INTERFERENCES TO ELIMINATION NEEDSCancer of the ColonFecal DiversionsUrinary Diversions2009

CANCER OF THE COLON95% AdenocarcinomaAge: over 50 yearsFamily history: 1st degree relativeHave history of chronic inflammatory bowel disease or polypsNO KNOWN CAUSE: 75% OF CASESRisk factors: diet high in fat, protein, beef, and low in fiber

SYMPTOMSRIGHT SIDED LESIONS:

Tumors can grow without disrupting bowel patternsDull abdominal painMelena (black tarry stools)

SYMPTOMSLEFT SIDED LESIONS(transverse & descending colon)ObstructionAbdominal painCrampingConstipationDistentionBright red blood in stool

SYMPTOMSRECTALLESIONSTenesmus (ineffective painful straining at stool)Rectal painFeeling of incomplete evacuation after a bowel movementAlternating constipation and diarrheaHematochezia: passage of red blood via the rectum

METASTASISLymph nodesLiver by way of the bloodstreamALSO: LungsBrainBonesAdrenal glandsPeritoneal seeding during surgery

DIAGNOSTIC LABORTORY TESTSFecal occult blood test (FOBT): indicates bleeding in the GI tractFalse positive: foods, vitamins, drugsfor 48 hours before test AVOID : meat, horseradish, beetsAVOID: vitamin C, ASA, ibuprofen, corticosteroids, salicylatesTwo stool samples tested on 3 consecutive daysNEGATIVE RESULTS DO NOT R/O COLON CANCER

DIAGNOSTIC LABORATORY TESTSAlkaline Phosphatase and SGOT to look for metastasis to the liverCarcinoembryonic antigen (CEA level); elevations indicate advanced adenocarcinoma; See this elevated in 70% of peoplelevels drop after removal of tumor; elevation at a later date indicate recurrence

DIAGNOSTIC EVALUATION DONE IN THE FOLLOWING ORDERRectal Exam (50% of tumors palpable on digital exam)Abdominal ExamBarium Enema (see polyps and small lesions)Sigmoidoscopy: (see lower colon, can do biopsy)***Colonoscopy: DEFINITIVE DX TESTCT scan confirms a masses and extent of disease

TREATMENTSurgical Intervention: colon resection (removal tumor & lymph nodes with reanastomosis)Colectomy (colon removal)Abdominal-perineal resection (removal of anus and rectum with a permanent colostomyCould have laparoscopic surgeryRadiation/Chemotherapy

TYPES OF COLOSTOMIESAscending colostomy: done for right sided tumorsTransverse double barreled colostomy: can be done quickly for emergency intestinal obstruction; 2 stomasproximal closest to small intestine drains fecesthe distal one drains mucous

TYPES OF COLOSTOMIESDescending colostomy: Done for left sided tumorsSigmoid colostomy:Done for rectal tumors

COLOSTOMYColostomies done on less than 1/3 of patients with colorectal cancerDEFINED: surgical creation of an opening (stoma) into the colonTemporary or permanentDrains the colon contents outside the bodyConsistency related to location in body

PREOP NURSING CAREAdequate elimination of wastesReduce painMaintain fluid and electrolytesMaintain adequate nutritionReduce anxietyReview concerns about colostomy

BOWEL PREPGOAL: to minimize bacterial growth and prevent complicationsHOW: 1-2 days clear liquidsLaxativesEnemasIngests GoLYTELY: clears feces from colonOral or IV antibiotics day before surgery

POSTOP NURSING CAREMaintain NGT to low suction 24-36 hrs (none for lap colon resection)NPO, IV fluids, I & OMaintain PCAAmbulateTEDS/ Sequential stockingsSQ HeparinProgress diet liquids to solids as tolerated

POSTOP NURSING CAREObserve abdominal wound for infection, dehiscence, hemorrhage, edemaSplint abdominal incision during C & DBObserve perineal wound for bleeding, infection, necrosisTeach colostomy care

