Honours in Nursing

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Colorectal cancer is the second most common cause of cancer-related deaths in the UK (Brooker, 2005); and this paper aims to discuss the treatment and care of a 68 year old gentleman who has been admitted for colostomy forming surgery. Consideration will be given to both the pre-operative and post-operative care that Mr Jones will receive; and we will discuss the factors surrounding his physical and emotional well being.

Aetiology & Pathophysiology

The lumen of the colon is lined with many cells which are subject to constant turnover. Adenocarcinomas form when too many dysfunctional cells lining the colon create a tumour (Whittaker, 2005). The exact cause of colorectal cancer is unclear (Alexander et al, 2006); however diet is thought to be the most important factor (Waugh & Grant, 2006).

The symptoms of colorectal cancer vary depending on the area of the bowel affected (Brooker, 2005). The symptoms of right sided tumours usually include: anaemia, weight loss, abdominal mass, ill-defined abdominal pain, and changes in bowel habit (Borwell, 2005). Left sided tumours usually present with symptoms such as: colicky abdominal pain, abdominal distension, alternating bowel habits, plus mucus and/or blood in the patients’ stool (Borwell, 2005).

Treatment of Colorectal Cancer

Treatment depends on the stage of the cancer and the prognosis of the disease (Whittaker, 2005). Radiotherapy and Chemotherapy are useful in shrinking the tumour prior to surgery; and used post operatively to treat metastases or in palliative care (Whittaker, 2005).

Surgery is usually the most common form of intervention offering the best chance of survival and involves resection of the tumour, the surrounding tissue, and the adjoining lymph nodes. It is then followed by either anastamosis of the remaining colon or by forming a stoma (Whittaker, 2005) which in Greek means mouth or opening (Dougherty & Lister, 2004). A colostomy; which is what Mr Jones’ surgery will result in, is a type of stoma but specifically involves the large bowel (Dougherty & Lister, 2004).

Pre-Operative Care

Pre-admission Clinics

Mr Jones’ preoperative preparation will have begun some time before being admitted to the ward. Stoma care nurses specialise in the care of people who undergo stoma surgery and in the case of elective surgery, such as this, will provide pre-operative information and support. Mr Jones will be informed of the surgical options available and given clear explanations on the changes to expect in his body function (Alexander et al 2006). His partner and/or family will be included in the discussions allowing the opportunity to raise issues such as sexuality, impotence, body image, odour and emotional support. Such pre admission appointments allow for psychological adjustment over a longer period of time, and the opportunity for Mr Jones to share information with his family (Alexander et al, 2006). An informed patient is better equipped to make decisions about their care and therefore he will also have received information booklets to enhance his learning (Alexander et al, 2006).

The stoma nurse will also look at other practical issues regarding Mr Jones stoma such as the position in which it will lie. A decision on the site will be made after observing Mr Jones, lying down, standing up, walking and sitting (Alexander et al, 2006). Furthermore, consideration will be given to any holistic issues surrounding Mr Jones’ stoma formation such as his physique, his prognosis (and the possibility of weight loss due to metastases), his employment and the types of activities he enjoys, his cultural beliefs, his level of dexterity, and any disabilities he may have such as poor eyesight (Porrett & McGrath, 2005).

Due to potential problems and Mr Jones’ acceptance of the stoma, an actual discharge date cannot be set prior to surgery. However in the clinics a discharge plan will be formed and Mr Jones will be told what is required of him before he can leave the ward. Information will be provided on the effects of his surgery and anaesthesia, exercise activities which will ensure a speedy recovery, the possibility of complications, and dietary & nutritional advice. He will then be educated in the care of his stoma. Topics such as changing the appliance, cleaning the skin, how to obtain further supplies, how to recognise complications, and how to talk about his feelings will be discussed. Additionally, it will be reinforced upon Mr Jones that information and support will be readily available after surgery (Walsh, 2002).

In accordance with SIGN guidelines (2007) the nurse will recommend that Mr Jones receives a visit from someone who has gone through the same experience (Walsh, 2002); and the British Colostomy Association of Great Britain can supply a list of ostomates who can perform this function (BCASS, 2007).

Finally the stoma nurse will assess Mr Jones’ home circumstances in order to make the appropriate referrals for his discharge. These may include a visit from the community nurse to remove his staples/sutures, or the occupational therapist to review Mr Jones’ mobility around the home and provide any suitable mobility aids (Brooker & Nicol, 2003).

Patient admission and the role of the ward nurse

Giving Mr Jones information and emotional support is known to reduce anxiety, post-operative complications, and increases collaboration. Psychological care needs to include Mr Jones’ family or significant others in order to develop a trusting relationship; and the benefits of spending time to allow fears to be expressed and support to be provided cannot be overstated. Therefore sensitive questioning by the ward nurse can determine what Mr Jones already understands about his condition and what he would like to know more about prior to his operation (Alexander et al, 2006).

