Med-Surg: Chapter 58: Colorectal Cancer

Question 1

Colorectal Cancer

Answer 1

-involves cancer of the rectum and large intestine

Question 2

Epidemiology

Answer 2

• third most common form of cancer
• second leading cause of death in the US
• found in distal portion of large intestine
• affects men slightly more
• African Americans
• early detection, one of the most curable of all cancers
• US one of the highest survival rates

Question 3

Risk Factors

Answer 3

• personal or family hx (first degree relative)
• hx of adenomatous polyps
• inflammatory bowel disease (IBD) for 10 years or more
• familial adenomatous polyposis
• hereditary non-polyposis colorectal cancer (HNPCC) or Lynch syndrome
• physical inactivity
• obesity (BMI >30)
• high-fat diets
• consumption of red meat (> 7 servings a week) and processed meats
• cigarette use
• alcohol intake (> four drinks per week)
• inadequate intake of fruits and vegetables
• risk of developing increases with age
• incidence higher in industrialized countries

Question 4

Familial Adenomatous Polyposis (FAP)

Answer 4

is an autosomal dominant disorder

• treatment involves total colectomy
• colonic adenomas appear during childhood

Question 5

Hereditary non-polyposis colorectal cancer (HNPCC) or Lynch’s Syndrome

Answer 5

• autosomal dominant syndrome

- early age onset and predominance of right colon tumors

Question 6

Pathophysiology

Answer 6

most are adenocarcinomas, which are a type of cancer that originates in glandular cells of internal organs

• metastasis can occur by direct extension to adjacent organs, lymphatic system, or the bloodstream
• cost common area of metastasis is to the liver, but can metastasize to lungs, brain, bones, and adrenal glands
• seeding may also occur during resection when the cancer cells break off from the tumor into the peritoneal cavity

Question 7

Clinical Manifestations

Answer 7

-in early stages symptoms are insidious and may be ignored until the disorder is advanced
-vary according to where the cancer is located in the intestine
-unexplained weight loss and fatigue may be the first signs for any location
>other: change in bowel regularity and/or the appearance of stool, blood in the stool (red or black depending on location); abdominal pain and/or distention, and a sensation of pressure as with incomplete evacuation after a bowel movement, along with clinical manifestations of anemia

Question 8

Specific to the area in which the primary tumor is located, clinical manifestations include

Answer 8

> Ascending colon:

• vague abdominal pain and/or cramping
• change in bowel habits
• anemia
• fatigue

> Transverse Colon:

• pain
• clinical manifestations of obstruction
• change in bowel habits
• anemia
• fatigue

> Descending colon:

• pain
• change in bowel habits
• bright red blood in stool
• clinical manifestations of intestinal obstruction

> Rectum:

• blood in stool
• change in bowel habits
• rectal discomfort
• feeling of incomplete evacuation

Question 9

Diagnostic Studies

Answer 9

• Fetal Occult blood test (FOBT)/ Fecal immunochemical test (FIT)
• Digital rectal Exam (DRE)
• Lower GI series
• Double-Contrast Barium Enema
• Sigmoidoscopy
• Colonoscopy
• Virtual Colonoscopy
• Fecal DNA testing
• Wireless Capsule Endoscopy
• abdominal x-ray
• CBC (may demonstrate anemia due to blood loss and elevated WBC secondary to inflammation or infection)

Question 10

Fecal Occult Blood Test (FOBT)

Answer 10

or fecal immunochemical test (FIT)

-stool sample is collected and placed on a special slide and tested for hidden blood

Question 11

Lower GI series

Answer 11

a tube is inserted into the rectum, and the large intestine is filled with barium

• asked to change positions several times in order to evenly distribute the barium
• x-ray pictures and/or video are taken
• the barium is constipating, so care should be taken to advise the patient to take appropriate measures to prevent constipation

Question 12

Double-Contrast Barium Enema

Answer 12

takes place after the patient has expelled most of the barium from the intestine

• the remaining barium clings to the intestinal wall
• the intestine is then inflated with air, and additional x-ray images are taken

Question 13

Sigmoidoscopy

Answer 13

a flexible tube with a light and a camera at the end is inserted into the rectum and colon up to the transverse colon

• the camera transmits images to a computer screen
• biopsies can be taken from the rectum and sigmoid colon

Question 14

Colonoscopy

Answer 14

a long, flexible tube with a light and camera on the end is inserted into the full length of the colon

• ability to view the entire colon as well as to remove polyps and take biopsies
• patient receives sedation for procedure

