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Nursing solutions for difficult cases

05-07-2013      1092 views

At the 14th International EAUN Meeting held in Milan in March this year, the session on Nursing Solutions for Difficult Cases attracted positive comments with many of the participants expressing their appreciation for the interesting practical problem raised by the speakers.

Due to the enthusiastic response, the Difficult Cases session has become a regular feature in the EAUN’s annual conference, informing urology nursing specialists of effective interventions and special handling procedures. After the lectures, the speakers and the audience also had the opportunity to discuss specific aspects.

DC13-01 Alcohol intake and Radical Cystectomy - how can we approach a safer patient outcome?

1. What was the problem you experienced in this patient?
When a patient is cleared for surgery - radical cystectomy - they will have counselling with a consultant and a nurse and is informed about the risks and possible complications postoperatively. This includes: infections; postoperative bleeding; thrombosis; delayed bowel function; death while in hospital and in the postoperative period.

The consultant has an obligation to ask the patient about conditions that will influence on the total outcome; this includes the preoperative intake of alcohol. It is known that a high alcohol intake (> 3 units per day) is a risk factor for overall complications, even death.

A female patient age 56, with a long medical record of bladder papillomas, now has bladder cancer. She was cleared and accepted Radical Cystectomy as the treatment. She did not hide the fact that her alcohol intake was higher than recommended: more than 50 units a week. Nobody in the team reacted.

Fig. 1 Danish example of AUDIT FOR alcohol abuse
Preoperatively the patient increased her alcohol intake. The operation was cancelled the day before, because the patient had symptoms of withdrawal. The consultant found it too risky to do the surgery due to the risk of complications, especially delirium. The patient was discharged to treatment for her alcohol abuse.

A month later she had the Radical cystectomy. In the postoperative period the patient often felt stigmatised - the staff questioned her about withdrawal symptoms whenever she was feeling different sensations in her body. This was very humiliating and offered a lot of tension between the patient and the staff. She was discharged after 8 days. Unfortunately, she had a severe relapse later.

2. Which nursing intervention did you provide?
The nurses and the team could have displayed a more pro-active attitude. It was not the first patient with a severe alcohol problem. Only one month before this case a male patient died after a radical cystectomy because of complications related to a high alcohol intake. At least the nurse could have commented on the amount of units of alcohol. The team think they have learned how important it is to act professional, but further progress must be initiated!

3. Which materials did you choose to help the patient?
1. We could have used a screening tool as a help to determine the severity of her alcohol problem. AUDIT (The alcohol use disorder test) is a validated screening tool. It is best to predict the effects of an on-going alcohol intake. AUDIT completed by the patient can help the consultant to determine how to treat the patient. Our consultants think that AUDIT in a moderated edition could be a tool in the counselling.
2. Alcohol intake is a difficult matter and can be a taboo. It takes special training to have this talk. 4. What were the results of your intervention?
We hope that we can achieve a better and safer outcome for patients who are at risk because of their alcohol intake. The topic needs further exploration.

Ingrid Sondergaard, Rn

Århus University Hospital - Skejby
Dept. of Urology
Århus N (DK)
DC13-02 Complicated ostomy and wound care after cystectomy and Bricker deviation (with complex comorbidity)

1. What were the problems you experienced in this patient?
A patient with complex comorbidity (APR, Fam. PolyPosisColi, pulmonary embolism after chemotherapy) now has T3N2M0 urothelial cell bladder cancer, for which the patient had a Brickerurinary diversion with complications and a new ileostomy. Complications led to a large abdominal wound, with the ileostomy in the middle and impossible wound care. Surgery is not possible because of the poor physical condition. General anaesthesia is not possible because of pulmonary embolism, high risk to get new fistulas because of chemo and adhesions. This is why the patient is given conservative treatment. Problems:

a. Long stay in hospital with very intensive (wound) treatment and nursing care.
b. Very difficult wound- and stoma care.
c. Hyper granulation after pinch grafting.
d. Necrosis after using wrong material by home care nurses, which was not communicated with our specialised ostomy/wound care team. As a result the wound got worse again.

2. Which nursing interventions did you provide?
Fig. 1: Wound manager
a. Use of special protocol for ‘long stay patients’: holistic approach: social, physical and emotional. Two or three nurses are assigned to the high care patient. They draw up an individual counselling plan (multidisciplinary), directed by the assigned nurses with a weekly update by the assigned doctor who is in charge of the medical plan. Only the assigned nurses and the assigned doctor will communicate about (medical) topics. A day programme is made for the patient.
b.Very specialised wound- and stoma care. We used different types of wound managers (Convatec, Coloplast) and stoma care materials to avoid leakage and skin problems. The ostomy/ wound care was very intense: 12 hours a day!
c. Clinical nurse specialist performed pinch grafting because SSG was not possible because of the poor physical condition. After the pinch grafting the wound started to overgrow itself, this is called hyper granulation. We treated this with a silver nitrate pen.

Fig. 2: Pinch grafting
d. Because of the use of a Convex Ring for the stoma in the home situation, necrosis appeared. This was not communicated on short term, so it got worse. After a consultation in our hospital, the specialised ostomy/wond care team changed material and treated the necrosis.

3. Which material did you choose to help the patient?
We had to adjust our strategy all the time because of new wounds, damaged skin, necrosis, leakage of faeces, etc. We’ve used wound managers from Convatec and Coloplast, convex pouch from Eakin, curvex pouch from Welland, Easyflex from Coloplast, Hollister pouch, stoma powder, paste, Duoderm Extra Thin from Convatec, Varimate hydrocolloid from Eurotec etc.

Fig. 3: Impressive growth with some hypergranulation after 3 weeks of pinch grafting

4. What were the results of your intervention? The result after 10 months of complications, intensively wound- and stoma care is show in Fig. 4. The wound- and stoma care can now be managed by the patient herself with help of the home care nurses. The patient is still consulting the ostomy/wound care team and the specialised nurse for the pinch grafting. She manages to be out of bed most of the day with a new dressing of the wound/ ostomy. In the end with almost no leakage!

Fig. 4: Self-management by the patient
We don’t often see these big problems with such a good result. Together with our patients we face challenging issues every day. We have great respect for the perseverance of our patients. Therefore, we want to thank them, and in this case especially Mrs. E., for their cooperation: without ‘them’, there would not be ‘us’.

If you are a nurse and encounter problems such as described in this article in daily nursing practice and you have found your own solutions, the EAUN invites you to take photos and submit your case (with unsolved problems or your solution) for the next International EAUN Meeting in Stockholm. To describe the case you have use a form with a list of standard questions, including a description of the problem, the nursing intervention provided, the material you have chosen to help the patient and the final results. Please visit for further information and to download the forms.

The submitters of the 10 best cases will be granted a free registration for the 15th International EAUN Meeting in Stockholm. We are looking forward to your Difficult Case before 1 December 2013!

Alice Van Der Scheer- Van Den Aakster, Rn

Antoni van Leeuwenhoek Hospital
Amsterdam (NL)

Marjette Beije, Rn

Antoni van Leeuwenhoek Hospital
Amsterdam (NL)

Article from European Urology Today, volume 25, No. 3

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