Write a report on Post-Operative Intestinal Obstrucion.
This report is based on the case study of a patient, who had been suffering from intestinal blockage after undergoing hemicolectomy due to colon cancer. In hemicolectomy the left side of the large intestine is surgically removed. This operation is mostly performed in case of colon cancers. In some cases the part of the colon is joined to the abdomen for the removal of the feces, known as stoma (Saklani et al., 2013).
The report critically discusses about the problems of the patient, the pathogenesis of the problem, and the different diagnostic techniques for the investigation of the disease. The report also provides an idea of the probable medications that could be given to the concerned patient. It can be difficult to diagnose an intestinal obstruction. The report shows that successful management can detect signs and symptoms subtly at first, followed by a goal to help the patient before the condition deteriorates. Whatever is the treatment, nurse participation in treatment and postoperative care is important. Staying updated with new findings and methods is the best option. An ability to recognize the patient’s physiological, psychological, and safety needs along with a willingness to interact with the patient and other health care providers will yield good results. An active approach in explaining the procedures and consequences will lessen patient anxiety and improve the patient’s scope of responding to the treatment.
Critical issue in the patient and the pathophysiology of the complication
This report provides a case study of a patient having colon cancer, who have undergone a left hemicolectomy with the formation of the stoma. A stoma is usually made where the surgeon brings a part of the colon from inside the body of the patient, through the abdomen and then stitches it down. It is normally done to divert the flow of the feces (Black, 2012). It is been reported that after the patient had been discharged after the surgery, the patient developed certain post operative symptoms like abdominal pain, bloating and less output from the stoma. Normally post operative complications might include infection in the wound, anatomic leakage. Sometimes the bowel, may take more time to start functioning properly, which is known as ileus (Ten Broek et al., 2013). In such a case the patient may develop abdominal distensions, bloating. If the bowel doesn’t start working properly then it can lead to a kink or an adhesion giving fries to blockage (Chapuis et al., 2013). In such a case the patient might develop abdominal cramps, bloating and abdominal distensions, just as we see in the report of the concerned patient. Ileus occurs due to the decreased motility of the gastrointestinal column (Vather, Trivedi & Bissett, 2013). The definite pathogenesis of ileus is multifactorial, the clinical picture shows transiently lessened propulsion of the contents of the intestine. The interaction between the central and the autonomic nervous system function, and some local substances, may alter the equilibrium of the intestine, which results in the unorganized electrical activity and paralysis of some segments of the intestine. No coordination in the propulsiveness of the intestinal muscles leads to the accumulation of fluids and gas within the bowel and often causes intestinal cramps (Doorly & Senagore, 2012).
Investigations and diagnostic tests for the disease
The case study of the patient shows that he has underwent for a CT due to the post operative complications. A systematic review has shown own that computed tomography with Gastrografin scanning can detect the post operative ileus with sensitivity. Multidetector CT scanning is also found to be an effective tool in the detection of the post operative ileus (Santillan, 2013). A plain radiograph of the abdomen shows ileus as dilatation of the colon. An abdominal X-ray can be done to detect the intestinal obstruction, although there are certain obstructions that cannot detect some abdominal obstructions. For some obstruction Air enema can be used, where the doctor will introduce air inside the colon through the rectum (Cameron & Cameron, 2013).
Pharmacological management of the disease
In the case study the patient is found to be suffering from minimal stoma output. In some patients, the stoma output may be minimal. This is normally caused by the formation ileus after the operation, followed by stoma formation —there are certain drugs can also decrease gut motility, such as the antimuscarinics and the opioids (Barletta, 2012). Stoma output can be increased by the application of Prokinetic drugs before meals, like metoclopramide, domperidone or erythromycin (Patil & Anitescu, 2012). The doctor will recommend bowel rest for a period of time along with continuous application of the intravenous fluids. Sometimes a nasogastric tube is passed through the nose to the stomach to ensure enteral feeding.
Glycerol suppositories should be inserted into the stoma opening (if the patient is suffering from constipation and feces can be seen on internal examination of the stoma).
For the patients with stoma, medicine doses with quick dissolution tablets, gelatin capsules should be used. Antibiotics which have a broad spectrum like Amoxicullin, ciprofloxacin can be used to modify the gut microflora. Magnesium containing Antacids can be used. Calcium containing Antacids should not be used as this might lead to constipation. In this case study the patient is reported to have a high blood pressure, so medicines like anti diuretics can be used for treating hyper-tension. Antideuretics like Flurosemide, metolazone can be used. In order to keep the electrolytes balance in the body potassium supplements should also be given. An epidural is used to give relief from the pain.
