Post-Operative Bowel Resection with Ileostomy
A colectomy involves removing a portion of the bowel. This may be done because of disease to a portion of the bowel or a treatment for traumatic injury. The two ends of the colon are reattached or anastomosed (Giddens 2017). There are a few different indications that a patient may need a bowel resection (colectomy) with ileostomy. An ileostomy is usually done on patients with ulcerative colitis, Crohn’s disease, diseased or injured colon, familial polyposis, trauma, and cancer. A patient with an ileostomy will have a stoma protruding from the abdomen. The stoma of an ileostomy is part of the ileum and will be rosy pink to red. If the stoma is blue this indicates ischemia, and a brown-black stoma indicates necrosis (Lewis 2017). The stoma will be moderately swollen after surgery and will resolve over the first six weeks. The stoma size will get smaller as will the stoma pouch opening. The ileostomy will start functioning when peristalsis returns. Drainage is normal and stool production will not begin until a few days after the patient is eating again especially if the colon was cleansed before surgery. Excessive amounts of gas are common during the first 2 weeks. Stool from an ileostomy is caustic to the skin so a secure pouching system is important to maintain skin integrity. If a patient is allowed to have stool from the stoma on the skin for a period of time skin breakdown will start to occur and the patient could start to form a wound. Patients with ileostomy must wear the pouch at all times because it is not possible to have regularity. The pouches should be changed every 4 to 7 days or when the pouch becomes full or any leakage occurs (Lewis 2017).
Patients with an ileostomy should be observed after surgery for signs and symptoms of fluid and electrolyte imbalance, especially potassium, sodium, and fluid deficits (Lewis 2017). Patients with new ileostomies lose the absorptive function provided by the colon and the delay provided by the ileocecal valve, as a result they may experience a period of high-volume output of stool when peristalsis returns (Lewis 2017). This means the patient my become dehydrated and could need extra fluids or even electrolyte replacement therapy. The patient should be assessed periodically for signs of dehydration. Infection from the surgical site is also a concern, the nurse should also look for signs of infection during any post-operative assessments. Patients may also need emotional support after the placement of an ileostomy. Patients may be angry, depressed, or resentful of their ileostomy. It could be worse than they thought it would be or they could be worried about body image, sexual function, how they could travel. They may also be worried about stool leaking in public or around their spouse or the way it smells or sounds of gas that cannot be controlled. These are all ligament concerns for the patient and they man need to be addressed by the nurse. Helping the patient to cope with the ileostomy is a great concern and will ultimately help the patient with recovery. The nurse should also encourage support from the caregiver, family, and friends as this reassures the patient that he or she is still cherished and valued despite having the ileostomy.
Prior to a nursing assessment on a post-operative patient with bowel resection with ileostomy, the nurse should review the patient’s chart and any notes from the surgeon or the surgical nurse. The nurse should look for any indications of complications from surgery that may have been excluded from the report taken from the surgical nurse. This is important because if anything were to arise that is directly associated with the complication then the nurse can quickly identify the issue. Labs should also be observed post-op. Labs like CBC, CMP, D-dimmer, and PT INR should all be observed. The CBC will show the nurse the patients Hematocrit and hemoglobin as well as white blood cell count. These are important to show signs of excessive blood loss and early signs of infection. The CMP will show signs of electrolyte imbalances like hyperkalemia, hypokalemia, hyponatremia, and hypernatremia. These are important especially with excessive loss of fluids from the ileostomy. It will also show any abnormalities in kidney function. The D-dimmer is important to show any signs of blood clots after surgery. Prevention of DVT’s and pulmonary embolus is essential post-op. Patients receiving anticoagulant therapy after surgery should have daily PT INR’s done to make sure the patient still has enough clotting factor to prevent spontaneous bleeding.
Cefazolin, also known by its trade name Ancef, is a first-generation cephalosporin antibiotic. It is used as a perioperative prophylaxis, septicemia, infections due to S. aureus, S. epidermidis, group A beta-hemolytic streptococci, E. coli, and S. pneumoniae. Typically, Cefazolin is given before, during, and after surgery for 24 hours every 6 – 8 hours. The effects of this medication are positive. The ultimate goal is to prevent infection and keep the patient infection free after surgery. Cefazolin should be used with caution in patients with history of gastrointestinal disease, especially ulcerative colitis.
