CA - Colorectal Cancer Flashcards
Whats colorectal cancer and how does it occur?
- malignant tumor that originates in the colon / rectum
- mutation in APC tumor suppressor genes of the epithelial cells -> small polyp forms = early adenoma -> develop further mutations -> colon cancer
Whats the difference between left & right sided colon cancer? Which is better?
What are the symptoms of each?
L: cancer grows inwards
- causes obstruction -> symptomatic: pain -> BETTER! easier to detect
- fresh blood in stools
- constipation, diarrhoea
- apple core lesion causes narrowed lumen
R: cancer grows vertically upwards & outwards along the wall -> BAD! takes longer to diagnose
- anemia, fatigue, weight loss
What are the Modifiable & Nonmodifiable risk factors?
Modifiable
1. smoking, excessive alcohol, obesity
2. eat alot of processed meat
Nonmodifiable risk factors
- >40 years old
- family history of colorectal cancer or colorectal polyps
- hyperinsulinemia = excess insulin in blood -> increases a growth factor that prevents apoptosis -> allows abnormal cells to survive
- inflammatory bowel disease like Crohn disease & ulcerative colitis -> causes genetic mutations over time
What are the clinical manifestations of colorectal cancer?
- Initially: asymptomatic
- Over time: immune response will fight tumour -> unintentional weight loss (increases metabolism & decreased absorption of nutrients)
- fever, malaise
If tumour grows enough to physically obstruct the bowel -> narrowing of the intestinal lumen -> obstruction
- colicky pains
- constipation / diarrhea
- narrowing of stools
- hematochezia / fresh blood with the stool
- iron deficiency anaemia.
Diagnosis of CC?
- History & physical assessment
- Colonoscopy with biopsy
- Laboratory test results are usually non-specific -> may show elevated blood levels of tumor markers like CEA.
Once diagnosis is confirmed:
4. Abdominal / pelvic CT scan / MRI
- stage the tumor by defining the location
- look for lymph node involvement or metastasis
Nursing management of CC?
- implement postoperative interventions
- monitor closely for complications
- semi-Fowler position - minimize tension on sutures and anastomosis site
- NPO, maintain NGT at low-intermittent suction
- provide the ordered IV fluids and medications.
- assess colostomy site & surrounding skin
NORMAL FINDINGS:
- pink or rosey red stoma
- minimal swelling or bleeding
- intact skin surrounding the stoma & stoma that stays well above the level of the skin with the colostomy bag securely in place
When peristalsis returns
- stop NGT
- monitor color, consistency, and amount of output from stoma.
What is the nursing management for a patient with Colorectal Cancer Pre-Op?
Assessment
Monitor for Vital Signs (ensure Vital Sign is stable to proceed for op)
Review medical history / drug history / surgical history
Allergies to drugs / latex / anesthesia / antibiotics
Abdominal examination & rectal examinations
FBC for any hemorrhage, on blood thinners? (Must be off for at least a week before procedure)
Review electrolyte level (renal panel) : Na, K, CI, Ca, bi-carbonate (checks renal & kidney function)
Ensure iv plugs are patent for procedure
5 checks 3 rights
Antibiotics prophylaxis to
Pre-op checklist:
Consent must be valid: Signed, dated, and written properly, error must countersign, (blood transfusion, anesthesia - due to risks involved, surgical)
Bloods - FBC, WBC, GXM abo compatibility for blood
transfusion, C-reactive protein (CRP) for reactive marker - infection cannot do surgery, PT/PTT Clotting ability
Remove dentures, dental clearance for loose tooth
Remove jewellery
Bowel prep – 1-2 days before to prevent surgical site contamination
Mark surgical site by the surgeon
Anesthetist to educate patient about PCA pump - controlled analgesia after operation
Don surgical gown
Ensure NBM status -> last meal and clear fluid decided by anesthetist
Planning
NBM w/ drip
Explain procedure to patient, obtain consent (verbal and written)
Ensure bloods tests are carried out (fbc, gxm, ptptt) and are within baseline
Initiate bowel prep (peg etc), ensure stool is of appropriate consistency and colouration
Intervention (done before the OP)
Abdo CT/MRI: identify stage of tumour
Lab test (elevated tumour markers CEA)
CBC - check anaemia
Colonoscopy with biopsy
Group Cross Match - determines blood type to ensure blood availability/ compatibility
Coagulation profile + Ptptt - ensure proper clotting
Renal, Liver Test - evaluate kidney function
History and physical assessment
Evaluation
Emotional readiness - Level of anxiety and mental stability
Physical Readiness - Confirm stable vital signs, no changes in baselines
Bowel prep readiness - Has the bowel contents been expelled effectively? Laxatives been administered in advance?
