Case StudyCase Study

Cancer Lower Rectum

By: Sai Yee Lone

I.D. 5015332

Presented to A. Chusri Manokarn

28 September 2008

ColonColon

AnatomyAnatomy The large intestine The large intestine

that runs from the that runs from the cecum to the rectum. cecum to the rectum.

It consists of 6 parts;It consists of 6 parts; Cecum Cecum Ascending colonAscending colon Transverse colonTransverse colon Descending colonDescending colon Sigmoid colon, andSigmoid colon, and RectumRectum

Physiology of colonPhysiology of colon Approximately 500 ml of food pass through Approximately 500 ml of food pass through

the colon daily. the colon daily. Absorb and remove waterAbsorb and remove water May also absorb harmful materialsMay also absorb harmful materials To keep the body alkalized, and To keep the body alkalized, and Accommodate the colonization of billions of Accommodate the colonization of billions of

beneficial microorganisms to aid us in beneficial microorganisms to aid us in breaking down waste matter.breaking down waste matter.

What is Rectal Cancer? What is Rectal Cancer?

Rectum is the large bowel that lies in the Rectum is the large bowel that lies in the pelvis, terminating at the anus. pelvis, terminating at the anus.

Cancer Cancer of the rectum is the disease of the rectum is the disease characterized by the development of malignant characterized by the development of malignant cells of the rectum. cells of the rectum.

What is colon & rectal cancer? What is colon & rectal cancer?

Cancer that begins in the colon is called colon Cancer that begins in the colon is called colon cancer. cancer.

Cancer that begins in the rectum is called Cancer that begins in the rectum is called rectal cancer. rectal cancer.

Cancers affecting either of these organs may Cancers affecting either of these organs may also be called colorectal cancer. also be called colorectal cancer.

Pathophysiology Pathophysiology

Staging for Colon Cancer Staging for Colon Cancer

Stage 0. - Stage 0. - very early. It is found only in the very early. It is found only in the innermost lining of the colon or rectum. innermost lining of the colon or rectum.

Stage I.Stage I. - involves more of the inner wall of - involves more of the inner wall of the colon or rectum. the colon or rectum.

Stage II.Stage II. - spread outside the colon or rectum - spread outside the colon or rectum to nearby tissue, but not to the lymph nodes. to nearby tissue, but not to the lymph nodes.

Stage III. -Stage III. - spread to nearby lymph nodes, but spread to nearby lymph nodes, but not to other parts of the body.not to other parts of the body.

Stage IV. -Stage IV. - spread to other parts of the body. spread to other parts of the body.

Colorectal cancer tends to spread to the liver Colorectal cancer tends to spread to the liver and/or lungs. and/or lungs.

Recurrent cancer. -Recurrent cancer. - means the cancer has means the cancer has come back after treatment. The disease may come back after treatment. The disease may recur in the colon or rectum or in another part recur in the colon or rectum or in another part of the body. of the body.

Stage Primary Tumor (T)Regional Lymph Node

(N)Remote

Metastasis (M)

Stage 0

Carcinoma in situ N 0 M 0

Stage I

Tumor may invade submucosa (T1) or muscularis (T2)

N 0 M 0

Stage II

Tumor invades muscularis (T3) or perirectal tissues (T4)

N 0 M 0

Stage IIIA

T 1-4 N 1 M 0

Stage IIIB

T 1-4 N 2-3 M 0

Stage IV

T 1-4 N 1-3 M 1

Comparing theory with the caseComparing theory with the case Patient has partial gut obstruction regarding to cancer rectum Patient has partial gut obstruction regarding to cancer rectum

(adenocarcinoma). (adenocarcinoma). TNM staging; can be considered as Stage III. The cancer has TNM staging; can be considered as Stage III. The cancer has

spread to nearby lymph nodes, but not to other parts of the spread to nearby lymph nodes, but not to other parts of the body.body.

Stage III, T4, N1, and M0; and the characteristic of the cancer Stage III, T4, N1, and M0; and the characteristic of the cancer that extends to regional lymph nodes. (T4, N1, and M0). that extends to regional lymph nodes. (T4, N1, and M0).

He was performed colostomy. He was performed colostomy. He was on colostomy bag and waiting for the plan of He was on colostomy bag and waiting for the plan of

chemotherapy. chemotherapy.

