Clinical review
Caring for patients with enterocutaneous fistulae Jenny Phillips/Margaret W alton, N orth Lincolnshire Health Authority, Lincoln Fistulae are distressing for both patients and staff. The management of fistulae presents a challenge to the nurse in terms of providing care for the psychological and physiological needs of the patient. This article describes the causes of fistulae and examines the nursing priorities and how to achieve them.
Mrs Phillips is the District Advisor in Tissue Viability and Mrs Walton is the Clinical N urse Specialist in Stoma Care for the North Lincolnshire Health A uthority, Lincoln. Mrs Phillips is based at St George’s Hospital, Long Leys Road, Lincoln, and Mrs Walton is based at the Lincoln County Hospital, Lincoln
496
0 the last 20 years, morbidity due to fistulae formation has been high, usually because of sepsis or poor nutritional intake (Devlin and Elcoat, 1983). Recently, however, improvements in care, e.g. the de velopment of agents that provide a greater degree of skin protection, effective ways of supplementing nutritional needs and anti biotic therapy, have all helped to reduce the morbidity rate. A fistula is ‘a track connecting two epithelial surfaces’ (Everett, 1985). These may be two internal organs or an internal organ and the skin. The latter is known as an enterocutaneous fistula and is the most common type. Fistulae are most commonly caused by the breakdown of an anastomosis postoperatively, or by inadvertent damage to in ternal organs during surgery (Everett, 1985). Fluid escapes through the layers of the wound forming a tract to the skin sur face. Malignancies or inflammatory diseases such as Crohn’s disease may also result in fistulae. The first sign of a fistula is an excess of fluid draining through the wound site. The type of fluid will help to pinpoint the site of the fistula (Table I). For example, the fluid escaping through a fistula from the small bowel or pancreas will contain a high proportion of digestive enzymes which can cause extreme excoriation when in contact with skin. All discharging fluid should be collected so that the amount of fluid loss can be measured. If there are multiple fistulae, it is desirable to collect fluid from each site. If surgery has been performed, the type of operation will indicate where the fistula may have occurred, otherwise radiological tests may be necessary to estab lish the site. In the past, probably because treatment options were so limited, early surgical in tervention was tried without much success. Nowadays, priorities of management are care of the skin, nutritional replacement,
and psychological care (Hall, 1981). It is also essential to consider fluid and electrolyte balance. Treatment requires a multidisciplinary approach involving medical and nursing staff as well as dieticians, pharmacists and laboratory staff. With appropriate manage ment a fistula will normally heal, but if it does not and surgical intervention is necess ary, the patient will be in a better condition to withstand it.
C are of the skin and m anagem ent In the management of a fistula or multiple fistulae care should be taken to select the best possible dressings/appliances with which to collect the discharge. Each patient must be assessed individually to ensure that he/she receives maximum benefit from the treatment being prescribed. In addition to psychological and nutritional states pa tients’ mobility should also be assessed. The objectives to be met when caring for pa tients with a fistula are shown in Tabic 2. Fistulae can appear anywhere on the Table I . Type of fluid loss from the various fistula sites 1_______________
__________
_
Gastric
Variable: a) watery b) bile stained c) contains recently consumed foodstuffs
Biliary tree/ duodenum
Bile stained
Pancreas
Colourless
Small bowel
Yellow-orange
Large bowel
Faeces
Urinary tract
Serous fluid or urine
Downloaded from magonlinelibrary.com by 134.148.005.068 on April 23, British Journal ol Nursing, 1992,Voi l,N2018. o 10
Caring for patients with enterocutaneous fistulae
body surface, in a wound, from a drain site, in a body crease or near a bony promi nence. The management of fistulae can be extremely difficult, especially if they are multiple or situated in a body crease. The nurse should assess the position of the fis tula when the patient is sitting or bending, as these movements can make the wearing of an appliance over the fistula more diffi cult and the most comfortable position for the patient must be found. Certain postures will aid the effluent drainage from the fis tula. To help nurses assess these patients it may be necessary to engage the help of clinical nurse specialists. A nurse who spe cializes in stoma care will have up-to-date information on products that will assist in the collection of fistula discharge and will be able to instruct nurses on their correct application. A clinical nurse specialist in tis sue viability will be able to recommend aids such as mattresses and cushions that will ensure the patient has maximum comfort and effective pressure area care; in addition, he/she will be able to give general advice on wound care.
