142 Ward Street, North Adelaide SA 5006Telephone: (08) 8267 3355 Fax: (08) 8361 8822

P A T I E N T E DU C A T I ON B O O K L E T

F OR B O W E L A N D R E C T A L P R O C E DUR E S

prior to admission

As a person who is about to have bowel surgery and/or rectal surgery, you will already have begun to give some consideration to your proposed operation.

♦ To facilitate your actual admission to hospital, we ask that you complete your admission forms and return to the appropriate hospital as soon as possible.

♦ Any queries you have regarding your procedure can be directed to our practice nurse Monday to Friday 10.00am to 4.00pm on8267 3355. Any queries regarding your admission, please contactthe hospital directly.

♦ Any queries regarding your anaesthetic please contact your anaesthetist directly. Our Practice Nurse will give you your anaesthetist’s name and contact number at the time of your booking.

♦ All patients being admitted to Calvary North Adelaide Hospital are asked to contact the pre-admission clinic on 8239 9252 to arrange an appointment.

♦ Please ensure you bring all your current medications into hospital with you in their original packaging with their directions of use.

♦ Prior to your admission to hospital it is necessary to make your own arrangements for transport home on discharge.

deep breathing exercises

You will meet your physiotherapist prior to surgery to assess your respiratory function and teach you deep breathing and coughing exercises. These exercises are important to aid your recovery by preventing any possible chest infections. Your physio may give you a‘tri-flow’ to assist with these exercises. A ‘tri-flow’ is a visual tool which shows you how well you are breathing.

The following is a general program that will suit most people. If you require something different your physio will advise you. These exercises can be practised prior to you surgery to help familiarise yourself with them.

♦ Take a slow, deep breath through your nose sending the air right down to the base of your lungs.

♦ Keep breathing in as much air as you can, hold the breath for 3 seconds at the end and then relax, gently breathing out through your mouth.

♦ Then take a second breath in the same manner.♦ Take a third deep breath.♦ Now cough 2-3 times in a row (once is insufficient). This will clear your

breathing passages. Ensure you support your tummy with a pillow whilst you cough.

♦ As you cough, concentrate on feeling your diaphragm force out all the air in your chest.

♦ Then take 3-5 normal breaths, exhale slowly and relax. Repeat this exercise at least once each hour.

leg exercises

While you are resting in bed it is important to do some leg exercises to maintain good blood circulation and prevent clots from forming in your legs. The following exercises are recommended as such:

Foot pumping- alternatively push your feet up and down. This should be done vigorously 30 times per hour.

Leg bends- alternatively bend one leg up and down and then the other. Your physiotherapist will advise you with this exercise to ensure no abdominal strain.

As soon as you are able the nurses will help you sit out of bed and get walking.

After your surgery you will need to do these exercises at least once per hour that you are awake. You should continue with these exercises until you are walking about independently.

pain scale

Because surgery causes some degree of pain and discomfort, we will inform you of some of the choices that are available to you during your hospitalisation.

♦ Ask the nurse how your pain medication is ordered for you.♦ Your pain medication may be scheduled to be given or taken

regularly at certain times. However, if it is not let the nursing staff know when the pain first starts.

♦ Do not wait until the pain is bad before you call for or take the pain medication. Trying to “wait a little longer” only allows the pain to worsen and means that it will take longer to control it and you may need higher dosages of medication if it becomes severe. You may be holding off because you are worried about becoming “addicted” to the medication. Remember, you are taking the medication to stop pain. When the pain stops, the majority of people stop taking the medication.

♦ Tell the nurse if the medicine does not help the pain so they can adjust it until you are comfortable.

♦ It is important that you have effective pain management so you can do your regular deep breathing and coughing exercises, turn comfortable in bed and sit out of bed. These are essential activities that speed up your recovery.

Pain scaleA pain scale is a tool used to describe and monitor pain levels. The nursing staff will monitor the effectiveness of the pain relief by asking you to rate your pain on a scale of 0 to 10;

0 = No Pain,10= Worst Possible Pain

You may feel some pain, even with the medication, but tell the nursing staff if the medication does not reduce you pain level or if your pain level increases. This may mean that your pain medication needs adjusting.

Pain assistance available

1. I n t r av e n o u s I n f u s i o n : This form of pain management is usually commenced in theatre and ismaintained continuously for as long as you require it following your surgery to give you continuous pain control. If this is not adequate, further pain control medications will be instigated.

