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Urinary diversions.

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Bladder cancer is now the fifth most common malignancy and the second most prevalent genitourinary malignancy. It occurs more frequently in men ages 50-70, and has a four times greater incidence in smokers. Other risk factors include work in industries that use dyes and aromatic amines (e.g., photography, health care, painters, track drivers) as well as a history of radiation to the pelvic area. Approximately 55,000 cases of bladder cancer occur each year, resulting in 13,400 deaths. Treatment depends upon the size and type of tumor, and ranges from intravesical chemotherapy to partial or total cystectomy (Russell, 2009). Radical/total cystectomy with urinary diversion is considered the optimal treatment of muscleinvasive bladder cancer (Overstreet & Sims, 2006).

Following bladder removal, another location for urine storage and excretion must be provided. The choice of urinary diversion procedure depends on many factors, including previous radiation, the stage of the cancer, other cancers, and patient age, dexterity, and preference. Of the three options for urinary diversion, two are considered continent urinary reservoirs (CURs). The third option requires external diversion of the urine (ileal conduit). The continent diversions are created by detaching sections of intestines and making a sphere-shaped reservoir. The first option is called an orthotopic bladder (neobladder). The pouch is created and attached to the urethra, resulting in urinary elimination through the natural urinary meatus. Catheterization of the neobladder may be required at times but is not always necessary. The second option, a continent internal reservoir (Indiana pouch), is made of sections of the ascending colon and terminal ileum. The ureters are connected to the pouch and a nipple valve, which attaches the pouch to the skin, is formed. Catheterization through the stoma is required for drainage of the reservoir (Russell, 2009). The ileal conduit is an external diversion with a stoma and ostomy pouching similar to a colostomy.

Postoperative care of all patients with urinary diversion involves meticulous care of drains and catheters. Both internal and external urinary diversions usually require nasogastric intubation for the first few days after surgery until bowel function returns. To prevent distention of the newly created CURs and allow for stoma healing in the ileal conduit, ureteral stents are placed and may be left in place for 2-3 weeks postoperatively. These stents may pass through the stoma of the ileal conduit or may come through the abdominal wall in patients with CUR; patients will have catheters into the newly created pouch to allow the internal tissues to heal. The patient with a neobladder will have a traditional indwelling catheter inserted through the urinary meatus into the neobladder. The patient with the Indiana pouch is most likely to have a Malcott drain into the newly created reservoir. Both drains will remain in place after the patient's hospital discharge, until the physician determines the pouch has healed enough for removal. Thorough discharge teaching regarding care, irrigation, and management of drains is necessary to prevent complications (Overstreet & Sims, 2006).

Case Study

John Jones, age 65, is admitted to the medical-surgical unit following total cystectomy with creation of a continent internal reservoir. He is receiving intravenous fluids at 125 cc per hour. He also has an epidural catheter for pain management, a nasogastric tube to low continuous suction, and oxygen at 2 liters per cannula. Vital signs are stable. In addition, he has two Jackson-Pratt (JP) drains to the right and left lower quadrants of his abdomen, ureteral stents draining in his left upper quadrant to a down drain bag, and a Malcott drain to his right upper quadrant that is attached to a down drain bag. Just below his umbilicus, where the stoma was placed, is a capped 12-French rubber catheter.

Questions

1. Prior to surgery, Mr. Jones had seen his primary care provider for an annual examination. Which symptom of bladder cancer experienced by Mr. Jones also is common in 85% of the population?

a. Low back pain

b. Stress incontinence

c. Painless hematuria

d. Bladder spasms

2. Four hours after Mr. Jones's arrival from the PACU, the nurse notes the patient's ureteral stents have drained 80 cc of urine. Both JP drains are draining about 40 cc per hour of reddish yellow fluid. The nurse's most appropriate immediate action would be to

a. continue to monitor the intake and output.

b. notify the surgeon and request a fluid bolus to improve the output.

c. continue the IV fluids at 125 cc/hour.

d. notify the surgeon and prepare to obtain specimens from the JP drains.

3. Postoperative orders include irrigation of the Malcott drain with 50-100 cc of normal saline every 4 hours. While performing the first irrigation, the nurse aspirates a large mucous plug. The nurse should

a. notify the surgeon.

b. chart this as a normal finding.

c. obtain a specimen for culture.

d. change the drainage bag.

4. Mrs. Jones arrives to visit her husband on his second postoperative day. Which of the following statements would indicate the need for further teaching?

a. "I'm so glad to see he will be able to urinate just like before surgery."

b. "I see he won't be allowed to eat for a few days."

c. "I plan to stop my volunteer work for 6 weeks."

d. "I'm having a meeting with the home care agency today."

5. Mrs. Jones will be managing her husband's drains and stoma care until his first postoperative appointment with the doctor. Discharge instructions should include which of the following?

a. Change stoma dressing and cleanse with alcohol every 4-6 hours.

b. Continue drain irrigations only when mucous plugs occur.

c. Drains and catheters can be connected to leg bags during the day.

d. Your ureteral stents will fall out in a week.

Answers with Rationale

1. c--Gross, painless hematuria is the first symptom in 85% of persons with bladder cancer (Russell, 2009).

2. d--An increase in Jackson-Pratt drainage could represent a urine leak and the surgical team should be notified (Overstreet & Sims, 2006).

3. b--Mucous is produced by the sections of intestine that form the pouch (Overstreet & Sims, 2006).

4. a--Continent internal reservoirs have an external stoma and must be catheterized at specified intervals to drain urine (Russell, 2009).

5. a--Daily stoma care is done with mild soap and water unless otherwise instructed (University of Wisconsin, 2010).

ADDITIONAL READINGS

Campbell, B. (2006). Bladder cancer: Revealing news about a hidden threat. Nursing 2006, 36(4), 54-57.

Marchese, K. (2006). Using Peplau's Theory of Interpersonal Relations to guide the education of patients undergoing urinary diversion. Urologic Nursing, 26(5), 363-370.

REFERENCES

Overstreet, D., & Sims, T. (2006). Care of the patient undergoing radical cystectomy with the robotic approach. Urologic Nursing, 26(2), 117-125.

Russell, S. (2009) The renal and urologic systems. In H. Craven (Ed.), Core curriculum for medical-surgical nursing (9th ed.) (pp. 322-323). Pitman, N J: Academy of Medical-Surgical Nursing.

University of Wisconsin School of Medicine and Public Health. (2010). Neobladder continent urinary diversion. Retrieved from http://www.uwhealth.org/healthfacts/B_EXTRANET_HEALTH_IN FORMATION-FlexMemberShow_Public_HFFY_ 1126651118981.html.

Margaret L. Myles, MSN, RN, CMSRN, is a Staff Nurse, MedicalSurgical Unit, Renown Medical Center, Reno, NV; and is a Member of the MSNCB Test Development Committee
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Title Annotation:Preparing for Certification
Author:Myles, Margaret L.
Publication:MedSurg Nursing
Geographic Code:1USA
Date:Mar 1, 2011
Words:1198
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