Colorectal Cancer PDF

Colorectal Cancer Dr. Samia H. Gaballah Associate Prof. Medical- Surgical Nursing Faculty of Nursing- Suez Canal University  Objectives At the conclusion of this lecture the student should be able to Define colorectal cancer (CRC) List the Risk Factors for CRC Identify the path physiology...

Colorectal Cancer Dr. Samia H. Gaballah Associate Prof. Medical- Surgical Nursing Faculty of Nursing- Suez Canal University  Objectives At the conclusion of this lecture the student should be able to Define colorectal cancer (CRC) List the Risk Factors for CRC Identify the path physiology of CRC List Signs and Symptoms of CRC Identify the clinical investigation for CRC Discuss management of CRC  Colorectal cancer Definition: Growth of tumor in the inner wall of the colon and rectum  Colorectal cancer Epidemiology:  The 3rd most common malignancy world wide (more than 1.2 million new cases annually)  Most common in males than females  Highest incidence rat in the economically developed countries  Most frequently diagnosed in adults between 65 and 74, but recently there is increased incidence of colorectal cancer in adults younger than 50 years of age  Colorectal cancer Risk factors: Cigarette smoking (rectal ˃ colon), dose relationship (pack/ year) and duration Family history of colon cancer (Lynch syndrome is hereditary non-polyposis colorectal cancer (HNPCC), is the most common cause of hereditary colorectal (colon) cancer) or polyps (familial adenomatous polyposis) High consumption of alcohol (i.e., >2 drinks daily in men, >1 drink daily in women)  Colorectal cancer Risk factors: High-fat, high-protein (red meats), processed meats as beef, hot dog and some luncheon meats Low-fiber diet History of genital cancer (e.g., endometrial cancer, ovarian cancer) or breast cancer (in women)  Colorectal cancer Risk factors: History of inflammatory bowel disease History of type 2 diabetes Increasing age Male gender Overweight or obesity Previous colon cancer or adenomatous polyps Racial/ethnic background: African American or Ashkenazi Jewish  Colorectal cancer Pathophysiology: Abnormal growth of tissue known as Polyp Transformation of polyp to a malignant tissue takes years Once transformation occur cancer begins to spread through the colon and rectum walls Invade blood, lymph nodes Or other organ directly (most often to the liver, peritoneum, and lungs)  Colorectal cancer Pathophysiology: Cancer of the colon and rectum is predominantly (95%) adenocarcinoma (i.e., arising from the epithelial lining of the intestine)  Colorectal cancer Clinical Manifestations: The symptoms are determined by the location of the tumor, the stage of the disease, and the function of the affected intestinal segment. Change in bowel habits (the most common presenting symptom) prolonged constipation or diarrhea, pencil thin stool Vague cramping or abdominal pain, discomfort, and or bloating Passage of blood in or on the stools Unexplained anemia, anorexia, weight loss, and fatigue Symptoms most commonly associated with right-sided lesions Dull abdominal pain Melena (i.e., black, tarry stools)  Colorectal cancer Clinical Manifestations: Symptoms most commonly associated with left-sided lesions Are those associated with obstruction (i.e., abdominal pain and cramping, narrowing stools, constipation, distention), as well as bright red blood in the stool. Symptoms most commonly associated with rectal lesions Tenesmus Rectal pain Feeling of incomplete evacuation after a bowel movement Alternating constipation and diarrhea Bloody stool  Colorectal cancer Assessment and Diagnostic Findings: It is recommended that all adults should begin periodic screening for colorectal cancer at the age of 50 years periodic screening at 40 years of age for those at higher risk of colorectal cancer (e.g., family history of Lynch syndrome or familial adenomatous polyposis (FAP), first-degree relative with a history of colorectal cancer) Colonoscopy is the only screening test that can also simultaneously remove precancerous polyps  Colorectal cancer Assessment and Diagnostic Findings: If there is tumor found, screening colonoscopy should have the tumor biopsied and tattooed during the colonoscopy to facilitate further intervention Laboratory studies CBC (to detect anemia), chemistry panel (to determine baseline status), and liver function tests (liver metastasis) Carcinoembryonic antigen (CEA) is a colon cancer tumor marker that predict the disease progression or recurrence  Colorectal cancer Complications: Partial or complete bowel obstruction (resected without anastomosis (e.g., Hartmann procedure) or with anastomosis (e.g., colectomy or partial colectomy)) Perforation (carries a bad prognosis; it is typically treated with an ostomy). Extension of the tumor and ulceration into the surrounding blood vessels can result in hemorrhage that managed surgically  Colorectal cancer Staging of Colorectal Cancer:  Colorectal cancer Medical Management: Surgery is the mainstay of treatment for colorectal cancer. It may be curative or palliative. The type of surgery recommended depends on the location and size of the tumor Patients who have Stage 0 tumors typically have endoscopic or laparoscopic excision of their