Table 2. Objectives to be m et when caring for patients with a fistula Patient’s morale must be maintained and they must be kept informed of what is happening to them._________________________________ Chosen appliances should keep the patient comfortable, dry and free from odour at all times.___________________ ___________________ The skin around the fistula must be protected and kept intact as discharge from a fistula can cause skin excoriation. ______________ Loss from the fistula should be measured and recorded. The type of loss should be noted, e.g. whether it is purulent and blood stained, contains faecal matter, or it is just a thin liquid.________ ________
Choosing appliances
Fig. 1. A fistula in the incision line following partial gastrectomy and formation of transverse colostomy; both are contained in the same appli ance.
Fig. 2. Two wound manager pouches over multiple fistulae following surgery for subphrenic abscess, illustrating use over bony prominence.
4ft«
Choices of fistula management appliances can be made from the current range of il eostomy pouches now available on the mar ket. Transparent pouches are better as they aid the observation of fistula discharge. Skin barriers on these pouches also protect the skin. The size and shape of the fistula will determine what size of pouch needs to be used. If there are multiple fistulae it may be necessary to contain them all within the one appliance. There are several large wound manager appliances available and they come in three sizes — small, medium and large (Figs. 1 and 2). If the fistulae are not close together it is better to contain each one individually so that the discharge can be measured and assessed. Nurses must always follow local policies for protection when dealing with body fluids. The skin around the fistula should be kept clean, dry and healthy. Depending upon the nature of the effluent, skin dam age can be severe, e.g. discharge from a fis tula of the biliary and upper intestinal tract quickly causes burning and excoriation of the skin because of the presence of digestive enzymes; however, irrespective of the type of discharge, damage will occur quickly if the skin is not protected. When applying a pouch to contain the effluent, it may be necessary to make the
Downloaded from magonlinelibrary.com by 134.148.005.068 on April 23, 2018. British Journal of Nursing, 1992,Vol l.N o 10
Caring for patients with enterocutaneous fistulae
( Constant leakage from a fistula and frequent appliance changes by the nurse unnecessary suffering and lower the patient’s morale. 3
area of skin around the fistula flat and level. This can be done with soft paste or Stomahesive paste which should be spread thickly and then pushed into shape around the fistula with a dampened glove finger. The appliance can then be placed on this and there should be no subsequent leakage or odour. Protective skin barriers can also be used before a stoma pouch is fitted. For example, Granuflex or Comfeel will adhere to moist excoriated skin and form a protective layer that can remain in situ for several days pro viding there is no leakage. Where a fistula lies in a body crease, Salts ostomy seals can be used effectively around the site before an appliance is placed in po sition. These seals are versatile and can be stretched or cut to fit around the fistula, thus ensuring that any leakage flows into the pouch. If a seal is used, it is a good idea to pinch the outer edge first. This en sures that it is flattened slightly before it is removed from the wax paper that covers it. Thus, when an appliance is fitted over the seal, there is a smooth transition onto the skin surface and a hard ridge is avoided. When fitting an appliance, it is important to make a template of the size of the fistula and to transfer this pattern to the appliance and cut it out correctly. If this is not done the fit will be unsatisfactory and there will be leakage. Constant leakage from a fistula and fre quent appliance changes by the nurse cause unnecessary suffering and lower the pa tient’s morale. Relatives’ attitudes may also be affected as this complication means that they face a long period of hospital visiting. It is of paramount importance that support is offered to relatives as well as patients.
N utritional replacement Nutritional replacement is a key objective in patient management. Many patients may have been malnourished before surgery and the formation of the fistula. Dickerson (1986) found that 40% of surgical patients were suffering from the effects of poor nut rition before surgery and after one week in hospital this figure rose to 60%. Enteral feeding is preferable as it provides effective nutritional replacement and carries only a small risk of complications, unlike total parenteral nutrition (TPN) which may re sult in displacement of the catheter and re duced gut activity leading to loss of normal gut flora which protects against infection and septicaemia (Maynard and Bihan, 1991). However, TPN will be necessary for
patients with a high-output fistula. Patients suffer from an imbalance of fluids and electrolytes because of the large amounts of fluid lost. In addition, they may suffer from malnutrition because of their inability to digest and absorb food. TPN solutions are made up daily by the phar macy according to the results of daily blood, urea and electrolyte tests. The sol ution is usually infused over 12-24 hours. Intravenous fluids also need to be given to replace the fluid that is lost. This is worked out by calculating the total amount of fluid lost by the patient in both urinary output and fistula effluent. Accuracy of fluid balance charts is ex tremely important. Enteral feeding of high protein and low residue supplements can be given via a fine-bore nasogastric tube, along with intravenous fluids. If patients are able to take small amounts orally then this must be encouraged as they will retain the sense of having a meal and it gives pa tients something to look forward to and therefore helps them psychologically. It is important that the methods of feeding and their rationale are explained to patients and relatives as they sometimes find it difficult to understand that sufficient nutrients are being received via alternative methods.
