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For patients who require radical cystectomy with urinary diversion, offer support and reinforcement of the information. Be sure what to expect. Involve another family member in the preoper-ative education. If it is needed, arrange a preoperative visit by someone who has adjusted well to a similar diversion.

If any type of stoma is to be created, arrange for a preoperative visit from the enterostomal therapist. The enterostomal therapist can assist in the selection and marking of the stoma site (although the stoma site is somewhat contingent upon the type of urinary diversion to be performed) and can introduce the patient to the external urine collection pouch and related care. Suggest involvement with community associations such as the United Ostomy Association and the American Cancer Society.

POSTOPERATIVE. Encourage the patient to look at the stoma and take an active part in stoma care as soon as possible. Allow him or her to hold the equipment, observe the amount and characteristics of urine drainage, and empty the urine collection pouch. Implement care to maintain integrity of the skin around the stoma or urinary diversion that has been created. Empty the urinary drainage pouch when it is about one-third full to prevent the weight of the pouch from breaking the skin seal and leaking urine onto the skin. Depending on the type of urinary diversion created, begin teaching stoma care and care of the system 2 to 3 days after surgery.

Be sensitive to the patient's feelings about the potential for altered sexual functioning after radical cystectomy. Listen attentively, and answer any questions honestly. Encourage the patient and partner to explore alternative methods of sexual expression. Consider referral to a sex

130 Blood Transfusion Reaction therapist. If appropriate, suggest that men investigate the possibility of a penile prosthesis with their physician.

• Description of all dressings, wounds, and drainage-collection devices

• Physical findings related to the pulmonary assessment, abdominal assessment, presence of edema, condition of extremities, bowel and bladder patterns of voiding

• Response to and side effects experienced related to intravesical instillations of chemotherapy or BCG; systemic chemotherapy

• Teaching performed, the patient's understanding of the content, the patient's ability to perform procedures demonstrated

PATIENT TEACHING. Following creation of an ileal conduit, teach the patient and significant others the care of the stoma and urinary drainage system. If needed, arrange for follow-up home nursing care or visits with an enterostomal therapist.

Teach the patient the specific procedure to catheterize the continent cutaneous pouch or reservoir. A simple stoma covering made from a feminine hygiene pad can be worn between catheterizations. Stress the need for the patient to wear a medical ID bracelet.

Following orthotopic bladder replacement, teach the patient how to irrigate the Foley catheter. Suggest the use of a leg bag during the day and a Foley drainage bag at night. Once the pouch has healed and the Foley catheter, ureteral stents, and pelvic drain have been removed, teach the patient to "push" or "bear down" with each voiding. Instruct the patient on methods for performing Kegel exercises during and between voidings to minimize incontinence. Suggest wearing incontinence pads until full control is achieved. Also instruct the patient on self-catheterization techniques in case the patient is unable to void. Instruct patients where to obtain ostomy pouches, catheters, and other supplies. Teach the patient how to clean and store catheters between use following the clean technique.

CARE OF SKIN IN EXTERNAL RADIATION FIELD. Encourage the patient to verbalize concerns about radiation therapy, and reassure the patient that she or he is not "radioactive." Instruct the patient to wash skin gently with mild soap, rinse with warm water, and pat the skin dry each day but not to wash off the ink marking that outlines the radiation field. Encourage the patient to avoid applying any lotions, perfumes, deodorants, or powder to the treatment area. Encourage the patient to wear nonrestrictive soft cotton clothing directly over the treatment area and to protect the skin from sunlight and extreme cold. Stress the need to maintain the schedule for follow-up visits and disease surveillance as recommended by the physician.

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