NUR114 Exam 3 Colorectal Cancer (CRC)
NURSING CARE OF THE CLIENT HAVING Bowel Surgery: POSTOPERATIVE NURSING CARE
Provide antacids, histamine2 receptor antagonists, and antibiotic therapy as ordered. The above medications may be ordered for the postoperative client, depending on the procedure performed. Antibiotic therapy is a common measure to prevent infection resulting from contamination of the abdominal cavity with gastric contents.
Colorectal Cancer (CRC) Nursing Care
Provide ostomy teaching (signs of ischemia to report, expected output, appliance management) if applicable
Colorectal Cancer (CRC) Sigmoidoscopy / Colonscopy
Provides a definitive diagnosis of CRC. This scope procedure permits visualization of tumors, removal of polyps, and tissue biopsy
Colorectal Cancer (CRC) Manifestations
*Occult or frank rectal belleding *Black, tarry stools *Manifestations of anemia *Weight loss *Change in blwel habits: alternating diarrhea & constipation; narrow and ribbonlike stools *Palpable abdominal mass *Cramping or vague lower abdominal pain
Foods That Color Stools of client with a colostomy
Beets and Red gelatin
Foods That Increase Stool Odor for client with a colostomy
*Asparagus *Beans *Cabbage *Eggs *Fish *Garlic *Onions *Some spices
Colorectal Cancer (CRC) Assesssment (Risk Factors)
*CRC more common in women *Rectal cancer more common in men *Adenomatous colon polyps affects the lining and become cancerous *Family history of CRC *Inflammatory bowel disease (Ulcerative colitis, Chrohn's disease) *High-fat, low fiber diet *Older than 50 years of age
Colorectal Cancer (CRC) occurs in stages from
0 to IV according to the tissue depth of a lesion, and whether it has spread to local or distal sites
Colorectal Cancer (CRC) Nursing Care
Provide postoperative care to prevent complications. Postoperatively, if the client has a stoma, assess the color and integrity of the stoma (an immediate postoperative stoma should be reddish pink, moist, and may have a small amount of visable blood; report any evidence of stoma ischemia (dead tissue) or necrosis)
NURSING CARE OF THE CLIENT HAVING Bowel Surgery: PREOPERATIVE NURSING CARE
Provide routine preoperative care for the surgical client as outlined in Chapter 4 .
Nursing Care of the Client with a Colostomy
Provide stomal and skin care for the client with a colostomy as for the client with an ileostomy (see the box on page 789). Good skin and stoma care is important to maintain skin integrity and function as the first line of defense against infection.
NURSING CARE OF THE CLIENT HAVING Bowel Surgery: POSTOPERATIVE NURSING CARE
Begin discharge planning and teaching. Consult with a dietitian for instructions and menu planning; reinforce teaching. Teach about potential postoperative complications such as abdominal abscess, or bowel obstruction, their signs and symptoms, and preventive measures.
Case Study Health Education for the Client and Family for " A Client with Colorectal Cancer"
Emphasize the importance of adequate fluid & salt intake; the R/F dehydration & hyponatremia is increased particularly during hot weather, when fluid is lost through perspiration as well as ileostomy drainage. Water intake should be sufficient to maintain pale urine & an output of at least 1 quart per day. When exercising in hot weather, the client should consume extra water & salt. High-potassium foods, such as bananas & oranges, may also be recommended. Loss of the reabsorptive surface of the large bowel increases the amount of water & sodium loss in the stool. If the ileostomy is high (more proximal in the ileum), additional potassium losses may also occur.
NURSING CARE OF THE CLIENT HAVING Bowel Surgery: PREOPERATIVE NURSING CARE
Insert a nasogastric tube if ordered. Although it is often inserted in the surgical suite just prior to surgery, the nasogastric tube may be placed preoperatively to remove secretions & empty stomach contents.
Colorectal Cancer (CRC) Therapeutic Procedures Radiation Therapy
Radiation therapy is given in conjunction with chemotherapy to improve prognosis (usually used for recal cancer to prevent lymph node involvement and recurrence)
Colorectal Cancer (CRC) Nursing Care
Slowly progress the diet after suctioning is discontinued and monitor the client's response and bowel sounds
Health Education about having a colostomy for the Client and Family
The diet for a client with a colostomy is individualized and may require no alteration from that consumed preoperatively. Dietary teaching should, however, include information on foods that cause stool odor and gas and foods that thicken and loosen stools.
