Caring for the patient undergoing surgical cancer treatment

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9 Caring for the patient undergoing surgical cancer treatment

Chapter aims

• To introduce the student to the principles of surgery

• To understand the impact of surgery on the individual with cancer

• To explore the care required when nursing a patient undergoing surgery as a cancer treatment

Introduction

The majority of patients with cancer will undergo surgery of some description at some point and you may meet them in a variety of healthcare settings while on placement. Surgery may be used for diagnostic purposes; to get rid of the cancer completely; prophylactically (to remove an organ/tissue that may become cancerous in the future); for supportive care (enteral feeding, central venous catheters); to reconstruct a part of the body to improve functioning and/or appearance; and to palliate symptoms.

The success of the surgical removal of cancer and the impact of surgery has improved over the past century due to the following:

• Increased knowledge of the natural history of cancer biology and an understanding of how cancers develop and behave.

• The development of diagnostic techniques: this has increased the accuracy of staging and grading, ensuring that surgery is used appropriately and improves surgical outcomes. For instance, it may be inappropriate for a patient with advanced secondary disease to undergo surgery which will not eradicate the disease or offer benefit. More detailed diagnosis often reduces the need for radical surgery, reducing the physical and psychological impact as well as improving the overall outcome. A good example of this is the introduction of sentinel node biopsy (Farrant 2004). Previously, when a woman underwent a mastectomy for breast cancer, the surgeon would routinely remove some or all of the lymph nodes from her armpit. This often meant that women experienced long-term lymphoedema (swelling) and weakness in the affected arm. Now during surgery, the surgeon injects a blue dye (sometimes with a radioactive tracer) into the tissue close to the cancer. The dye drains into a number of the lymph nodes; these are then known as the sentinel nodes and are removed to see if they contain cancer. If they are positive then the patient will most likely have a second operation to remove most of the lymph nodes under the arm.

• New microsurgical techniques such as laparoscopic and endoscopic procedures: these allow more conservative treatment, having less of an impact on physical functioning and appearance as well as a shorter postoperative stay.

• Since the Calman Hine report (DH 1995), surgical teams are dedicated to specific types of cancers. Surgeons must undertake a number of specific procedures a year to ensure competence, and all procedures are monitored locally, regional and nationally to ensure quality standards and equity.

• Recovery time in hospital has reduced as a result of the introduction of enhanced recovery programmes. These involve extra pre-, peri- and postoperative hydration and nutrition; regular analgesia; early removal of catheters/drains; and increased exercise soon after surgery (Slater 2010).

• The introduction of ‘rapid discharge programmes’ following surgery has improved physical and psychological recovery, such as the introduction of discharge after 23 hours from returning to the ward following breast surgery (DH 2007).

Prior to surgery, patients need to fully understand the procedure they are having. The healthcare team needs to outline the potential risks involved, the short- and long-term potential consequences of the procedure and possible complications. Gaining informed consent can sometimes be difficult if a patient lacks ability to comprehend often complex information – this may be due to a learning disability or a lack of education. The distress caused by diagnosis can often hamper an individual’s ability to process information. As healthcare professionals, we have a duty of care professionally, legally and ethically to ensure the welfare of patients. This may mean we need to act as an advocate, speaking on behalf of the patient during decision-making situations.

image Activity

Read the article by Ford (2010) or Caulfield (2005) (see References):

Observe a patient being consented for an invasive procedure (this may be a central venous access device insertion or surgery). Write a summary of the main ethical, legal and professional aspects of accountability when gaining consent.

NMC Domain 1: 1.1; 1.2; 1.4; 1.5; 1.6; 1.7; 1.8; 1.9

The nursing role is essential in preoperative assessment and preparing the patient for theatre, both physically and mentally. Patients often feel positive about having the cancer ‘cut out’, but often have a lack of appreciation of the impact of surgery in the short and long term. Preoperative assessment should involve:

– medical history (co-morbidities and medication)

– functional assessment

– psychosocial assessment

– skin assessment

– nutritional assessment

– hydration/renal function

– pain assessment.

Depending on the type and extent of surgery (and the preoperative status of the patient), the patient will require a varying amount of postoperative nursing intervention to manage their airways, circulation, hydration, nutrition, elimination, tissue viability, personal hygiene, mobility and emotional status, as well as to ensure they are comfortable and pain is minimised.

image Activity

If you are allocated to a placement where there are many patients with cancer undergoing surgery, find out what preoperative assessment tool is used. Consider what the priorities of care are for a patient before surgery. How might a patient feel prior to surgery? Consider what the surgical risks might be for a patient undergoing surgery.

Read Preoperative care, Section 1 in Pudner (2010) (see References). Write a preoperative plan of care to meet the physical and emotional needs of a surgical patient you have cared for.

If you are in your final year of the course, then you might teach a less experienced student nurse how to prepare a patient for theatre or you might delegate an aspect of postoperative care. Remember, when delegating, you need to consider your accountability and what you need to ensure before delegating. Refer to the NMC guidelines:

http://www.nmc-uk.org/Nurses-and-midwives/Advice-by-topic/A/Advice/Delegation/ (accessed November 2011).

