your recovery from bowel surgery information booklet information leaflets/on the a-z... · ask you...

Leaflet Ref: 15035 Published: 06/16 Review: 05/19

Contact: 01625 421000 www.eastcheshire.nhs.uk t @eastcheshirenhs t @echonhscharity

Patient Information Leaflet

Your recovery from bowel surgery Information Booklet

Department of Surgery

http://www.eastcheshire.nhs.uk/

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Index

1. Introduction 3 2. Preparation for Surgery 3

3. Arriving in hospital 6

4. Your surgery 8

5. Enhanced Recovery after Surgery (ERAS) 10

6. After your surgery 12

7. When you leave hospital 13

8. Teams you may meet during your stay 16

9. Other helpful information 21

10. Contact details 31

11. Useful Contacts 33

12. Appendix 1 35

13. References 37





1. Introduction This booklet is designed to provide you with general information about bowel surgery as offered by East Cheshire NHS Trust (MDGH). Do please take the time to read it before your appointment at the Bowel Surgery Awareness (BSA) Clinic as it may answer many of your questions. If, having read it, you still have questions and concerns please do not hesitate to contact us directly, or raise them at your next appointment. If you have had your surgery as an emergency we hope that you would still find a lot of useful information to help answer your questions both in hospital and at home. Your Bowel Operation There are a number of reasons why bowel surgery is undertaken these include;

Cancer

Diverticular disease

Crohns disease and Ulcerative Colitis

Fistulae

Volvulus Your Consultant will have spoken to you about the specific operation you are having performed and your diagnosis but if you still have any further questions please do not hesitate to either get in touch or ask at the BSA clinic.

2. Preparation for the Surgery

Pre operative Assessment Before your planned surgery you will be required to attend the hospital for a pre-operative assessment. This is an assessment of your health and medical history to check on your fitness for surgery. The Pre-operative Assessment Suite is situated on the 1st floor of the main hospital building near wards 1 and 2. The appointment lasts for approximately 1 hour 15 minutes.





Please note there is no waiting area within the pre-operative Assessment Suite so you will be given a ‘coaster’ and asked to take a seat on a chair in the main corridor nearby. The ‘coaster’ will then light up and vibrate alerting you to return to the pre-operative assessment suite to have your assessment. A relative or friend can either accompany you if you wish or there are refreshment facilities within the main hospital to be able to wait for you there. At your appointment we will:

Confirm your personal and social details and contact telephone numbers.

Ask you about your medical history and operations you have had.

Ask you about medications you are taking so please bring a copy of your repeat prescription or a list of your medications to assist with this (including any supplements bought over the counter).

Measure your height, weight, blood pressure and pulse readings.

Take any necessary blood tests, perform an electrocardiogram (ECG) - this is a tracing of your heart rhythm and they will listen to your heart and lungs with a stethoscope.

Take a swab from your nostril and groin which is sent for MRSA screening.

Discuss your admission, surgery and recovery, including providing you with any necessary nutritional supplement drinks and bowel preparation medications which may need to be taken prior to your admission.

Discuss whether it may be necessary to have an iron infusion prior to your surgery.

Following the assessment you may be advised that other tests are required or that you need to see an anaesthetist prior to your surgery. These will be organised and you will be advised of any appointments. If you are asked to attend for further tests or to see an anaesthetist try not to worry as this is being done for your safety and reduce the risks to you of complications from either the anaesthetic or surgery. Advice may be given regarding your medications in case any of them need to be stopped or dosages altered prior to your admission for your operation. Bowel Surgery Awareness (BSA) Clinic Prior to your surgery we will ask you to attend the BSA clinic. This will usually be the Friday afternoon before the week your surgery is due to take place.





The clinic is aimed at all people who are to undergo bowel surgery regardless of the diagnosis and is held in the Macmillan Cancer Resource Centre, located on the ground floor near the RVS shop at Macclesfield District General Hospital. What happens in the clinic depends on your diagnosis and operation and which consultant you are under the care of. It may include the following:

Marking of your abdomen (tummy)

Additional blood test

Holistic Needs Assessment (discussing your worries and concerns) and the formation of a plan of care for you.

Your consent for surgery and signature.

Discussion of any research trials you have agreed to take part in.

Information regarding your recovery.

Information on bowel function (if your operation is for reversal of a stoma) You are welcome to bring your relative/carer to the clinic and your appointment may last between 1 to 3 hours depending upon what you require. Things to do before your Operation What can I do to help make the operation a success? Lifestyle changes If you smoke, try to stop smoking now. Stopping smoking several weeks or more before an operation may reduce your chances of getting complications and will improve your long-term health. For help and advice on stopping smoking, go to www.nhs.uk/smokefree You have a higher chance of developing complications if you are overweight. For advice on maintaining a healthy weight, go to www.nhs.uk/livewell/healthy-eating/pages/healthyeating.aspx Regular exercise can reduce the risk of heart disease and other medical conditions, improve how your lungs work, boost your immune system, help you to control your weight and improve your mood. Exercise should help to prepare you for the operation, help with your recovery and improve your long-term health. For information on how exercise can help you, go to www.nhs.uk/livewell/healthy-eating/pages/healthyeating.aspx Before you start exercising, you should ask a member of the healthcare team or your GP for advice.


http://www.nhs.uk/smokefree

http://www.nhs.uk/livewell/healthy-eating/pages/healthyeating.aspx







If you do not have the internet to access this information please see your specialist nurse who will be able to provide you with the information. Iron Infusion If you are found to be anaemic before your surgery you may require an iron infusion. If this is necessary you will be contacted by a member of staff who will arrange for you to be admitted. This admission is for approximately half a day only and you will be sent written information with the details.

3. Arriving in Hospital Most patients will be admitted to Hospital on the day of surgery, but sometimes it is necessary to admit patients beforehand. You will have been informed if this is necessary for you. Your admission letter will advise what time to report to the Day Case Unit, this is situated on the first floor in the Hospital. Your details will be checked and you will be booked in and then directed either to the surgical admissions lounge (SAL) or the surgical ward. The Surgical Admissions Lounge (SAL)

This is situated on the first floor and is accessed past the endoscopy main reception and is signposted. The SAL is an area designed for all admissions for surgery that day and consists of a lounge area with seating, consultation rooms, and toilet and shower facilities. Your relative/ carer will be able to

accompany you to this area but unfortunately due to limited space they will be unable to stay with you. The nurse on the lounge will give your relative/carer a contact number and an approximate time to call to check on your progress. At the SAL you will be greeted by one of the nurses who will go through your admission details. You will also be seen by your Consultant’s team.