2. E p i d u r a l : Prior to your surgery your anaesthetist will insert a fine catheter (tube) into the epidural space between the bones in your back. Pain control medication is then administered by an infusion pump through this catheter. You will have no sensation around the wound and your legs may feel heavy or may even have no sensation. This is normal and will be managed by your nurse and anaesthetist. This will not prevent you from siting out of bed. The catheter can stay in position for up to 72 hours post operatively and is then replaced with other forms of analgesia.

3. P a t ie n t C o n t r o l led A n al g e sia ( P C A ) : A PCA gives you control over your pain management. Instead of relying on the nursing staff to give you pain relief, you can push a button which makes an extremely accurate and reliable medical instrument, called a PCA infuser, deliver the right amount of pain medication through the drip in your vein – safely, quickly and very comfortably. This sophisticated machine will not over-dose you as it has a lock out device on it that prevents you from doing so.

4. I n t r a m u s c u l a r I n j e c t i on : To relieve pain throughout your body, medications can be injected into a muscle in your arm, leg or buttocks. This form of pain medication is ordered and administered to you, in consultation with the nurse and doctor.

5. S u b c ut a n e o u s I n je c t i o n : A small plastic tube is inserted under the skin and secured with tape. This is used as an access point to administer your pain medication.

6. O r al A n a l g e s i a This type of pain management is given to you by tablets usually at 4-6 hourly intervals when you request the medication. Oral medication also works for a longer period and is a step forward towards discharge. You will probably be sent home with this type of pain medication.

Managing pain at home

When it comes to effective pain management, the tips you have learned in hospital also work at home. To get the best pain relief possible, remember to:

♦ Use your medication only as directed. If your pain is not relieved or if it gets worse, call your doctor on 8267 3355. If pain lessens, try taking your medication less often.

Remember that medications need time to work. Most tablets need at least 20 – 30 minutes to take effect.

preparation for bowel and rectal surgeryBowel and rectal surgery can be undertaken via one of two approaches. One method, open surgery, is the established operation in which a cut is made down the midline of the abdomen and the piece of affected bowel is removed. The cut in the abdomen wall is sewn up. The second method, laparoscopic surgery, involves using a surgical telescope to look at the bowel. Long instruments are placed through small cuts in the abdominal wall. These instruments are technically designed to assist your doctor to remove the affected bowel without the need for a large incision in the abdominal wall. Your surgeon will discuss the most appropriate method of surgery with you.

This booklet section outlines the day to day expected progress of those patients having open surgery.This process may be sped up for patients having laparoscopic surgery. All discharges will be appropriate to the recovery process.

Da y 1 – B e for e You r O p er a t i o n :

♦ Please report to the admissions desk at the appropriate hospital to be admitted.

♦ You will be escorted to the ward and a nurse will confirm the information you supplied on your admission forms.

♦ The nurse will check your temperature, pulse, blood pressure and weight.

♦ You may be required to have a routine blood test and be fitted for special white stockings that prevent any risk of blood clots in your legs.

♦ If appropriate, it may be necessary to have an ECG (a picture of the electrical impulses of your heart).

♦ You would have completed your “bowel preparation” in readiness for your surgery. The purpose of the bowel preparation is to empty and cleanse your bowel. You may be fasting already or be asked to fast from food and fluid soon after.

♦ The nurses will show you the Critical Care Unit where you will stay after your operation.

♦ The anaesthetist and physiotherapist will visit you prior to surgery depending on the time you are scheduled to go into the operating theatre.

♦ It is important to talk to the nurses and the anaesthetist about the sort of pain assistance that will best suit you post op. There are several options available and we encourage you to be involved with the choice of pain relief.

♦ You will be dressed in a special gown and white stockings ready for theatre.You will be taken to theatre on your bed.

♦ If you have chosen an epidural for your pain assistance, you will be

taken to recovery for the insertion of the epidural catheter (tube).

Da y 1 : - A ft e r You r O p er at i on :

♦ After your operation you will spend 1 – 1½ hours in the recovery room before being transferred to the Critical Care Unit for further recovery.

♦ When you wake up, you will have an abdominal wound and a drip. You may also have a urinary catheter (a tube that drains urine from your bladder) , a wound drain (a small tube attached to a bottle that collects the little fluid that drains from the cut), and a nasogastric tube (a tube in your nose that drains any excess stomach fluid).