Tumors of the rectum usually are treated with an
abdominoperineal resection in which the sigmoid colon, rectum, and anus are removed through both abdominal and perineal incisions. A permanent sigmoid colostomy is performed to provide for elimination of feces
Case Study Health Education for the Client and Family for " A Client with Colorectal Cancer"
* While caring for the ostomy, explain procedures to the client. Teaching is immediate and ongoing to facilitate acceptance of the ostomy and self-care.
Case Study: DIAGNOSES for " A Client with Colorectal Cancer"
*Acute Pain related to surgical intervention * Risk for Impaired Skin Integrity (Peristomal) related to fecal drainage and pouch adhesive *Risk for Constipation/Diarrhea related to effects of surgery on bowel function *Disturbed Body Image related to colostomy *Risk for Sexual Dysfunction related to wide rectal incision, radiation therapy, and colostomy
Risk factors indicative of individual at risk for colon cancer include:
*Age *Family history of Colorectal Cancer (CRC) *Personal history of Crohn's Disease
Foods That Thicken Stools of client with a colostomy
*Applesauce *Bananas *Bread *Cheese *Yogurt *Pasta *Pretzels *Rice *Tapioca *Creamy peanut butter
Colorectal Cancer (CRC) Diagnostic Procedures include:
*Barium enemas *CT scans of the abdomen, pelvis, lungs, and liver *Chest x-ray *Liver scans may be done to further identify the specific location of cancer and to identify sites of metastases
Foods That Increase Intestinal Gas for client with a colostomy
*Beer *Broccoli *Brussels sprouts *Cabbage *Carbonated drinks *Cauliflower *Corn *Cucumbers *Dairy products *Dried beans *Peas *Radishes *Spinach
Colorectal Cancer (CRC) S/S
*Blood in stool *Changes in bowel habits (constipation, diarrhea) *Cramps and/or gas *Palpable mass *Weight loss and fatigue *Vomiting *Abdominal distention *Abdominal bowel sounds indicative of obstruction (high-pitched tingling bowel sounds)
Diagnostic Tests for Colorectal Cancer (CRC)
*CBC may show anemia from chronic blood loss and tumor growth *Fecal occult blood (by guaiac or hemoccult testing) detects blood in the feces *Carcinoembryonic antigen (CEA) is a tumor marker used to estimate prognosis, monitor treatment, and detect cancer recurrence *Signoidoscopy or colonoscopy is used to detect and visualize tumors, as well as tissue biopsy *CT scan, MRI, or ultrasounic examination may be used to assess tumor depth and involvement of other organs *Tissue biopsy confirms cancerous tissue and evaluates cell differentiation
Foods That Loosen Stools of client with a colostomy
*Chocolate *Dried beans *Fried foods *Greasy foods *Highly spiced foods *Leafy green vegetables *Raw fruits and juices *Raw vegetables
Colorectal Cancer (CRC) Client Outcomes
*Client will be cancer free without recurrance for 5 years *Client will adapt to bowel redirective surgery (colostomy)
Colorectal Cancer (CRC) Surgical Interventions
*Colon resection *Colectomy *Colostomy *Abdominoperineal (AP) resection surgeries may be performed to remove all or portions of CRC
Colorectal Cancer (CRC) Health Promotion / Disease Prevention
*Eat a diet high in fruits, vegetables, and whole grains *Decrease intake of fats and meat proteins *Drink alcohol in moderation and stop smoking
Colorectal Cancer (CRC) Client Education Preoperative
*Educate the client regarding preoperative diet (clear liquids several days prior to surgery) *Instruct the client to complete bowel prep with cathartics as prescribed *Inform the client of the administration of antibiotics (neomycin, metronidayole [Flagyl]) to evadicate intestional flora
Colorectal Cancer (CRC) Therapeutic Procedures Chemotherapy
*If stage IV is found, chemotherapy is routinely given. *Angiogensis inhibitors (inhibit growth of new blood vessels to tumors) bevacizumab (Avastin) *Tyrosine kinase inhibitors (decreases cell proliferation and increases cell death of certain cancers):cetuximab (Erbitux) and panitumumab (Vectibix)
Case Study Health Education for the Client and Family for " A Client with Colorectal Cancer"
*Instruct now to use an electric razor to shave the peristomal hair if necessary. An electric razor prevents accidental cutting of the stoma with a razor blade.
