Colorectal Cancer

Colorectal cancer or colon cancer is a disease in which the cells in the rectum or colon grow out of control. This type of cancer occurs when tumors form in the large intestine lining. The risk of acquiring this disease increases after age 50. The most common type of colon cancer is the Adenocarcinoma, which could spread by direct extension through the walls of the intestine or through the lymphatic or circulatory system. According to the Duke’s Classification of colorectal cancer, there are four stages of this cancer. Stage A is when it is confined to the bowel mucosa; the patient has a 5 year survival rate. Stage B is when the tumor invades the muscle wall. Stage C is when the lymph node becomes involved. Lastly, stage D is when metastases or a locally unresectable tumor occurs. In this stage, there is a less than 5% 5 year survival rate. 

Nursing Diagnoses 

Diarrhea

May be related to

• Inflammation
• Irritation
• Intestinal malabsorption or partial narrowing of the intestinal lumen, secondary to the process of intestinal malignancy

Characterized by

• Increased bowel sounds / peristaltic
• Improved liquid defecation
• Stool color changes
• Pain / cramping abdominal

Imbalanced nutrition less than body requirements 

May be related to

• Impaired absorption of nutrients
• Hypermetabolic state, secondary to the process of intestinal malignancy

Characterized by

• Weight loss, decreased subcutaneous fat / muscle mass, poor muscle tone
• Increased bowel sounds
• Pale conjunctiva and mucous membranes
• Nausea, vomiting, diarrhea

Anxiety

May be related to

• psychological factors (the threat of changes in health status, socio-economic status, functions, roles, interaction patterns)
• sympathetic stimulation (neoplastic process)

Characterized by

• Acute phase of disease exacerbation
• Increased tension, distress, fear
• Irritable behavior
• Narrows the focus of attention

Ineffective individual coping

May be related to

• intensity and repetition stressor adaptive threshold exceeded (chronic illness, death threats, the vulnerability of individuals, severe pain, no adequate support system)

Characterized by

• Declare an inability to face problems, hopelessness, anxiety
• Declared worthless
• Depression and dependence

Knowledge deficit

About

• Condition
• prognosis 
• Treatment needs related to less exposure and or misinterpretation of information

Characterized by

• Ask questions, request information or a statement of the concept of fault
• Does not accurately follow the instructions
• Complications / exacerbations can be prevented

Nursing Notes

Causes, risk factors

Modifiable

• Diet: Whether diet plays a role in developing colon cancer remains under debate. The belief that a high-fiber, low-fat diet could help prevent colon cancer has been questioned. Studies do indicate that exercise and a diet rich in fruits and vegetables can help prevent colon cancer.
• Obesity: Obesity has been identified as a risk factor for colon cancer.
• Smoking: Cigarette smoking has been definitely linked to a higher risk for colon cancer.
• Drug effects: Recent studies have suggested that estrogen replacement therapy and nonsteroidal anti-inflammatory drugs such as aspirin may reduce colorectal cancer risk.

Non-Modifiable

Most colorectal cancers arise from adenomatous polyps-clusters of abnormal cells in the glands covering the inner wall of the colon. Over time, these abnormal growths enlarge and ultimately degenerate to become adenocarcinomas.

People with any of several conditions known as adenomatous polyposis syndromes have a greater-than-normal risk of colorectal cancer.

• In these conditions, numerous adenomatous polyps develop in the colon, ultimately leading to colon cancer.
• The cancer usually occurs before age 40 years.
• Adenomatous polyposis syndromes tend to run in families. Such cases are referred to as familial adenomatous polyposis (FAP). Celecoxib (Celebrex) has been FDA approved for FAP. After 6 months, celecoxib reduced the mean number of rectal and colon polyps by 28% compared to placebo (sugar pill) 5%.

Another group of colon cancer syndromes, termed hereditary nonpolyposis colorectal cancer (HNPCC) syndromes, also run in families. In these syndromes, colon cancer develops without the precursor polyps.

• HNPCC syndromes are associated with a genetic abnormality. This abnormality has been identified, and a test is available. People at risk can be identified through genetic screening.
• Once identified as carriers of the abnormal gene, these people require counseling and regular screening to detect precancerous and cancerous tumors.
• HNPCC syndromes are sometimes linked to tumors in other parts of the body.

Also at high risk for developing colon cancers are people with any of the following:

• Ulcerative colitis or Crohn colitis (Crohn disease)
• Breast, uterine, or ovarian cancer now or in the past
• A family history of colon cancer
• The risk of colon cancer increases 2-3 times for people with a first-degree relative (parent or sibling) with colon cancer. The risk increases more if you have more than one affected family member, especially if the cancer was diagnosed at a young age.