(T= Tumors, N= Lymp Nodes, M= Metastasis)(T= Tumors, N= Lymp Nodes, M= Metastasis)

Signs & Symptoms Signs & Symptoms A change in bowel habitsA change in bowel habits

Diarrhea, constipation, or Diarrhea, constipation, or feeling that the bowel does feeling that the bowel does not empty completely not empty completely

Blood (either bright red or Blood (either bright red or very dark) in the stool very dark) in the stool

Stools that are narrower Stools that are narrower than usual than usual

General abdominal General abdominal discomfort (frequent gas discomfort (frequent gas pains, bloating, fullness, pains, bloating, fullness, and/or cramps) and/or cramps)

Weight loss with no known Weight loss with no known reason reason

Constant tiredness Constant tiredness

VomitingVomiting

Risk factorsRisk factors

Family history of colorectal cancerFamily history of colorectal cancer Family history of colonic polyps Family history of colonic polyps History of Ulcerative Colitis History of Ulcerative Colitis Personal history of cancer Personal history of cancer Over age 50 Over age 50

Comparing theory with the caseComparing theory with the case

The patient has general abdominal discomfort The patient has general abdominal discomfort (frequent gas pains, and/or cramps), (frequent gas pains, and/or cramps),

He has a change in bowel habits. He is also He has a change in bowel habits. He is also feeling that the bowel does not empty feeling that the bowel does not empty completely. completely.

Tiredness Tiredness Over age 50, but his family doesn’t have Over age 50, but his family doesn’t have

history of colorectal cancer.history of colorectal cancer.

Medical Medical DiagnosisDiagnosis

X-rays of the large intestine X-rays of the large intestine A sigmoidoscopy for examination under a A sigmoidoscopy for examination under a

microscope.microscope. A colonoscopy - to see inside the rectum A colonoscopy - to see inside the rectum A polypectomy is the removal of a polyp during a A polypectomy is the removal of a polyp during a

sigmoidoscopy or colonoscopy.sigmoidoscopy or colonoscopy. A biopsy is the removal of a tissue sample for A biopsy is the removal of a tissue sample for

examination under a microscope by a pathologist examination under a microscope by a pathologist to make a diagnosis. to make a diagnosis.

Comparing theory with the caseComparing theory with the case

He was ordered several diagnostic tests to He was ordered several diagnostic tests to identify his problems: identify his problems:

ColonoscopyColonoscopy Sigmoidoscopy Sigmoidoscopy X-rays of the large intestineX-rays of the large intestine X- rays of the lungs for pneumonia X- rays of the lungs for pneumonia

Treatment/ Treatment/ collaborative carecollaborative care

Most patients with rectal cancer required Most patients with rectal cancer required permanent colostomies (an opening at the permanent colostomies (an opening at the skin with a bag for stool drainage)skin with a bag for stool drainage). .

Radiation, and Radiation, and ChemotherapyChemotherapy The only chance for cure of a rectal cancer is The only chance for cure of a rectal cancer is

to remove it surgically.to remove it surgically.

Removal of the part of the rectum involved with Removal of the part of the rectum involved with tumor as well as: tumor as well as: a) the lymph glands that can potentially be involved a) the lymph glands that can potentially be involved

with tumor spread.with tumor spread. b) the blood vessels supplying that portion of the b) the blood vessels supplying that portion of the

rectum. rectum.

The decision-making process can be extremely The decision-making process can be extremely complicated. This process is tailored to the complicated. This process is tailored to the individual patient.individual patient. It is important to consult a It is important to consult a board certified colon and rectal surgeon who is board certified colon and rectal surgeon who is familiar with the current treatment strategies for familiar with the current treatment strategies for rectal cancer.rectal cancer.

Removal part of the rectum Removal part of the rectum

Complications of rectal Complications of rectal cancercancer lower GI bleeding, the differential

diagnosis includes colorectal cancer,

inflammatory bowel disease (ulcerative colitis or Crohn disease).,

Uremia foreign bodies, polyps, metastatic disease,

intestinal lymphomas, or Kaposi sarcoma involving the gut.

Causes of intestinal obstruction other than cancer include adhesions, peritonitis, inflammatory bowel disease, fecal impaction, strangulated bowels, and ileus.

Obstruction is less common for right-sided lesions because the ascending colon is wider than the distal colon and the fecal content is fluid.

