COLORECTAL CANCER

 also known as bowel cancer, colon cancer, or rectal cancer, is any cancer that
affects the colon and the rectum.
 tumors of the colon and rectum are relatively common
 the colorectal area (the colon and rectum combined)
 3rd leading cause of cancer death in both men and women worldwide (2018).

 the second leading cause of cancer death in both men and women
 The lifetime risk of developing colorectal cancer is 1 in 17
 Incidence increases with age (the incidence is highest in people older than 85
years) and is higher in people with a family history of colon cancer and those with
IBD or polyps.
 The exact cause of colon and rectal cancer is still unknown, but risk factors have

been identified
 Early diagnosis and prompt treatment could save almost three of every four
people.
 Most people are asymptomatic for long periods
 Hereditary colon cancer accounts for about 6% of all colon cancers.

Clinical Manifestations

The symptoms most commonly associated with right- sided lesions:

-dull abdominal pain
-melena (ie, black, tarry stools).

The symptoms most commonly associated with left-sided lesions:

-associated with obstruction (ie, abdominal pain and cramping, narrowing stools,
constipation, distention)
-bright-red blood in the stool.

Symptoms associated with rectal lesions:

-tenesmus (ie, ineffective, painful straining at stool)

-rectal pain
-the feeling of incomplete evacuation after a bowel movement
-alternating constipation
-diarrhea
-bloody stool

Pathophysiology

-Cancer of the colon and rectum is predominantly (95%) adenocarcinoma (ie, arising
from the epithelial lining of the intestine).

-It may start as a benign polyp but may become malignant, invade and destroy normal
tissues, and extend into surrounding structures.

-Cancer cells may migrate away from the primary tumor and spread to other parts of the
body (most often to the liver, peritoneum, and lungs).

Assessment and Diagnostic Findings

-abdominal
-rectal examination
-fecal occult blood testing
-barium enema
-proctosigmoidoscopy
-colonoscopy
-colonoscopy with biopsy
-cytology smears.
-Carcinoembryonic antigen (CEA) studies
 Complications

-partial or complete bowel obstruction

-Extension of the tumor and ulceration into the surrounding blood vessels result in
hemorrhage
-Perforation
-abscess formation
-peritonitis
-sepsis
-shock

Colon cancer in the elderly has been closely associated with dietary carcinogens.
-Lack of fiber is a major causative factor because the passage of feces through the
intestinal tract is prolonged, which extends exposure to possible carcinogens.
-Excess dietary fat
-high alcohol consumption
-smoking all increase the incidence of colorectal tumors
-Physical activity and dietary folate have protective effects.
 Medical Management
-symptoms of intestinal obstruction is treated with IV fluids and nasogastric suction.
-blood component therapy- for significant bleeding
-depends on the stage of the disease
-consists of surgery to remove the tumor, supportive therapy, and adjuvant therapy.

Adjuvant Therapy: chemotherapy, radiation therapy, immunotherapy, or multimodality

therapy- typically demonstrate delays in tumor recurrence and increases in survival
time.

Adjuvant Therapy

Dukes’ class C(non-metastasized colon cancer):

-5-fluorouracil (5-FU; Adrucil) plus leucovorin calcium

Other agents include: oxaliplatin (Eloxatin) and capecitabine (Xeloda).

Dukes’ class B or C rectal cancer:
- 5- FU
-high doses of pelvic irradiation
-Mitomycin.

Radiation therapy is used before, during, and after surgery to shrink the tumor; to
achieve better results from surgery; and to reduce the risk of recurrence.

Surgical Management

-primary treatment for most colon and rectal cancers.

-may be curative or palliative
-type of surgery recommended depends on the location and size of the tumor.
-Cancers limited to one site can be removed through the colonoscope.
-Laparoscopic colotomy with polypectomy minimizes the extent of surgery needed in
some cases.
-A laparoscope is used as a guide in making an incision into the colon; the tumor mass
is then excised.
-Laparoscopic colectomy has also been shown to have equivalent surgical outcomes to
open colectomy and is associated with decreased length of stay, decreased use of pain
medications, and improved quality of life
-Use of the neodymium/yttrium- aluminum-garnet (Nd:YAG) laser is effective with some
lesions as well.
-Bowel resection is indicated for most class A lesions and all class B and C lesions.
-Surgery is sometimes recommended for class D colon cancer
Possible surgical procedures include the following:

