Of cancers of the colon, 65% occur in the rectum and in the sigmoid and descending colon, 25% occur in the cecum and ascending colon, and 10% occur in the transverse colon. Most colorectal tumors (95%) are adenocarcinomas and develop from an adenomatous polyp. Once malignant transformation within the polyp has occurred, the tumor usually grows into the lumen of the bowel, causing obstruction, and invades the deeper layers of the bowel wall. After penetrating the serosa and the mesenteric fat, the tumor may spread by direct extension to nearby organs and the omentum. Metastatic spread through the lymphatic and circulatory systems occurs most frequently to the liver, as well as the lung, bones, and brain.
The cause of colorectal cancer is largely unknown; however, there is much evidence to suggest that incidence increases with age. Risk factors include a family history of colorectal cancer and a personal history of past colorectal cancer, ulcerative colitis, Crohn’s disease, or adenomatous colon polyps. Persons with familial polyposis coli, an inherited disease that is characterized by multiple (100) adenomatous polyps, possess a risk for colorectal cancer that approaches 100% by age 40. Other risk factors include obesity, diabetes mellitus, alcohol usage, night shift work, and physical inactivity. It has been strongly suggested that diets high in fat and refined carbohydrates play a role in the development of colorectal cancer. High-fat content results in increased amounts of fecal bile acid. It is hypothesized that intestinal bacteria react with the bile salts and facilitate carcinogenic changes. In addition, fat and refined carbohydrates decrease the transit of food through the gastrointestinal (GI) tract and increase the exposure of the GI mucosa to carcinogenic substances that may be present. Recent research indicates that aspirin, cytochrome C oxidase (COX)-2 selective nonsteroidal anti-inflammatory drugs (NSAIDs), folate, calcium, and estrogen replacement therapy have a potential chemoprotective effect and may prevent colorectal cancer.
Nursing care plan assessment and physical examination
Seek information about the patient’s usual dietary intake, family history, and the presence of the other major risk factors for colorectal cancer. A change in bowel pattern (diarrhea or constipation) and the presence of blood in the stool are early symptoms and might cause the patient to seek medical attention. Patients may report that the urge to have a bowel movement does not go away with defecation. Cramping, weakness, and fatigue are also reported. As the tumor progresses, symptoms develop that are related to the location of the tumor within the colon. When the tumor is in the right colon, the patient may complain of vague cramping or aching abdominal pain and report symptoms of anorexia, nausea, vomiting, weight loss, and tarrycolored stools. A partial or complete bowel obstruction is often the first manifestation of a tumor in the transverse colon. Tumors in the left colon can cause a feeling of fullness or cramping, constipation or altered bowel habits, acute abdominal pain, bowel obstruction, and bright red bloody stools. In addition, rectal tumors can cause stools to be decreased in caliber, or “pencil-like.” Depending on the tumor size, rectal fullness and a dull, aching perineal or sacral pain may be reported; however, pain is often a late symptom.
Inspect, auscultate, and palpate the abdomen. Note the presence of any distension, ascites, visible masses, or enlarged veins (a late sign due to portal hypertension and metastatic liver involvement). Bowel sounds may be high-pitched, decreased, or absent in the presence of a bowel obstruction. An abdominal mass may be palpated when tumors of the ascending, transverse, and descending colon have become large. Note the size, location, shape, and tenderness related to any identified mass. Percuss the abdomen to determine the presence of liver enlargement and pain. A rectal tumor can be easily palpated as the physician performs a digital rectal exam.
Individuals who observe healthy lifestyles may feel anger when the diagnosis is made. Treatment for colorectal cancer can result in a colostomy and impotence in men. Many persons have grave concerns about the possibility of these consequences. Assess the patient and his or her significant others’ knowledge and feelings related to these issues.
Nursing care plan primary nursing diagnosis: Pain related to tissue injury from tumor invasion and the surgical incision.
Nursing care plan intervention and treatment
Although treatment depends on individual patient characteristics, the location of the tumor, and the stage of disease at the time of diagnosis, surgery has been the primary treatment for colorectal cancers. Adjuvant chemotherapy and radiation therapy may be used to improve survival or control symptoms. The exact surgical procedure performed depends on the location of the tumor in the colon and the amount of tissue involved.
All patients who are undergoing bowel surgery require careful preoperative care in order to minimize the possibility of infection and promote the adjustment to bodily changes. If nutritional deficits are present, a low-residue diet high in calories, carbohydrates, and protein is given until serum electrolytes and protein levels return to normal. Total parenteral nutrition may be ordered. Twenty-four hours before the scheduled surgery, the physician usually orders a “bowel prep,” which consists of a clear liquid diet, a regimen of cathartics and cleansing enema, and oral and intravenous antibiotics to minimize bacterial contamination during surgery.
