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Case Study MSN III: Post-operation Day 3 Sigmoid Colectomy for Sigmoid CaGroup 3Anith Al Bakri A/P Mustafa Al Bakri (25908)Awng Nashyarudin (29032)Dg Noraini Bt Tajudin (26172)Outline of PresentationPathophysiologyIntroduction: patients profile11 Functional Health PatternAssessmentsDiagnostic/Laboratory InvestigationsSurgical ManagementMedical Management Pharmacological ManagementNursing ProgressNursing Care PlanHealth EducationConclusion

2Pathophysiology(sigmoid colon cancer)Growth of tissue or tumor usually begins as a non-cancerous polyp on the inner lining of the colonA tumor can be benign (not cancer) or malignant (cancer) cancerous growth involves the destruction of the epithelial cell layer, by which the effectiveness of absorption of excess water at the colon is greatly reduced causing the patient to present with symptoms such as diarrhea, constipation, rectal bleeding, blood in the stools, changes in stool consistency, and abdominal pain.

Sigmoid Colectomy -removing part of the left side of the colon known as the sigmoid colon.

Symptoms of colon cancer include diarrhea, constipation, rectal bleeding, blood in the stools, changes in stool consistency, narrow stools, abdominal pain, pain during defecation, frequent urge to defecate, fatigue, weakness, irritable bowel syndrome, iron deficiency anemia and unexplained weight loss

Read more:http://www.doctortipster.com/19782-grape-seed-is-effective-against-colon-cancer.html#ixzz2wxXvbCNGThe wall of the colon made up of several layerscancer starts in the innermost layer and can grow through some or all of the other layersBefore a cancer develops, a growth of tissue or tumor usually begins as a non-cancerous polyp on the inner lining of the ColonA tumor is abnormal tissue and can be benign (not cancer) or malignant (cancer)factor forcolon canceris age. It is said that 90% of people who get diagnosed by colon cancer get diagnosed at the age of 50 or above. Other risk factors include being sedentary, being obese, tobacco smoking, diets which are high in fat and low in fiber and dietsrich in red meat. Still other people get colon cancer when they have diabetes, acromegaly, ulcerative colitis, Crohns disease and radiation treatment for other cancers.

Read more:http://www.doctortipster.com/19782-grape-seed-is-effective-against-colon-cancer.html#ixzz2wxZBgbm3Few risk factors factors responsible for development of cancerous growth includes age, being sedentary, being obese, tobacco smoking, diets which are high in fat and low in fiber

3Introduction: Patients profileMadam N, an 81 years old Iban lady came to the emergency and trauma department on 24/2/2014, present with an abdominal pain and distension for one month and was worsening for the last two days, vomiting after eating for one month, chronic constipation for two days, generalised body weakness, poor oral intake and loss of weight.

Past medical history: She has a known case of hypertension and is currentlyunder follow up at Kota Samarahan. Past surgical history: Sigmoid colectomy done on 7/3/2014Family history: Madam N has a family history of hypertension.Last hospital admission: This will be her fist admissionAllergies: No known food and drinks allergiesCurrent complain: Poor oral intake, abdominal pain at operation site(pain score: 3/10)411 Functional Health Pattern5Assessments (done on 10/3/2014)6Diagnostic /Laboratory investigation Investigation Purpose Findings X ray

To examine the right location of triple line in post insertion of CVP 1st: incorrect location of triple line2nd : correct location of triple lineBlood test (FBC, BUSE, creatinine, PT, PTT, INR)To detect abnormality in blood composition level, electrolyte level)Low Ca, K, Mg, prolonged PT, PTTUSG abdomenTo look for intra-abdominal collection / evidence of anastomatic leak on post sigmoid colectomy .No evidence of leak Arterial blood gas (ABG)Determine thephof the blood, thepartial pressureofcarbon dioxideand oxygen, and thebicarbonatelevelPartially compensated metabolic alkalosis with hyperventilation.7Surgical ManagementOperation undergone: Sigmoid Colectomy (7/3/2014)Pre-operativeInformed consentBlood transfusion consentCBD insertion

Post-colectomypain score monitoring

8Medical ManagementIVF 1.5 L/day N/saline alternate dextrose 5%Central venous line inserted on 11 March 2014 at 11amChest X-rayTPN was started at 12ml/kg/day which equivalent to 600kcal/day @ 11 March 2014Increase caloric requirement from 12kcal/kg/day to 15kcal/kg/day to 18kcal/kg/day to 21kcal/kg/day to 25kcal/kg/day CVP monitoring. CVP reading at 5cm H2O at 12 March 2014 @ 12pmFFP was administered on 12March 2014Daily wound inspectionWound drain on left lower quadrant abdomenDrain charting Daily dressing with kaltostatCentral venous line inserted on 12 March 2014 at 11am9Pharmacological management Routes &DrugsIndication Dosage Frequency

