Question

Patient Introduction

Location: Surgical Unit 0800

Report from night nurse:

Situation: Mr. Hayes is a 43-year-old white male who underwent a laparoscopic abdominal perineal resection with a permanent sigmoid colostomy 3 days ago for rectal cancer.

Background: Mr. Hayes experienced weight loss, increasing fatigue, and narrowing stools with blood, which led to the diagnosis of rectal adenocarcinoma and the recent surgery.

Assessment: Vital signs have been stable with a saturation of 94%–97%. Pain level is currently 1 after pain medication was administered an hour ago. The colostomy appliance is an open-ended pouch attached to a skin barrier. The stoma is red and moist with liquid, brown stool output. The three small abdominal incisions are open to air. There is a clean pad covering the perineal incision. Mr. Hayes has been up and ambulating and is taking full liquids.

Recommendation: It is time for Mr. Hayes's morning assessment. Assess his colostomy, and empty the pouch, if necessary. He can advance to a regular diet as tolerated. Start providing patient education to prepare him for discharge in 2–3 days.

Opening Questions

How did the simulated experience of Marvin Hayes’s case make you feel?

Talk about what went well in the scenario.

Reflecting on Marvin Hayes’s case, were there any actions you would do differently if you were to repeat this scenario? If so, how would your patient care change?

Scenario Analysis Questions*

PCC         What priority problem(s) did you identify for Marvin Hayes?

PCC         What potential problems could arise due to the newly placed colostomy?

PCC         Discuss what type of diet would be appropriate for Marvin Hayes.

PCC/T&C   Discuss the importance of peer support groups with other adults with colostomies.

EBP          Explain why it is important to measure the stoma at least once a week for the first 6-8 weeks after surgery.

T&C      What other interprofessional team members should be involved in Marvin Hayes’s care?

I                 Cite one source that you could give to Marvin Hayes that would provide more information on colostomy care and resources.          

Concluding Questions

Describe how you would apply the knowledge and skills that you obtained in Marvin Hayes’s case to an actual patient care situation.

Answer 1

The colostomy is a surgical procedure in which a stoma is created from which the healthy large intestine or colon is drawn to the anterior surface of abdomen. This colostomy is created to drain the stool out of the body or give the intestines time to heal itself like case of rectum cancer, any surgery involving removal of part of intestines or colon or in fecal incontinence.The colostomy can be temporary or permanent.

Patient education about colostomy care:

• Eat well balanced diet including vegetables and fruits.
• Drink atleast 6-8 glasses of water daily.
• The strong odour producing food include garlic, onion, broccoli,cabbage. If odour is your concern then limit the use of these foods.
• Chew your food thoroughly.
• Learn to apply and self evacuate the pouch.
• You can apply the pouch in sitting or standing position.
• Excessive hairs need the pouch application should be removed and it should be wrinle free.
• The best time to change the pouch is morning before drinking and eating.
• Watch for stool consistency and color of stoma frequently.
• Change the pouch when it is one third full.

Mr. Hayes's experience with the operative procedure went well with formation of good colostomy. The experience to have cancer is a devastating one. It is not easy to cope with the thought that one is suffering from cancer. Mr. Hayes who underwent colostomy after the surgery will have to make certain lifestyle changes to cope with this change in the body image. All the actions taken by the nurse in the above scenario is satisfying except that more frequent supervision of the stoma is required and to change the pouch as its one third full.

PROBLEMS: The problem that is found in the Mr. Hayes's situation is the presence of liquid brown stool, difficulty in coping with the changed body image, lack of confidence to perform colostomy care.

COMPLICATIONS: The common potential complications seen after a newly placed colostomy includes bleeding, infection, leakage around the stoma, injury to the surrounding organ during the procedure, narrowing of the stoma.

DIET: The diet of Mr. Hayes should be well balanced consisting of fruits and vegetables. Eat at regular intervals. Eat in a peaceful environment and chew your food adequately. Take plenty of fluids about 6-8 glasses every day. Limit gas forming foods like onion, garlic, cabbage, broccoli, fish. Eating yogurt or buttremilk can reduce gas. Try new foods one at a time. Avoid gaining excessive weight. Be cautious while taking foods that are not completely digestible like peas, celery, seeds and nuts,raisins, coconut etc. Include foods high in fibre in your diet to prevent constipation. Limit coffee, chocolate, lemon juice.

PEER SUPPORT: Since the changes brought in the lifestyle and the body image of the individuals with colostomy can be coped better if they seek the help of peer support groups and other people with colostomies. This will help them to understand their condition better and also eliminate the fear and concern regarding colostomy care. They can have open discussion among the peer regarding there condition which will help them to cope adequately with the situation.

MEASURING STOMA: The stoma should be observed and measured at least once a week for the first 6- 8 weeks after the surgery in order to identify any inflammation of the stoma and herniation for the stoma from the initial placement.

TEAM MEMBERS: The members included in the team of colostomy care are doctors, nurses, stoma care nurse, physiotherapist, dietician, social worker and member of pastoral care team.

Reference for patient: Measuring your stoma- ostomy care and supply.

ANSWER: From the above case scenario, knowledge regarding the general presentation of colostomy is achieved. How the patient's diet should be planned. What are the various patient education to be provided. The demonstration of colostomy care and return demonstration will be practiced in order to ensure that the patient knows how to manage his stoma. This patient care situation have also imparted knowledge regarding the psychological aspect of the disease and ways to cope with the changes.