Assessment

Ascending (right) colon cancer

• Occult blood blood in stool
• Anemia
• Anorexia and weight loss
• Abdominal pain above umbilicus
• Palpable mass

Distal colon/rectal cancer

• Rectal bleeding
• Change bowel habits
• Constipation or diarrhea
• Pencil or ribbon shaped stool
• Tenesmus
• Sensation of incomplete

Diagnostic evaluation

• Fecal occult blood test (FOBT) – checks for hidden blood in the stool. Sometimes cancers or polyps can bleed and this test is used to pick up small amounts of bleeding. Have this test every year.
• Flexible sigmoidoscopy – an exam where a health care provider looks at the rectum and the lower part of the colon using a sigmoidoscope, a tube with a light on the end. Have this test every 5 years.
• Colonoscopy – an exam when a health care provider looks at the rectum and the entire colon using a colonoscopy, an instrument with a light on the end. If polyps are found, they can be removed. Have this test every 5 to 10 years.
• Double contrast barium enema (DCBE) – a series of x-rays of the colon and rectum. You are first given an enema with barium in it, which outlines the colon and rectum on the x-rays. Have this test every 5 to 10 years (only if not having a colonoscopy every 10 years).
• Digital rectal exam – a health care provider inserts a lubricated, gloved finger into the rectum to feel for any problem areas. Have this test every 5 to 10 years at the time of other screening tests (flexible sigmoidoscopy, colonoscopy, or DCBE).

Primary nursing diagnosis

• Pain related to tissue injury from tumor invasion and the surgical incision

Therapeutic intervention/medical management

Treatment of cancer depends on the stage of disease and related complications. Obstruction is treated with intravenous  fluids and nasogastric suction and with blood therapy if bleeding is significant. Supportive therapy and adjuvant therapy (e.g., chemotherapy, radiation therapy, immunotherapy) are included.

Surgical management

• Surgery is the primary treatment for most colon and rectal cancers ; the type of surgery depends on the location and size of tumor, and it may be curative or palliative.
• Cancers limited to one site can be removed to a colonoscopy
• Laparoscopy colostomy with polypectomy.
• Neodymium-yttrium-aluminum-garnet (Nd:YAG) laser is effective in some lesions
• Bowel resection with anastomosis and possible temporary or permanent colostomy or ileostomy ( less than 1/3 of patients) or coloanal reservoir (colonic J pouch).

Pharmacologic intervention

• Narcotic analgesic is often administered as patient-controlled anesthesia to manages surgical pain or pain from metastasis

Nursing intervention

• Administer chemotherapy agents as ordered, provide care for the client receiving chemotherapy.
• Provide care for the client receiving radiation therapy.
• Provide care for the client with bowel surgery.

Documentation guidelines

• Response to diagnosis of colorectal cancer,diagnostic tests,and treatment regimen
• Description of all dressings, wounds, and drainage collection devices: Location of drains; color and amount of drainage; appearance of the incision; color of the ostomy stoma; presence, amount,and consistency of ostomy effluent

Discharge & home healthcare guidelines

Patient teaching

• Teach the patient the care related to the abdominal incision and any perineal wounds. Give instructions about when to notify the physician (if the wound separates or if any redness, bleeding, purulent drainage, unusual odor, or excessive pain is present).
• Advise the patient not to perform any heavy lifting (􏰀10 lbs),pushing,or pulling for 6 weeks after surgery.
• If the patient has a perineal incision, instruct her or him not to sit for long periods of time and to use a soft or “waffle”pillow rather than a rubber ring whenever in the sitting position.
• Teach the patient colostomy care and colostomy irrigation.
• Give the following instructions for care of skin in the external radiation field:Tell the patient to wash the skin gently with mild soap,rinse with warm water,and pat the skin dry each day; not to wash off the dark ink marking that outlines the radiation field; to avoid applying any lotions, perfumes,deodorants,and powder to the treatment area; to wear nonrestrictive soft cotton cloth- ing directly over the treatment area; and to protect skin from sunlight and extreme cold.
• Explain the purpose, action,dosage,and side effects of all medications prescribed by the physician.

Follow-up

• Stress the need to maintain a schedule for follow-up visits recommended by the physician. Encourage patients with early-stage disease and complete healing of the bowel to eat a diet consisting of a low-fat and high-fiber content with cruciferous vegetables (Brussels sprouts,cauliflower,broccoli,cabbage). Most colorectal tumors grow undetected as symptoms slowly develop. Survival rates are best when the disease is discovered in the early stages and when the patient is asymptomatic. Unfortunately,50% of patients have positive lymph node involvement at the time of diagnosis. Participation in procedures for the early detection of colorectal cancer needs to be encouraged. Suggest follow-up involvement with community resources such as the United Ostomy Association and the American Cancer Society.