- Email: [email protected]
Reflections on urinary diversion
M Claire Plourde, RN
Reflections on urinary diversion A patient, Mrs F, who had urinary tract diversion five years ago told me recently that she remembered, on awakening in the recovery room, the first word spoken by the nurse as she turned the bed linen down to check the wound. It was “yuk.” The nurse called to another for help but she was told that the patient was hers and she would have to care for “it” herself. They were not aware that Mrs F could hear them talking, but the patient vividly recalls her feeling of rejection and how repulsive she must be to others.
M Claire Plourde, RN, is head nurse, department of urology, and chairman, inservice education, at the Lahey Clinic Foundation, Boston. A member of the AORN Board of Directors, she is a graduate of S t Elizabeth’s Hospital School of Nursing, Brighton, Mass.
A patient may read much into a facial expression, a n unspoken word, or, in this case, one spoken word. We, in turn, can learn from the wordless language of our patients. Are we truly “listening” to their cries for help in their periods of crises? Since 1950 when Eugene Bricker, MD, perfected the procedure for ileal conduit, thousands of these operations have been performed. The ileal conduit or ileal loop may be necessitated by cancer of the bladder, mechanical obstruction, neurogenic bladder, urinary incontinence, severe interstitial cystitis, or a congenital anomaly such as exstrophy of the bladder. In this technique, the ureters are anastomosed to a n isolated segment of ileum near its proximal end, the distal end having been everted and sutured to the skin (Fig 11.l A urinary appliance is secured over the stoma a t the completion of the operation. Because the operation creates distortion and alteration of body image, the patient’s healthy and realistic self-image is important. How the patient perceives himself before operation has tremendous bearing on his acceptance of the surgical alteration. Schilder defines body image as the mental picture of the body’s appearance.2 This is ever changing with no
AORN Journul, January 1976, V o l 2 3 , N o 1
45
end point to development. He believes that body image is based not merely on experience, memory, and past association, but also on will, attitude, and purpose. Fisher and Cleveland have found that a n individual with a clear definitive body image and firm ego integrity is usually an independent person with well-defined goals and a positive approach to daily l i ~ i n g .Those ~ with poorly delineated body boundaries and
poorly integrated body image tend t o be quiet and less oriented to achievement. The process of developing body image begins early. The idea of the body a s “me” gradually develops during infancy. In utero the fetus begins exploring with hand-to-mouth movements. The newborn continues this process with sucking and feeling. The baby touches and explores his own body, reaches for things around him,
Fig 1. (A) lleostomy site prepared prior to opening abdomen. (B) Ileostomy site need not be conventional. Flank drain routinely
placed. Shortest possible ileal segment formed. (C) Eversion of ileal stoma. The drain site is the surgeon’s preference.
46
AORN Journal, January 1976, Val 23, NO I
M
ultiple concerns regarding the physical aspect of his reservoir are legitimate.
and learns from his environment. From these interactions stem the sense of ego, the beginning of selfawareness, and the development of a unique, multifaceted individual. Throughout his growing phases and experiences, the child is forming opinions about his body concept and degree of body boundary. He is mentally forming a picture of the physical appearance of his body. The degree of body definiteness will vary with his individual age level. The individual’s sense of identity, initiative, and good peer relationships are included in the number of personality variabledemonstrating a positive self-concept which is a part of body image. These self-perceptions are a product of experiences with others and their responses to him. Attitudes, social perceptions, and interactions within his family structure toward his body greatly influence the child. As the child grows physically, body image is continually modified through this integration of multiple perceptions. In body image alteration, emotional, perceptual, and psychosocial reactions are natural. For the patient with a n ileal loop, there is a drastic change in body structure and function. The patient now has a constant reminder of physical change-the ileal pouch on the abdominal wall and the release of urine from a n “abnormal” place. Thus, health team members are faced with
two goals: to help the patient adjust to altered body image and to return him to homeostatis. Nursing care includes a concern for human need and a respect for human dignity. With the innovative technology in today’s operating rooms, the nurse working within this setting must contribute effectively toward continuous and comprehensive patient care. We must maintain that human element of caring. We all need to share the human needs of our patients as well as the nursing needs. The feelings, attitudes, and beliefs of the health team do affect the patient. We need to communicate our concern and our caring, by words, touch, body language, eye contact, or sincere listening. In this manner we can convey our concern, regard, and respect for the turmoil the patient may be undergoing. Establishing rapport with the child or adult prior to the operation begins in the physician’s office and on the nursing unit. Discussion of the details with the patient and his family. should include not only a n explanation of the impending surgery and examination of the appliance, but also what the creation of this new bladder from a piece of ileum will mean to the patient. Such explanation helps prepare the patient to cope with the impending crisis before the event occurs. The amount of inforination that can be assimilated by
AORN Journal, Jariuury 1976, Vol 23, No I
47
T
he patient who needs help with his appliance cannot wait until 7 am tomorrow.