Patient education - Drugs, operation and post-op information/instructions given prior. Patient understand the risks of the surgery?
Patient consent taken
**Educate pt of PCA pump BEFORE op
What is the nursing management for a patient with Colorectal Cancer Post-Op?
Assessment
📋Head to toe assessment (ABCDE) → Check for lines. I.e. central line, iv, idc, drainage(stoma)
Airway: chest rise & fall, signs of RD
Breathing:
central perfusion is pink (no cyanosis),
subcostal retractions
breathing sounds: no wheezing/gurgling, equal air entry – Make sure airway is patent!
Circulation:
Vitals: blood pressure, HR,
capillary refill (subjective: depends on use of bear hugger - keeps patient warm during op), good perfusion,
neurovascular ax (assess the extremity where line is inserted i.e. right femoral -> right leg), put on calf compression to keep blood circulating in the legs,
IV Lines: POETS: Patency, no kinks, no dislodgement upon transfer
IDC: ensure output to monitor for renal function/renal perfusion, Stoma circulation: pink, moist (sheen), slight bleeding is fine but not bleeding profusely
Disability:
CLC (pt is still drowsy, 10-11 ok, <8 is a universal sign for intubation [pt cannot maintain airway]),
post-op delirium is common in elderly patients (takes a longer time for kidneys to excrete the medication)
observe effect of GA
ensure they do not put too much pressure on their abdomen, wound drainage to drain irrigation & serous fluid, fresh blood at the start, not in large volumes, should decrease after time, more stale than fresh. Passive and active suction. Inform the doctor when fresh blood is present in large amounts.
NGT (NBM, aspirate gastric juice, decompress the stomach) acid produces air -> pt unable to pass gas -> pressure on wound and lungs -> put ngt on passive drainage. Active aspiration - keep pulling till there’s no more air.
Exposure:
IAPP — do carefully
Auscultate — may hear a lot of gas
Palpation — don’t press too hard
Percussion — may be very tympanic
🧑⚕️Check pt’s med Hx, allergies, meds given at OT/PACU:
✏️Pain assessment (COLDSPA)
🔍Surgical site (check for signs of infection - high fever for a longer duration, pus after pt is discharged)
✅Check vital signs (bp, hr, temp for signs of infection)
🩺Check return of bowel sounds → whether its active → to determine if patient can drink/eat if not can cause aspiration
👁️Monitor for post-op complications: don’t breathe properly in pain - lung collapse (atelectasis) get pt to use spirometry, hemorrhage, urinary retention (unless pt voids within 6-8 hrs of surgery), DVT
🖥️Assess level of consciousness via clc (observe for ams)
Planning
Stoma/colostomy and wound care
🫧Clean wound and change dressing as needed according to type of dressing used
🐦Assist patient in semi-fowler position to minimise tension on the sutures
Breathing exercises — Spirometry
Intervention
🧑⚕️Monitor vitals
💊Administer meds
🔍Regular wound and stoma assessment Q2H
Monitor colour, consistency, amount of output from stoma
Monitor for signs of infection/obstruction(redness, foul-smelling odour)
🏍️Encourage mobilisation as per physio recommendation
🍎Maintain strict I/O charting
👄❌NBM (Nil By Mouth)
Evaluation
💩 Bowel movement returns to normal
😀 Stoma remains pink and healthy
👍 No signs of infection/leakage
💧 No post-op complications(dehydration, obstruction, infection etc)
Infection: discharge, pus, fever, redness, pain
Atelectasis: PT OT for the pt
Normal to see:
bag with gas (flatus)
some secretions
Burping
Discharge: Stoma Care
Teach Patient how to maintain the stoma:
Arrange for Patient Education before discharge at the hospital to teach the patient/ family how to apply the stoma/ wafer.
What activities to avoid for the first few months after stoma creation(swimming/intensive exercise/ baths)
Can shower
Shape of stoma can change 6months - 1year
Teach patient how to assess the health of the Stoma site:
Changes in colour/ size/ pain/ difficulty attaching bag
How to change Stoma bag/water correctly to ensure cleanliness
How to use the measuring tool to check the size of the stoma bag to be used
Help patient to deal with emotions of having a stoma bag
Refer to a Medical Social Worker
Guide on clothing choices if body image/appearance is a concern(ie. Baggy clothing)
If patient is worried about finances of maintaining a stoma, refer to MSW
Tell patient there are different Ostomy Bags that suits their own financial/ lifestyle needs
Ostomy Association of Singapore
Stoma Care Brochure: https://www.ntfgh.com.sg/docs/ntfghlibraries/brochures-document/a-guide-to-stoma-care.pdf?sfvrsn=41065fd5_1