Postoperatively, direct nursing care toward providing comfort, preventing complications from major abdominal surgery, and promoting the return of bowel function. Monitor vital signs and drainage from wounds and drains for signs of hemorrhage and infection. A nasogastric (NG) tube connected to low intermittent or continuous suction is usually present for gastric decompression until bowel sounds return. Note the amount and color of the gastric drainage, as well as the presence of abdominal distension.
Patients who require a colostomy return from surgery with an ostomy pouch system in place, as well as a large abdominal dressing. Observe the condition of the stoma every 4 hours. A healthy stoma is beefy red and moist, whereas a dusky appearance could indicate stomal necrosis. A small amount of stomal bleeding is common, but any substantial bleeding should be reported to the surgeon. The colostomy usually begins to function 2 to 4 days after surgery. After surgery, adjuvant radiation therapy to the abdomen or pelvis is used when there is high risk for local recurrence. Adjuvant chemotherapy (5-fluorouracil plus leucovorin) is used when there is high risk or evidence of metastatic disease. Radiation therapy and chemotherapy may be used as palliative measures to reduce pain, bleeding, or bowel obstruction in patients with advanced and metastatic disease.
Encourage the patient to verbalize fears and clarify the physician’s explanation of diagnostic results. Dispel any misconceptions about the need for a permanent colostomy, and clarify the purpose of a temporary colostomy, if suggested.
If a colostomy is to be performed, encourage the patient and her or his significant other to verbalize concerns about sexual functioning after surgery. Impotence is only a problem after abdominal perineal resection (APR) in men, but the presence of a stoma and a drainage pouch with fecal effluent can affect self-identity and sexual desires in both men and women.
After surgery, discuss methods to decrease the impact of the ostomy during intimate times. After surgery, help the patient avoid complications associated with bowel surgery. Assist the patient toturn in bed and perform coughing, deep-breathing, and leg exercises every 2 hours to prevent skin breakdown, as well as to avoid pulmonary and vascular stasis. Teach the patient to splint the abdominal incision with a pillow to minimize pain when turning or performing coughing and deep-breathing exercises. The patient who has had an APR may find the side-lying position in bed the most comfortable. Provide a soft or “waffle” pillow (not a rubber doughnut) for use in the sitting position. Change the perineal dressing frequently to prevent irritation to the surrounding skin.
Showing the patient pictures of an actual stoma can help reduce the “shock” of seeing the stoma for the first time. Allow him or her to hold the equipment, observe the amount and characteristics of effluent, and empty the ostomy pouch of contents or gas. Take care when emptying or changing the pouch system not to contaminate the abdominal incision with effluent. Teaching the patient about home care of an ostomy can begin on the second or third postoperative day. Have the patient and a family member demonstrate ostomy care correctly before hospital discharge. Be alert to signs that indicate the need for counseling, and suggest a referral if the patient is not adjusting well.
Nursing care plan discharge and home health care guidelines.
Teach the patient the care related to the abdominal incision and any perineal wounds. Give instructions about when to notify the physician (if the wound separates or if any redness, bleeding, purulent drainage, unusual odor, or excessive pain is present). Advise the patient not to perform any heavy lifting (10 lbs), pushing, or pulling for 6 weeks after surgery. If the patient has a perineal incision, instruct her or him not to sit for long periods of time and to use a soft or “waffle” pillow rather than a rubber ring whenever in the sitting position. Teach the patient colostomy care and colostomy irrigation. Give the following instructions for care of skin in the external radiation field: Tell the patient to wash the skin gently with mild soap, rinse with warm water, and pat the skin dry each day; not to wash off the dark ink marking that outlines the radiation field; to avoid applying any lotions, perfumes, deodorants, and powder to the treatment area; to wear nonrestrictive soft cotton clothing directly over the treatment area; and to protect skin from sunlight and extreme cold. Explain the purpose, action, dosage, and side effects of all medications prescribed by the physician.
Stress the need to maintain a schedule for follow-up visits recommended by the physician. Encourage patients with early-stage disease and complete healing of the bowel to eat a diet consisting of a low-fat and high-fiber content with cruciferous vegetables (Brussels sprouts, cauliflower, broccoli, cabbage). Most colorectal tumors grow undetected as symptoms slowly develop. Survival rates are best when the disease is discovered in the early stages and when the patient is asymptomatic. Unfortunately, 50% of patients have positive lymph node involvement at the time of diagnosis. Participation in procedures for the early detection of colorectal cancer needs to be encouraged. Suggest follow-up involvement with community resources such as the United Ostomy Association and the American Cancer Society.