Colorectal Cancers (Sherpath)
A patient with colorectal cancer (CRC) asks the nurse about the common sites of metastasis. Which response by the nurse is most appropriate?
"Colorectal cancers frequently metastasize to the liver because the blood flows from the intestines to the liver."
Chemotherapy is recommended for stage III tumors and high-risk stage II tumors. It includes various combinations of medications:
5-fluorouracil (5-FU) alone or in combination with oxaliplatin Folinic acid (leucovorin) alone or in combination with oxaliplatin Oxaliplatin Oral fluoropyrimidines Bevacizumab in combination with chemotherapy to treat metastatic CRC
Postoperative care includes:
Assessing suture integrity and wounds Providing sterile wound care and drain care Assessing for signs and symptoms of complications, including change in drainage, fever, or an increase in white blood cells (WBCs). Notify the health care provider with any concerns Assessing the patient's fluid status, vital signs, and pain management Noting the number of stools per day and type of bowel movements Providing patient and caregiver education preoperatively and until discharge (Home health care may continue after discharge)
Nursing interventions include:
Assessing the stoma function, location, and peristomal area Encouraging the patient to look at the stoma and participate in ostomy self-care; however, meet the patient where they are at and do not push Providing patient and caregiver teaching about ostomy care and function Performing meticulous peristomal care to prevent skin breakdown Consulting with a dietitian and a Wound, Ostomy, Continence Nurse (WOCN) Offering the patient information regarding support groups for patients with ostomies
How does nearly all colorectal cancer start?
as polyps (specifically adenomatous)
What are polyps?
small vascular growths on the mucous membrane (in the granular tissue of intestinal lining)
Primary Tumor
Tx: primary tumor cannot be assessed because of lack of information Tis: (carcinoma in situ) earliest stage: has not grown beyond mucosa layer T1: grown into submucosa T2: grown through submucosa into the muscularis propria T3: grown through muscularis propria into the subserosa, but not to neighboring organs and tissues T4: has completely spread through colon or rectal wall into nearby tissues/organs
Statistics
Third leading cause of cancer-related deaths Third most common cancer
Surgical Treatment for In Situ CRC
This polypectomy during colonoscopy procedure is considered successful when: The margins of the resected polyp are free of cancer The cancer is well differentiated There is no apparent lymphatic or blood vessel involvement
Other Screening Methods
Tissue biopsy (confirmatory) Complete blood count (CBC) for identifying anemia, coagulation studies, and liver function tests Computerized tomography (CT) scan Magnetic resonance imaging (MRI)
Transverse colon
Transverse colon: pain, change in bowel habits, anemia
The nurse is educating a group of individuals at a wellness center about screening for colorectal cancer (CRC). Which statement made by a participant indicates a need for further education?
"Since I am 55 and have no family history of colorectal cancer, I do not need to have a colonoscopy for another 5 years."
The nurse is caring for a patient who reports diffuse abdominal pain and recent weight loss. Which personal/social history findings suggest the patient is at increased risk for colorectal cancer (CRC)?
A 10-year history of diabetes Drinks at least 2 beers per day A 35-year history of cigarette smoking
Preparing Patients for CRC Screening
A clear liquid diet will be prescribed 24-48 hours prior to the procedure, and the patient will be given a bowel cleansing solution to drink. Polyethylene glycol (PEG) lavage solutions are typically given for bowel cleansing, though magnesium citrate solution, bisacodyl tablets, or suppositories may also be given before the PEG lavage to remove the bulk of stool so that only 2 L of solution are needed. The nurse will teach the patient that stools will be loose or liquid and should appear clear or clear yellow when the colon is clean. The nurse should instruct the patient to consume nothing by mouth (NPO) the day of the test. This procedure can be performed as inpatient or outpatient procedure. If the patient is having an outpatient procedure, the nurse will instruct the patient to bring someone else who will drive home after the procedure because of the sedative drugs used during the procedure.
The nurse is caring for a patient with stage III colorectal cancer (CRC) who is receiving chemotherapy and reports poor appetite, nausea and vomiting, hair loss, and fatigue. The nurse notes dry mucus membranes and poor skin turgor. Which action should the nurse take first?
Administer intravenous (IV) fluids
A postoperative patient reports a pain level of 5/10 after undergoing surgical removal of a rectal tumor. The nurse notes a heart rate of 122 beats/minute, blood pressure of 88/66 mm Hg, respiratory rate of 16 breaths/minute, SpO2 93% on room air, and a temperature of 102.8° F. Which action should the nurse take first?
Administer intravenous fluids
A patient reports severe diarrhea several days after undergoing surgery to remove a colorectal tumor. The nurse notes diminished rectal tone. Which actions should the nurse take? Select all that apply. Administer loperamide Administer a bulking agent Obtain a 24-hour diet recall Refer the patient to a dietician Notify the health care provider Document the number of stools/day NOT SURE
Administer loperamide Administer a bulking agent Notify the health care provider Document the number of stools/day
The nurse is caring for a postoperative patient after a tumor resection in the distal rectum. The nurse notes a hemoglobin level of 7.3, heart rate of 116 beats/minute, and blood pressure of 96/74 mm Hg. After calling the primary care provider, which actions should the nurse take?