Morphine sulfate, also known by its trade names Astramorph PF, Avinza, and DepoDur, is a narcotic agonist. It is an opiate analgesic that binds with opioid receptors within the CNS. It alters pain perception and emotional response to pain. It is used for the relief of moderate to severe, acute, or chronic pain. It is the drug of choice for pain due to myocardial infarction due to the decreased cardiac workload and hemodynamic effects. Morphine is variably absorbed from the gastrointestinal tract. It is a good medication to relieve pain after a bowel resection with ileostomy. The nurse should monitor vital signs for 10 minutes after IV administration to check for signs of decreased respirations, heart rate, and blood pressure. The nurse should also monitor daily pattern of bowel activity and stool consistency to avoid constipation.
COPD and Type 2 Diabetes
Chronic obstructive pulmonary disease (COPD) is the most common chronic lung disease and is characterized by increased resistance to airflow as a result of airway obstruction or airway narrowing (Lewis 2017). COPD is a preventable and treatable disease associated with an enhanced chronic inflammatory response in the airways and lungs, mainly caused by cigarette smoking and other noxious particles and gases (Lewis 2017). The predominant inflammatory cells in COPD are neutrophils, lymphocytes, and macrophages. This pattern of inflammatory cells is different from that in asthma which are eosinophils, mast cells, neutrophils, lymphocytes, and macrophages (Lewis 2017). These inflammatory cells in COPD release oxidants that adversely affect the lungs and inactive antiproteases which prevent the natural destruction of the lungs, stimulate mucus secretion, and increase fluid in the lungs (Lewis 2017). Patients with exacerbation of COPD will present with dyspnea, wheezing, chest tightness and coughing. The patient may also be in a tripod position because that is the position in which they feel they can get the most air. Spirometry is required to confirm the diagnosis of COPD. Spirometry confirms the presence of airflow obstruction and determines the severity of COPD (Lewis 2017). Smoking cessation in a patient with COPD is the most important intervention. The sooner the smoker stops smoking the less pulmonary function is lost and the sooner the symptoms decrease. Patients with COPD are at increased risk for alterations in acid-based balance. If I patient cannot breathe and is having dyspnea, they could start to develop respiratory acidosis. Respiratory acidosis is a condition that arises when the lungs cannot get rid of enough of the carbon dioxide (CO2) that is produced by the body. The excess CO2 causes the blood and body fluids to become more acidic. The most immediate correction of this is to open the airways and allow for better gas exchange. An ABG will need to be obtained in any patient with COPD to see the levels of CO2 as well has pH and HCO3 levels. This could also be benifical in a patient with type 2 diabetes, as these patients can have issues with metabolic acidosis from diabetic keto acidosis (DKA).
Type 2 diabetes is characterized by a combination of inadequate insulin secretion and insulin resistance (Lewis 2017). Unlike type 1 diabetes, a person with type 2 diabetes produces endogenous insulin from the pancreas but the body has become either insulin resistant or does not produce enough insulin. A normal part of nursing duties is preforming an assessment. Before the assessment a nurse needs to gather data on the patient to know what to look for during the assessment. Patients that are diabetic will possibly need an A1C, so the nurse knows how long the patient’s blood sugar has been high. The nurse will also need a CBC and CMP to check for elevated white blood cell count to check for signs of infection as well as see the liver function and kidney function and know what the blood glucose is.
Prednisone, also known by its trade name Prednisone Intensol, is an adrenal corticosteroid and glucocorticoid. It inhibits accumulation of inflammatory cells at inflammation sites and inhibits the release of mediators of inflammation. It prevents or suppresses cell-mediated immune reactions and decreases tissue response to inflammatory process. It is used for acute or chronic adrenal insufficiency, congenital adrenal hyperplasia, allergic reactions, asthma, and COPD.
Advair Diskus, also known as fluticasone/salmeterol, is a corticosteroid anti-inflammatory, antipruritic. It controls the rate of protein synthesis and depresses migration of polymorphonuclear leukocytes and stabilizes lysosomal membranes. All of this prevents and controls inflammation. It is inhaled and used as long-term control of persistent bronchial asthma and COPD to assist in reduction oral corticosteroid therapy.
Albuterol also known as Proair HFA, Proventil HFA, and Ventolin HFA, is a sympathomimetic (adrenergic agonist) bronchodilator. It stimulates beta2-adrenergic receptors in the lungs, resulting in relaxation of bronchial smooth muscle. It relieves bronchospasm and reduces airway resistance. It is used to relieve bronchospasm due to reversible obstructive airway disease, and prevention of exercise-induced bronchospasm.