Please be aware that your operation may not be carried out in the morning, but later in the day. The Consultant Surgeon, Anaesthetist and Specialist Nurses need to review all patients prior to commencing their theatre lists you may find it helpful to bring a book or magazine to read whilst you are waiting. Your Admission You will have received instructions in your admission letter about when to stop eating and drinking. However please take the nutritional drinks at 6am provided by the Pre op Nurse (unless you are diabetic). You will not be allowed any solid food for six hours before your operation. If your operation is going to be in the afternoon, you may be given more nutritional drinks to have during the morning. You may be given an enema to clear the contents of your bowel before your operation. The nurse will administer this if required. On the day of your surgery you will be asked to shower at the hospital using anti-septic wash, followed by dressing in a clean operating gown. This is to help reduce the risk of wound infection after your operation. You will be measured for surgical support stocking to wear prior to your operation, during your stay and on discharge (further details provided in the after surgery section). These are to reduce the risk of a blood clots forming in the veins in your legs Anaesthetic Review Your anaesthetist will visit you before your operation. Your anaesthetist will ask you again about your health and discuss the anaesthetic and pain relief techniques suitable for you, together with their advantages and risks. Hopefully your questions will all be answered by now but if not. Please do not hesitate to discuss any concerns you have with your Anaesthetist. The surgical wards Once you have awakened from your anaesthetic you will go back to the surgical ward. Sometimes patients go to the High Dependency unit (HDU) for observation overnight. Ward 1 is a 21 bedded ward. Although the ward accommodates a mix of men and women, the area on the ward where you will be accommodated will be the same sex





as you. Ward 1A is a 13 bedded ward; this is the women’s unit and has female beds only. Although there are some single rooms on the wards these cannot be requested in advance and only accommodate patient’s dependant upon their clinical requirements. We are happy to take telephone calls from your family and friends to check on your progress but it is better to nominate one person to ring the ward and to then cascade this information to the rest of the family and friends. This will reduce the amount of telephone calls that take the nurses away from their clinical duties. The nominated person is advised to phone after 10am which is after the Consultant ward rounds. Visiting Times The Surgical Ward current visiting times are 2-4pm and 7-8pm These may change in the future so please do ask on your admission.

4. Your Surgery Your surgeon will have advised you already about your own reasons for needing the operation; however, it is ultimately your decision to go ahead with the operation or to

decline treatment. The information below outlines the types of bowel surgery and any risks/complications involved to help you make an informed decision. If you have any further questions you should ask your surgeon or your specialist nurse. Are there any alternatives to surgery? This will depend on the reason why your surgeon has recommended surgery. You should discuss the options carefully with your surgeon.

What does your operation involve? Bowel operations are performed under a general anaesthetic. There are two approaches to bowel surgery. – Laparoscopic (Keyhole) or Open. Your Surgeon will discuss which option is appropriate for you as not all patients are suitable for Keyhole surgery. Although the surgical approach may differ, the aim of the surgery is to remove the diseased part of your bowel. Your surgeon will discuss whether the bowel can be re-joined or not and whether you will require a temporary





or permanent stoma (a bag to divert your motion). Laparoscopic surgery involves carrying out the operation through small cuts in the abdomen. After filling the abdominal cavity with carbon dioxide gas, the surgeon inserts a narrow telescope attached to a camera and uses other special instruments through the cuts to remove the diseased part of the bowel. Most of the operation is performed through these small cuts, but a slightly larger opening is needed to remove the section of bowel from the body. Open surgery involves a large cut down the abdomen (tummy) to enable access to the diseased part of the bowel. Cutting through the large abdominal muscles can be more painful during recovery and therefore pain relieving medicine is often required for longer. What are the risks/complications of surgery? The healthcare team will try to make your operation as safe as possible. However, complications can happen. Some of these can be serious. You should ask your surgeon if there is anything you do not understand. The complications fall into three categories: 1. Complications of anaesthesia Your anaesthetist will be able to discuss with you the possible complications of having an anaesthetic. 2. General complications

Pain, which happens with every operation. We will try our best to manage your pain effectively. They will give you medication to control the pain and it is important that you take it as you are instructed so you can make a good recovery. Shoulder tip pain is common after keyhole surgery due to trapped gas, it usually settles within a few hours.

Bleeding during or after surgery. You may need a blood transfusion or another operation.

Infection in the surgical wound. If this happens, you may need treatment with antibiotics or further surgery.

Chest infection. After the operation, deep breathing and physiotherapy will help prevent a chest infection.

Scarring of the skin, particularly if the wound gets infected.

Developing a hernia in a scar caused by failure of the deep muscle layers to heal. This appears as a bulge called an incisional hernia. If this causes problems, you may need a further operation.

Blood clots in the legs (deep-vein thrombosis), which can occasionally move through the bloodstream to the lungs (pulmonary embolus), making it difficult for you to breathe. Nurses will get you out of bed soon after surgery and give you daily injections to reduce the risk of blood clots and you will also be advised to wear anti–embolism stockings.





Difficulty passing urine after the catheter has been removed. This is more common if you had problems passing urine before the operation.

Anastomotic leak. There is about a 10% risk of this complication happening. This is a serious complication that may happen if the join (anastomosis) between the ends of the bowel fails to heal, leaving a hole. Bowel contents leak into the abdomen, leading to pain and serious illness. This often needs another operation. Your surgeon may need to make a temporary stoma (opening the bowel out through the abdominal wall).

Damage to other structures inside the abdomen. The blood vessels to the testicles or ovaries, and the ureters (which drain urine from the kidneys) are particularly at risk.

Injury to the bowel. The risk is higher if you have had abdominal surgery before.