Psychological factors and body image All patients who have undergone surgery and a subsequent change in body image will find difficulty in coping with the complica tions of fistula formation and the need to wear appliances which may be subject to leakage and odours. They will see this as a step backwards in their recovery process. Patients will also experience a general feeling of weakness and loss of appetite. This will impair their concentration and they will need careful counselling to ensure that they understand fully what is happen ing and the treatment that is being given. They may lose their will to fight, becoming apathetic and depressed. This in turn will lead to low morale. Elcoat (1986) states that ‘frequent consul tations between all team members is essen tial as the patient’s condition changes rapid ly. Any measures to lessen anxiety must be worthwhile.’ All patients need to be given the time to express their fears and anxieties. Careful planning of nursing care is of para mount importance and all care plans need to be updated on a regular basis. The ex pertise of the multidisciplinary team should be sought on a regular basis so that the pa-
499
Downloaded from magonlinelibrary.com by 134.148.005.068 on April 23, 2018. British Journal of Nursing, 1992, Vol 1, No 10
Caring for patients with enterocutaneous fistuiae
tient’s needs are met. It may also be necess ary to enlist the services of the hospital chaplain if that is the patient’s wish. Support must be regularly offered to the relatives. Explanation of the care required will assist them in what is sometimes a pro longed period of hospital visiting.
Conclusion The multidisciplinary team faces many challenges when caring for the patient with a fistula as extensive management is re quired. The planning of individualized care for a patient with a fistula is of paramount importance, requiring the skills of all carers involved. Assessment and evaluation should be carried out on a regular basis to
KEY POINTS • Formation of fistuiae need not mean a high risk of morbidity. • Individual patient assessment will ensure maximum benefit from prescribed treatment. • Effective skin management is of paramount importance for patient comfort. • Maximal nutritional replacement is essential for survival. • Good communication is necessary to maintain the patient's morale.
ensure that physical, psychological and spiritual needs are being met. Modern stoma appliances help to make the patient feel comfortable, provide excellent skin care and keep leakage and odour to a minimum. Nutrition and fluid replacement will con tinue to be a priority and it is important that doctors and nurses recognize the signs of malnourishment and dehydration. The King’s Fund Centre Report (1992) pro poses that nutrition should become an inte gral part of the curriculum for medical stu dents and that a department with a special interest in nutrition should be set up. The present trends in nurse education stress the importance of being healthy; however, nurses need to know more about the sick person and be able to recognize the malnourished patient in terms of assess ment and nursing intervention.
Devlin HB, Elcoat C (1983) Alimentary tract fistula, stomatherapy techniques of management. World I Surg 7: 489-94 Dickerson J (1986) Hospital induced malnutrition — a cause for concern. Prof Nurs l(ii): August 293-96 Elcoat C (1986) Stoma Care Nursing. Bailltere Tindall, London Everett W (1985) Wound, sinus or fistula? In: Westaby S, ed. Wound Care. William Heinemann Medical Books Ltd, London: 84-90 Hall M (1981) Care of fistula and d rain sites. In: Breckman B, ed. Stoma Care. Beaconsfield Pub lishing Ltd, Buckinghamshire: 158-66 King’s Fund Centre (1992) A Positive Approach to Nutrition as a Treatment. King’s Fund Centre, London Maynard N D, Bihan DJ (1991) Postoperative feeding: time to rehabilitate the gut. Br Me d ] 303: 1007-8
The Royal Marsden Hospital in association with British Journal of Nursing presents
NATIONAL STUDY DAY FOR HEALTH CARE PROFESSIONALS at The Royal Marsden Hospital, London Tuesday, 27 October 1992
New Developments in Breast Care For further details please contact Robyn-Jane Howitt, Mark Allen International Conferences, Croxted Mews, 288 Croxted Road, London SE24 9DA Tel: 081-671 7521; Fax: 081-671 7327 500
Downloaded from magonlinelibrary.com byof 134.148.005.068 on April British Journal Nursing, 1992, Vol I, No 23, 10 2018.
