1. Pathophysiology & Etiology
1.1. Most are adenocarcinomas (Begin as adenomatous polyps, most develop in retum, sigmoid colon).
1.2. Typically grow undetected, no manifestations until spread into deeper layers of bowel tissue, adjacent organs.
1.3. Metastasis to regional lymph nodes common form of spread.
1.4. Seeding of tumor can occur when tumor extends through serosa or during surgical resection
1.5. Etiology: Third most common cancer in US; more men than women; earlier diagnosis, better treatment leads to increased survival rate; occurs most after 50, risk continues to rise with increased age.
2. Symptoms
2.1. Depend on location, type, extent, complications
2.2. Rectal bleeding is often the initial manifestation
2.3. Early Manifestations
2.3.1. Change in bowel habits, diarrhea or constipation
2.4. Late Manifestations
2.4.1. Pain, anorexia, weight loss
2.5. Bowel cancer often produces no manifestations until it its advanced.
2.5.1. Grows slowly --> 5-15 yrs of growth may occur before manifestations develop.
2.6. A palpable abdominal or rectal mass may be present
2.7. Patient sometimes presents with anemia from occult bleeding.
3. Lifespan Considerations
3.1. Children & Adolescents
3.1.1. Isolated juvenile polyps most common type
3.1.1.1. Lack malignant potential but cause lower GI bleeding
3.1.2. Juvenile polyposis
3.1.2.1. Diffuse juvenile polyposis of infancy: fatal
3.1.2.2. Juvenile polyposis and juvenile polyposis coli increase risk of colorectal cancer in adulthood
3.1.3. Adenomas unusual in this population
3.2. Pregnant Women
3.2.1. Rare, but diagnosis and treatment are challenging
3.2.2. Manifestations often mimic those of pregnancy
3.2.3. Diagnostic imaging and other procedures are limited during pregnancy
3.2.4. Use of chemotherapeutic agents limited
3.2.5. Gestational age and tumor stage
3.2.6. Sometimes presents choice of saving mother's life over life of fetus
3.3. Older Adults
3.3.1. Most patients with colorectal cancer are > 70 y/o
3.3.2. Challenges
3.3.2.1. Discrepancy b/w physiologic, chronologic age
3.3.2.2. Coexisting medical conditions
3.3.2.3. Physiologic and social care issues
3.3.3. Use of geriatric assessment recommended
4. Diagnostic & Laboratory Tests
4.1. Diagnostic Tests
4.1.1. Sigmoidoscopy or colonoscopy: Primary means to detect, visualize tumors
4.1.2. Radiologic examinations
4.1.3. Biopsy
4.1.4. Chest X-Ray
4.1.5. CT Scan
4.1.6. MRI
4.1.7. Ultrasound
4.2. Laboratory Tests
4.2.1. Fecal Occult Blood
4.2.2. CBC: To detect anemia
4.2.3. CEA levels (tumor marker that can be detected in the blood of patients with colorectal cancer.
4.3. Used to estimate prognosis, monitor treatment, and detect cancer recurrence
5. Interventions
5.1. Surgery
5.1.1. Surgical resection of tumor, adjacent colon regional lymph nodes
5.1.1.1. Laser photocoagulation during endoscopy
5.1.1.2. Abdominoperineal resection with anastomosis of remaining bowel: curative
5.1.1.3. Local excision for small, well-differentiated, mobile polypoid lesion
5.1.1.4. Fulguration for patients who are poor surgical risks
5.1.1.4.1. May need to be repeated at intervals
5.1.2. Colostomy
5.1.2.1. May be temporary or permanent
5.1.2.2. Sigmoid colostomy: Most common
5.1.2.3. Double-Barrel colostomy
5.1.2.3.1. Two stomas created
5.1.2.4. Transverse loop colostomy
5.1.2.4.1. Emergency procedure to relieve intestinal obstruction or perforation
5.1.2.5. Hartmann Procedure
5.1.2.6. Temporary Colostomy
5.1.2.7. Laser Photocoagulation
5.1.2.7.1. Uses heat to destroy small tumors
5.1.2.7.2. Palliative surgery for advanced tumors
5.1.2.7.3. Can be performed endoscopically
5.1.2.7.4. Useful for patients who cannot tolerate major surgery
5.2. Collaborative
5.2.1. Surgeons, nurses specializing in care of ostomies, dietary counselors, radiation therapists, primary care nurse, nutritionists, hematologists, surge techs, etc.