Non pharmacological treatment
Non pharmacological treatment of the intestinal obstruction involves introduction of the fluids in the body. Fluid intake should be increased. Electrolytes can be given along with the fluids in order to maintain the electrolyte content of the body. After the operation the patient should be encouraged to move as soon as possible. They should avoid increased physical activities and the heavy lifting of substances.
Doctors diagnose diseases and prescribe medicines, treatments and surgeries, but it’s the nurses, that often explains the medical procedures, help to manage the symptoms, listen to the concerns, respond to the emergencies, allay with patient fear, soothe worries and chalk out ways to make things bearable (Andrews & Morgan, 2012).
The following are the interventions that a nurse should follow for the patients suffering from intestinal obstructions-
Apart from all these it is the duty of a nurse to provide psychological care to the patient. A nurse’s mission is not only to save lives but to preserve and to promote the quality of life. A patient having such a critical issue is often faced by anxiety and fear. It is the duty of a nurse to cheer the patients up, reassure him, collect informations and offer explanations for the symptoms, and what to expect during the recovery period. One should be sure to involve the patient’s family in the plan of care when appropriate (Thompson & Magnuson, 2012). A patient with hemicolostomy may experience issues regarding self esteem and have trouble with body shape. Supportive care, encouragement and a reference to the colostomy support group are important to provide suitable nursing care after the operation (Maung et al., 2012).
Hospital stay is usually about 2- 5 days for a key hole surgery and about 5-7 days for an open surgery. If staples and external sutures are used then the hospital stay may take 10-14 days after the operation. Following hospital discharge patients are advised to remain mobile and should avoid doing any physical exercise and should avoid taking fibrous and spicy foods. A follow up report should be fixed after two weeks but a patient can see the concerned doctor at any time if problems persist (Jain & Vargas 2012).
In the following report the patient is seen to be suffering from intestinal distension, intestinal cramping bloating and low output from the stoma. Among the different complications due to intestinal blockage, dehydration due to electrolyte imbalance had been focused in this topic.
In some cases the stoma output of the patients are huge or the patient may suffer from severe diarrhea as a result the net fluid and the electrolytes, that are responsible for many biochemical activities of the body is lost. Severe dehydration can lead to failure of organs, shock and finally death (Schneider et al., 2013).
In order to replace the fluids back to the normal amounts, intravenous fluids like St Mark’s solution and Dioralyte’s double strength solution can be used can be given and fluids containing electrolytes can be infused for getting the right amount of electrolytes in the body (Ouaïssi et al., 2012).
An extensive research has been performed through different databases like Google scholar, Pubmed, NCBI , Charles Darwin university library and more to find out the all the facts related to this critical issue. A thorough research has been done through the various research journals.
The journal by Ouaïssi et al (2012) suggests that the definite pathogenesis of ileus is multifactorial, the clinical picture shows transiently lessened propulsion of the contents of the intestine. The interaction between the central and the autonomic nervous system function, and some local substances, may alter the equilibrium of the intestine, which results in the unorganized electrical activity and paralysis of some segments of the intestine which leads to bowel blockage.
In the research by Doorly & Senagore, (2012) it has been found that Postoperative ileus (POI) is an unavoidable outcome of most of the abdominal surgery. Although ileus is thought to be a disease of the small intestine, the duration of POI may be dependent on the return of colonic motility. Physicians should analyze the risk factors leading to the development of POI to help prevent this morbid and financial problem. POI is multifactorial in origin and the causative factors involve neuromuscular, inflammatory, and pharmacologic factors.
The journal by Jain & Vargas, (2012) discusses about challenges faced in the management of acute pseudo-obstruction in colon.
In the journal by Maung et al (2012) management of the intestinal obstruction has been described. Water-soluble oral contrast medium (WSCM) is preferred for both diagnostic and therapeutic purposes in patients undergoing nonoperative management.
Hyaluronic acid, icodextrin and Carboxycellulose membrane decrease the incidence of adhesions. Icodextrin may decrease the risk of obstruction.
In the journal of Andrew & Morgan, (2012) one gets an idea about the Constipation management in palliative care. It also provides information about treatments and the potential of independent nursing.