him at this time depends on his level of anxiety. It is necessary to create a climate where the patient feels free to express his fears and ask questions. During the preoperative visit, the nurse can tell the patient what he may expect the morning of the operation. The nurse should try to reduce the patient’s anxiety by answering his questions. This visit can help establish a relationship to enable her to make nursing assessments such as the patient’s response to alteration of body image. The patient’s degree of stress can be eased by discussing with him what will happen immediately before and after surgery. He may be told that upon awakening in the recovery room, he will have a temporary bag over his stoma. With only a surgical spray dressing on his incision, he will be able to see his wound. The multiple concerns regarding the physical aspect of his reservoir for the collection of-urine are legitimate, eg, bulk, odor, burning under the faceplate, a nonadhering faceplate, accidents that dislodge the bag resulting in embarrassing wetness, and fear of faulty equipment, such as a cracked faceplate or belt hook. To ensure correct alignment of the bag and a tight fit, the stoma must be positioned properly to the patient’s body contour. In caring for the stoma, all the skin around the everted bud should be covered with a properly measured face-
48
plate. The skin surface must be dry if using double-faced adhesive discs or a tacky surface if cement is used for sealing the faceplate. Should the bag adhesion be precluded by peristomal dermatitis, in extreme instances it may be necessary to remove the appliance and leave an indwelling catheter in the stoma. During hospital confinement, the skin surrounding the stoma is kept vigorously dry. A standard gooseneck lamp with a 60 watt bulb, 18 inches away from the stoma for 20-minute intervals will help the dermatitis. Sun lamps and ultraviolet lamps should be avoided. I t may be necessary to use an antibiotic or a steroid skin cream, ie, betamethasone valerate, if catheter diversion does not improve the dermatitis in 48 hours. The management and care of the appliance must be explained to the patient in detail to avoid confusion or misunderstanding, even though the many details may be overwhelming for a patient to learn in this time of crises. If possible, it would be advantageous for the patient if the nurse incorporates some of this teaching in the preoperative nursing care plan. Learning under stress is difficult and usually transient. Teaching must be kept in perspective. Instruction should be individual, personal, without audience or distractions, and with protection of the patient’s privacy. The patient must be taught:
AORN Journal, January 1976, V o l 2 3 , No I
the best time to change the appliance (early morning before the patient has taken fluids) to empty the appliance whenever it is full to prevent distention and breakage ” of the seal to use night drainage, which prevents bacterial collection and stagnation of trapped urine to have a t least two complete appliances (Given good care, they will last longer and save time in changing.) to anticipate needs so that the supply of equipment is not depleted to manage any skin irritation that may occur (Leakage can be a problem if the skin surface is not clean and free of moisture when the appliance is changed.) to have a n adequate daily intake of fluids. In renal insufficiency, fluid intake may be high due to the body’s demand. Excluding this problem, forced fluids can be overdone. Dilution may even have an adverse effect on systemic antiseptics, especially antibiotics; particularly on effective urinary excretion levels. While ostomy therapists are available in most hospitals today where ileal loop procedures are performed, the unit nurse must be aware of and alert to the multiple problems confronting these patients, and she must feel secure and a t ease in handling them. The patient who needs help with
his appliance cannot wait until 7 am tomorrow when the stoma1 therapist returns to duty. The nurse should give the patient prompt attention and have compassion for the Patient’s Plight. Remove the appliance, dry the skin thoroughly, and apply a temporary double-faced adhesive appliance. This will usually suffice. Admitting your lack of knowledge (an exercise in humility) will cultivate the patient’s knowledge and desire to aid you in his special gadgetry, serving to reinforce his own ability to learn self-care and eventual independence. The patient’s psychosocial and physiologic needs must be met. He must adjust to the appearance of the stoma, which initially may be repulsive to him. The patient must deal with the loss of a normal body function. The stoma and bag must now be incorporated into his own body image. Patients differ in their mental acceptance and outlook. Some have great difficulty. This has been and can be expressed by severe depression before and after operation, aggressive behavior with each encounter after operation with the health team and extending to family members, or the extreme, in withdrawal from society in a denial or nonacceptance of what is happening to him. The support given to the patient at this time is crucial, and the family’s attitude and acceptance toward the stoma will have a great impact on the patient’s adjustment to his operation. Open discussion, knowledge of ostomy
AORN Journal, January 1976, Vol23, No 1
49
0
nly a few work or play activities are prohibited.
