Colorectal Cancer Pathophysiology and Risk Factors

Pathophysiology of Colorectal Cancer

• Colorectal cancer originates in the rectum and small intestine
• Most colorectal cancers are found in the distal portion of the small intestine
• Early detection makes colorectal cancer one of the most curable cancers

Colorectal Cancer Staging

• TNM staging classifies Tumor size, Node involvement, and Metastasis
• Stages include I, II, III, and IV
• Prognosis worsens as tumor size and depth increase, along with lymph node involvement and metastasis

Risk Factors for Colorectal Cancer

• Men are at higher risk than women
• African American ethnicity increases risk
• Age range of 45-75 years increases risk
• Family history of colorectal cancer is a risk factor
• History of adenomatous polyps increases risk
• Diet low in fruits and vegetables can contribute to risk
• Inflammatory Bowel Disease (IBD) for 10+ years increases risk
• Physical inactivity increases risk
• Obesity is a risk factor
• Diet high in fat and red meat can increase risk
• Smoking and alcohol consumption increase risk
• Diabetes Mellitus Type 2 (DM2) increases risk

Expected Findings of Colorectal Cancer

• Early stages of colorectal cancer often have insidious symptoms
• Unexplained weight loss and fatigue are hallmark signs
• Changes in bowel regularity and/or stool appearance occur
• Blood in stool may be red or black depending on the location
• Abdominal pain and distention may occur
• Pressure sensation with incomplete bowel evacuation may be present
• Anemia can occur

Lab Tests for Colorectal Cancer

• A Complete Blood Count (CBC) is performed
• Carcinoembryonic Antigen (CEA) levels increase with abnormal mucosal cells

Diagnostic Procedures for Colorectal Cancer

• Fecal occult blood test is used
• Lower GI series is used
• Double contrast barium enema should not be administered to patients with diverticulitis
• Colonoscopy is the gold standard for colorectal screening
• Sigmoidoscopy is used
• Fecal DNA testing is performed
• Digital rectal exam is performed on males

Therapeutic Procedures for Colorectal Cancer

• Chemotherapy is used for stage II or III cancer
• Radiation is used to reduce tumor size
• Temporary or permanent colostomy may be necessary
• Colectomy involves excision of part or all of the colon
• Hemicolectomy involves excision of ½ or less of the colon
• Abdominoperineal resection involves removing the affected colon and rectum, closing the anus; the colon is removed through an abdominal incision

Complications of Colorectal Cancer

• Chemotherapy patients may experience fatigue, increased risk of infection, and anemia
• Radiation patients may experience diarrhea, bloody stool, and weight loss
• Post-op complications include blood loss, anastomoses, infection, and abdominal dehiscence

Nursing Assessments for Colorectal Cancer

• Monitor vital signs to measure physiological function and provide a post-surgery baseline
• Monitor serum electrolytes and CBC values for inflammation and infection risk
• Assess current knowledge of the disease and pre/post-operative care to provide incision and drain education, managing post-op expectations to alleviate concerns and fears

Nursing Actions for Colorectal Cancer

• Bowel prep is performed (if ordered) to minimize bacterial growth and prevent contamination with feces during surgery, using polyethylene glycol solution for cleansing, and antibiotics prior to incision to reduce infection risk
• Establish a therapeutic relationship to enhance patient trust and reduce anxiety and fear
• Ensure that a surgical consent form is signed and witnessed, as this is a legal requirement for all invasive procedures and must be obtained before any sedative, hypnotic, narcotic, or anesthetic agent is administered

Patient Education for Colorectal Cancer

• Pre-operative teaching regarding ostomy care increases compliance with treatment and reduces anxiety, often involving a wound ostomy continence nurse
• Pain management includes education about the PCA pump and how post-operative pain will be managed to decrease fear and anxiety

