the patient's lifestyle.

* Lavatory accessibility in the patient's living facility and community.

* Caregiver availability.

* Interference of urethral catheters in sexually active patients.

* Interference with vocational or avocational endeavors.

Medical Considerations

* Cancer.

* Extensive perineal wound frequently contaminated by feces.

* Inflammatory bowel disease.

* Refractory fecal incontinence.

* Recurrent fecal impaction or chronic constipation.

* Intestinal obstruction.

* Recurrent autonomic dysreflexia.

* Chronic genitourinary problems (for example, urinary tract infection, high intravesical pressure, difficulty voiding).

Review of the Literature

A review of the literature in the area of SCI and ostomies revealed several common recurring themes. In general, authors noted that diversions should be indicated by quality-of-life issues and/or medical reasons. There are numerous pros and cons to the procedures, and diversions are not without complications. Preserving the upper renal tract is imperative. To maximize outcomes, partnering with patients, families, and caregivers is essential, as is collaborating with members of the interdisciplinary team. Patient self-care and independence are optimal goals. In this review, urinary and fecal functioning will be discussed, and several issues related to quality of life are considered. Optimal urinary and fecal functioning is a desirable but difficult goal to achieve for patients with SCI.

Urinary and Fecal Functioning

In a prospective study involving 108 women and 434 men with SCI, Jackson and DeVivo (1992) found the primary method of bladder management for women was an indwelling urethral catheter compared to external condom drainage for men. The authors found that women incurred fewer urologic complications, with the exception of urinary tract infections, than their male counterparts, regardless of what type of bladder management they used. Moreno et al. (1995) reported an improved quality of life and sexuality in three women with SCI who received continent urinary diversions.

Preserving renal function is the paramount goal in managing neurogenic bladders (Stover, Lloyd, Waites, & Jackson, 1989). For urinary diversions, the basic principles of low-pressure urine storage, complete bladder emptying, and avoiding infection must be achieved for patients with SCI (Hollander & Diokno, 1993). Complications incurred from creating incontinent ileo-vesicostomy urinary diversions in 23 SCI patients to gain a low-pressure bladder included stenosis in three patients and poor drainage requiring revision in two patients (Schwartz, Kennelly, McGuire, & Faerber, 1993). Razi and Bennett (1996) highlighted the importance of a thorough pre-operative evaluation and patient history prior to selecting the appropriate urinary reconstruction procedure.

The National Institute on Disability and Rehabilitation Research Consensus Statement (1993) related that bacteriuria is expected with indwelling catheters, and more than half of SCI patients with urinary tract diversions have bacteriuria. However, only symptomatic patients should be treated.

For SCI patients who use a colostomy as an alternative to bowel management, studies have defined the indications for such an intervention. Saltzstein and Romano (1990) surveyed 341 patients with SCI and colostomies to determine self-care needs, quality of life, and other factors. The authors found that when colostomy was performed, self-care improved with shortened routines and a decreased incidence of pressure ulcers (Saltzstein & Romano, 1990). In a study of 20 SCI patients receiving colostomies, bowel care time decreased from an average of 98.6 min/day to 17.8 min/day after colostomy (Stone, Wolfe, Nino-Murcia, & Perkash, 1990).

Decter and Bauer (1993) related that the general principals of urologic management in children with SCI do not vary greatly from adults with SCI. In some cases, compliance with urologic routines may be improved with children as the parents are frequently the primary caregivers. According to the authors, parents and children often consider social acceptability of continence as the goal of a management program, whereas the health care provider perceives avoidance of upper urinary tract deterioration as the key driver.

SCI Bowel and Bladder Function

Initial assessment of a patient with SCI should always include a thorough history of the person's bowel and bladder management program. Considerations should include frequency of intervention, complications, sizes/types of urinary and fecal devices, medications, activity, and other factors. Generally, persons with upper motor neuron (UMN) cord lesions (L-3 and above) have spastic bowel and bladder function, whereas persons with lower motor neuron (LMN) cord lesions distal to this have flaccid bowel and bladder function. Sometimes, however, there may be persons who have mixed UMN and LMN clinical presentations.

In UMN impairment, the injury is above the conus medullaris and the reflex defecation center is intact. Due to interruption of the neural impulses to the brain, patients sustaining UMN injuries do not perceive an urge to defecate and there is no conscious control of the external sphincter. Reflex activity prevails, however, and spastic contraction of sphincters generally control stool leakage. Persons with UMN impairment and no ostomy typically have bowel care routines every day, every other day, or 3 times a week at a set time. Digital stimulation is frequently done to stimulate reflex activity to promote evacuation in patients with UMN lesions (Zejdlik, 1992). During this procedure, one or two fingers are inserted just past the second anal sphincter and set into a semi-circular motion toward the spine for approximately a minute for every 15 to 20 minutes. By contrast, individuals with LMN bowel function typically have damage below the conus medullaris or sacral nerve roots in the cauda equina (horse's tail). Injuries at this level result in direct damage to the reflex defecation center causing flaccidity. Consequently, there is a loss of anal tone, decreased peristalsis, and loss of sphincter tone which may cause fecal oozing.