Caring for patients with enterocutaneous fistulae Jenny Phillips/Margaret W alton, N orth Lincolnshire Health Authority, Lincoln Fistulae are distressing for both patients and staff. The management of fistulae presents a challenge to the nurse in terms of providing care for the psychological and physiological needs of the patient. This article describes the causes of fistulae and examines the nursing priorities and how to achieve them.
Mrs Phillips is the District Advisor in Tissue Viability and Mrs Walton is the Clinical N urse Specialist in Stoma Care for the North Lincolnshire Health A uthority, Lincoln. Mrs Phillips is based at St George’s Hospital, Long Leys Road, Lincoln, and Mrs Walton is based at the Lincoln County Hospital, Lincoln
496
0 the last 20 years, morbidity due to fistulae formation has been high, usually because of sepsis or poor nutritional intake (Devlin and Elcoat, 1983). Recently, however, improvements in care, e.g. the de velopment of agents that provide a greater degree of skin protection, effective ways of supplementing nutritional needs and anti biotic therapy, have all helped to reduce the morbidity rate. A fistula is ‘a track connecting two epithelial surfaces’ (Everett, 1985). These may be two internal organs or an internal organ and the skin. The latter is known as an enterocutaneous fistula and is the most common type. Fistulae are most commonly caused by the breakdown of an anastomosis postoperatively, or by inadvertent damage to in ternal organs during surgery (Everett, 1985). Fluid escapes through the layers of the wound forming a tract to the skin sur face. Malignancies or inflammatory diseases such as Crohn’s disease may also result in fistulae. The first sign of a fistula is an excess of fluid draining through the wound site. The type of fluid will help to pinpoint the site of the fistula (Table I). For example, the fluid escaping through a fistula from the small bowel or pancreas will contain a high proportion of digestive enzymes which can cause extreme excoriation when in contact with skin. All discharging fluid should be collected so that the amount of fluid loss can be measured. If there are multiple fistulae, it is desirable to collect fluid from each site. If surgery has been performed, the type of operation will indicate where the fistula may have occurred, otherwise radiological tests may be necessary to estab lish the site. In the past, probably because treatment options were so limited, early surgical in tervention was tried without much success. Nowadays, priorities of management are care of the skin, nutritional replacement,
and psychological care (Hall, 1981). It is also essential to consider fluid and electrolyte balance. Treatment requires a multidisciplinary approach involving medical and nursing staff as well as dieticians, pharmacists and laboratory staff. With appropriate manage ment a fistula will normally heal, but if it does not and surgical intervention is necess ary, the patient will be in a better condition to withstand it.
C are of the skin and m anagem ent In the management of a fistula or multiple fistulae care should be taken to select the best possible dressings/appliances with which to collect the discharge. Each patient must be assessed individually to ensure that he/she receives maximum benefit from the treatment being prescribed. In addition to psychological and nutritional states pa tients’ mobility should also be assessed. The objectives to be met when caring for pa tients with a fistula are shown in Tabic 2. Fistulae can appear anywhere on the Table I . Type of fluid loss from the various fistula sites 1_______________
__________
_
Gastric
Variable: a) watery b) bile stained c) contains recently consumed foodstuffs
Biliary tree/ duodenum
Bile stained
Pancreas
Colourless
Small bowel
Yellow-orange
Large bowel
Faeces
Urinary tract
Serous fluid or urine
Downloaded from magonlinelibrary.com by 134.148.005.068 on April 23, British Journal ol Nursing, 1992,Voi l,N2018. o 10
Caring for patients with enterocutaneous fistulae
body surface, in a wound, from a drain site, in a body crease or near a bony promi nence. The management of fistulae can be extremely difficult, especially if they are multiple or situated in a body crease. The nurse should assess the position of the fis tula when the patient is sitting or bending, as these movements can make the wearing of an appliance over the fistula more diffi cult and the most comfortable position for the patient must be found. Certain postures will aid the effluent drainage from the fis tula. To help nurses assess these patients it may be necessary to engage the help of clinical nurse specialists. A nurse who spe cializes in stoma care will have up-to-date information on products that will assist in the collection of fistula discharge and will be able to instruct nurses on their correct application. A clinical nurse specialist in tis sue viability will be able to recommend aids such as mattresses and cushions that will ensure the patient has maximum comfort and effective pressure area care; in addition, he/she will be able to give general advice on wound care.