• Segmental resection with anastomosis (ie, removal of the tumor and portions of the
bowel on either side of the growth, as well as the blood vessels and lymphatic nodes)
• Abdominoperineal resection with permanent sigmoid colostomy (ie, removal of the
tumor and a portion of the sigmoid and all of the rectum and anal sphincter, also called
Miles resection)
• Temporary colostomy followed by segmental resection and anastomosis and
subsequent reanastomosis of the Peritoneum sutured Distal sigmoid Catheter
colostomy, allowing initial bowel decompression and bowel preparation before resection
• Permanent colostomy or ileostomy for palliation of unresectable obstructing lesions
• Construction of a colo-anal reservoir called a colonic J pouch.
 Assessment

- health history about the presence of fatigue, abdominal or rectal pain (eg, location,
frequency, duration, association with eating or defecation), past and present elimination
patterns, and characteristics of stool (eg, color, odor, consistency, presence of blood or
mucus).
- history of IBD or colorectal polyps
-family history of colorectal disease
-current medication therapy

dietary patterns: fat and fiber intake, amounts of alcohol consumed and history of
smoking.
-history of weight loss and feelings of weakness and fatigue.
- auscultation of the abdomen for bowel sounds and palpation of the abdomen for areas
of tenderness, distention, and solid masses.
-Stool specimens are inspected for character and presence of blood.

Nursing Diagnoses

• Imbalanced nutrition, less than body requirements, related to nausea and anorexia
• Risk for deficient fluid volume related to vomiting and dehydration
• Anxiety related to impending surgery and the diagno- sis of cancer
• Risk for ineffective therapeutic regimen management related to knowledge deficit
concerning the diagnosis, the surgical procedure, and self-care after discharge
• Impaired skin integrity related to the surgical incisions (abdominal and perianal), the
formation of a stoma, and frequent fecal contamination of peristomal skin
• Disturbed body image related to colostomy
• Ineffective sexuality patterns related to presence of ostomy and changes in body
image and self-concept

Planning and Goals

• The major goals for the patient may include attainment of optimal level of nutrition;
maintenance of fluid and electrolyte balance; reduction of anxiety; learning about the
diagnosis, surgical procedure, and self-care after discharge; maintenance of optimal
tissue healing; protection of peristomal skin; learning how to irrigate the colostomy
(done only with sigmoid colostomies) and change the appliance; expressing feelings
and concerns about the colostomy and the impact on self; and avoidance of
complications.

Nursing Interventions

Preparing the Patient for Surgery

• providing information about postoperative care, including stoma care if a colostomy is

to be created
• supporting the patient and family emotionally
• Physical preparation for surgery involves building the patient’s stamina in the days
preceding surgery and cleansing and sterilizing the bowel the day before surgery.
• If the patient’s condition permits, the nurse recommends a diet high in calories,
protein, and carbohydrates and low in residue for several days before surgery to
provide adequate nutrition and minimize cramping by decreasing excessive
peristalsis.
• A full liquid diet may be prescribed for 24 to 48 hours before surgery to decrease bulk.
• If the patient is hospitalized in the days preceding surgery, parenteral nutrition may be
required to replace depleted nutrients, vitamins, and minerals.
• In some instances, parenteral nutrition is administered at home before surgery.
• Antibiotics such as kanamycin (Kantrex), neomycin (Mycifradin), and cephalexin (Ke-
flex) are administered orally the day before surgery to reduce intestinal bacteria. The
 bowel is cleansed with laxatives, enemas, or colonic irrigations the evening before and
the morning of surgery.
• For the patient who is very ill and hospitalized, the nurse measures and records intake
and output, including vomitus to provide an accurate record of fluid balance.
• The patient’s intake of oral food and fluids may be restricted to prevent vomiting. The
nurse administers antiemetics as prescribed.
• Full or clear liquids may be tolerated, or the patient may be allowed nothing by mouth.
• A nasogastric tube may be inserted to drain accumulated fluids and prevent
abdominal distention.
• The nurse monitors the abdomen for increasing distention, loss of bowel sounds, and
pain or rigidity, which may indicate obstruction or perforation.
• monitor IV fluids and electrolytes.
• observes for signs of hypovolemia
• assesses hydration status; and reports decreased skin turgor, dry mucous
membranes, and concentrated urine.
• The nurse assesses the patient’s knowledge about the diagnosis, prognosis, surgical
procedure, and expected level of functioning after surgery.
• If the patient is admitted the day of surgery, the physician’s office may arrange for the
patient to be seen by a WOC nurse in the days preceding surgery.

