1 A CASE STUDY ON EXPLORATORY LAPAROTOMY WITH ADHESOLIYSIS, RIGHT HEMICOLECTOMY WITH PRIMARY END-TO-END ANASTOMOSIS ________________________________

In Partial Fulfillment of the Course Requirement In Surgical Nursing

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Presented to: The Faculty of Cebu Doctors University College of Nursing _____________________________ Submitted by: xxxxxxxxxxxxxxxxxxxxxxx Phi 2nd generation Class 2009 30 September 2008

2 TABLE OF CONTENTS I. Introduction . 3 II. Objectives ... 5 III. Nursing Assessment. A. Personal History Patients Profile Family and Individual Information Level of Growth and Development Normal Development at Particular Stage The Ill Person at Particular Stage of Patient B. Diagnostic Results... C. Present Profile of Functional Health Patterns . Health Perception / Health Management Pattern Nutritional Metabolic Pattern Elimination Pattern Activity / Exercise Pattern Cognitive / Perceptual Pattern Rest / Sleep Pattern Self perception Pattern Role Relationship Pattern Sexuality Reproductive Pattern Coping Stress Tolerance Pattern Value Belief System D. Pathophysiology and Rationale. Normal Anatomy and Physiology of Affected Organ Schematic Drawing of the Pathophysiology of the Disease The Disease Process and its Effects on Other Organs Classical and Clinical Symptoms of Disease with Rationale IV. Nursing Intervention A. Care Guide of Patient with the Disease Condition B. Actual Patient Care: Nursing Care Plans Brunswick Lens Model SOAPIE Charting Health Teaching Plan Drug Therapeutic Record V. Evaluation and Recommendation VI. Evaluation and Implication of the Case Study .. VII. Referral and Follow - Up ......... VIII. Bibliography 8

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3 I. INTRODUCTION A fistula is an abnormal opening between two or more organs or structures. The etiology of postsurgical fistula formation varies widely according to the organs involved, precipitating factors, patient risk factors, and surgical technique or procedure The complexity of an enterocutaneous fistula depends on the volume and nature of the output low volume output is <200 mL/24 hours, moderate output is 200 to 500 mL/24 hours, and high output is >500 mL/24 hours. Approximately 30% of all types of fistulas close spontaneously within 6 to 7 weeks. Fistula management is complex and requires clinical knowledge, critical thinking, and technical skill. Factors known to increase the risk of postsurgical fistula formation include, but are not limited to: inadequate blood supply to anastomoses, tension on suture line, distal obstruction, improper suturing technique, foreign body close to anastomosis, tumor or disease in the anastomotic area, hematoma or abscess formation in the mesentery or anastomotic area, and malnutrition. Peri-fistula skin denudation is a complication often seen in the patient with a fistula. When fistula drainage containment is less than optimal, persistent moisture and chemical irritation from the drainage can cause severe excoriation. Approaches to fistula management include large pouches that cover the entire wound, skin barriers to protect the surrounding skin, and the use of transparent dressings. Pouching the wound and fistula helps achieve and maintain wound hygiene by preventing drainage from contaminating the wound. When the fistula is located within the wound, achieving a seal with a pouching system is virtually impossible because the tissue around the fistula does not facilitate adhesion. The use of gauze dressings and pouching methods utilizing complex techniques such as silicone dental molds of the fistula surface to achieve fistula containment and preserve skin integrity while preventing wound contamination. Additional methods of drainage containment include troughing procedures, saddle bagging, bridging, and condom and suction catheters used in combination with complex or routine pouching.

4 In the procedure Exploratory Laparotomy it is used to visualize and examine the structures inside of the abdominal cavity it also includes Adhesiolysis in which this procedure is used to remove scar tissue inside the uterus and in the reproductive tract. This procedure is generally used when scar tissue becomes problematic due to pain symptoms or interference with fertility and lastly, hemicolectomy is performed for bowel cancer, diverticular disease, Crohns disease, trauma and certain rarer bowel disorders. The operation is performed through an incision in your abdomen. Either the right or left side of the bowel may be removed. I have chosen exploratory Laparotomy, adhesiolysis and right hemicolectomy for my case study because I would like to impart knowledge and render effective nursing care to my patient who has underwent the procedure, particularly, at promoting patients health and reducing postoperative complications. This study was also chosen for my benefit in completing my medical-surgical requirements. Through this case study I expect that I will be able to gain and learn new things and to relate them and apply them when providing care to my patient with the said condition, I expect to gain proper knowledge, skills and attitude in providing care to post exploratory Laparotomy patient and with this study, may it guide me to become a better, effective and efficient nurse.

5 II. OBJECTIVES A. STUDENT CENTERED 1. General Objectives: After 5 days of holistic nursing care, the patient will be able to gain adequate knowledge, positive attitude and appropriate skills in the care of a post-Exploratory Laparotomy patient. Student Nurse: Specific Objectives: After 8 hours of the student nurse-patient interaction, the student nurse will be able to: 1. relate patients personal history in terms of: 1.1 patients profile. 1.2 family and individual information, social and health history. 1.3 level of growth and development. 1.3.1 1.3.2 normal development at young adult stage. the ill person at young adult stage.

2. identify the normal and abnormal physical assessment findings through inspection, palpation, percussion and auscultation. 3. give the significance of the patients diagnostic results post-operatively. 4. cite the patients present profile of functional health patterns . 5. review the normal anatomy and physiology of the digestive system. 6. illustrate through a schematic diagram the clinical pathophysiology of colo-cutaneous fistula.