Post-Op Nursing Assessments for Colorectal Cancer

• Monitor vital signs every 4 hours, including infection precautions, atelectasis, and bleeding
• Monitor Hematocrit and Hemoglobin (H&H) for bleeding and nutritional deficits
• Monitor White Blood Cells (WBCs); a mild elevation within 48 hours is expected due to inflammatory response; later elevation may indicate infection
• Monitor for Nausea/Vomiting (N/V); bowel sounds can be absent for 1-3 days post-op; maintain NPO status with IV fluids and electrolytes as needed; use NG tube for stomach decompression until bowel function returns and advance diet as tolerated
• Monitor Intake and Output (I&Os); fluid losses can decrease renal perfusion leading to fluid retention; at least 30 mL/hr urine output by post-op day 3 is considered normal
• Assess the stoma, which should be reddish-pink and moist, possibly with some edema that should subside in a few days, with slight bleeding or serosanguinous drainage; contact provider with any discoloration (necrosis)
• Assess ostomy drainage for type, amount, appearance, and consistency based on ostomy placement (e.g., closer to small intestine means more liquid, requiring monitoring of fluids and electrolytes for low potassium)
• Assess the abdominal/perineal dressing/incision for excessive drainage
• Provide pain management to efficiently return the patient to their optimal functioning level

Nursing Actions for Post-Op Colorectal Cancer

• Administer IV fluids to replace post-op losses and balance fluids
• Maintain NPO status/advance diet as tolerated to prevent nausea/vomiting until bowel function returns
• Provide NG tube care, recording output, and maintaining placement until bowel function returns to prevent nausea/vomiting; ensure consistent drainage; lack of output indicates obstruction, requiring decompression/clearing of secretions

Patient Education for Surgery

• Pain management strategies include PCA pump or epidural anesthesia for the first few days post-op
• Drain management includes noting the appearance and amount of drainage, and encouraging turning, coughing, deep breathing, and incentive spirometer use 10x/hr to promote lung expansion, prevent atelectasis, and mobilize secretions
• Implement early ambulation to prevent VTE
• Make appropriate referrals to social work, home health, and ostomy support groups

Locations of Ostomies

• Ileostomy: liquid to semi-liquid output, monitor potassium (K+)
• Ascending colostomy: semi-liquid output
• Transverse colostomy: semi-liquid to semi-formed output
• Descending colostomy: semi-formed stool
• Sigmoid colostomy: formed stool

Pathophysiology of Hepatitis

• Inflammation of liver cells, caused most commonly by a virus, impairs normal liver function
• Hepatitis limits the ability of the liver to detoxify substances, produce proteins and clotting factors, and alters the ability to store vitamins, fats, and sugars

Alterations in Health (Diagnosis) of Hepatitis

• Hepatitis viruses are classified by letters A-G, differing in incubation period, mode of transmission, and other characteristics
• Avoid alcohol after diagnosis

Risk Factors for Hepatitis

• Alcohol abuse
• Exposure to some OTC medications
• Medications such as statins, anabolic steroids, methotrexates, valproic acid, and tetracyclines
• Toxins such as industrial chemicals, carbon tetrachloride, phosphorus, and mushrooms
• Type 1: adolescent females with other autoimmune disorders like Diabetes Mellitus (DM), Graves' disease, and Ulcerative Colitis (UC)

Expected Findings with Hepatitis

• Clay-colored stool
• Abdominal pain
• Irritability
• Pruritus (itching)
• Nausea/Vomiting (N/V)
• Fever
• Malaise
• Jaundice
• Lab abnormalities
• Right Upper Quadrant (RUQ) pain

Lab Tests for Hepatitis

• Increased Alanine Aminotransferase (ALT)/Aspartate Aminotransferase (AST)
• Increased bilirubin
• Increased serum ammonia
• Decreased albumin
• Complete Blood Count (CBC)

Complications of Hepatitis

• Fulminant viral hepatitis: a severe, rapidly progressing, life-threatening form of acute liver failure, symptoms include neurological decline, GI bleeding, thrombocytopenia, fever, oliguria, and ascites
• Hepatic encephalopathy: presents with impaired menstruation, AMS, confusion, somnolence, insomnia due to toxin accumulation as hepatocytes aren't functioning correctly
• Organ rejection and infection are potential complications, with signs and symptoms including RUQ pain, high HR, fever, changes in bile, jaundice, and increased WBC count, occurring within 4-10 days
• Untreated hepatitis can lead to cirrhosis and eventually liver cancer

