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).
Immediate Post-operative Care
In the pre-operative period the focus of nursing care was on the psychological preparation of Mr Jones. However, immediately after surgery, the physical care of Mr Jones becomes the priority (Porrett & McGrath, 2005).
Mr Jones will require close observations during the immediate post-operative period; and in the first 24 hours the nurse will look for changes which might indicate shock or haemorrhage (Alexander et al, 2006). To monitor general recovery; the vital signs of BP, pulse, temperature, and respiration rate should be recorded every 15 minutes (Brooker & Nicol, 2003). The nurse should look for signs of excessive blood loss on dressings and in wound drainage bags. Blood pressure is monitored and will fall in the case of haemorrhage. Pulse is also observed and will increase in order to preserve blood pressure in the event severe internal or external bleeding. Peripheral vasoconstriction also signifies blood loss and is the body’s conservation of blood to the vital organs such as the heart and brain; resulting in a pale clammy appearance. If blood loss continues, eventually the kidneys will cease to function, and urine production will decrease rapidly (Alexander et al, 2006).
Particular attention should also be made to the stoma itself for the first 48 hours after surgery to ensure that it is viable (Alexander et al, 2006). A pink shiny appearance indicates a good blood supply (Dougherty & Lister, 2004); whereas a blue/black appearance indicates necrosis (Borrett & McGrath, 2005). The size of the soma should also be noted as oedema can occur; and the best way to do this is to ensure a transparent device is applied for the first few days (Borrett & McGrath, 2005). The nurse should also listen for bowel sounds, which indicates the colon is functioning properly. Once these are heard Mr Jones can be recommenced on oral fluids starting with sips and eventually moving on to a light diet (Punder, 2000).
Post-operative pain needs close attention and although this is initially the responsibility of the anaesthetist, the nurse should ensure that Mr Jones remains comfortable. Good pain control allows for early activity; therefore minimising the potential problems of immobility such as chest infections, DVT, and pressure ulcers. Patient controlled analgesia is an effective way of administering small boluses of IV analgesic; and gives greater relief compared with patients receiving injections. However, to ensure optimal effectiveness the nurse must make certain that Mr Jones is shown how to operate the device correctly (Alexander et al, 2006).
Continuing Post-operative Care & Discharge
As Mr Jones recovers from the immediate post operative period, the nursing care provided will aim to promote maximum independence (Pudner, 2000). This stage of care focuses on recovery and rehabilitation. Observations can now be reduced so long as they are within normal limits; allowing Mr Jones time to recuperate (Walsh, 2002). Sleep is especially important for Mr Jones; as recovery by the body usually takes place during periods of rest. To do this the nurse can reduce any excessive noise where possible, and although observations are still required; these should be minimised during the night.
Upon his return to the ward, Mr Jones may be anxious to speak to the doctor about his prognosis following surgery. When information cannot be immediately given, it is the nurses’ job to reassure Mr Jones; and when he has been seen by the doctor it is the nurses’ duty to clarify Mr Jones’ understanding and answer any of his questions (Alexander et al, 2006).
Wound infection is also another consideration for the nurse. The key aim is to promote healing as soon as possible with minimal scarring and complication (Brooker & Nicol, 2003). To ensure this, nurse must apply the aseptic technique when changing dressings and observe for signs of infection such as raised temperature, wound inflammation, and exudate (Walsh, 2002).
As previously mentioned Mr Jones’ education regarding his stoma formation will have been started before his admission. It is now up to the nurse to reinforce the information he has learnt and help him to care for himself (Alexander et al, 2006). During the initial post operative period Mr Jones will be too unwell to care for the stoma and the responsibility will rest with the nurse (Borrett & McGrath, 2005). However, once he starts to recuperate, Mr Jones will be encouraged to observe (Dougherty & Lister, 2004) then gradually take over, firstly under supervision; before finally being able to perform care independently (Borrett & McGrath, 2005).
The discharge plan for Mr Jones will already have been created by the stoma care nurse prior to admission, and Mr Jones’ should be aware what is required of him before discharge. At this point it is the ward nurses responsibility to ensure that Mr Jones’ fluid intake is normal, that he is able to eliminate and urinate normally, that he is active and free from pain, that his vital signs are within normal limits, that he is able to demonstrate an understanding of his stoma care; and that his wound is clean, dry and intact (Walsh, 2002). Once Mr Jones is able to meet this criteria the nurse can then organise the appropriate support for his discharge such as transport and community services (Brooker & Nicol, 2003).
This paper has endeavoured to provide a broad but brief insight into the holistic care provided for Mr Jones during his colostomy forming surgery. However, there are numerous factors to consider and due to the word allowance of this assignment it was not possible to mention them all in detail. The main aspects for a nurse to remember are that pre-operatively the focus must be on the psychological welfare of Mr Jones; and his understanding and acceptance of the stoma is required to enhance a speedy recovery (Porrett & McGrath, 2005). To ensure this, the nurse must educate, reassure and more importantly listen to Mr Jones as he expresses his fears, and asks questions (Dougherty & Lister, 2004). One of the most important aspects of care to remember is that of therapeutic relationships. By being supportive, listening to, and acknowledging the patients fears, by offering good clear explanations, and building trust; nurses can make a positive difference to the patients experience (Walsh, 2002).
Post operatively the nurse must shift their focus to the physical care of Mr Jones, ensuring that his vital signs and wounds are monitored regularly; and any problems reported immediately (Porrett & McGrath, 2005). The complications with regards to Mr Jones’ acceptance of the stoma should be minimal, as long as the training and support he received pre-operatively was adequate (Alexander et al, 2006). However, constant assessment of Mr Jones’ psychological state should be made to ensure he is coping. And finally; to ensure adequate rehabilitation occurs at home, the nurse must make the appropriate referrals and supply the correct level of community support to Mr Jones’ upon his discharge.
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