tumors Laparoscopic surgery for Stage I, II, and III colorectal tumors achieves equivalent oncologic outcomes to surgery done by traditional open laparotomy  Colorectal cancer Medical Management: Possible surgical procedures as Segmental resection with anastomosis (i.e., removal of the tumor and portions of the bowel on either side of the growth, as well as the blood vessels and lymphatic nodes)  Colorectal cancer Medical Management: Possible surgical procedures as Abdominoperineal resection with permanent sigmoid colostomy (i.e., removal of the tumor and a portion of the sigmoid and all of the rectum and anal sphincter, also called Miles resection)  Colorectal cancer Medical Management: Possible surgical procedures as Temporary colostomy followed by segmental resection and anastomosis and subsequent reanastomosis of the colostomy, allowing initial bowel decompression and bowel preparation before resection Permanent colostomy or ileostomy for palliation of unresectable obstructing lesions Construction of a coloanal reservoir called a colonic J-pouch, which is performed in two steps.  Colorectal cancer Adjuvant therapy: Stage treatment Follow up Stage 0 disease not require chemotherapy or radiation therapy do not require specific follow-up Stage I disease not require chemotherapy or radiation therapy require specific colonoscopies follow-up 1-year postoperatively, then again in another 3 years, and then every 5 years Stage II disease Antimetabolite chemotherapeutic drug routine follow-ups and CEA capecitabine (Xeloda) for 6 months testing every 3 to 6 months for 5 In poorly differentiated tumors years Capecitabine is equivalent to the dual Colonoscopy every 1-year chemotherapeutic drugs 5-fluorouracil and postoperatively, and then every leucovorin. 5 years  Colorectal cancer Adjuvant therapy: Stage treatment Follow up Stage III disease combination chemotherapeutic drug of 5- routine follow-ups and CEA fluorouracil, leucovorin, and oxaplatin, called testing every 3 to 6 months FOLFOX. for 5 years Stage IV treatment is highly variable and individualized, done on an ongoing basis have metastases based upon the extent of the tumor mass to distant organs Chemotherapy as in stage III Nursing Management of Patient With Colorectal Cancer  Colorectal cancer Nursing Management: Assessment The nurse obtains a health history about the presence of fatigue, abdominal or rectal pain (e.g., location, frequency, duration, association with eating or defecation), past and present elimination patterns, and characteristics of stool (e.g., color, odor, consistency, presence of blood or mucus). A history of IBD or colorectal polyps  Colorectal cancer Nursing Management: Assessment A family history of colorectal disease, Lynch syndrome, or FAP, and current medication therapy. The nurse assesses dietary patterns, including fat and fiber intake, as well as amounts of alcohol consumed and history of smoking. Documents a history of weight loss and feelings of weakness and fatigue. Assessment includes auscultation of the abdomen for bowel sounds and palpation of the abdomen for areas of tenderness, distention, and solid masses. Stool specimens are inspected for character and presence of blood.  Colorectal cancer Nursing Management: Diagnosis Imbalanced nutrition: less than body requirements related to nausea and anorexia Risk for infection related to surgery on bowel and disruption of colonic bacteria Risk for deficient fluid volume related to vomiting and dehydration Risk for ineffective health management related to knowledge deficit concerning the diagnosis, the surgical procedure, and self-care after discharge Anxiety related to impending surgery and the diagnosis of cancer Impaired skin integrity related to the surgical incisions (abdominal or perianal)  Colorectal cancer Nursing Management: Collaborative problems/potential complications Potential complications may include the following: Intraperitoneal infection Complete large bowel obstruction GI bleeding Bowel perforation Peritonitis, abscess, and sepsis  Colorectal cancer Nursing Management: Planning and Goals The major goals for the patient may include Attainment of optimal level of nutrition Prevention of infection Maintenance of fluid balance Reduction of anxiety Learning about the diagnosis, surgical procedure, and self-care after discharge Maintenance of optimal tissue healing Avoidance of complications.  Colorectal cancer Nursing Intervention: Providing preoperative intervention Maintaining Optimal Nutrition. Recommends a diet high in calories, protein, and carbohydrates and low in residue for several days before surgery to provide adequate nutrition Minimize cramping by decreasing excessive peristalsis. A full or clear liquid diet may be prescribed for 24 to 48 hours before surgery to decrease bulk. If the patient is hospitalized in the days preceding surgery, parenteral nutrition may be required to replace depleted nutrients, vitamins, and minerals. In some instances, parenteral nutrition is given at home before surgery.  