Caregivers as healthcare managers: health management activities, needs, and caregiving relationships for colorectal cancer survivors with ostomies.

PURPOSE: While the burdens and rewards of cancer caregiving are well-documented, few studies describe the activities involved in cancer caregiving. We employed a social-ecological perspective to explore the work of cancer caregiving for long-term colorectal cancer (CRC) survivors with ostomies. We focused on healthcare management, defined here as the ways in which informal caregivers participate in healthcare-related activities such as managing medical appointments and information, obtaining prescriptions and supplies, and providing transportation to obtain healthcare services. METHODS: This ethnographic study included 31 dyads consisting of long-term CRC survivors (>5 years postsurgery) and their primary informal caregivers. Survivors were members of integrated healthcare delivery systems. We interviewed participants using in-depth interviews and followed a subset using ethnographic methods. Medical record data ascertained survivors' cancer and medical history. RESULTS: We classified families into a matrix of healthcare management resources (high vs. low) and survivors' healthcare needs (high vs. low). We found that patients' healthcare needs did not always correspond to their caregivers' management activities. CRC survivors with high needs had more unmet needs when caregivers and survivors differed in the level of caregiver involvement they desired or regarded as optimal. This discrepancy was particularly evident in nonmarital relationships. CONCLUSIONS: As cancer survivors age and grow in number, it becomes increasingly important to understand how informal caregivers support survivors' well-being. Framing healthcare management as a component of caregiving provides a useful perspective that could facilitate future research and interventions to support survivors, particularly those with significant sequelae from their cancer treatment.

The relationship between spiritual well-being and psychosocial adjustment in Taiwanese patients with colorectal cancer and a colostomy.

PURPOSE: We examined relationships among demographic and clinical characteristics, spiritual well-being, and psychosocial adjustment in Taiwanese patients with colorectal cancer and a colostomy. DESIGN: A descriptive, cross-sectional, exploratory study design was used to answer research questions. SUBJECTS AND SETTING: Participants were recruited from the outpatient ambulatory clinic in the gastrointestinal surgical department at the medical center of National Taiwan University. Forty-five Taiwanese patients aged 42 to 83 years who were diagnosed with colorectal cancer and underwent colostomy surgery participated in the study. METHODS: Participants completed a personal data questionnaire designed for this study, along with 2 validated instruments, the Spiritual Well-Being Scale and the Psychosocial Adjustment to Illness Scale-Self Report. FINDINGS: Forty-five persons participated in the study; 69% reported a moderate level of spiritual well-being. Participants reported strong adjustment to extended family relationships, but poor adjustment in sexual relationships. Spiritual well-being was significantly associated with psychosocial adjustment (r = -0.52, P < .01), and 4 predictors (income change after surgery, self-rated disease severity, time since surgery, and spiritual well-being) accounted for 53% of the variance in psychosocial adjustment. CONCLUSIONS: Spiritual well-being plays an important role for Taiwanese patients when faced with psychosocial adjustment related to life with colorectal cancer and a colostomy.

Managing neurogenic bowel dysfunction.

This series of articles for rehabilitation in practice aims to cover a knowledge element of the rehabilitation medicine curriculum. Nevertheless they are intended to be of interest to a multidisciplinary audience. The competency addressed in this article is 'The trainee consistently demonstrates a knowledge of the pathophysiology of various specific impairments including bowel dysfunction' and 'management approaches for specific impairments including bowel dysfunction'.

Resección intestinal masiva. Proceso de adaptación nutricional / Massive intestinal resection. Nutritional adaptation process