The neurogenic bladder has similar implications as the aforementioned neurogenic bowel. Individuals with UMN bladders are usually hyperreflexic, as the SCI occurs above the level of the reflex voiding center in the spinal cord. This results in a loss of sensation to void, bladder spasticity, loss of voluntary control of urethral sphincters, and loss of reflex activity to void when stretch receptors in the detrusor muscle are stimulated. Bladder over distention frequently occurs due to sphincter spasms and difficulty voiding. A sustained high intravesical pressure ([is greater than] 40 cm [H.sub.2]O) can result in vesico-ureteral reflux causing pyelonephritis and renal calculi (Perkash, 1993).

Patients with LMN bladders present similarly to the LMN bowel -- flaccid, not responding to reflexes. Since the reflex voiding center is directly damaged, bladder tone is compromised and there is no sensation of fullness. Over distention is common due to an inability to void.

Assessment

When assessing patients' abilities to care for their ostomies, it should not be assumed that patients cannot change their pouch just because they have quadriplegia. To obtain a more in-depth appreciation of the unique needs and outcomes for persons with SCI, various aspects of assessment will be reviewed.

The extent of functional impairment for patients with SCI is predominantly related to the level of injury, and whether the injury is complete. These two factors have considerable effect on individuals' abilities to perform procedures necessary to achieve independence with their urinary or fecal diversion. Persons who are paraplegic have injuries to the second thoracic segment (T-2) or below, whereas persons who are quadriplegic have injuries to the first thoracic segment (T-1) or above. Neurologic impairment that is complete indicates there is loss of all sensory and motor function below the level of injury; if the injury is incomplete, there is preservation of some sensory and/or motor function.

Thus, it is possible for persons who have neurologically incomplete quadriplegia to manage their ostomy needs better than a person with high paraplegia who is neurologically complete. Patients with other types of spinal cord impairment, such as multiple sclerosis, must also be thoroughly assessed to determine motor and sensation limitations.

Hand dexterity, including both fine and gross motor skills, are of paramount importance if the person with a SCI is a candidate for self-care. Dexterity and strength are required for such tasks as obtaining the supplies/equipment, cutting the appliance, applying adhesives or skin barriers, attaching appliances, applying accessories, cleansing the skin, observing the stoma site, and other functions (see Figures 1 & 2).

[Figures 1-2 ILLUSTRATION OMITTED]

Stoma prolapse must be assessed, particularly if the person has a higher level of injury, as abdominal musculature is more compromised than in a person with a lower level of injury. In a study of 17 patients with SCI, Arun, Ledgerwood, and Lucas (1990) concluded that persons with injuries T-10 and above were more likely to have prolapsed stomas. Patients at this level have impaired neuromuscular function of the lower abdominal quadrants (Arun et al., 1990).

Further considerations must also be recognized by the medical-surgical nurse. For example, muscle relaxants commonly used to treat spasticity may decrease gut motility and result in constipation. Autonomic dysfunction may result in diaphoresis, significantly reducing the adherence of the ostomy appliance to the skin. This dysfunction may also alter vital signs in the person with SCI. Baseline vital signs are highly significant, as a "fever" of a person with SCI/D may be an elevation of one degree from a baseline of 97.2 F, or even lower than the baseline. Excessive flatus, caused by lack of motility and incomplete digestion, must be managed to avoid further respiratory compromise due to bloating.

Autonomic dysfunction can also result in an extremely serious complication in persons with injuries T-6 and above. Termed autonomic dysreflexia, this hyperreflexic state is caused by stimulation of the sympathetic nervous system in the thoracolumbar area where the autonomic nervous system outflow tracts are located. The individual may have signs/symptoms of an extremely high blood pressure (pressures [is greater than] 40 mmHg above baseline are significant), severe pounding headache, diaphoresis, nasal stuffiness, bradycardia, and apprehension. This emergent condition is usually caused by urinary stimulation, but may be precipitated by stimuli related to the bowels, or noxious stimuli (for example, ingrown toenail and instrumentation in the abdominoplevic area). Treatment is directed towards removing the source of stimulation (for example, catheterizing the continent urinary pouch and intervening in intestinal blockage with ileostomy). Medications such as nifedipine (10 mg bite and swallow), or 2% nitroglycerin ointment (1" applied above the level of injury) may be used if the high blood pressure is refractory to conservative management (Consortium for Spinal Cord Medicine, 1997).