♦ If you are having rectal surgery you may have a drain coming from your bottom wound. The nurse will look after all these tubes.

♦ You will be wearing an oxygen mask or nasal specs (little soft plastic tubing that sits in you nose) that delivers oxygen to you while you are still drowsy from the operation.

♦ You will probably be attached by small leads to a monitor on the wall, so that the Nurses and Doctors can monitor your heart activity.

♦ The nurses will record your heart rate, blood pressure, pulse and temperature regularly.

♦ Pain relief will be given to you in a method decided by you and the anaesthetist. It is important that you advise the nurses if you have any discomfort because there are many ways of controlling your pain. Remember that to help you, the staff need to know how you are feeling!

♦ After your operation you will only be allowed to have a few ice chips to suck for the first few days, but you can have regular mouth washes to keep your mouth comfortable.

♦ You will be reminded and supervised to regularly undertake deep breathing and coughing, and leg exercises as directed by the Physiotherapist and/or nurse and then continue whenever you think of them.

How Your Bowels Works Post Operatively:When your bowel is handled in an operation it goes to sleep and stops working. It gradually wakes up. This usually occurs once you become active. Your stomach will start to make rumbly noises and you may experience some wind pains. Eventually you will pass some wind from your bottom. This means that air is being transported by your bowel and that you are ready to commence taking some fluids by mouth. Your diet will change from fluids to a full diet depending upon how you cope with each stage. A sleepy bowel is fairly delicate and we take each stage carefully.

D a y 2 a n d 3 A f t e r You r S u r g e r y :

♦ You will be cared for in the Critical Care Unit.♦ Your Doctor will visit you and explain how the operation went.

♦ Your temperature, pulse and blood pressure will be checked regularly.

♦ Pain control will continue in the same manner as Day 1.♦ You may require ongoing routine blood tests.♦ The drip will continue to deliver you fluids and your wound drains and

urine catheter is likely to remain in at this stage.♦ You will continue on ice chips and progress to fluids.♦ The nurse will help you with your hygiene needs.♦ It is anticipated you will sit out of bed for ½ - 1 hour at least twice per

day and if you are able, a short walk is allowed with assistance from the Physio/ Nurse.

♦ Your close family can visit you but, for the first few days, you are not usually up to having a lot of visitors. It is probably best to tell your friends to visit when you are back in the general ward and will appreciate the visit. No flowers are allowed in the Critical Care Unit, therefore it is suggested that family and friends do not send them until Day 4 or later.

♦ Usually you are starting to feel a little brighter and well enough to return to the general ward.

♦ If you have a wound in your bottom, this will be monitored with a changeable dressing.

Da y 4 – 8 A f te r You r S u r g e ry :

♦ The Doctor will visit you.♦ The nurse will assist you with showering as required.♦ You will be encouraged to sit out of bed and walk as much as you

can manage throughout the day.♦ During this period there are a variety of progressive steps that can

happen on slightly different days according to you, but they will all happen.♦ You will become more mobile with short walks gradually increasing in

length and your independence in the bathroom will be regained.♦ You will get a rumbly stomach, discomfort and eventually pass wind

from your bottom.♦ The urine catheter will be removed when you are able to use the toilet.♦ If present, the wound drain in your abdomen will be removed and if you

have one in your bottom this will also be removed.♦ The tube in your nose (if applicable) will be removed.♦ You will have more choice of fluids. When you are tolerating

adequate quantities of fluid orally, your drip will be stopped.♦ As your bowels begin to work, you will slowly return to a light and

then a normal diet.♦ Your need for pain relief will start to lessen and you will commence on

oral tablets for any pain you still may have.♦ The nurses will ask you if you need any help at home and arrange this if

you do.

D ay 9 - 1 1:

♦ During these last few days in hospital, you will be encouraged to regain your independence ready for discharge.

♦ Your doctor will visit you and give you instructions for home as well

as a follow up appointment time.♦ The nurse will confirm any community services (e.g. Home

Nurses) that have been arranged.♦ Before discharge the staples will be removed from your wound and

steri-strips applied. These can be removed 4-5 days after discharge.♦ Your diet will be returning to a high fibre diet and you should make

sure you drink plenty of water when you get home.

preparation for bowel and rectal surgery with stoma

P r i o r t o D a y o f A d m i s s i on :

♦ You will have a pre arranged appointment to see the Stomal Therapy Nurse(STN). You need to allow about 1 ½ hours for this appointment.

