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Focus on Colorectal Cancer
(Relates to Chapter 43, “Nursing Management: Lower Gastrointestinal Problems,” in the textbook)
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Colorectal Cancer Third most common form of cancer
Second leading cause of cancer-related deaths 85% of colorectal cancers arise from adenomatous polyps
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Colorectal Cancer Etiology and Pathophysiology
More common in men Risk factors Family or personal history of colorectal cancer Increased age Colorectal polyps
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Colorectal Cancer Etiology and Pathophysiology
Risk factors (cont’d) Inflammatory bowel disease (IBD) Lifestyle factors Obesity Smoking Alcohol Large amounts of red meat
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Colorectal Cancer Etiology and Pathophysiology
Adenocarcinoma is most common type Most arise from adenomatous polyps Tumors spread through the walls of the intestine into musculature into the lymphatic and vascular system
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Colorectal Cancer Etiology and Pathophysiology
Most common sites of metastasis Regional lymph nodes Liver Lungs Peritoneum
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Incidence of Colorectal Cancer
Fig. 43-8
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Cancer of the Cecum Fig. 43-9
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Colorectal Cancer Clinical Manifestations
Usually nonspecific, do not appear until advanced Symptoms include Hematochezia Passage of blood through rectum Melena Black, tarry stools
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Colorectal Cancer Clinical Manifestations
Symptoms (cont’d) Abdominal pain Changes in bowel habits Weakness
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Colorectal Cancer Clinical Manifestations
Symptoms (cont’d) Anemia Weight loss Rectal bleeding Most common symptom Most often with left-sided lesions
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Colorectal Cancer Clinical Manifestations
Cancer on the right side Different symptoms from those on the left side of the colon
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Colorectal Cancer Clinical Manifestations
Fig
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Colorectal Cancer Clinical Manifestations
Left-sided lesions Rectal bleeding Alternating constipation and diarrhea Narrow, ribbonlike stools Sensation of incomplete evacuation
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Colorectal Cancer Clinical Manifestations
Right-sided lesions Usually asymptomatic Vague abdominal discomfort Colicky abdominal pain Iron-deficiency anemia Occult bleeding
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Colorectal Cancer Diagnostic Studies
Family history Physical examination Digital rectal examination Colonoscopy
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Colorectal Cancer Diagnostic Studies
Colonoscopy Gold standard Entire colon is examined Biopsies can be obtained Polyps can be immediately removed and sent to laboratory for examination
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Colorectal Cancer Diagnostic Studies
Fecal occult blood tests Cancerous tumors bleed intermittently into colon Used to detect very small quantities of blood Does not detect nonbleeding tumors
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Colorectal Cancer Diagnostic Studies
Fecal occult blood tests (cont’d) Guaiac-based tests (FOBT) Avoid NSAIDs, vitamin C, citrus juices, red meat for 3 days before test Six samples from three consecutive bowel movements Fecal immunochemical test (FIT) No special restrictions Two stool specimens
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Colorectal Cancer Diagnostic Studies
Stool DNA test DNA markers are shed from premalignant adenomas and cancer cells in stool and not degraded Stools collected and analyzed Not yet sensitive enough to replace other screening methods
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Colorectal Cancer Diagnostic Studies
Colonoscopy and tissue biopsies confirm diagnosis Additional laboratory studies must be done CBC Coagulation studies Liver function tests
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Colorectal Cancer Diagnostic Studies
Carcinoembryonic antigen (CEA) Complex glycoprotein Produced by 90% of colorectal cancers Helpful in monitoring disease recurrence
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Colorectal Cancer Diagnostic Studies
CT scan or MRI Helpful in detecting Liver metastases Retroperitoneal and pelvic disease Depth of penetration of tumor in bowel wall
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Colorectal Cancer Collaborative Care
Prognosis and treatment correlate with pathologic staging of the disease Duke’s classification TNM system Preferred classification system
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Colorectal Cancer Collaborative Care
Surgical therapy Polypectomy during colonoscopy used to resect colorectal cancer in situ If cancer is localized, can be resected with healthy tissue and cancer-free ends sewn together Lymph nodes removed
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Colorectal Cancer Collaborative Care
Chemotherapy and radiation therapy If cancer has spread to lymph nodes or nearby tissue Once cancer has spread to distant sites, surgery is palliative
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Colorectal Cancer Collaborative Care
Surgical goals Complete resection of tumor Site of cancer dictates site of resection Thorough exploration of abdomen Removal of all lymph nodes that drain the area Restoration of bowel continuity Prevention of surgical complications
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Colorectal Cancer Collaborative Care
Optimal procedure: Bowel resection with reanastomosis of remaining segments ↓ Colonic bacteria to prevent infection and breakdown at site
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Colorectal Cancer Collaborative Care
Preoperative preparation Bowel cleansing agent Unless patient has bowel obstruction or perforation Oral antibiotics
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Colorectal Cancer 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
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Colorectal Cancer Collaborative Care
Chemotherapy (cont’d) First-line treatment of metastatic colorectal cancer 5-Fluorouracil (5-FU) plus leucovorin and irinotecan
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Colorectal Cancer Collaborative Care
Biologic and targeted therapy Two monoclonal antibodies Targets epidermal growth factor receptor cetuximab (Erbitux) Targets vascular endothelial growth factor bevacizumab (Avastin)
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Colorectal Cancer Collaborative Care
Radiation therapy May be used postop as an adjuvant to surgery and chemotherapy or as palliative for metastasis
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Nursing Management Nursing Assessment
Past health history Previous breast or ovarian cancer Familial polyposis Villous adenoma Adenomatous polyps Inflammatory bowel disease
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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
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Nursing Management Nursing Diagnoses
Diarrhea or constipation Acute pain Fear Ineffective coping
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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
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Nursing Management Nursing Implementation
Health promotion American Cancer Society recommends starting at age 50 Yearly fecal occult blood test or fecal immunochemical test Double contrast enema every 5 years Sigmoidoscopy every 5 years Colonoscopy every 10 years
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Nursing Management Nursing Implementation
Health promotion Screening for high-risk patients should begin before age 50 and at more frequent intervals
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Nursing Management Nursing Implementation
Health promotion Colonoscopy only detects polyps when bowel has been adequately prepared Ingesting clear liquids for 24 hours before colonoscopy and using an oral preparation required before colonoscopy
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Nursing Management Nursing Implementation
Acute intervention Preoperative care Provide information about prognosis and future screening Support dealing with diagnosis Inform of the extent of the surgical procedure and the amount of care necessary to facilitate healing
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Nursing Management Nursing Implementation
Preoperative care (cont’d) Emotional support Taught side-to-side positioning Teach on sitz bath positioning
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Nursing Management Nursing Implementation
Acute intervention Postoperative care Management differs depending on the type of wound Type of management is individualized If drains present, remain in place until drainage is less than 50 ml per 24 hours
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Nursing Management Nursing Implementation
Postop care (cont’d) Drainage must be assessed for amount, color, consistency Wound should be examined regularly Record bleeding, excessive drainage, and odor Monitor suture line for infection Pain control Sexual dysfunction education
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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
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Nursing Management Nursing Implementation
Evaluation Expected outcomes Minimal alterations in bowel elimination patterns Relief of pain Balanced nutritional intake
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Nursing Management Nursing Implementation
Evaluation Expected outcome Quality of life appropriate to disease progression Feelings of comfort and well-being
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