6 7. discuss the pathophysiology of colo-cutaneous fistula. 8. explain the perioperative process of Exploratory Laparotomy. 9. compare the classical manifestations of Exploratory Laparotomy and the patients clinical manifestations of Exploratory Laparotomy. 10. present care guide of patient who has undergone Exploratory Laparotomy . 11. formulate actual patient care as to its: 11.1 11.2 11.3 11.4 11.5 12. provide nursing care plan. drug therapeutic record. Brunswick lens model. SOAPIE charting. health teaching plan. evaluation of patients postoperative condition and resulting

recommendations. 13. enumerate the implications of this study to 13.1 13.2 13.3 the nursing practice. the nursing education. the nursing research.

7 B. PATIENT CENTERED Specific Objectives: After 8 hours of the nurse-patient interaction, the patient and significant others will be able to:

1. establish a trusting relationship with the student nurse 2. explain the disease process in their own level of understanding 3. enumerate some factors which contributed to the occurrence of the condition 4. discuss measures to regain optimal functioning 5. state the importance of strict adherence to the therapeutic regimen 6. verbalize fears and concerns regarding post-Exploratory Laparotomy 7. demonstrate beginning skills in rendering care to the post- Exploratory Laparotomy patient 8. apply health teachings provided by student nurse for the maintenance of good health during and after hospitalization 9. participate with the medical regimen and nursing management provided by the entire health care team

8 III. NURSING ASSESSMENT 1. Personal History 1.1. Patients Profile Name: Mrs. Suliva, Myra M. Hospital No: 340828 Age: 30 years old Sex: Female Civil Satus: Married Religion: Roman Catholic Date of Admission: May 4, 2008 Ward No: Female Surgical Bed No. 3 Complaints: Wound Dehiscence Impression/ Diagnosis: Colo-Cutaneous Fistula Operation Performed: Exploratory Laparotomy, Adhesiolysis, and Right Hemicolectomy with Primary end-to-end anastomosis Physician: Dr. Almendras, J.

1.2. Family and individual information, social and health history. Mrs Suliva, Myra M., 30 yrs. Old, married and has two children ages 5 years old and 3 years old from Camansi Mohon, Sogod Cebu City was admitted in Cebu Doctors University Hospital abdominal site. Thirteen months prior to admission was advice for surgery to remove a cyst from her abdomen. Surgery was performed in April 2007 at Chong Hua. Cyst was sent for Biopsy upon which Tuberculosis of the Intestine was determined. Twelve months prior to admission, patient felt some pain and irritating at the wound site at which time she was advised for colostomy at Chong Hua Hospital. Colostomy was placed in June for the first time due to chief complain of pain at

9 2007. Ten months prior to admission, patient began a course of Tuberculosis medication which she took, as scheduled. She proceeded to maintain monthly check-ups at Chong Hua Hospital for the next five months. Colostomy was removed in July 2007 because of irritation or allergy at wound site as advised by her doctor at Chong Hua Hospital. She finished her course of Tuberculosis medications in April 2008. One month prior to admission, Patient consulted with Dr. J. Almendras who advised her to have surgery to close the wound because there was the presence of wound dehiscence. The patient is health conscious, and verbalized that she is not an alcoholic drinker and never smokes at all. Patient does not have Hypertension, Bronchial Asthma and Diabetes Mellitus. Her mothers side was known to be hypertensive. Patient claimed that she has no history of Pulmonary Tuberculosis. She is only the member of the family who has the kind of problem.

10 1.3 Level of Growth and Development

1.3.1

Normal Development at Particular Age

YOUNG ADULTHOOD: 20-40 years

Young and middle adulthood is a period of challenges, rewards, and crises. Challenges may include the demands of work and raising families, although adults can also be rewarded by successes in their career endeavors and in their personal lives. Adult development involves orderly changes in characteristics and attitudes. Developmental changes are based on earlier characteristics that help shape subsequent behavior and characteristics. The changes experienced by young adults include the natural processes of maturation and socialization. They are active and must adapt to new experiences (Potter & Perry, 2001). PHYSICAL DEVELOPMENT The young adult has completed physical growth by the age of 20. An exception to this is the pregnant or lactating woman. The physical, cognitive, and psychosocial changes and the health concerns of the pregnant woman and the childbearing family are extensive. Young adults are usually quite active, experience severe illnesses less commonly than older age groups, tend to ignore physical symptoms, and often postpone seeking health care. Physical characteristics of young adults begin to change as middle age approaches. Unless clients have illnesses, assessment findings are generally within normal limits. Nonetheless, clients in this developmental stage may benefit from a personal lifestyle assessment. A personal lifestyle assessment can help nurses and client identify habits that increase the risk for lifestyle-precipitated diseases. A personal lifestyle assessment of the young adults includes assessment of general life satisfaction; hobbies and interests; habits such as diet, sleeping, exercise, sexual habits, and use of caffeine, alcohol, and illicit

11 drugs; home conditions, including housing, economic condition, type of health insurance, and pets; and occupational environment, including type of work, exposure to hazardous substances and physical or mental strain. Family history of cardiovascular, renal, endocrine, or neoplastic disease increases the risk of illness as well. The nurses role in health promotion is to identify modifiable factors that increase the young adults risk for health problems and to provide client education and support to reduce unhealthy lifestyle behaviors. Psychosocial DEVELOPMENT The emotional health of the young adult is related to the individuals ability to address and resolve personal and social tasks. The young adult is usually caught between wanting to prolong the irresponsibility of adolescence and wanting to assume commitments. Certain patterns or trends, however, are relatively predictable. Intimacy Vs. Isolation Between the ages of 23 and 28, the person refines self-perception and ability for intimacy. From 29 to 34, the person directs enormous energy toward achievement and mastery of the surrounding world. The years from 35 to 43 are a time of vigorous examinations of life goals and relationships. Alterations are made in personal, social, and occupational lives. Often, the stresses of this reexamination result in a midlife crisis in which marital partner, lifestyle, and occupation may change. Support from the nurse, access to information, and appropriate referrals provide opportunities for achievement of a clients potential. Because health is not merely the absence of disease but involves wellness in all human dimensions, the holistic, humanistic nurse acknowledges the importance of the young adults psychosocial needs in other dimensions. The young adult must make decisions concerning career, marriage, and parenthood. Although each person makes these decisions based on individual factors, the