Ipratropium bromide (Atrovent) is an anticholinergic bronchodilator. It blocks action of acetylcholine at parasympathetic sites in bronchial smooth muscle. The therapeutic effect of Atrovent is that is causes bronchodilation and inhibits nasal secretions. It is used as maintenance treatment of bronchospasm due to COPD, bronchitis, emphysema, and asthma. Albuterol and Atrovent given in an inhalation solution together is called a DuoNeb. Simultaneous administration of both an anticholinergic and a β2-sympathomimetic is designed to produce greater bronchodilation effects than when either drug is utilized alone at its recommended dosage.
Type 2 diabetics may not use insulin until the disease has progressed to a point to where the body is no longer producing insulin. When they do start using insulin, they will use Regular Humulin insulin. Regular Humulin insulin is an exogenous insulin and antidiabetic. Insulin facilitates the passage of glucose, potassium, and magnesium across cellular membranes of skeletal muscle, cardiac muscle, and adipose tissue. Insulin controls storage and metabolism of carbohydrates, protein and fats, and promotes conversion of glucose to glycogen in the liver. This all is important in controlling the glucose levels in diabetic patients. Regular Humulin insulin is a short-acting insulin which onset is within 30-60 minutes of administration.
Schizophrenia
Schizophrenia is a serious mental illness characterized by a person experiencing a combination of delusions and hallucinations. Because these delusions and hallucinations feel as real as the world around them, a person with untreated schizophrenia can sometimes have trouble distinguishing actual reality from this altered reality that their brain is telling them (Halter 2018). Schizophrenia-spectrum disorders are inherited. About 80% of the risk of schizophrenia comes from genetic and epigenetic factors (factors such as toxins or psychological trauma that affect the expression of genes) (Halter 2018). Neurotransmitter imbalance: like dopamine and serotonin may play a role in causing schizophrenia (Halter 2018). All patients diagnosed with schizophrenia have at least one psychotic symptom such as hallucinations, delusion, and / or disorganized speech or though (Halter 2018). The symptoms are severe enough to disrupt normal activities such as school, work, family and social interaction, and self-care. Basic needs such as hygiene, nutrition, and healthcare are often neglected, and socialization and relationships are often disrupted (Halter 2018). For the acute phase of schizophrenia, the overall goal is patient safety and stabilization. Assessment involves interviewing the pt and observing behavior and other manifestations of the disorder. Information from others who know the pt is also important as pts may conceal or minimize symptoms. Assessment should include a mental status examination along with review of spiritual, cultural, biological, phycological, social, and environmental elements that might be affecting the presentation. Trust, a therapeutic nurse-patient relationship, sound therapeutic communication skills, and an understanding of the disorder and what pts may be experiencing all strengthen the assessment. If the patient is taking any medications for schizophrenia labs may need to be drawn to check the levels of the medications in the body. This would be to assess if the patient is compliant with medication, as well as to check if the therapeutic levels of the medication is being achieved based on patient presentation. The patient may also need a consultation with a psychiatric doctor or nurse for assessment. If the patient is suicidal or homicidal the patient should be free from any substance that may impair judgment prior to the psychiatric assessment such as alcohol or drugs.
Risperidone also known by the trade name Risperdal, is a benzisoxazole derivative antipsychotic. It may antagonize dopamine and serotonin receptors and suppress psychotic behavior. It is used in the management of manifestations of psychotic disorders (e.g. schizophrenia). It is also used for treatment of acute mania associated with bipolar disorder.
Cogentin or generic benztropine is an anticholinergic antiparkinson agent. It selectively blocks central cholinergic receptors and assists in balancing cholinergic/dopaminergic activity. Cogentin is used to treat symptoms of Parkinson's disease or involuntary movements due to the side effects of certain psychiatric drugs (antipsychotics such as chlorpromazine/haloperidol).
Haloperidol (Haldol) is a first-generation antipsychotic, antiemetic, and antidyskinetic that blocks receptors for dopamine within the CNS, as well as outside the CNS. It is used for treatment of psychoses (including schizophrenia), Tourette’s disorder, and emergency sedation of severely agitated/psychotic patients. Side effects include extrapyramidal reactions like parkinsonism (bradykinesia, masklike facies, drooling, tremor, and gait problems), acute dystonia, and akathisia (compulsive restless movement, anxiety, and agitation).
References
Giddens, J. (2017). Concepts for nursing practice. St. Louis, MO: Elsevier.
Lewis, S. M., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-surgical nursing: Assessment and management of clinical problems. St. Louis, MO: Elsevier.
Hodgson, B. B., & Kizior, R. J. (2012). Saunders nursing drug handbook 2012. St. Louis, MO: W.B. Saunders.
Halter, M. J. (2018). Varcarolis foundations of psychiatric-mental health nursing: A clinical approach. St. Louis, MO: Elsevier.