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Case study stoma


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Case study stoma

  1. 1. Case Study - WalterA patient’s experience of a stomafollowing curative bowel surgery:Opportunities for the acute therapy teamto enhance recovery and promotequality of lifeBeki DellowOccupational Therapist – Acute Therapy Team (Surgical Rotation) March 2012
  2. 2. Learning Outcomes Brief explanation of the meaning of ‘stoma’ and causes of bowel cancer Review bowel cancer statistics and importance of screening Gain an overview of a specific patient’s experience pre/post operatively (bowel surgery) Review guidelines and evidence to support practice in stoma care and assessment of quality of life Consider opportunities for the acute therapy team to enhance the patient experience and their quality of life, promote recovery and decrease length of stay Summary & conclusion Questions
  3. 3. StomaFrom classical Greek meaning ‘Mouth’ ‘Artificial opening’ (Black 2000) There are approximately 100,000 people in the UK with a stoma (Windsor and Conn 2008)
  4. 4. Causes of Bowel Cancer High intake of red and processed meat will increase the chances of developing bowel cancer whereas a diet rich in fibre will reduce your risk Around 13% of bowel cancers in the UK are linked to overweight or obesity Research has shown that drinking as little as 10g/day of alcohol (around 1 unit) can increase the risk of bowel cancer Smoking increases the risk of bowel cancer People with a first-degree relative with bowel cancer are at twice the average risk of developing it themselves People with diabetes, ulcerative colitis or Crohns disease all have an increased risk of bowel cancer Being physically active reduces risk of colon cancer (Cancer Research UK 2011)
  5. 5. Bowel Cancer UK Incidence Statistics Approximately 110 new cases of colorectal cancer are diagnosed daily The third most common cancer in women after breast and lung, third in males after prostate and lung In 2008 - 39,991 new cases of large bowel cancer registered: two- thirds (25,551) in the colon and one-third (14,440) in the rectum (Cancer Research UK 2011; NICE 2011)
  6. 6. Bowel Cancer UK Incidence Statistics Bowel cancer is the third most common cause of cancer death among men (11% of all male cancer deaths). It is the third most common cause of death among women (10% of all female cancer deaths) The lifetime risk for men of being diagnosed with colorectal cancer is estimated to be 1 in 15 and for women 1 in 19 In 2009, there were 15,908 deaths from bowel cancer Bowel cancer mortality rates have overall decreased: For men, European age-standardised mortality rates were 35% lower in 2007-09 than in 1971- 73. For women, rates were 47% lower in 2007-09 than in 1971-73 (Cancer Research UK 2011)
  7. 7. Average number of new cases per year and age-specific incidence rates per 100,000 population (UK)
  8. 8. The importance of bowel screening Has been shown to reduce the risk of dying from bowel cancer by a quarter in people who are screened in England Most cases of colorectal cancer develop slowly over a number of years from adenomas, or benign polyps, which can transform into malignant adenocarcinomas. This provides the opportunity for screening to detect and treat benign polyps before malignant transformation occurs Can detect colorectal cancers at an early stage when survival rates are highest Those who attend screening have a 25% reduction in their risk of dying from colorectal cancer (Cancer Research UK 2011)
  9. 9. Survivorship Five-year survival rates for male rectal cancer rose from 25% in the early 1970s to 51% in mid 2000s and from 27% to 55% for female rectal cancer These improvements are a result of earlier diagnosis and better treatment but there is still much scope for further progress Ten-year survival rates are only a little lower than those at five-years indicating that most patients who survive for five years are cured from this disease Patients who are diagnosed at an early stage have a much better prognosis than those who present with more extensive disease Bowel cancer incidence is generally higher in populations with ‘westernised’ diets and these populations also tend to have a higher proportion of overweight and obese people and lower levels of exercise (Cancer Research UK 2011)
  10. 10. Case study - Walter  78-year-old male  Lives with supportive wife (retired nurse)  Short-term memory difficulties  Motivated and positive
  11. 11. Walter’s journey 28/10/11 Visit to GP 2 – 3 months bleeding from rectum 14/11/11 Colonoscopy Rectal examination Biopsies of large bowel (definite palpable mass) Mucosa taken 23/11/112 week fast track referral for CT &suspected colorectal cancer Local staging of Primary tumour with MRI 11/11/11 Letter received by consultant from GP 8cm mass on left lateral wall of rectum confirmed. Tumour likely to be a carcinoma Explained to Walter and his wife