NMC Domain 1: 1.4

NMC Domain 2: 2.6

NMC Domain 3: 3.1; 3.2; 3.3; 3.4; 3.6; 3.9

NMC Domain 4: 4.6

image Activity

Identify a patient who has undergone surgery for cancer. Was the surgery the first treatment they received? Find out why surgery was selected. What is the impact of this particular surgery on this patient? Think about the physical changes: how might this make the patient feel? Will they have to make adjustments in their life? Is any further treatment planned?

NMC Domain 1: 1.1; 1.4

NMC Domain 2: 2.4

NMC Domain 3: 3.1; 3.2; 3.3; 3.4; 3.6; 3.7; 3.8; 3.10

image Activity

Revisit your lecture notes on wound healing. Summarise the main points and the most conducive environment for prompt healing.

Write a care plan of the immediate postoperative care required. Consider the importance of accurate and thorough documentation. Refer to the NMC (2009) Record Keeping: Guidance for Nurses and Midwives:

http://www.nmc-uk.org/Documents/Guidance/nmcGuidanceRecord​KeepingGuidanceforNursesandMidwives.pdf (accessed November 2011).

NMC Domain 1: 1.7; 1.8

NMC Domain 3: 3.1; 3.2; 3.3; 3.4; 3.10

NMC Domain 4: 4.3

The multiprofessional team is key in ensuring an optimal rehabilitation. Often the team members will have introduced themselves to the patient preoperatively, explaining their role and what will happen after surgery. The speed of recovery will obviously vary enormously, but once the patient has made sufficient recovery and is deemed ‘medically fit’ and ready to return home, a comprehensive discharge plan of care should be in place to ensure rehabilitation and postoperative support. This is especially important in light of rapid discharge procedures.

With less time in hospital postoperatively, patients and carers are increasingly required to manage the consequences of surgery. To do this, they require clear, understandable, tailored information. This includes having the opportunity to discuss with their medical consultant the nature of their surgery and its progress prior to leaving hospital, as this will lessen their anxieties and provide much needed information prior to their post-discharge review meeting in the outpatients clinic (Mitchell 2010).

Prior to discharge, a referral to community services will usually be required to provide relevant care from the GP and/or district nurse. A follow-up appointment will be made for the patient to return for a postoperative progress assessment and to discuss the need for any further treatments.

image Activity

Identify a patient who is due to be discharged home from hospital and plan the discharge by considering:

What rehabilitation do they require?

Are there any household alterations required before discharge?

Which other multiprofessionals need to be involved?

What information does the patient and their family need?

Is transport required?

What medication does the patient need once at home?

Are there any referrals to community services required?

Read the Royal College of Nursing discharge guidelines:

http://www.rcn.org.uk/__data/assets/pdf_file/0011/​78509/001376.pdf (accessed November 2011).

NMC Domain 1: 1.3; 1.4; 1.5; 1.6

NMC Domain 2: 2.1; 2.2; 2.3; 2.5; 2.6

NMC Domain 3: 3.1; 3.3; 3.4; 3.5; 3.8; 3.10

Often, once surgery has been completed, an adjuvant therapy such as cytotoxic therapy or radiotherapy is planned. It is important that patients know what treatment (if any) they are planned for next, when the next treatment might occur and what they need to know beforehand as this helps reduce anxiety.

References

Caulfield H. Vital notes for nurses: accountability. Edinburgh: Wiley-Blackwell; 2005.

Department of Health. A policy framework for commissioning cancer services. London: Calman-Hine report). HMSO; 1995.

Department of Health. The cancer reform strategy. London: HMSO; 2007.

Farrant A. A kinder way to stage breast cancer. Cancer Nursing Practice. 2004;3(9):12–15.

Ford L. Consent and capacity: a guide for district nurses. British Journal of Community Nursing. 2010;15(9):456–460.

Mitchell M. A patient-centred approach to day surgery nursing. Nursing Standard. 2010;24(44):40–46.

Pudner R. Nursing the surgical patient, 3rd ed. Edinburgh: Baillière Tindall; 2010.

Slater R. Impact of an enhanced recovery programme in colorectal surgery. British Journal of Nursing. 2010;19(17):1091–1099.

Further reading

Randle J., Coffey F., Bradbury M. Oxford handbook of clinical skills in adult nursing. Oxford: Open University Press, 2009.

Rothrock J.C., Alexander S. Alexander’s surgical procedures, 14th ed. St Louis: Mosby; 2011.

Wicker P., O’Neil J. Caring for the perioperative patient (essential clinical skills), 2nd ed. Edinburgh: Wiley-Blackwell; 2010.

Websites

NMC guidelines – Delegation: http://www.nmc-uk.org/Nurses-and-midwives/Advice-by-topic/A/Advice/Delegation/ (accessed May 2011).

Royal College of Nursing, 2004. Day surgery: Discharge planning http://www.rcn.org.uk/__data/assets/pdf_file/0011/78509/001376.pdf (accessed May 2011).

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