Routine bowel or urinary diversion irrigation should be evaluated for need and the patient's or caregiver's ability to perform the procedure. Serious consideration should be given to the possibility of undetected perforations when irrigating the insensate bowel or urinary diversion.

Plan of Care

Outcomes and interventions unique to the person with SCI have been identified (see Table 2). Young and McRae (1991) described a comprehensive teaching program for a person with quadriplegia related to self-catheterization of a continent diversion. The plan involved medical evaluation, nursing evaluation and preoperative teaching, occupational therapy assessment of upper extremity function and adaptive equipment needs, preoperative equipment training, collaborative stoma site identification, and postoperative teaching (Young & McRae, 1991).

Table 2. Unique Aspects of Persons with Spinal Cord Impairment and Ostomy
PATIENT OUTCOME                   INTERVENTION

Pre-Operative Management

Bowel cleansed pre-operatively.   Initiate bowel cleansing routine
                                   2 to 3 days prior to surgery.

Optimal stoma site.               Consult wound, ostomy, continence
                                  nurse (ET) to mark stoma site
                                  higher than usual, if the patient
                                  is in a wheelchair, to compensate
                                  for a protuberant abdomen due to
                                  poor abdominal muscle control.
                                  Avoid lap tray levels, braces,
                                  belts, etc. over stoma. Wear
                                  adaptive clothing (for example,
                                  zipper, instead of buttons).

Appliance Management

Stoma visualized when patient     Use an adjustable mirror that
is quadriplegic with a            can be positioned on a table
cervical fusion resulting in      or other stable surface.
limited neck motion,              Stoma should be visualized
                                  with the patient in a
                                  wheelchair, with clothes on.

Decreased need for cutting        Use pre-cut appliances, if
an appliance if compromised       indicated. Obtain a sized mold
dexterity,                        cutter. Cut ahead of time.

Pouch drainage for patients       Provide a drainage receptacle
with impaired hand function.      with a large graspable handle
                                  if patient is unable to use
                                  the toilet. Use a drainable pouch
                                  longer than usual (for example,
                                  16") as this may be easier to
                                  drain.

Appliance wafer intact.           Consider wafer options due to
                                  dissolvability if body
                                  temperature is excessively
                                  warm/diaphoretic. Consider
                                  medication to control diaphoresis.
                                  Use adhesives, belts, waterproof
                                  tape, and other supplies
                                  to enhance wearability.

Complication Prevention

Urinary tract infection free.     Obtain a return demonstration
                                  by the patient/caregiver in
                                  the catheterization of continent
                                  diversions, pouch irrigations,
                                  and other procedures
                                  to confirm good technique.
                                  Increase fluids to dilute urine.

Detection of leakage/             Select a stoma site with
skin impairment with decreased    cutaneous sensation, if possible.
visualization.                    Using a mirror, observe
                                  peri-stomal skin to determine
                                  if leakage is present.

Absence of prolapse.              Mark site in abdominal wall
                                  muscle.

Control/evacuation of flatus.     Use a gas filter or two-piece
                                  so flatus may be evacuated.
                                  Use odor controllers.

Absence of skin dermatitis.       Consider pouch cover to avoid
                                  effects of plastic on
                                  diaphoretic skin.

Absence of intestinal             Consider continuing stool
blockage.                         softeners and laxatives post-
                                  operatively. Instruct in dietary
                                  restrictions (for example, corn).
                                  Perform abdominal massage
                                  and increase the patient's
                                  activity level.

No mucous build-up in             Perform bowel care of lower
distal colon.                     tract 3to 4times a year to
                                  evacuate mucus in distal segment
                                  due to spastic colon.

Spasms managed.                   Consider antispasmotic
                                  medications to manage spasms
                                  that may affect appliance
                                  adherence, stoma positioning,
                                  and dexterity. Increase dietary
                                  fiber as these medications
                                  may result in constipation.

Low pressure urinary              Encourage the patient to have
evacuation.                       periodic urodynamic studies
                                  to evaluate adequate bladder
                                  emptying. Lower bladder
                                  pressure to avoid vesico-ureteral
                                  reflux and autonomic
                                  dysreflexia.

Psychosocial Management

Positive body image               Select low-profile appliance
with ostomy, compounded with      and loose clothing. Review
disability,                       means of managing accidents
                                  with functional limitations.

Sexuality expressed in            Explore sexual expression
context of individuality and      options.
disability.

Travel with confidence.           Increase supply inventory,
                                  as needed, and place in carry-on
                                  bag with medications.


Peer counseling is frequently helpful to promote outcomes related to ostomy acceptance and management. Instead of having an able-bodied person perform peer counseling, an ostomate with a similar disability should visit the person pre and postoperatively (for example, an ostomate with quadriplegia).