Abnormal joining together of tissue (adhesions), which form when scar tissue develops inside the abdomen. Adhesions do not usually cause any major problems but can lead to bowel obstruction. If you have had abdominal surgery before, your surgeon will have to cut through the adhesions first. This makes injuring the bowel more likely, and increases the possibility of converting to open surgery.

Death due to complications can happen with colorectal (bowel) surgery. 3. Specific complications for keyhole surgery

Converting to open surgery. If the surgeon is unable to identify the anatomy and carry out the operation safely, they will convert to open surgery.

Surgical emphysema (crackling sensation in the skin due to trapped gas), which settles quickly and is not serious.

5. Enhanced Recovery after Surgery (ERAS)

ERAS is a specific way of planning your care both before and after bowel surgery. An important aspect of ERAS is that you understand what ERAS aims to achieve and how you can help yourself to recover from surgery and return to your usual activities. There are four areas of ERAS outlined below that will be discussed in more detail in this booklet.





1. Nutrition

ERAS focuses on nutrition both before and after your operation. Unless you are diabetic you will be given some carbohydrate drinks to take to drink the evening before and the morning of your surgery. Building up the carbohydrate levels in your body helps to prepare your body to recover from surgery. These drinks also help your body to compensate if you are not eating as much as you would usually. ERAS enables patients to eat much sooner after bowel surgery than in the past. You will be encouraged to drink fluids and eat a light diet as early as the evening of your surgery (according to instruction by your Surgical Team). You will then build up to a normal diet slowly. After your operation you will be given regular protein drinks. It is very important to take these drinks after your surgery as they can build up your energy levels and help your wound to heal.

2. Mobilisation

Early mobilisation is an essential part of ERAS. You will be encouraged to sit out of bed for a period the morning after your surgery and the Physiotherapy team will support you in early mobilisation. This will help to prevent complications such as chest infections and blood clots in lungs and legs. Moving around will also help your bowels to resume activity. You can help yourself by carrying out deep breathing exercises (10 deep breaths with your mouth open every hour) and by mobilising as much as you are able to.

3. Discharge planning

ERAS aims to discharge you home and back to your usual activities much sooner than traditionally. As soon as you are eating, drinking and are mobile, this may be between 2 and 7 days if you do not experience any complications such as a chest or wound infection, you will be discharged from Hospital. A member of the integrated discharge team will be able to discuss plans with you if you anticipate a problem with early discharge this maybe a nurse or a social worker. Please discuss this with your ward nurse as soon as possible on your admission so that there is ample time to set up any additional services required for your discharge.





4. Information and support

You will have been given an information pack (white plastic envelope file) which provides you with some written information and contact numbers which you may find useful. You will also have met with and discussed your surgery with the Consultant Surgeon who will be performing your operation. You may have also met with the Consultants or Specialist Nurse who will be involved in your care and can offer support before, during and after your surgery. You will be given the contact number for your Specialist Nurse. There is also a dedicated telephone number that you can use. Please phone if you have any questions or concerns. You may also phone your surgeon’s secretary (via hospital switchboard) and a message will be passed on to the appropriate team who will then telephone you back.

6. After your surgery You will have a drip in your arm to give you adequate fluids until you can drink sufficiently yourself. Once you are taking enough fluids by mouth, the drip in your arm will be removed. You will usually be able to drink water immediately after your operation and you will be encouraged to try a warm drink or some clear soup later in the evening if you feel able to. Over the following few days you will be encouraged to take extra nutritional drinks to help with wound healing and your energy levels. Once fluids are tolerated you will be allowed to take a light diet, eating little and often and building up to a normal diet. You may be given oxygen to breathe through a nasal tube. You will have a catheter into your bladder so that we can monitor how well your kidneys are working and how much urine you are making. This is usually removed after a few days. You may have one or more drains in your abdomen (tummy) to allow drainage of blood or fluid into a bottle. This is usually removed a few days after your operation. It is common to feel sickly following your operation. You will be prescribed regular anti-sickness medication to help with this. Occasionally it is necessary to put a tube into your stomach via your nose to stop any vomiting. The Surgical team will ask you daily if you have passed flatus (wind) from the back passage or if you have passed a bowel motion and what this motion looked like.





Please be aware that bowel motions are disrupted after an operation. It is usual not to have a bowel motion for several days after surgery but some people experience diarrhoea. You may require bowel medication to help with the consistency of your bowel motion. Your wound (cut) will be closed with skin staples, dissolvable stitches or skin glue. You will be advised which has been used. You may or may not have a dressing covering your wound (no dressing if glue is used). If you do have a wound dressing this is not removed for 48 hours unless very soiled. If after 48 hours your wound is clean and dry no further dressing will be required. Your wound will be checked by a member of the surgical or nursing team and you will be advised when to have any skin staples removed. After bowel surgery it is not uncommon to experience a wound infection which may result in the wound opening requiring daily dressings. This does not usually delay discharge but may require visits from the District Nurses. If you have a temporary or permanent stoma, you will need to learn how to change the bag and care for your stoma. The stoma nurse will help you. Good pain relief is important after your surgery; it will help you recover more quickly and reduce post-operative complications. There are several methods of pain control available; these will be discussed with you by an anaesthetist before your operation. It is important to let the doctors or nurses know if you are in pain, so they can manage it more effectively.