Introducción: La resección masiva de intestino delgado (RMID) con remanente inferior a los 60 cm de yeyuno ocasiona una grave depleción hidroelectrolítico-vitamínica y calórico-proteica. En espera de trasplante intestinal viable la mayoría de RMID dependen de la Nutrición Parenteral (NPT). Caso clínico: Varón de 32 años. RMID por traumatismo seccionante de la raíz de la arteria mesentérica superior. En primera intervención de urgencia : yeyunostomía con resección de I. Delgado, colon derecho y bazo. A los 6 meses: anastomosis yeyunocólica con remanente yeyunal de 12 cm y colecistectomía profiláctica. Actuación nutricional: 1ª fase.—Estabilización hemodinámica y estimulación enteral (6 meses): NPT + Nutrición Enteral con fórmula elemental + solución oral glucohidroelectrolítica (SOGH) + 15 g/d de glutamina oral + omeprazol. Indicadores de progresión: bioquímica, balance I/P. 2ª fase.—Adaptación digestiva con integración del colon ( 8 meses): Sustitución de NPT por NP Periférica a tiempo parcial. Dieta culinaria progresiva asociada a polienzimático pancreático, omeprazol, SOGH, glutamina, fórmula elemental. Indicadores de progresión: bioquímica, diuresis, peso y deposiciones. 3ª fase. Autosuficiencia sin dependencia parenteral: Dieta oral libre fragmentada asociada a polienzimático pancreático, bebidas mineralizadas, complemento enteral de fórmula, suplementos orales de Ca y Mg, polivitamínico-mineral oral, vitamina B12 im/mensual. Situación actual (52 meses de evolución): Ligera ganancia ponderal, diuresis > litro/día, 2-3 deposiciones normales, sin signos clínicos de deficiencias y valores de micronutrientes en sangre normales. Conclusión: Prescindir de la NP en RMID es posible considerando, como en este caso, una edad y etiología no desfavorables, y la precoz aplicación de un protocolo de adaptación del remanente adecuado

Introduction: Massive small bowel resection (MSBR) with a remnant jejunum shorter than 60 cm produces severe water, electrolytes, vitamins and protein-caloric depletion. While waiting for a viable intestinal transplantation, most of MSBR patients depend on total parenteral nutrition (TPN). Clinical case: 32 years old male, with MSBR due to sectioning trauma of the superior mesenteric artery root. First surgical intervention: jejunostomy with small bowel, right colon, and spleen resection. Six months later: jejunocolic anastomosis with 12-cm long jejunum remnant and prophylactic cholecystectomy. Nutritional intervention: 1st phase. Hemodynamic stabilization and enteral stimulation (6 months): TPN + enteral nutrition with elemental formula + oral glucohydroelectrolitic solution (OGHS) + 15 g/d of oral glutamine + omeprazol. Clinical course indicators: biochemistry, I/L balance. 2ª phase. Digestive adaptation with colonic integration (8 months): replacement of TPN by part-time peripheral PN. Progressive cooked diet complemented with pancreatic poly-enzyme preparation, omeprazol, OGHS, glutamine, elemental formula. Clinical course indicators: biochemistry, diuresis, weight and feces. 3ª phase. Auto-sufficiency without parenteral dependence: fragmented free oral diet supplemented with pancreatic poly-enzyme preparation, mineralized beverages, enteral formula supplement, Ca and Mg oral supplements, oral multivitamin and mineral preparation, monthly IM vitamin B12. Current situation actual (52 months): slight ponderal gain, diuresis > liter/day, 2-3 normal feces, no clinical signs of any deficiency and normal blood levels of micronutrients. Conclusion: It may be possible to withdraw from PN in MSBR considering, as in this case, favorable age and etiology and early implementation of an appropriate protocol of remnant adaptation

Ostomy care and rehabilitation in colorectal cancer.

OBJECTIVES: To review ostomy care in colorectal cancer, current trends in assessment, management, and treatment, and the role of the enterostomal therapy (ET) nurse in cancer care. DATA SOURCES: Published literature and the author's clinical experiences in ostomy wound care. CONCLUSION: Care of the patient with colorectal cancer requiring an ostomy involves both physical and psychological rehabilitation. The education and skills of an ET/wound, ostomy, and continence (WOC) nurse can provide a valuable service to the patient/family, surgeon, oncology nurse, and other health care providers. IMPLICATIONS FOR ONCOLOGY NURSES: An ostomy is not a handicapping procedure. Living well with a colostomy can be achieved through proper patient preparation, education, and planning. Provision of individualized comprehensive care facilitates physical and psychological rehabilitation.

