1st Trigger : Ron
2nd Trigger: Sarah
3rd Trigger: Ebony
4th Trigger: Sunita
5th Trigger: Ivana
Steve Little Part 1
Trigger 1
You are a student nurse on an afternoon shift on a colorectal ward. You have been allocated
to care for Steve who has been diagnosed with recto-sigmoid carcinoma. Steve is scheduled
for an anterior resection +/- temporary loop ileostomy the following morning.
What is an anterior resection?
This is an operation to remove part of the rectum and part of the left side of the large bowel. It is most
commonly performed for bowel cancer. It can be performed open with an incision in the abdominal wall
or laparoscopically, commonly called keyhole surgery.
After the segment of bowel is removed, along with its blood supply, the two ends of bowel are joined
together with stitches or stapling devices. This requires the anal canal to be preserved, and the bowel
upstream to be able to be brought down to join the rectum or anus without compromising the bowels
blood supply.
It is uncommon to require a bag or stoma in association with a high anterior resection, which involves
removing the upper part of the rectum, and if it is required it is usually associated with some emergency
situations and when the patient is very unhealthy.
It is more common to require a bag or stoma in association with a low or very low anterior resection,
which involves removing most or all of the rectum. The bag or stoma is usually a loop ileostomy to divert
faecal matter from the downstream bowel join.
If the anus has to be cut out because of the rectal tumours position, or a bowel join cannot be performed, a
left sided end colostomy is usually created.
The risks associated with an anterior resection can be related but not limited to the wounds (wound
,infection, hernia), the bowel join (leakage, bleeding), and to the patient’s heart (arrhythmia), lungs
(infection), kidneys and urinary system and the venous system (deep vein thrombosis, pulmonary
emboli). (Farrell, 2017; Rodriguez-Bigas, 2016).
!
What is a loop ileostomy?
A loop ileostomy is formed by pulling a loop of ileum through the skin, while it remains attached to both
upstream and downstream portions of intestine beneath the skin. The resulting stoma has two openings,
one from the upstream side, the other from the downstream side. The upstream opening flows digestive
waste, while the downstream opening (known as a “mucous fistula”) secretes mucus that’s generated in
the downstream portion of intestine (Rodriguez-Bigas, 2016).
, You and the RN discuss that Steve needs to be educated about preoperative fasting, bowel
preparation and pre-operative antibiotics.
What is the rationale behind preoperative fasting and preoperative bowel preparation?
If foods and fluids are consumed by patients that are healthy and going through with elective
surgery this can still cause complications during the operation. The importance about
preoperative fasting helps lower the risks of aspiration of residual gastric volume, pH variations
and changes in the oesophageal sphincter tone. Preoperative fasting (normally from midnight)
plays a big role in reducing risks of pulmonary aspiration (Gebremedhn & Nagaratnam, 2014).
The importance of preoperative bowel preparation is to clean out the bowel completely to ensure
the dr can thoroughly examine the patients colon (Endoscopy, 2018). The preparation should
remove all faecal matter and it should not cause any discomfort within the patient (Saltzman &
Cash, 2015). It is important to know that inadequate bowel preparation can affect up to 30% of
colonoscopies not allowing an effective examination to be complete. This can leave polyp, cecal
intubation, procedure times and examinations as consequences due to undetected complications
in the bowel (Writers, 2017).
References
, Is it permanent?
An ileostomy that’s intended to be permanent will be an “end” ileostomy. In this case, a single cut end of
ileum is pulled through the skin and made into a stoma. The resulting stoma has a reasonably round cross
section, and forms a spout that helps keep the caustic output away from the skin. Such a stoma is
relatively easy to care for.
A loop ileostomy is formed by pulling a loop of ileum through the skin, while it remains attached to both
upstream and downstream portions of intestine beneath the skin. The resulting stoma has two openings,
one from the upstream side, the other from the downstream side. The upstream opening flows digestive
waste, while the downstream opening (known as a “mucous fistula”) secretes mucus that’s generated in
the downstream portion of intestine.
Considering that, in every situation involving a temporary ileostomy, there is always some remaining
intestine downstream from the stoma site (which hasn’t been removed but is only being bypassed), a loop
stoma tends to be the natural choice. There can be situations in which either a loop stoma or end stoma
can be used for a temporary ileostomy, but even then, the loop stoma tends to be preferred because it can
be closed more easily and safely when it comes time to reverse the temporary ostomy (Rodriguez-Bigas,
2016).
Complications w/ ileostomy
Risks that are specific to ileostomies include:
● damage to the surrounding organs
● internal bleeding
● an inability to absorb enough nutrients from food
● urinary tract, abdominal, or lung infections
● an intestinal blockage due to scar tissue
● wounds that break open or take a long time to heal
The skin around the stoma can become irritated or moist, which will prevent getting a seal with the
ostomy pouch. This can result in a leakage. A doctor can prescribe a medicated topical spray or powder to
heal this irritated skin.
Sometimes the ileostomy doesn't function for short periods of time after surgery. This isn't usually a
problem, but if the stoma isn't active for more than six hours and the patient experiences cramps or
nausea, they may have an obstruction.