12 nurse should understand the general principles involved in these aspects of psychosocial development while assessing the young adults psychosocial status. COGNITIVE DEVELOPMENT Rational thinking habits increase steadily through the young and middle adult years. Formal and informal educational experiences, general life experiences and occupational opportunities dramatically increase the individuals conceptual, problem-solving, and motor skills. Identifying preferred occupational areas is a major task of young adults. An understanding of how adults learn assists the nurse in developing teaching plans. When determining the amount of information that the individual needs to make decisions, considerable factors are to be observed. Because young adults are continually evolving and adjusting to changes in their environment, their decision-making processes should be flexible. The more secure young adults are in their roles, the more flexible and open they are to change. Insecure persons tend to be more rigid in making decisions. SPIRITUAL DEVELOPMENT Not all adults progress through Fowlers stages to the fifth, called the paradoxical-consolidative stage. At this stage, the individual can view truth from a number of viewpoints. Fowlers fifth stage corresponds to Kohlbergs fifth stage of moral development. Fowler believes that only some individuals after the age of 30 years reach this stage. In early adulthood, people tend to be less dogmatic about religious beliefs, and religion often offers more comfort to the early adults than it did previously. People in this age group often rely on spiritual beliefs to help them deal with illness, death, and tragedy. EMOTIONAL DEVELOPMENT Emotional development usually involves preserving the stability established during previous stages. Young adults are subjected to many emotional stresses related to

13 career, marriage, family and other similar situations, if emotional structure is strong, most young adults can cope with these worries. They find satisfaction in their achievements, take responsibility for their actions, and learn to accept criticism and to profit from mistakes. SEXUAL DEVELOPMENT Sexuality and sexual desire usually begins to appear along with the onset of puberty. The expression of sexual desire among young adults (or anyone, for that matter), might be influenced by family values and influences, the culture and religion they have grown up in social engineering, social control, taboos, and other kinds of social mores. The risks of young adults sexual activity are sometimes associated with: emotional distress (fear of abuse or exploitation), sexually transmitted diseases (including HIV/AIDS) and pregnancy through failure or non-use of contraceptives. Safe sexual behavior is an indicator of physical health in young adulthood. Useful indicators include age at first sexual intercourse, the number of lifetime sexual partners, frequency and consistency of condom use, STD diagnosis, early pregnancy and birth (by age 21) for females, and having caused a pregnancy and having fathered a child by age 21 for males.

14 1.3.2 Ill Person at Young Adulthood Illness behavior is any activity undertaken by a person who feels ill, to define the state of his health and to discover a suitable remedy. When young adults seek health care, the nurses focus on the goal of wellness can guide clients to evaluate health behaviors, lifestyle, and environment. Attention to risk factors that can be altered to improve the clients health, such as stress, obesity, use of tobacco, excessive alcohol consumption, poor nutrition, and unsafe sexual practices, can increase the quality of life and add years to it. Throughout life, people are exposed to many stressors. After these stressors are identified, the client and nurse can work together to intervene and modify the stress response. Specific interventions for stress reduction can fall into three categories. First, the frequency of the stress-producing situation is minimized. Together the nurse and client identify approaches to prevent stressful situations, such as habituation, change avoidance, time blocking, time management and environmental modification. The second category is psychophysiological preparation to increase stress resistance, such as increasing self-esteem, improving assertiveness, redirecting goal alternatives, and reorienting cognitive reappraisal. Last, the physiological response to stress is avoided. The nurse uses relaxation techniques, imagery, and biofeedback to recondition the clients response to stress. The nurse must be able to asses the health status of the middle adult client. Such assessment offers direction for planning nursing care and is useful in evaluating the effectiveness of nursing interventions. The nurse must also be able to frequently obtain data indicating positive and negative health behaviors by the client. Examples of positive health behaviors include regular exercise, adherence to good dietary habits, avoidance of excessive consumption of alcohol, participation in routine screening and diagnostic tests for disease prevention and health promotion, and lifestyle changes to reduce stress. In the planning,

15 implementation, and evaluation phases, the nurse helps the client maintain habits that protect health and offers healthier alternatives to poor habits.

16 2. Diagnostic results 2.1 Laboratory work-ups 2. Diagnostic Results Diagnostic test May 5, 2008 1. Complete Blood Count Hematocrit Normal value Result Significance - A decreased hematocrit can be due to either an overhydration or a true decrease in the number of RBCs. - Because hemoglobin is a component of RBC, all conditions that cause a low RBC count also result in a low hemoglobin level. Some of the common conditions are blood loss and anemia.