Providing Emotional Support

• assess the patient’s anxiety level and coping mechanisms

• suggest methods for reducing anxiety, such as deep- breathing exercises and
visualizing a successful recovery from surgery and cancer.
• arrange a meeting with a spiritual advisor if the patient desires or with the physician if
the patient wishes to discuss the treatment or prognosis.
• helps reduce this fear by presenting facts about the surgical procedure and the
creation and management of the ostomy.
• If the patient is receptive, the nurse can use diagrams, photographs, and appliances
to explain and clarify.

Maintaining Optimal Nutrition

• The nurse teaches all patients undergoing surgery for colorectal cancer about the
health benefits to be derived from consuming a healthy diet.
• A complete nutritional assessment is important for the patient with a colostomy. The
patient avoids foods that cause excessive odor and gas, including foods in the cab-
bage family, eggs, asparagus, fish, beans, and high-cellulose products such as
peanuts.
• It is important to determine whether the elimination of specific foods is causing any
nutritional deficiency.
• Nonirritating foods are substituted for those that are restricted so that deficiencies are
corrected.
• The nurse advises the patient to experiment with an irritating food several times before
restricting it, because an initial sensitivity may decrease with time. The nurse can help
 the patient identify any foods or fluids that may be causing diarrhea, such as fruits,
high-fiber foods, soda, coffee, tea, or carbonated beverages.
• Diphenoxylate with atropine may be prescribed as needed to control the diarrhea.
• For constipation, prune or apple juice or a mild laxative is effective. The nurse
suggests fluid intake of at least 2 L per day.

Providing Wound Care

• The nurse frequently examines the abdominal dressing during the first 24 hours after
surgery to detect signs of hemorrhage.
• It is important to help the patient splint the abdominal incision during coughing and
deep breathing to lessen tension on the edges of the incision.
• The nurse monitors temperature, pulse, and respiratory rate for elevations that may
indicate an infectious process.
• If the patient has a colostomy, the stoma is examined for swelling (slight edema from
surgical manipulation is normal), color (a healthy stoma is pink or red), discharge (a
small amount of oozing is normal), and bleeding (an abnormal sign if bright red or
beyond trace amounts).
• If the malignancy has been removed using the perineal route, the perineal wound is
observed for signs of hemorrhage. This wound may contain a drain or packing that is
removed gradually. Bits of tissue may slough off for a week. This process is hastened
by mechanical irrigation of the wound or with sitz baths performed two or three times
each day initially. The condition of the perineal wound and any bleeding, infection, or
necrosis is documented.

Monitoring and Managing Complications

• The patient is observed for signs and symptoms of complications.

• It is important to frequently assess the abdomen, including bowel sounds and
abdominal girth, to detect bowel obstruction.
• monitors vital signs for increased temperature, pulse, and respirations and for
decreased blood pressure that may indicate an intra-abdominal infectious process.
• It is important to report rectal bleeding immediately because it indicates hemorrhage.
• The nurse monitors hemoglobin and hematocrit levels and administers blood
component therapy as prescribed.
• Any abrupt change in abdominal pain is reported promptly.
• Elevated white blood cell counts and temperature or symptoms of shock are reported
because they may indicate sepsis.
• The nurse administers antibiotics as prescribed.
• Frequent activity (eg, turning the patient from side to side every 2 hours), deep
breathing, coughing, and early ambulation can reduce the risk for these complications.
• The incidence of complications related to the colostomy is usually less than that of an
ileostomy.
• Some common complications are prolapse of the stoma, parastomal hernia,
perforation (from improper stoma irrigation), stoma retraction, mucocutaneous
 separation, and skin irritation leakage from an anastomotic site can occur if the
remaining bowel segments are diseased or weakened.
• Leakage from an intestinal anastomosis causes peritonitis with abdominal distention
and rigidity, temperature elevation, and signs of shock. Surgical repair is necessary.