care, and acceptance by relatives and friends of the patient’s altered appearance will aid in self-acceptance. Encouraging the patient to talk and then listening to him may be the major contribution of the nurse. She should also stimulate open discussion between the patient and family members helping to reinforce the realistic goal of his return to society and a productive future. Creating a n environment where the patient may discuss his feelings freely will do much to help alleviate tensions and a sense of inadequacy. The patient’s ability to cope with the overall crisis will be easier with constant support and encouragement. Because every action by the nurse will have major impact on the patient, her sensitivity and creativity can be paramount in helping the patient overcome these threats to his body integrity. The nurse should endeavor to understand how the patient sees himself and his experiences. The major step occurs when the patient acknowledges the change in his body structure and recognizes how these changes will affect his daily pattern of living. In planning nursing care, we must consider the ability of the patient to function as a n integral member of society for the rest of his life. Major problems the patient will face are related to family, work, social and sexual activity. Personal contact with a patient who has previously had urinary diversion can, many times, give a patient additional insight and support. To see another person alive, well, and
50
willing to discuss the adjustment to living can be a stimulant to the patient’s psyche; he is not alone. It affords the patient another opportunity to express openly his own feelings. This support must be continued after the patient is discharged from the hospital. He should be assured someone is available when needed, only a telephone call away, during the adjustment period and until he is in full control of the situation. For example, bleeding may occur around the outer aspect of the stoma if the faceplate overrides the stoma in any way. The patient may initiate this bleeding by not obtaining a “bull’s eye” in the application, or it can occur if the cement has loosened and the disc has changed position. The patient may panic a t the sight of blood if someone is not available to respond to his problem. In talking with his physician, the patient can be reassured, in many instances, that sexual activities need not diminish or change. If impotence is a sequel to the operation, this probability should be discussed with the patient and his sexual partner before the operation. An understanding and supportive partner is invaluable, be the patient male or female. Only a few work or play activities are prohibited. Contact sports, such as football, hockey, rugby, lacrosse, soccer, and perhaps basketball, are not recommended. The patients may participate in tennis, swimming, water skiing, ice skating, cross-country skiing, and horseback riding, to name
AORN Journal, January 1976, Vol23, No 1
only a few. Specific work requirements should be discussed with the physician. Teaching, caring, learning, and sharing are the links between the patient and the health team members. A patient seen in the office for followup studies who has the pungent odor of an ill-cared-for appliance requires firm reinforcement of the importance of good hygiene. Many patients develop their own resources and may, of necessity, institute steps t o correct some situations. One of our patients, a 6-year-old boy, used his ingenuity when the outlet spout dropped down into the “hopper” at school while he was emptying his appliance. He plugged the open end with tissue paper and folded the bag in a n upward position on itself until he returned home. It has been our experience that children who have a urinary diversion before puberty enter adolescence without major psychological problems. Positive reinforcement is a must. The child builds on his previous experiences with his body. If they have been good, he will adapt to the rapid growth and bodily changes that occur in adolescence. It is imperative that each nurse in contact with the child be honest. If a treatment will cause discomfort, the child must be told. His trust and confidence may be lost if he is deceived. Open lines of communication must be maintained for discussion of everyday problems as they arise. If the youngster receives direct responses to his questions in language he can understand, many problems may be averted. Recently, during a family conversation, a 16-year-old sibling asked his mother if his 13-year-old brother (with a urinary diversion) would ever be able to father a child. The patient spoke u p and said he had wondered about that himself. The mother told them that it had been the parents’ understanding at the time of operation