37-49%

33.9%

Hemoglobin

13-18g/100ml

11.1g/100ml

White Blood Cell Basophil Eosinophils Monocytes Platelet

4,500-11,000/mm3 0-1 0-8 0-7 150,000350,000/mm3 25-35 pg 78-100 fl

12,410 million/mm3 -increased- infection 0 0 3 173,000/mm3 - normal - normal - normal - normal

Mean corpuscular hemoglobin Mean corpuscular volume

27.7pg 84.5 fl

- normal - normal

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Mean corpuscular hemoglobin concentration

31-37 %

33%

- normal Source: Laboratory Diagnostic with and tests Nursing

Implication by Kee, Joyce LeFever

3. Present profile of Functional Health Patterns 3.1 Health perception/Health management pattern

Client describes health prior to confinement as well as she accounts herself as clean from smoking and drinking. Client claims to practice environmental sanitation, eating of fruits and vegetables and confesses that she has no regular exercise but that her nature of work serves similar purpose. Client has received complete immunization from infancy to childhood at her birthplace, Sogod. Preoperatively, client feels so restless because of the pain felt in her abdomen. Post operatively, patient appears tired as she has slow guarded movements and could only speak minimally. Discomforts of postoperative surgery were evident as the patient felt ppain, and feeling of weakness. However, she verbalizes that she is happy for a successful operation, and describes her health better, now that she is slowly recovering.

18 3.2 Nutritional Metabolic pattern

Client is accustomed to take three full meals per day with a snack in between meals. She has no supplementary diet but sees to it that he is able to eat fruits &/or vegetables and drinks her calcium-rich milk. A confessed water therapy fanatic, she enjoys drinking 1-2 247ml bottles of mineral water before and/or after eating. She took no other supplementary diet. At 100 lbs, client claims to have maintained such weights as far as she could remember. Preoperatively, she wasnt allowed to have anything per mouth since she was given an emergency operation. Presently she is advised to eat a soft diet. She drinks 8 to 10 glasses of water every day and sees to it that she is able to drink a glass or so of milk ever now and then. As usual, she has no picky-eating habits as she claims to be a healthy eater.

3.3 Elimination pattern Prior to hospitalization, the patient reports to have difficulties in urination and bowel elimination. She claims to have the following urinary characteristics: yellowish, 5-8 times a day in frequency, approximately 3-4 glasses a day in timing of early dawn, lunch breaks, afternoon breaks and before sleeping. Her bowel elimination characteristics are as follows: yellowish brown in color, once every two days in frequency, and about early morning in timing. Preoperatively, she was inserted with a catheter so as to prevent bladder distention during operation. After surgical procedure, patients catheter was still inserted two days but resumed normal excretion free of assistive devices the afternoon thereafter. She experienced constipation day after operation but was given laxatives and enough hydration which recommenced normal defecation for her. For two post-operative days, client had a low-grade fever but was relieved with tepid sponge bath and oral antipyretics. At present, patients skin exhibits good color and turgor, stable temperature and no edema noted.

19 3.4 Activity Exercise pattern Working as a MEPZA operator, patient covers a wide variation of physical activities from sitting down while watching over her bosss things to housekeeping. When not on work, she stays at home and do cleaning activities. Though she may not have a specific exercise plan, she claims that this physical routine is enough to keep her healthy and on the go. She finds comfort in cleaning and relaxes by spending quality time with her husband of common law and she enjoys karaoke. She is able to perform activities of daily living with neither difficulty nor any complaints of dyspnea or fatigue. Preoperatively, however, she was already feeling faint, weak and unable to carry herself as there is pain in her abdominal site. A day post operatively, client maintains bed rest but resumed normal ambulation two days after. She currently walks around the ward in compliance to early ambulation and is passively assisted by her student nurse in charge. She reports of ability to perform activities of daily living with neither difficulty nor any complaints of dyspnea or fatigue as expected.

3.5 Cognitive perceptual pattern Client has no problems in hearing, smelling and tasting. However, she used to have glasses but discontinued using them because her grade has increased. She wasnt able to find time to visit her optometrist to update them. She claims no experience of vertigo and has no insensitivity to superficial pain. She also claims no insensitivity to cold/heat. She can read well and write legibly. Other than the reading glasses, she has no other aids needed to assist her sensory perception. No changes were felt preoperatively and post-operatively.

3.6 Rest or Sleep pattern Client is accustomed to start her sleep as early as 8 oclock in the evening and wakes up at around 4 oclock in the morning totaling to 8 full hours of sleep. Her normal sleep routine includes drinking water before she lies down. She says it helps her go to sleep especially when she is not yet sleepy. Preoperatively, client was scheduled for the operation for closure of wound

20 and was rushed to the operating room. It was then she was able to rest for an hour or so and was then ready for operation. Postoperatively, client is in full bed rest. She has been in bed for two full days which left her no other option but to rest as her body demands. As for the third day, client was already active and walking around the ward. She reports no difficulty in sleeping and states feeling of being rested adequately there on. 3.7 Self-Perception pattern Prior to confinement, client was concerned of financial matters more than of her disturbed health. She defined herself then as healthy as a horse but has realized how things do not seem as they are. This matter being the fact that the entire symptom she had was only feeling faint before she knew what was going on with her. Preoperatively, she stresses concern on her scheduled operation and wishes to have it over as soon as possible. She attributes her ill condition to the fact that she has not been taking much care for self and was only focusing on others. She wants to be able to be useful to her husband and thus sees getting better and maintaining health a tactful decision. Postoperatively, however, she is much concerned of her health now. Her present health goal is to get well as soon as possible after a successful surgery and to go home and be with her family. 3.8 Role Relationship Pattern A native of Sogod, Cebu herself, client speaks the Visayan dialect well and relevantly. She is able to verbalize her thoughts and feelings without hesitation be it verbal, writing or in gestures. A high school graduate, she feels the need to give the last say about any decision regarding her life in common law to her partner and states that since he (the partner) has the higher educational attainment and is more mature, he should know better. Client also seeks out the aid of closer family members from her father and mother who really supported all through the days when she was hospitalized. This observation can much be seen especially during the post operative period.

