Nurses Should Be Proactive in Recognizing Bowel Problems After Rectal Surgery

TON - October 2011 Vol 4 No 7 — October 19, 2011

STOCKHOLM—Oncology nurses can take simple measures to help patients manage incontinence related to surgery for rectal cancer.

Restoration of intestinal continuity and preservation of the anal sphincter is now done via an ultralow anterior resection, but this can leave patients with functional problems that need attention, said Claire Taylor, RN, a lecturer at the Burdett Institute of Gastrointestinal Nursing at St. Mark’s Hospital in London.

“First, make the problem known,” she said. This means overcoming the taboo surrounding defecation, encouraging patients to talk about their problem, and dispelling the myths that the condition is ‘normal,’ ‘will get better soon,’ or is something the patient must ‘learn to cope with,’” she said.

Although permanent stomas are used less frequently now, rectal cancer patients often receive temporary loop ileostomies and at least 40% of them will get a temporary stoma. In 30% of these cases the stoma becomes permanent due to functional changes, delays in treatment, and other issues. Bowel symptoms will occur in most of these patients, including urgency, frequency, erratic bowel habits, incontinence, tenesmus, and evacuation difficulty.

“These patients feel very tied to the toilet, and this has a psychosocial component,” she said. Nurses can help these patients regain confidence, she suggested.

Recommendations for Treatment

Patients with fecal incontinence should be assessed thoroughly before any treatments are considered and should be managed appropriately with conservative measures before specialized treatments are initiated.

“For this, I suggest a nurse-led intervention that occurs early in the treatment course, rather than a wait-andsee approach,” Taylor said. Symptoms im prove in most patients by 1 year, although they remain more prevalent than in the healthy population.

Even if they are better by the end of the first postoperative year, “this is a year of symptoms in which we could have been helping the patients, stopping them from slipping into a vicious circle of fear of incontinence leading to behavioral change.”

Taylor described the first steps to take for patients to experience an improvement in symptoms and sense of control over their bowels.

The first is self-management. Patients should receive written information and be referred to websites and support groups. Nurses should manage expectations, which are an important determinant of long-term health status. Studies have shown that 50% of patients are unhappy with the information they received with regard to wind/gas, difficult evacuation, medications, use of pads, and unspecified other bowel problems. Nurses can provide better education.

Perianal skin soreness should be addressed (Table). Nurses should review and adjust diet and fluid intake (caffeine, alcohol, fiber) and medications, consider prescribing an antidiarrheal (loperamide, titrated closely) and glycerin suppositories (to aid in complete evacuation), and address toilet access. Behavioral techniques can be very helpful. Patients should train themselves to wait at least 5 minutes before toileting when they feel the urge, and to perform “control” exercises 10 times a day.

Referral to a specialist may be necessary when conservative interventions fail and more complex, longer-term input is required: biofeedback, bowel retraining, electrical stimulation, or rectal irrigation, she said. “The goal is to empower patients, but nurses can also do more to assess and help them manage this condition,” Taylor concluded.

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