Colorectal Disorders/Cancer

Types of Chemo

*5-Fluorouracil (5-FU) *Folinic Acid (Leucovorin) *Avastin (Monoclonal Antibody)-cuts off blood supply to tumor so it can't grow

Nursing Assessment Post-Op

-Assess incisional sites -Assess stoma and surrounding skin (functioning ostomy) Monitor: -vitals -NG placement, can be removed when bowel sounds return -Bowel sounds-return of peristalsis -I & O -Pain -Drainage in colostomy pouch

2 Staging Systems for Colorectal Cancer

-DUKES -TNM

Cecum

11%

Transverse Colon

12%

Rectum

24%

Sigmoid Colon

24%

Ascending Colon

25%

Laproscopic Surgery for Colon Cancer-what should you expect post-op?

5 puncture wounds on the patient's abdomen

Descending Colon

6%

Colostomy Irrigation

Ascending and Transverse colostomies: liquid to semi-liquid stool, *can not be successfully irrigated Sigmoid and Descending colostomies: semi-formed to formed stool, *can often be regulated with the irrigation method

CRC Research and Treatment

Chemoprevention (primary prevention) -Aspirin, NSAIDs and Statins: for a healthy GI tract (inhibits prostaglandins) -Calcium -Vitamin D and Folic Acid -Smoking cessation -Lose weight -Avoid high meat consumption (esp. red meat) New in Research: -genetics -earlier detection -Colon Cancer specific antigen-2 (CCSA-2) -Immunotherapy -Stool DNA testing -Tumor Growth Factors -Advancements in Chemotherapy

What is the most common symptom that prompts the patient to seek health care?

Rectal Bleeding

Polyps

benign, non-cancerous tumor

Metastasis to the Liver

-commonly metastasizes to the liver because the venous blood flow from the colorectal tumor goes through the portal vein

Diverticulitis

-avoid foods with seeds (strawberries, raspberries, popcorn) -can lead to perforation, peritonitis, and sepsis *Often treated with antibiotics and a temporary ostomy

Screening For High Risk Individuals

-FAP: screening begins at age 10-12 -HNPCC: begin at age 20-25, colonoscopy every 1-2 years with biopsy for dysplasia (abnormality)

Screening Tests primarily for cancer

-Fecal Occult Blood Test (FOBT): (perform every year) if positive, patient will get a colonoscopy -Fecal Immunochemical Test (FIT): (perform every year) if positive, pt will get a colonoscopy

Screening For People at Increased Risk

History of polyp on prior colonoscopy -small rectal polyp, same as those at average risk -adenomas or villous features-colonoscopy 3 years after polyp removal Patient with CRC-colonoscopy within one year after recection (if normal, repeat in 3 years) Patient with family hx-CRC in first degree relative before age 60-colonoscopy at age 40, or 10 years before youngest case in immediate family

Adenomatous Polyps (Adenomas)

polyps that have the potential to change into cancer

Clear Liquids before Colonoscopy

tea, black coffee, water, apple juice, white grape juice No: OJ, creamer in coffee, milk, etc.

Kock Pouch (K Pouch)

-Form of ileostomy (continent) -a reservoir is created with the ileum and then a stoma is created with the ileum

Possible Protectants (Chemoprotection)

-NSAIDs -Aspirin -High fiber, low fat diet, lots of fruits and vegetables -regular physical exercise

Pre-Op Physical Teaching

-Ostomy Care -Extent of Surgical Procedures -*Side to Side Positioning -Sitz Baths (bath in which a person sits in a warm pool of water, causes vasodilation and quickens healing, used for perineal incision) -Sexual Function/Sexual Activity may be altered

Interventions for Ostomy Patients/CRC Patients

-PCA for pain management -Use of Sitz baths -Side to side positioning -aseptic technique -clear liquid diet when diet resumes -have person of same sex discuss concerns with patient -encourage self care -TPN

HNPCC Screening

-People with this known HNPCC should be monitored with colonoscopy every 1-2 years, begins at the age of 20 -avg. age of onset is 44 years old -less aggressive than colorectal cancers without a known risk factors -occurs on the right side in 50% of cases -children have a 50% chance of inheriting the gene

Transverse Colostomy with Double Barreled Stoma

-Transverse colon is cut and two stomas are created with each cut end -one is the functional ostomy, the other is for mucous elimination-called a mucous fistula

HNPCC-Hereditary Non-Polyposis Colorectal Cancer/Lynch Syndrome

-a mutation in the gene that "error checks" DNA (repairs genes) -autosomal dominant disorder -people with this gene have 80-90% lifetime risk of developing colorectal cancer -*Arises from a single colorectal lesion

Familial Adenomatous Polyposis (FAP)

-autosomal dominant disorder -it is a mutation in the adenomatous polyposis coli (APC) gene -characterized by the presence of colorectal polyps (hundreds to thousands) -polyps begin in teenage years -individuals with FAP tend to develop colon cancer early in life (avg. age 39)

Screening for the general population

-begins at age 50 Tests: -Flexible sigmoidoscopy (every 5 years) if positive, the patient will get a colonoscopy -Colonoscopy (every 10 years) -Double contrast barium enema (every 5 years) if positive, patient will get a colonoscopy -CT colonoscopy

Clinical Manifestations-Cancer of the Rectum

-blood in stool -tenesmus (straining to move bowels, but fail to have a BM) -rectal pain -feeling of incomplete evacuation -constipation/diarrhea