Question 15

Virtual Colonoscopy

Answer 15

performed in the CT scanning department or MRI

• a tube is inserted into the rectum
• For CT, carbon dioxide is administered to enlarge the colon for better viewing
• For MRI, a contrast medium is given through the rectum to expand the large intestine
• cross-sectional images are produced and processed to create three-dimensional, computer-generated images of the large intestine
• sedation not required

Question 16

Fecal DNA Testing

Answer 16

colorectal cancers contain abnormal DNA that is shed in the stool
-if this test is positive, it should be followed with a colonoscopy

Question 17

Wireless Capsule Endoscopy

Answer 17

“Pill camera”

• size of a vitamin
• patient swallows the pill with the camera within the pill, and the camera captures video throughout the GI tract
• takes 8 hours to pass through the GI tract while images are recorded on a portable device
• images are transferred from the portable device to a computer

Question 18

Diagnostic Gold Standards

Answer 18

Colonoscopy

Question 19

Diagnosis: Colonoscopy

Answer 19

gold standard

• biopsies can be taken
• polyps can be removed
• expensive
• invasive

Question 20

Serum Carcinoembryonic antigen (CEA)

Answer 20

elevated CEA indicates overexpression of an oncofetal glycoprotein that is normally present by mucosal cells

Question 21

What would a CBC show

Answer 21

• anemia due to blood loss

- elevated WBC secondary to inflammation or infection

Question 22

What would a CT, MRI, or abdominal x-rays provide?

Answer 22

information about abdominal obstruction

Question 23

Treatment

Answer 23

• chemotherapy

- radiation

Question 24

Chemotherapy

Answer 24

• used as an adjuvant for patients whose tumors cannot be completely removed
• for stage II or III
• chemotherapy interrupts the DNA production of cells; cannot distinguish between healthy cells and cancer cells
• intra-arterial chemotherapy may be given into the liver if metastasis has occurred
• side effects: diarrhea, mucositis, leukopenia, mouth ulcers, alopecia, and peripheral neuropathies

Question 25

Radiation Therapy

Answer 25

• can be used preoperatively to reduce the size of the tumor, making it easier to remove all or most of the tumor
• used as a palliative measure to control pain, hemorrhage, bowel obstruction, or metastasis to the lung in advanced disease
• used pre-operatively, intraoperatively, or post-operatively

Question 26

Screening Recommendations for Colorectal Cancers

Answer 26

People with Average Risk:
>Age 45-75
-high-sensitivity fecal occult blood test (FOBT) annually
-highly sensitive guaiac-based fecal occult blood test (gFOBT) every year
-multi-targeted stool DNA test (MT-sDNA) every 3 years
-flexible sigmoidoscopy (FSIG) every 5 years
-virtual colonoscopy every 5 years
-colonoscopy every 10 years

> Age 76-85

• do not screen routinely
• decision based on overall health and prior screening hx

> Age older than 85

• do not screen
• people with risk factors such as inflammatory bowel disease (IBD), familial adenomatous polyposis (FAP), and Lynch’s syndrome should follow their providers recommendations

> People at increased or high risk

• might begin before age 45 and be screened more often
• strong family hx of colorectal cancer or certain types of polyps
• personal hx of colorectal cancer or certain types of polyps
• hx of inflammatory bowel disease
• family hx of hereditary colorectal cancer
• personal hx of radiation to the abdomen or pelvic area to treat a prior cancer

Question 27

Surgical management

Answer 27

surgery to remove the affected portion of the colon
-adjacent lymph nodes also removed
-depending on location, temporary or permanent colostomy may be performed
-often a temporary colostomy is performed, and at a later time after healing has taken place, an anastomosis (attachment of one end to the other) is performed to reconnect the colon to the rectum to allow for normal defecation
>Colectomy
>Hemicolectomy
>Abdominoperineal resection

Question 28

Colectomy

Answer 28

excision of part of or all of the colon

Question 29

Hemicolectomy

Answer 29

excision of half or less of the colon (may be right or left)

Question 30

Abdominoperineal Resection

Answer 30

the affected colon and affected rectum are removed, and the anus is closed

• the colon is removed through an abdominal incision, and the rectum is removed through a perineal incision
• the ileostomy is permanent

Question 31

Complications of Chemotherapy

Answer 31

• fatigue
• increased risk of infection
• anemia

Question 32

Complications of Radiation

Answer 32

radiation enteritis may develop and lead to diarrhea, blood in the stool, and weight loss