Health Health EducationEducation

Even though we don't know exactly what causes colorectal cancer, there are Even though we don't know exactly what causes colorectal cancer, there are some steps you can take to reduce your risk.some steps you can take to reduce your risk.

Screening tests:Screening tests: the best way to help prevent the best way to help prevent Can found and remove , to be cured Can found and remove , to be cured

Diet: Diet: It is important to eat plenty of fruits, vegetables, and whole grain foods It is important to eat plenty of fruits, vegetables, and whole grain foods and to limit and to limit intake of high-fat foods, but not to eat the foods contain a lot gases; of high-fat foods, but not to eat the foods contain a lot gases; for example, beans.for example, beans.

Exercise: Exercise: Activity may be performed as tolerated.Activity may be performed as tolerated.

Vitamins: Vitamins: suggest that taking a daily multivitamin containing folic acid or suggest that taking a daily multivitamin containing folic acid or folate can lower colorectal cancer risk. Other studies suggest that getting more folate can lower colorectal cancer risk. Other studies suggest that getting more calcium and vitamin D can help.calcium and vitamin D can help.

Aspirins & other drugs: Aspirins & other drugs: Aspirin and drugs such as ibuprofen (Motrin, Advil) Aspirin and drugs such as ibuprofen (Motrin, Advil) or naproxen (Aleve) appear to prevent the growth of polyps.or naproxen (Aleve) appear to prevent the growth of polyps.

Nursing InterventionNursing Intervention Instruct in important of food intake.Instruct in important of food intake.

Provide regular dietary intake, limit fat food, Provide regular dietary intake, limit fat food, but do not even eat the food contains gases; but do not even eat the food contains gases; e.g., beans.e.g., beans.

Instruct patients to aware of infections. Instruct patients to aware of infections.

Provide colostomy bag care and hygiene care. Provide colostomy bag care and hygiene care.

Encourage patients to do exercise as tolerant.Encourage patients to do exercise as tolerant.

Instruct in self-care measure regarding diets, Instruct in self-care measure regarding diets, hygiene, exercise, and medication hygiene, exercise, and medication administration.administration.

Case StudyCase StudyNursing ManagementNursing Management

Sex:Sex: Male Male Age:Age: 78 yrs.78 yrs. Admission:Admission: 8 August 20088 August 2008 Diagnosis:Diagnosis: CA Lower RectumCA Lower Rectum Operation: Operation: Hight:Hight: 160 Cms 160 Cms Weight: Weight: 52 Kgs52 Kgs EducationEducation OccupationOccupation Language Language ReligionReligion Marital status Marital status

Health statusHealth status Chief complaintChief complaint

Present illnessPresent illness

Past illnessPast illness

Operation Operation

Underlying CA Underlying CA Rectum Rectum (Adenocarcinoma (Adenocarcinoma well differentiate)well differentiate)

Summarization of LaboratorySummarization of Laboratory WBC WBC 11 x 10^3/ul 11 x 10^3/ul (normal 4.5 – 10) (normal 4.5 – 10) (High) (High)

RBC RBC 3.38 x 10^6/ul 3.38 x 10^6/ul (normal 4.5 – 6.5) (normal 4.5 – 6.5) (Low) (Low)

Hemoglobin 9.4 g/dl Hemoglobin 9.4 g/dl (normal 13 – 18) (normal 13 – 18) (Low) (Low)

Hematocrit Hematocrit 27.7 % 27.7 % (normal 39 - 54 %) (normal 39 - 54 %) (Low) (Low)

Lymphocyte 15 x 10^3/ul Lymphocyte 15 x 10^3/ul (normal 150-400) (normal 150-400) (Low) (Low)

PT PT 19.7 sec19.7 sec (normal 10.5 – 12.5) (normal 10.5 – 12.5) (High) (High)

INR INR 9.6 sec 9.6 sec (normal 11.3 – 11.8) (normal 11.3 – 11.8) (Low) (Low)