Assess the surgical incision site Give a bolus of intravenous (IV) fluids Administer packed red blood cells (PRBCs)
The postoperative assessment of a patient with a new colostomy reveals a clean, dry surgical dressing and tenderness around the surgical area. The patient is sleepy, but arousable; has absent bowel sounds; SPO2 90% on room air, respiratory rate of 10 breaths/minute, heart rate of 78 beats/minute, blood pressure of 98/62 mm Hg. Which action should the nurse take first?
Apply oxygen via nasal cannula
Ascending colon and cecum
Ascending colon and cecum: anemia, hematochezia, bowel obstruction
The nurse is caring for a patient with colorectal cancer (CRC). Which assessment findings indicate the possibility of metastases?
Ascites The liver is a common site of CRC metastasis. Liver metastasis may be indicated by ascites. Lower back pain The bones are a common site of CRC metastasis. Metastasis to the bone may be indicated by lower back pain. Elevated bilirubin level The liver is a common site of CRC metastasis. Metastasis to the liver may be indicated by elevated bilirubin levels.
Goals of Surgical Therapy for CRC
Complete resection of the tumor with clear margins of healthy tissue Identify tumor spread through exploration of the abdomen Removal of all lymph nodes that drain the area in which the cancer is located Restoration of bowel continuity Prevention of surgical complications
The nurse is caring for a patient with diagnosed colorectal cancer (CRC) who reports severe abdominal tenderness, constipation, and fatigue. The nurse notes a hemoglobin level of 7 and bright red blood in the stool. Where would the nurse suspect the tumor is located?
Descending colon Patients with CRC in the descending colon present with abdominal pain, changes in bowel habits, fatigue, and bright red blood in the stool.
Descending colon
Descending colon: hematochezia (bright red), pain, changes in bowel habits
A patient taking antidiarrheal agents after colorectal surgery reports abdominal distention and cramping. The nurse notes a firm lower abdomen. Which provider order should the nurse implement next to address this problem?
Discontinue the antidiarrheal medication
The nurse is caring for a patient immediately prior to a colonoscopy. The patient reports frequent clear yellow, liquid stools after taking the entire bowel prep solution. Which action should the nurse take?
Document the findings as normal When a bowel prep has been successful, the patient will report clear yellow, liquid stools. The nurse will document this as a normal finding.
Risk Factors:
Family History of colorectal cancer or adenomatous polyps in a first-degree relative Family history of familial adenomatous polyposis (FAP) Hereditary nonpolyposis colorectal cancer (HNPCC; often called Lynch Syndrome) Medical History of diabetes mellitus Personal history of familial adenomatous polyposis (FAP) Personal history of hereditary nonpolyposis colorectal cancer (HNPCC; often called Lynch Syndrome) History of colorectal cancer History of inflammatory bowel disease Obesity Personal/Social Excessive intake of red/processed meat Sedentary lifestyle Consumption of alcohol (>4 drinks per week) Cigarette smoking
Early manifestations
Fatigue Weight loss Iron-deficiency anemia Rectal bleeding Abdominal pain Changes in bowel habits As CRC advances, patients begin to experience abdominal pain, may have a palpable mass, and hepatomegaly and ascites may be noted.
Screening Tests
Flexible sigmoidoscopy every 5 years (only 50% of colorectal cancers are found with FS) Colonoscopy every 10 years (is the gold standard for colorectal cancer screening) Double-contrast barium enema every 5 years Computerized tomography (CT) colonography (virtual colonoscopy) every 5 years
Which meal choice is most appropriate for the nurse to provide a patient the day before a colonoscopy?
Gelatin (not red), clear carbonated soda, and chicken broth The patient should be on a full liquid diet the day prior to a colonoscopy. Gelatin (not red), clear carbonated soda, and chicken broth fit in this diet. The gelatin should not be red as red gelatin could appear as blood during the colonoscopy.
The nurse is caring for a female patient after an abdominal-perineal resection (APR) of a rectal tumor. Which assessment finding is most concerning and warrants immediate health care provider notification?
Hemoglobin 7.2 g/dL This patient just had an APR and has a very low hemoglobin level. This may be an indication of hemorrhage and the nurse will need to report this to the health care provider
Surgical Treatment for Stage II CRC
Low-risk stage II tumors are treated with wide resection and reanastomosis. Chemotherapy is used in addition to surgery for high-risk stage II tumors.
