Ileal Conduit: Low Output, Denuded Skin, Rising Creatinine
Ms. L., 58, had a radical cystectomy with ileal conduit 12 days ago. She presents to the clinic with a 2-day history of dizziness, decreased urine in the pouch, and poor appetite. Her stoma is pink and moist but the skin at the 3 o'clock position is denuded and painful; she has been using a convex two-piece system with a barrier ring since discharge. Pouch output today is 350 mL since 07:00 (it is now 15:00), and yesterday's total was 1.9 L. She reports nausea and drinking about 500 mL of tea daily. BP 102/64 sitting, 88/58 standing, HR 108, temperature 37.4°C, mucous membranes dry. Creatinine is 1.7 mg/dL (discharge 0.9), potassium 5.6 mmol/L, sodium 132. Stoma is 28 mm; the wafer opening she cut is 35 mm.
1. What are the priority nursing assessments and likely causes of her presentation?
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The priority is volume depletion with prerenal acute kidney injury and electrolyte disturbance. Her stoma output yesterday was 1.9 L, but today's output is only 350 mL by mid-afternoon and intake is about 500 mL of tea, so she is behind on fluids. Orthostatic hypotension, tachycardia, dry mucous membranes, nausea, rising creatinine, hyperkalemia, and hyponatremia all support dehydration. Assess mental status, weight trend, stoma color and moisture, pouch volume and frequency, urine color, skin turgor, and whether the stoma is swollen or the pouch is leaking. Consider obstruction or ileus if output remains low despite intake, but the prior high output and poor intake make hypovolemia most likely. Notify the provider for IV fluids, electrolyte management, and possible admission. Avoid nephrotoxic drugs and do not give potassium.
2. What stoma and pouching changes do you recommend and why?
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Measure the stoma, which is 28 mm, and cut the wafer to 28–30 mm, not 35 mm; the current opening is too large and exposes skin to effluent. The denuded area at 3 o'clock is likely leakage damage. Convexity may be appropriate for a flush stoma, but the skin is already broken, so use a soft convex or flat barrier with a cohesive ring and skin protectant, and reassess for tension or ischemia. Change the pouch less frequently only if it seals; avoid alcohol-based products on denuded skin. Consult wound, ostomy, and continence nursing. Document stoma size, skin description, pouching system, and patient response.
3. What self-care education is essential before discharge?
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Teach her to drink 2–3 L of fluid daily unless restricted, sipping small amounts between meals, and to avoid caffeine and alcohol. Explain signs of dehydration-dizziness, dark urine, decreased output, headache-and when to call. Teach pouch emptying, measuring the stoma, and correct wafer sizing. Review a low-fiber progression only if advised, and avoid nephrotoxins such as NSAIDs. Emphasize that ileal conduit urine contains mucus normally. Provide written instructions and a follow-up call within 48 hours. Include family in teaching because she lives alone.