that this should not present any problem, but that she would doublecheck with the physician. After she asked the physician, she was able to reassure the patient and family members. Here, definitive action and response to a logical question was demonstrated. Some years ago, a 5-year-old boy with congenital massive hydronephrosis and megaloureters had reimplantations that failed, necessitating ileal diversion. Today, at 16, he is a n average teenager who is 5’8” tall, swims, plays tennis and basketball, and enjoys trips with his church and school groups. He has accepted the stoma into his total body image. Learning to adapt has been a difficult, personal process. Ego integrity is present today as his personality continues to develop and mature, and his opinion of his body image is realistic. Adapting took time, patience, understanding, family support, and much love. Positive attitudes, support, and knowledgeable interactions of the entire health team with the patient and his family are essential in aiding the rehabilitation and reintegration of the patient’s body image. Notes 1 . J B Dowd, S Shah, “Technique of ureteroileal cutaneous anastomosis (the ileal loop),” Surgical Clinics of North America 45 (June 1965) 741-750. 2. P Schilder, The lmage and Appearance of the Human Body (New York: John Wiley and Sons, 1964) 353. 3. S Fisher, S E Cleveland, Body lmage and Personality (New York: Dover Publications, 1964) 206-229. References Kolb, L C, “Disturbances of body image,” in Handbook of Psychiatry, S Arieti, ed. (New York: Basic Books, 1959) 749-769. Murray, R L, ed. “Symposium on the concept of body image,” Nursing Clinics of North America 7 (December 1972) 593-707. Watson, E J, A M Johnson, “The emotional significant of acquired physical disfigurement in children,” American Journal of Orthopsychiatry 28 (January 1958) 85-97.
AORN Journal, J a n u a r j 1976, V o l 2 3 , N o 1
51
Reflections on urinary diversion A patient, Mrs F, who had urinary tract diversion five years ago told me recently that she remembered, on awakening in the recovery room, the first word spoken by the nurse as she turned the bed linen down to check the wound. It was “yuk.” The nurse called to another for help but she was told that the patient was hers and she would have to care for “it” herself. They were not aware that Mrs F could hear them talking, but the patient vividly recalls her feeling of rejection and how repulsive she must be to others.
M Claire Plourde, RN, is head nurse, department of urology, and chairman, inservice education, at the Lahey Clinic Foundation, Boston. A member of the AORN Board of Directors, she is a graduate of S t Elizabeth’s Hospital School of Nursing, Brighton, Mass.
A patient may read much into a facial expression, a n unspoken word, or, in this case, one spoken word. We, in turn, can learn from the wordless language of our patients. Are we truly “listening” to their cries for help in their periods of crises? Since 1950 when Eugene Bricker, MD, perfected the procedure for ileal conduit, thousands of these operations have been performed. The ileal conduit or ileal loop may be necessitated by cancer of the bladder, mechanical obstruction, neurogenic bladder, urinary incontinence, severe interstitial cystitis, or a congenital anomaly such as exstrophy of the bladder. In this technique, the ureters are anastomosed to a n isolated segment of ileum near its proximal end, the distal end having been everted and sutured to the skin (Fig 11.l A urinary appliance is secured over the stoma a t the completion of the operation. Because the operation creates distortion and alteration of body image, the patient’s healthy and realistic self-image is important. How the patient perceives himself before operation has tremendous bearing on his acceptance of the surgical alteration. Schilder defines body image as the mental picture of the body’s appearance.2 This is ever changing with no
AORN Journul, January 1976, V o l 2 3 , N o 1
45
end point to development. He believes that body image is based not merely on experience, memory, and past association, but also on will, attitude, and purpose. Fisher and Cleveland have found that a n individual with a clear definitive body image and firm ego integrity is usually an independent person with well-defined goals and a positive approach to daily l i ~ i n g .Those ~ with poorly delineated body boundaries and
poorly integrated body image tend t o be quiet and less oriented to achievement. The process of developing body image begins early. The idea of the body a s “me” gradually develops during infancy. In utero the fetus begins exploring with hand-to-mouth movements. The newborn continues this process with sucking and feeling. The baby touches and explores his own body, reaches for things around him,
Fig 1. (A) lleostomy site prepared prior to opening abdomen. (B) Ileostomy site need not be conventional. Flank drain routinely
placed. Shortest possible ileal segment formed. (C) Eversion of ileal stoma. The drain site is the surgeon’s preference.