Conclusion
The following report is based on the case study of a patient who has suffered hemicolectomy due to colon cancer and is now suffering from intestinal obstruction. It can be reviewed from the researches that the pathogenesis of post operative intestinal obstruction is multifactorial. Ileus occurs due to the decreased motility of the gastrointestinal column. The concerned patient is having minimal output of stool from the stoma. Thus, medications should be prescribed that would increase the mobility of the colon, he should be given fluids in order to restore the electrolytes in the body. The patient has been reported to have abdominal cramps, so medicines for that have also been prescribed. It can be difficult to diagnose an intestinal obstruction. The report shows that successful management can detect signs and symptoms subtly at first, followed by a goal to help the patient before the condition deteriorates. Whatever is the treatment, nurse participation in treatment and postoperative care is important. Staying updated with new findings and methods is the best option. An ability to recognize the patient’s physiological, psychological, and safety needs along with a willingness to interact with the patient and other health care providers will yield good results. An active approach in explaining the procedures and consequences will lessen patient anxiety and improve the patient’s scope of responding to the treatment.
References
Andrews, A., & Morgan, G. (2012). Constipation management in palliative care: treatments and the potential of independent nurse prescribing. International journal of palliative nursing, 18(1).
Barletta, J. F. (2012). Clinical and economic burden of opioid use for postsurgical pain: focus on ventilatory impairment and ileus. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy, 32(9pt2).
Black, P. (2012). Choosing the correct stoma appliance. Gastrointestinal Nursing, 10(7).
Cameron, J. L., & Cameron, A. M. (2013). Current Surgical Therapy E-Book. Elsevier Health Sciences.
Chapuis, P. H., Bokey, L., Keshava, A., Rickard, M. J., Stewart, P., Young, C. J., & Dent, O. F. (2013). Risk factors for prolonged ileus after resection of colorectal cancer: an observational study of 2400 consecutive patients. Annals of surgery, 257(5), 909-915.
Doorly, M. G., & Senagore, A. J. (2012). Pathogenesis and clinical and economic consequences of postoperative ileus. Surgical Clinics of North America, 92(2), 259-272.
Jain, A., & Vargas, H. D. (2012). Advances and challenges in the management of acute colonic pseudo-obstruction (ogilvie syndrome). Clinics in colon and rectal surgery, 25(01), 037-045.
Maung, A. A., Johnson, D. C., Piper, G. L., Barbosa, R. R., Rowell, S. E., Bokhari, F., … & Kerwin, A. J. (2012). Evaluation and management of small-bowel obstruction: an Eastern Association for the Surgery of Trauma practice management guideline. Journal of Trauma and Acute Care Surgery, 73(5), S362-S369.
Ouaïssi, M., Gaujoux, S., Veyrie, N., Denève, E., Brigand, C., Castel, B., … & Nocca, D. (2012). Post-operative adhesions after digestive surgery: their incidence and prevention: review of the literature. Journal of visceral surgery, 149(2), e104-e114.
Patil, S. K., & Anitescu, M. (2012). Opioid?Free Perioperative Analgesia for Hemicolectomy in a Patient With Opioid?Induced Delirium: A Case Report and Review of the Analgesic Efficacy of the Alpha?2 Agonist Agents. Pain Practice, 12(8), 656-662.
Saklani, A. P., Naguib, N., Shah, P. R., Mekhail, P., Winstanley, S., & Masoud, A. G. (2013). Adhesive intestinal obstruction in laparoscopic vs open colorectal resection. Colorectal disease, 15(1), 80-84.
Santillan, C. S. (2013). Computed tomography of small bowel obstruction. Radiologic Clinics of North America, 51(1), 17-27.
Schneider, E. B., Hyder, O., Brooke, B. S., Efron, J., Cameron, J. L., Edil, B. H., … & Pawlik, T. M. (2012). Patient readmission and mortality after colorectal surgery for colon cancer: impact of length of stay relative to other clinical factors. Journal of the American College of Surgeons, 214(4), 390-398.
Ten Broek, R. P., Issa, Y., van Santbrink, E. J., Bouvy, N. D., Kruitwagen, R. F., Jeekel, J., … & van Goor, H. (2013). Burden of adhesions in abdominal and pelvic surgery: systematic review and met-analysis. Bmj, 347, f5588.
Thompson, M., & Magnuson, B. (2012). Management of postoperative ileus. Orthopedics, 35(3), 213-217.
Vather, R., Trivedi, S., & Bissett, I. (2013). Defining postoperative ileus: results of a systematic review and global survey. Journal of gastrointestinal surgery, 17(5), 962-972
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