If the SCI patient cannot independently perform his/her ostomy management, the availability of a competent caregiver is of extreme importance. The caregiver should have hands-on training, and the person with an SCI should be able to verbally direct him/her in ostomy management. The interdisciplinary team plays an integral part in planning, implementing, and evaluating the care plan. In addition to the usual cadre of the nurse, physician, and social worker, other disciplines are essential to illicit input and intervene. For example, the occupational therapist identifies adaptive equipment to visualize the stoma, facilitate appliance application, drain pouches/leg bags, etc. The psychologist may consult with the team, patient, and family regarding quality-of-life issues and body image. A pharmacist, knowledgeable of antispasmodics and other medications frequently used by the person with SCI, may review the need for stool softeners, laxatives, and other pharmaceuticals. Comprehensive discharge planning and followup in the community setting are essential components of the health care equation.

Conclusions

Based upon a thorough history and assessment, the medical-surgical nurse can optimize the patient's and caregiver's knowledge and skill to achieve positive ostomy management and self-perception outcomes. If conservative alternatives to quality-of-life issues and medication indications have been thoroughly explored, and the person with a SCI does have a urinary or fecal diversion, the nurse should feel confident that the plan of care is individualized. By considering assessment parameters, the interdisciplinary team can modify interventions as necessary to attain desired outcomes and enhance a positive body image. The patient and caregiver can partner with the interdisciplinary team to turn "disability" into "possibilities" for successful ostomy management."

References

Arun, H., Ledgerwood, A., & Lucas, C.E. (1990). Ostomy prolapse in paraplegic patients: Etiology, prevention, and treatment. Journal of the American Paraplegia Society, 13, 7-9.

Consortium for Spinal Cord Medicine. (1997). Acute management of autonomic dysreflexia: Adults with spinal cord injury presenting to health-care facilities. Washington, DC: Paralyzed Veterans of America.

Decter, R.M., & Bauer, S.B. (1993). Urologic management of spinal cord injury in children. Urologic Clinics of North America, 20, 475-483.

Hollander, J.B., & Diokno, A.C. (1993). Urinary diversion and reconstruction in the patient with spinal cord injury. Urologic Clinics of North America, 20, 465-74.

Jackson, A.B., & DeVivo, M. (1992). Urological long-term follow-up in women with spinal cord injuries. Archives of Physical Medicine and Rehabilitation, 17, 1029-1035.

Moreno, J.G., Chancellor, M.B., Karasick, S., King, S., Abdill, C.K., & Rivas, D.A. (1995). Improved quality of life and sexuality with continent urinary diversion in quadriplegic women with umbilical stoma. Archives of Physical Medicine and Rehabilitation, 76, 758-762.

National Institute on Disability and Rehabilitation Research Consensus Statement. (1993). The prevention and management of urinary tract infections among people with spinal cord injuries (January 27-29, 1992). SCI Nursing, 10, 49-59.

Perkash, I. (1993). Long-term urologic management of the patient with spinal cord injury. Urologic Clinics of North America, 20, 423-434.

Razi, S.S., & Bennett, C.J. (1996). Selection the appropriate urinary diversion procedure in the spinal cord injured: A poignant reminder. The Journal of Spinal Cord Medicine, 19, 197-200.

Saltzstein, R.J., & Romano, J. (1990). The efficacy of colostomy as a bowel management alternative in selected spinal cord injury patients. Journal of the American Paraplegia Society, 13, 9-13.

Schwartz, S.T., Kennelly, M.J., McGuire, E.J., & Faerber, G.J. (1993). Incontinent ileo-vasicostomy urinary diversion in the treatment of lower urinary tract dysfunction. The Journal of Urology, 152, 99-102.

Stone, J.M., Wolfe, V.A., Nino-Murcia, M., & Perkash, I. (1990). Colostomy as treatment for complications of spinal cord injury. Archives of Physical Medicine & Rehabilitation, 71, 514-518.

Stover, S.L., Lloyd, K., Waites, K.B., & Jackson, A.B. (1989). Urinary tract infection in spinal cord injury. Archives of Physical Medicine and Rehabilitation, 70, 47-54.

Young, M.N., & McRae, K.R. (1991). Self-catheterization of continent diversions for patients with quadriplegia. Progressions, 3, 3-12.

Zejdlik, C.P. (Ed.). (1992). Management of spinal cord injury (2nd ed.). Boston: Jones and Bartlett Publishers.

Susan S. Thomason, MN, RN, CS, CETN, is Coordinator, Spinal Cord Injury/Disorders Outpatient Center, James A. Haley Veterans' Hospital, Tampa, FL.
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Date:Apr 1, 2000
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