Postoperative care for a client following a colon resection for colorectal cancer (CRC) includes:
*Monitor and treat pain, and evaluate pain-relief measures *Provide wound care using surgical aseptic technique to prevent infection *Advise the client to use stool softeners to prevent straining
Case Study: PLANNING AND IMPLEMENTATION for " A Client with Colorectal Cancer"
*Provide analgesia as ordered, evaluating its effectiveness. *Discuss foods that cause odor and gas. *Teach colostomy care. *Maintain consistent nursing personnel assignment to facilitate trust. *Refer to the local United Ostomy Association. *Provide a list of local medical supply companies for ostomy supplies. *Provide for privacy when teaching and discussing concerns about ostomy.
Colorectal Cancer (CRC) Nursing Care
*Provide client education regarding activity limits (no lifting) *Advise the client to use stool softeners to avoid straining
NURSING CARE OF THE CLIENT HAVING Bowel Surgery: POSTOPERATIVE NURSING CARE
*Provide routine care for the surgical client (Chapter 4 ). *Monitor bowel sounds and degree of abdominal distention. Surgical manipulation of the bowel disrupts peristalsis, resulting in an initial ileus. Bowel sounds and the passage of flatus indicate a return of peristalsis.
Colorectal Cancer (CRC) Client Outcomes Complications
*Recurrence of tumor at surgical ir distant site (mestastasis) *Nursing Actions: support client with prognosis and ensure that the client understands treatment options
Case Study: EXPECTED OUTCOMES for " A Client with Colorectal Cancer"
*Report pain within an acceptable range that allows ease of movement and ambulation. *Perform colostomy care using correct technique. *Demonstrate willingness to discuss changes in sexual function. *Wear clothing to enhance physical and emotional self-esteem.
Colorectal Cancer (CRC) Interdisciplinary Care
*Stoma nurse referral for instruction of care of colostomy *Referral to ostomy support group
Case Study Health Education for the Client and Family for " A Client with Colorectal Cancer"
*Teach to check the stoma and peristomal skin with each pouch change. Ongoing assessment is important for optimal health and function of the stoma and surrounding skin. Stripping of tape or excessively frequent pouch removal may cause mechanical trauma to peristomal skin. Chronic skin irritation by ileostomy effluent may lead to pseudoveracous lesions, or wartlike nodules.
Case Study Health Education for the Client and Family for " A Client with Colorectal Cancer"
*Teach to manage the pouch clamp, to empty, rinse, and perform pouch changes. Self-care is vital to independence and self-esteem.
Colonscopies should begin by age
45 for individuals who have a family history of cancer, and at age 50 for those who don not have a family history of cancer
Nursing Care of the Client with a Colostomy
A small needle hole high on the colostomy pouch will allow flatus to escape. This hole may be closed with a Band-Aid and opened only while the client is in the bathroom for odor control. Ostomy bags may "balloon" out, disrupting the skin seal, if excess gas collects.
NURSING CARE OF THE CLIENT HAVING Bowel Surgery: POSTOPERATIVE NURSING CARE
Alert all personnel caring for the client with an abdominoperineal resection to avoid rectal temperatures, suppositories, or other rectal procedures. These procedures could disrupt the anal suture line, causing bleeding, infection, or impaired healing.
Health Education about having a colostomy for the Client and Family
Allow ample time for the client (and family, if necessary) to practice changing the pouch, either on the client or a model. Practice of psychomotor skills improves learning and confidence.
Health Education about having a colostomy for the Client and Family
Prior to discharge, provide written, verbal, and psychomotor instruction on colostomy care, pouch management, skin care, and irrigation for the client. Whether the colostomy is temporary or permanent, the client will be responsible for its management. Good understanding of procedures and care enhances the ability to provide self-care, as well as self-esteem and control.
