Assessment- scenario based nursing care plan - Nursing and Acute Care

The aim of this week's IBL session is to help students investigate on bowel surgeries, care of colostomy, patient and family education, psychosocial impact, collaborative care and genetic counselling. Although Mr Jones is diagnosed with bowel cancer, we are not going into the multimodal treatments of cancer, as this will be a focus in Cancer IBL in week 6. 

Part 1 -

Mr Peter Jones is a 62-year-old man who lives in a Western suburb of Melbourne. He retired a few years ago after many years of service as a truck driver. He weighs 84kgs, leads a sedentary lifestyle and spends most of his day watching television. He is a smoker and drinks about four stubbies a day. He also has hypertension for the past eight years. For the last couple of months, Mr Jones has been noticing blood in his stool but ignored it and did not care to mention to Mrs Jones. In the last week, he has also been experiencing abdominal pain that comes and goes in waves and he is very constipated. Since this morning, he has been experiencing increased bloating and discomfort in his abdomen, which then progressed as severe abdominal pain, not relieved by any remedies offered by Mrs Jones. Soon he was taken to the emergency department of the closest hospital. Initial abdominal x-ray and a CT scan revealed a tumour obstruction in the recto sigmoid region of the colon and multiple lesions in the liver.

Abdominal x-ray

Interpretation of abdominal x-ray

This upright abdominal x-ray shows multiple air-fluid levels, which are indicative of a bowel obstruction.   Most bowel obstructions are small-bowel obstructions, caused by intra peritoneal adhesions.  However, a careful review of this shows dilation of the large intestine, indicated by the larger calibre of the air-filled segments.  The air extends into the left lower quadrant and pelvis, indicating that the obstructive lesion is quite distal, in the recto-sigmoid region.  Therefore, this is a distal large bowel obstruction.

CT scan

Interpretation of the CT scan

A CT scan of the upper abdomen shows metastasis in the liver of a patient with carcinoma of the large bowel. Note the dark areas in the liver (left side and centre of picture).

Interpretation of the CT scan

This abdominopelvic CT scan shows the obstructing lesion.  Rectal contrast was administered, and bright, undiluted contrast can be seen filling the ascending rectal segment (to the right of the arrows).   The gut proximal to the lesion is markedly dilated with air-fluid levels, and there is some contrast present, indicating that the obstruction was not quite complete, though certainly high-grade.

Mr Jones was taken in for an emergency laparotomy for the resection of the recto-sigmoid tumour. Post operatively he has a stoma and a large dressing covering his laparotomy wound. On the first post operative day when the nurse comes to assess the Mr Jones, he was awake and Mrs Jones was beside him. Mrs Jones requested if you could tell her about the surgical procedure Mr Jones underwent.

Learning triggers

1) What is intestinal obstruction? What are the types of intestinal obstruction? What is the difference in the clinical manifestations of small or large intestinal obstruction?

2) What are the surgical goals and the pre-operative preparation for a patient going for colorectal surgery?

3) What is the surgical management for colorectal cancer?

4) What are the types of ostomies? What are the specific nursing management after ostomy surgery?

5) Identify some of the general post-operative nursing care concerns after a laparotomy?

Rationale/clinical reasoning relating to the IBL scenario

1) What are some of the presenting complaints of Mr Jones that is indicative of bowel obstruction?

2) How will you assess and prepare Mr Jones for the emergency laparotomy?

3) What type of surgery does Mr Jones need for his recto sigmoid tumour? Why is a colostomy performed in Mr Jones' case?

4) How long will it take for Mr Jones's colostomy to be active? What are some of the possible areas of concerns of Mr Jones going home with a colostomy?

5) Prepare a patient & family teaching guide for Mr Jones & Mrs Jones on ostomy self care. What are the effects on food on stoma output?

Part 2 -

During the post operative period Mr Jones was referred to a medical oncologist for further management of his colon cancer with metastasis to the liver. The treatment plan for cancer requires Mr Jones to make frequent visits to the ambulatory care setting for the continuation of his chemotherapy.

Mrs Jones told the nurse she was having trouble coping with the diagnosis and anxious about the thoughts of regular travel to have the treatment. She also expressed feelings of helplessness in not knowing what she could do to help her husband.

Mrs Jones also worries about their children, who are now in their 30s, if there is chance of them inheriting the cancer? You read in the notes that Mr Jones' paternal aunt had colon cancer at the age of 78. In addition, an older brother of Mr Jones was diagnosed with colon cancer 5 years ago at the age of 68.

1) What are the nursing and collaborative care concerns leading up to Mr Jones's discharge?

2) How will you address Mrs Jones's fears about the possibility of their children getting bowel cancer?

Genetic counselling - Watch the video and come up with an empathetic, yet realistic response that you would give Mrs Jones.

Attachment:- Assignment Files.rar