Therapeutic Procedure for Hepatitis

• Liver transplant if cirrhosis is Hep C related (cadaver or alive)

Hepatitis A

• Most common
• Transmission route is fecal/oral from contaminated food, water, or shellfish infected with the virus
• Phase 1 involves abrupt onset of fever with anorexia, N/V/D, abdominal pain, urticaria, and hepatosplenomegaly
• Later phases include clay-colored stools, increased bilirubin, and jaundice 4-30 days post onset, usually with mild clinical manifestations
• Diagnosed by blood test for presence of Hepatitis A immunoglobulin M
• Vaccine available: 2 injections

Hepatitis B

• Spread person to person by blood, body fluids/secretions (semen) via mucus membranes, contact with infected fluids, childbirth, skin puncture (needles)
• Vaccine available, with 3 injections
• Symptoms include clay-colored stool and dark urine
• Risk factors include sexual contact with infected persons or multiple partners, male homosexual activity, injection drug abuse, blood transfusion, and hemodialysis
• Acute form lasts less than 6 months
• Chronic form lasts more than 6 months

Hepatitis C

• Spread through blood or body fluids and from mother to baby during childbirth
• Sharing contaminated needles of IV drug users and unintended needlesticks in the healthcare environment are major risks
• Can be asymptomatic
• No vaccine available

Hepatitis D

• Not common in the United States, only occurs in people infected with Hepatitis B virus (required to replicate)
• Spread through contact with infectious blood, most commonly in IV drug users
• No vaccine available

Hepatitis E

• Caused by Hepatitis E virus transmitted via the fecal-oral route, primarily through water that is contaminated in areas of poor sanitation; rare in the US
• No vaccine available

Hepatitis G

• Transmitted by infected blood and blood products
• Risk factors include hemophiliacs and those who require blood transfusions
• No vaccine available

Nonviral Forms of Hepatitis

• Caused by ingested, inhaled, or injected toxins or medications
• Clinical manifestations are similar to those of viral hepatitis, including anorexia, nausea/vomiting (N/V), jaundice, and hepatomegaly

Nursing Assessments for Hepatitis

• Monitor vital signs, including high temperature and high heart rate, related to infectious process
• Monitor serum liver enzymes; elevation indicates liver injury and enzyme release into the bloodstream
• Monitor serum bilirubin; this is a by-product of RBC breakdown, and the liver is responsible for removing it; yellow pigmentation of skin/sclera indicates jaundice, while green indicates a severe condition
• Assess nutritional intake; loss of appetite occurs due to abdominal fullness or lack of desire to eat food
• Monitor daily weight to assess nutritional intake and weight loss
• Monitor Intake and Output (I&Os); fluid volume status or depletion may occur, fluid overload associated with ascites may develop due to liver damage caused by the inflammatory and infectious processes
• Watch for signs of organ rejection after liver transplantation

Nursing Actions for Hepatitis

• Administer medications
• Provide small, frequent meals and supplements to counter decreased appetite
• Administer antiemetics for nausea/vomiting, but note that some are metabolized by the liver and should be used cautiously
• Balance activity and rest to decrease metabolic demands on the liver
• Encourage periods of rest during physical activity to maintain strength and conditioning

Patient Education on Hepatitis

• Nutritional teaching should focus on balanced nutrition to promote energy, small frequent meals for increased nutritional intake, decreased protein intake (as the liver metabolizes protein), limited fat, adequate hydration, and avoidance of alcohol
• Avoid NSAIDs
• Emphasize good hand hygiene before and after meals and bathroom use to decrease transmission via the fecal/oral route
• Avoid needle sharing and unprotected sex
• Obtain Hepatitis A and B vaccines

Pathophysiology of Cholecystitis

• Inflammation of the gallbladder caused by an obstruction of bile flow
• Classifications include calculous (presence of gallstones) and acalculous (without gallstones, associated with biliary stasis/slowed or stopped bile flow)