Table 2. Objectives to be m et when caring for patients with a fistula Patient’s morale must be maintained and they must be kept informed of what is happening to them._________________________________ Chosen appliances should keep the patient comfortable, dry and free from odour at all times.___________________ ___________________ The skin around the fistula must be protected and kept intact as discharge from a fistula can cause skin excoriation. ______________ Loss from the fistula should be measured and recorded. The type of loss should be noted, e.g. whether it is purulent and blood stained, contains faecal matter, or it is just a thin liquid.________ ________
Choosing appliances
Fig. 1. A fistula in the incision line following partial gastrectomy and formation of transverse colostomy; both are contained in the same appli ance.
Fig. 2. Two wound manager pouches over multiple fistulae following surgery for subphrenic abscess, illustrating use over bony prominence.
4ft«
Choices of fistula management appliances can be made from the current range of il eostomy pouches now available on the mar ket. Transparent pouches are better as they aid the observation of fistula discharge. Skin barriers on these pouches also protect the skin. The size and shape of the fistula will determine what size of pouch needs to be used. If there are multiple fistulae it may be necessary to contain them all within the one appliance. There are several large wound manager appliances available and they come in three sizes — small, medium and large (Figs. 1 and 2). If the fistulae are not close together it is better to contain each one individually so that the discharge can be measured and assessed. Nurses must always follow local policies for protection when dealing with body fluids. The skin around the fistula should be kept clean, dry and healthy. Depending upon the nature of the effluent, skin dam age can be severe, e.g. discharge from a fis tula of the biliary and upper intestinal tract quickly causes burning and excoriation of the skin because of the presence of digestive enzymes; however, irrespective of the type of discharge, damage will occur quickly if the skin is not protected. When applying a pouch to contain the effluent, it may be necessary to make the
Downloaded from magonlinelibrary.com by 134.148.005.068 on April 23, 2018. British Journal of Nursing, 1992,Vol l.N o 10
Caring for patients with enterocutaneous fistulae
( Constant leakage from a fistula and frequent appliance changes by the nurse unnecessary suffering and lower the patient’s morale. 3
area of skin around the fistula flat and level. This can be done with soft paste or Stomahesive paste which should be spread thickly and then pushed into shape around the fistula with a dampened glove finger. The appliance can then be placed on this and there should be no subsequent leakage or odour. Protective skin barriers can also be used before a stoma pouch is fitted. For example, Granuflex or Comfeel will adhere to moist excoriated skin and form a protective layer that can remain in situ for several days pro viding there is no leakage. Where a fistula lies in a body crease, Salts ostomy seals can be used effectively around the site before an appliance is placed in po sition. These seals are versatile and can be stretched or cut to fit around the fistula, thus ensuring that any leakage flows into the pouch. If a seal is used, it is a good idea to pinch the outer edge first. This en sures that it is flattened slightly before it is removed from the wax paper that covers it. Thus, when an appliance is fitted over the seal, there is a smooth transition onto the skin surface and a hard ridge is avoided. When fitting an appliance, it is important to make a template of the size of the fistula and to transfer this pattern to the appliance and cut it out correctly. If this is not done the fit will be unsatisfactory and there will be leakage. Constant leakage from a fistula and fre quent appliance changes by the nurse cause unnecessary suffering and lower the pa tient’s morale. Relatives’ attitudes may also be affected as this complication means that they face a long period of hospital visiting. It is of paramount importance that support is offered to relatives as well as patients.
N utritional replacement Nutritional replacement is a key objective in patient management. Many patients may have been malnourished before surgery and the formation of the fistula. Dickerson (1986) found that 40% of surgical patients were suffering from the effects of poor nut rition before surgery and after one week in hospital this figure rose to 60%. Enteral feeding is preferable as it provides effective nutritional replacement and carries only a small risk of complications, unlike total parenteral nutrition (TPN) which may re sult in displacement of the catheter and re duced gut activity leading to loss of normal gut flora which protects against infection and septicaemia (Maynard and Bihan, 1991). However, TPN will be necessary for
patients with a high-output fistula. Patients suffer from an imbalance of fluids and electrolytes because of the large amounts of fluid lost. In addition, they may suffer from malnutrition because of their inability to digest and absorb food. TPN solutions are made up daily by the phar macy according to the results of daily blood, urea and electrolyte tests. The sol ution is usually infused over 12-24 hours. Intravenous fluids also need to be given to replace the fluid that is lost. This is worked out by calculating the total amount of fluid lost by the patient in both urinary output and fistula effluent. Accuracy of fluid balance charts is ex tremely important. Enteral feeding of high protein and low residue supplements can be given via a fine-bore nasogastric tube, along with intravenous fluids. If patients are able to take small amounts orally then this must be encouraged as they will retain the sense of having a meal and it gives pa tients something to look forward to and therefore helps them psychologically. It is important that the methods of feeding and their rationale are explained to patients and relatives as they sometimes find it difficult to understand that sufficient nutrients are being received via alternative methods.