  12. 12. Staging: The 1932 Dukes’ classification of tumoursUICC/TNM Modified DukesStage 0 Carcinoma in situ AStage I No nodal involvement, no distant metastasis Tumour invades submucosa (T1, N0, M0) Tumour invades muscularis propria (T2, N0, M0)Stage II No nodal involvement, no distant metastasis B Tumour invades into subserosa (T3, N0, M0) Tumour invades into other organs (T4, N0, M0)Stage III Nodal involvement, no distant metastasis C 1 to 3 regional lymph nodes involved (any T, N1, M0) 4 or more regional lymph nodes involved (Any T, N2, M0)Stage IV Distant metastasis (any T, any N, M1) D
  13. 13. 09/12/11 Reviewed at clinic by consultant in colorectal and general surgery Diagnosis of T2 carcinoma of the Lower rectum Walter advised of temporary diverting stoma 21/12/11 Possible permanent colostomy Colorectal Enhanced Recovery SURGERY 10.30 – 12.30 Low Anterior Resection & Loop Ileostomy Wound covered 29/11/11 High volume epidural controlling pain MDT discussion• Review of histology from colonoscopy 18.00 – Walter is reviewed by the surgeon• Biopsies from large bowel mucosa (sit out and mobilise as able) are infiltrated by poorly differentiated Walter mobilised in the evening Adenocarcinoma Urine output satisfactory• CT - no evidence of metastatic disease• MRI – low rectal adenoma or early invasion lesion (T2NO-LOREC Stage 1) Stoma Care Nurses informed
  14. 14. Walter’s surgery: Low anteriorresection with loop ileostomy
  15. 15. 23/12/11 – DAY TWO• Nursing staff - ‘IV & edpidural down’ Christmas Eve – DAY THREE• Therapy assistant – ‘Mobile with supervision Walter is discharged home of one staff’ from hospital• Stoma Nurse – 30 minute education session with patient (wife present) – Diet, stoma self-care equipment supplier and kit, stoma care advice line• Occupational therapist - observingWalter reports: ‘my pain is not too bad, just when I’m ONE WEEK AFTER DISCHARGEcoughing’ • Stoma nurse – telephone contactWalter’s wife reports: ‘ the fast track and enhanced to arrange follow-up home visitrecovery is fabulous. I’m particularly surprised thatmy husband is returning home at day three, all beingwell. I am happy with the service and pre-oppreparation also’ TWO WEEKS AFTER DISCHARGE • Stoma nurse – follow up visit Walter managing well with wife’s support 22/12/11 – DAY ONE 08.20am – ‘doing fantastically, mobilising’• Physiotherapist – ‘Independent with epidural stand. Taught deep breathing exercises and cough’ WEEK THREE• Stoma Nurse – First visit, education • Occupational therapist – session with occupational therapist Telephone call – wife reports present. ‘Participated well, slightly muddled’ Walter managing well, with min support
  16. 16. Acute therapy team role? Assessment and enabling strategies Education Supporting role, rehabilitation and follow-up – collaboration with intermediate care teams and stoma nurses
  17. 17. Assessment and enabling strategies Self-care Quality of life Mobility and exercise
  18. 18. Enabling engagement in stoma self-care occupationInvolves a complex interaction betweenthe occupation itself; Walter’s beliefs,values and identity; and theinstitutional, cultural, social andphysical environment in which theoccupation is performed(Van Huet et al, 2010)
  19. 19. Analysis of Walter’s occupational performance‘Occupational performance analysis is a structured evaluationprocess that uses observation of an individual to identify anddefine factors that support or hinder occupational performanceand prevent that person from being a full participant in life’(Chard, 2010 p161)
  20. 20. Assessment Objective (observation)Careful observation of Walter’s performanceof the self-care occupation to determine:- Capacities to complete the specific tasks Degree and nature of assistance required Need for support Need for further targeted assessment of areas of difficulty Causes of any activity limitations (Van Huet et al, 2010)
  21. 21. Assessment Subjective (questionnaire)Collect data that reflects Walter’s perspectivesand perceptions of self-care (self-report) Indicates what Walter believes is occurring during performance Highlights what Walter believes is particularly problematic Gain and in-depth picture of Walter’s self-care needs, abilities, choices and desires (Van Huet et al, 2010)
  22. 22. Quality of life
  23. 23. Assessment tools There are limited quality of life evaluation tools (Baxter et al 2006)1994 – Major quality of life international study using the Quality of Life Index (QLI) developedby Padilla and Grant (1985) - 16 countries 5289 patients recruited by stoma care nurses Patients completed a questionnaire 4 times in first year (discharge, 3, 6 & 12 months). The following year, one questionnaire at 18 & 24 months (voluntary basis)Findings: Showed change with time – biggest improvement between hospital discharge and 3 months (patients generally enjoyed a better quality of life) Those with good relationship with a stoma nurse after discharge had a significantly higher QOL than those who had a poor relationship Changing appliances - most patients had moderate confidence at hospital discharge. Those high in confidence had a higher QLI score. At 3 months, those with decreased confidence had a decrease in QLI scoreHelping to increase patients’ confidence in changing their appliance has a positive effect onQuality of life (Black 2000)
  24. 24. Stoma-QoL questionnaire
  25. 25. Mobility and exercise
  26. 26. Education Pre and post op physiotherapy Information leaflet – exercises and advice Reinforcing stoma self-care in and out of hospital – Occupational therapists and therapy assistants
