Mhm.

Yeah.

Three.

Thank you.

Yeah.

Mhm.

Our next speaker really does not need an introduction 

dot Rodriguez.

Co investigator program director chief finished 

chemotherapy.

Department of nursing will present to you 

multiple stomachs and the many problems involved.

Dot okay.

Yeah never 

rest.

How long?

Just read my talk.

There are many reasons why a person may have more than one 

stormer.

Sometimes the multiple stoners are planned as a part of the 

original treatment and sometimes they're unplanned and are 

part of the sick.

Well a that follows the initial surgery.

I'm gonna talk about multiple stomachs and Anderson and give you some 

examples of the reasons why we may have a 

patient with multiple stomachs and 

Anderson.

Some of the patients having the multiple stomach present us 

with the following I think the first and most common when this total 

pelvic exoneration and this may be either from 

invasive cancer of the cervix,

cancel the bow that has invaded the bladder or 

cancer of the bladder that has invaded the bowel.

We also have Children with multiple with 

total public exonerations that have malignant sarcoma,

such as sarcoma by authorities.

A second instance,

maybe a total systemic to me with surgical trauma to the 

rectum requiring a temporary diverting 

colostomy.

A third instance,

maybe a total suspect mirror and your exoneration 

where the patient was radiated pre operatively 

and followed later with bowel obstruction,

necessitating a colostomy.

1/4 instance,

maybe a colostomy with or without a mucus 

fistula.

With radiation is a pre op or post op 

treatment following later by hemorrhagic 

cystitis necessitate or urinary diversion.

1/5 instance,

maybe two separate primary diseases,

either malignant or benign.

We had one patient who came with an Elias to me from 

austin colitis and was referred to us with cancer of the 

bladder and had a urinary diversion.

Another instance,

maybe perforated bowel from invasive 

tumor,

obstruction or pelvic abscesses.

And another instance maybe fistulas develop either 

from either from the disease process.

Or is this a quella from radiation or chemotherapy?

Yeah.

We've talked a little bit about the importance of marking stomach 

stomach sites for individual stomach and it 

really becomes more important when you're talking about two or three 

or even four stomachs,

especially um when you're having a 

small abdomen to allow these thomas if we 

have a total pelvic exoneration patient.

And we're planning this,

we prefer to mark the urinary stoma 

slightly higher and to the right.

This gives us a lead way to wear appliance 

for the urinary clients to have a belt if that's 

needed.

This is our preference.

A few years ago 

urinary stones were put on the bottom,

put on the lower side and not much thought was given to the patient.

We're in the appliance and you can see the problem that this lady had with 

a urinary stone which is on her right and 

very low and retracted.

She wears dressings and she has one friend that she 

visits and when she goes there she takes a plastic sheet 

so she can sit on the furniture.

And I think this is very far from the concept of social 

rehabilitation.

But now we're paying more attention to the person's 

appliances and marking the stoma sites and 

if we do have a preference we will do as a as a previous 

slide showed with the urinary slightly higher to the right.

But even today it's not always possible to put the 

urinary stone on the top.

For example this patient had a total pelvic exoneration.

She was marked with a urinary stomach on the top.

However her medicine terry was not sufficient and links to 

allow the sigmoid conduit to be brought higher up on the 

abdomen.

She's very obese patient had a very thick abdominal 

wall.

And so the surgeons at the time of surgery uh 

did reverse her stoma site selections and put her 

colostomy significantly higher than a urinary.

And we've had no problem with her appliances 

frequently with Children or were small adults.

There's not room to stagger the stone LMA's 

and you can see with this child he was done.

His surgery was done outside of Anderson.

He has uh your reader Rostam ease and a sigmoid 

loops colostomy.

And of course they're on the same level and doesn't give you too much 

room to put appliances with this group of 

people.

We try to put them in appliances that do not 

necessitate belt.

He's still in post op appliances,

pediatric size.

This is another patient whose stomachs are are 

on the same plane.

His colostomy was not planned but was as a result of 

surgical trauma.

And obviously if you put a belt on his face plate on his 

your new face plate it's going to either come right across the 

stomach or else it's gonna slip upward 

and cause a plate to slip.

