Bowel Scenario

Question 1

What is the pathophysiology of the large bowel?

Answer 1

Large intestine consists of:
Vermiform appendix
Caecum
Ascending, transverse and descending sigmoid colon.
Most nutrients already absorbed by small intestine.

Question 2

What is the main function of the large bowel?

Answer 2

Remove remaining water and solidify the material into faeces.
Contains bacteria to aid digestion.
Colon intermittently contracts pushing waste material into the rectum.

Question 3

What is the function of the rectum and anus?

Answer 3

Defecation takes place, excreting waste products.

Occurs under neurological voluntary control in adults.

Question 4

What are the 4 major functions of the large bowel?

Answer 4

Reabsorption of water and mineral ions such as sodium and chloride.
Formation and temporary storage of faeces.
Maintaining a resident population of over 500 species of bacteria.
Bacterial fermentation of indigestible materials.

Question 5

What is bacterial fermentation in the large bowel?

Answer 5

the bacteria that inhabit the large intestine can further digest some material creating gas.
Bacteria also make some important substances such as Vitamin K (important role in blood clotting).

Question 6

What are the clinical features of bowel cancer?

Answer 6

Anaemia
Change in bowel habit
Rectal blood loss
General malaise
Anorexia/weight loss
Colicky pain
Bowel obstruction

Question 7

What is chemotherapy?

Answer 7

Chemotherapeutic drugs target rapidly dividing cells and cause cell death in 2 ways:
- interfering with the cell’s genetic information
-disrupting the normal process of cell division
The drugs can be used singularly or in combination (most common).
Usually given in cycles with a rest period in between.

Question 8

What is radiotherapy?

Answer 8

Ionised particles (electrons, protons and gamma rays) are used to attack cancer cells and damage their DNA.
Given via external beam to a targeted point, occasionally placed inside tumour (brachytherapy).
Usually given daily for up to 7 weeks.

Question 9

What are the side effects of radiotherapy?

Answer 9

Skin reactions: usually in 2nd/3rd week of treatment, local to site of radiotherapy, skin very vulnerable.
Pruritus (itch): caused by decreased production of sweat and sebaceous glands, excessive drying causes itching.
Erythema: inflammatory rection in epidermis.
Alopecia
Dry + moist desquamation(peeling of skin)

Question 10

What are the investigations and screening for bowel cancer?

Answer 10

Digital rectal exam and abdominal examination.
Colonoscopy
Sigmoidoscopy depending on surgeon's choice.
May have barium enema to show tumours.
CT scan and ultrasound of liver
Stool specimen and FOB/FIT test.
Staging of cancer.
FBC.

Question 11

What is an FOB and/or FIT test?

Answer 11

FIT test now used in Scotland.
One sample of poo collected to be checked.
FOB test detects tiny amounts of hidden blood in poo (occult blood).
Bowel cancers/polyps sometimes bleed but there can be other causes.
If blood is detected by FOB/FIT then further testing will be offered, usually a colonoscopy.

Question 12

What is a colonoscopy?

Answer 12

A thin, flexible tube (colonoscope) is inserted into the rectum to examine the lining of the bowel.
Small camera on the end of the tube is used to take pictures and samples may be collected.
Requires bowel preparation to clear the bowel, given in the form of laxatives and a specific diet the day before.

Question 13

How is cancer staged?

Answer 13

TMN staging
T(Tumour) staging is the size of the primary tumour.
N(Nodes) describes presence of lymph node involvement.
M(Metastasis) describes presence/or lack of metastasis.

Question 14

What is combined chemotherapy and radiotherapy used for?

Answer 14

Preparation for surgery.
Agressive cancer management.
Symptom control in palliative care.

Question 15

How does chemotherapy affect normal cells and what areas are affected?

Answer 15

Chemotherapeutic drugs attack rapidly replicating cells which means normal cells are also at risk of damage.

Areas affected include:
Bone marrow
Digestive system
Hair and nails
Reproductive system
Peripheral nervous system

Question 16

Why are regular blood tests (FBC) important when receiving chemotherapy?

Answer 16

Chemotherapy affects the bone marrow where blood cells are made, therefore the levels of blood cells tend to drop.
FBC shows the number of white blood cells, red blood cells and platelets in the blood.

Question 17

How are the blood cells affected during chemotherapy? (bone marrow suppression)

Answer 17

Reduced red cell count: causes anaemia, increased cardiac workload, dyspnoea, confusion and lethargy/fatigue.
Reduced white cell count: results in patient becoming immunocompromised and/or neutropenic (low level of neutrophils), making them more susceptible to infection.
Reduced platelet count: increases risk of bleeding, purpura (blood spots) and peripheral rashes.

Question 18

What is neutropenia?

Answer 18

Decreased number of leucocytes and neutrophils (white blood cells) in the blood.
Can be life threatening and puts patients at increased risk of infection.

Question 19

What is pancytopenia?

Answer 19

Decreased number of all cells in bone marrow.

Question 20

How should bone marrow levels be monitored?

Answer 20

Regular FBC’S, before, during and after treatment, suppression generally peaks at 7-10 days.
Monitor for infection - even low grade pyrexia needs vigorous treatment.
Check for bruising, petechiae (blood spots) and bleeding.
Check haemoglobin levels, a drop will cause patient to become dyspneic (SOB) and lethargic.
All symptoms should be treated with caution.

Question 21

Bone marrow suppression - How are reduced white blood cells + reduced platelets treated?

Answer 21

Antibiotics
Swab any lesions
Blood cultures
Prophylactic antibiotic 
Anti-fungal
Anti-viral
May require isolation.
For reduced platelets - platelet transfusion

Question 22

Chemotherapy- how would you care for a patient with diarrhoea/constipation?