Types of Polyps
Hyperplastic Nonneoplastic growths (noncancerous)Never cause symptoms and remain small Adenomatous Neoplastic 85% of these polyps linked to adenocarcinoma Risk of cancer increases with size Sessile Flat, broad based, and directly attached to the intestinal wall Polyps tend to be sessile when small Pedunculated Attached to the intestinal wall by a thin stalk Polyps become pedunculated as they enlarge
Common late clinical manifestations include:
Intestinal obstruction or perforation Nausea/vomiting Hyperactive bowel sounds proximal to the obstruction
Demographics
More common in men Individuals of African American ethnicity have the highest mortality rate Risk increases with age Incidence is increasing for those under the age of 50, who consume high-fat, low-fiber diets
Metastasis
Mx: presence of distant metastasis cannot be assessed M0: no distant metastasis seen M1: distant metastasis present
The nurse is caring for a patient with diagnosed colorectal cancer (CRC). The patient reports constipation and abdominal discomfort. The nurse notes a distended abdomen. Which additional findings would indicate an intestinal obstruction?
Nausea and vomiting bsent bowel sounds distal to the obstruction
CRC are to promote:
Normal bowel elimination patterns Quality of life appropriate to the disease process and effects on lifestyle Relief from pain Feelings of comfort and well-being
Lymph Node Involvement
Nx: nodes cannot be assessed N0: no regional lymph node involvement N1: cancer found in 1-3 nearby lymph nodes N2: cancer found in 4 or more nearby lymph nodes
The nurse is caring for a patient with abdominal distention, diarrhea, and a pain level of 4/10. The nurse notes a hemoglobin level of 9.8 g/dL, white blood cell (WBC) count of 12.0 cells/µL, and serum potassium 4.1 mEq/L. Which action should the nurse take first?
Obtain a stool sample for occult blood
What is colorectal cancer?
Term used for cancer that starts in the colon or rectum. These cancers can also be referred to separately as colon cancer or rectal cancer, depending on where they start. Colon cancer and rectal cancer have many features in common.
Nursing Assessment for Patients with Colorectal Cancer (CRC)
Past Medical History Previous cancer diagnoses, results of past colonoscopies, and/or history of inflammatory bowel disease History of breast or ovarian cancer, familial polyposis, villous adenoma, and/or adenomatous polyps Current Medications Medications affecting bowel function (e.g., laxatives, antidiarrheal drugs) Personal/Social History Nutrition Elimination patterns Current symptoms Abdominal and low back pain Tenesmus, which is a feeling of constantly needing to pass stool, even if the colon is empty Changes in bowel habits (diarrhea/constipation), rectal bleeding, black tarry stools, and/or thinning in diameter of stools (pencil-like stools) Late signs Pallor Cachexia or muscle wasting Lymphadenopathy
A patient admitted with a tumor in the sigmoid colon is scheduled for a bowel resection the next day. The patient reports abdominal pain rated at 10/10. The nurse notes a rigid, board-like abdomen and a temperature of 102.3° F. Which action should the nurse take?
Prepare the patient for surgery for a temporary colostomy
Ongoing Care The nurse should:
Provide psychological support and discuss the patient's feelings with them Teach patients to manage changes that are the result of the cancer and cancer treatment Administer antidiarrheal drugs, such as loperamide or bismuth subsalicylate, or bulking agents to control diarrhea Provide ostomy rehabilitation, including teaching and ongoing support Implement interventions to prevent skin breakdown
Rectum
Rectum: hematochezia (bright red), discomfort, changes in bowel habits
Radiation
Some patients may receive radiation therapy as an adjuvant to surgery and chemotherapy or as a palliative measure for metastases. The nurse should assess and monitor the patient for side effects, such as nausea, vomiting, and pain at the radiated site, including proctitis, redness, and skin irritation and breakdown. Severe fatigue is also a result of the treatment.
Stool Testing
Stool tests must be done frequently, since tumor bleeding occurs at intervals and easily may be missed if only a single test is done: High-sensitivity fecal occult blood test (FOBT) every year or fecal immunochemical test (FIT) every year Assess for blood in the stool
Surgical Treatment for Stage III and IV CRC
Surgery and chemotherapy are used to treat CRC in this stage. Radiation and chemotherapy may be done before surgery to reduce tumor size prior to resection. If stage IV cancer has spread to distant sites: Surgery is palliative. Chemotherapy is used to control the spread. Radiation is used to provide pain relief.
The nurse is reviewing the medical record of a recently admitted patient with colorectal cancer (CRC). According to the Tumor, Nodes, Metastasis (TNM) system, which finding indicates the patient has a poor prognosis?
T3N2M1 This patient has a primary tumor that has grown through muscularis into the serosa, but not to neighboring organs and tissues. The cancer has spread to at least four lymph nodes, and the cancer has metastasized. Therefore, this patient has a poor prognosis.
Carcinoembryonic Antigen (CEA)
Used to monitor for disease recurrence after surgery or chemotherapy Not a good screening tool because of the large number of false positives. Used in conjunction with symptoms Levels also may be increased in noncolon carcinomas, as well as some nonneoplastic conditions, such as inflammatory bowel disease (IBD), pancreatitis, cirrhosis, and chronic obstructive pulmonary disease (COPD)