7. When you leave hospital

Diet A healthy, varied diet is recommended. Make sure that you eat regular meals, three or more times a day and try to drink approximately two litres of fluid daily. Your bowels Please remember that your bowel habits may change after surgery. Your motions may become loose and more frequent or you may become more constipated. Certain foods previously tolerated may cause loose motions and these should be avoided. If loose motions or constipation lasts for more than 3-4 days, you may require some medication. Your GP can prescribe this for you. Passing Urine You may get the feeling that your bladder is not emptying fully after you have had a urinary catheter, this usually resolves with time. If you have excessive stinging or





burning when passing urine, please contact your GP as you may have a urine infection. Wound care It is not unusual for your wound to be slightly red and uncomfortable for the first few weeks following your surgery. If your wound is inflamed, painful, swollen or discharging fluid, please contact your GP who will need to examine you and may prescribe antibiotics. Abdominal pain You may need to take regular pain relieving medicine (tablets) for a short period after your discharge. This should be reduced as soon as the discomfort settles. You may suffer from colicky type pains during the first week following your operation. This pain usually lasts up to a few minutes but goes away between spasms. If you have severe pain lasting for more than one to two hours, have a fever or generally feel unwell you should contact a member of the Enhanced Recovery Team on 07769 620 452, or the on-call Surgical Registrar in the hospital via the hospital switchboard on 01625 421000 as you may need to attend Accident and Emergency Department to be examined. Prevention of blood clots Whilst in hospital you will have been given an injection every evening to reduce the risk of blood clots forming in your lungs and legs. You will be required to continue these injections for 28 days after your operation. It is preferable if either you or your relative/carer can administer this following discharge and the ward nurse will show you to do this. A district nurse or practice nurse can be arranged in specific circumstances. It is advisable to wear your anti embolism stockings for the duration of these injections, if you are not fully mobile after the injections have finished it is advisable to continue to wear the stockings until you are fully mobile. You may remove the stockings to shower/bathe. The stockings can be washed and put back on. Sepsis

Sepsis is caused by germs (e.g. bacteria) getting into your body. It can develop following surgery, wound infections, chest infections and even simple cuts or bites.

Sepsis can be a life threatening condition that arises when the body’s response to an infection injures its own tissues and organs. Sepsis can lead to shock, multi-organ failure and death if not recognised and treated promptly. It is crucial that you don’t delay and seek medical attention.

If caught early, sepsis can be treated very easily with antibiotics and fluids.





If you experience two or more of the following signs please seek immediate medical advice;

Uncontrollable shivering

Very high or a low temperature

Racing heart beat

Rapid, shallow breathing

Confusion or feeling very drowsy

In the early stages, it is difficult to distinguish sepsis from Flu. If your skin becomes pale, cold or mottled, if you lose consciousness or don’t pass water for 18 hours then you should go to hospital to be assessed. Don’t be afraid to say “I think I (or my relative/friend) has sepsis”. Early treatment can mean a good recovery.

Resuming usual activities Activity is encouraged form the first day after your operation with help from the physiotherapist. It is important to continue regular exercise several times a day during your convalescence. Walking is the best form of exercise after your operation – remember to start slowly and build yourself back up to your previous level of fitness. Common sense will guide your exercise and activities, but remember that it is normal to feel tired for many months after major surgery. Further information regarding fatigue is given later in the booklet. Do not do anything that causes significant pain or involves heavy lifting for six weeks after your operation. Your physiotherapist will give you more advice prior to your discharge from hospital. Work Returning to work is dependent on the individual and how you feel and also on your type of occupation. If your job involves heavy manual labour, you may need to stay off work longer or resume work on lighter duties. The hospital initially will provide you with a sick note, please see your GP for further sick notes. Driving We recommend that you contact your insurance company and tell them what operation you have had. As a general rule, you should not drive until you are confident that you can drive safely and comfortably.





Follow-up Your Specialist Nurse will telephone you after your discharge to monitor your progress and to advise and support you during your recovery. You will receive an appointment to receive results of the specimen taken during your operation and to discuss any further treatment you may require. You will receive an out patient clinic appointment approximately 6-8 weeks after your surgery.

8. Teams you may meet during your stay

The Acute Pain Team You will be visited by the pain management nurses during your stay, please let them know if you have any pain problems.

Pain relief after bowel surgery

Good pain management is important and will help you recover more quickly after your operation and reduce post-operative complications. It is important that you are comfortable enough to deep breathe, cough and mobilise out of bed. Good pain control will allow you to sleep better, help your body heal quicker and enable you to go home sooner.

Pain Assessment Your pain will be assessed regularly after your operation. The nurses will assess the degree of pain based upon the pain ruler below. You will be asked you to rate the level of your pain from 0 – 10, at rest and on movement. Accuracy improves management, so please be as honest and accurate as possible.

Option for Pain Relief following your operation

There are several methods available for the management of your pain. These will be discussed with you by an anaesthetist before your operation. Please let the anaesthetist know if you take regular strong painkillers, as your painkiller dose after your operation may need adjusting.





Oral painkillers

This regime involves the administration of a strong painkilling tablet every six hours

Occasionally, despite regular painkillers, you may experience stronger pain. You will have additional painkillers prescribed to help relieve this pain but you will need to ask your nurse for these. Do not wait to be asked if you need more painkillers and do not feel afraid of being a nuisance

You will be given these strong painkillers usually for 2-3 days and then stepped down to moderate pain killers.

Intravenous Morphine pump

This is called a PCA (Patient Controlled Analgesia) and allows you to press a button to get a dose of pain relief when you need it. This involves using a machine attached to an intravenous line (or drip) which allows safe doses of morphine (or similar drug) to be given directly into your vein when you press the button. After a dose is given the machine will lock out for a period of time, normally 5 minutes. Only you can tell when you need more analgesia and therefore you should never let your friends or relatives press the button for you. Pain is normally worse on movement and it may be helpful for you to press the button 5-10 minutes before moving. The nursing staff will carry out regular checks on you and make sure that you are comfortable and using the button appropriately.

Epidural Analgesia

An epidural is an injection in your back, like a spinal, but with a bigger needle and with an epidural a plastic tube is also left inside your back. Your anaesthetist will explain if an epidural would be appropriate for you, and explain the risks. If you have an epidural it usually run continuously, and you will be given a button to press when you need extra pain relief. Epidurals can give effective pain relief for 2-3 days after your operation. As with any invasive technique side effects and complications can occur. All of the side effects described can occur without an epidural the most common are minor and easily treated – serious complications are fortunately rare. The risk of complications should be balanced against the perceived benefits and compared with the alternative methods of pain relief. Your anaesthetist will discuss this with you. Common side effects and complications of epidurals

Because local anaesthetics are used you may experience some numbness and weakness in the treated area, this is normal and should wear off when treatment is stopped. Because the epidural affects the nerves that supply the bladder, it will be necessary to pass a tube into the bladder to drain urine whilst you have the epidural. Blood pressure is commonly lowered because the local anaesthetic affects the nerves going to the blood vessels. Extra fluids and/or drugs can be given into your





vein to treat this.

