Introduction: In 2006, the colorectal cancer is 2nd most common cancer in Hong Kong; there were 2230 newly diagnosis case of colorectl cancer and it is a 3rd major cause of cancer deaths (Hong Kong Hospital Authority, 2006). Many patients with colorectal cancer will undergo bowel resection to remove the tumour. At least 40% of patients who undergo colorectal surgery are likely to have a post-operative ‘STOMA’ (Beck & Justham 2009).
However, the word STOMA can raise anxieties and fears and cause psychological distress (Bokey & Shell, 1985). Patient Profile My client is a 77 years old gentleman – Mr.Cheng. He lives with his wife. He has two daughters and a son, but they are not living with him. His wife is 75 years old. He had an operation, TURP for BPH, in 1993.
He also suffered from DM and HT which requries long term medication and follow-up in general out-patient clinic, however, his DM is not well controlled. Several months ago, Mr. Cheng noted some blood coming with stool, sensation of teneumus and changing in bowel habit with reduction in diameter of stool. Initially, he did not recognize it was a health problem and thought it was normal due to aging.Afterward, he told this issue to his daughter in one family gathering. His daughter suspected that it might be a sign of medical problem and brought him to clinic for medical consultation. In the out-patient clinic, physical examination was performed and the doctor told him a rectal mass was found at 4cm from anal verge and Mr. Cheng was referred to Pamela Youde Nethersole Eastern Hospital (PYNEH) for investigation.
According to the colonoscopy report, its showed 1mm polyps at proximal ascending colon and proximal transverse colon were found and polypectomy was performed.Besides, a growth at 4-10cm from anal verge with 3/4 circumference was seen and biopsy was taken. The rectum biopsy shows adenocarcinoma. From the computer tomography (CT) report, the finding was equivocal rectal wall thickening at the posterior aspect of mid-rectum which may represent the tumor. A 0. 6cm perirectal lymph node was noted. No evidence of liver and lung metastases. The staging from endoscopic ultrasound of rectum was uT2N0.
The tumor marker (CEA) was 38. 9 and the random glucose was a bit high; otherwise the blood result was grossly normal.Patient’s son and daughter were interviewed by medical officer and the working diagnosis of CA rectum was explained. Mr. Cheng’s operation was planned on 20th August, 2009. However, Mr. Cheng and his family members were very worry about the operation and post-operative stoma.
Therefore stoma specialist and patient supporting group were contacted for counselling. Applied Physiology & Pathophysiology: Colorectal cancer, also called colon cancer or large bowel cancer, includes cancerous growths in the colon, rectum and appendix.Many colorectal cancers are thought to arise from adenomatous polyps in the colon. The risk factors include: age, most cases occur in the 60s and 70s; present of polyps, particularly adenomatous polyps; heredity (family history of colon cancer, especially in a close relative before the age of 55 or multiple relatives); familial adenomatous polyposis (FAP) carries a near 100% risk of developing colorectal cancer by the age of 40 if untreated; smoking and drinking, especially heavily, may be a risk factor.Diet with high in red and processed meat and low in fiber, are associated with an increased risk of colorectal cancer.
Crohn’s disease have a more than average risk of colorectal cancer, but less than that of patients with ulcerative colitis (Royle & Walsh, 1993). [pic] [pic] The symptoms of colorectal cancer depend on the location of tumor in bowel and whether it has spread to elsewhere in the body. Symptoms and signs are divided into local, constitutional (affecting the whole body) and metastatic (caused by spread to other organs). Local symptoms are more likely if the tumor is located closer to the anus.There may be a change in bowel habit (new-onset constipation or diarrhea in the absence of another cause), and a feeling of incomplete defecation (tenesmus) and reduction in diameter of stool; tenesmus and change in stool shape are both characteristic of rectal cancer. Lower gastrointestinal bleeding, including the passage of bright red blood in the stool, may indicate colorectal cancer, as may the increased presence of mucus.
If the tumor is large enough to fill the entire lumen of the bowel may cause bowel obstruction. (Black & Matassarin-Jacobs, 1993) The treatment depends on the staging of the cancer.When colorectal cancer is caught at early stages (with little spread) it can be curable.