Patient Assessment & Pre-operative Care

The assessment of Mr Jones is required to identify any special needs, highlight potential problems and provide a baseline against which post-operative measurements can be made (Alexander et al, 2006). This is usually done using a nursing model such as Roper, Logan and Tierney’s activities of daily living (Holland et al, 2003).

Surgery in older people is associated with increased risk of post operative complications, especially if the patient already has a coexisting disease. For example if Mr Jones already has a cardiovascular disease then he is more like to develop a myocardial infarction or arrhythmia following surgery (Alexander et al, 2006).

All patients receiving a general anaesthetic are at risk of developing a chest infection. This is due to the build up of mucus which is not expelled because of the lack of movement, depressed breathing and the inability to cough. Therefore prior to surgery, Mr Jones should be taught deep breathing exercises and encouraged to lie upright in bed post-operatively (Alexander et al, 2006).

During the pre-operative assessment the nurse should assess Mr Jones for risk factors which may attribute to the development of deep vein thrombosis (DVT) or pulmonary embolism (PE). These include increased age, obesity, clotting disorders, immobility, and major abdominal surgery. To prevent an incident of DVT or PE anti embolic stocking are applied to the legs to increase blood flow and inhibit stasis of venous circulation. However if Mr Jones has significant leg oedema, or severe peripheral arterial disease; the use of stockings may not be possible (Alexander et al, 2006). Therefore, a low-dose subcutaneous injection of Heparin may be administered as a prophylaxis instead (BNF, 2007).

Another important factor to consider prior to Mr Jones’ surgery is that of consent, and it is the nurses’ job to act as an advocate for Mr Jones; ensuring he is informed and supported at all times (Brooker & Nicol, 2003). The level of Mr Jones’ comprehension with regards to his procedure and prognosis should be constantly monitored by the nurse to ensure he knows what to expect (Dougherty & Lister, 2004). All too often the patient and their family are so emotionally overcome that they do not grasp all that has been said. The nurse can determine what information has been given, then, in simple terms; can repeat any necessary information (Walsh, 2002).

Usually, surgeons will prescribe a bowel preparation 1-2 days before the operation to reduce the risk of infection from faecal contamination (Borwell, 2005). These preparations can include Fleet, Picolax or Klean-prep and ensure the bowel is free of any solid contents (BNF, 2007).

In addition, Mr Jones will be not be allowed any food or fluids 4-6 hours prior to surgery, in order to avoid the risk of regurgitation and inhalation of gastric contents whilst under the anaesthetic (Jamieson, 2002). However the undesirable results of prolonged fasting are dehydration and electrolyte imbalance, particularly in older patients; which may potentially render them unfit for surgery. To prevent this; intravenous fluids may be prescribed if Mr Jones displays any signs of dehydration (Alexander et al, 2006).

If Mr Jones is particularly anxious the anaesthetist may prescribe a “premed”. This is a drug such as diazepam which constitutes to part of the anaesthetic. It is used to relax and relieve anxiety; and will be given just before Mr Jones leaves the ward for theatre (Alexander et al, 2006).

In addition to the previous information, most hospitals also employ a standardised checklist which is completed on the morning of surgery and includes the following criteria: –

* Ensure Mr Jones is wearing an identification band with the correct information (Dougherty & Lister, 2004).

* Ensure any allergies have been noted, and are clearly marked on a separate wrist band (Alexander et al, 2006).

* Encourage Mr Jones to empty his bladder prior to the operation to allow better access to the abdominal cavity during surgery (Dougherty & Lister, 2004).

* Ask Mr Jones to remove any jewellery to prevent accidental loss or diathermy burns (Alexander et al, 2006).

* Ask Mr Jones to remove any prostheses such as glasses, dentures, hearing aids or artificial limbs to prevent loss or damage during surgery (Alexander et al, 2006). However to aid communication some items may be retained until he is anaesthetised.

* Check that Mr Jones has undergone any relevant procedures prior to his operation such as x-rays, blood tests or ECG’s and ensure the results are included in his notes (Dougherty & Lister, 2004).

* Encourage Mr Jones to shower in order to minimise the risk of wound infection post-operatively (Dougherty & Lister, 2004).

* Ensure that the stoma site has been marked correctly by the stoma nurse or surgeon (Dougherty & Lister, 2004).

* Record Mr Jones’ pulse, blood pressure, respiration, and temperature to provide a baseline for comparison (Dougherty & Lister, 2004).

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