Question 33

Post Operative Complications

Answer 33

• blood loss
• anastomoses
• infection
• incisional dehiscence

Question 34

Pre-operative Patient: Assessment and Analysis

Answer 34

• assess current knowledge of the disease and treatment
• understanding of the location, type, severity, and classification of the cancer is key to providing holistic care
• clinical presentation is associated with the location of the tumor, and includes unexplained weight loss, fatigue, blood in the stool, and clinical manifestations of anemia

Question 35

Pre-operative Patient: Nursing Diagnoses

Answer 35

• knowledge deficit r/t surgery for colorectal cancer

- fear r/t the potential outcome for surgery for colorectal cancer

Question 36

Preoperative Patient: Nursing Assessment

Answer 36

> Vital Signs
-measure physiological function and provide baseline for after surgery

> Serum Electrolytes and CBC

• serum electrolytes are within normal limits prior to surgery
• CBC provides baseline data about hemoglobin and hematocrit; and WBC that may be elevated due to inflammation or infection

> Current knowledge of disease and pre/postoperative care

• reinforce any teachings given by the surgeon, such as the incision and any drains that may be present after surgery
• knowledge of what to expect postoperatively helps to alleviate concerns and fears associated with the surgery

Question 37

Postoperative Patient: Nursing Actions

Answer 37

> Bowel Prep (if ordered)

• will likely receive a “bowel prep” prior to surgery to minimize bacterial growth and prevent contamination with feces during surgery
• most common prep: polyethylene glycol solution (e.g. GoLYTELY)
• an antibiotic may also be given prior to the incision, also to reduce the risk of infection

> Establish a therapeutic relationship
-enhances the trust of the patient and decreases anxiety and fears

> Ensure the surgical consent form is signed and witnessed

• legal requirement for all invasive procedures
• must be signed prior to the patient receiving any sedative, hypnotic, narcotic, or anesthetic agent

Question 38

Preoperative Patient: Teaching

Answer 38

> Preoperative teaching r/t ostomy care

• more likely the patient will be compliant with the treatment regimen, and have less anxiety and fear on what to expect
• if has adequate teaching r/t ostomy care, the patient demonstrates better adjustment postoperatively
• if the patient is expected to have an ostomy performed during surgery, a preoperative consultation is necessary with the wound ostomy continence nurse (WOCN)

> Pain

• teach about methods of pain management postop, such as patient-controlled anesthesia (PCA), epidural anesthesia with the progression to oral pain medication
• knowledge that the pain will be managed post-op will decrease anxiety and fears

Question 39

Postoperative Patient: Assessment and Analysis

Answer 39

• vital signs measure physiological functions and should be within the range of preoperative levels
• after anesthesia, note ability to arouse and orientation to surroundings; change in LOC is often first sign of other complications
• patient is better able to participate in activities to prevent postoperative complications if pain is treated
• postoperatively, pain in the surgical area is expected
• the bowel sounds will be severely diminished or absent, which is expected due to surgical manipulation
• The CBC may demonstrate mild anemia, and the WBC elevated due to inflammation, and is monitored for infection
• assessment of stoma

Question 40

Postoperative Patient: Nursing Diagnoses

Answer 40

• acute pain associated with the surgical incision
• potential for infection associated with interruption of primary defenses (skin) and indwelling tubes and drains
• risk for imbalanced fluid volume associated with the response to abdominal surgery
• knowledge deficit associated with postoperative care
• disturbed body image associated with ostomy

Question 41

Postoperative Patient: Nursing Assessments

Answer 41

> Vitals signs at least every 4 hours

• a mild elevation in temperature may be expected in the first 48 hours b/c of inflammatory response to surgery
• a marked elevation in the first 48 hours is usually related to atelectasis
• after the first 48 hours, the patient should continue to be assessed for infection
• elevations in heart rate and decreased in blood pressure are indicative of decreased fluid volume status

> Hemoglobin and Hematocrit
-monitor daily b/c is may indicate bleeding and/or nutritional deficits

> WBC

• monitored every day for the first few days
• a mild elevation can be expected in the first 48 hours b/c on inflammatory response
• later, an elevation may indicate infection or other complications

> Nausea and Vomiting

• anesthesia and manipulation of the bowel decrease peristalsis, and bowel sounds may be absent for 1 to 3 days after surgery
• patient will not have anything to eat or drink after surgery (NPO), with IV fluids and electrolyte replacements given as needed
• patient may have an NG tube for stomach decompression postoperatively, must be frequently assessed for patency; NG tube remains in place until bowel function returns; then begins with a clear liquid diet, advancing the diet as tolerated

