1. Focus on Colorectal Cancer (Relates to Chapter 43, “Nursing Management: Lower Gastrointestinal Problems,” in the textbook) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

2. 2 Colorectal Cancer Third most common form of cancer Second leading cause of cancer-related deaths 85% of colorectal cancers arise from adenomatous polyps. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

3. 3 Incidence of Cancer Fig. 43-7. Incidence of colorectal cancer. Approximately one half of all colon cancers occur in the rectosigmoid area. Percentages are listed for males (M) and females (F). Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

4. 4 Etiology and Pathophysiology More common in men Risk factors  Family or personal history of colorectal cancer  Increased age  Colorectal polyps  IBD Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

5. 5 Etiology and Pathophysiology Risk factors (cont’d)  Lifestyle factors  Obesity  Smoking  Alcohol  Large amounts of red meat Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

6. 6 Etiology and Pathophysiology Adenocarcinoma is the most common type. Most arise from adenomatous polyps. Tumors spread through the walls of the colon into musculature and into the lymphatic and vascular system. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

7. 7 Cecum and Colon Carcinomas Fig. 43-8. A, Carcinoma of the cecum. The fungating carcinoma projects into the lumen but has not caused obstruction. B, Carcinoma of the descending colon. This circumferential tumor has heaped-up edges and an ulcerated central portion. The arrows identify separate mucosal polyps. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

8. 8 Etiology and Pathophysiology Most common sites of metastasis  Regional lymph nodes  Liver  Lungs  Bones  Brain Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

9. 9 Clinical Manifestations Usually nonspecific, do not appear until advanced Symptoms vary on the basis of location. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

10. 10 Clinical Manifestations Symptoms of left-sided lesions  Rectal bleeding  Alternating constipation, diarrhea  Change in stool caliber  Sensation of incomplete evacuation Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

11. 11 Clinical Manifestations Symptoms of right-sided lesion  Usually asymptomatic  Vague abdominal cramping  Colicky abdominal pain Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

12. 12 Signs and Symptoms by Location Fig. 43-11. Sigmoid colostomy. Distal bowel is oversewn and left in place to create Hartmann’s pouch. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

13. 13 Diagnostic Studies Family history Physical examination Digital rectal examination Colonoscopy Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

14. 14 Diagnostic Studies Colonoscopy  Gold standard  Entire colon is examined.  Biopsies can be obtained.  Polyps can be immediately removed and sent to the laboratory for examination. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

15. 15 Diagnostic Studies Fecal occult blood tests  Cancerous tumors bleed intermittently into the colon.  Used to detect very small quantities of blood  Do not detect nonbleeding tumors Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

16. 16 Diagnostic Studies Stool DNA test  DNA markers are shed from premalignant adenomas, and cancer cells in stool are not degraded.  Stools are collected and analyzed.  Not yet sensitive enough to replace other screening methods Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

17. 17 Diagnostic Studies Colonoscopy and tissue biopsies confirm diagnosis. Additional laboratory studies must be done.  CBC  Coagulation studies  Liver function tests Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

18. 18 Diagnostic Studies Carcinoembryonic antigen (CEA)  Complex glycoprotein  Produced by 90% of colorectal cancers  Helpful in monitoring disease recurrence Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

19. 19 Diagnostic Studies CT scan or MRI  Helpful in detecting  Liver metastases  Retroperitoneal and pelvic disease  Depth of penetration of tumor in bowel wall Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

20. 20 Collaborative Care Prognosis and treatment correlate with pathologic staging of the disease.  TNM system Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

21. 21 Collaborative Care Surgical therapy  Surgery is the only cure.  Polypectomy during colonoscopy is used to resect colorectal cancer in situ.  If cancer is localized, it can be resected with healthy tissue, and cancer-free ends sewn together.  Lymph nodes removed Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

22. 22 Collaborative Care Surgical goals  Complete resection of tumor  Thorough exploration of abdomen  Removal of all lymph nodes that drain the area  Restoration of bowel continuity  Prevention of surgical complications Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

23. 23 Collaborative Care Site of cancer dictates site of resection.  Local excision  Low anterior resection (LAR)  Abdominal perineal resection (APR) ↓ Colonic bacteria to prevent infection and breakdown at site Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