NURSING CARE OF THE CLIENT HAVING Bowel Surgery: PREOPERATIVE NURSING CARE
Arrange for consultation w/ enterostomal therapy (ET) specialist if appropriate. The ET nurse is trained to identify & mark an appropriate stoma location, taking into consideration the level of ostomy, skinfolds, & the client's clothing preferences. Initial ostomy care teaching also is provided by the ET nurse during the preoperative visit.
NURSING CARE OF THE CLIENT HAVING Bowel Surgery: POSTOPERATIVE NURSING CARE
Assess color amount, and odor of drainage from surgical drains and the colostomy (if present), noting any changes or the presence of clots or bright bleeding. Initial drainage may be bright red and then become dark and finally clear or greenish yellow over the first 2 to 3 days. A change in the color, amount, or odor of the drainage may indicate a complication such as hemorrhage, intestinal obstruction, or infection.
Nursing Care of the Client with a Colostomy
Assess stoma appearance and surrounding skin condition frequently (see the box page 789). Assessment of stoma and skin condition is particularly important in the early postoperative period, when complications are most likely to occur and most treatable.
Nursing Care of the Client with a Colostomy
Assess the location of the stoma and the type of colostomy performed. Stoma location is an indicator of the section of bowel in which it is located and a predictor of the type of fecal drainage to expect.
NURSING CARE OF THE CLIENT HAVING Bowel Surgery: POSTOPERATIVE NURSING CARE
Assess the position and patency of the nasogastric tube, connecting it to low suction. If the tube becomes clogged, gently irrigate with sterile normal saline. A nasogastric or gastrostomy tube is used postoperatively to provide gastrointestinal decompression and facilitate healing of the anastomosis. Ensuring its patency is important for comfort and healing.
Colorectal Cancer (CRC) Carcinoembryonic Antigen (CEA) serum test
CEA levels are elevated in most individuals with CRC
Colorectal Cancer (CRC) Health Promotion / Disease Prevention
CRC can be cured with detection. Regular colorectal screenings and fecal occult blood tests should be done annually for individual's 50 years or older, or earlier and more frequently if there is a family history of CRC
Colorectal Cancer (CRC)
Cancer of the rectum or colon. Most CRCs are adenocarcinoma, meaning a tumor that arises from a gland in the epithelial layer of the colon. Adenocarcinoma grows slowly and begins as a polyp. If caught early when it's still benign, it can be removed during a colonoscopy. If left untreated, the polyp will grow and risk of malignancy increases. Many times the client is asymptomatic but occult blood is discovered in the stool during a rectal exam.
Colorectal Cancer (CRC) Hemocric (HCT) & Hemoglobin (Hgb)
Decrease due to intermittent bleeding
Case Study Health Education for the Client and Family for " A Client with Colorectal Cancer"
Discuss dietary concerns. A low-residue diet is recommended initially (see Table 26-8). Foods that may cause excessive odor or gas are typically avoided as well. Because food blockage is a potential problem, high-fiber foods are limited, & foods that may cause blockage, such as popcorn, corn, nuts, cucumbers, celery, fresh tomatoes, figs, strawberries, blackberries, & caraway seeds, are avoided. S/S of food blockage include abdominal cramping, swelling of the stoma, & absence of ileostomy output for over 4 to 6 hours.
Case Study Health Education for the Client and Family for " A Client with Colorectal Cancer"
Discuss manifestations of fluid and electrolyte imbalances: *Extreme thirst *Dry skin and oral mucous membrane *Decreased urine output *Weakness, fatigue *Muscle cramps *Abdominal cramps, nausea, vomiting *Shortness of breath *Orthostatic hypotension (feeling faint when suddenly changing positions).
Colorectal Cancer (CRC) Client Education Postoperative
Educate the client regarding the care of the incision, activity limits, and ostomy care if applicable
Nursing Care of the Client with a Colostomy
Empty a drainable pouch or replace the colostomy bag as needed or when it is no more than one-third full. If the pouch is allowed to overfill, its weight may impair the seal and cause leakage.