> Intake and Output

• fluid losses from surgery result in decreased renal perfusion, leading to fluid retention
• the lower output is caused by increased aldosterone and antidiuretic hormone secretion because of the surgery and associated stress associated
• should maintain 30 mL/hr of urine output
• patient may have an indwelling urinary (Foley) catheter in place after surgery, with standards measures taken to prevent UTI
• low urine output compared with intake in the first 24 ours is normal as long as 30 mL/hr is maintained
• by the third postoperative day, urine output normalizes

> Stoma (opening of the ostomy)

• determines the health of the stoma
• should be reddish pink and moist
• may be some edema initially; subsides in a few days
• may be slight bleeding or serosanguineous drainage
• any discolorations could be a sign of necrosis and be reported

> Ostomy Drainage

• type, amount, appearance, and consistency of drainage will differ as to where the ostomy is placed
• the closer to the small intestine, the more liquid the stool
• for the patient with an ileostomy, it is important to monitor fluid and electrolyte balance due to potential loss of potassium

> Abdominal/perineal dressing/incision
-incisions and dressings should not have excessive drainage b/c this could indicate complications (bleeding)

> Pain
-pain management necessary for the patient to return to an optimal level of functioning and to prevent postoperative complications

Question 42

Common Locations of Stomas

Answer 42

• Ileostomy (liquid to semi liquid stool)
• Ascending colostomy (semiliquid stool)
• Transverse Colostomy (semiliquid to semiformed stool)
• Descending Colostomy (semiformed stool)
• Sigmoid Colostomy (formed stool)

Question 43

Postoperative Patient: Nursing Actions

Answer 43

> Administer IV fluids
-Iv fluids maintained postoperatively to replace fluid losses in surgery and to assist in maintaining proper fluid balance

> Maintain NPO/ Advance diet as tolerated

• prevention of nausea and vomiting until bowel function returns
• return of bowel sounds is required prior to advancing the diet to minimize nausea and vomiting

> Nasogastric Tube Care

• for stomach decompression
• output
• NG tube that allows for gastric decompression remain in place until bowel function returns, preventing nausea and vomiting from occurring
• ensure consistent drainage, as lack of output from the drain may = obstruction
• without adequate decompression and drainage, there may be pressure on the surgical site

> Implement Pain management strategies

• adequate pain management is important in postoperative period
• may have a PCA pump or epidural analgesia for the first few days postop
• if pain is adequately controlled, patient will return to an optimal level of activity sooner and prevent postoperative complication

> Drain management

• drains prevents fluid accumulation near the site of surgery
• may be drains placed within the perineal and/or abdominal incision such as a Penrose drain, JAckson-pratt, or Hemovac
• notes appearance and amount of drainage frequently, and drainage usually serosanguineous
• drains monitored for decreasing amount of drainage an are usually left in place 3 to 5 days
• make note of amount, color, and odor

> Turning, coughing, deep breathing, and incentive spirometer 10 times every hour while awake
-promotes lung expansion, prevents atelectasis, and helps mobilize secretions to be expectorated

> Implement early ambulation

• promotes circulation and prevention of postoperative complications such as a venous thromboembolism (VTE)
• may also be receiving anticoagulation therapy with heparin or Lovenox for VTE prophylaxis

> Perianal Care

• for pt who has undergone abdominoperineal resection, note that the perineal incision is much more sensitive and a greater source of pain than the abdominal incision
• often complains of phantom rectal sensation due to the fact that sympathetic nerves responsible for rectal control are not severed during surgery
• area should be inspected frequently for drainage and abscess (localized collection of pus) formation
• sitz baths may be ordered for comfort and gentle cleansing

> Make appropriate referrals

• social worker/case manager
• home health agency
• ostomy support group

Question 44

Teaching

Answer 44

> methods to prevent postoperative complications

>ostomy teaching: assist the WOCN with ongoing teaching r/t care of the ostomy

Question 45

Evaluating Care Outcomes

Answer 45

at discharge the patient demonstrates stable vital signs, adequate hematocrit and hemoglobin, no signs of infection, positive bowel sounds, ability to care for surgical incision site, and ostomy (if required), and pain management strategies
-requires follow-up care for return of normal bowel function, and adaptation to the diagnosis and treatment

Question 46

Colon Cancer: Risk Factors, S/S, Metastasis

Answer 46

> Risk Factors:

• alcohol, excessive
• beer consumption
• intestinal polyps, polyposis
• obesity, high-fat diet
• chronic bowel disease- Crohn’s or Ulcerative Colitis

> S/S:

• altered bowel habit- constipation or diarrhea; thin, ribbon-like stools
• blood in stool –overt or occult
• abdominal distention
• anorexia
• weight loss
• unexplained anemia

> Metastasis:
-liver, lung, or muscle