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Colorectal Cancer Lewis, pp. 1035-1046 Concept 3, pp. 141-148 CSC pp. 691-696 Colorectal Cancer—statistics Third (ACS) leading cause of death from cancer Most are adenocarcinoma Approximately 70-75% occur in colon; 25-30% in rectum with ½ occurring in the rectosigmoid area Over ¾ of cancers come from polyps that spread into mucosal lining and into lymph system and then to liver*,lungs, bone, brain More common in men than women Mortality rates highest among blacks Colorectal Cancer—Risk Factors >50 y.o. PMH or FH Hx polyps, polyposis, or inflammatory bowel disease Obesity Inactivity Smoking ETOH Diet high in animal fat Manifestations Maybe none for 5-15 years Hematochezia or melena Abdominal pain/cramping Weakness, anemia, weight loss Change in bowel habits Change in stool caliber Fullness in lower abdomen or rectum or palpable mass Complications Intestinal obstruction (pain, vomiting, distention, unusual bowel sounds, no stool) Anemia from blood loss Perforation with peritonitis (sudden pain, distention, fever, sepsis) Fistula formation Diagnostics Colonoscopy is gold standard—polyps or tumors may be seen, but bx is confirmation Hemoccult or guaiac (FOB) CBC Coag studies Liver functions CEA—initial and to monitor treatment and recurrence CT or MRI Collaborative Care: Surgery Treatment depends on TNM classification Polypectomy during colonoscopy for in-situ Colon resection (right or left hemicolectomy) with endto-end anastomosis with lymph removal (lap procedures increase recovery time) Abdominal-perineal resection (rectal) with ostomy; lower abdominal resection (rectosigmoid) without ostomy to preserve anal sphincter If metastasized, surgery may be palliative to control bleeding or obstructive sx Chemo and Radiation Therapy Several options in pharmacology book. Treatment is highly individualized. Chemo for + lymph nodes using a triple combo of 5FU, leucovorin and usually one other drug If triple is not an option, then Xeloda Biologic and targeted therapies slow/prevent tumor growth by stopping vessel formation or inhibiting growth factors in tumor Radiation as adjuvant or for metastasis to reduce tumor size & provide symptomatic relief Nursing Management: History Colon, breast, ovarian cancer, familial or hereditary polyposis, inflammatory bowel dz, meds affecting bowel function High-fat, low-fiber diet Weakness, fatigue, anorexia, wt loss, N/V Bowel changes: urgency, bleeding, mucoid, black, gas, decrease in caliber, pain Nursing Management: Objective Data Pallor, cachexia, lymphadenopathy Abd mass, distention, ascites, hepatomegaly Hemoccult + stools, anemia + DRE, + scopes, + radiography Nursing Management: Preop Care Preop teaching—may need ostomy teaching by wound care or ostomy care nurse, preferably Need info about bowel prep procedure Bowel cleansing and or antibiotics to decrease contamination Postop Nursing Management If reanastamosis is done, then postop care is routine abdominal surgery. Incision may be large, but closed with staples. Remember to check incision, dressing, and drainage. Lap procedures will only have small midline incision and lap sites covered with Tegaderm Pt may have NGT or TPN. May be NPO, ice chips, or clear liqs depending on type of surgery Surgical Nsg Care cont’d Monitor for infection in any skin break Provide adequate pain control and give prophylacticly Monitor for signals of readiness to resume oral intake If abdominal-perineal surgery is done for extensive metastasis, care of both an abdominal and an open perineal wound and drain management is necessary. Ostomy care if indicated Probs with sexual dysfunction Patient Education For screening: – FOB q yr – Patients > 50 to have routine colonoscopy; 45 in blacks—repeat q 10 y unless + hx; flex sig q 5y – Teaching regarding colonoscopy prep – Teach patients how to recognize early warning signs For postop: – Home instruction on sitz baths, wound & ostomy care – Don’t forget psychosocial issues & grief mgmt Ostomies (1039) Ileostomy—small bowel; Colostomy—colon Sigmoid (permanent) most common; doublebarrel (temporary or permanent); transverse loop (temporary) Continent pouch—total colectomy with reanastamosis at ileoanal area with formation of an ileoanal pouch (J-pouch, Kock pouch) Prostate Cancer Lewis, pp. 1386-1391 Concept 3, pp. 169-175 Prostate Cancer Most common cancer in men and 2nd leading cause of death from cancer. 2/3 are over 65 y.o. Almost 30,000 die each year. Interestingly, early dx leads to cure. 5-year survival rate is 100% Risk Factors >50 y.o. African American (twice as likely) Family hx (father or brother twice as likely) High fat diet, Vitamin A supplements, low intake of fruits and vegs Vasectomy (more circulating testosterone) Manifestations of Prostate Cancer Asymptomatic at 1st Dysuria, urgency, frequency, hesitancy, dribbling, nocturia, retention, interrupted stream, inability to urinate, hematuria, oliguria Painful ejaculation, back, hip, leg pain and perineal or rectal discomfort and anemia, nausea, wt loss may be sx of metastasis Complications Metastasis to lymph nodes, bones, bladder, lungs, and liver Bone mets are especially painful because of spinal cord compression and destruction of pelvic bone, femoral head, or lumbosacral spine. Pain control is important aspect of care. Diagnostics DRE reveals hard, nodular, asymetrical gland PSA>4 (not all elevations are cancer). For screening and monitoring success of tx CBC for anemia; elevated alkaline phosphatase indicates malignancy Transrectal US; CT, MRI, bone scan, needle bx Medical Management of Prostate Cancer Depends on stage Pharmacologic: androgen deprivation therapy or androgen antagonist therapy (estrogen) Proscar (for BPH) may reduce risk; also black or cayenne pepper (capasazin) External beam or brachytherapy (internal radiation with seed implants)—with or without surgery Cryotherapy—liquid nitrogen placed into prostate Surgical Management Surgical tx includes radical prostatectomy (prostate, seminal vesicles, part of bladder neck and lymphs are removed) by one of three methods: suprapubic, retropubic, perineal—see p. 1389, Figure 55-5 May also be done laproscopically and with nerve-sparing procedure Orchiectomy may also be done if late stage Complications Urinary incontinence Erectile dysfunction Hemorrhage Urinary retention Infection Dehiscence DVT and PE Nursing Management: Health Promotion Teach importance of PSA and DRE beginning at age 50 and 45 for African Americans If risk factors are present, screening may need to be done earlier Teach symptoms of enlarged prostate and to seek help when it happens Stress high success rate with early detection Postop Nursing Management Monitor for return of sensation from spinal anesthesia and protect from injury Monitor 3-way Foley and CBI if used Keep CBI running at rate that keeps urine pink without clots Watch for hemorrhage FF, keep strict I&O (subtract CBI) Monitor surgical incision Postop Nursing Care cont’d After CBI is d/c, urine will be cranberry Monitor for clots—call MD for irrigation order Usually go home with cath; After cath is out, urine is racked (monitored by comparison samples) Push fluids! Clots must be prevented Expect bladder spasms and discomfort with first voiding which will be small Give analgesics and also antispasmodics (if ordered), stool softeners Emotional support Patient/Family Education after Surgery • • • • Catheter care and bag-switching Kegel exercises Wearing pad up to one year Avoid intraabdominal pressure: Valsalva, lifting, long trips, strenuous activity, sitting or walking for long periods • Caffeine restriction, FF, urine will be cloudy • Watch for bright red bleeding, infection, decreased UOP, incision, calf tenderness