So with that group of people we do put them in 

appliances and take belts off of them.

Sometimes two stoners are brought out on the same side of the 

abdomen and this can be a problem leaving 

you sufficient room to put two separate 

appliances.

This is one patient who has a urinary 

diversion and then a colostomy above it and then 

a officially in the middle of his lower 

incision.

His three appliances.

He happened to be a big enough man where he could tolerate 

three appliances with two of them being on one side of the abdomen.

You're not always that fortunate to have that much 

room.

Well we do have mucus officials.

We prefer that they be placed away from the functioning 

stoner and not placed as a double barrel.

If they are placed next to the colostomy as a double barrel than 

this necessitates a large appliance around the 

colostomy.

Most of the the mucus fiscal has done and Anderson are 

either put in the opposite quadrant of the abdomen or in the 

lower midline incision or below the 

colostomy stoma.

As this one was done.

This patient didn't need an appliance over his mucous official 

but he didn't need one over his penrose drain site 

for him.

We just put a four by four goals over his mucous fistula.

We do have a large number of patients at Anderson's 

who have a mucus official stoma that 

have to wear appliances.

So attention to that site should not be neglected.

It should be planned as well as the functioning 

colostomy.

If the loop of bowel that's associated with the mucus 

official has been irradiated or if it has 

disease tumor in it.

Or if a fecal or urinary official 

develops into it,

then the drainage will be enough where the person has to wear an 

appliance over that.

So you can almost be talking about a official of draining 

that's similar to a urinary or an Elias.

To me,

this is one way that had his mucous official down in the lower part 

of her midline incision and it's connected 

with radiated about which strains kind of a clear 

liquid substance continuously.

It's almost like a urinary diversion for her.

And in terms of the amount of drainage.

So we did put her in a pediatric 

urinary appliance and she wears it as a permanent 

appliance.

It was quite satisfactory for her.

So I do want to emphasize that if you are planning for a mucus 

officially,

even though you do not anticipate it draining,

you might keep in mind that someday it may start draining 

and you'd like to move it away from the original stone.

Um When caring for multiple 

stomachs,

I think there are several things that are important to keep in mind.

I think one of the most important things is try to keep the drainage 

from eats toma confined to its own area.

If you have a urinary and faecal drainage,

I think you should protect the urinary stone and 

urinary drainage from stool or from fish to a 

drainage.

If you have an incision or an open wound,

then you should uh certainly protect the incision an 

open wound from drainage from the urinary.

The fecal are the fiscal of drainage.

This is one patient who came in had an emergency Elias to 

me in the middle of the night,

she had a perforated barrel and a pelvic abscess.

So she had an Elias to meet a mucus official in 

the lower midline incision and to penrose 

drains for pelvic abscesses.

And of course we did,

keeping appliance on each of these and keep them 

separated from each other.

It is very important that you go from the cleanest area 

and work toward the more contaminated area.

For example,

you would go from the urinary first and then to the colostomy and 

then to the pure land drainage area.

When you're caring for drain sites,

it's important that you use sterile technique to protect the 

patient and also to protect you and other 

patients.

You must remember when you have a penrose drain site,

you have a two way canal for infection going into the 

patient as well as coming out.

And you do need to use sterile technique when you're taking 

care of those.

We do like to keep a separate seal on each appliance as I 

mentioned.

And it can be a problem.

You may have to alter the opening in your appliances if 

geographically you're trying to plan for two appliances 

fitting next to each other.

And I mean by cutting the opening not in the center of the appliance but 

moving it to the edge where you can fit two appliances 

next to each other.

This is the same way three weeks later in the clinic after a 

return visit.

And sometimes it seems like some of my slides 

are so bad.

I'd like to show you that they do get well and And 

not have to wear four bags home and I have this 

next shot.

So what to show what she looked like.

I like to put a few positive points and what I'm talking about 

the complicated patients.

This next patient uh,

was a problem.

She had a descending colostomy with the mucus fischel 

approximately four cm below it.

Now the nice thing that happened to her was she developed a urinary 

fistula into her mucus official and she had 

urine coming out the mucus official.

So it was essentially functioning as a urinary 

diversion.