However, when it is detected at later stages (when distant metastases are present) it is less likely to be curable. For surgeries can be categorised into curative, palliative, bypass, fecal diversion, or open-and-close (Black & Matassarin, 1993). In my case study, Mr. Cheng needed to undergo Abdominoperineal Resection of Rectum (APR). APRs involves removal of the anus, the rectum and part of the sigmoid colon along with the associated (regional) lymph nodes, through incisions made in the abdomen and perineum.The end of the remaining sigmoid colon is brought out permanently as an opening, called a colostomy, on the surface of the left lower quadant of abdomen (Dorothy & Debra, 1993).
[pic] [source: http://visuals. nci. nih. gov/details. cfmAV-0000-4119] [pic](Source=http://www. cancer. gov/Templates/db_alpha. aspx? CdrID=377733) Patient assessment and Problem identification Assessment involves identification of a patient’s individual needs and concerns to allow for preparation for surgery, and highlights potential post-operative problems.
Patient assessment can be separated into two areas: psychological and physical (Rust 2007) 1st Assessment – day before operation (19th August, 2009) Mr. Cheng was admitted to 10F ward of PYNEH for operation, he came with his daughter. The stoma specialist and me arranged an interview room for them to explain the indication of operation, possible complications, the reason of fashion a stoma and related post-operative care; and prepared for optimal site of stoma siting. During the procedure, Mr.
Cheng and his daughter showed their worry about the risk of operation, the possible spread of the cancer and the altered body image (present of stoma). Though our assessment, we found that Mr. Cheng has difficultly in caring his stoma. It was because he could not bend his neck because of limited neck movement due to aging.
Therefore, his stoma care will be needed by others. 2nd Assessment on post-operative day (20th August, 2009) I visited Mr. Cheng after he was warded from operation.
His blood pressure was stable with 110-120/60mmHg, Pulse: 70-80/mim. Temperature: 36. 8? C. He looked tired and sleepy.We did the stoma and wound assessment: stoma size was 33mm diameters, color was beefy red with 10ml blood strain fluid was collected in pouch over 6 hours.
The abdominal wound was covered with dressing and mild blood stain discharge was noted and abdominal drain was placed. The perineal wound was present and also a pelvis drain was placed for facilitating drainage. The surrounding skin of the perineal wound had mild redness. Moderate tenderness of abdomen was noted when we were doing palpation which may be related to pain. 3rd Assessment on post-operative day 1 (21st August, 2009)Patient’s general condition was stable, Blood pressure around 140-150/70mmHg, Pulse: 70/min, Temperature normal, H’stix on high side: 13-15mmol/L, oral medication (DM and HT drug) was resumed and soft diet was commended. For stoma assessment: size was similar (33mm diameter), color was beefy red and with blood strain fluid but not function. Peristomal skin was healthy and pouching system had no leakage.
He still complained a bit painful around the abdominal and perineal wound. For inspection, I found that the perineal wound was oozing with some old blood.I applied the ‘Roy Adapatation Model’ to address Mr.
Cheng and his daughter’s needs. This model comprises the four domain concepts of person, health, environment, and nursing and involves a six step nursing process. Six-step nursing process which includes: assessment of behaviour, assessment of stimuli, nursing diagnosis, goal setting, intervention and evaluation. Through the discussion with patient and his daughter; they worry about patient’s prognosis, the recovery process, and the ability in caring of new fashioned stoma. Nursing Diagnosis and Interventions 1) Nursing Diagnosis : Fear related to pain, present of stoma after surgery as evidence by verbalization of worries and facial expression Goal: Fear will be relieved and gain confident in caring of stoma Nursing Intervention: I assessed the possible contributing factors such as life style changed; and disappointment or stressor. We (stoma specialist and me) arranged a private area where the patient and his daughter felt comfortable and they could ask personal questions and express their feeling without the fear of being interrupted (Rust 2007).During the counseling session; I tried to speak calmly and slowly and used simple and direct statement and gave suggestion to manage daily activities with general explanations and its rationales. During the counseling session, I kept observing any signs and symptom of stress or depression coming from patient and his daughter.