Psychological factors and body image All patients who have undergone surgery and a subsequent change in body image will find difficulty in coping with the complica tions of fistula formation and the need to wear appliances which may be subject to leakage and odours. They will see this as a step backwards in their recovery process. Patients will also experience a general feeling of weakness and loss of appetite. This will impair their concentration and they will need careful counselling to ensure that they understand fully what is happen ing and the treatment that is being given. They may lose their will to fight, becoming apathetic and depressed. This in turn will lead to low morale. Elcoat (1986) states that ‘frequent consul tations between all team members is essen tial as the patient’s condition changes rapid ly. Any measures to lessen anxiety must be worthwhile.’ All patients need to be given the time to express their fears and anxieties. Careful planning of nursing care is of para mount importance and all care plans need to be updated on a regular basis. The ex pertise of the multidisciplinary team should be sought on a regular basis so that the pa-
499
Downloaded from magonlinelibrary.com by 134.148.005.068 on April 23, 2018. British Journal of Nursing, 1992, Vol 1, No 10
Caring for patients with enterocutaneous fistuiae
tient’s needs are met. It may also be necess ary to enlist the services of the hospital chaplain if that is the patient’s wish. Support must be regularly offered to the relatives. Explanation of the care required will assist them in what is sometimes a pro longed period of hospital visiting.
Conclusion The multidisciplinary team faces many challenges when caring for the patient with a fistula as extensive management is re quired. The planning of individualized care for a patient with a fistula is of paramount importance, requiring the skills of all carers involved. Assessment and evaluation should be carried out on a regular basis to
KEY POINTS • Formation of fistuiae need not mean a high risk of morbidity. • Individual patient assessment will ensure maximum benefit from prescribed treatment. • Effective skin management is of paramount importance for patient comfort. • Maximal nutritional replacement is essential for survival. • Good communication is necessary to maintain the patient's morale.
ensure that physical, psychological and spiritual needs are being met. Modern stoma appliances help to make the patient feel comfortable, provide excellent skin care and keep leakage and odour to a minimum. Nutrition and fluid replacement will con tinue to be a priority and it is important that doctors and nurses recognize the signs of malnourishment and dehydration. The King’s Fund Centre Report (1992) pro poses that nutrition should become an inte gral part of the curriculum for medical stu dents and that a department with a special interest in nutrition should be set up. The present trends in nurse education stress the importance of being healthy; however, nurses need to know more about the sick person and be able to recognize the malnourished patient in terms of assess ment and nursing intervention.
Devlin HB, Elcoat C (1983) Alimentary tract fistula, stomatherapy techniques of management. World I Surg 7: 489-94 Dickerson J (1986) Hospital induced malnutrition — a cause for concern. Prof Nurs l(ii): August 293-96 Elcoat C (1986) Stoma Care Nursing. Bailltere Tindall, London Everett W (1985) Wound, sinus or fistula? In: Westaby S, ed. Wound Care. William Heinemann Medical Books Ltd, London: 84-90 Hall M (1981) Care of fistula and d rain sites. In: Breckman B, ed. Stoma Care. Beaconsfield Pub lishing Ltd, Buckinghamshire: 158-66 King’s Fund Centre (1992) A Positive Approach to Nutrition as a Treatment. King’s Fund Centre, London Maynard N D, Bihan DJ (1991) Postoperative feeding: time to rehabilitate the gut. Br Me d ] 303: 1007-8
The Royal Marsden Hospital in association with British Journal of Nursing presents
NATIONAL STUDY DAY FOR HEALTH CARE PROFESSIONALS at The Royal Marsden Hospital, London Tuesday, 27 October 1992
New Developments in Breast Care For further details please contact Robyn-Jane Howitt, Mark Allen International Conferences, Croxted Mews, 288 Croxted Road, London SE24 9DA Tel: 081-671 7521; Fax: 081-671 7327 500
Downloaded from magonlinelibrary.com byof 134.148.005.068 on April British Journal Nursing, 1992, Vol I, No 23, 10 2018.