It was a real problem because of the crevices,

because of the geography of our 

abdomen and because of the location to the,

to the fecal diversion.

We did want to keep the urine and the feces separated.

And there was a time where we thought we may have to encompass them 

into one pouch.

But it was our challenge to keep them separate and 

protect the lady from an infection.

And we did that by using uh cutting the 

openings in the pouch up in the corner of each 

pouch and using a small piece of stone adhesive as 

a kind of a washer.

I don't know if you can tell from that slide,

but we had injected some dye into her bladder and you can see it 

coming out into the pouch and confirmed are 

um suspicion that it was a urinary leak.

And she was able to wear these for three days which we felt was 

satisfactory in view of the the small amount of 

it.

He's a very that we had to hold an appliance on when 

we are working with patients.

And we have like 1/4 of an inch or 

um less than a half an inch.

And he's,

if we use every little trick we can think of.

We had cement to it,

we use stone adhesive.

We may fill in the valleys with pace.

We start adding everything we can think of to make the 

appliance stay on.

I do think you need when you're taking care of 

patients who have two or more stumbles to remember 

to protect the second appliance from the belt.

If a patient is wearing a belt,

don't let it ride over the second the second 

stormer unless you have some protection 

if possible,

you might can get the patient out of a second 

appliance.

For example this lady had an exoneration.

She irrigates her colostomy and is regulated 

so she can get out of her colostomy appliance and 

just where security pouch.

We do try to achieve that goal with our total public 

exonerations because most of them have sigmoid or low 

descending colostomy and we do try to get them out of a 

second plant if that's possible,

it's not always possible.

And we do have to for some of them were security patches 

or even colostomy bags.

But that is a goal that you might want to work with.

I have a case presentation of a lady who at one time had 

five Stomachs and I'll show you some slides in a minute.

But I do want to tell you a little bit about her history.

She was a 53 year old West Texas Housewife and was 

referred to Anderson with a suspicious rectal lesion 

and a vaginal discharge.

She had two married daughters and her husband worked for an oil drilling 

company.

After diagnostic studies and biopsies.

Her diagnosis with was adenocarcinoma of the 

rectum with direct extension to the uterus 

cervix and upper vagina,

and metastatic adenocarcinoma of the right ovary.

An interesting point in this latest history was 28 years 

prior to admission,

she had been treated in Shreveport Louisiana with radium 

implants and external radiation therapy 

for a squamous cell carcinoma of the Cervix.

According to an operative pathology report,

it would be presumptive to include that The prior radiation 

was an ideological factor in the production of the rectal 

carcinoma,

but some of the atypical growth appearance of the tumor 

was related to radiation induced changes in the rectum.

On January 22,

1968,

she had a total pelvic exoneration at Anderson with an illegal 

conduit,

a descending colostomy and a sigmoid lid.

She had an amazingly stormy postoperative period 

On her 10th post opera today,

her sigmoid lid pulled loose a portion of her 

small bowel fell down into her pelvis.

She was taken back to surgery and the bounce pulled back 

to the abdomen and researcher,

the sigmoid lid in place at this time.

Also the right,

Your federal elio conduit anastomosis 

was also researchers as it had partially pulled 

away.

On the 39th Postoperative Day,

she presented with the right you're a troll.

Elio conduit fistula.

She was again taken back to surgery with 

approximately one half of the illegal conduct being resected 

and the ureter is real nest in most of the remaining a little 

loop.

She also developed a bleeding stress ulcer and a 

wound infection.

However,

she did recover and was discharged on March the 

24th the 57th day after her 

admission in good condition with a guarded 

prognosis at home,

this patient gain rate returned to work and enjoy good 

health.

She continued to do well for 5.5 years to 

discredit her guarded prognosis.

However,

on December 11,

1973 she was readmitted with a partial small bowel 

obstruction.

On 14 December,

share an exploratory lap license of 

adhesions and ilia,

ascending colon,

side to side and esteem Asus.

With one half of her small bowel bypassed,

She was maintained on ivy hyper lamentation.

For three weeks.

She had multiple pulmonary emboli,

but she did recover quite well and was discharged in 

January 74.

Again,

she remained in good health until August 5,

74 when she returned leaking stool through the 

Perineum.

