COLOSTOMY

a. A colostomy is a surgically created, artificial opening (stoma) into the colon through the abdomen. It may be temporary or permanent.
b. A temporary colostomy is normally made for diversion of fecal material. Fecal diversion is utilized in order to rest a portion of the colon following intestinal surgery, in preparation for further surgery, or in cases of severe inflammatory disease (such as diverticulitis).
c. A permanent colostomy serves as an artificial anus for the remainder of the patient's life. This procedure is done in conjunction with the removal of the lower bowel and rectum. Although there is no sphincter muscle control at the stoma, bowel movements may be controlled by a daily routine that encompasses diet, physical activity, and colostomy irrigation’s. Consistency of the bowel movements generally depends upon the location of the colostomy (see figure 1-5), but can be manipulated by the patient's choice of diet.
d. Whether temporary or permanent, a colostomy can be very distressing to the patient. Patients with colostomies require encouragement, understanding, and assistance in overcoming the negative emotions associated with a colostomy, and in learning independence and self-sufficiency in living with a colostomy.
e. Colostomy "training" should begin as soon as possible, with the permission of the physician, after surgery. The ease and skill with which the nursing personnel care for the patient with a colostomy are important in helping the patient physically and emotionally. The patient and his family will learn that a colostomy can be effectively managed to allow a full and active life.
f. There are several different surgical procedures that create different types of colostomies. The procedure used will depend upon the nature of the disease, the desired end result (temporary or permanent), and the physician's preference, among other things. For example:

Figure 1-5. Colostomy sites.

(1) Two stoma openings can be created at the abdominal surface (double barrel). One serves as a temporary artificial anus for the functioning part of the gastrointestinal tract, discharging feces, and flatus. The second opening leads to the nonfunctioning part of the colon and rectum. Mucous or serous secretions are normally discharged from this opening. This opening may also be utilized for irrigation of the resting colon. This procedure would be utilized when the colostomy is temporary. Later surgery would involve closing the stomas with re-anastomosis of the bowel.
(2) A single colostomy may be done at one of the sites illustrated in figure 1-5. The site chosen normally depends upon the portion of the bowel that must be removed. The colostomy site is created at a section of healthy bowel. The bowel distal to the colostomy is removed and the rectum surgically closed.

Isolation nursing (transmission-based precautions)

Specific precautions are required for some patients because their condition (e.g. a bone marrow transplant) puts them at particular risk of infection from others (protective isolation), or because they themselves are a potential source of infection (source isolation). Source isolation is usually only necessary to prevent contact, droplet or airborne transmission of micro-organisms, usually either in respiratory droplets or dust, as in the cases of Mycobacterium tuberculosis and methicillin-resistant Staphylococcus aureus (MRSA). Precautions might involve separating the infected or vulnerable person from other patients by placing them in a single room, and healthcare workers using barriers such as plastic aprons, disposable gloves and masks.
If a single room is used, you should keep the door closed to restrict the spread of infectious micro-organisms. Sometimes it may be more appropriate or the only option to keep infected patients together in one bay, or at one end of the ward. However, overcrowding increases the risk of transmission of airborne pathogens.
Where gross contamination of the environment is likely, for instance in the case of profuse diarrhoea, a single room may be preferable, but the most essential requirement is a separate toilet and wash basin to reduce the risk of transmission via contact with contaminated surfaces.
Healthcare workers must understand the relevance of the routes of transmission to care effectively for patients (e.g. isolating patients with malaria is unnecessary because they cannot transmit the disease to others and standard precautions alone are necessary). However, blood from these patients cannot be used for transfusion because of the risk of infection in the recipient. It is essential that isolating a patient in a single room is undertaken in a systematic and appropriate way following a comprehensive risk assessment, and is regularly reassessed.

A variety of isolation policies are used. Disease-specific isolation precautions have the advantage of eliminating unnecessary practices and can be incorporated into the care plan for the individual patient. However, the disadvantage is that staff need to identify the relevant precautions for each patient. Transmission-based precautions group together diseases requiring similar precautions. The disadvantage of this system is that some precautions may be used unnecessarily for some patients. However, staff need to learn fewer procedures and are therefore less likely to make mistakes.

