Cancer of the Colon and Rectum

(Colorectal Cancer)

Colorectal cancer is predominantly (95%) adenocarcinoma,

with colon cancer affecting more than twice as many people
as rectal cancer. 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). 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 inflammatory bowel disease
(IBD) or polyps. If the disease is detected and treated at
an early stage before the disease spreads, the 5-year survival
rate is 90%; however, only 39% of colorectal cancers are
detected at an early stage. Survival rates after late diagnosis
are very low.
Clinical Manifestations
• Changes in bowel habits (most common presenting symptom),
passage of blood in or on the stools (second most common
symptom).
• Unexplained anemia, anorexia, weight loss, and fatigue.
• Right-sided lesions are possibly accompanied by dull abdominal
pain and melena (black tarry stools).

• Left-sided lesions are associated with obstruction (abdominal

pain and cramping, narrowing stools, constipation, and
distention) and bright red blood in stool.
• Rectal lesions are associated with tenesmus (ineffective
painful straining at stool), rectal pain, feeling of incomplete
evacuation after a bowel movement, alternating constipation
and diarrhea, and bloody stool.
• Signs of complications: partial or complete bowel obstruction,
tumor extension and ulceration into the surrounding
blood vessels (perforation, abscess formation, peritonitis,
sepsis, or shock).
• In many instances, symptoms do not develop until colorectal
cancer is at an advanced stage.
Assessment and Diagnostic Methods
• Abdominal and rectal examination; fecal occult blood testing;
barium enema; proctosigmoidoscopy; and colonoscopy,
biopsy, or cytology smears.
• CEA studies should return to normal within 48 hours of
tumor excision (reliable in predicting prognosis and recurrence).
Gerontologic Considerations
The incidence of carcinoma of the colon and rectum
increases with age. These cancers are considered common
malignancies in advanced age. In men, only the incidence of
prostate cancer and lung cancer exceeds that of colorectal
cancer. In women, only the incidence of breast cancer
exceeds that of colorectal cancer. Symptoms are often insidious.
Patients with colorectal cancer usually report fatigue,
which is caused primarily by iron deficiency anemia. In early
stages, minor changes in bowel patterns and occasional bleeding
may occur. The later symptoms most commonly reported
by the elderly are abdominal pain, obstruction, tenesmus, and
rectal bleeding.
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, and smoking all
increase the incidence of colorectal tumors. Physical activity
and dietary folate have protective effects.
Medical Management
Treatment of cancer depends on the stage of disease and
related complications. Obstruction is treated with IV fluids
and nasogastric suction and with blood therapy if bleeding
is significant. Supportive therapy and adjuvant therapy (eg,
chemotherapy, radiation therapy, immunotherapy) are
included.
Surgical Management
• Surgery is the primary treatment for most colon and rectal
cancers; the type of surgery depends on the location and size
of tumor, and it may be curative or palliative.
• Cancers limited to one site can be removed through a
colonoscope.
• Laparoscopic colotomy with polypectomy minimizes the
extent of surgery needed in some cases.
•Neodymium:yttrium-aluminum-garnet (Nd:YAG) laser is
effective with some lesions.
• Bowel resection with anastomosis and possible temporary
or
permanent colostomy or ileostomy (less than one third of
patients) or coloanal reservoir (colonic J pouch).
NURSING PROCESS
THE PATIENT WITH COLORECTAL CANCER
Assessment
• Obtain a health history about the presence of fatigue,
abdominal or rectal pain, past and present elimination
patterns, and characteristics of stool.
• Obtain a history of IBD or colorectal polyps, a family
history of colorectal disease, and current medication
therapy.
• Assess dietary patterns, including fat and fiber intake,
amounts of alcohol consumed, and history of smoking;
describe and document a history of weight loss and
feelings of weakness and fatigue.
• Auscultate abdomen for bowel sounds; palpate for areas of
tenderness, distention, and solid masses; inspect stool for
blood.
Diagnosis
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 diagnosis of cancer
• Risk for ineffective therapeutic regimen management
related to deficient knowledge concerning the diagnosis,
surgical procedure, and self-care after discharge
• Impaired skin integrity related to surgical incisions, stoma,
and fecal contamination of peristomal skin
• Disturbed body image related to colostomy
• Ineffective sexuality patterns related to ostomy and selfconcept
Collaborative Problems/Potential Complications
• Intraperitoneal infection
• Complete large bowel obstruction
• Gastrointestinal bleeding and hemorrhage
• Bowel perforation
• Peritonitis, abscess, sepsis
Planning and Goals
The major goals 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 (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 Patient for Surgery
• Physically prepare patient for surgery (diet high in
calories, protein, and carbohydrates and low in residue;
full liquid diet 24 to 48 hours before surgery or parenteral
nutrition [PN] if prescribed).
• Administer antibiotics, laxatives, enemas, or colonic irrigations
as prescribed.
• Perform intake and output measurement of hospitalized
patient (including vomitus); nasogastric tube and IV fluid
and electrolyte management.
• Observe for signs of hypovolemia (eg, tachycardia,
hypotension, decreased pulse volume); monitor hydration
status (eg, skin turgor, mucous membranes).
• Monitor for signs of obstruction or perforation (increased
abdominal distention, loss of bowel sounds, pain, or
rigidity).
• Reinforce and supplement patient’s knowledge about diagnosis,
prognosis, surgical procedure, and expected level of
function postoperatively. Include information about postoperative
wound and ostomy care, dietary restrictions,
pain control, and medical management.
• See “Nursing Management” under “Cancer” for additional
information.
Providing Emotional Support
• Assess patient’s level of anxiety and coping mechanisms
and suggest methods for reducing anxiety, such as deep
breathing exercises and visualizing a successful recovery
from surgery and cancer.
• Arrange meetings with a spiritual advisor, if desired.
• Provide meetings for patient and family with physicians
and nurses to discuss treatment and prognosis; a meeting
with an enterostomal therapist may be useful.
• Help reduce fear by presenting facts about the surgical
procedure and the creation and management of the
ostomy.
Maintaining Optimal Nutrition
• Teach about the health benefits of a healthy diet; diet is
individualized as long as it is nutritionally sound and does
not cause diarrhea or constipation.
• Advise patient to avoid foods that cause excessive odor
and gas, including foods in the cabbage family, eggs,
asparagus, fish, beans, and high-cellulose products such as
peanuts; nonirritating foods are substituted for those that
are restricted so that deficiencies are corrected.
• Suggest fluid intake of at least 2 L per day.
Maintaining Fluid and Electrolyte Balance
• Administer antiemetics and restrict fluids and food to prevent
vomiting; monitor abdomen for distention, loss of
bowel sounds, or pain or rigidity (signs of obstruction or
perforation).
• Record intake and output, and restrict fluids and oral food
to prevent vomiting.
• Monitor serum electrolytes to detect hypokalemia and
hyponatremia.
• Assess vital signs to detect signs of hypovolemia: tachycardia,
hypotension, and decreased pulse volume.
• Assess hydration status and report decreased skin turgor,
dry mucous membranes, and concentrated urine.
Supporting a Positive Body Image
• Encourage patient to verbalize feelings and concerns.
• Provide a supportive environment and attitude to promote
adaptation to lifestyle changes related to stoma care.
• Listen to the patient’s concerns about sexuality and function
(eg, mutilation, fear of impotence, leakage during
sex). Offer support and, if appropriate, refer to an
enterostomal therapist, sex counselor or therapist, or advancd practitioner

