Case Study MSN III:

Post-operation Day
3 Sigmoid
Colectomy for
Sigmoid Ca
Group 3
Anith Al Bakri A/P Mustafa Al Bakri
(25908)
Awng Nashyarudin (29032)
Dg Noraini Bt Tajudin (26172)

Outline of Presentation
Pathophysiology
Introduction: patients profile
11 Functional Health Pattern
Assessments
Diagnostic/Laboratory Investigations
Surgical Management
Medical Management
Pharmacological Management
Nursing Progress
Nursing Care Plan
Health Education
Conclusion

Pathophysiology
(sigmoid colon cancer)
Growth of tissue or tumor
usually begins as a noncancerous polyp on the inner
lining of the colon
A tumor can be benign (not
cancer) or malignant (cancer)
cancerous growth involves the
destruction of the epithelial cell
layer, by which the effectiveness
of absorption of excess water at
the colon is greatly reduced
causing the patient to present
with symptoms such as
diarrhea, constipation, rectal
bleeding, blood in the stools,
changes in stool consistency,
and abdominal pain.
Sigmoid Colectomy -removing

Introduction: Patients profile

Madam N, an 81 years old Iban lady came to the emergency and trauma
department on 24/2/2014, present with an abdominal pain and
distension for one month and was worsening for the last two days,
vomiting after eating for one month, chronic constipation for two days,
generalised body weakness, poor oral intake and loss of weight.

Past medical history

: She has a known case of hypertension
and is currently
under follow up at Kota Samarahan.
Past surgical history
: Sigmoid colectomy done on 7/3/2014
Family history
: Madam N has a family history of hypertension.
Last hospital admission : This will be her fist admission
Allergies
: No known food and drinks allergies
Current complain
: Poor oral intake, abdominal pain at operation
site
(pain score: 3/10)
4

11 Functional Health
Pattern
Health Perception
& Health
Management
Ex-smoker-40 years, quit
for 1 year
Non-alcoholic
On hypertension
medication

Coping Stress
Tolerance / SelfPerception / Self
Concept Pattern
Concerned about her
recovery from the
disease to go back
home.

Role-Relationship
Pattern
Previously: farmer
Currently: unemployed
Support system: family
members
Family concern: financial
issue

Nutrition /
Metabolic Pattern

Sensory
Perceptual Pattern

Poor oral intake

Loss of appetite due to
vomiting out food
Loss of weight (53kg50kg)

Hearing: Slightly
impaired (age-related
changes)
Vision: Glaring &
blurring (age-related
changes)

Elimination Pattern

Cognitive
Perceptual Pattern

Value-Belief
Pattern

Alert, oriented, able to

comprehend and express
self
Clear speech and
appropriate level of
interaction

Christian; receives
prayers from family and
friends

Bladder habits: normal

(depends on amount of
fluid intake), CBD in-situ
Bowel habits: no more
constipation; normal
(once in 2-3 days)

Activity / Exercise
Pattern
Previous ADL:
independent
In ward: needs
assistance from others
Bed-bound

Sexuality /
Reproductive
Pattern
Married with 2
daughters and 4
grandchildren

Sleep / Rest Pattern

Sleep and rest well

Assessments (done on 10/3/2014)

Physical Assessment
Clinical Data
Height
: 155 cm
Weight
: 50 kg
General Appearance
: Madam N appears clean and neat but looks weak
Temperature
: 36.9oC
Pulse
: 89 beat / minute
Blood Pressure
: 130/72 mmHg
Pain Score
: 3 / 10
Respiratory rate
: 21 breaths / minute
SpO2
: 100%

Health Assessment
Metabolic Integumentary
Skin
:Senilis petachae observed with fragile, dry skin and poor skin
turgor
Mouth
:Madam Ns gum and teeth condition is normal
Abdomen
:Operation site at left iliac fossa dressed with Kaltostat
dressing and drain in-situ. Bowel sound present;
tender
and soft upon palpitation.