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3.9 Sexuality-Reproductive pattern The patient is slightly uncomfortable about the topic however, she said that her sexual urge did not decrease as she approaches. They use natural method of family planning but verbalized that they do not need it right now because the couple are not engaging in intimate activities for many years. 3.10 Coping-Stress tolerance pattern

Ever since, client claims to have been a second opinion-seeker when it comes to decisionmaking. She finds her husband as her best friend and as the best advice giver. Preoperatively, she states that without her husband she could not be better. Of course, when needed she also seeks her parents guidance. Postoperatively, she was very emotional but displays a good promise of coping with it at a healthy rate/ as expected. She talks to her husband in order to ease her boredom and loneliness and claims that talking helps even if the other party only just listens.

3.11 Value-Belief System Growing up as a believer in Christ, she finds strength and draws purpose and vigor from her faith. She not only finds drive from her family but also from her healthy relationship with God. According to her, her present condition has not changed her faith in God; however it has even increased her faith since she believes that this is part of Gods purpose for her and that she trusts God in her healing. She reports that what is made accessible to her like the Eucharistic celebration is enough for her belief to be kept sustained. No changes were reported preoperatively and postoperatively. Moreover, in the latter period, she claims her faith has strengthened.

22 4. Pathophysiology and Rationale:

4.1 Explain the Normal Anatomy and Physiology of Organ/System Affected

The colon is a storage tube for solid wastes. The main function of the colon appears to be extraction of water and salts from feces. In mammals, it consists of the ascending colon, transverse colon, the descending colon, and the sigmoid colon. The colon from cecum to the splenic flexure (the junction between the transverse and descending colon) is also known as the right colon. The remainder is known as the left colon. The location of the parts of the colon are either in the abdominal cavity or behind it in the retroperitoneum. The colon in those areas is fixed in location. Arterial supply to the colon comes from branches of the superior and inferior mesenteric arteries. Flow between these two systems communicates via a "marginal artery" that runs parallel to the colon for its entire length. Historically, it has been believed that the arc of Riolan, or the meandering mesenteric artery (of Moskowitz), is a variable vessel connecting the proximal SMA

23 to the proximal IMA that can be extremely important if either vessel is occluded. However, recent studies conducted with improved imaging technology have questioned the actual existence of this vessel, with some experts calling for the abolition of the terms from future medical literature. Venous drainage usually mirrors colonic arterial supply, with the inferior mesenteric vein draining into the splenic vein, and the superior mesenteric vein joining the splenic vein to form the portal vein that then enters the liver. Lymphatic drainage from the entire colon and proximal two-thirds of the rectum is to the paraortic nodes that then drain into the cisterna chyli. The lymph from the remaining rectum and anus can either follow the same route, or drain to the internal illiac and superficial inguinal nodes. The dentate line only roughly marks this transition. Ascending colon The ascending colon, on the right side of the abdomen, is about 12.5 cm long. It is the part of the colon from the cecum to the hepatic flexure (the turn of the colon by the liver). It is retroperitoneal in most humans. In ruminant grazing animals the cecum empties into the spiral colon. Anteriorly it is related to the coils of small intestine, the right edge of the greater omentum, and the anterior abdominal wall. Posteriorly, it is related to the iliacus, the iliolumbar ligament, the quadratus lumborum, the transverse abdominis, the diaphragm at the tip of the last rib; the lateral cutaneous, ilioinguinal, and iliohypogastric nerves; the iliac branches of the iliolumbar vessels, the fourth lumbar artery, and the right kidney. The ascending colon is supplied by parasympathetic fibers of the vagus nerve (CN X). Arterial supply of the ascending colon comes from the ileocolic artery and right colic artery, both branches of the SMA. While the ileocolic artery is almost always present, the right colic can be absent in 5-15% of individuals.

24 Transverse colon The transverse colon is the part of the colon from the hepatic flexure (the turn of the colon by the liver) to the splenic flexure (the turn of the colon by the spleen). The transverse colon hangs off the stomach, attached to it by a wide band of tissue called the greater omentum. On the posterior side, the transverse colon is connected to the posterior abdominal wall by a mesentery known as the transverse mesocolon. The transverse colon is encased in peritoneum, and is therefore mobile (unlike the parts of the colon immediately before and after it). More cancers form as the large intestine goes along and the contents become more solid (water is removed) in order to form feces. The proximal two-thirds of the transverse colon is perfused by the middle colic artery, a branch of superior mesenteric artery, while the latter third is supplied by branches of the inferior mesenteric artery. The "watershed" area between these two blood supplies, which represents the embryologic division between the midgut and hindgut, is an area sensitive to ischemia. Descending colon The descending colon is the part of the colon from the splenic flexure to the beginning of the sigmoid colon. It is retroperitoneal in two-thirds of humans. In the other third, it has a (usually short) mesentery. Arterial supply comes via the left colic artery. Sigmoid colon The sigmoid colon is the part of the large intestine after the descending colon and before the rectum. The name sigmoid means S-shaped. The walls of the sigmoid colon are muscular, and contract to increase the pressure inside the colon, causing the stool to move into the rectum. The sigmoid colon is supplied with blood from several branches (usually between 2 and 6) of the sigmoid arteries, a branch of the IMA. The IMA terminates as the superior rectal artery. Sigmoidoscopy is a common diagnostic technique used to examine the sigmoid colon.

