Advanced Nursing Practice In Colorectal And Stoma Care – Care Plan For Post-operative Patient

Plan of Care

Discuss about the Advanced Nursing Practice in Colorectal and Stoma Care.

The purpose of this report is to analyze the case of Simon Jones who has undergone and abdominoperineal resection and develop a comprehensive care plan for Simon Jones post-operatively on the ward. It is based on the principle of patient-centered care and covers all the component of integration of care and continuity of care to provide physical and emotional comfort to patient (Elwyn et al. 2014). It discusses the professional responsibility of the care team in planning care for Simon based on long and short term goals. This will depend on patient’s health status post-surgery. The legal and ethical aspects of care are also discussed with special attention to patient’s optimum health and recovery. The report explains the rationale for the health professional who have the main role in providing care to Simon.

Simon Jones a retired army officer currently working as a book keeper had completed a faecal occult blood test (FoBT) and the review by the GP has found his bowel screening test gave positive result. He was referred to a colorectal surgeon, Mr Baker who reviews his case completes a colonoscopy on him after detection of lesion below the bowel. He was finally diagnosed with colorectal cancer and had to complete six week of chemotherapy and radiotherapy before operation. After six weeks of chemotherapy, he had an abdominoperineal resection to take out the sigmoid colon on his abdomen. He is transferred from theatre to recovery room with continous abdomen stitch and hydrocolloid dressin, perineal wound and indwelling catheter.

The care plan of Simon Jones will depend on his condition post surgery. On admission to PACU, he was difficult to arouse, had elevated pulse rate and he was grimacing and writhing with pain in the bed. In case of management of postoperative pain in Simons, care plan will depend on psychological condition, sensitivity to analgesics and intraoperative course in treatment. Review of medications and anesthesia given to patients intraoperatively will also help in determining appropriate care plan for Simons (Story et al. 2015). During surgery, his bowel was transected, sigmoid colon was exteriorized and abdominal wound was closed with muscular and skin stitch. A perineal incision was also made to remove his rectum. He had a stoma site and transparent drainage stoma bag in situ. He has also been given a triflow to clear secretions and blocked mucus. To facilitate recovery, it will be necessary for the patient to do breathing and bed exercise. Deep breathing and bed exercise is essential to check chest infection and keep lungs inflated. Patient tend to become weak after surgery and lack of breath may cause lung problems in patients such as pneumonia. Hence a therapist support may help Simon to do breathing exercise. It will help to check postoperative pulmonary complication in patient (Silva et al. 2013).

Legal and Ethical Considerations in Care

Another important part of care plan for Simon is to take care for his stoma and wounds post-operation. It will be necessary to teach him how to take care of the stoma. Stoma is a small opening made by surgeon during the abdominopereneal resection to create passage for passing off of waste from the body. Unlike anus, the stoma does not has sphincter muscles, hence a stomal bag is necessary to collect waste. A stomatal therapy nurse may assist patients like Simon to provide stoma care education and assess Simon for peri-stomal skin action and bowel consistency. This will comprise giving teachings on removing soiled ostomy bags and cleaning the stoma. Improving Simon’s skill in coleostomy is very important so that he can independently manage his ostomy at home after discharge (Barnwell 2015). In the long term, it is also possible that Simon’s stoma will shrink, so he needs to check for the shrinkage as in that case new ostomy bags with small holes will be required (Williams 2015). Regular consultation with stomal therapy nurse will be necessary to control any chance of stomal necrosis and ulceration near the area. Simon should also be advised to clean dry the stoma area and empty the ostomy pouch always to prevent skin breakdown and reduce skin irritation. This care plan will help to maintain integrity of the skin area around the stoma (Boyles and Hunt 2016). Research studies have also showed that this form of stoma care education helps patients to adapt coping strategies to manage the newly formed stoma (Williams 2015).

Another care plan for Simon is to take care for his perineal wounds and incision. It is possible that there might be leakage from the wounds and patients may need support from nurse to clean the wounds. Simon will be discouraged from sitting for long hours as this may cause his incision to open up and drain. Gauze damp dressing is also required around the wound and Simon must be advised by the nurse to pat dry the incision after taking shower. Nurse may also educate him to refer to the surgeon immediately in case he notices redness around the incision (Althumairi et al. 2016). Impaired perineal wound healing is a major challenge in caring for patients post abdominoperineal resection as research shows that radiotherapy increases wound problems (Musters et al. 2014). Simon had undergone six weeks radiotherapy and chemotherapy before operation which might make him vulnerable for perineal wound problems. Research has also indicated that the use of negative pressure therapy might be an effective intervention to improve wound healing and reduce perineal complications in patients (Sumrien et al. 2016).

Simon has been restricted from many taking foods that might cause diarrhea and constipation. The restricted diet post operation might have made him vulnerable to nutritional impairment. The diet plan of Simon should be made such that nutritional needs are met. He should start eating solid food gradually to reduce the chance of abdominal cramps and nausea. Foods high in cellulose and grapes, cabbage and bananas as these foods increase ileal effluents. Patients with abdominoperineal resection often complains about abdominal bloating and nausea post operation, hence they must be advised to eat slowly to understand what they can tolerate (Gillis et al. 2016). As Simon is taking many narcotic drugs, it might lead to side-effects of constipation. Hence the surgeon reconsiders the side effects of each medication before advising it to such patients. Besides this medication management is required to reduce chance of complication in patient.