Health Education about having a colostomy for the Client and Family
If an abdominoperineal resection has been performed, emphasize the importance of using no rectal suppositories, rectal temperatures, or enemas. Suggest that the client carry medical identification or a Medic-Alert tag or bracelet. These measures are important to prevent trauma to the tissues when the rectum has been removed.
Nursing Care of the Client with a Colostomy
If ordered, irrigate the colostomy, instilling water into the colon similar to an enema procedure. The water stimulates the colon to empty.
Case Study Health Education for the Client and Family for " A Client with Colorectal Cancer"
Instruct to report abnormal appearance of the stoma or surrounding skin (as noted previously and below) to the physician: a. Narrowing of the stoma lumen. This indicates stenosis and may interfere with fecal elimination. b. Lacerations or cuts in the stoma. The stoma contains no nerves, so trauma may occur without pain. c. Separation of the stoma from the abdominal surface. This potential complication may require surgical repair.
Colorectal Cancer (CRC) Fecal Occult Blood Test (FOBT)
Involves getting two stool samples within three consecutive days. False-positive results can occur with the ingestion of some foods or drugs. In general, meat, NSAIDS, and vitamin C are avoided for 48 hours prior to testing.
Case Study: ASSESSMENT for " A Client with Colorectal Cancer"
Madonna Hart, RN, completes the admission assessment. Mr. Cunningham states that his bowel habits have recently changed, but denies pain or other symptoms. Physical assessment findings include T 98.4F (36.9C), P 82, R 18, and BP 118/78. He is 70 inches (178 cm) tall and weighs 185 lb (84 kg). Laboratory findings are normal except for the previous pathology report of adenocarcinoma of rectal lesion. Mr. Cunningham states, "I really don't want a colostomy, but if that is what it takes to get rid of this, I'm ready to get it over with."
Colorectal Cancer (CRC) Nursing Care
Maintain NG suction (decompression)
NURSING CARE OF THE CLIENT HAVING Bowel Surgery: POSTOPERATIVE NURSING CARE
Maintain intravenous fluids while nasogastric suction is in place. The client on nasogastric suction is unable to take oral food and fluids and, moreover, is losing electrolyte-rich fluid through the nasogastric tube. If replacement fluid and electrolytes are not maintained, the client is at risk for dehydration, sodium, potassium, and chloride imbalance, and metabolic alkalosis.
Colorectal Cancer (CRC) Nursing Care
Management of a colostomy may be more difficult with older adult clients because of impaired vision and the need for fine motor skills
Case Study Health Education for the Client and Family for " A Client with Colorectal Cancer"
Notify the physician or enterostomal therapy nurse if: *The above measures fail to relieve the obstruction. *Signs of a partial obstruction persist including high-volume odorous fluid output, abdominal cramps, nausea, and vomiting. *There is no ileostomy output for 4 to 6 hours. *Signs of fluid and electrolyte imbalance occur, such as weakness, dizziness, lightheadedness, or headache.
Case Study: EVALUATION for " A Client with Colorectal Cancer"
On discharge, Mr. Cunningham is able to empty and rinse out his colostomy pouch. He is changing the pouch & caring for surrounding skin appropriately. Ms. Hart has given him verbal & written instructions on colostomy care. He verbalizes understanding of phantom rectal pain, & the importance of avoiding rectal suppositories. He expresses an understanding of the need to avoid heavy lifting, & the importance of follow-up care. Ms. Hart has referred Mr. Cunningham to a home health agency in his community for further questions & follow-up care.
NURSING CARE OF THE CLIENT HAVING Bowel Surgery: PREOPERATIVE NURSING CARE
Perform bowel preparation procedures as ordered. Oral & parenteral antibiotics as well as cathartics & enemas may be prescribed preoperatively to clean the bowel & reduce the risk of peritoneal contamination by bowel contents during surgery.
Nursing Care of the Client with a Colostomy
Position a collection bag or drainable pouch over the stoma. Initial drainage may contain more mucus and serosanguineous fluid than fecal material. As the bowel starts to resume function, drainage becomes fecal in nature. The consistency of drainage depends on the stoma location in the bowel.