2nd Trigger: Sarah
3rd Trigger: Ebony
4th Trigger: Sunita
5th Trigger: Ivana
Steve Little Part 1
Trigger 1
You are a student nurse on an afternoon shift on a colorectal ward. You have been allocated
to care for Steve who has been diagnosed with recto-sigmoid carcinoma. Steve is scheduled
for an anterior resection +/- temporary loop ileostomy the following morning.
What is an anterior resection?
This is an operation to remove part of the rectum and part of the left side of the large bowel. It is most
commonly performed for bowel cancer. It can be performed open with an incision in the abdominal wall
or laparoscopically, commonly called keyhole surgery.
After the segment of bowel is removed, along with its blood supply, the two ends of bowel are joined
together with stitches or stapling devices. This requires the anal canal to be preserved, and the bowel
upstream to be able to be brought down to join the rectum or anus without compromising the bowels
blood supply.
It is uncommon to require a bag or stoma in association with a high anterior resection, which involves
removing the upper part of the rectum, and if it is required it is usually associated with some emergency
situations and when the patient is very unhealthy.
It is more common to require a bag or stoma in association with a low or very low anterior resection,
which involves removing most or all of the rectum. The bag or stoma is usually a loop ileostomy to divert
faecal matter from the downstream bowel join.
If the anus has to be cut out because of the rectal tumours position, or a bowel join cannot be performed, a
left sided end colostomy is usually created.
The risks associated with an anterior resection can be related but not limited to the wounds (wound
,infection, hernia), the bowel join (leakage, bleeding), and to the patient’s heart (arrhythmia), lungs
(infection), kidneys and urinary system and the venous system (deep vein thrombosis, pulmonary
emboli). (Farrell, 2017; Rodriguez-Bigas, 2016).
!
What is a loop ileostomy?
A loop ileostomy is formed by pulling a loop of ileum through the skin, while it remains attached to both
upstream and downstream portions of intestine beneath the skin. The resulting stoma has two openings,
one from the upstream side, the other from the downstream side. The upstream opening flows digestive
waste, while the downstream opening (known as a “mucous fistula”) secretes mucus that’s generated in
the downstream portion of intestine (Rodriguez-Bigas, 2016).
, You and the RN discuss that Steve needs to be educated about preoperative fasting, bowel
preparation and pre-operative antibiotics.
What is the rationale behind preoperative fasting and preoperative bowel preparation?
If foods and fluids are consumed by patients that are healthy and going through with elective
surgery this can still cause complications during the operation. The importance about
preoperative fasting helps lower the risks of aspiration of residual gastric volume, pH variations
and changes in the oesophageal sphincter tone. Preoperative fasting (normally from midnight)
plays a big role in reducing risks of pulmonary aspiration (Gebremedhn & Nagaratnam, 2014).
The importance of preoperative bowel preparation is to clean out the bowel completely to ensure
the dr can thoroughly examine the patients colon (Endoscopy, 2018). The preparation should
remove all faecal matter and it should not cause any discomfort within the patient (Saltzman &
Cash, 2015). It is important to know that inadequate bowel preparation can affect up to 30% of
colonoscopies not allowing an effective examination to be complete. This can leave polyp, cecal
intubation, procedure times and examinations as consequences due to undetected complications
in the bowel (Writers, 2017).
References
, Is it permanent?
An ileostomy that’s intended to be permanent will be an “end” ileostomy. In this case, a single cut end of
ileum is pulled through the skin and made into a stoma. The resulting stoma has a reasonably round cross
section, and forms a spout that helps keep the caustic output away from the skin. Such a stoma is
relatively easy to care for.
A loop ileostomy is formed by pulling a loop of ileum through the skin, while it remains attached to both
upstream and downstream portions of intestine beneath the skin. The resulting stoma has two openings,
one from the upstream side, the other from the downstream side. The upstream opening flows digestive
waste, while the downstream opening (known as a “mucous fistula”) secretes mucus that’s generated in
the downstream portion of intestine.
Considering that, in every situation involving a temporary ileostomy, there is always some remaining
intestine downstream from the stoma site (which hasn’t been removed but is only being bypassed), a loop
stoma tends to be the natural choice. There can be situations in which either a loop stoma or end stoma
can be used for a temporary ileostomy, but even then, the loop stoma tends to be preferred because it can
be closed more easily and safely when it comes time to reverse the temporary ostomy (Rodriguez-Bigas,
2016).
Complications w/ ileostomy
Risks that are specific to ileostomies include:
● damage to the surrounding organs
● internal bleeding
● an inability to absorb enough nutrients from food
● urinary tract, abdominal, or lung infections
● an intestinal blockage due to scar tissue
● wounds that break open or take a long time to heal
The skin around the stoma can become irritated or moist, which will prevent getting a seal with the
ostomy pouch. This can result in a leakage. A doctor can prescribe a medicated topical spray or powder to
heal this irritated skin.
Sometimes the ileostomy doesn't function for short periods of time after surgery. This isn't usually a
problem, but if the stoma isn't active for more than six hours and the patient experiences cramps or
nausea, they may have an obstruction.