POSTOP NURSING CARE CONTINUEDTeach high fiber, high roughage dietTeach to avoid foods that cause excessive odor and gas (broccoli, brussel sprouts, cauliflower, cucumbers, mushrooms, peas, cabbage, eggs, fish, beans, garlic, turnips, fish, peanuts, chewing gum, smoking, beer, skipping meals)Teach foods that avoid odors: buttermilk, cranberry juice, parsley, yogurt. Charcoal filters, pouch deodorizers, breath mint in pouchTeach to avoid foods that cause diarrhea (fruits, soda, coffee, tea, carbonated beverages)

POSTOP COLOSTOMY MANAGEMENTfrom OR with ostomy pouch in place or petrolatum gauze over stoma covered by dry sterile dressing; pouch laterAssess color and integrity stoma: moist, reddish pink, protrude from abdominal wall 3/4 inch, small amt of bleeding at stoma commonAssess peristomal skin (no excoriation)

POSTOP COLOSTOMY CARECALL MD FOR: Signs of ischemia/necrosis: dark red, purplish, black color, dry, firm, flaccidUnusual bleedingSeparation of stoma from wall

WOUNDSFor AP resection: perineal wound has JP drainsSerosanguineous drainage seen 1-2 moHealing takes 6-8 moPhantom rectal sensations commonRectal pain/itching common: benzocaine, sitz baths

POSTOP COLOSTOMY CAREStarts working 2-4 days postopMay see lots of gas initiallyStool initially liquid then becomes normal based on locationAscending colon: liquidTransverse colon: pastyDescending colon: solidStoma shrinks 6-8 wks after surgery: measure once weekWafer opening 1/8-1/16 inch larger than stoma pattern to prevent constriction

COLOSTOMY CAREWhen washing skin around stoma avoid moisturizing soaps; interferes with adhesion of applianceSkin prep applied before putting on appliance to protect skinChange bag if there is leakageSigmoid colostomy: irrigation regulates elimination, but can be through diet

COMPLICATIONS OF COLOSTOMYProlapse of the stoma (due to obesity)Perforation (due to improper stoma irrigation)Stoma retractionFecal impactionSkin irritationPulmonary complications

ILEOSTOMYDEFINED: surgical creation of an opening into the ileum or small intestines usually by means of an ileal stoma on the abdominal wallPermanent or TemporaryAllows for drainage of fecal matter (effluent) from the ileum to the outside of the bodyDrainage is liquid and occurs at frequent intervals

PREOPERATIVE NURSINGIntensive fluids, blood and protein replacementAntibioticsLow residue dietAbdomen marked for proper placement of stoma by surgeon or enterostomal therapist usually in the RLQ 2 inches below the waist crease away from skin foldsTeaching about ileostomy

POSTOPERATIVE NURSINGObserve stoma: pink to bright red and shinyFecal drainage begins 72 hours after surgery and is continuous draining into an ileostomy bagStrict I&O of urinary and fecal outputMaintain IV fluids; watch for electrolyte losses (Na and K)NGT initiallyAfter NGT removal, sips of clear liquids with progression to low residue diet Early ambulation

ILEAL CONDUIT URINARY DIVERSION (ILEAL LOOP)Oldest of the urinary diversion proceduresA portion of the ileum becomes a conduitUrine is diverted by implanting the ureter into a loop of ileum that is led out through the abdominal wallDone when bladder has to be removed for cancer of the bladder

CONTINENT ILEAL URINARY RESERVOIR (KOCK POUCH)Transplanting the ureters to an isolated segment of ileum (pouch) with a nipple like one way valveUrine is drained by a catheter

URETEROSIGMOIDOSTOMYUreters are surgically implanted into the sigmoid colon allowing urine to flow through the colon out of the rectum

CUTANEOUS URETEROSTOMYBringing detached ureter through abdominal wallAttaching ureter to an opening in the skin

*Family history: 1st degree relative 3-4 times greater risk sister, sibling, child

*Melena (black tarry stools): the tumors ulcerate and bleed intermittently so the stool is dark by the time it exits

*Obstruction: growth of tumor stops stool from passingAbdominal painCrampingNarrowing of stoolsConstipationDistention*Peritoneal seeding during surgery: Ca cells break off from tumor into peritoneal cavity

*Reduce anxiety: ostomate visitSurgeon will review risks for low rectal surgery: postop sexual dysfunction and urinary incontinence as a result of nerve damageReview concerns about colostomy

**Phantom rectal sensations common: symnpathetic innervation for rectal control has not been interrupted