5.3. Radiation Therapy
5.3.1. Not primary treatment
5.3.2. Used with surgical resection for treating rectal tumors
5.3.3. Small rectal cancers may be treated intracavitary, external, or implantation radiation
5.3.4. Used preoperatively or postoperatively to decrease rate of recurrence of pelvic tumors
5.3.5. Used preoperatively to shrink tumors
5.4. Pharmacologic Therapy
5.4.1. Chemotherapy
5.4.1.1. Fluorouracil (5-FU) and folinic acid used postoperatively as adjunctive therapy for colorectal cancer
5.4.1.2. When combined with radiation therapy, reduces recurrence rate, prolongs survival of patients with stage II or III rectal tumor
5.4.1.3. Benefit for patients with colon cancer less clear
5.4.1.4. Irinotecan or oxaliplatin for colorectal cancer
6. Risk Factors
6.1. Genetic Factors
6.1.1. Family Hx
6.1.2. Familial adenomatous polyposis lead to colon cancer unless colon is removed
6.1.3. Lynch Syndrome (Hereditary non-polyposis colorectal cancer) increased risk
6.2. Inflammatory Bowel Disease
6.3. Age > 50 y/o
6.4. Diet
6.4.1. High calorie, high meat proteins, high fat
6.4.2. This diet is thought to increase the population of anaerobic bacteria in the gut. These anaerobes covert bile acids into carcinogens.
7. Prevention
7.1. Early detection begging at age 50
7.1.1. Yearly fecal occult blood test or fecal immunochemical test; stool DNA q 3 yrs; flexible sigmoid sigmoidoscopy q 5 yrs; double-contrast barium enema q 5 yrs; colonoscopy q 10 yrs; CT colonography q 5 yrs
7.2. Regular colonoscopies lower risk --> removal of polyps before they become malignant tumors.
7.3. Diets high in fruits & vegetables, folic acid, and calcium appear to decrease risk of colorectal cancer
8. Nursing Process
8.1. Nurses will consider: Physical care needs, patients emotional response to diagnosis
8.2. Assessment
8.2.1. Observation & Patient Interview
8.2.1.1. Bowel Patterns
8.2.1.2. Weight loss
8.2.1.3. Fatigue
8.2.1.4. Decreased activity tolerance
8.2.1.5. Blood in stool
8.2.1.6. Pain with defacation
8.2.1.7. Abdominal discomfort, perineal pain
8.2.1.8. Diet
8.2.1.9. Family History
8.2.2. Physical Examination
8.2.2.1. Bowel sounds
8.2.2.2. General Appearance
8.2.2.3. Weight
8.2.2.4. Abdominal shape, contour
8.2.2.5. Abdominal tenderness
8.2.2.6. Stool hemoccult or guaiac
8.3. Diagnosis
8.3.1. Infection, Risk for
8.3.2. Pain, Acute
8.3.3. Imbalanced Nutrition: Less Than Body Requirements
8.3.4. Anticipatory Grieving
8.3.5. Sexuality Pattern, Ineffective
8.4. Planning
8.4.1. Patient will show no signs of infection
8.4.2. Patient will rate pain at 3 or less on scale of 1-10
8.4.3. Patient will demonstrate proper ostomy care and management
8.4.4. Patient will verbalize feelings r/t diagnosis, prognosis
8.4.5. Patient will receive adequate emotional and physical support from family or significant others
8.4.6. Patient will make informed decisions about treatment
8.5. Implementation
8.5.1. Reduce risk for Infection
8.5.2. Manage pain effectively
8.5.2.1. Patient may experience "phantom" rectal pain after abdominoperineal resection
8.5.3. Reduce risk for sexual dysfunction
8.5.3.1. Encourage expression of sexual concerns
8.5.3.2. Reassure patient, significant other, that effect on sexuality is temporary
8.5.3.3. Refer patient, significant other, to social services
8.5.3.4. Arrange for visit from member of United Ostomy Association (UAO)
8.6. Evaluation
8.6.1. Patient does not demonstrate any signs or symptoms of infection
8.6.2. Patient maintains adequate hydration
8.6.3. Patient rates pain at 3 or less on scale of 1-10
8.6.4. Patient is able to perform essential ADLs
8.6.5. If infection is present, early identification of stomal necrosis, ischemia, skin irritation can prevent serious complications