Chapter 18 — Nursing and Multidisciplinary Team Excellence

Purpose: much of the patient’s surgical experience is decided after they leave theatre — clear numerical thresholds mean escalation never depends on guesswork.

🎨 INFOGRAPHIC / VISUAL BLUEPRINT — CHAPTER 18

• Chapter colour palette: Emerald (#047857) header bar, Mint Cream (#ECFDF5) panels, Deep Forest (#064E3B) text.
• Hero graphic: A three-phase nursing ribbon (pre-operative verification → ward monitoring → discharge teach-back), a “plain warm-water sitz bath” badge, and four SBAR threshold cards (temperature above 38.0 °C; no void in 6–8 hours; bleeding > 1 pad/hour; escalating pain ≥ 7/10).
• Icon set: Clipboard, bladder scanner, sanitary pad with clock, thermometer, telephone (SBAR), water basin.
• Bedside aphorism banner: “Antiseptics belong on the floor, not in a sitz bath. Clear numbers beat “monitor closely” every time.”

1. The Three-Phase Perioperative Nursing Journey

Table 18.1 — Nursing checklist by phase

2. The Plain Warm-Water Sitz Bath Rule

• Plain warm water (about 37–40 °C) for 10–15 minutes, 2–3 times daily and after bowel movements — soothing and cleansing without rubbing [C]. Data for sitz baths are limited (AGA 2026) [U].

• Additives are unnecessary. Salt has no proven benefit.

• Avoid antiseptics — chloroxylenol (Dettol), cetrimide, povidone-iodine, or potassium permanganate concentrates — which irritate or burn anoderm and open wounds [C].

3. SBAR Escalation Thresholds

Table 18.2 — Four numerical triggers

📞 READY-TO-USE SBAR SCRIPT

• S: “Dr [name], I am calling from ward [X] about [patient], bed [Y], 6 hours after excisional haemorrhoidectomy, soaking more than one pad per hour with bright blood and clots.”
• B: “Three-column haemorrhoidectomy at 10:00. Pre-operative Hb 134 g/L. No anticoagulants.”
• A: “Three pads in 2 hours; heart rate up from 78 to 108/min; BP 104/66 mmHg; temperature 37.1 °C. I am applying pressure; IV access is working.”
• R: “Please review at the bedside within 15–30 minutes. Shall I send FBC, coagulation, and group-and-crossmatch now?”

4. Multidisciplinary Mini-Guide

Algorithm 18.1 — Post-operative ward escalation

[POST-ANORECTAL PROCEDURE MONITORING]
|
+-- Temperature above 38.0 C -> inspect perineum for
|   redness, crepitus, pus -> SBAR (pelvic sepsis?)
|
+-- No void in 6-8 h -> warm shower, bladder scan
|   -> > 400 mL with discomfort -> SBAR (catheter)
|
+-- Bleeding > 1 pad/h, clots, HR > 110, SBP < 100
|   -> pressure, observations, IV access -> SBAR
|
+-- Pain >= 7/10 and rising -> BLADDER SCAN FIRST,
|   inspect for haematoma -> SBAR
|
+-- Every SBAR call ends with a time-bound request:
    "Please review within 15-30 minutes"

5. Ward Traps

6. Role-Targeted Action Boxes

🚑 ER DOCTOR ACTION BOX

• Recurrent rectal prolapse in a child → think cystic fibrosis and refer (Chapter 14).

🩺 FAMILY MEDICINE / GP CLINIC BOX

• Pregnant women need fibre and reassurance first, not steroid marathons; most haemorrhoids improve after delivery (Chapter 13).

🏥 ER & WARD NURSE CARE AND SBAR BOX

• End every SBAR call with a time-bound recommendation, never “just letting you know”.

💊 CROSS-SPECIALTY PRESCRIBING TRAP

• Codeine or tramadol as the main discharge analgesic after haemorrhoidectomy produces hard stools on day 3–4. Prefer regular paracetamol plus an NSAID (if suitable), topical agents, and a daily stool softener.

⛔ NEVER DO THIS

• Never add antiseptics to a sitz bath.
• Never give more opioid for post-operative pain before scanning the bladder.
• Never hand over “monitor closely” without numbers.

📝 COMMON DOCUMENTATION ERROR

• Pad counts, void times, and bladder-scan volumes not recorded; SBAR calls without the time and the response.

📨 REFERRAL URGENCY BOX

The Patient in Front of You — Chapter 18 Mini-Case

🧑‍⚕️ THE PATIENT IN FRONT OF YOU

Seven hours after a three-column haemorrhoidectomy under spinal anaesthesia, a 48-year-old man reports 8/10 lower abdominal and perineal pain and restlessness. He has not passed urine despite drinking. The pad shows a small serosanguinous stain. Bladder scan: 620 mL.

Step 1 Connect pain to retention: restlessness and pain with 620 mL in the bladder is acute urinary retention.

Step 2 Threshold crossed: no void by 6–8 hours and a scan above 400 mL.

Step 3 SBAR and decompress: request catheterisation now; multimodal non-opioid analgesia; avoid further opioid.

Board-Style Question — Chapter 18

A 28-year-old man with active Crohn’s proctitis (six bloody stools a day, raised calprotectin) requests removal of prolapsing grade III haemorrhoids and oedematous tags. What is correct?

• A. Immediate excisional haemorrhoidectomy and tag excision
• B. Defer haemorrhoid procedures and control the IBD first
• C. Stapled haemorrhoidopexy
• D. Band all three columns today

Answer and explanation

• ❌ A Excision in active Crohn’s disease risks non-healing wounds, stenosis, and sepsis.
• ✅ B Correct. The AGA 2026 update advises delaying haemorrhoid treatment until complete remission of IBD.
• ❌ C A stapler in inflamed rectum risks dehiscence, sepsis, and fistula.
• ❌ D Banding inflamed mucosa risks ulceration, bleeding, and sepsis.

Ten-Item Rapid Revision Checklist — Chapter 18

• 01 I ensure the patient voids before theatre.
• 02 I avoid excessive IV fluids once the patient is drinking.
• 03 I scan the bladder if there is no void within 6–8 hours.
• 04 I count pads and check the bed for concealed bleeding.
• 05 I escalate a temperature above 38.0 °C after anorectal procedures.
• 06 I use plain warm water for sitz baths.
• 07 I use teach-back before discharge.
• 08 I give written return triggers (Appendix D).
• 09 I end every SBAR call with a time-bound request.
• 10 I know where to find specialty mini-guides in this book.

Five Most Dangerous Mistakes — Chapter 18

1. ⚠️ Treating post-operative restlessness with opioid when the bladder is full.
2. ⚠️ Missing concealed bleeding under the patient.
3. ⚠️ Recommending antiseptic sitz baths.
4. ⚠️ Handing over “monitor closely” without numbers.
5. ⚠️ Discharging without teach-back and written triggers.

Suggested Figure and Table Captions for the Medical Illustrator — Chapter 18

• Figure 18.1. Three-phase perioperative nursing ribbon.
• Figure 18.2. Four SBAR threshold cards.
• Table 18.1. Nursing checklist by phase.
• Table 18.2. SBAR escalation thresholds.
• Algorithm 18.1. Post-operative ward escalation.