Backache – commonly occurs after surgery, with or without an epidural and is often caused by lying on a flat firm operating table, and any period of prolonged bed-rest. All of the above painkilling regimes are supplemented with:

Paracetamol every 6 hours

Regular anti-sickness medication to prevent nausea and vomiting.

Non drug treatments for pain

Positioning - sometimes moving your position can help alleviate pain

Psychological - if you are anxious about anything whilst you are in hospital, please let the staff know and they will help you if possible.

Mobilising/exercising

You will normally be expected to get out of bed the day after surgery. To prevent postoperative complications, physiotherapy/exercise is carried out regularly, to ensure normal mobility is resumed as soon as possible following your operation. You may experience stronger pain during physiotherapy and walking. It is important that you are comfortable enough to be able to comply with physiotherapy, please let your physiotherapist and nurse know if you require a stronger painkiller before your physiotherapy. We advise that you request it 30-40 minutes prior physiotherapy to allow the painkiller to be effective.

Key message

we will try our best to control your pain effectively after your operation.

if your pain is not controlled to a tolerable level do not suffer in silence, it is important to make the doctors or nurses aware if you are in pain. Do not wait to be asked and do not feel afraid of being a nuisance.

let us know if you feel sick.

Good pain control will help you to recover more quickly after your operation, allow you to sleep better and reduce postoperative complications. As a result you may be able to leave hospital sooner.

Macmillan Colorectal and Stoma Care Nursing Team You may be given the contact details of the Macmillan Colorectal Nursing team dependant upon your diagnosis. You will be allocated a key worker who you can contact if you have any further questions or want to discuss any worries or concerns. If your surgery involves formation of a stoma you will see the stoma care nurse who will teach you how to manage this and give you all the appropriate information.





Surgical Nurse Practitioner If your consultant has a nurse practitioner you will see them during your stay. A nurse practitioner has undergone additional training and will see you on the morning ward rounds, in theatre and may see you in the clinic after your discharge. The Ward Nursing Team During your stay you will be cared for by a team of both qualified nurses and health care assistants and student nurses. Your allocated nurse each day will introduce her/him self to you. If you or your family have any questions or concerns while you are in hospital please do ask the nurse who is looking after you. All staff are available to assist you with anything you need, please ask Your Consultants Team Your consultant will have a team of senior and junior doctors who will manage you care on the ward and report to your consultant. Critical Care Outreach Team (CCOT) The CCOT is a critical care service provided by a team of specialists to rapidly identify patients who are acutely ill. The overall aim of the service is to contribute to a safe clinical environment throughout your stay.

We do this by utilising a “Track and Trigger” tool that allows the team to identify patients whose condition may be deteriorating. This is a simple scoring system which is applied each time you have your routine observations (such as blood pressure, heart rate and temperature) recorded.

If the score reaches a pre-determined “trigger point” your team will follow an escalation of care guideline to ensure the appropriate health care professional will review you in a timely manner. The critical care outreach team will advise on your clinical management and the frequency of observations and ensure you are managed in the appropriate location.





Physiotherapist Physiotherapy after bowel surgery.

Bowel surgery is a major procedure to the body and how quickly you recover and get back to your normal levels of activity will depend on a number of factors. Your physical abilities before having the surgery and whether or not you have any underlying health problems may determine your rate of recovery, as will your experience of any complications during/after surgery. It is therefore very important once you have had your operation to avoid any further problems such as chest infections and DVT’s to ensure you recover as quickly as possible.

Breathing exercises

Straight after an operation, the effects of surgery, anaesthesia and the analgesia can affect the amount of oxygen your lungs can get into the body which is vital for all the cells in your body to function. It is therefore important to begin your breathing exercises (appendix 1) as soon as you can which will help you get more air into your lungs and help keep your lungs clear by removing phlegm. It is normal to have some phlegm on your chest, which can be coughed up and either swallowed or removed from the mouth.

Movement

To prevent the risk of DVT’s it is important that you do your foot and ankle exercise whilst in bed, this helps reduce the chance of getting a DVT.

Soon after the surgery, once you have woken up the nursing staff will help you to move and sit out in a chair at your bedside to speed your recovery and avoid chest infections and the risk of a DVT. The Physio will check you are doing all your exercises and progress your mobility until you are ready for home. Dietician

Registered Dietitians are qualified to translate scientific information about nutrition and food into practical dietary advice. Your doctor or nurse may refer you to be seen by the dietitian during your stay if needed e.g. if you are at risk of malnutrition due to a having a reduced appetite or unintentional weight loss. Dietitians can also provide evidence based advice regarding dietary practices which can sometimes be necessary following bowel surgery. You may be seen whilst on the ward or in an outpatient clinic once discharged.





Pharmacist A pharmacist is a trained professional who helps the team to manage your medications. The pharmacist visits the ward on a regular basis to check the medications that you are prescribed. Integrated Discharge Team Planning for your discharge will start on or before your admission to hospital, where possible. The Integrated Discharge Team will support you and ward staff to plan your discharge. Depending on your individual needs you may be assessed by different members of the team, such as a Physiotherapist, Occupational Therapist, Dietician or other professionals. They will advise you and your family/carer about any equipment or services you may need for discharge. There are occasions when your medical condition has become stable but your recovery is not complete. You may be referred for rehabilitation services at home or in an Intermediate Care Unit. If you need practical help or information for when you are discharged, a social worker can arrange services for you based upon an assessment of your need and eligibility. Some services are means tested which may mean you will have to pay a contribution but the social worker will explain this to you. If you or your carer have any questions relating to discharge planning, the ward nurse will be happy to help you or you can contact the Integrated Discharge Team.

