INTERFERENCES TO ELIMINATION NEEDS Cancer of the Colon Fecal Diversions Urinary Diversions 2009

CANCER OF THE COLON  95% Adenocarcinoma  Age: over 50 years  Family history: 1 st degree relative  Have history of chronic inflammatory bowel disease or polyps  NO KNOWN CAUSE: 75% OF CASES  Risk factors: diet high in fat, protein, beef, and low in fiber

SYMPTOMS  RIGHT SIDED LESIONS :  Tumors can grow without disrupting bowel patterns  Dull abdominal pain  Melena (black tarry stools)

SYMPTOMS  LEFT SIDED LESIONS  (transverse & descending colon)  Obstruction  Abdominal pain  Cramping  Constipation  Distention  Bright red blood in stool

SYMPTOMS RECTAL LESIONS  Tenesmus (ineffective painful straining at stool)  Rectal pain  Feeling of incomplete evacuation after a bowel movement  Alternating constipation and diarrhea  Hematochezia: passage of red blood via the rectum

METASTASIS  Lymph nodes  Liver by way of the bloodstream  ALSO: –Lungs –Brain –Bones –Adrenal glands  Peritoneal seeding during surgery

DIAGNOSTIC LABORTORY TESTS  Fecal occult blood test (FOBT): indicates bleeding in the GI tract  False positive: foods, vitamins, drugs for 48 hours before test –AVOID : meat, horseradish, beets –AVOID: vitamin C, ASA, ibuprofen, corticosteroids, salicylates  Two stool samples tested on 3 consecutive days  NEGATIVE RESULTS DO NOT R/O COLON CANCER

DIAGNOSTIC LABORATORY TESTS  Alkaline Phosphatase and SGOT to look for metastasis to the liver  Carcinoembryonic antigen (CEA level); elevations indicate advanced adenocarcinoma; –See this elevated in 70% of people –levels drop after removal of tumor; elevation at a later date indicate recurrence

DIAGNOSTIC EVALUATION DONE IN THE FOLLOWING ORDER  Rectal Exam (50% of tumors palpable on digital exam)  Abdominal Exam  Barium Enema (see polyps and small lesions)  Sigmoidoscopy: (see lower colon, can do biopsy)  ***Colonoscopy: DEFINITIVE DX TEST  CT scan confirms a masses and extent of disease

TREATMENT Surgical Intervention:  colon resection (removal tumor & lymph nodes with reanastomosis)  Colectomy (colon removal)  Abdominal-perineal resection (removal of anus and rectum with a permanent colostomy  Could have laparoscopic surgery Radiation/Chemotherapy

TYPES OF COLOSTOMIES  Ascending colostomy: done for right sided tumors  Transverse double barreled colostomy: can be done quickly for emergency intestinal obstruction; –2 stomas –proximal closest to small intestine drains feces –the distal one drains mucous

TYPES OF COLOSTOMIES Descending colostomy:  Done for left sided tumors Sigmoid colostomy:  Done for rectal tumors

COLOSTOMY  Colostomies done on less than 1/3 of patients with colorectal cancer  DEFINED: surgical creation of an opening (stoma) into the colon  Temporary or permanent  Drains the colon contents outside the body  Consistency related to location in body

PREOP NURSING CARE  Adequate elimination of wastes  Reduce pain  Maintain fluid and electrolytes  Maintain adequate nutrition  Reduce anxiety  Review concerns about colostomy

BOWEL PREP  GOAL: to minimize bacterial growth and prevent complications  HOW: –1-2 days clear liquids –Laxatives –Enemas –Ingests GoLYTELY: clears feces from colon –Oral or IV antibiotics day before surgery

POSTOP NURSING CARE  Maintain NGT to low suction hrs (none for lap colon resection) –NPO, IV fluids, I & O  Maintain PCA  Ambulate  TEDS/ Sequential stockings  SQ Heparin  Progress diet liquids to solids as tolerated

POSTOP NURSING CARE  Observe abdominal wound for infection, dehiscence, hemorrhage, edema  Splint abdominal incision during C & DB  Observe perineal wound for bleeding, infection, necrosis  Teach colostomy care