General Pre-Operative Teaching

-bowel prep (laxatives "whole gut lavage", enemas, antibiotics) -oral antibiotics (Neomycin, Erythromycin) -Phantom pain -catheter -N/G tube -blood transfusion -diet -TPN post-op -mucosal drainage -pain management (PCA, Epidural) -IV central or peripheral

Colonoscopy vs. Sigmoidoscopy

-colonoscopies examine the entire colon -sigmoidoscopies examine only the sigmoid colon, or the lower 1/3 of the colon

Clinical Manifestations-Cancer of Left Sided Descending Colon

-dull pain -change in bowel habits -alternating diarrhea and constipation -obstruction -bright red blood in stools -ribbon-like stools (due to narrower lumen)

Clinical Manifestations-Cancer of Right Sided Ascending Colon

-dull pain (vague) -anemia -black stool -weakness

Pre-Op Psychological/Psychosocial Teaching

-fear/anxiety -role change -alteration in body image -coping

Etiology of Colorectal (What puts a person at risk?)

-generally unknown -occurs equally in men and women -greater than 50 years old -family hx of colorectal cancer -previous hx of colorectal cancer (site of surgical anastomosis) -hx of ovarian, breast, or uterine cancer -high fat and low fiber diet (controversial) -2 genetic links to colorectal cancer (FAP and HNPCC) -colorectal polyps (adenomatous polyps) -chronic inflammatory bowel diseases

Virtual Colonoscopy

-less invasive, less expensive -computer recreation of the colon -greater detail than fiberoptic view -takes 15 minutes -no sedation necessary -Patient can continue to take Warfarin (Coumadin) -*Can not remove polyps or take biopsy

Ascending/Transverse Colostomy

-loose stool, liquid consistency -requires colostomy pouch

Chemo S/Es

-loss of appetite -mouth sores (stomatitis) -diarrhea -rash -alopecia -leukopenia, anemia, thrombocytopenia, neutropenia -fatigue

*Symptoms

-may not be evident in the beginning of the disease process -location of cancer determines symptoms

Characteristics of Stomas-Edema

-mild to moderate: normal in the initial postoperative period -moderate to severe: obstruction of the stoma, allergic reaction to food, gastroenteritis

Descending Colostomy/Sigmoidostomy

-more formed stool -does not necessarily require a pouch

Chemotherapy For CRC

-most patient will need some sort of chemo after surgery (except those in the earliest stages) *It is recommended for patient with: -positive lymph nodes -metastatic disease -in conjunction with radiation therapy

Goals for Ostomy Patients/CRC Patients

-obtain normal bowel elimination pattern -QOL appropriate to disease progression -relief of pain -evidence of self care -feeling of self-worth, comfort -no metastases or recurrence of cancer

Role of the Home Care Nurse

-overall health -skin integrity: appearance/function of stoma -bowel output -complications -acceptance and progression -adjustments -follow up treatments and MD visits

Management of a Perineal Wound

-packing of the entire wound -partial closure -primary closure of the perineum

Patient Problems related to colostomies

-pain -grieving -altered skin integrity -body image disturbance -anxiety -risk for sexual dysfunction -fear -risk for fluid volume deficit -risk for infection -Altered nutritional balance

Digital Rectal Exam (DRE)

-part of routine physical exam -detects masses in anal canal and lower rectum -*can't detect colorectal cancer

Characteristics of Stomas-Color

-rose to brick red: viable stoma -pale: may indicate anemia -blanching, dark red, purple to black: indicates inadequate blood supply to the stoma or bowel from adhesions, low flow, or excessive tension on the bowel at the time of construction, EMERGENCY situation needing immediate attention

Screening FAP

-screening should begin between age 10-12 for those with a family hx of FAP, and be repeated every year until polyps are gone -once polyps appear, removal of the colon is usually recommended (total colectomy with ileostomy, or ileoanal pull through)

Characteristics of Stomas-Bleeding

-small amount: normal -moderate to large amount: abnormal

Ileostomy

-stoma will be positioned as close to the midline as possible -skin care -avoid foods high in fiber or hard to digest -fluids

Loop Stoma

-the colon is pulled through the omentum, a bridge is created, and the skin and peritoneum are sutured under the loop

Radiation for Colorectal Cancer

-used most often for RECTAL cancer -Radiation to the pelvis can be used before surgery to shrink the tumor and make it more resectable -Radiation to the pelvis can be used after surgery to prevent recurrence as well -Palliative treatment: reduce tumor size and offer relief of symptoms -Brachytherapy ("seed radiation"): external or internal

Discharge Planning

-wound care -stoma care in collaboration with enterostomal therapist (ET) -avoid heavy lifting -refer to ostomy society -discuss potential adjuvant therapies -well balanced diet in collaboration with dietary

Treatments for Colorectal Cancer

Surgery -polypectomy with colonoscopy (only when margins of polyp are free of cancer) -Colectomy-with reanastamosis -Colectomy with Colostomy-temporary or permanent (Abdominalperineal resection with colostomy) -Ileostomy -K Pouch-continent Ileostomy Adjuvant Therapy -Radiation -Chemotherapy

TNM

T-how far primary tumor grew into wall of intestine N-extent of spread to nearby lymph nodes M-whether or not cancer has metastasized