Roles of Advanced Practice Nurses in Caring for Patients with Short Bowel Syndrome: A Case Study

Abstract

Short bowel syndrome (SBS) is a medical condition characterized by significant loss of bowel length or function, leading to malabsorption of nutrients, reducing the bowel length to less than 180–200 centimeters (cms) in adults. This condition is frequently associated with massive intestinal resection and necrotizing enterocolitis. Parenteral nutrition (PN), administered via central venous catheters, is the standard treatment for all stages of SBS management. However, long-term hospitalization to receive PN is challenging due to bed availability constraints, prompting the development of home parenteral nutrition (HPN) systems. 

This article aims to describe the roles of advanced practice nurses (APNs) in managing the nutritional needs of patients with SBS, particularly those experiencing helplessness about their treatment. By applying Orem’s self-care deficit nursing theory (SCDNT), this article seeks to guide and motivate patients to achieve self-care, enabling them to manage home parenteral nutrition safely and effectively. 

The case study was a male patient aged 39 years old, diagnosed with short bowel syndrome following severe complications from descending aortic dissection and subsequent intestinal ischemia. The patient underwent multiple surgeries, including jejunocolonic anastomosis, leaving only about 100 cms of functional bowel. Besides, the patient also has bowel ischemia, which the doctors decided not to remove due to the risk of life-threatening complications. This anatomical and functional loss resulted in diarrhea and severe malabsorption. The patient can consume very little food orally and requires long-term parenteral nutrition. From the initial assessment, the patient exhibited: 1) signs of helplessness, self-care deficits, and depression, adversely impacting his motivation to take care of himself; 2) symptoms of fluids and electrolytes imbalance due to diarrhea and inefficient nutrient absorption from the intestines; 3) risk of insufficient intake of nutrients and vitamins for the body’s needs; and 4) risks of complications from receiving total parenteral nutrition (TPN) at home. 

As an advanced practice nurse (APN), the author intervened using Orem’s self-care deficit theory as a framework to address the patient’s self-care deficits and restore the patient’s motivation. Initially, the APN visited the patient daily and provided emotional support and care in all aspects, using the wholly compensatory nursing system. After one week, the patient began to talk more, showed more hope, and took more interest in self-care. The APN then provided partly compensatory nursing care, offering emotional support, education, and motivation for self- care management. The APN also developed a tailored care plan focusing on PN administration at home while ensuring patient safety and minimizing complications. The intervention emphasized the patient’s ability to self-manage with partial assistance, transitioning from wholly compensatory nursing systems to partly compensatory nursing systems by supportive and educative strategies. This involved teaching the patient and family caregivers about aseptic techniques, catheter care, PN preparation, and nutrition management. 

The outcomes of care are divided into patient outcomes, care provider outcomes, and quality of care outcomes. Regarding patient outcomes, it was found that the patient regained the ability to take care of himself and had an improved quality of life. The patient was able to return to work and perform daily activities typically. Additionally, the patient was able to manage total parenteral nutrition (TPN) at home without complications. After receiving TPN at home for 6 months, the patient was able to close the abdominal stoma and began eating by mouth normally. After 1 year, the patient was able to stop receiving TPN, discontinue antidepressant medication, and showed no relapse within the 1-year follow-up period. As for the care provider outcomes, the advanced practice nurse utilized competencies, including providing direct care, collaborating with interdisciplinary teams, applying evidence-based practices in patient care, serving as the consultant for ward nurses, offering guidance and education to patients and families, and being change agents. The case study highlighted the important role of advanced practice nurses in caring for patients with short bowel syndrome. The promotion of holistic care helped reduce the length of hospital stays, reduce healthcare costs, and improve the efficiency of patient care. In terms of the quality of care outcomes, the hospital had no existing system for home-based parenteral nutrition. Therefore, the author developed a protocol for home-based central parenteral nutrition, with the patient serving as the first model case at the hospital. This led to the development of a system that benefits patients with short bowel syndrome or other groups of patients who require central parenteral nutrition at home. 

In conclusion, the role of APNs is instrumental in managing SBS patients with complexity. By applying Orem’s Self Care Deficit Nursing Theory, APNs can address both physical and psychological aspects of care, fostering holistic self-care and improving the patient’s quality of life and overall patient outcomes. This article presents a case study that led to developing a practical and feasible home-based parenteral nutrition within the healthcare system, highlighting its feasibility and benefits.