Medical OrderMedical Order Vit-KVit-K 10 mg vein OD 10 mg vein OD (06:00)(06:00) AtivanAtivan (0.5 mg) x 1 hs. (0.5 mg) x 1 hs. (20:00)(20:00) Folic acid Folic acid 1 x 1 Oral Pc 1 x 1 Oral Pc (08:00)(08:00) MTV MTV 1 x 2 Oral Pc 1 x 2 Oral Pc (08:00) (08:00) LasixLasix 40mg 0.5 x 1 Feeding pc 40mg 0.5 x 1 Feeding pc FluimucilFluimucil 100mg 1 sac Oral tid. pc.100mg 1 sac Oral tid. pc. Air- XAir- X 1 x 3 Oral pc bid.1 x 3 Oral pc bid. ParacetamolParacetamol 500 x 2 tab prn. q 4-6 hr500 x 2 tab prn. q 4-6 hr IV medication:IV medication:a)a) Simbicort -Simbicort - 1 Puff x 2 vein at 6:00, 18:00 hr.1 Puff x 2 vein at 6:00, 18:00 hr.b)b) Ventolin - Ventolin - 2 puff vein prn.2 puff vein prn.

Nursing DiagnosisNursing Diagnosis

(1)(1) Abdominal distension r/t absence of passing stool Abdominal distension r/t absence of passing stool even by colostomy bag.even by colostomy bag.

Subjective data:Subjective data: Patient said that his abdominal discomfort was Patient said that his abdominal discomfort was

getting better. He passed stool one time this getting better. He passed stool one time this morning. He can not sleep well last night because he morning. He can not sleep well last night because he always feels thirty. always feels thirty.

He said that he wants to go home, and he wants to He said that he wants to go home, and he wants to eat by mouth. eat by mouth.

He told me that he drank a cup of Milo at 6 am. He told me that he drank a cup of Milo at 6 am.

Objective data:Objective data: Patient was on NG tube for receiving medication. Patient was on NG tube for receiving medication. Patient has tender abdomenPatient has tender abdomen On NPO (but the doctor let him drink water) On NPO (but the doctor let him drink water) On bed rest, supine position. On bed rest, supine position. Has colostomy bag at LLQ. Has colostomy bag at LLQ. Goal:Goal: - - To reduce abdominal distentionTo reduce abdominal distention

Expected Outcome:Expected Outcome: Patient will be able to pass stool by colostomy bag.Patient will be able to pass stool by colostomy bag. Abdominal distension will be absent. Abdominal distension will be absent.

(1) (1) Assess for V/S Assess for V/S

(2) Arrange for fowler’s position (2) Arrange for fowler’s position

(3) Provide clean and calm environment (3) Provide clean and calm environment

(4) Administer medications as prescribed:(4) Administer medications as prescribed:

a) Air- X (180 mg) 1 sac by NG tube oral pc., a) Air- X (180 mg) 1 sac by NG tube oral pc., b) provide IV drip Acetar-5 1000cc rate 80cc/hr b) provide IV drip Acetar-5 1000cc rate 80cc/hr

continuously continuously c) Vit- K 10 mg vein OD c) Vit- K 10 mg vein OD d) Ativan (0.5 mg) 1x1 hs.,d) Ativan (0.5 mg) 1x1 hs.,

Nursing InterventionNursing Intervention

(2)(2) Restlessness r/t coughing with a lot of sticky bubble Restlessness r/t coughing with a lot of sticky bubble sputum of secretion.sputum of secretion.

Subjective data:Subjective data: Patient said that he can’t sleep well, and coughs very often in Patient said that he can’t sleep well, and coughs very often in

order to remove sputum of secretion. order to remove sputum of secretion.

Objective data:Objective data: On NG tube On NG tube On Oxygen canula 6 Lpm On Oxygen canula 6 Lpm cough with bubble sputum of secretioncough with bubble sputum of secretion WBC = 11.00 x 10^3/uL (High, mild infection) WBC = 11.00 x 10^3/uL (High, mild infection) inadequate sleeping patterninadequate sleeping pattern

Nursing DiagnosisNursing Diagnosis

Goal:Goal: to reduce coughing, secretion and to promote rest.to reduce coughing, secretion and to promote rest.

Expected outcome:Expected outcome: no coughing, and sputum with bubble will be no coughing, and sputum with bubble will be

absent, and absent, and the patient will be able to sleep well.the patient will be able to sleep well.