♦ The purpose of this visit is to give you information about your stoma surgery and to ease some of your concerns about living with a stoma.

♦ The STN may also use this opportunity to “site” you for your stoma.♦ If you wish you may bring your partner or ‘significant’ other to

the appointment as he/ she may also have questions to ask.

W h o i s a St o ma l T her a p y N u r s e ( S T N ) ? :

♦ A Stomal Therapy Nurse is a registered nurse who has undertaken further education in stoma care. The role of the STN is to give guidance and education to patients and their families who have had or are about to have surgery that may involve the formation of a stoma. The STN works in close association with medical and allied health members. This is to ensure you receive all the help available to make the transition of having a stoma more comfortable.

W h a t is a S t o ma ? :

♦ The word stoma is derived from the Greek word meaning “mouth or opening.”

♦ It is formed when a portion of the bowel is brought out through an opening and sutured to the abdomen to allow the passage of faeces from the body.

♦ A stoma can be formed as a loop or an end.♦ It may be temporary or permanent.

A temporary stoma is formed to divert the flow of faeces away from a diseased or damaged part of the intestinal tract until normal function can be restored.

A special appliance is worn over the stoma to manage the flow of faeces from the stoma.The type of stoma and the position of the stoma depend on the operation you are having.

type of faecal stomas

♦ C o l o s t o m y : a stoma created from the large bowel or colon, usually sited on the left side of the abdomen. Output varies from a thick paste-like motion to a formed stool. The type of stoma appliance worn over a colostomy is a “closed” bag which is changed when it is 1/3 to 1/2 full.

♦ Ile o s t o m y : a stoma created from the small bowel or ileum, usually sited on the right side of the abdomen. Output varies from liquid faeces to a thicker fluid consistency. The type of stoma appliance worn over an ileostomy is a “drainable” bag which is emptied several times a day when it is 1/3 to 1/2 full.

S i t i n g Y o u r S t o m a : ♦ The Stomal Therapy Nurse will mark with a cross on your

abdomen the most appropriate position for your stoma to be formed.♦ Many factors must be considered when planning the best site for your

stoma. The type of work you do the leisure activities you enjoy and the location of the belt-line of your skirt and/or trousers.

♦ For this reason siting is best done while you are wearing your normal daytime clothing.

♦ You will be asked to lie down, sit up and stand while the STN observes your abdomen for creases and folds which need to be avoided.

♦ Ideally the stoma is sited within your vision, away from your belly- line and avoiding abdominal creases and folds. This makes it easier for you to look after.

♦ It is important that you are happy with the final decision. This is your stoma and you will be the one caring for it on a daily basis.

♦ The cross on your abdomen is marked with a permanent texta and covered with a waterproof dressing to ensure it does not wash off before surgery.

♦ The doctor will remove the dressing at the time of surgery.

Da y o f Op e r a t i o n : - D a y 1 – 3 :

♦ Your stoma will be checked to ensure it is red, moist and healthy.♦ The output from your stoma is likely to be producing a little blood

stained fluid.♦ Your STN will demonstrate how to empty and change your stoma bag

and talk you through the procedure.♦ This is your first lesson towards independence.

P os t Op e ra t i o n : - Da y 4 – 7 :

♦ By now your stoma may be producing a little faecal fluid and wind.

♦ You can start to become independent by recognising when your stoma bag requires emptying and alert the nurse when it’s 1/3 to 1/2 full.

♦ You will learn how to manage the clip on the end of your drainable bag (if applicable).

♦ Initially you will need the nurse to assist you to empty your bag by holding the flask while you drain the contents, or by helping you to the bathroom. As you become more mobile you will manage this on your own.

♦ Your STN will teach you to change your stoma bag and over time you will become more independent and confident.

♦ You will be taught how to gently remove your soiled appliance and to clean the stoma and surrounding skin.

♦ You will learn how to measure your stoma and cut the clean bag or base to the appropriate size.

♦ You will be assisted to position the clean bag or base over your stoma and clip the bag to the base if applicable.

♦ You will join the Colostomy Association of South Australia or Ileostomy Association of South Australia to enable you to obtain free stoma appliances for discharge.