I reassured them the pouching system with different features that can help them to adapt the change easily and minimized the embarrassment. For example, they can choose the closed colostomy bag with flatus filter, which can facilitate the dispersion of gas and odor.Besides, I taught to the patient the proper usage of PCA pump. I also introduced different posture and positioning that could help him not to alter the perineal wound and it may minimize the pain feeling. On the other hand, I appraised their effort in learning the care on stoma and their supportive attitude. Besides, I also shared with them some relaxation measures (such as deep breathing exercise and listening to music).
I reinforced them the present of stoma will not affect their daily life. He can resume a well balance diet and I suggested Mr.Cheng takes eight to ten cups of fluid per day.
I advised him that those foods or fluids such as cabbage, eggs, onions, spicy foods and carbonated drinks can cause excessive wind. I also reminded him fibrous foods such as corn, nuts, mushrooms and skins on fruits are difficult to digest and can cause blockages. It was advisable to avoid such foods in the first six weeks after surgery to prevent blockage from occurring (Vujnovich 2008). Besides, I reassured Mr. Cheng that he can go for swimming, hiking as tolerated.After counseling session, the written information and a contact number was given to them so that they can ring the stoma care nurse for advice if they have any further questions. I also assessed their financial status, however, patient daughter said that they do not have financial problem. Patient and his daughter showed understanding and verbalized that their fear was minimized and they gain confidence in caring of the stoma.
(2) Nursing Diagnosis : Knowledge deficit related to care stoma, change of ouching system and observe for complication as evidence by verbalization and facial expression Goal: Understand and gain confidence in the caring of stoma and knowledge the potential complication of stoma Nursing Intervention: As Mr. Cheng and his daughter had no idea about the basic knowledge of stoma care, I will put the main focus on enhancing the most basic technique of stoma care and promote their self confident. Firstly I assessed their education level and ability in receiving the information. I tailored made an education program for them.
I used the information leaflet, diagram and picture that helping them for easy understanding. The following information was given to patient and his daughter: I instructed them to wash their hands thoroughly and prepared the area for the procedure and ensured that patient was in a comfortable position to perform the procedure. Firstly, I advised her to use an absorbent towel to protect the clothing when removing the pouch. Then, use one hand to hold the skin taut, the other hand to pull the pouch gently which can reduce trauma to the peristomal skin and promote comfort.It is acceptable to dispose of used stoma care equipment and pouching in the domestic rubbish bin and double wrap it in the disposal bags (Rust 2007). This is to ensure that all clinical waste is disposed properly and reduced the risk of cross-infection.
Cleansing the stoma and surrounding skin by using disposable cloths and tap water and ensures that the stoma and peristomal skin are kept clean and thoroughly dry before applying the new appliance which reduces the risk of skin excoriation. I also instructed them how to observe the stoma and peristomal area for variances from the norm and reported it to the nurse for intervention.The size of the template and the positioning of the pouch are important to prevent and ill-fitting pouch; if the template is too large it will lead to excoriation of skin, potential pouch leakage due to poor adherence and associated pain and distress for the patient (Rust 2007). A template that is too small causes leakage from the pouch and potential trauma to the stoma (approximately 2mm of skin should be visible around the stoma).
The stoma should be measured regularly in the first few weeks, as the size of stoma alters several days after surgery in conjunction with the subsiding edema (Black 1997).Usually, the stoma reaches a regular size after about six weeks following surgery (MacKeigan & Catalda, 1993). Concerning about the stoma complication, I selected the most common complication which may be occurred within the first year of surgery – peristomal hernia and prolapse (Black 1997). I advised them to avoid lifting heavy weights for three months following the operation. Moreover, I introduced the supporting group (Stoma Association) to them and encouraged them to participate in the group to share experiences.
