One of the nurses’ key role in clinical settings is to provide services addressing patients’ needs especially in conditions where patients are undergoing any form of surgical process for the first time. These services range from providing psychological and educational aid to addressing the physical needs of patients before and after they undergo any form of surgery. These services are necessary since most patients are usually unprepared when faced with specific conditions that require a surgical process to either remove or modify a specific part of their body. Nurses play one of the key parts during the entire surgical period as they provide transitional services before and after the surgical process. This eases the treatment process and helps in the quick recovery of patients. Total cystectomy, the complete removal of the urinary bladder as well as its associated organs such as the urethra, vas deferens, prostate, and vesicles, is an example of a surgical process requiring adequate care before and after the operation (Herdiman et al., 2013; Kim et al., 2013). Once total cystectomy is carried out, another surgical process referred to urinary diversion has to be implemented to ensure the normal resumption of body processes. Various forms of urinary diversion are available, which ensures that the functions of the bladder within the body are delegated to specific organs of the body. Nursing care is necessary in such cases to deal with the misunderstanding, myths, and misconceptions surrounding such conditions (Daneshmand and Ashley, 2015). Most patients who face such condition may not have adequate information on how to cope with the condition and may be susceptible to increased depression or be stressed because of their new conditions. Nursing care in patients who undergo total cystectomy and ileal conduit urinary diversion should incorporate psychological, educational and physical help provided to the patient during and before the surgical process.
Types of Urinary Diversions
There exist three types of urinary diversions that could be used to substitute the excised bladder. The methods include the non-continent urinary diversion, continent non-orthotopic diversion and the continent orthotopic urinary diversion (Thüroff et al., 2012). The first kind involves the use of an external ostomy bag that is used to collect urine. Continent non-orthotopic diversion involves the creation of a mechanism that ensures catheterization of an intestinal pouch while the last method involves the construction of a neo-bladder that allows the release of urine. An ileal conduit is an example of a continent orthotopic urinary diversion. The specific type of the chosen urinary diversion technique depends on a number of variables including age of patient, obesity levels, state of renal function as well as willingness of an individual to learn how to use the new structure within the body (Thüroff et al., 2012; Raynor et al., 2013; Daneshmand and Ashley, 2015). The ileal conduit is considered one of the oldest and the best standard methods of urinary diversion. It is one of the easiest methods, which is most preferred by the older population. It involves dissecting the bladder and anastomosing it to form a totally new conduit. The ileal conduit is then brought forward to the abdominal wall. After that, a bag designed to collect urine is made from one of the parts that have been anatomized before placing two ureters in the different stomas (Ardelt et al., 2012; Torrey et al., 2012; Raynor et al., 2013). The ureters are placed to prevent any form of occlusion. Nonetheless, patients diagnosed with specific conditions such as bowel diseases and colon cancer are not eligible for using the abovementioned urinary diversion method. The method is also associated with a number of issues including urinary leakage, renal calculi, small bowel obstruction, wound infection, gangrene as well as delayed complications including renal deterioration, which is caused by the increased chronic influx of urine and pyelonephritis.
Psychological, Educational, and Physical Needs of Patients
The satisfaction of patients’ psychological needs will play a key role in the recovery process as well as the manner in which the patients perceive themselves before and after radical cystectomy is carried out. Patients with ileal conduit are more likely to have different concerns including continuous inconstancies of urine, sexual concerns, and altered body image. All of these factors may affect the way in which individuals perceive themselves in the outside environment, and if not adequately controlled and assessed, they increase the possibility of an individual being diagnosed with depression after the surgery has been carried (Gilbert et al., 2013; Silberstein et al., 2013). Positive body images are known to enhance any form of psychological adjustments including such aspects as self-worth, decrease in the manifestation of depression and interpersonal anxiety. Nurses should encourage the patient to express their fears, worries, potential embarrassment and disgust regarding the surgery due to the upcoming ostomy (Yang et al., 2013; Daneshmand, 2015; Kabei et al., 2015). After that, all these fears should be consequently addressed and managed in a calm atmosphere. Myths and misconceptions that arise from the information provided by the patient should be demystified. Such aspects as increased consumption of food that would change the shape of the ostomy and wearing of specific clothes to accommodate for the pouching should be dispelled. When most of these fears are adequately addressed, there is a huge probability that the patients will cope with all changes they face. The nurse can go a step further and invite an individual who successfully underwent the same operation to communicate with the patient, so that one copes with all possible fears associated with this condition and boosts one’s confidence.