Discharge planning in rehabilitation following surgery for a stoma.

Discharge planning and establishing goals for rehabilitation after stoma surgery is an ongoing process, which should be preceded by an holistic assessment, ideally carried out by a specialist practitioner with knowledge and experience in this area. The practitioner needs to have effective listening skills to ensure that both practical and psychological care are patient-centred. The patient and his/her carers must be involved in all aspects of care planning and establishing goals for rehabilitation. The specialist practitioner should adopt an evidence-based approach to care, ensuring that important aspects of care, such as the early teaching of stoma management skills, are not neglected. The specialist practitioner may not be able to meet all the patient's needs and should refer on to other specialist staff where these services are available. Such multidisciplinary input, utilizing appropriate problem-solving approaches with the involvement of patients and their carers, can only enhance the quality of care delivered and optimize the process of rehabilitation.

The effect of progressive muscle relaxation training on anxiety and quality of life after stoma surgery in colorectal cancer patients.

The aim of the study was to evaluate the effects of the use of progressive muscle relaxation training (PMRT) on anxiety and quality of life in colorectal cancer patients after stoma surgery. A randomised controlled trial was used with repeated measures assessment over 10 weeks post-stoma surgery. Fifty-nine patients participated in the study and were randomised to a control group receiving routine care (n=30) and an experimental group receiving routine care and PMRT through two teaching sessions and practice at home for the first 10 weeks. The State-Trait Anxiety Inventory and two Quality of Life Scales were used to collect the data of interest in three occasions, namely during hospitalisation, at week 5 and at week 10 post-surgery. The use of PMRT significantly decreased state anxiety and improved generic quality of life in the experimental group (P<0.05), especially in the domains of physical health, psychological health, social concerns and environment. Social relationships decreased in both groups. In relation to the disease-specific quality of life measure, differences were observed only in the 10-week assessment, with the experimental group reporting better quality of life at 10 weeks, but not over time as compared to the control group. The use of PMRT should be incorporated in the long-term care of colorectal cancer patients, as it can improve their psychological health and quality of life. This may be a cost-effective intervention that needs minimal training and could easily be offered to those patients that they would like to use it as part of the specialist care provided to stoma patients.

The role of barium enema in colostomy closure in trauma patients.

Recently, the routine use of barium enema preceding colostomy closure in trauma patients has been challenged. It has been argued that the nature of the injury should be apparent from the initial laparotomy and that the likelihood of finding an unsuspected colonic lesion in the young, previously healthy patients who constitute the majority of trauma patients is very small. We retrospectively reviewed 124 consecutive cases of patients who received colostomy takedowns for trauma. One hundred six of the patients had preoperative barium enema evaluation. 87.1 per cent of the examinations were negative, with a subsequent stoma closure complication rate of 20.4 per cent. Of the 13 positive barium enemas, 9 were falsely positive. These patients had a higher stoma closure complication rate of 39 per cent, a fact that could not be explained on the basis of their abnormal studies. The 18 patients who did not have barium enema performed did not have an increase in complications (17.6%). Barium enema failed to uncover unsuspected pertinent diagnoses, often added unnecessary delays and expense, and in no case changed the operative management. Contrast studies were found to be useful in defining anatomy in cases of known fistulas and when the takedowns were performed without the benefit of operative reports from the previous surgery.

Biofeedback training to obtain continence in permanent colostomy. Experience of two centers.

Biofeedback training is proposed as rehabilitative training for patients with permanent colostomies to help them achieve fecal continence. The results of a preliminary study of 18 patients are reported.

[Delayed rehabilitation of colostomized patients. Our experience]. / La riabilitazione tardiva del paziente colostomizzato. La nostra esperienza.

Rehabilitation by means of periodic irrigation is an easy-to-use method that is generally well accepted by the patient. By "giving up" an hour less a day, or better still every 48 hours, the patient can avoid the inconvenience of numerous, continual and uncontrollable evacuations. In confirmation of previous experiments, no significant differences were observed concerning early rehabilitation (up to 10 years after the operation). Irrigation has also been shown to have few negative aspects.