24. 24 Collaborative Care Chemotherapy  Positive lymph nodes at time of surgery  Metastatic disease  Used as an adjuvant following colon resection  As primary treatment for nonresectable colorectal cancer Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

25. 25 Collaborative Care Chemotherapy (cont’d)  5-Fluorouracil (5-FU) plus leucovorin or irinotecan  Capecitabine (Xeloda) or oxaliplatin (Eloxatin) may also be used as first-line therapy. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

26. 26 Collaborative Care Biologic and targeted therapy  Two monoclonal antibodies  Block epidermal growth factor receptor  Cetuximab (Erbitux)  Panitumumab (Vectibex)  Prevents angiogenesis  Bevacizumab (Avastin) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

27. 27 Collaborative Care Radiation therapy  May be used postop as an adjuvant to surgery and chemotherapy, or as palliative therapy for metastasis Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

28. 28 Nursing Management Nursing Assessment Past health history  Previous breast or ovarian cancer  Familial polyposis  Villous adenoma  Adenomatous polyps  Inflammatory bowel disease Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

29. 29 Nursing Management Nursing Assessment Medications Weakness or fatigue Change in bowel habits High-calorie, high-fat, low-fiber diet Increased flatus Feelings of incomplete evacuation Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

30. 30 Nursing Management Nursing Diagnoses Diarrhea or constipation Acute pain Fear Ineffective coping Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

31. 31 Nursing Management Planning Overall goals  Normal bowel elimination patterns  Quality of life appropriate to disease progression  Relief of pain  Feelings of comfort and well-being Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

32. 32 Nursing Management Nursing Implementation Health Promotion  American Cancer Society recommends starting at age 50 with regular screenings.  Screening for high-risk patients should begin before age 50 and should be done at more frequent intervals. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

33. 33 Nursing Management Nursing Implementation Health Promotion  Colonoscopy detects polyps only when the bowel has been adequately prepared.  Ingesting clear liquids for 24 hours before colonoscopy and using an oral preparation required before colonoscopy Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

34. 34 Nursing Management Nursing Implementation Acute Intervention  Preoperative care  Provide information about prognosis and future screening.  Provide support in dealing with diagnosis.  Inform about the extent of the surgical procedure and the amount of care necessary to facilitate healing. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

35. 35 Nursing Management Nursing Implementation  Preoperative care (cont’d)  Emotional support  Taught side-to-side positioning  Teaching on sitz bath positioning Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

36. 36 Nursing Management Nursing Implementation Acute intervention  Postoperative care  Management differs depending on the type of wound.  Type of management is individualized.  If drains are present, remain in place until drainage is less than 50 mL per 24 hours. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

37. 37 Nursing Management Nursing Implementation  Postop care (cont’d)  Drainage must be assessed for amount, color, and consistency.  Wound should be examined regularly.  Record bleeding, excessive drainage, and odor.  Monitor suture line for infection.  Help with pain control.  Provide sexual dysfunction education. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

38. 38 Nursing Management Nursing Implementation Ambulatory and home care  Psychologic support  Chemotherapy  Perineal wound may not be completely healed before discharge.  Must be taught wound management Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

39. 39 Nursing Management Nursing Implementation Evaluation  Expected outcomes  Minimal alteration in bowel elimination patterns  Relief of pain  Balanced nutritional intake Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

40. 40 Nursing Management Nursing Implementation Evaluation  Expected outcomes  Quality of life appropriate to disease progression  Feelings of comfort and well-being Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

41. Case Study 41 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

42. 42 Case Study 65-year-old man is admitted for a colon resection following a diagnosis of colorectal cancer. At time of admission, he complains of changes in constipation, bloody stools, abdominal pain, and weight loss. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

43. 43 Case Study History of coronary artery disease and hypertension Currently taking antihypertensive medication and 81 mg of aspirin daily Currently, he is NPO and has an NG tube. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

44. 44 Discussion Questions 1.What is his priority of care provided before surgery? 2.What interventions can you perform to help alleviate stress? Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

45. 45 Discussion Questions 3.After surgery, what can he expect? 4.What teaching should you do with his family? Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.