NURSING CARE OF THE CLIENT HAVING Bowel Surgery: POSTOPERATIVE NURSING CARE
Resume oral food and fluids as ordered. Initial feedings may be clear liquids, progressing to full liquids, and then frequent small feedings of regular foods. Monitor bowel sounds and monitor for abdominal distention frequently during this period. Oral feedings are reintroduced slowly to minimize abdominal distention and trauma to the suture lines.
Colorectal Cancer (CRC) Nursing Care
Support the client who is experiencing disturbed body image.
Colorectal Cancer (CRC) / Colectomy
Surgical removal of part of the colon with an end-to-end anastomosis or placement of external stoma is performed. An external stoma or colostomy may be temporary or permanent.
Case Study Health Education for the Client and Family for " A Client with Colorectal Cancer"
Teach self-care measures to relieve food blockage: *Take a warm shower or tub bath. This can help relax the abdominal muscles. *Assume a knee-chest position. The knee-chest position reduces intra-abdominal pressure. *Drink warm fluids or grape juice if not vomiting. This provides a mild cathartic effect. *Massage peristomal area. Massage may stimulate peristalsis and fecal elimination. *Remove pouch if the stoma is swollen, and apply a pouch with a larger opening. If the stoma swells, the pouch may create a mechanical obstruction to output.
Colorectal Cancer (CRC) Health Promotion / Disease Prevention
Undergo a colonscopy every 10 years after a baseline colonscopy. If polyps are found, colonscopies need to be done more frequently.
Nursing Care of the Client with a Colostomy
Use caulking agents, such as Stomahesive or karaya paste, and a skin barrier wafer as needed to maintain a secure ostomy pouch. This may be particularly important for the client with a loop colostomy. The main challenge for a client with a transverse loop colostomy is to maintain a secure ostomy pouch over the plastic bridge.
Nursing Care of the Client with a Colostomy
When a colostomy irrigation is ordered for a client with a double-barrel or loop colostomy, irrigate the proximal stoma. Digital assessment of the bowel direction from the stoma can assist in determining which is the proximal stoma. The distal bowel carries no fecal contents and does not need irrigation. It may be irrigated for cleansing just prior to reanastomosis.
Case Study for "A Client with Colorectal Cancer"
William Cunningham is a 65-year-old retired railroad employee, husband, & father of three grown children. For the past 3 months, Mr. Cunningham has noticed small amounts of blood & occasional mucous in his stools. He has a sensation of pressure in the rectum, & notices that his stools are smaller in diameter, about the size of pencil. After palpating a mass on digital examination of the rectum, the physician orders a colonoscopy. A large sessile lesion is found in the rectum & biopsied. The pathology report shows the lesion to be adenocarcinoma. Mr. Cunningham is scheduled for an abdominoperineal resection and sigmoid colostomy.
Colorectal Cancer (CRC) can metastasize through
blood and lymph to the liver (most common), lungs, brain, or bones. Spreading can occur as a result of peritoneal seeding (during surgical resection of tumor). The most common location of CRC is the rectosigmoidal region
Acute Pain relating to the client with colorectal cancer
may experience pain related to preparatory procedures, diagnostic examinations, & surgery. Following an abdominoperineal resection, "phantom" rectal pain R/T the severing of nerves during the wide excision of the rectum may develop. Finally, the primary tumor itself &, potentially, metastatic tumors may impinge on nerves & other organs, causing pain. In the early postoperative period, an epidural infusion or PCA often is used to manage pain. PCA, routine administration of ordered analgesics, or a continuous analgesia delivery (CAD) system also may be used for pain management when the tumor is far enough advanced to preclude surgical resection. See Chapter 9 for more information on caring for clients with pain.
Fecal Occuly Blood Tests
should be done annually starting at age 50. However, fecal occult blood tests are not diagnostic of colon cancer, and a colonoscopy will need to be done to confirm the diagnosis
A sigmoid colostomy is
the most common permanent colostomy performed, particularly for cancer of the rectum. It is usually created during an abdominoperineal resection. This procedure involves the removal of the sigmoid colon, rectum, and anus through abdominal and perineal incisions. The anal canal is closed, and a stoma formed from the proximal sigmoid colon. The stoma usually is located on the lower left quadrant of the abdomen.