Gallstones

• Hard deposits formed from bile contents that often cause obstruction of ducts in and around the gallbladder (palpable fullness) also known as cholethiasis
• Cholesterol stones are most common
• Pigmented stones contain bilirubin
• Mixed stones contain both

Risk Factors for Cholecystitis

• The "5 Fs": Fat, Fair, Female, Fertile, Forty
• Women are more prone than men
• Older age increases risk
• Those of European descent are more likely to be affected than African Americans
• Pregnancy is a risk factor
• Genetics play a role
• Obesity increases risk
• Rapid weight loss (e.g., after surgery) can increase the risk
• Eating large amounts of food with saturated fats increases risk

Expected Findings of Cholecystitis

• Right Upper Quadrant (RUQ) pain
• Rebound tenderness
• Guarding
• High temperature
• High heart rate
• Colicky pain (intermittent and radiating pain to back)
• Positive Murphy's sign (pain on palpation of RUQ upon deep inspiration)
• Jaundice
• Older adults and diabetics (DM) may present with vague symptoms

Lab Tests for Cholecystitis

• CBC indicating increased White Blood Cell (WBC) count due to inflammation
• Liver Function Tests (LFTs) showing elevated liver enzymes due to blockage of bile flow in bile ducts
• Cholangiogram to image the biliary tree

Diagnostic Procedures for Cholecystitis

• Abdominal X-ray
• Abdominal ultrasonography
• CT scan

Medications for Cholecystitis

• NPO (nil per os)
• IV hydration
• Electrolyte and fluid imbalance correction
• Pain management (no morphine)
• IV antibiotics

Client Education for Cholecystitis

• Avoid fatty foods
• Avoid fried foods
• Avoid ice cream
• Avoid dairy products
• Avoid red meat
• Avoid alcohol

Therapeutic Procedures

• Lithotripsy for small gallstones
• Laparoscopic cholecystectomy (preferred)
• Open cholecystectomy
• T-tube insertion for bile drainage

Nursing Assessments

• Elevated temperature (high temp) and heart rate (high HR) reflecting inflammation secondary to gallstones, elevated respiratory rate (high RR) due to anxiety and pain, and decreased blood pressure (low BP) from dehydration and inflammatory response
• Dehydration resulting from nausea/vomiting (N/V) and insufficient oral intake increases BUN and creatinine
• Increased WBCs signify inflammation
• Elevated skin bilirubin and liver enzymes are caused by bile duct blockage
• Decreased skin turgor signifies dehydration
• Pain is intermittent and colicky, characterized by severe epigastric RUQ pain radiating to the back, shoulder, and chest, with a fast onset (1 hour) after eating high-fat meals and commonly occurring at night, potentially mimicking myocardial infarction (MI)
• Abdominal assessment reveals distension, abnormal bowel sounds, and a positive Murphy's sign
• Steatorrhea (excess fat in stool/oily stool) such as clay-colored stools is caused by bile flow blockage
• Daily weight provides information regarding fluid losses and gains
• Intake and Output (I&Os) provide data about fluid volume status and aid in preventing dehydration
• Assessment of nutritional intake determines diet history, fat intake, and implicated foods that contribute to symptoms

Nursing Actions for Cholecystitis

• Maintain NPO status to prevent gallbladder contraction, which releases bile and causes pain from the inflamed gallbladder
• Antibiotics to reduce and treat inflammation
• Administer bile acid reducers to help dissolve gallstones
• Administer analgesics for pain management (avoid morphine)
• Administer antiemetics to decrease nausea/vomiting
• Promote bed rest in Semi-Fowler's position, as lying flat may increase pain
• NGT with low suction to decompress the stomach and remove gastric secretions

Patient Education on Cholecystitis

• Post-operative instructions: signs and symptoms of infection, prevention of constipation, low-fat diet, and activity restrictions
• T-tube management: monitor the insertion site for inflammation and drainage; the T-tube should be emptied when ½-⅔ full to decrease pull on the insertion site
• Avoid a diet high in saturated fats
• Understand the disease's clinical manifestations, progression, diagnostic procedures, and interventions; this is essential for patients to recognize and report worsening symptoms that may indicate relapse or complications, improving overall management and health