Answer 22

Anal skin care
Use of barrier creams
Monitor fluid balance to prevent dehydration - food and fluid charts.
IV rehydration and electrolyte replacement if indicated.
Monitor nutrition and weight to prevent significant weight loss - use MUST tool if weight loss occurs.
Document skin care.
Medication - loperamide

Question 23

Chemotherapy- how would you care for a patient with nausea?

Answer 23

Assess potential for nausea/vomiting, reduce anxiety level.
Buccal (on gum line, against cheek) anti-emetic (ondansetron), give regularly according to protocol.
Monitor fluid balance and for intake with charts - encourage nutrition with small meals/snacks to prevent weight loss
If oral fluid intake low, consider IV fluids.
If oral medication not tolerated, consider IV medication.
Reduce odours in clinical area where possible.
Non-pharmalogical methods: ginger, travel bands, diversional activities.
Auscultate bowel sounds, note absence or hyperactive sounds.
It uncontrolled review treatment in line with chemo protocol.

Question 24

Chemotherapy- how would you prevent and treat mouth/yeast infection?

Answer 24

Promote regular oral hygiene
Regular mouth care if indicated.
Treat with anti-thrush medication (e.g. Nystatin).

Question 25

Chemotherapy - how would you treat a patient with fatigue?

Answer 25

Offer advice and strategies for coping with fatigue. | Consider sleeping tablets if caused by insomnia.

Question 26

What is the role of the stoma nurse post-op?

Answer 26

Review stoma and function. Provide reassurance to patient. Perform first bag change. Provide education and ensure patient is able to self-manage. Prepare patient for discharge , arranging post-op appointments. Advise and organise required equipment (bags, flanges etc). Monitor stoma (size, swelling, colouring etc).

Question 27

What is the role of the stoma nurse pre-op?

Answer 27

Provide information and literature re. surgery. Provide information on appliances. Siting of the stoma. Answer questions/concerns

Question 28

What are the two types of ileostomy?

Answer 28

Loop ileostomy: loop of small intestine pulled out through cut in abdomen. Colon+rectum in place. Temporary. End ileostomy: whole colon removed through cut in abdomen, end of small intestine forms stoma. Permanent.

Question 29

What are the two types of colostomy?

Answer 29

Loop colostomy: loop of colon pulled out through abdomen, has 2 openings. Temporary and reversible, often used in emergencies. End colostomy: one end of colon pulled out to form stoma. Often used when part of colon/rectum has been removed. Permanent.

Question 30

What are the 4 types of stoma bags?

Answer 30

One piece : fits around stoma, attached with adhesive. Whole bag needs removed when changing. Two piece: base plate fits around stoma, bag attaches to plate. Base plate changed 2-3 days. Closed bags: cannot be emptied/drained. Best for from stools, regular changing. Drainable bags|: have opening for draining of bag contents. Best used with loose stools, requires changing 2-3 days.

Question 31

What is ERAS?

Answer 31

``` Enhanced Recovery After Surgery. Aims to shorten time spent in hospital post-surgery. Reduces anxiety and stress. Prevents diabetic type symptoms. Reduces thirst. Promotes healing. Reduces cost of prolonged hospital stay. Reduces HAI's. ```

Question 32

What is the ERAS pre-op protocol?

Answer 32

Oral diet up until 6 hours before surgery. Clear, non-fat fluids allowed until 2 hours before surgery. Pre-op carbohydrate loading drinks given up to 2 hours pre-op, as they evacuate the stomach in 1.5 hours. Standard checks: CXR, ECG, routine bloods, height, weight, allergies, history, baseline vital signs.

Question 33

What is the ERAS post-op protocol?

Answer 33

laparoscopic surgery where possible. No drains, only surgical glue and steri-strips for closure. One dose intrathecal morphine - effects gut motility so give different painkillers thereafter and step down when possible. IV fluids initially(slowly to avoid overload) and small sips, gradually increasing if tolerated until IV can be removed. All lines/catheters removed ASAP. Encourage patient to be out of bed on day 0, minimum of 6/24 hours as encourages recovery. No NG required unless paralytic ileum. Post-op lactulose to reduce strain on stoma and stimulate bowel. TED stockings. Deep breathing exercise to prevent chest infection.

Question 34

ERAS Protocol - what should the appearance of the stoma be post-op + what is important regarding stoma bag?

Answer 34

Red and shiny, usually round or oval in shape, swollen for 6-8 weeks. Above skin level. Notify surgeon if pale in colour. Dark hue may suggest anaemia or ischaemia. Pouch should fit correctly. Clear bag should be used for 2 days to monitor output.

Question 35

How should you care for a stoma?

Answer 35

Skin must be protected from irritable digestive enzymes. Careful cleaning and drying of skin around stoma important. Avoid soaps with moisturiser as residue can interfere with bag adhesion, warm water acceptable. Adhesive remover can be used.

Question 36

What is important before discharge post-stoma surgery?

Answer 36

If flatus present but no bowel movement patient can be discharged. Diet advice should be given. Patient should be self-caring by time of discharge. Patient informed of 'phantom rectum' which causes the patient to feel the need to defecate urgently.

Question 37

How does the nurse care for the patient with altered body image due to stoma?

Answer 37

Consider patient perception of stoma and ability to manage it. Are they able to self-manage? Involve family/carers in post-op care and education where possible. How is patient able to adapt to having the stoma? Explain the need for time. Important to have support in place post-op, low mood common and can affect quality of life. Stages of grief can occur - Loss, Denial, Anger and Depression due to mourning the loss of their old self. Consider issues with patient's sexuality with stoma: loss of confidence, feeling of being unattractive, fear of intimacy, lack of acceptance from partner which can result in decreased sexual function. Provide reassurance regarding stoma, appearance, future health and importance of acceptance. Determine if psychological support required.