Colorectal Cancer Risk Factors - Article Example

Case study – Colorectal cancer Patient profile Giovani Carboni, a 56 year old man, has a market garden in a rural township. Mr. Giovani's wife and family drove 30km to take him to the nearest hospital because of his deteriorating health.   Subjective data: . Complains of bright red bleeding during a bowel movement . Family states that has become thinner over the past several months and has little appetite. . Describe feeling weak and being easily fatigued; he appears ill . Complains of abdominal pain and a feeling of fullness . Bowel pattern has episodes of constipation followed by diarrhea . No prior screening for colorectal cancer; family history of colorectal cancer is unknown. Objective data: Physical examination . Temperature: 38 degrees . Heart rate: 100 bpm; BP: 120/74mmHg . Weight: 63.6kg; height: 172.5cm . Mild palpation over transverse and descending colon elicits pain . Digital rectal examination revealed a mass. Laboratory test . Double-contrast barium enema showed two medium-sized tumors . Haematocrit: 26% . Hemoglobin level: 90g/L. (Brown &Edward,2005) Analysis of the condition: From the condition the patient is presented in with and from the lab and diagnostic study it could be seen that the patient is suffering from colorectal cancer. This could\d be assumed from the bleeding during bowel movement, feeling week and fatigued, thinning all due to blood loss, severity shown by low hemoglobin level, 90g?L ( normal for 50 years men is 140- 1774 g/L) and lower haematocrit value- 26% (normal- 40-54%), suggesting a impending addition of anemia. The feeling of fullness and alternating pattern of diarrhea and constipation, adds to the finding. The rectal scan confirms the presence of medium sized tumor. This warrants the start of immediate medication and further care. Additionally the complete family history has to be again obtained to look in for any hereditary condition that could ease up the process of proper diagnosis. Before getting into nursing care, it becomes impervious to understand the situation. Description of condition: Colorectal cancer described to be the third most common cancer occurring both in men and women. Statistics shows that by the year 2007, over 150,000 cases of colon and rectal cancer will be diagnosed, and more than 52,000 people will die from the disease, accounting for about 10% of all cancer-related deaths.( Brotzman and Russell Robertson ,2007) Colorectal cancer, also called colon cancer or large bowel cancer could be described as cancerous growths in the colon, rectum and appendix. Many colorectal cancers are thought to arise from adenomatous polyps- mushroom like growth, in the colon. As any other type, they are also usually benign, but at times develop into cancer. The main concern here is that often the colorectal cancer goes unnoticed in its early stage, almost symptom less till the advanced stage. (Chao etal.,2005). The main symptoms for the colorectal cancer are, change in bowel habits ,change in frequency (constipation and/or diarrhea), change in the quality of stools ,change in consistency of stools ,Bloody stools or rectal bleeding ,Stools with mucus ,Tarry stools Feeling of incomplete defecation or reduction in diameter of feces or rarely bowel obstruction . On other hand it can be constitutional symptoms. But generally Anemia, with symptoms such as dizziness, malaise and palpitations. Can be seen, clinically with manifestations as change in pallor, low hemoglobin level etc. also at times can be seen Anorexia, Asthenia, and weakness and Unexplained weight loss. These are the common symptoms seen. But when it reaches metastatic stage, symptoms as shortness of breath as in lung metastasis, Epigastric or right upper quadrant pain, as in liver metastasis can be seen.( Park etal.,2005) The main risk factors are age, with the risk increasing with age, polyps of colon, a family history of colon cancer or adenamotous polyposis, smoking, diet high in red meat and low in vegetables, fibers and fruits, physical inactivity, rarely exposure to virus, alcohol and other environmental factors. In our patient it could be seen that age and nutrition style could have been a reason as no family history or reports of smoking or alcohol consumption is seen. The diagnoses usually involves, Digital Rectal scan, Fecal occult blood test, endoscopy etc. other screening test involves, double contrast Barium enema, virtual colonoscopy, computed axial tomography, and blood test for proteins that may indicate the presence of tumor. (Jerome J. DeCosse etal.,1994) When observed the pathogenesis it could be seen that, colorectal cancer is a disease originating from the epithelial cells lining the gastrointestinal tract. Hereditary or somatic mutations in specific DNA sequences, among which are included DNA replication or DNA repair genes, and also the APC, K-Ras, NOD2 and p53 genes, lead to unrestricted cell division. Before starting the treatments the cancer has to be staged. As proposed by Dr Cuthbert E. Dukes in 1932, stage A- when tumor is confined to the wall, B- if tumor invades through the wall, C- lymph nodes involvement, D- distant metastasis. The list of treatment involves, surgery, chemotherapy, radiation, immunotherapy etc. the prognosis is that chances are high if detected in early stage. Treatment and nursing care: The management of colorectal cancer is a field that requires the involvement of a multidisciplinary team of caregivers to provide the best possible care and support for the patient. For this patient, the primary treatment of choice