This was a small bowel,

paranal fistula.

She was again taken to surgery in the area of the 

small bowel that was communicating with the perineum 

was segmented,

brought out as a mucus fistula and the 

remaining small bowel and asked the most into the ascending 

colon.

She had an ass demotic leakage of stool into the 

abdomen and developed a large abscess and wounded his.

Since We're up to operating 

procedure No six.

Now,

as she was taken back to surgery and Elias to me was 

performed.

It was estimated that should approximately 1/3 of her small 

bowel left retention 

searchers were in place and she was again started on ivy hyper 

lamentation.

Her post operative course was again rocky,

complicated by sepsis and multiple problems with fluid 

electrolyte balance on october though 

she was discharged on flex a cow,

sodium chloride,

sodium bicarbonate and potassium with 

coding and pro ban theme to decrease her stomach and small 

bowel secretions.

However,

she did return in six days with dehydration and fluid 

electrolyte problems and joined us with possible 

hepatitis.

She was submitted and again hyper lamentation was started 

On January the 9th 1975.

She was again returned to surgery to connect her 

Elias to me back into racing and colon.

In an effort to give her a little bit more about so she can maintain her 

nutritional status On January.

The 24th,

her wounded hissed.

She was again returned to the O.

R.

her wounded breeding and close with heavy wire 

searchers under anesthesia.

And this is where we start our slides on this series.

Okay,

You can enter conduit or urinary diversion 

which was from our original exoneration 1968.

We have a catheter into that.

You can see her nonfunctioning small colostomy 

stoma down toward her left.

The largest oma is her functioning Elias to me 

at the end of her incision which is down 

toward your left,

there's a mucus fistula,

her head's over here towards me,

Her urinary diversions on her right,

her head is toward me,

her feet are over there to your left.

If you can get all that perspective.

And her penrose drain is in her lower left hand quadrant.

So if you got all those stuff was identified,

you can see one real problem with her with the retention 

suitors.

This lady is on her eighth operation.

She has been radiated,

she's on hyper lamentation.

An interesting thing that we've noted as many of our hyper 

augmentation patients get this real slick shiny 

skin.

Mr Key told us to dr Copeland,

our chief on hyper lamentation.

And he says that's an interesting observation and that's it.

You know,

it is interesting but it's hard to keep an appliance on that 

slick skin and we really can't account for what it is 

yet.

Anyway,

she had that and not those heavy wires,

futures were draining all the time.

So they were breaking the seal on our appliances.

So we did start her off for the first three days with 

a sump tube into a conduit to drain 

that and kind of get started on some of our appliances.

She had uh if you can imagine you have one third of her 

small bowel left.

She had what you would call an exaggerated short bowel 

syndrome.

So her output was quite high.

We did use um skin barriers um 

the colostomy stoma of course was not functioning,

but it was kind of irritated and a little bit weepy.

And we did put a skin barrier on that just to protect the 

skin,

her Elias to me stomach.

And we would separate our skin barriers from each other and 

also try to keep them from lying over the retention features 

because the retention futures were weeping up under 

him and breaking their seal.

And then eventually did put her urinary bag on 

her.

We did this lady,

we did our wound care twice a day.

It would um Peroxide and Q 

tips and whatever to keep it clean and keep the 

crust from building up.

And we left a hair dryer and cool under 24 hours 

because the retention suitors were so weepy 

that they were breaking ourselves.

So we just took the hairdryer up to a frame 

over a bed and kept it going for 24 hours 

and we were able to keep appliances on her.

In the midst of all this,

she developed a small val cutaneous fistula 

which we were lucky enough that that one close spontaneously on 

hyperpigmentation.

She also had sepsis and gi bleeding post 

operatively.

When you start talking about the emotional stability 

of this lady,

she was extremely stable person.

But if you can imagine on the eighth operations she was just 

very shaky,

very vulnerable to almost anything.

And with the bags everywhere with us spending so much 

time with her doing her dressings and they were very painful 

to clean.

Those retention suitors would medicated for pain every 

time before we got in there.

But for her it was a very emotionally 

anxious period and she did have periods 

of paranoia and 

just a lot of feelings that reflected the 

amount of stress she had on her.

