12 Case study 2
caring for a patient in a general surgical ward
• To enable you to reflect on prior learning from other chapters
• To explore in more detail through one specific case study the kind of surgical interventions you may come across in caring for patients in a general surgical ward
• To focus on the total care of a patient who may be admitted onto a general surgical ward, from pre-admission to discharge home and care in the community
• To enable you to identify learning opportunities as well as meeting your practice learning outcomes
Introduction
Patients admitted to a general surgical ward have a short-term stay of a few days or a longer stay of a week or more, depending on the type of surgery and whether any perioperative complications occur. In this chapter, we explore the care of a patient who has had a medical diagnosis of cancer of the bowel, identified following the NHS over-60s bowel screening initiative (NHS Bowel Cancer Screening Programme 2009). It is beyond the scope of this book to cover everything with regards to caring for someone after major abdominal surgery. It is advisable, therefore, that you supplement the information in this chapter with that in other chapters plus relevant further reading.
Introduction to patient and clinical problem
Mrs Nadira Ahmad is a 62-year-old woman who responded to the over-60s bowel screening initiative after seeing an advert for it at her local hospital. A test kit was sent to her and she found this helpful as it meant she could do it in the privacy of her own home, even though she still found it embarrassing. She had been concerned as she had experienced some rectal bleeding and had not told anyone, but she knew from information in her GP centre that ‘something was not right’ – the poster in the hospital had triggered further inquiry when she realised she could do something without alerting too many people, especially her family. She had been experiencing a change in her normal bowel movements and some discomfort on the right side of her abdomen which she had put down to ingesting the wrong kind of food and ‘wind’. She had also been very tired which she had put down to her age.
Two weeks later, Nadira Ahmad receives a letter telling her that she needs to contact the screening service
Access the NHS Cancer Screening site and read the information about the initiative and the process prior to the patient receiving the screening test kit. See the link to the information and the kit instructions. A short animated film can also be found there as well as instructions in different languages:
http://www.cancerscreening.nhs.uk/bowel/ (accessed December 2011).
http://www.cancerscreening.nhs.uk/bowel/ipc-pack.html (accessed December 2011).
to make an appointment to see a specialist nurse. She is informed that her GP has been sent a letter as well explaining why she needs to contact the nurse. If she prefers, she may go to her GP who knows her and her family as well as her health history.
She is now very concerned. She has asked her daughter, who she eventually confided in, to look for any information on the Internet, and a link from the cancer screening programme site led them to video information about the bowel, polyps and possible investigation of colonoscopy for cancer. This is in her own language of Urdu, which helps her: http://www.remedica.com/bowel/default.aspx (accessed December 2011).
In order to help patients such as Nadira Ahmad, you need to understand the physiology of the gastrointestinal tract as well as the nature of polyps and why they can turn cancerous.
If you are in a day surgery unit or an outpatient department where colonoscopies are carried out, you will need to communicate effectively with patients and be mindful of different cultural and religious backgrounds as well as your own communication skills.
View the online explanation for the physician about polyps and colonoscopies on the same site:
http://www.remedica.com/bowel/default.aspx (accessed December 2011).
See Box 12.1 for an explanation of what the NHS screening site states about colonoscopy for service users and the general public.
Box 12.1 What is a colonoscopy?
A colonoscopy is an investigation that involves looking directly at the lining of the large bowel. A thin flexible tube with a tiny camera attached (a colonoscope) is passed into the back passage and guided around the bowel. If polyps are found, most can be removed painlessly using a wire tube passed down the colonoscope tube.
Read the definition in Box 12.1 and compose a more detailed explanation in order to teach another student what happens in a colonoscopy. What would you say differently? For example, would you use the term ‘back passage’ in your explanation or would the word ‘rectum’ be more appropriate?
There are references to physiology textbooks throughout this book and you may have one that you have a personal preference for. To help patients like Nadira Ahmad, it is important that you are fully prepared to answer any questions you feel confident to answer within your sphere of knowledge and responsibility. Being knowledgeable about how the bowel works and what happens in a colonoscopy is essential both pre- and postoperatively should she require major surgery.
Communicating with her in a culturally appropriate way is also very important, as it is with all patients.
Attending for a colonoscopy
After contacting the specialist nurse at the local screening centre, Nadira Ahmad arranges an appointment and her daughter accompanies her. Here is what happens at the clinic.
This is a 45 minute consultation to allow you to discuss with the Specialist Screening Practitioner any concerns you may have about your results. The Nurse will explain about the next investigation which is called colonoscopy.
She will assess your health to see whether you are suitable to have the next investigation. A Health Questionnaire will be completed so it is important to bring information with you about the tablets you take.
The Nurse will also explain about the diet you need to follow three days before colonoscopy and the bowel preparation you need to take 24 hours before your investigation. (From http://www.mccn.nhs.uk/patients/tests/screening/bowel-screening-process.php (accessed December 2011)).
During your clinical placement in either surgical nursing or community nursing, organising an insight day or a 2–3-day spoke placement is very helpful for understanding the patient experience, communication skills and the role of the nurse in this type of new screening service. It is also important for understanding health policy such as that which has influenced the introduction of this screening programme across the UK.
Read the article by Coutts (2010) (see References) for the main report explaining the rationale for the initiation of the bowel screening programme.
http://www.cancerscreening.nhs.uk/bowel/ethnicity-finalreport.pdf (accessed December 2011).

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