25 Redundant colon One variation on the normal anatomy of the colon occurs when extra loops form, resulting in a longer than normal organ. This condition, referred to as redundant colon, typically has no direct major health consequences, though rarely volvulus occurs resulting in obstruction and requiring immediate medical attention. A significant indirect health consequence is that use of a standard adult colonoscope is difficult and in some cases impossible when a redundant colon is present, though specialized variants on the instrument (including the pediatric variant) are useful in overcoming this problem. The large intestine comes after the small intestine in the digestive tract and measures approximately 1.5 meters in length. Although there are differences in the large intestine between different organisms, the large intestine is mainly responsible for storing waste, reclaiming water, maintaining the water balance, and absorbing some vitamins, such as vitamin K. By the time the chyme has reached this tube, almost all nutrients and 90% of the water have been absorbed by the body. At this point some electrolytes like sodium, magnesium, and chloride are left as well as indigestible carbohydrates known as dietary fiber. As the chyme moves through the large intestine, most of the remaining water is removed, while the chyme is mixed with mucus and bacteria known as gut flora, and becomes feces. The bacteria break down some of the fiber for their own nourishment and create acetate, propionate, and butyrate as waste products, which in turn are used by the cell lining of the colon for nourishment. This is an example of a symbiotic relationship and provides about one hundred calories a day to the body. The large intestine produces no digestive enzymes chemical digestion is completed in the small intestine before the chyme reaches the large intestine. The pH in the colon varies between 5.5 and 7 (slightly acidic to neutral).

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4.2 Schematic Drawing to show the Pathophysiology of Exploratory Laparotomy with Adhesiolysis, Right hemicolectomy with Primary End-to-End Anastomosis on ColoCutaneous Fistula Colo-cutaneous Fistula
Predisposing Factors Inadequate blood supply to the anastomosis site, Sepsis Shock/hypotension Precipitating Factors Wound dehiscence Presence of open wound Infection

Colo-cutaneous Fistula

The inflammatory process that leads to abscess may begin with an abrasion or tear in the lining of the anal canal, rectum, or perianal skin and subsequent infection by Escherichia coli, staphylococci, or streptococci. Trauma may result from injections for treatment of internal hemorrhoids, enema-tip abrasions, puncture wounds from ingested eggshells or fish bones, or insertion of foreign objects. Other preexisting lesions include infected anal fissure, infections from the anal crypt through the anal gland, ruptured anal hematoma, prolapsed thrombosed internal hemorrhoids, and septic lesions in the pelvis, such as acute appendicitis, acute salpingitis, and diverticulitis. Systemic illnesses that may cause abscesses include ulcerative colitis and Crohns disease. However, many abscesses develop without preexisting lesions.

Signs and Symptoms The list of signs and symptoms mentioned in various sources for Fistula includes the 5 symptoms listed below: Classical Signs and Symptoms - Abdominal Pain - Dizziness - feeling of weakness Clinical Signs and Symptoms - right lower quadrant pain - experience fainting - experiences fatigue

Nursing Management Keep Patient in Bed rest Providing a moist healing environment Avoiding wound contamination Accurately measuring drainage Preventing periwound skin breakdown Medical Management Negative pressure wound therapy pouching system Narcotic analgesics Antihypertensive (e.g., calcium channel blockers) Iron supplements Optimum Level of Surgical Management Cryosurgery Electrocautery Laparoscopic surgery Laser surgery Microsurgery Achieving patient comfort, mobility, and odor control Providing nutritional support.

Functioning

4.3 Pathologic Process of Colo-Cutaneous fistula and its effect on different organ/system The inflammatory process that leads to abscess may begin with an abrasion or tear in the lining of the anal canal, rectum, or perianal skin and subsequent infection by Escherichia coli, staphylococci, or streptococci. Trauma may result from injections for treatment of internal hemorrhoids, enema-tip abrasions, puncture wounds from ingested eggshells or fish bones, or insertion of foreign objects. Other preexisting lesions include infected anal fissure, infections from the anal crypt through the anal gland, ruptured anal hematoma, prolapsed thrombosed internal hemorrhoids, and septic lesions in the pelvis, such as acute appendicitis, acute salpingitis, and diverticulitis. Systemic illnesses that may cause abscesses include ulcerative colitis and Crohns disease. However, many abscesses develop without preexisting lesions. As the abscess produces more pus, a fistula may form in the soft tissue beneath the muscle fibers of the sphincters (especially the external sphincter), usually extending into the perianal skin. The internal (primary) opening of the abscess or fistula is usually near the anal glands and crypts; the external (secondary) opening, in the perianal skin.

The peak incidence of colo- cutaneous fistula occurs in people in their 30s and 40s, but theres also a high occurrence in infants. Men are affected two to three times more often than women. About 30% of patients have a previous history of abscess.

4.4 Comparative Chart of Colo- cutaneous fistula (PREOPERATIVE) CLASSICAL SYMPTOM Abdominal Pain CLINICAL SYMPTOM Manifested -right lower quadrant pain; complains of on and off tolerable pain with a scale of 6 from 110 pain scale, felt at the right lower quadrant ,lasts for around 15 to 30 seconds, dull pain, aggravated by movement and sitting relieved by rest and relaxation in bed, no treatment prescribed. Maybe a sign of acute intestinal obstruction (www.google.com) RATIONALE

Vomiting

Not manifested

(www.answers.com)

Blood in the stool along with painful defecation

Not manifested

(www.answers.com)

Faintness / Dizziness

Manifested -client reports experience of fainting prior to admission

Faintness and dizziness occur in the presence of significant bleeding (www.answers.com)

Referred shoulder pain is related to diaphragmatic irritation from blood in the

peritoneal cavity. (http://www.tabebak.com/The sis/GynaeNursing/ECTOPICP.htm)