46
AORN Journal, January 1976, Val 23, NO I
M
ultiple concerns regarding the physical aspect of his reservoir are legitimate.
and learns from his environment. From these interactions stem the sense of ego, the beginning of selfawareness, and the development of a unique, multifaceted individual. Throughout his growing phases and experiences, the child is forming opinions about his body concept and degree of body boundary. He is mentally forming a picture of the physical appearance of his body. The degree of body definiteness will vary with his individual age level. The individual’s sense of identity, initiative, and good peer relationships are included in the number of personality variabledemonstrating a positive self-concept which is a part of body image. These self-perceptions are a product of experiences with others and their responses to him. Attitudes, social perceptions, and interactions within his family structure toward his body greatly influence the child. As the child grows physically, body image is continually modified through this integration of multiple perceptions. In body image alteration, emotional, perceptual, and psychosocial reactions are natural. For the patient with a n ileal loop, there is a drastic change in body structure and function. The patient now has a constant reminder of physical change-the ileal pouch on the abdominal wall and the release of urine from a n “abnormal” place. Thus, health team members are faced with
two goals: to help the patient adjust to altered body image and to return him to homeostatis. Nursing care includes a concern for human need and a respect for human dignity. With the innovative technology in today’s operating rooms, the nurse working within this setting must contribute effectively toward continuous and comprehensive patient care. We must maintain that human element of caring. We all need to share the human needs of our patients as well as the nursing needs. The feelings, attitudes, and beliefs of the health team do affect the patient. We need to communicate our concern and our caring, by words, touch, body language, eye contact, or sincere listening. In this manner we can convey our concern, regard, and respect for the turmoil the patient may be undergoing. Establishing rapport with the child or adult prior to the operation begins in the physician’s office and on the nursing unit. Discussion of the details with the patient and his family. should include not only a n explanation of the impending surgery and examination of the appliance, but also what the creation of this new bladder from a piece of ileum will mean to the patient. Such explanation helps prepare the patient to cope with the impending crisis before the event occurs. The amount of inforination that can be assimilated by
AORN Journal, Jariuury 1976, Vol 23, No I
47
T
he patient who needs help with his appliance cannot wait until 7 am tomorrow.
him at this time depends on his level of anxiety. It is necessary to create a climate where the patient feels free to express his fears and ask questions. During the preoperative visit, the nurse can tell the patient what he may expect the morning of the operation. The nurse should try to reduce the patient’s anxiety by answering his questions. This visit can help establish a relationship to enable her to make nursing assessments such as the patient’s response to alteration of body image. The patient’s degree of stress can be eased by discussing with him what will happen immediately before and after surgery. He may be told that upon awakening in the recovery room, he will have a temporary bag over his stoma. With only a surgical spray dressing on his incision, he will be able to see his wound. The multiple concerns regarding the physical aspect of his reservoir for the collection of-urine are legitimate, eg, bulk, odor, burning under the faceplate, a nonadhering faceplate, accidents that dislodge the bag resulting in embarrassing wetness, and fear of faulty equipment, such as a cracked faceplate or belt hook. To ensure correct alignment of the bag and a tight fit, the stoma must be positioned properly to the patient’s body contour. In caring for the stoma, all the skin around the everted bud should be covered with a properly measured face-