Psychosocial Assessment
Geriatric Depression Scale
Score: 2 / 15
6

Diagnostic /Laboratory investigation

Investigation

Purpose

Findings

X ray

To examine the right

location of triple line in
post insertion of CVP

1st: incorrect location of

triple line
2nd : correct location of
triple line

Blood test (FBC, BUSE,

creatinine, PT, PTT, INR)

To detect abnormality in
blood composition level,
electrolyte level)

Low Ca, K, Mg,

prolonged PT, PTT

USG abdomen

To look for intraabdominal collection /

evidence of anastomatic
leak on post sigmoid
colectomy .

No evidence of leak

Arterial blood gas (ABG)

Determine thephof the

blood, thepartial
pressureofcarbon
dioxideand oxygen, and
thebicarbonatelevel

Partially compensated
metabolic alkalosis with
hyperventilation.

Surgical Management
Operation undergone: Sigmoid Colectomy
(7/3/2014)
Pre-operative
Informed consent
Blood transfusion consent
CBD insertion
Post-colectomy
pain score monitoring

Medical Management

IVF 1.5 L/day N/saline alternate dextrose 5%

Central venous line inserted on 11 March 2014 at 11am
Chest X-ray
TPN was started at 12ml/kg/day which equivalent to
600kcal/day @ 11 March 2014
Increase caloric requirement from 12kcal/kg/day to
15kcal/kg/day to 18kcal/kg/day to 21kcal/kg/day to
25kcal/kg/day
CVP monitoring. CVP reading at 5cm H2O at 12 March 2014
@ 12pm
Daily
wound inspection
FFP was
administered
on 12March 2014
Wound drain on left lower quadrant abdomen
Drain charting
Daily dressing with kaltostat
Central venous line inserted on 12 March 2014
at 11am
9

Pharmacological management
Routes
&Drugs

Indication

Dosage

Frequency

Side effect

T. Tramadol

Reduce postoperative pain

50mg

TDS

Dizziness,
bloating,
indigestion

T. Paracetamol

Reduce postoperative pain

1g

QID

Not COMMON,
with the proper
use

T. Slow
potassium

Hypokalemia
(k : 1.92)

2tablet

TDS

Nausea,
vomiting, gas,
or diarrhea

Mist NACL

Hyponatremia
(na: 122)

2g

TDS

Not COMMON,
with the proper
use

IV Pantoprazole

Prevention of
gastric ulcer

40 mg

BD

Headache,
dizziness
Nausea,
vomiting

IV Magnesium
sulphate

Hypomagnesem
ia (mg:0.83)

1 vial in 500ml
NS

2 Hours

Heart
disturbances;
Rash or flushing;

S/C Clexane

Prevention of
DVT

40mg

OD

Bleeding,
10
thrombocytopen

Nursing Progress
Post-colectomy Day 3
(10/3/2014)

-Patient not tolerating orally

-Wound breakdown observed
during inspection
-Dressing with Kaltostat
-IVD 1.5 L/day N/saline alt D5%
Post-colectomy Day 4
(11/3/2014)

-CVL was inserted by doctor

-X-ray taken
-TPN started at 600kCal/day
-Encourage ambulation

Post-colectomy Day 6
(13/3/2014)

-TPN administered as prescribed

-Wound care: dressing with
Kaltostat
-strict I/O charting
-decrease IVD 1L/day all N/saline
alt D5%
Post-colectomy Day 5
(12/3/2014)

-TPN increase to 750kcal/day

-CVP monitoring started
-Trace HPE
11

Nursing Care Plan

Identified Nursing Diagnosis
Imbalanced nutrition: less than body requirements related to poor oral
intake as evidenced by verbalization of patient , loss of weight (53 to
50kg ), dehydration (CVP reading : 5 cm H20) and poor skin turgor.
Pain at operation site related to surgical operation (Post-operation Day
3 Sigmoid Colectomy) as evidenced by verbalization of patient and
pain score of 3 / 10.
Risk for ineffective airway clearance related to immobility and pain at
operation site as evidenced by observation of resting in bed/bedbound.
Risk for impaired skin integrity related to immobility as evidenced by
poor skin turgor, fragile and dry skin.
Risk for nosocomial infection related to invasive procedures such as
central line, urinary catheter, and cannulation in-situ as evidenced by
long stay of hospitalization.