9. Other helpful Information

The Macmillan Support and Information Service

This is situated in the Macmillan Cancer Resource Centre and is available to any one affected by cancer. The service is open from 8.30am – 5.00pm (4.00pm Fridays), providing information, emotional and practical support to patients, families and friends. The service offers a ‘drop in’ service and welcomes any visitors who may wish to just call in and see what is on offer in the





first instance. There are many information booklets available covering everything from specific information about a condition to emotional and financial information. Appointments can also be made throughout the week to access one of the many support services which are offered such as counselling, complementary relaxation therapy, hypnotherapy and benefits advice. A walking group and a ‘Health and Well being’ after treatment group for colorectal cancer patients is also available. Clinical Trials Team Macclesfield District General Hospital is part of a Research Active Trust. To improve treatment in the future investment in clinical trials is needed today. This is why the team are involved in over 60 clinical trials. The Oncology Research Team The dedicated team consists of Research Nurses, Research Assistant and Clinical Trials Administrators. Although named the Oncology Research team, the team also recruit to some non cancer trials if available. What is a Clinical Trial? Clinical Trials are carried out on large groups of patients to try to find new and better treatments. They are the only reliable way to find out if a new treatment is better than what is already available. What do “phases of trial” mean?

Phase 1 – checks that the treatment is safe and finds the best dose to use.

Phase 2 – checks how well a test or treatment works.

Phase 3 – compares new treatment with the current treatment. Phase 2 and 3 trials are only run at Macclesfield Hospital. What are the risks and benefits of being on a trial? Clinical trials are carefully designed. Trials have to have an independent committee to check that they are safe to run. They also check there is a potential benefit to patients.





All trials at Macclesfield are multi- centred trials. This means they are run in many other hospitals across the country or sometimes across the world. Patients are monitored very carefully during the trial, therefore, if you take part in a trial you may have extra tests and you may be asked extra questions. This could mean extra visits to the hospitals. Your participation in a Clinical Trial is voluntary, and you can withdraw from a trial at any time without giving a reason; you just need to let one of your care team know. Unfortunately, not everyone is eligible to take part in a trial, but the team try to offer a trial to everyone that is eligible. What is Randomisation? Some trials are randomised. This is when a computer decides if the patient gets the normal standard treatment or the trial treatment which is thought may be better. Giving Consent The Consultant or Research Nurse will discuss the trial with you and you will be given the opportunity to ask questions. You will be given a Patient Information Leaflet about the trial which you will be able to take home to read through and if you wish discuss with family and friends. A member of the Research Team will contact you a few days later to ask if you have any new questions, if you need more time to consider the trial, or if you would like to take part in the trial. If you are happy to enter the trial it is important that you feel that you understand the trial, so that you know:

What the trial is about.

What the treatment involves.

What side effects there may be

What you will have to do. If you decide to enter the trial you will be asked to come into the hospital for an appointment with the Research Team where there will be more opportunity to discuss the trial and for you to ask questions. The team try to co-ordinate this with one of your other appointments if possible. Feel free to bring a family member or friend with you to your appointment. When you are happy and when the Research Nurse feels that you understand the trial you will then be asked to sign a consent form. No-one can enter you into a trial without your consent.





If you decide you do not want to take part in the trial, your care will not be affected in any way, and you will receive all the standard care that is appropriate for your type of illness. Here at Macclesfield, Colorectal Clinical Trials are co-ordinated by The Research team, based in the Macmillan Cancer Resource Centre, along with your Consultant and your Specialist Nurse.

Research Today For A Better Tomorrow

Fatigue After a big operation and sometimes depending upon your diagnosis some people report they are suffering from ‘fatigue’. You may have fatigue and not be aware of this and may wonder why your recovery is slow. The next section is to help you recognise if you do have fatigue and some strategies to help mange this;

What is Fatigue? Fatigue describes a feeling of overwhelming tiredness or exhaustion that is not relieved by rest. It affects people not only physically but psychologically and emotionally and makes everyday tasks more difficult or even impossible to carry out. Causes of fatigue Fatigue is an extremely common symptom experienced by people with particular illnesses such as cancer. It can be caused by the illness itself or by treatments such as chemotherapy or radiotherapy. Anaemia is a common cause of fatigue in people with cancer. Other causes include weight loss, weakness, pain, breathlessness or fluid retention. These symptoms can also worsen existing fatigue, as can some of the psychological effects of the illnesses with which you are dealing. Low mood or anxiety can both contribute to fatigue. Who to talk to It is important to talk to the doctor or nurse involved in your care. They may identify factors which can be addressed, such as anaemia or loss of appetite, or they may refer you to other health care professions such as Occupational Therapists, Physiotherapists, Dietician or Social Workers.





Effects of Fatigue Fatigue often leads to changes in people’s activity levels and way of life, e.g. reducing or stopping paid work, reducing housework and maintenance work, increasing rest, altering sleep, reducing social activities or hobbies, altering concentration. People may avoid doing certain activities completely as they require too much effort, but this then results in frustration, low mood and reduced fitness levels as muscles weaken. The Activity Cycle A common cycle for people with fatigue involves tending to push themselves until fatigue tells them to stop. This is invariably followed by a period of rest and feelings of frustration – i.e.: good day → over activity →increased fatigue → prolonged rest People tend to stay in the ‘Activity Cycle’ because they feel they must get things done or ‘finish the job’ or feel guilty if other people are doing things for them. The strategies outlined in this booklet are designed to break the activity cycle by planning and pacing activities rather than have bursts of over-activity that lead to exhaustion, followed by a reduction in activity and a time of prolonged rest. The 3 ‘P’s’ - Pacing, Planning and Prioritising

Pacing Pacing means balancing activity so that your day is divided into periods of rest and activity. Pacing can help you manage your day and stay in control. Pacing means doing the activity you had planned, however you feel, not doing too much or too little. On a good day stick to your plan but try to break up activities more.

Planning Try to plan activities so that more difficult tasks are spread out over a day or week. Plan what order to do things in, decide if you need help to do them or if you need to change the way you do the activity If you have times of day when you generally have more energy, it may help to plan to do certain tasks, e.g. cooking, housework, gardening at a time of day when you have most energy. If you know you will have a busy day e.g. Tuesday plan to have a very quiet day on Monday and Wednesday, if possible.

Prioritising Decide the most important things you need to do in the day or the week, what has to be done that day, what could wait until the next day / week or what someone else could do for you.