  27. 27. Supporting role & rehabilitationOn the road to rehabilitation, most patients go through at least three stages :-1. Learn to basically care for their stoma and manage their equipment2. Complete with stoma, engages in activities of daily living they regard as part of their normal lifestyle3. Report feeling ‘back to normal’ or ‘being myself again’. The stoma is experienced as an integral part of the person instead of being separate or added onto themOur care must be relevant to our patients’ needs and also promote theirlonger-term psychological and physical rehabilitation (Breckman 2005)
  28. 28. NICE Guideline Colorectal Cancer (2011) Patient-centred care – Take into account their needs and wishes; involve family and carers with consent; informed decisions; good communication Before surgery, offer all patients information about the likelihood of having a stoma, why it might be necessary and how long it might be needed for Ensure a trained stoma professional gives specific information on the management and care of stomas Quality of life - Colorectal cancer-specific patient-reported outcome measures (PROMs) should be developed for use in disease management and to inform outcome measures in future clinical trials
  29. 29. ‘The essence of successful stoma care is knowing,valuing and working with each patient as an individualhuman being. Their physical and psychological needs,goals capabilities and resources can then be used tohelp them to move from feeling and acting as a ‘stomapatient’ to being a person engaged in their normallifestyle who happens to have a stoma’(Breckman 2005)
  30. 30. Summary: Getting the balance right The quality of pre-operative preparation can contribute greatly to patients quality of life and acceptance of their stoma The presence of any stoma, either permanent or temporary, affects patients’ lives, therefore carefully planned siting is critical to promote independence in self-care Psychological care is important to help patients to form positive attitudes towards their new form of bowel elimination and changes to their body image Patients are discharged very soon after surgery and this restricts the time available to help them gain adequate knowledge and skills to manage self-care at home (Black 2000, Borwell and Breckman 2005)
  31. 31. Conclusion The impact of rectal surgery goes well beyond the physiological changes a person will experience With the appropriate knowledge, skills and sensitivity, we as health care professionals can help our patients to make the transition from despair to adjustment and rehabilitation, ultimately enhancing their quality of life and promoting recovery (Winney 2005)
  32. 32. Questions?
  33. 33. References Baxter NN, Novotny PJ, Jacobson T, Maidl LJ, Sloan J (2006) A stoma quality of life scale Diseases of the Colon & Rectum 49(2): 205-12 Black PK (2000) Holistic Stoma Care London: Bailliere Tindall Borwell B, Breckman B (2005) Types of bowel stoma and why they are created. In: Breckman B (Ed) Stoma Care and Rehabilitation Oxford: Elsevier Churchill Livingstone Breckman B (Ed) (2005) Stoma Care and Rehabilitation Oxford: Elsevier Churchill Livingstone Burch J (Ed) (2008) Stoma Care Chichester: John Wiley & Sons Ltd Cancer Research UK (2011) Colorectal Cancer Fact Sheet London: Office for National Statistics [Online] Available from: [Accessed 25/02/2012]
  34. 34. References Chard G (2010) Analysis of Occupational Performance. In: Curtin M, Molineux M, Supyk- Mellson (Eds) Occupational Therapy and Physical Dysfunction: Enabling Occupation (6th Ed) London: Churchill Livingstone Elsevier Curtin M (2010) Enabling Skills and Strategies. In: Curtin M, Molineux M, Supyk-Mellson (Eds) Occupational Therapy and Physical Dysfunction: Enabling Occupation (6th Ed) London: Churchill Livingstone Elsevier Curtin M, Molineux M, Supyk-Mellson (Eds) (2010) Occupational Therapy and Physical Dysfunction: Enabling Occupation (6th Ed) London: Churchill Livingstone Elsevier Jones DJ (1999) ABC of Colorectal Diseases (2nd Ed) London: BMJ Books NICE (2011) Colorectal Cancer: The Diagnosis and Management of Colorectal Cancer Manchester: NICE Padilla G, Grant M (1985) Quality of life as a cancer nursing outcome variable Advances in Nursing Science 8: 45-60
  35. 35. References Prieto L, Thorsen H, Juul K (2005) Development and Valdation of a Quality of Life Questionnaire for Patients with Colostomy or Iliostomy Health and Quality of Life Outcomes 3(62) [online] Available from: [Accessed 04/12/2012] Sumsion T (2010) The Art or Person-Centred Practice. In: Curtin M, Molineux M, Supyk- Mellson (Eds) Occupational Therapy and Physical Dysfunction: Enabling Occupation (6th Ed) London: Churchill Livingstone Elsevier Van Huet H, Parnell T, Mitsch V, McLeod-Boyle A (2010) Enabling Engagement in Self-care Occupations. In: Curtin M, Molineux M, Supyk-Mellson (Eds) Occupational Therapy and Physical Dysfunction: Enabling Occupation (6th Ed) London: Churchill Livingstone Elsevier Windsor A, Conn G (2008) Surgery. In: Burch J (Ed) Stoma Care Chichester: John Wiley & Sons Ltd Winney J (2005) Consequences of rectal surgery. In: Swan E (Ed) Colorectal Cancer London: Whurr Publishers