12

Diagnosis: Imbalanced nutrition: less than body requirements related to poor oral
intake evidenced by verbalization of patient , loss of weight (53 to 50kg ) and poor
skin turgor.
1
Goal: Patients will have good tolerance to oral intake and balanced nutrition as
evidenced by no further weight loss within 3 days. (10/3/14 @9am)
Intervention:
Assess the extent of nutritional imbalance such as monitoring the daily weight
to identifying the need for further intervention
Assess and provide patient preferred food as this will make her more tolerate to
take the food based on her choice.
Encourage patient and caregiver to give small frequent meals so that she will
gradually more tolerate to take food and enhance absorption of the nutrient
effectively.
Encourage care giver to prepare home cooked food so that patient will tolerate
more to those familiar food.
Provide a pleasant environment during her mealtime (eg: free from bad smell,
oral hygiene, encouragement to enhance her mood to eat)
Administer analgesics as prescribed before meal time to ensure patient is free
from pain during meal time and able to have meal comfortably.
Administer Total Parenteral Nutrition (TPN) as prescribed by doctor to provide
enough and compensate for body need of nutrient to ensure patient received a
balanced nutrition.
Administer IV fluid as prescribed to ensure patient receives enough amount of
fluid to compensate for and prevent dehydration.
Monitor CVP reading to assess for hydration status and evaluate for any
changes form the earlier management.
Evaluation: Patient gradually showing evidenced of receives enough nutrition, 13
improved in tolerance to oral intake, as evidence by no further weight loss and

Diagnosis: Pain at operation site related to surgical operation (Post-operation Day

Sigmoid Colectomy) as evidenced by verbalization of patient and pain score of 3 /

3
10.
2

Goal: Patient will verbalize less pain or no pain as evidenced by pain score of 0-1/10
within 3 days of care (10/3/2014 @ 9am).

Intervention:
Assess site, onset, characteristics, radiation, associated symptoms, time,
exacerbating factor and severity of pain to determine patients pain.
Give reassurance to patient to allay feelings of anxiousness that
aggravates pain and to promote cooperation from patient.
Teach patient deep breathing exercise technique to ease pain especially
during procedures such as dressing
Apply diversional therapy such as talking to patient, listening to music to
divert patients attention from the pain
Administer analgesic medication as prescribed (T. Tramadol 50mg TDS, T.
PCM 1g QID) to reduce pain at operation site.
Monitor vital signs of patient (blood pressure, respiratory rate, pulse rate,
temperature) especially pain score as an indication of pain levels.
Reassess pain score of patient to determine effectiveness of management.
Evaluation: patient verbalized less pain as evidenced by pain score of 1 / 10 on
last day of attachment in surgical ward (13/3/2014 @ 1.30 pm)

14

Health education
Encourage oral
intake by
encouraging
family members
to bring favorite
food from home

Health
Education
Teach family members

on wound care such as

changing soaked
dressing, and
inspecting the wound
for discharges and
healing as a discharge
planning for when they
are required to do it at
home.

Teach family
members the
importance and
needs of hand
hygiene (soap and
water, alcoholbased) with the
correct technique of
hand-washing
especially when
about to touch the
patient
15

Conclusion
In conclusion, Madam N is still currently receiving her
medical and nursing care at the Female Surgical Ward. Her
latest diagnosis is Post-operative Sigmoid Colectomy for
Sigmoid cancer complicated with wound breakdown.
Hence, there is a need for Madam N to be under the care
of healthcare providers to promote a physical,
psychological and emotional well-being of patient.
Therefore, the collaboration care between doctors, nurses,
nutritionist, pharmacist and physiotherapist for further
management in Madam Ns case are being done in order
to improve the quality of care for patient.

16

17

References
Cancer Research UK (2013). Types of surgery for bowel cancer. Retrieved March
19, 2013 from
http://www.cancerresearchuk.org/cancer-help/type/bowel-cancer/treatment/surgery/
which-surgery-for-bowel-cancer
Seymour, E. & Eli, D. E. (2001). Clinician's Handbook of Prescription Drugs . 1 st
ed. McGraw Hill Publication. Chicago.