Bladder Managment for Adults with Spinal Cord Injury - 41

CLINICAL PRACTICE GUIDELINE

Prolonged ileus (more common in SCI). Intestinal or urinary leak. Sepsis and wound infection. Ureteroileal stricture. Stomal stenosis. Parastomal hernia. Intestinal obstruction due to adhesions. Urinary infection and stone disease.
(Scientific evidence–III; Grade of recommendation–C; Strength of panel opinion–Strong)

Assistance required. Preferably, individuals should be independent in their care; otherwise a knowledgeable caregiver needs to be available to assist with emptying the collection bag, changing the appliance every 5–7 days, cleaning the stoma, and assessing skin integrity at the stoma site and surrounding area. Some individuals may feel overwhelmed after the surgery and need the assistance of health-care providers and family members until they can gradually assume their own care. Cosmesis. Individuals who experience a change in self-image because they can no longer toilet normally will need an opportunity to verbalize their feelings and may need additional time to adjust, both physically and mentally. Most will not have to sacrifice stylish clothing to accommodate the urine collection device, though constricting clothing should be avoided. Interference with social/sexual function. After the normal postoperative period and upon the physician’s advisement, sexual activities may be resumed. Any limitations will be dictated by the individual and not by the procedure itself. If desired, appliance covers can may be made or purchased. Consultation with a mental health professional may help to alleviate any lingering fears about the procedure or about changes in the perceptions of others. Reversibility. It is possible but not probable to reverse this procedure if the bladder is intact.
Adapted from Joseph, A.C., A. Hixon, J. Giroux, D. Briggs, M. Gardenhire, D. Diaz, and J. Wells. Nursing clinical practice guideline: neurogenic bladder management. Spinal Cord Injury Nursing 15 (2) (1998): 21–56.

Rationale: All of these complications are well recognized with major intestinal surgery and with ileal conduit urinary diversion. Individuals with SCI are more prone to prolonged ileus and are often slower to recover than able-bodied individuals (Creasey and Dahlberg, 2001).

Nursing Considerations for Urinary Diversion
The success of this bladder management option hinges on both objective and subjective assessments of the individual’s ability to alter his or her care. Individuals who can accept the necessary lifestyle changes are able to successfully adapt to the storage of urine in an external appliance and to changes in body image. Preoperative. The focus is on preparing the individual and his or her family to accommodate changes in lifestyle. Perioperative. Prior to surgery, the individual will receive bowel cleansing, antibiotics, a lowresidue diet, adequate hydration, and confirmation of the site (if applicable), as determined by the surgeon and by institution procedure and policy. If the individual will have a stoma, a wound and continence therapist or other qualified health-care provider will mark the site, the location of which will depend on body physique (bony prominences or skin creases), old abdominal scars, hand function, and usual beltline of clothing. The individual will be evaluated both lying down and sitting up in a chair; self-care is easier if the individual can see the stoma. Postoperative. The focus is on maintenance of homeostasis through adequate hydration and fluid elimination.

Cutaneous Ileovesicostomy
Cutaneous ileovesicostomy is a variant of urinary diversion in which a segment of ileum is connected to the bladder and then brought to the lower abdominal wall. Externally, it is similar to ileal conduit diversion. Rather than dividing the ureters and connecting them to the ileal segment, the ileal segment is connected to the bladder. This method has the advantage of leaving the ureterovesical juncture intact and providing low pressure egress of urine to an external collector. 1. Consider cutaneous ileovesicostomy for individuals who require urinary diversion with normal ureterovesical junctions.

Bladder Managment for Adults with Spinal Cord Injury

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