Notices at the entrance to a patient’s room or by the bed, should indicate any special precautions that are being observed, while maintaining confidentiality. Isolation can be stressful for patients. It is therefore important that you discuss, agree and record the patient’s needs in a care plan. The recommended period of isolation varies for each infection, but usually precautions can cease once symptoms have resolved, or after a short course of antimicrobial therapy.

For detailed information about isolation precautions, refer to the US CDC guideline for isolation precautions in hospitals (1996). Always follow your local policies and seek advice from your local Infection Control Team.
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The safe disposal of sharps

Sharps injury with inoculation of blood and other potentially infectious body fluids is the most common route for transmitting hepatitis B and HIV to healthcare workers.

All work with sharps should be careful, attentive and unhurried. You should take special care when using needles and scalpels, handling sharp instruments, cleaning used instruments and disposing of sharps.

Sharps containers should comply with British Standard 7320, United Nations Standard 3291, or their equivalent. Sharps containers must:
• be puncture-resistant and leakproof, even if they fall over or are dropped
• be capable of being handled and moved whilst in use
• have a handle that is not part of the closure device and does not interfere with the normal use of the container
• have an opening that, in normal use, will inhibit removal of contents but allow disposal of items with one hand, without contaminating the outside of the container
• have a closure device attached for sealing when the container is three-quarters full or ready for disposal
• have a horizontal line to indicate when the container is three-quarters full and be marked with the words “Warning – do not fill above the line”
• be made of material that can be incinerated
• be yellow
• be clearly marked with the words “Danger”, “Contaminated sharps” and “Destroy by incineration” or “To be incinerated”.
Observe the following safety precautions when using and disposing of sharps:
• do not pass sharps directly from hand to hand, keep handling to a minimum
• avoid recapping, bending, breaking or manipulating used needles
• if removal of the needle from the syringe is unavoidable, use a sharps box with a needle-removing facility; or use forceps; or approach the needle carefully along the barrel of the syringe, using a gloved hand. Take extreme care
• discard disposable sharps in an appropriate sharps container (conforming to British Standard 7320, United Nations Standard 3291, or equivalent)
• do not overfill the container
• drop items in carefully; do not push items down.
Locate sharps containers in a safe position, not on the floor. Dispose of containers by the licensed route, according to your local policy. Consider the use of needle safety devices where there are clear indications that they will provide safer systems of working for healthcare workers.
Always follow your local policies.
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Education of patients, carer and healthcare workers

To improve outcomes and reduce healthcare costs, it is essential that everyone involved in providing care in hospitals and the community is educated about standard precautions and trained in hand decontamination, the appropriate use of protective clothing and the safe disposal of sharps. Adequate supplies of liquid soap, alcohol hand rub/gel, towels and sharps containers must be available wherever care is delivered.

NB: Adequate supplies of liquid soap, alcohol hand rub/gel, towels and sharps containers must be available wherever care is delivered.

Standard precautions – Summary
• Apply good basic hygiene practices with regular handwashing.
• Cover existing wounds or skin lesions with waterproof dressings.
• Avoid carrying out invasive procedures if suffering from chronic skin lesions on hands.
• Avoid contamination of clothes by using appropriate personal protective equipment.
• Protect mucous membranes of eyes, mouth and nose from splashes of blood or blood-stained fluids.
• Prevent puncture wounds, cuts and abrasions in the presence of blood or blood-stained body fluids.
• Avoid using sharps wherever possible.
• Use safe handling procedures for handling and disposal of needles and other sharps.
• Use approved procedures for sterilisation and disinfection of instruments and equipment.
• Clear spillages of blood and other body fluids promptly and disinfect contaminated surfaces.
• Institute a procedure for safe disposal of contaminated waste
• Follow statutory requirements for the safe disposal of used and infected linen
• Make sure the environment of patients' is visibly clean and free from dust and dirt.