♦ You will be educated regarding diet selection in preparation for you progressing to a light diet

P os t Op e ra t i o n : - Da y 8 – 1 1 :

♦ By now you will be independent in emptying your stoma bag.♦ You will be changing your stoma bag or base on your own with the STN

standing by for support only.♦ Your STN will again discuss with you the care of your stoma and

lifestyle issues to reinforce previous information.♦ If you wish a visit from a person who has had a similar operation to you,

this can be arranged.

day of discharge

Arrangements may be made for a STN to visit you at home for continued support while you gain confidence in your stoma management.

♦ The visiting STN will provide professional advice and support while you continue to change your own bag.

♦ At the Colorectal Surgery we conduct Stomal Therapy Clinics fortnightly on Wednesdays. Our experienced STN is available for appointments for a small fee. Appointments can be made by phoning 8267 3355. All appointments are at 142 Ward Street, North Adelaide.

On discharge you will have: Stoma supplies for one month Information on product codes Information on how to order supplies Dietary advice Discharge letter for your visiting STN Out patients follow-up appointment with your STN at your hospital or the

Colorectal Surgery.

diet

Over the period of your stay in hospital your diet will change. This information should be considered in conjunction with the section of this booklet “Preparation for Bowel and Rectal Procedures.”

It is i m p o r t a n t t o r e m e m be r w i t h e a c h m e a l y o u s h o ul d :

♦ Always sit out of bed in a backed chair so you are relaxed and that your meal is easily digested.

♦ Always eat slowly and chew your food well.♦ Eating small frequent meals and including snacks or nourishing fluids,

when directed, will assist recovery.

F a s t ing : When you are first admitted and up to surgery you will be asked to fast from all food and fluids. This is essential to help prevent vomiting.

Aft e r S u r g er y : Initially after surgery you will be asked to remain fasting, but may have a small quantity of ice chips to keep your mouth moist and comfortable. Your doctor will judge when it is suitable for you to start eating and drinking again.

B e l o w a r e e x a m p l e s o f s t a ge s o f d i e t : CLEAR FLUIDS: Some examples are clear soups/broths, jelly, apple juice. Black teas or coffee.

NOURISHING FLUIDS: Some examples are, egg-flips, flavoured milk, and if necessary, supplemented with products like Sustagen and Ensure.

LIGHT DIET: This means that you can have a small serve of anything soft on the menu.

FULL DIET: This is anything on the menu without restriction. However, you are encouraged to eat as your appetite directs you. Individual tolerance to foods varies so you are encouraged to experiment and gradually increase the variety in your diet. Liquids are an important part of your recovery so you are encouraged to drink plenty of water.If you have a stoma the stomal therapist will discuss with you the effect certain foods may have with you.

At any time during your stay should you have any questions regarding diet, either as an inpatient or on discharge, please do not hesitate to ask the nurse caring for you. If your food intake was poor prior to admission, you have lost weight, if you are requiring several operations or if your appetite is slow to return you will be referred to a dietician.

Colorectal Surgery: 8267 3355 Ashford Hospital: 8375 5222 Calvary Hospital: 8239 9100 Central Districts Hospital: 8250 4111 Western Hospital: 8356 1222

discharge from hospital

Please arrange to have a relative or a friend pick you up from hospital by 10am on the day of your designated discharge.

Y o u r d isc h a r g e i n s t r u c t i on s a r e a s f o l l o w s:

♦ Please remember to take home with you (a suggestion is to tick off as you receive them): Your medication (including discharge medications your doctor may

have ordered). Your X-rays (including any taken into hospital). Your appointment cardfor follow-up with your doctor or stoma

therapist. Community Service letters. Any hire equipment that has been organised for you. All personal belongings, including those valuables that may have

been locked in the safe. Your stoma appliances and information package where

applicable.

♦ You are likely to tire more easily than usual, so though there are no limitations or specific exercise requirements, it is essential that you take slow walks for short distances regularly rather than over exert yourself. It is also recommended that you avoid heavy lifting for 4-6 weeks post-operatively.

♦ If you have any concerns you can contact our practice nurse, the hospital ward you were on, or the Stoma Therapy nurse you were seeing (if applicable) at any time:

Information in this h a n d o u t provided with compliments of Calvary North Adelaide Hospital