(POSTOPERATIVE) CLASSICAL SYMPTOM Pain CLINICAL SYMPTOM Manifested -patient reports of Pain is a subjective symptom in which the patient exhibits a RATIONALE

intermittent gnawing pain feeling of distress. felt at surgical site lasting Stimulation of, or trauma to, from 30 to 60 seconds aggravated by coughing and movement relieved by proper positioning, splinting, deep breathing and use of analgesics certain nerve endings as a result of surgery causes pain. (Lippincotts Manual of Ng Prac. By Sandra Nena pg.119)

Constipation

Manifested -still unable to pass stool

[Post operatively, in any surgical client] narcotic use,

-abdominal pain -nausea -NPO temporarily

will retard peristalsis. (Lippincotts Manual of Ng Prac. By Sandra Nena pg.119)

Most patients experience Headache Not manifested some discomforts postoperatively. These are usually related to the general anesthetic and the surgical procedure. (Lippincotts Manual of Ng Prac. By Sandra Nena pg.118)

Feeling of weakness

Manifested

-patient stays in bed most of the time and carries out activities with assistance; complains of fatigue (lippincott's Manual of Ng. Prac. By Sandra Nena pg.118)

NURSING INTERVENTIONS 1. Care Guide of Post Exploratory Laparatomy

IMPROVING RESPIRATORY STATUS Patients undergoing abdominal surgery are especially prone to pulmonary complications. Thus, the nurse reminds patients to take deep breaths and cough every hour to expand the lungs fully and prevent atelectasis. The early and consistent use of incentive spirometry also helps improve respiratory function. Early ambulation prevents pulmonary complications as well as other complications, such as thrombophlebitis. Pulmonary complications are more likely to occur in the elderly and in obese patients.

ASSESSING NEUROLOGIC STATUS Assess the client for level of consciousness, orientation, and lingering effects of anesthesia in the first 24 hours. In young adults, cognitive deficits may only remain for days or so. Compare present mental status with preoperative ability to clearly define the clients neurologic status. Medications are slower to clear through the kidneys, and hypothermia and pain can also affect cognition. Clients need to know that impaired cognition is to be expected especially older clients, in whom the fear of dementia may be marked. If they are not aware that the condition is temporary, clients may believe that

they have had a stroke during surgery from which they will never recover. This in turn can lead to depression with decreased coping ability. Nurses can facilitate recovery by promoting cognitive activity, repeating instructions often if needed, having patience with clients slow in recovery, and fostering hope. Document changes every shift. If a decrease in cognition appears, notify the physician immediately. Most common is the slow steady progress in return to preoperative status.

MONITORING THE WOUND Assess the dressing and the amount and character of any drainage that is present. Be alert to the method of care that the surgeon prefers. Some surgeons leave the original surgical dressing intact for 24 to 48 hours. Others request that the dressing be changed as it becomes soiled. If the wound is closed and left to heal by first intention, dressings on the wound may be minimal, and the client may be allowed to shower after 24 hours. If the wound healing is to be by second or third intention, then it is left open to heal from the fascia to the skin, and special wound handling must occur. Measures can include wound packing, dressings, drains, ostomy bags, and so on, depending on wound size, and location and drainage from the wound. Measure and record the amount of drainage for comparison with later assessments to guide future care plan changes. If wound infection develops, the clinical manifestations appear in the wound 3 to 4 days postoperatively. Clinical manifestations include redness beyond the incision line, edema that remains after the initial swelling, increasing pain, and increased drainage. Sometimes drainage becomes purulent or foul-smelling. The client may also have fever, malaise, anorexia and leukocytosis. Notify the surgeon of any suspected wound infection.

Wound cultures may be ordered to verify that organisms in the wound are sensitive to the antibiotics taken.

PROMOTING COMFORT All clients who have just had surgery will experience pain. Pain medication should be given when needed and before the pain becomes severe. When the demand approach (prn meds) is used for analgesia, it is crucial to medicate the client at the onset of the pain. When pain becomes too severe, more medication and a longer time are needed for the medication to take effect. Document the date and time of the medication, the amount given, and the route of administration. Also include a description of the pain the client is experiencing and the effectiveness of the pain medication in controlling it. Consider the time of onset of medication effect in determining when evaluation of pain control should be assessed. For example, reassess the client 30 minutes after oral pain medication is administered. IV medications should control pain within 5 to 10 minutes. It is usually the nurse who determines whether the client is obtaining a sufficient dose of medication, whether pain is being controlled, or whether it is causing side effects such as nausea and vomiting. Communicating these details to the physician allows for a change to best suit the clients needs, leading to a positive outcome for pain relief. It is vital that pain be managed if the client is to comply with instructions for coughing, deep breathing, relaxation techniques, diversion, and ambulation.

REDUCING NAUSEA AND VOMITING

Postoperative nausea and vomiting do not occur frequently; however, the surgical experience for those clients with postoperative nausea and vomiting will remain uniquely unpleasant. Vomiting is a reflex, and the reflex is stimulated in many ways. Stimuli can arise from gastrointestinal tract distention on irritation, vagal stimulation, centers in the cerebrum, the chemoreceptor trigger zone (CTZ) located in the floor of the fourth ventricle in the brain, rotation or disequilibrium of the vestibular labyrinths of the ear, increased intracranial pressure, pain, or sensory perceptions. Several medications stimulate the CTZ, including morphine, meperidine, cardiac glycosides, and the amphetamines. Postoperative nausea and vomiting can be prevented by reducing movement, controlling pain, and early intervention with antiemetics. Several categories of medications are used to control postoperative nausea and vomiting and include (1) anticholinergics and histamine type 1 (H1) receptor antagonists, which reduce excitability of the labyrinth receptors; (2) antidopaminergic drugs, which depress the CTZ; and the (3) gastrointestinal antispasmodics, which promote forward peristaltic movement.