I do have some slides that show after her 

retention suitors came out and that we did 

manage to keep her skin in good shape and keep her appliances 

on.

And this is the way that she went home with three 

functioning stone as one being her 

Elias to me,

one being her mucus fiscal and one being a urinary 

diversion.

Her colostomy stone was not functioning actually.

She could just wear a little golf square on that.

But I just wanted to show that you can manage these 

multiple officials if it takes a lot of time and a 

little uh engineering on the part of 

moving appliances and putting them here and there and not 

going with what we used to think was the typical,

I didn't want to talk a little bit about the psychological 

aspects of multiple stomachs and I 

think a great deal of the patient's emotional response 

has to do with his preparation for multiple stomachs 

and the circumstances under which he has them.

All the feelings that you have with a single lies to me,

all the feelings of fear and shame and 

worthlessness and anger and grief and 

even relief accompany a single stone was 

surely you're going to have with multiple stomachs,

especially when you have to consider all the additional management 

and time that the patient has to spend and taking care of his office to 

me and learning how to take care of exhaust me.

But we found that patients who are prepared for two stone was 

initially such as the total public 

exonerations adapt to both.

Stone was very quickly and almost do as well as 

the one with single stoners.

They've realized the necessity of customers and are from 

the very beginning emotionally prepared to accept to stop 

Hamas.

A tremendous amount of effort is made from the medical 

staff,

the nursing staff and the et staff to support 

these people and a great deal of time is spent with them 

helping them learn self care.

Mhm.

Frequently in our institution,

the second stone is not a planned one and that's 

the group of people who we found have the most emotional 

problems adapting to their second stoner.

And I think some of the feelings expressed are those of betrayal.

For example,

some of them said my doctor didn't tell me this was a 

possibility or this hospital has 

done this to me.

They have feelings of blame for somebody or 

something or somebody else's fault 

did this.

I think frequently a patient can go through the 

adjustment phases with one stone and do quite 

well.

And then when you superimpose the second stoner on him,

his problems getting those adjustment phases and 

gear again and doing it the second time completely.

And often you find that these patients are still lingering 

and thoughts of anger and blame and doubt 

or guilt.

It appears sometimes that when a person has the 

first diagnosis of cancer,

he is convinced that he can win,

he can beat that disease.

Almost everybody that comes here that has their initial 

diagnosis is convinced they're going to be cured.

But there's something about the recurrence of cancer when they 

get it back for the second time,

they have it and they feel that it's recurred.

There's something about that that's very 

devastating to the person emotionally and I think it 

comes to life to them the reality that they may not be 

immortal and that they may not whip this disease.

I think it's very similar when a second stoma is 

imposed on a person after the first one is there.

They may not have enough courage to muster 

up the strength to go through all these adaptive processes again.

And they really need a lot of support.

I think that they are very vulnerable at this time.

In psychologically,

it can be very crucial period for them.

I think that when the stomach is is the quality of the 

treatment for cancer,

whether it was surgery,

radiation,

or chemotherapy,

great care must be taken not to belittle the 

patient's treatment.

It is very easy to let this out that.

Well,

you wouldn't have had this second storm if you hadn't been radiated 

or you wouldn't have had this second stone.

But if your chemotherapy had done this,

you have to be really careful not to belittle the 

patient's treatment to him because this 

will only intensify his feelings of 

anger or blame.

And I think instead he needs a more intense and 

positive reinforcement,

not only in his staff,

but in his own ability to learn and manage his own 

care.

You have to watch these people if they have a lot of guilt 

feelings or they have a lot of blame on somebody else,

then help them work through it.

But certainly don't reinforce this and say that 

the treatment caused your stomach.

I think here we do have a lot of stones that are sick.

Well it to our treatment,

but you have to realize the positive side of it.

How many persons have been uh 

what we like to call cured our 

control for many years because of the treatment,

we are going to have complications from our treatment and we have 

to accept those and accept them with a positive 

attitude.

Multiple stomachs can be a tremendous challenge,

not only from the standpoint of physical management,

but also from the aspects of patient teaching an 

emotional support.

As general stonewall therapist.

You will be the ones that will be called on to take these challenge and I 

hope you'll take it with a positive attitude.