After session, I showed different types of pouching system (included one-piece and two-piece open / close end bag) and gave them the information for buying the pouching system. After giving the reassurance and appropriate information on caring of stoma; Mr. Cheng and his daughter became more cheerful and showed confidence in caring of stoma bag. Due to my 3rd visit was on post-operative day 1; I could not show the skill of changing stoma bag (because the stoma was not yet function) but they actively participated in emptying the pouch and skill was satisfactory.Moreover, I taught them the possible complications on stoma and peristomal skin and reassurance the patient that the stoma would not affect their usual daily life if they care the stoma properly. (3) Nursing Diagnosis : Potential for wound infection related to present of incision wound in abdomen and perineal Goal: minimize the chances of infection on abdominal and perineal wound Nursing Intervention: I assessed the predictors factors of infection such as the background information of the surgery such as the length and type of the surgery performed.If the duration of surgery performed is longer than 2 hours and genitourinary procedure is involved, it has higher risk for infection (Black & Matassarin-Jacobs, 1993). I also assessed the patient past health history that he is suffered from diabetes mellitus and which is not well control by oral hypoglycemic drug.
It is also a risk factor affecting the wound healing. I evaluated patient’s vital signs and body temperature and all laboratory results e. g. wound swab culture, complete blood picture.
If there have any abnormalities; doctor should be informed immediately.Moreover, the drainage system was ensured to function well, no blockage, kinking; and monitor the color, amount and texture of drainage were monitored closely. Patient with a perineal wound has higher risk of wound infection. Therefore, the signs and symptoms of infection were observed closely.
As the dressing was soaking with old blood stain fluid, I preformed the wound dressing with normal saline, and covered with plain gauze in order to facilitate the drainage of exudates and using micropore as adhesion tape as to prevent trauma the perineal skin (Thomas 1990).The old dressing was saved for inspection and the findings were documented for reference. (4) Nursing Diagnosis : Potential for impaired skin integrity related to inappropriate of stoma siting, in-proper handling / caring of stoma and changing of pouching system and fecal irritation on the peristomal skin. Goal: no damage on peristomal skin Nursing Intervention: First of all, we needed to assess patient’s eyesight, manual dexterity and any disabilities as these might affect management of the stoma. Like Mr. Cheng, he has the problem to bend his neck.Therefore, I have observed Mr.
Cheng closely post-operatively. I also selected an appropriate appliance and teaching plan; and identified the care-giver to be involved in learning of stoma care. Moreover, I explained to the support person that some patients will require short or long-term support to gain independence. It was because care-giver might have different expectations and let them to express their difficultly. The position of the stoma is critical importance for the patient return to a full and active life (Vujnovich 2008).A poorly sited stoma can lead to post-operative complications, which include appliance leakage and excoriated peristomal skin, as well as psychological problems. The stoma should be sited in the most appropriate position for the patient. Areas to avoid include the incision site, previous scars, areas the patient cannot see, wounds, bony prominences, the patient’s waistline and skin folds and creases (MacKeigan & Cataldo, 1993).
Ideally the site should be placed within the rectus muscle to reduce the risk of parastomal hernia (Nursing Standard 2004). On day of post-operation, we applied a clear pouching bag without flatus filter that llowed me to observe the condition of stoma and its output; and detect any abnormalities as soon as possible. Mr. Cheng was instructed to inform nurse, once leakage of stoma bag or abnormalities was noted. We planned to provide more information on caring of stoma on next day after operation. Summary Many patients with colorectal cancer will undergo bowel resection to remove the tumour. However, most of patients who undergo colorectal surgery are likely to have a ‘STOMA’ (NICE 2004) and the word ‘STOMA’ can raise anxieties and fears and cause psychological distress.Patients with ostomies (ostomates) lost conscious control over defecation and external pouching has to be applied for body waste collection.
Despite recent advanced in surgery, ostomy stoma still brings enormous physical and psycholosocial impacts to the patient and his/her caregivers. Potential threat of life posed by the disease or injury, uncertainty, altered body image and lower personal esteem are commonly experienced. As Enterostomal Therapy (ET) has a unique role in the identification of needs of patients and their caregivers, provision of holistic ostomy care, education and counseling.ET nurse also bear the responsibility to improve the quality of life of ostomates and ultimately contribute to their recovery and well-being (Hospital Authority 2008). Reference: 1. Beck, M. , Justham D. (2009).
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