Colorectal Cancer

1. Colorectal Cancer Dr. Belal Hijji, RN, PhD February 6, 2012

2. Learning Outcomes At the end of this lecture, students will be able to: • Describe the incidence and trend of colorectal cancer in Saudi Arabia compared to the United States of America. • Identify the risk factors for the development of colorectal cancer. • Discuss the clinical picture of colorectal cancer along with the assessment and diagnostic evaluation. • Discuss the medical management of a patient with colorectal cancer. • Describe the nursing process as a framework for caring for a patient with colorectal cancer.

3. The colon and rectum Source: http://www.cancer.gov/cancertopics/wyntk/colon-and-rectal/page2

4. Incidence of Colorectal Ca in KSA Versus USA ASR for colorectal cancer (1994-2003) in the Kingdom of Saudi Arabia and the United States of America Source: Ibrahim, E. et al. (2008). Past, Present and Future of Colorectal Cancer in the Kingdom of Saudi Arabia. The Saudi Journal of Gastroenterology. 14(4): 178–182.

5. The age-standardized rate for colorectal cancer for males and females in the Kingdom of Saudi Arabia and the USA (1994-2003). Source: Ibrahim, E. et al. (2008). Past, Present and Future of Colorectal Cancer in the Kingdom of Saudi Arabia. The Saudi Journal of Gastroenterology. 14(4): 178–182.

6. Predicted colorectal cancer burden in the Kingdom of Saudi Arabia, up to 2030 Source: Ibrahim, E. et al. (2008). Past, Present and Future of Colorectal Cancer in the Kingdom of Saudi Arabia. The Saudi Journal of Gastroenterology. 14(4): 178–182.

7. Risk Factors For Colorectal Cancer • Increasing age (highest in people older than 85 years). • Family history. • Previous colon cancer. • High consumption of alcohol. • Cigarette smoking. • Obesity and history of gastrectomy. • History of inflammatory bowel disease. • High fat, high protein, low fiber diet. • Genital cancer or breast cancer.

8. Clinical Manifestations • Three factors greatly determine the signs and symptoms experienced by a patient with colorectal cancer. These are: • Location of tumor. • Stage of disease. • Function of the affected intestinal part. • Most commonly, patients have change in bowel habits and passage of stool with blood. Other clinical manifestations include unexplained anemia, anorexia, weight loss, and fatigue. • Right-sided lesions are associated with: • Abdominal pain and melena.

9. Clinical Manifestations (Continued…) • Left-sided lesions, causing obstruction, are associated with: • Abdominal pain and cramping. • Narrowing stools and constipation. • Distention and bright red blood in stool. • Rectal lesions are associated with: • Ineffective, painful straining at stool. • Rectal pain. • A feeling of incomplete evacuation after a bowel movement. • Alternating constipation and diarrhea. • Bloody stools.

10. Assessment and Diagnostic Findings • Abdominal and rectal examination. • Stool for occult blood. • Barium enema. • Proctosigmoidescopy. Most important • Colonoscopy. • Carcinoembryonic antigen may be useful

11. Medical Management of a Patient With Colorectal Cancer • If there is intestinal obstruction, patients are treated with IV fluids and nasogastric suction. Blood transfusion if there is significant blood loss. • Treatment of this disease depends on its stage and consists of surgical removal of tumor, supportive therapy, and adjuvant therapy. By adjuvant therapy we mean chemotherapy, radiotherapy, immunotherapy that a patient with non-metastasised colon cancer would receive. The standard adjuvant therapy is 5-fluorouracil and leucovorin calcium. Radiotherapy is used before, during, and after surgery to shrink the tumor and to reduce recurrence. • Radiotherapy is also used for unresectable tumors for symptoms relief. • Surgery is the primary treatment for most colorectal cancers.

12. Medical Management of a Patient With Colorectal Cancer (Continued…) • Colostomy: This is a surgical creation of an opening into the colon. It could be temporary or permanent. Permanent colostomy for rectal cancer

13. Colostomy (Continued…):

14. Nursing Management of a Patient With Colorectal Cancer Assessment • Collect subjective data about: • Presence of fatigue. • Abdominal or rectal pain. • Past and present elimination pattern. • Characteristics of stool. • Family history and fat and fiber intake. • Alcohol intake and smoking. • Weight loss. • Auscultate the abdomen for bowel sounds. • Palpate the abdomen for distention and solid masses.

15. Nursing Management of a Patient With Colorectal Cancer (Continued…) • 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 cancer diagnosis and impending surgery. • Impaired skin integrity related to surgical incisions. • Disturbed body image related to colostomy.

16. Nursing Management of a Patient With Colorectal Cancer (Continued…) • Planning and goals • Attainment of optimal nutrition. • Maintenance of fluid and electrolyte balance. • Reduction of anxiety. • Attainment of optimal wound healing. • Expressing feelings and concern about colostomy and the impact on self.

17. Nursing Management of a Patient With Colorectal Cancer (Continued…) • Nursing Interventions • Patient Preparation for Surgery. • Build the patient’s stamina days before surgery. • Cleanse the bowel the day before surgery. • If possible, provide a diet high in calories, protein, and carbohydrate for several days before surgery. • Provide full liquid diet if prescribed 24 to 48 hours before surgery to reduce bulk. • Clean the bowel with laxatives and/ or enemas the evening before and the morning of surgery. • Record intake and output to provide an accurate record of fluid balance.

18. Nursing Management of a Patient With Colorectal Cancer (Continued…) • Nursing Interventions • Patient Preparation for Surgery (Continued…). • Insert nasogastric tube if ordered to drain accumulated fluids and prevent abdominal distention. • Monitor the patient for increasing abdominal distention, loss of bowel sounds, and pain or rigidity, which may indicate intestinal obstruction or perforation. • Observe the patient for signs of hypovolemia (tachycardia, hypotension, decreased pulse volume). • Assess hydration status.

19. Nursing Management of a Patient With Colorectal Cancer (Continued…) • Nursing Interventions (Continued…) • Providing Emotional Support. • Assess the patient’s level of anxiety. • Suggest methods for reducing anxiety such as deep breathing exercises and visualising a patient who successfully recovered from surgery and cancer. • Provide factual information about the colostomy site to reduce the patient’s fear that everybody will be aware of the ostomy. • Providing Postoperative Care. • Pain management. • Abdominal assessment for bowel sounds. • Mobilise the patient out of bed on the 1st day postop.

20. Nursing Management of a Patient With Colorectal Cancer (Continued…) • Nursing Interventions (Continued…) • Maintaining Optimal Nutrition. • Teach patients undergoing surgery about the health benefits of consuming healthy diet. • Perform complete nutritional assessment to evaluate the nutritional status of the patient. • Advise the patient on avoiding foods that cause excessive odor and gas such as foods in cabbage family, eggs, asparagus, fish, and beans. • Help the patient identify any foods or fluids that may cause diarrhea including fruits, high fiber foods, soda, coffee, tea, or carbonated drinks. • Advise a fluid intake of at least 2 L/ day

21. Nursing Management of a Patient With Colorectal Cancer (Continued…) • Nursing Interventions (Continued…) • Supporting a Positive body Image. • Encourage the patient to verbalise feelings and concerns about altered body image, and to discuss the surgery and the stoma if one was created. • If applicable, teach the patient about colostomy care in an open, accepting manner and encourage him to talk about his feeling about the stoma. 21