Jennie Burch

Constipation, treatment and biofeedback therapy.

Constipation is commonly encountered by the community nurse, particularly in older people. A comprehensive assessment is required prior to treatment, to exclude potential pathologies such as a bowel cancer. There are many potential causes of constipation, such as poor diet or use of opioid analgesia. This can guide the nurse to a potential treatment, for example to include more fibre in the diet or to possibly change the analgesia used. However if these and/or other therapies fail, biofeedback therapy offers a non-surgical option. Biofeedback therapy includes patient education, retraining of the bowels and muscles, behavioural therapies and psychological support.

Stoma appliances and accessories: getting it right for the patient

This article will examine some of the appliances and accessories that can be used to care for a stoma. There are three types of stoma that can be surgically formed and each will be discussed. Furthermore, there will be brief explanations of why stomas might be formed and what the output from each stoma type will be. Complications are associated with stomas, such as sore skin, which is commonly seen within the first few months after the stoma is formed. This important topic is examined and some of the accessories that can be used to treat these issues will be explored. To aid the reader to undertake their own research on the topic, the websites from some of the stoma manufacturers are included. These websites contain more details about appliances, accessories and information for people with a stoma that can be of benefit to nurses too.

Active and passive compliance in an enhanced recovery programme

IntroductionEnhanced recovery after surgery (ERAS) is a well-established and accepted practice following colorectal surgery and has been demonstrated to reduce hospital length of stay (LOS) and 30-day morbidity. Despite evidence to support the individual elements on which the programme is based, there remains uncertainty as to how many and which of these are required to realise its benefits. Furthermore, elements of an ERAS programme might either precipitate or reflect recovery, in which case compliance could have a role in the improvement or prediction of outcome.Materials and methodsA multidimensional prospective database of 799 consecutive patients undergoing colorectal surgery within an established ERAS programme at a single institution was interrogated. After application of exclusion criteria, 614 patients were studied. The novel concept of ‘active compliance’ is introduced. An ERAS element is classified as ‘active’ if the participation of the patient is required to achieve its compliance. This contrasts with ‘passive’ compliance, where an intervention is delivered to the patient without their direct contribution. The short-term surgical outcomes of this cohort are reported with reference to ERAS protocol compliance.ResultsCompliance with the passive elements of the programme was higher than with the active elements. Univariate and multivariate analyses demonstrate that poor compliance with active but not passive elements of the programme was significantly associated with major morbidity. Receiver operator characteristic curve analysis demonstrated active compliance to be a stronger predictor of both major morbidity (AUC 0.71 vs. AUC 0.56) and length of stay (AUC 0.83 vs. 0.57) when compared with passive compliance.ConclusionThe results suggest that poor active compliance may be a surrogate marker of morbidity which can be recognised in the early post-operative period. This implies the potential for timely diagnosis and intervention. This aspect of ERAS compliance is clinically relevant yet has achieved scant attention. Independent validation of our observations is required.

Preoperative Optimisation and Conditioning of Expectations

Enhanced recovery aims to reduce the systemic response to surgical stress and in doing so improve the quality and rapidity of a patient’s recovery. It is a structured evidence-based process that encompasses the perioperative period of care and produces considerable reduction in postoperative complication rates and length of hospital stay [1–4]. The majority of patients undergoing elective colon and rectal surgery are suitable for this process. This chapter focuses on colorectal surgery but the principles are transferrable to many other surgical specialities. The chapter aims to cater to the needs of the multidisciplinary team, and a more detailed scientific explanation of some of the aspects covered in this chapter will be available from other sources. We explore the rationale for the preoperative optimisation and conditioning of expectations and describe how the multidisciplinary team can achieve this and how general practitioners can participate in the process.

Preoperative carbohydrate loading in the enhanced recovery pathway

The enhanced recovery pathway is an evidence-based surgical care pathway that includes preoperative, perioperative and postoperative care and results in fewer complications and a shorter length of stay in hospital. There are a variety of elements associated with this pathway and one is the use of a preoperative carbohydrate-loading drink. The consumption of this drink, which is specifically designed to be safely consumed a few hours before surgery, is discussed with a review of the literature on the topic.

Stoma care in the community

There are over 100 000 people in the UK with a stoma. For nurses working within the community and dealing with a variety of conditions, making a decision regarding the most appropriate stoma appliance to use on ostomates can be a challenge. This article gives a general overview of stomas and stoma appliances. It then discusses the various stoma accessories and gives recommendations for when and how they should be used.

Research and expert opinion on siting a stoma: a review of the literature

Marking the optimal position for a stoma on the patients body before an operation is likely to result in fewer postoperative problems such as appliance leakage. A literature search was undertaken to examine and evaluate current practice internationally. Four recent articles describe the procedure; these articles were consensus documents or expert opinion, with limited robust research to support the statements made. Despite some variations in techniques, there was general agreement within the articles. Interestingly, when comparing recent and historical information on stoma siting, there were reassuringly few changes. Thus, in practice, although poorly researched, it is considered essential for people to have their stoma site marked as part of their preoperative preparation before elective stoma-forming surgery.

Evaluating a nurse scholarship programme: realising potential

Evaluation is an integral component of any nurse education programme and ideally requires a multi-method approach. This article describes both the formative and summative evaluation of the St Marks Burdett nurse scholarship from the perspective of the health professionals involved. During the nursing scholars specialty placements, their achievements were recorded alongside a more detailed insight into their ongoing development during weekly supervision sessions. The summative evaluation comprised recording their attendance at taught study days, progress in academic modules and one-to-one interviews. A survey was also conducted to gather feedback about the scholarship. The evaluation indicated that this programme helped the nursing scholars gain exposure to a broad range of gastrointestinal nursing clinical environments, provided them with the resources needed to continue to develop academically and professionally, and helped them to achieve career progression in specialist nursing.

Stoma care: an update on current guidelines for community nurses

Community nurses are familiar with stomas but it can be difficult to keep up-to-date with the newest guidelines on the topic. Reviewing the literature from NICE (National Institute for Health and Care Excellence) provides little advice for people caring for patients with a stoma. There were three NICE documents found; one on colorectal cancer (NICE, 2011), one on inflammatory bowel disease (NICE, 2015a) and one on bladder cancer (NICE, 2015b). The colorectal cancer guidelines discuss stomas in respect of preoperative discussions to include the care and management of stomas by a stoma specialist nurse. Looking at the inflammatory bowel disease (IBD) guidelines, they simply state that support may be required in relation to equality and diversity. Whereas the bladder cancer guidelines state that a discussion is needed to explore urinary diversions to include a stoma (ileal conduit); none of these are useful to guide the community nurse in stoma care. There are now documents available from the ASCN (Association of Stoma Care Nurses) that offer more assistance. These guidelines are written using the best available evidence, which in most cases is not research. While they are written for stoma specialist nurses, they may be of use to the community nurse.

Use of barrier creams for sore skin

S18 British Journal of Nursing, 2015 (Stoma Supplement), Vol 24, No 5