Side effect T. TramadolReduce post-operative pain50mg TDSDizziness, bloating, indigestionT. Paracetamol Reduce post-operative pain1gQIDNot COMMON, with the proper useT. Slow potassium Hypokalemia (k : 1.92)2tabletTDSNausea, vomiting, gas, or diarrheaMist NACL Hyponatremia (na: 122)2gTDSNot COMMON, with the proper useIV Pantoprazole Prevention of gastric ulcer40 mgBDHeadache, dizzinessNausea, vomitingIV Magnesium sulphateHypomagnesemia (mg:0.83) 1 vial in 500ml NS2 HoursHeart disturbances;Rash or flushing;S/C ClexanePrevention of DVT 40mgOD Bleeding, thrombocytopenia, 10-TPN increase to 750kcal/day-CVP monitoring started-Trace HPENursing ProgressPost-colectomy Day 3 (10/3/2014)-Patient not tolerating orally-Wound breakdown observed during inspection-Dressing with Kaltostat -IVD 1.5 L/day N/saline alt D5%

Post-colectomy Day 4 (11/3/2014)-CVL was inserted by doctor-X-ray taken-TPN started at 600kCal/day-Encourage ambulation

11Post-colectomy Day 5 (12/3/2014)Post-colectomy Day 6 (13/3/2014)-TPN administered as prescribed-Wound care: dressing with Kaltostat-strict I/O charting-decrease IVD 1L/day all N/saline alt D5%Nursing Care PlanIdentified Nursing Diagnosis

Imbalanced nutrition: less than body requirements related to poor oral intake as evidenced by verbalization of patient , loss of weight (53 to 50kg ), dehydration (CVP reading : 5 cm H20) and poor skin turgor.Pain at operation site related to surgical operation (Post-operation Day 3 Sigmoid Colectomy) as evidenced by verbalization of patient and pain score of 3 / 10. Risk for ineffective airway clearance related to immobility and pain at operation site as evidenced by observation of resting in bed/bed-bound.Risk for impaired skin integrity related to immobility as evidenced by poor skin turgor, fragile and dry skin.Risk for nosocomial infection related to invasive procedures such as central line, urinary catheter, and cannulation in-situ as evidenced by long stay of hospitalization. 12Diagnosis: Imbalanced nutrition: less than body requirements related to poor oral intake evidenced by verbalization of patient , loss of weight (53 to 50kg ) and poor skin turgor.Goal: Patients will have good tolerance to oral intake and balanced nutrition as evidenced by no further weight loss within 3 days. (10/3/14 @9am)

Intervention:Assess the extent of nutritional imbalance such as monitoring the daily weight to identifying the need for further interventionAssess and provide patient preferred food as this will make her more tolerate to take the food based on her choice.Encourage patient and caregiver to give small frequent meals so that she will gradually more tolerate to take food and enhance absorption of the nutrient effectively.Encourage care giver to prepare home cooked food so that patient will tolerate more to those familiar food.Provide a pleasant environment during her mealtime (eg: free from bad smell, oral hygiene, encouragement to enhance her mood to eat)Administer analgesics as prescribed before meal time to ensure patient is free from pain during meal time and able to have meal comfortably.Administer Total Parenteral Nutrition (TPN) as prescribed by doctor to provide enough and compensate for body need of nutrient to ensure patient received a balanced nutrition.Administer IV fluid as prescribed to ensure patient receives enough amount of fluid to compensate for and prevent dehydration.Monitor CVP reading to assess for hydration status and evaluate for any changes form the earlier management.Evaluation: Patient gradually showing evidenced of receives enough nutrition, improved in tolerance to oral intake, as evidence by no further weight loss and patient verbalization. (13/3/14 @9am)

113Diagnosis: Pain at operation site related to surgical operation (Post-operation Day 3 Sigmoid Colectomy) as evidenced by verbalization of patient and pain score of 3 / 10.

Goal: Patient will verbalize less pain or no pain as evidenced by pain score of 0-1/10 within 3 days of care (10/3/2014 @ 9am).Intervention:Assess site, onset, characteristics, radiation, associated symptoms, time, exacerbating factor and severity of pain to determine patients pain.Give reassurance to patient to allay feelings of anxiousness that aggravates pain and to promote cooperation from patient.Teach patient deep breathing exercise technique to ease pain especially during procedures such as dressingApply diversional therapy such as talking to patient, listening to music to divert patients attention from the painAdminister analgesic medication as prescribed (T. Tramadol 50mg TDS, T. PCM 1g QID) to reduce pain at operation site.Monitor vital signs of patient (blood pressure, respiratory rate, pulse rate, temperature) especially pain score as an indication of pain levels.Reassess pain score of patient to determine effectiveness of management.

Evaluation: patient verbalized less pain as evidenced by pain score of 1 / 10 on last day of attachment in surgical ward (13/3/2014 @ 1.30 pm)214Health education15Conclusion In conclusion, Madam N is still currently receiving her medical and nursing care at the Female Surgical Ward. Her latest diagnosis is Post-operative Sigmoid Colectomy for Sigmoid cancer complicated with wound breakdown. Hence, there is a need for Madam N to be under the care of healthcare providers to promote a physical, psychological and emotional well-being of patient.

Therefore, the collaboration care between doctors, nurses, nutritionist, pharmacist and physiotherapist for further management in Madam Ns case are being done in order to improve the quality of care for patient.

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References

Cancer Research UK(2013). Types of surgery for bowel cancer. Retrieved March 19, 2013 from http://www.cancerresearchuk.org/cancer-help/type/bowel-cancer/treatment/surgery/which-surgery-for-bowel-cancer Seymour, E. & Eli, D. E. (2001). Clinician'sHandbook of Prescription Drugs . 1st ed. McGraw Hill Publication. Chicago.18