Goal setting It can be helpful to set some goals for yourself. Make sure they are realistic and achievable. If you have a larger goal, maybe break it into smaller steps, e.g. going on holiday – plan days out first and progress from there. Choose a goal which will give you enjoyment or a sense of achievement. Write down your goals and tick off when you achieve them. Energy conservation and work simplification at home Consider your everyday activities – are you using excess energy simply getting on or off a chair, standing to brush your teeth or preparing food, bending down to sweep? Some simple solutions are discussed in the following information. Accept offers of help – with cooking, shopping, housework. Saving energy with meal preparation

Sit on a perching stool to prepare food.

Use some frozen meals that only need microwaving

Cook double and freeze half

Try simple ‘one pan’ meals to minimize washing up It may be useful to discuss any difficulties with carrying out everyday tasks with an Occupational Therapist – they can advise you on different ways of doing things or provide equipment to help you maintain independence whilst conserving your energy. Childcare Looking after children can be tiring for anyone but when you are fatigued the effort required can be overwhelming. Some ideas which may help include:

Explaining to your children/grandchildren that you feel very tired & may not be able to do everything you normally do

Involve your children in small household tasks – pay them some pocket money for this if necessary!

Plan achievable, enjoyable activities to do with your children e.g. watch a DVD together, sit on a bench whilst they play in a play area

Accept offers of babysitting, lifts to / from school so you have time to rest.





Work You may have had to reduce your time at work, or even stop, but if you have been able to continue there may be ways to make working life more manageable:

Talk to your employer about how your fatigue affects you – be honest if things are getting too much

Change / reduce your hours if possible. If you take longer to get ready in the morning negotiate a later start time

Build short breaks into your day to ‘recharge your batteries’

Discuss alterations to your role if the work is physically demanding e.g. involves lifting

Wellbeing - Nutrition / Diet

Eating little and often may be easier than facing or preparing large meals

If your taste it altered, try new foods which appeal to you.

Fruit smoothies give you fruit and protein without the need for lots of preparation.

Drink plenty to avoid dehydration and constipation

Your specialist nurse can give you leaflets on healthy eating or refer you to a Dietician if necessary

Exercise / Activity Fatigue will often result in people doing less and becoming inactive. This then causes muscles to weaken, plus general de-conditioning, so that when an activity is attempted more energy is then required. This can cause people to become frustrated, demoralized and even less active and so the cycle continues.

By maintaining a regular level of activity or exercise this can maintain muscle strength and general conditioning of all our body’s systems. It can also help to improve appetite, mood, circulation, bowel function and sleep. Research shows that exercise, such as walking, is very helpful in managing fatigue. General rules of exercise – should be:

Enjoyable

Functional e.g. walking

Individualized – according to persons fitness, age, current problems such as weakness, pain, bone problems, breathlessness

Walking is one of the best forms of exercise.





Gentle stretching techniques such as Tai Chi, Yoga, and Pilates can aid suppleness, balance and relaxation. Some people enjoy exercising using games consoles e.g. Wii. If you previously attended a gym this could be gently reintroduced but be sure to discuss current health issues with the gym staff. They may require you to check first with your GP. Gentle chair or bed exercises also help to maintain fitness. Risks - do not exercise if:

You have a high temperature

You feel dizzy or faint

You are very short of breath, especially if this is new / sudden

You have new or unexplained pain

You have an infection, are anaemic or have low platelets or white cell count

It may be useful to speak to a Physiotherapist to get further advice. Sleep/ Rest It is important to get a balance between exercise and rest / sleep. Try to keep a normal sleeping routine even if you feel tired all the time. Some tips for good sleep:

Get up at a similar time each morning – avoid spending too much time in bed.

Have a day-time nap to ‘recharge your batteries’ but limit this to an hour or so to prevent problems sleeping at night.

Avoid stimulants such as tea, coffee, cola at night. Milky drinks can help with sleep

Keep a steady temperature in your bedroom.

Try mental exercises to help get off to sleep e.g. reciting a poem, writing a letter in your head, writing alphabetical lists e.g. names, countries





Relaxation and Stress Management Make time for activities which help you to relax. If you find it difficult to unwind it may be useful to try some specific relaxation techniques, either physical ones where you focus gradually on relaxing all areas of your body or mental techniques to help you relax your mind.

Stress and anxiety use up energy and can increase your fatigue. These are some ideas to help manage stress and help you to relax:

Talk to others about your concerns

Try some distraction techniques, reading, TV, radio, painting, crosswords, listening to music

Try gentle exercises

Complementary Therapy – it is well worth asking about accessing Complementary Therapy to have treatments such as massage, reflexology, Reiki. A Complementary Therapist may also be able to discuss some relaxation techniques with you or give you a relaxation tape / CD.

If you need psychological support your Doctor or Nurse may be able to refer you for counselling or Art Therapy.

Managing Setbacks Positive Thinking - It is not uncommon to have setbacks with your fatigue following periods of stress by overdoing certain activities. Don’t worry about setbacks, these can be managed using the strategies discussed earlier, i.e. planning, prioritizing, relaxation, etc. Positive thinking is also very important in managing setbacks. Negative thoughts such as ‘I ought to be coping better’ or ‘I should be doing more’ are unhelpful and will add to your distress. Try to identify and challenge any negative thoughts and find a more positive way of thinking about the situation e.g. writing your achievements down (however small) such as going for a walk, getting some housework done, etc, to remind yourself that you have been able to regain control, e.g.: Rather than thinking ‘I have to do everything just like I always did’ instead try telling yourself ‘If I pace myself, I can get A and B done today and do C and D later in the week’ ‘I’ll manage it if I do it in stages’

REMEMBER THE STORY OF THE TORTOISE AND THE HARE!





A thought to finish with: Save your energy to do the things you enjoy most, which will maintain or improve your quality of life. In summary We hope that the information provided in this booklet has answered all of your questions. If you have any further questions please do not hesitate to ask a member of your team.





10. Contact Details

There is a phone dedicated to ERAS patients where you can leave a message or be directed to how you can access help if your telephone call is out of office hours.