Patient education on how to use the bladder is supposed to begin before the surgery is initiated and restarted immediately after the surgery is finished. The education component should not be limited by the patient alone; it should also involve the family members and other providers who are close to the patient. The patient should be taught how the orthotopic bladder would function after the surgery as compared to the normal bladder. Some key aspects that the nurse will be required to teach the patient include micturition and increased pressure associated with abdominal straining as well as pelvic relaxation (Pu et al., 2013; Zabell et al., 2015). Prior to the surgery, the patient should be informed about the postoperative tubes and drains that are more likely to be placed during the surgery as well as the need to perform self-care for the stoma, controlling drainage and odor. All this information should be provided in the simplest language that the patient is more likely to understand without any difficulty. Pre-operative teaching enhances the reinforcement and application of specific taught techniques in the post-operative period. Other important elements to be taught before the surgery include such aspects as the identification of the stoma sites and avoiding folding of the skin and bones in the regions that are more likely to be affected by the surgery (Pu et al., 2013; Lee et al., 2014; Al Hussein Al Awamlh et al., 2015; Zabell et al., 2015; Siddiqui and Izawa, 2016). In addition, the nurse should show the scar tissue area to the patient. The specific point where the stoma should be placed should be identified based on the patient’s style of clothing and occupation. Care should be taken to ensure that the stoma is placed in areas that are far away from any form of irritation and are accessible for the manipulations (YANG et al., 2013; Lee et al., 2014; Singh et al., 2014). The patient should be able to identify the stoma without any difficulty. The patient should be also shown how to cover and disguise the collecting device with the required seal and how to prevent any form of leakage. The patient should also be taught how to clean and maintain the site to reduce instances of infection caused by microorganisms.
The nurse should carry out bowel preparation activities that prevent fecal contamination with the suggested site. The nurse should also decompress the bowel during the surgical process. Immediately after the successful completion of the surgery, the nurse should ensure that the medical staff monitors the condition of the patient during the first hours after the surgery. The nurse should also monitor the release of urine after every four hours and report to the physician in case the amount of urine is be less than 30 ml for the entire four hours (Daneshmand, 2015). The recommended amount of urine for an individual who is recovering is 30 ml per hour (Hautmann et al., 2013; Silberstein et al., 2013; Daneshmand, 2015). The nurse should also timely detect specific conditions such as tissue edema and bleeding that may interfere with the drains, stoma, and catheters placed in different regions. The color and consistency of urine should also be assessed. Pink or green urine should attract the nurse’s attention. Red urine may be indicative of bleeding. The mucus produced during the preceding phase should also be keenly checked to ensure it does not block various sites. Other critical aspects that the nurse should pay attention to include the serum electrolyte values, the size, color and condition of the stoma as well as the condition of the ileal catheter (Thüroff et al., 2012). All these processes are supposed to be carried out during the entire period when the patient is in the clinical setting.
Once anatomic integrity is ensured and the patient has proven to the nurses that one can adequately manage their condition without any help from the supportive staff, then it is possible to discharge the patient. This normally happens in three to four weeks after the post-operative surgery (Daneshmand and Ashley, 2015). This way the patient can become self-sufficient and apply the taught practices. However, the nurse should regularly check on the patient to ensure the integrity of the stoma as well as the integrity of the reservoir.
Patients undergoing total or radical cystectomy and, finally, urinary diversion are exposed to a number of psychological and physical issues that are new to them. The nurse should address all major educational, psychological and physical aspects, assisting the patient to recover fully. The presence of the nurse during the entire process reduces fear and facilitates the patient’s recovery.
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