(1)Assess for V/S (1)Assess for V/S

(2) Assess for O2 canula saturation (2) Assess for O2 canula saturation

(3) Arrange fowler’s position (3) Arrange fowler’s position

(4) Administer medication as doctor’s ordered: (4) Administer medication as doctor’s ordered: a) Fluimucil (100 mg) 1 sac + 1 glass of a) Fluimucil (100 mg) 1 sac + 1 glass of

water water b) Ativan (0.5 mg) 1x1 hs., b) Ativan (0.5 mg) 1x1 hs.,

Nursing InterventsionNursing Interventsion

Nursing DiagnosisNursing Diagnosis

(3)(3) Inadequate hygiene care r/t uncomfortable physical movement Inadequate hygiene care r/t uncomfortable physical movement regarding to retaining on colostomy bag, NG tube, and regarding to retaining on colostomy bag, NG tube, and condom catheter for so long time.condom catheter for so long time.

Subjective data:Subjective data: He said that he felt itchy in the head. He said that he felt itchy in the head. He didn’t take a shower for 2 months. He didn’t take a shower for 2 months.

Objective data:Objective data: He had dandruffs on the head. He had dandruffs on the head. NG tubeNG tube colostomy bagcolostomy bag condom catheter condom catheter PT = 19.7 sec (High)PT = 19.7 sec (High)

Goal:Goal: To promote hygiene care and to prevent To promote hygiene care and to prevent

injuriesinjuries

Expected outcome:Expected outcome: Patient will feel fresh and show good mood. Patient will feel fresh and show good mood. no dandruffs no dandruffs no s/s of infectionno s/s of infection no rupture skin no rupture skin

Nursing InterventionNursing Intervention

(1) Assess patient’s v/s in q 4 hr. (1) Assess patient’s v/s in q 4 hr. (2) Provide hair shampoo at bed (2) Provide hair shampoo at bed (3) Provide NG tube care (3) Provide NG tube care (4) Provide Catheter care and perineum care (4) Provide Catheter care and perineum care (5) Colostomy bag care (5) Colostomy bag care (6) Provide bed bathing (6) Provide bed bathing

Patient ActionPatient Action

EvaluationEvaluation Patient has a lot of secretion and clear Patient has a lot of secretion and clear Patient can sleep at night; even can take a nap in day Patient can sleep at night; even can take a nap in day

time. time. Abdominal distention was absent.Abdominal distention was absent. patient can receive BD well by NG tube. patient can receive BD well by NG tube. Patient’s stool can drainage, but contains a lot of Patient’s stool can drainage, but contains a lot of

gases. gases. Whether the patient’s condition is better. Whether the patient’s condition is better. Observe general s/s by performing physical Observe general s/s by performing physical

education. education.

ConclusionConclusion Patient is Thai male, age 78. He is well conscious. Patient is Thai male, age 78. He is well conscious. He was underlying Cancer Lower Rectum (Adenocarcinoma well He was underlying Cancer Lower Rectum (Adenocarcinoma well

differentiate). differentiate). He was readmitted on 8 August 2008. Two days before admission, he He was readmitted on 8 August 2008. Two days before admission, he

had difficult breathing, edema at both arms and legs, and he could not had difficult breathing, edema at both arms and legs, and he could not eat. eat.

Now he is waiting for the plan of chemotherapy. Now he is waiting for the plan of chemotherapy. He can’t perform self-care by himself properly. He can’t perform self-care by himself properly. He is on NG tube for feeding, on oxygen canula 6 lpm, on IVF Acetar He is on NG tube for feeding, on oxygen canula 6 lpm, on IVF Acetar

1000cc vein 80cc per hour to maintain body electrolyte balance. 1000cc vein 80cc per hour to maintain body electrolyte balance. In addition, he has colostomy bag at Left Lower Quadrant to collect In addition, he has colostomy bag at Left Lower Quadrant to collect

stools drainage. stools drainage. He was also on condom catheter to collect his output. He was also on condom catheter to collect his output. He was still admitted to receive his healthcare services. However, his He was still admitted to receive his healthcare services. However, his

vital signs are normal. vital signs are normal.

ReferenceReference

Adult Health Nursing., Christensen Kockrow. Adult Health Nursing., Christensen Kockrow. (2006) (2006)

http://www.colonrectalcare.com/ http://www.colonrectalcare.com/ http://www.colonrectal.net/cancermanagement.htm http://www.colonrectal.net/cancermanagement.htm

http://www.thefreedictionary.com/ http://www.thefreedictionary.com/ http://www.google.co.th/ http://www.google.co.th/ http://www.wikipedia.org/ http://www.wikipedia.org/ http://www.nlm.nih.gov/medlineplus/http://www.nlm.nih.gov/medlineplus/