Enhanced Recovery phone - 07769 620452

Name Telephone Contact Number

Hospital switchboard 01625 421000

Wards

Ward 1 01625 661001

Ward 2 01625 661002

Ward 1a (Women’s unit) 01625 663596

Surgical Admissions lounge 01625 661737

Consultant Secretaries

Surgical Secretary to Mr Khan 01625 661348

Surgical Secretary to Mr Ward 01625 661348

Surgical Secretary to Mr Sadat 01625 661551

Surgical Secretary to Mr Smart 01625 661113

Surgical Secretary To Mr Habeeb 01625 661551

Nurse Practitioners 01625 661536 or

Advanced Surgical Care Practitioner (Mr Ward Team)

01625 421000 Bleep 5081

Advanced Perioperative Specialist Practitioner (Mr Khan team)

01625 421000 Bleep 5150

Advanced Surgical Nurse Practitioner (Mr Sadat team)

01625 421000 Bleep 9302

Macmillan Colorectal Nursing Team 01625 661598

Colorectal Nurse Specialists 01625 421000 Bleep 3397

Stoma Care Nurse Specialists 01625 421000 bleep 3380 or 3470

Macmillan Cancer Resource Centre

Information and Support 01625 663128 or 663129

Reception 01625 663148





Other services

Pre –Op Assessment Unit 01625 661088

Acute Pain Team 01625 661739 or 01625 421000 bleep 3402

Oncology Research Team 01625 663115

Integrated Discharge Team. 01625 661459





11. Useful Contacts

Age UK www.ageuk.org.uk Beating Bowel Cancer Contact details: 08450 719300 Nurse advisory line phone: 02089730011 www.bowelcancer.org.

Bowel Cancer UK Contact details: 020 79401760 www.bowelcanceruk.org.uk/ British Association for Counselling and Psychotherapy www.bacp.co.uk British Red Cross www.redcross.org.uk Colostomy Association Helpline 0800 328 4257 www.colostomyassociation.org.uk Crohn’s and Colitis UK www.crohnsandcolitis.org.uk Disability Rights UK www.disabilityalliance.org Ileostomy Association 0800 018 4724 www.iasupport.org Macmillan Cancer Support Contact details: 0808 808 0000 (Mon–Fri 9am to 8pm). www.macmillan.org.uk Maggie’s Cancer Caring Centres www.maggiescentres.org


http://www.ageuk.org.uk/

http://www.bowelcancer.org/

http://www.bowelcanceruk.org.uk/

http://www.bacp.co.uk/

http://www.redcross.org.uk/

http://www.colostomyassociation.org.uk/

http://www.crohnsandcolitis.org.uk/

http://www.disabilityalliance.org/

http://www.iasupport.org/

http://www.macmillan.org.uk/

http://www.maggiescentres.org/




Pelvic Radiation Disease Association www.prda.org.uk

Relate www.relate.org.uk


http://www.prda.org.uk/

http://www.relate.org.uk/




12. Appendix 1

ACBT ACTIVE CYCLE OF BREATHING TECHNIQUE

Please note these are guidelines only, your physiotherapist may provide other information that may be suited to your needs. What is ACBT? The active cycle of breathing technique are breathing exercises aimed to:

Loosen and clear secretions (phlegm)

Improve ventilation It is a cycle of different types of breath which help to move secretions from the bottom of the lungs towards the main airways. The ACBT Cycle Comprises of four main parts: 1. Breathing Control/Relaxed Breathing

Normal gentle breathing using the lower chest: a) Rest one hand over the stomach so that you can feel it rise and fall as you

breathe. b) Breathe in gently through the nose c) Breathe out gently, keeping the shoulders relaxed

2. Deep Breathing

a) Take a slow deep breath in. Try to ensure your neck and shoulders Remain relaxed.

b) Hold the breath for about 3 seconds c) Breathe out gently d) Repeat this 3-4 times. 3. Huff This is a sharp breath out through an open mouth (imagine steaming up a mirror) and this should help you to force secretions (phlegm) to a point where you are able to cough them up (i.e. when phlegm is at the back of the throat).





4. Cough Only cough once you have secretions (phlegm) that are ready to be cleared. The Cycle How often should you do them? These exercises can be practiced in whatever position you find comfortable. If you have a chest infection you may want to complete the cycle several times during the day to clear the secretions. Three deep breaths every half an hour will maintain good ventilation and help to monitor secretions. When do I stop? You should stop once two cycles have been completed without clearing secretions (phlegm) or you are too tired to continue. If you are not sure when your lungs are clear, breath out, if there is no rattle then your lungs are clear.

Huff followed by Cough

Breathing Control Breathing Control

3-4 Deep Breaths

Breathing Control

3-4 Deep Breaths





13. References Delivering Enhanced Recovery – Helping patients to get better sooner after surgery. 2010 Department of Health. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_115155 Feedback on an enhanced recovery programme for colorectal surgery. Author(s): Taylor et al. British Journal of Nursing, 10 March 2011, vol. /is. 20/5; (286-290) Impact of an enhanced recovery programme in colorectal surgery. Author(s): Slater R. Citation: British Journal of Nursing, 23 September 2010, vol. /is. 19/17; (1091-1099) The Enhanced Recovery Programme for stoma patients: an audit Author(s): Bryan S, Dukes S. Citation: British Journal of Nursing (BJN), 08 July 2010, vol. /is. 19/13; (831-834) Sepsis Alliance 2016 (Homepage of Sepsis Alliance), (Online). Available www.sepsis.org


http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_115155

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_115155

http://www.sepsis.org/




For further information on the references and sources used for this leaflet, please contact

01625 661184.

Comments, compliments or complaints We welcome any suggestions you have about the quality of our care and our services. Contact us: Freephone: 0800 1613997

Phone: 01625 661449 Textphone: 01625 663723 Customer Care, Reception,

Macclesfield District General Hospital, Victoria Road, SK10 3BL

For large print, audio, Braille version or translation, contact Communications and Engagement on 0800 195 4194.

East Cheshire NHS Trust operates a smoke-free policy (including e-cigarettes)

For advice on stopping smoking please contact our Stop Smoking

Service on 0800 085 8818.

East Cheshire NHS Trust does not tolerate any form of discrimination, harassment, bullying or abuse and is committed to ensuring that patients, staff and the public are treated fairly, with dignity and respect.


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