Monitoring and Managing Complications

• Before and after surgery, observe for symptoms of complications;
report; and institute necessary care.
• Administer antibiotics as prescribed to reduce intestinal
bacteria in preparation for bowel surgery.
• Postoperatively, examine wound dressing frequently during
first 24 hours, checking for infection, dehiscence, hemorrhage,
and excessive edema.
Promoting Home- and Community-Based Care
TEACHING PATIENTS SELF-CARE
• Assess patient’s need and desire for information, and
provide information to patient and family (see “Providing
Emotional Support” earlier under “Nursing
Interventions”).
• Provide patients being discharged with specific information
relevant to their needs.
• If patient has an ostomy, include information about
ostomy care and complications to observe for, including
obstruction, infection, stoma stenosis, retraction or
prolapse, and peristomal skin irritation.
• Provide dietary instructions to help patient identify and
eliminate foods that can cause diarrhea or constipation.
• Provide patient with a list of prescribed medications, with
information on action, purpose, and possible side effects.
• Demonstrate and review treatments and dressing changes,
stoma care, and ostomy irrigations, and encourage family
to participate.
• Provide patient with specific directions about when to call
the physician and what complications require prompt
attention (eg, bleeding, abdominal distention and rigidity,
diarrhea, fever, wound drainage, and disruption of suture
line).
• Review side effects of radiation therapy (anorexia, vomiting,
diarrhea, and exhaustion) if necessary.
• Refer patient for home nursing care as indicated.
Evaluation
Expected Patient Outcomes
• Consumes a healthy diet and maintains fluid balance
• Experiences reduced anxiety
• Learns about diagnosis, surgical procedure, preoperative
preparation, and self-care after discharge
• Maintains clean incision, stoma, and perineal wound
• Verbalizes feelings and concerns about self
• Recovers without complications

381-Handbook for Brunner and Suddarth's Textbook of Medical-Surgical Nursing, 12th Edition-Suzann