Simon is most likely to experience fear and anxiety post-operation and the wound complication and disease process may cause him acute pain. It will be extremely necessary to address pain and provide them relief through relaxation skills. Measures like repositioning and mouth care will help to prevent discomfort and promote relaxation. Although little ambulation is recommended however he should be discouraged front sitting for long houses. Ambulation is important post-operatively to reduce muscle stiffness and increase opportunities of normal functioning in Simon (Vignali et al. 2016). Ambulatory assistance can be provided by a nurse or a physiotherapist. Patients experience chronic pain in the pelvic area after the rectal cancer treatment and in that case appropriate pain management is necessary to improve the quality of life of patients. Surgeon will help to decide the appropriate pain medication for Simon in case of continuous acute pain (Feddern et al. 2015).

Considering the case of Simon Jones, there are many legal and ethical issues involved in Simon’s care and treatment. Firstly the health professionals involved in treatment of Simon Jones need to ensure that they deliver holistic care to Simon and cover all aspects of patient assessment. The legal and ethical responsibilities before the surgery are to make patient aware of the purpose of surgery and give detail on any risk involved in the surgery. The legal responsibility for health professionals is to take informed consent of patients, understand patient’s right and maintain confidentiality of patient’s record (Cainzos and Gonzalez-Vinagre 2014). The current medico-legal litigation makes it necessary for health professionals to provide all appropriate information about treatment so that they can engage in shared decision making and give informed consent for the treatment. Autonomy, capacity and disclosure are the three criteria to effective informed consent process. It is a complex process however this stage is important develops trust based relationship with patients. Many ethical and legal issues might arise if health professionals do not engage in this process effectively (Cawich et al. 2013). Simon’s surgeon Mr. Baker gave detail of each phase of treatment to Simon and rational for those treatment. For example after the CT scan he explains him that his cancer is very close to the anus and operation on the lower part of the bowel is necessary. He also took care to explain every detail of the surgery and the risk of complications in it related to wounds, infection and sexual impairment. Hence, this helps in fulfilling the legal and ethical aspects in care before surgery and also enables people to effectively engage in shared decision making.

After the surgery, the stoma care nurse and other nurse will play a vital part in caring for Simon and managing his recovery. The day to day ethical and mental status of patients may not be the same; hence they may face many dilemmas in care. However in any situation, it is their ethical responsibility to maintain patient’s advocacy in planning and provide safe patient-centered care. In health care setting, ethical issues might arise in the area of autonomy, beneficence (doing good), non-maleficence (avoiding harm), justice, veracity and fidelity. In the area of autonomy, the nurse has to maintain and respect patient’s privacy and rights while giving Simon stoma care education. In the case study, it was found that Liz communicated with Simon in each stage of treatment and was constantly involved in updating him about stoma care (Kadam and Shinde 2014). According to the principle of beneficence and non-maleficence, a nurse has the responsibility to preoperatively determine the stoma site by interacting with patient and Liz did it in the case study. Nurse also has the duty to provide stoma care training to enhance patient’s quality of living and constantly take measures to prevent any harm to patients (Thorpe et al. 2014). Liz also did the same for Simon. Before the discharge of patient from hospital, stoma care nurse will have to provide care to patients and inform them about all the stoma resources available in the country so that patient familiarize with the product. This is a part of principle of justice in nursing and it assist patient to recognize the most appropriate stoma product for management of stoma (Barnwell 2015). All the issues related to problems of quality care can be avoided of the nurse maintains consistency in care by fulfilling all the ethical responsibilities involved in stoma care. 

Simon’s treatment is managed by a inter-professional health care team like general practitioner and practice nurse before diagnosis, colorectal surgeon, colorectal support nurse, pathologist, radiologist, oncologist who were involved in care planning and treatment after diagnosis of rectal cancer. Stomal therapy nurse and pathology registered nurse were also involved in care preoperatively and post-operations. As this case study mainly focus on the care planning for Simon post-operation, the most critical part will be paid by the stomal therapy nurse. Stomal therapy nurse has been particularly regarding as the main contributor in care, because a patient with abdominopereneal resection can pass their waste only through stoma post-operations and lack of knowledge about stoma care might make their life very difficult. Hence, stomal care nurse plays a key role in providing support to Simon post-operations and develop his skills to understand all aspects of stoma care. They provide holistic care patients and educate them about ways to change the stomal bag and maintain the skin integrity around the stoma (Davenport 2014).

The stomal care nurse first starts interaction with patients before operations to determine the site of stoma which will be appropriate for patients. Then they play the main role in their recovery post operations to make patients comfortable with the stoma and the attached device. They give stoma care education related to bowel action from the stoma, keeping ostomy bag clean and infection free and changing pads regularly. They also give education on range of stomal bags which might be appropriate for patients and gives detail on places from where they can access all stoma resources and products. The main purpose is to make the patients manage his stoma and care for it independently to enhance his quality of living (Dutton et al. 2014). 

Conclusion

The report on plan of care for Simon, a patient with abdominopereneal resection gives an idea about the ways to manage patient’s care to make the recovery process fast and quick. The care plan for assisting patients in ambulation and managing pulmonary infections will help to achieve short-term goal of protecting patients from any infections and other complication post surgery. Besides this the stoma care plan is a long-term outcome goal to make patients independent with stoma care to enhance his quality of living. From this report, it can be said that effective stoma care education is the most critical aspect of care for Simon and Liz, the stomal therapy nurse was committed to her job of consistently managing his wounds and provide stoma care education.

References

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