IMPROVING NUTRITIONAL STATUS

The nurse encourages the patient to eat a diet of low in fat and salt, since the patient is hypertensive and diabetic. High in proteins and additional iron also is recommended since protein facilitates healing and tissue regeneration while iron helps

correct anemia when present. High fiber diet and increase fluid intake, including fruit juices, promote softer stool. This may also aid in stimulating peristalsis. At the time of hospital discharge, there are usually no special dietary instructions other than to maintain a nutritious diet except for the low salt and low caloric diet to maintain her blood sugar and for her hypertension.

MONITORING AND MANAGING POTENTIAL COMPLICATIONS

Bleeding may occur as a result of inadvertent puncture or nicking of a major blood vessel. Postoperatively, the nurse closely monitors vital signs and inspects the surgical incisions and drains, if in place for evidence of bleeding. The nurse also periodically assesses the patient for increased tenderness and rigidity of the abdomen. If these signs and symptoms occur, they are reported to the surgeon. The nurse instructs the patient and family to report to the surgeon any change in the color of stools because this may indicate complications.

Exploratory Laparotomy, if not properly and carefully done, would lead to surgical hazards. Complications of treatment may be severe. Surgery may precipitate an anastomotic leak, a fistula, pneumonia, and empyema. Rarely, radiation may cause esophageal perforation, pneumonitis and pulmonary fibrosis, or myelitis of the spinal cord. Prosthetic tubes may dislodge and perforate the mediastinum or erode the tumor.

V. Evaluation and Recommendation The medical and nursing interventions rendered to the patient showed good improvements in the patients current condition. The student nurse was able to achieve the objectives and was able to apply her knowledge, attitude and skills in caring for a post-exploratory Laparotomy patient. The patient responded positively to the treatment and nursing interventions. The patient has considerably recovered from her admitting

impression. After the 5-day period of student nurse-patient interaction, the patient and significant others have gained trust in the student nurse and the patients health has been restored to its optimum. The student nurse recommends that once the patient gets discharged, she will follow her diet therapy and drink plenty of water so as to prevent constipation and bowel straining and, consequently, not to aggravate the healing abdominal wounds. The full cooperation and active participation in the treatment and in self care interventions of the patient have been very essential for the fast recovery of the patient. Because infection cannot be totally ruled out, complete caution and discipline are needed. The patient should also be instructed about managing postoperative pain and reporting signs and symptoms of intra-abdominal complications, including loss of appetite, vomiting, pain, distention of the abdomen, and temperature elevation. A positive attitude must always be maintained by the patient that he could fully recover without any complications through proper compliance with medication therapy and cooperation with other health care activities.

VI. Evaluation and Implication of this Case Study To: Nursing Practice This case study aims to provide deeper understanding of the disease condition to the nurses concerned. It should help the nurses in improving their standard of care for the patients who underwent Exploratory Laparotomy, Adhesiolysis and Right Hemicolectomy with Primary End-to-End anastomosis. It is proposed as a guide and reference for students who are practicing in a medical setting and for professional registered nurses providing nursing care to clients with post- Exploratory Laparotomy, Adhesiolysis and Right Hemicolectomy with Primary End-to-End anastomosis.

This case study provides information about colo-cutaneous fistula and its treatment which includes surgery. In this case, the surgery performed Exploratory Laparotomy, Adhesiolysis and Right Hemicolectomy with Primary End-to-End anastomosis. This would also serve as a help to the nursing practice since it provides an appropriate plan of care for patients who underwent this operation for efficient nursing care. Classroom discussion of the different surgical cases is one thing, but actual encounter in the clinical area is a whole new experience. Actual application and observation of the different signs and symptoms in clinical practice allows the student nurses to apply what they have learned in theory into real situations. With combined knowledge from books as well as from actual experiences, they become more able and effective in caring for patients who have undergone Exploratory Laparotomy, Adhesiolysis and Right Hemicolectomy with Primary End-to-End anastomosis.

Nursing Education To the nursing education, this case study would help in sharing data or information about the pathologic condition, which is colo-cutaneous fistula, and its management as well as the preoperative and postoperative nursing interventions needed for the promotion of patients recovery. With these, the students as well as the teachers would gain additional information about the disease and patients condition so that it would equip them for an efficient nursing care in the future. Nursing Research

This case study would help in the nursing research as a source of data for example, in tracking the population of persons with this condition. With this information, it would make us aware of its growing incidence rate and the need to treatment and share the importance of early detection or early prevention of this disease condition.

VI.

Referral and follow-up In about 6 weeks time the patient would be able to recover postoperatively. With

proper compliance to medications and treatments prescribed, further complications would be prevented. In contrast, patient must be alert for complications such as signs of hemorrhage and subdural injection, hematoma. If signs occur, patient must refer to surgeon immediately. In addition, follow-up visits are also recommended for continuous monitoring to ensure a smooth recovery. The patient is expected to come back 1 month after she will be released .

VIII. Bibliography

Books: Bare, Brenda., & Suzanne Smeltzer Textbook of Medical Surgical Nursing 9th edition Black, Joyce M. Medical Surgical Nursing Clinical Management for Positive Outcomes, 6th edition

Bullock, Barbara L. Patophysiology and Alterations in function, 4th edition Byrne Judith Laboratory Tests and Implications for Nursing Care, 2nd edition Ignatavicius, Donna D., Workman, Linda M., Medical Surgical Nursing Critical thinking for Collaborative Care., 4th edition Lippincott. The Lippincott Manual of Nursing Practice, 7th edition. Philadelphia, USA: Lippincott William & Wilkins, 2001. Potter and Perry Fundamentals of Nursing, 5th edition Internet: www.google.com www.medlineplus.com www.medicinenet.com www.yahoo.com