48
plate. The skin surface must be dry if using double-faced adhesive discs or a tacky surface if cement is used for sealing the faceplate. Should the bag adhesion be precluded by peristomal dermatitis, in extreme instances it may be necessary to remove the appliance and leave an indwelling catheter in the stoma. During hospital confinement, the skin surrounding the stoma is kept vigorously dry. A standard gooseneck lamp with a 60 watt bulb, 18 inches away from the stoma for 20-minute intervals will help the dermatitis. Sun lamps and ultraviolet lamps should be avoided. I t may be necessary to use an antibiotic or a steroid skin cream, ie, betamethasone valerate, if catheter diversion does not improve the dermatitis in 48 hours. The management and care of the appliance must be explained to the patient in detail to avoid confusion or misunderstanding, even though the many details may be overwhelming for a patient to learn in this time of crises. If possible, it would be advantageous for the patient if the nurse incorporates some of this teaching in the preoperative nursing care plan. Learning under stress is difficult and usually transient. Teaching must be kept in perspective. Instruction should be individual, personal, without audience or distractions, and with protection of the patient’s privacy. The patient must be taught:
AORN Journal, January 1976, V o l 2 3 , No I
the best time to change the appliance (early morning before the patient has taken fluids) to empty the appliance whenever it is full to prevent distention and breakage ” of the seal to use night drainage, which prevents bacterial collection and stagnation of trapped urine to have a t least two complete appliances (Given good care, they will last longer and save time in changing.) to anticipate needs so that the supply of equipment is not depleted to manage any skin irritation that may occur (Leakage can be a problem if the skin surface is not clean and free of moisture when the appliance is changed.) to have a n adequate daily intake of fluids. In renal insufficiency, fluid intake may be high due to the body’s demand. Excluding this problem, forced fluids can be overdone. Dilution may even have an adverse effect on systemic antiseptics, especially antibiotics; particularly on effective urinary excretion levels. While ostomy therapists are available in most hospitals today where ileal loop procedures are performed, the unit nurse must be aware of and alert to the multiple problems confronting these patients, and she must feel secure and a t ease in handling them. The patient who needs help with
his appliance cannot wait until 7 am tomorrow when the stoma1 therapist returns to duty. The nurse should give the patient prompt attention and have compassion for the Patient’s Plight. Remove the appliance, dry the skin thoroughly, and apply a temporary double-faced adhesive appliance. This will usually suffice. Admitting your lack of knowledge (an exercise in humility) will cultivate the patient’s knowledge and desire to aid you in his special gadgetry, serving to reinforce his own ability to learn self-care and eventual independence. The patient’s psychosocial and physiologic needs must be met. He must adjust to the appearance of the stoma, which initially may be repulsive to him. The patient must deal with the loss of a normal body function. The stoma and bag must now be incorporated into his own body image. Patients differ in their mental acceptance and outlook. Some have great difficulty. This has been and can be expressed by severe depression before and after operation, aggressive behavior with each encounter after operation with the health team and extending to family members, or the extreme, in withdrawal from society in a denial or nonacceptance of what is happening to him. The support given to the patient at this time is crucial, and the family’s attitude and acceptance toward the stoma will have a great impact on the patient’s adjustment to his operation. Open discussion, knowledge of ostomy
AORN Journal, January 1976, Vol23, No 1
49
0
nly a few work or play activities are prohibited.
