This case study shows an emergency operation for perforated diverticulum.
Jane was admitted to A&E during the night with acute abdominal pain; she had been unwell for a few days before her admission. Jane was in severe pain; her pulse was rapid and she was cold and clammy. The A&E doctor had examined her, requested a plain abdominal radiograph and referred her to the colorectal team. The registrar from the colorectal team had examined her at the request of his colleague, the senior house officer. Their opinion was that Jane had a perforated bowel and needed an emergency operation.
An intravenous infusion of fluid was started and Jane was taken straight to the operating theatre where she had a laparotomy and Hartmann's procedure with an end-colostomy. Her sigmoid colon had perforated, causing peritonitis, and there appeared to be a diverticulum present. The specimen was sent to the histopathology laboratory for a histological analysis. The colostomy was not sited preoperatively but on the operating table by the surgeon. Jane was transferred to the intensive care unit (ICU) from the theatre recovery suite. Jane required careful monitoring for the next 48 hours. She had the intravenous fluid in situ and was prescribed a course of broad-spectrum antibiotics; a catheter was draining her bladder of urine and a drain was in situ in her abdominal cavity. Jane was intubated for the first 36 hours and then weaned off until she was breathing unaided. Her wound and colostomy were observed regularly. Her colostomy did work in the first 12 hours and then nothing else was produced from it. The stoma care nurse (SCN) visited Jane in the ICU, having been alerted to her presence. The SCN took Jane a holdall of supplies that would be required for changing the colostomy bag. The wound did not ooze and the dressing was not changed until just before her discharge to the ward.
On admission to the colorectal ward Jane was conscious and alert, although she still looked unwell. Jane was introduced to the nurse who would be her named nurse during her stay. The nurse placed all Jane's belongings into the locker, including the holdall of stoma care supplies. She then checked all Jane's observations, checked the wound and colostomy bag, and left Jane to rest.
Over the next few days Jane's recovery was uneventful, but on the seventh day the nurse noticed, when she was changing Jane's dressing, that there was a red area at the end of the laparotomy scar; the nurse reported this to the nurse in charge and documented her findings in the nursing care plan. The following day Jane was taken by the SCN to the bathroom to learn how to change her colostomy bag; when the stoma nurse removed the colostomy bag she noticed a big red area creeping out from under the wound dressing. The SCN took Jane back to her bed after completing the colostomy bag change and then took the dressing off to look at the wound. As she took the dressing off it became apparent that a small area of the wound had broken down and pus was oozing from it. The SCN took a swab of the pus and informed the doctor of this event. During the ward round the doctors looked at Jane's wound and requested that the sutures in the lower end of the wound be removed to allow the pus to ooze out. By the next day things had become worse; the open area of oozing was now throughout the lower half of the wound and large gaping holes in the scar were appearing. The wound had totally broken down and was now a large gaping hole at the lower end of the wound. Jane was very tearful and distraught at the sight of her abdomen and she felt that she had suffered enough without this indignity of her abdomen opening up. The SCN talked to Jane and tried to help her understand why her wound had broken down and how it would heal.
The SCN explained to Jane that her wound had opened up because there was infection present. Jane asked how this could have happened because she had been on antibiotics. The SCN tried to reassure Jane that sometimes this does happen, even though taking antibiotics. The stoma nurse reassured her that the wound would heal but it would take a little longer and the scar might not be as neat as had been planned. The way forward was to pack the wound to encourage healing and to do this regularly every day. The importance of healing must be from the inside to the outside; if the outside heals first the cavity underneath will break down again.
During the next 10 days Jane needed a great deal of support and counselling to help her come to terms with her illness and now her change in body image. Jane had only been ill for 3 days before her hospital admission and coming to terms with its outcome was taking its toll on her. She had not been aware of having diverticular disease, because she had never suffered any symptoms from it or been aware of its existence. Jane had thought she had a bug at first, or maybe appendicitis. When she had consented to the surgery she had not fully understood the full implications of the proposal because she was feeling so ill when she signed the form. All she wanted was to have the pain stop and she felt that surgery was the only answer. The SCN explained that the surgery could be described as life saving because Jane's bowel had already perforated and bowel contents were escaping into her abdomen. Jane said she did not like her colostomy and was afraid of it and she did not even want to look at it. The SCN explained that most patients who had a colostomy as an emergency procedure felt the same way. The SCN explained that the colostomy was intended to be temporary and should be reversed some time in the future.
The nurse went on to say that the important thing was to learn how to deal with the colostomy, change the bag as necessary, and try to recover from the surgery. After major surgery the human body has to have a period of convalescence to let it recover. Jane's operation and its subsequent problems were having an effect on her and, because she had been so ill, she was unable to cope with these problems. When she is feeling a little better she will be able to deal with these problems easily. Jane said that she felt too weak to argue and she'd wait and see; in the meantime she hated everything.
Jane's wound began to heal slowly and the doctors told her that by the end of the week she would be able to go home and the district nurses would be able to continue with the care of the wound. This news cheered Jane up and she began to think about going home. Jane lived with her husband and he was looking forward to her coming home, but at the same time had reservations. He was not sure how Jane would cope or how he would. The SCN spoke to both of them about the discharge; she explained to Colin, Jane's husband, that he would need to look after the cooking and housework when Jane came home, because she would not be able to. Jane said that she was not sure about Colin's cookery skills. The stoma nurse went on to say that Jane would be able to look after herself and her colostomy but not the housework or cooking. She would be able to 'potter' around but would tire very easily.
Jane's discharge was planned with the district nurse visiting daily to change the dressing; the SCN made a date for a home visit to check on Jane and her stoma care. The consultant would review Jane at her routine outpatient appointment and set a date for the reversal of her colostomy.
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