heal. Lucy is extremely upset with the prospect of having an ileostomy formed but agrees to have the surgery.
Lucy was admitted for surgery on Thursday morning and spent the first night and day in the surgical high dependency unit (SHDU), as the surgery was more complex than planned and the Chron’s and fistula damage were more extensive than originally thought. Lucy ended up requiring a pan proctocolectomy with permanent ileostomy formation.
On Saturday afternoon at 13:00, Lucy returns from the SHDU and you are the nurse taking over her care and are required to assess and complete her care plans. Lucy is now day two post-operatively, and the SHDU nurse informs you that Lucy’s recovery was uncomplicated, and Lucy’s vital signs have been stable throughout her stay on SHDU. Lucy’s pain has been managed with a patient-controlled analgesia machine (PCAM) containing morphine and has been receiving oral paracetamol 1 gram, four times a day. Lucy has been reporting that her pain score is 3/10 on rest and 7/10 on mobilisation. Due to this Lucy has refused to leave her bed. She however did manage to mobilise with minimal assistance of one to a commode at her bedside to pass urine after her catheter was removed this morning. Lucy’s catheter was removed at 7am and she has passed 150mIs at Slam. Lucy also managed to wash in bed.
Lucy had been tolerating a light diet and fluids, supplemented with three times a day Fortisip juice. However, Lucy reported feeling nauseated after breakfast and at 10:00 vomited 300mIs of food and bile. Cyclizine 50mg was given intravenously through a cannula with good effect. Lucy also has ondansetron and metoclopramide prescribed if required. Lucy reports that she is feeling nauseated again after the transfer.
Lucy has a midline wound that has been closed with clips and dressed with an opsite dressing. The wound has not been reviewed since theatre, but the dressing is intact with a small, contained blood stain. The rectovaginal fistula has passed a small amount of mucus since theatre. Pressure areas are intact, although vulva area remains excoriated and Lucy has been prescribed Fragmin and anti-embolic stockings, though she has declined to wear them as they are causing her legs to feel hot and itchy whilst she is in bed.
Lucy’s ileostomy has been active with flatus and 800mIs of type 7 stool has been emptied in the last 24 hours. The stoma looks pink and healthy; however, the peri-stomal skin is starting to become excoriated. Lucy is refusing to engage with her ileostomy and the nursing staff have been providing all care for it. Lucy refused to engage with the stoma specialist nurse yesterday, telling her that the stoma was ‘disgusting and smelly’
Lucy’s husband and children visited yesterday, and Lucy became very emotional. Lucy is concerned about how she will manage to care for her children and her stoma on discharge.
The surgeon would like to discharge Lucy on day 4 post-operatively and over the weekend he would like her PCAM machine to be weaned off and transferred back to oral morphine and paracetamol, he would also like Lucy to increase her dietary intake, be mobilising independently around the ward and independently managing her stoma. The clips in Lucy’s midline wound are due to be removed ten days post-operatively.
On Sunday morning you are the nurse taking over Lucy’s care. The handover reports that she has continued to complain of pain overnight and has been using her PCAM machine regularly. She has also been coughing overnight and it has been recommended that she sits out of bed to minimise her risk of a post-operative chest infection.