care, and acceptance by relatives and friends of the patient’s altered appearance will aid in self-acceptance. Encouraging the patient to talk and then listening to him may be the major contribution of the nurse. She should also stimulate open discussion between the patient and family members helping to reinforce the realistic goal of his return to society and a productive future. Creating a n environment where the patient may discuss his feelings freely will do much to help alleviate tensions and a sense of inadequacy. The patient’s ability to cope with the overall crisis will be easier with constant support and encouragement. Because every action by the nurse will have major impact on the patient, her sensitivity and creativity can be paramount in helping the patient overcome these threats to his body integrity. The nurse should endeavor to understand how the patient sees himself and his experiences. The major step occurs when the patient acknowledges the change in his body structure and recognizes how these changes will affect his daily pattern of living. In planning nursing care, we must consider the ability of the patient to function as a n integral member of society for the rest of his life. Major problems the patient will face are related to family, work, social and sexual activity. Personal contact with a patient who has previously had urinary diversion can, many times, give a patient additional insight and support. To see another person alive, well, and
50
willing to discuss the adjustment to living can be a stimulant to the patient’s psyche; he is not alone. It affords the patient another opportunity to express openly his own feelings. This support must be continued after the patient is discharged from the hospital. He should be assured someone is available when needed, only a telephone call away, during the adjustment period and until he is in full control of the situation. For example, bleeding may occur around the outer aspect of the stoma if the faceplate overrides the stoma in any way. The patient may initiate this bleeding by not obtaining a “bull’s eye” in the application, or it can occur if the cement has loosened and the disc has changed position. The patient may panic a t the sight of blood if someone is not available to respond to his problem. In talking with his physician, the patient can be reassured, in many instances, that sexual activities need not diminish or change. If impotence is a sequel to the operation, this probability should be discussed with the patient and his sexual partner before the operation. An understanding and supportive partner is invaluable, be the patient male or female. Only a few work or play activities are prohibited. Contact sports, such as football, hockey, rugby, lacrosse, soccer, and perhaps basketball, are not recommended. The patients may participate in tennis, swimming, water skiing, ice skating, cross-country skiing, and horseback riding, to name
AORN Journal, January 1976, Vol23, No 1
only a few. Specific work requirements should be discussed with the physician. Teaching, caring, learning, and sharing are the links between the patient and the health team members. A patient seen in the office for followup studies who has the pungent odor of an ill-cared-for appliance requires firm reinforcement of the importance of good hygiene. Many patients develop their own resources and may, of necessity, institute steps t o correct some situations. One of our patients, a 6-year-old boy, used his ingenuity when the outlet spout dropped down into the “hopper” at school while he was emptying his appliance. He plugged the open end with tissue paper and folded the bag in a n upward position on itself until he returned home. It has been our experience that children who have a urinary diversion before puberty enter adolescence without major psychological problems. Positive reinforcement is a must. The child builds on his previous experiences with his body. If they have been good, he will adapt to the rapid growth and bodily changes that occur in adolescence. It is imperative that each nurse in contact with the child be honest. If a treatment will cause discomfort, the child must be told. His trust and confidence may be lost if he is deceived. Open lines of communication must be maintained for discussion of everyday problems as they arise. If the youngster receives direct responses to his questions in language he can understand, many problems may be averted. Recently, during a family conversation, a 16-year-old sibling asked his mother if his 13-year-old brother (with a urinary diversion) would ever be able to father a child. The patient spoke u p and said he had wondered about that himself. The mother told them that it had been the parents’ understanding at the time of operation
that this should not present any problem, but that she would doublecheck with the physician. After she asked the physician, she was able to reassure the patient and family members. Here, definitive action and response to a logical question was demonstrated. Some years ago, a 5-year-old boy with congenital massive hydronephrosis and megaloureters had reimplantations that failed, necessitating ileal diversion. Today, at 16, he is a n average teenager who is 5’8” tall, swims, plays tennis and basketball, and enjoys trips with his church and school groups. He has accepted the stoma into his total body image. Learning to adapt has been a difficult, personal process. Ego integrity is present today as his personality continues to develop and mature, and his opinion of his body image is realistic. Adapting took time, patience, understanding, family support, and much love. Positive attitudes, support, and knowledgeable interactions of the entire health team with the patient and his family are essential in aiding the rehabilitation and reintegration of the patient’s body image. Notes 1 . J B Dowd, S Shah, “Technique of ureteroileal cutaneous anastomosis (the ileal loop),” Surgical Clinics of North America 45 (June 1965) 741-750. 2. P Schilder, The lmage and Appearance of the Human Body (New York: John Wiley and Sons, 1964) 353. 3. S Fisher, S E Cleveland, Body lmage and Personality (New York: Dover Publications, 1964) 206-229. References Kolb, L C, “Disturbances of body image,” in Handbook of Psychiatry, S Arieti, ed. (New York: Basic Books, 1959) 749-769. Murray, R L, ed. “Symposium on the concept of body image,” Nursing Clinics of North America 7 (December 1972) 593-707. Watson, E J, A M Johnson, “The emotional significant of acquired physical disfigurement in children,” American Journal of Orthopsychiatry 28 (January 1958) 85-97.
AORN Journal, J a n u a r j 1976, V o l 2 3 , N o 1
51