for colorectal cancer would be surgery. The filed of surgery in present day has increased to such a extent that , more advanced laparoscopic techniques are available for colon resection and cryosurgery at the stage of metastatic liver disease. Along with the surgery , after the post-operative recuperation, the radiation therapy, chemotherapy, and immunotherapy can be applied. In the latest decade, the use of adjunctive therapy is recommended as a thing to improve long-term patient outcome. The type of operative procedure suitable for Mr. Giovanni can be chosen as a method of treatment based on the tumor location within the colorectal area and adjacent organ involvement. (Groenwald & Frogge-Hansen,1997) Generally if the cancer in ascending colon is a right hemicolectomy, then a transverse colectomy procedure would be better choice, similarly for a descending/sigmoid colon resection by a left hemicolectomy would be optimal. Resection of a cancer in the rectum highly depends on the level of the lesion. An abdominoperineal resection is performed only if a condition arises where, anal sphincter function cannot be preserved, then the anus is removed. Thus before surgery from the diagnostic procedure, the site for colostomy is selected.( Finne,1991) The Preoperative teaching for the patient: Preoperative education sessions, the session that would prepare the patient for the surgery is aimed at both the patient and caregivers. Here the physician would explain about procedure and would answer the query technically. As a Nurse, it would be our responsibility to reinforce the information given to doctor by the practitioner. For example the patient has to be informed by the nursing in charge about the number and purpose of tubes and holders that would be hooked on to the patient as IV lines, foley catheters, nanogastric tubes catheters and colostomy bag. Other duty as a nursing care instructor would be to perform the preoperative preparation includes cleansing of the colon and rectum with a goal to reduce the bacteria level as low as possible. Then the patient would be put in low residue liquid diet, to achieve thorough bowel cleansing. Also can be given for drinking the isotonic lavage solution or GoLYTELY. Also to be administered the prophylactic broad-spectrum antibiotics at the scheduled times on the day before surgery. Intravenous (IV) antibiotics may be ordered prior to the operative procedure on the day of surgery. (Hampton etal.,1992) Post-operative care Nursing care of post-operative patients starts virtually immediately after a colon resection that includes monitoring of patient for signs of post-operative complications, aids tp control the pain, assist the patient with activity progression updates, and preparing the patient and caregivers for hospital discharge. Maintaining invasive lines (IV solutions) is also a post-operative concern and the clinician may choose to apply a bendable armboard to prevent displacement of the invasive line). The patient is generally kept NPO until bowel function returns. A nasogastric (NG) tube is connected to low suction to drain air and fluid from the intestinal tract to prevent distention. It becomes the duty of the nursing staff to monitor the amount, color, and consistency of NG output. To help prevent NG tube movement, an adhesive-back holder with a Velcro-type locking device can be used for 2 or more days with that help to keep NG tubes in place. These would be removed after the GI function returns to normal. After this oral diet would be started from a clear liquid diet that would eventually improve to soft/general diet. (Schwartz etal.,1991) The IV fluid replacement would be maintained to keep the patient’s fluid and electrolyte balanced during the post-operative period. Intake and output is to be recorded every 8 hours. A Foley catheter may be attached for 4 to 5 days to avoid over distention of the patient’s bladder and to accurately record the patient’s urinary output that can be held I place using a holder. Electrolytes, especially potassium, are to monitored regularly with regular laboratory evaluation. IV antibiotics may be administered for 24 to 48 hours post-operatively, unless the patient is exhibiting signs or symptoms of infection. To prevent the deep vein thrombosis and pulmonary emboli through venous return, a sequential compression device can be used. If it appears that the patient may be in prolonged bed rest , the patient may be placed on anticoagulant therapy, as subcutaneous heparin. To prevent post-operative venous stasis and lung atelectasis frequent and early ambulation must be performed. Also as a pain control measure the patient may be administered drug through patient controlled analgesic pump after explaining the procedure thoroughly to the patient. But still as a nursing care measure, patient has be evaluated frequently for potential side effects, which may include respiratory depression, sedation, itching, and nausea. Also the patient can be encouraged to practice for every hour. The use of an incentive spirometer may further encourage the patient to deep breath. Abdominal dressing if any has to be periodically checked for bleeding and peplaced. Also a drain can be implanted surgically. Evaluation of a colostomy stoma should reveal a dark pink or red color. If the stoma turns a dusky color, the physician should be notified, as blood flow may be compromised. (Desch etal.,2005) Post-operative complications Nursing involvement is essential in the early detection and intervention to minimize post-operative complications. After surgery for colorectal