Colorectal cancer Nursing Intervention: Providing preoperative intervention Preventing Infection. The bowel is cleansed with laxatives, enemas, or colonic irrigations the evening before and the morning of surgery. Some surgeons prescribe antibiotics such as kanamycin (Kantrex), ciprofloxacin (Cipro), neomycin (Mycifradin), metronidazole, and cephalexin (Keflex) to be given orally the day before surgery to reduce intestinal bacteria. IV antibiotics such as cefazolin (Ancef) and metronidazole are given immediately before surgery  Colorectal cancer Nursing Intervention: Providing preoperative intervention Maintaining Fluid Volume Balance. Measures and records I&O, including vomitus, to provide an accurate record of fluid balance. The patient’s intake of oral food and fluids may be restricted to prevent vomiting. The nurse administers antiemetic agents as prescribed. Full or clear liquids may be tolerated, or the patient may be NPO.  Colorectal cancer Nursing Intervention: Providing preoperative intervention Maintaining Fluid Volume Balance. An NG tube may be inserted to drain accumulated fluids and prevent abdominal distention. The nurse monitors the abdomen for increasing distention, loss of bowel sounds, and pain or rigidity, which may indicate obstruction or perforation. It also is important to monitor IV fluids and electrolytes. Monitoring serum electrolyte levels can detect the hypokalemia and hyponatremia that occur with GI fluid loss. The nurse observes for signs of hypovolemia (e.g., tachycardia, hypotension, decreased pulse volume); assesses hydration status; and reports decreased skin turgor, dry mucous membranes, and concentrated urine.  Colorectal cancer Nursing Intervention: Providing preoperative intervention Providing Preoperative Education. Assesses the patient’s knowledge about the diagnosis, prognosis, surgical procedure, and expected level of functioning after surgery. Educate the patient about the physical preparation for surgery, the expected appearance and care of the wound, dietary restrictions, pain control, and medication management. All procedures are explained in language the patient understands.  Colorectal cancer Nursing Intervention: Providing postoperative intervention Maintaining Optimal Nutrition. Educate the patient about the health benefits of consuming a healthy diet. The diet is individualized as long as it is nutritionally sound and does not cause diarrhea or constipation. The return to normal diet is rapid.  Colorectal cancer Nursing Intervention: Providing Postoperative intervention Providing Wound Care. Frequently examines the abdominal dressing during the first 24 hours after surgery to detect signs of hemorrhage. Help the patient splint the abdominal incision during coughing and deep breathing to lessen tension on the edges of the incision. Monitors temperature, pulse, and respiratory rate for elevations that may indicate an infectious process.  Colorectal cancer Nursing Intervention: Providing Postoperative intervention Providing Wound Care. If the malignancy has been removed using the perineal route, the perineal wound is observed for signs of hemorrhage. This wound may contain a drain or packing that is removed gradually. Bits of tissue may slough off for a week. This process is hastened by mechanical irrigation of the wound or with sitz baths performed two or three times each day initially.  Colorectal cancer Nursing Intervention: Providing Postoperative intervention Monitoring and Managing Potential Complications. Frequently assess the abdomen, including bowel sounds and abdominal girth, to detect bowel obstruction Monitors vital signs for increased temperature, pulse, and respirations and for decreased blood pressure that may indicate an intra-abdominal infectious process Rectal bleeding must be reported immediately because it indicates hemorrhage.  Colorectal cancer Nursing Intervention: Providing Postoperative intervention Monitoring and Managing Potential Complications. Monitors hemoglobin and hematocrit levels and administers blood component therapy as prescribed. Any abrupt change in abdominal pain is reported promptly. Elevated white blood cell counts and temperature or symptoms of shock are reported because they may indicate sepsis. The nurse administers antibiotics as prescribed.  Colorectal cancer Evaluation: Expected patient outcomes may include: Consumes a healthy diet ❖ Avoids foods and fluids that cause diarrhea, constipation, and obstruction ❖Substitutes nonirritating foods and fluids for those that are restricted Does not exhibit any signs or symptoms of infection ❖Is afebrile Maintains fluid balance ❖Experiences no vomiting or diarrhea ❖Experiences no signs or symptoms of dehydration  Colorectal cancer Evaluation: Expected patient outcomes may include: Acquires information about diagnosis, surgical procedure, preoperative preparation, and self-care after discharge ❖Discusses the diagnosis, surgical procedure, and postoperative self-care ❖Demonstrates techniques of ostomy care Feels less anxious ❖Expresses concerns and fears freely ❖Uses coping measures to manage stress  Colorectal cancer Evaluation: Expected patient outcomes may include: Maintains clean wound(s) Recovers without complications ❖Regains normal bowel activity ❖Exhibits no signs and symptoms of perforation or bleeding ❖Identifies signs and symptoms that should be reported to the health care provider THANK YOU Questions…?