POSTOP NURSING CARE CONTINUED  Teach high fiber, high roughage diet  Teach to avoid foods that cause excessive odor and gas (broccoli, brussel sprouts, cauliflower, cucumbers, mushrooms, peas, cabbage, eggs, fish, beans, garlic, turnips, fish, peanuts, chewing gum, smoking, beer, skipping meals)  Teach foods that avoid odors: buttermilk, cranberry juice, parsley, yogurt. –Charcoal filters, pouch deodorizers, breath mint in pouch  Teach to avoid foods that cause diarrhea (fruits, soda, coffee, tea, carbonated beverages)

POSTOP COLOSTOMY MANAGEMENT  from OR with ostomy pouch in place  or petrolatum gauze over stoma covered by dry sterile dressing; pouch later Assess color and integrity stoma:  moist, reddish pink, protrude from abdominal wall 3/4 inch, small amt of bleeding at stoma common  Assess peristomal skin (no excoriation)

POSTOP COLOSTOMY CARE CALL MD FOR:  Signs of ischemia/necrosis: dark red, purplish, black color, dry, firm, flaccid  Unusual bleeding  Separation of stoma from wall

WOUNDS For AP resection: perineal wound has JP drains  Serosanguineous drainage seen 1-2 mo  Healing takes 6-8 mo  Phantom rectal sensations common  Rectal pain/itching common: benzocaine, sitz baths

POSTOP COLOSTOMY CARE  Starts working 2-4 days postop  May see lots of gas initially  Stool initially liquid then becomes normal based on location –Ascending colon: liquid –Transverse colon: pasty –Descending colon: solid  Stoma shrinks 6-8 wks after surgery: measure once week  Wafer opening 1/8-1/16 inch larger than stoma pattern to prevent constriction

COLOSTOMY CARE  When washing skin around stoma avoid moisturizing soaps; interferes with adhesion of appliance  Skin prep applied before putting on appliance to protect skin  Change bag if there is leakage  Sigmoid colostomy: irrigation regulates elimination, but can be through diet

COMPLICATIONS OF COLOSTOMY  Prolapse of the stoma (due to obesity)  Perforation (due to improper stoma irrigation)  Stoma retraction  Fecal impaction  Skin irritation  Pulmonary complications

ILEOSTOMY  DEFINED: surgical creation of an opening into the ileum or small intestines usually by means of an ileal stoma on the abdominal wall  Permanent or Temporary  Allows for drainage of fecal matter (effluent) from the ileum to the outside of the body  Drainage is liquid and occurs at frequent intervals

PREOPERATIVE NURSING  Intensive fluids, blood and protein replacement  Antibiotics  Low residue diet  Abdomen marked for proper placement of stoma by surgeon or enterostomal therapist usually in the RLQ 2 inches below the waist crease away from skin folds  Teaching about ileostomy

POSTOPERATIVE NURSING  Observe stoma: pink to bright red and shiny  Fecal drainage begins 72 hours after surgery and is continuous draining into an ileostomy bag  Strict I&O of urinary and fecal output  Maintain IV fluids; watch for electrolyte losses (Na and K)  NGT initially  After NGT removal, sips of clear liquids with progression to low residue diet  Early ambulation

ILEAL CONDUIT URINARY DIVERSION (ILEAL LOOP)  Oldest of the urinary diversion procedures  A portion of the ileum becomes a conduit  Urine is diverted by implanting the ureter into a loop of ileum that is led out through the abdominal wall  Done when bladder has to be removed for cancer of the bladder

CONTINENT ILEAL URINARY RESERVOIR (KOCK POUCH)  Transplanting the ureters to an isolated segment of ileum (pouch) with a nipple like one way valve  Urine is drained by a catheter

URETEROSIGMOIDOSTOMY  Ureters are surgically implanted into the sigmoid colon allowing urine to flow through the colon out of the rectum

CUTANEOUS URETEROSTOMY  Bringing detached ureter through abdominal wall  Attaching ureter to an opening in the skin