cancer, post-operative complications may include wound infection, anastomotic leakage, intestinal obstruction, urinary retention, and intra-abdominal abscess. Long-term effects after an abdominoperineal resection may include sexual dysfunction and impotence. (Figueredo,2003) Discharge planning The average length of stay for an individual who has an operative procedure for colorectal cancer is less than 5 days. Appropriate referrals need to be made at the time of hospital admission. The patient is referred to a Wound/Ostomy/Continence Nurse if he or she will have an abdominoperineal resection and permanent colostomy. Dietary services may be required to determine the patient’s caloric needs or dietary modifications secondary to the operative procedure. A social worker may become involved to aid with a smooth transition from hospital to home. (Renehan etal.,2002) Nursing staff should instruct the patient and caregiver about untoward complications, which may include fever, chills, shortness of breath, erythema of the incision line, wound separation, and more. They should be advised to call the physician if any of these complications occur. The type and necessity of adjunctive therapy may be made at the time of hospital discharge and can ask them to meet an oncologist or radiation oncologist as follow up measure. Also the blood relatives of patient may be advised to undergo medical test to diagnose any impending risk of colorectal cancer disposition in them. The next treatment would be chemotherapy or radiation therapy advised to reduce the size of tumor. Usually these therapies can be either used before, after or as replacement of surgery.( Jeffery etal.,2002). Many researches have indicated that most patients and their families usually after diagnosis want to know the truth about their illness, even though it might not be much appealing to them. But generally it becomes the duty of all healthcare professionals ethically to tell patients and families the truth about their illness, prognosis, and available treatment options, including hospice care. If done otherwise, it would withhold the patients and his family from making treatment and/or end-of-life choices that is consistent with their wishes. But the main reason for a prevailing strain in informing the patient is usually the fear of taking away a patient’s hope that makes a physician to with hold the prognosis result from the patient. (Meropol &Schulman,2007) When it comes to the case of cancer it is usually surrounded by strong ethical issues. It has become mandatory that the patient is informed by the health care professional about the clinical condition, available treatment, and prognosis and after care. As it is life threatening situation, ethically the obligation of both patient and their family becomes necessary. Conclusion Caring for patients with colorectal cancer requires a multidisciplinary approach. Each team member adds his or her particular expertise in a different specialty to the overall management of the patient with colorectal cancer with the ultimate goal to improve the patient’s outcome and quality of life. Thus as a nursing professional, their role is intricate when it comes to treating the colorectal cancer patient. A reflective approach, evidence based practice, planned care would benefit them. References: 1. Brown D and Edwards H, 2005. Lewis Medical Surgical Nursing 1st edition or 2nd edition, Elsesevier Australia. 2. Gregory L. Brotzman and Russell G. Robertson (2007). Colorectal Cancer Risk Factors. Colorectal Cancer. Retrieved on 2008-01-16. 3. Chao A, Thun MJ, Connell CJ, McCullough ML, Jacobs EJ, Flanders WD, Rodriguez C, Sinha R, Calle EE. Meat consumption and risk of colorectal cancer. JAMA 2005;293:172-82. PMID 15644544. 4. Park Y, Hunter DJ, Spiegelman D, Bergkvist L, Berrino F et al. Dietary fiber intake and risk of colorectal cancer: a pooled analysis of prospective cohort studies. JAMA 2005;294:2849-57. PMID 16352792. 5. Jerome J. DeCosse, MD; George J. Tsioulias, MD; Judish S. Jacobson, MPH (Feb 1994). "Colorectal cancer: detection, treatment, and rehabilitation". Retrieved on 2008-01-16 6. Dukes CE. The classification of cancer of the rectum. Journal of Pathological Bacteriology 1932;35:323. 7. Groenwald S, Frogge-Hansen M. Cancer Nursing: Principles & Practice. Jones & Bartlett, 1997. 8. Finne, CO III. Advances in colorectal cancer. J Enterostomal Therapy 1991; 18:82. 9. Hampton B, Bryant R. Ostomies & Continent Diversions: Nursing Management. Mosby, 1992. 10. Schwartz S, Shires G, Spencer F. Principles of Surgery. WB Saunders, 1994 11. Desch CE, Benson AB 3rd, Somerfield MR, et al; American Society of Clinical Oncology (2005). "Colorectal cancer surveillance: 2005 update of an American Society of Clinical Oncology practice guideline". J Clin Oncol 23 (33): 8512-9. 12. Figueredo A, Rumble RB, Maroun J, et al; Gastrointestinal Cancer Disease Site Group of Cancer Care Ontario's Program in Evidence-based Care. (2003). "Follow-up of patients with curatively resected colorectal cancer: a practice guideline.". BMC Cancer 3: 13. Renehan AG, Egger M, Saunders MP, O'Dwyer ST (2002). "Impact on survival of intensive follow up after curative resection for colorectal cancer: systematic review and meta-analysis of randomised trials". BMJ 324 (7341): 831-8. 14. Jeffery M, Hickey BE, Hider PN (2002). "Follow-up strategies for patients treated for non-metastatic colorectal cancer". Cochrane Database Syst Rev. CD002200.. 15. Meropol, N.J., Schulman, K.A. (Guest Editors) Reviews: Perspectives on the cost of cancer care. J. Clin. Oncol. 25(2):2007. Read More