1 / 59

Colorectal Cancer

Colorectal Cancer. Brunner, pp. 1098-1107. Colorectal Cancer Statistics and Risk. Second 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

tyne
Télécharger la présentation

Colorectal Cancer

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Colorectal Cancer Brunner, pp. 1098-1107

  2. Colorectal Cancer Statistics and Risk • Second 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 • Risk factors p. 1099, Chart 38-9

  3. Manifestations • Maybe none for 5-15 years • Hematochezia or melena • Abdominal pain/cramping • Weakness, fatigue, anemia, weight loss • Change in bowel habits • Change in stool caliber • Fullness in lower abdomen or rectum or palpable mass

  4. Complications • Intestinal obstruction (pain, vomiting, distention, unusual bowel sounds, no stool) • Iron-deficiency anemia from blood loss • Perforation with peritonitis (sudden pain, distention, fever, sepsis) • Fistula formation

  5. Diagnostics • Colonoscopy is gold standard—polyps or tumors may be seen, but bx is confirmation. Starting at 50, then depending on findings, family hx—may be q 5 or q 10yr • Hemoccult or guaiac (FOB) • Barium enema • Labs: CBC, coag studies, liver functions, CEA—initial and to monitor treatment and recurrence • CT or MRI

  6. Collaborative Care: Surgery • Treatment depends on Dukes or TNM classification • Polypectomy during colonoscopy for in-situ • Colon resection (right or left hemicolectomy) with end-to-end anastomosis with lymph removal (lap procedures decrease recovery time) • Abdominal-perineal resection with ostomy • A-P resection with temporary ostomy to preserve anal sphincter. May include construction of rectal pouch. • If metastasized, surgery may be palliative to control bleeding or obstructive sx

  7. Chemo and Radiation Therapy • Treatment is highly individualized, but combo platters are usually used. Most common drugs: • 5-FU • Leucovorin • Xeloda • Mitomycin • Radiation as adjuvant or for metastasis to reduce tumor size & provide symptomatic relief

  8. 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

  9. Nursing Management: Objective Data • Pallor, cachexia, lymphadenopathy • Abd mass, distention, ascites, hepatomegaly • Hemoccult + stools, anemia • + DRE, + scopes, + radiography

  10. Preop Nursing Management • Preop teaching—may need ostomy teaching by wound care or ostomy care nurse, preferably • Dietary modifications may be done several days before surgery • Need info about bowel prep procedure • Bowel cleansing and or antibiotics to decrease contamination • Maybe need TPN before surgery • Need a lot of emotional support

  11. 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

  12. 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

  13. Patient Education • For screening: • FOB q yr • Patients > 50 to have routine colonoscopy; 45 in blacks—repeat q 10 y unless + hx • Teaching regarding colonoscopy prep • Teach patients how to recognize early warning signs • For postop: • Home instruction on sitz baths, wound & ostomy care, dietary management • Don’t forget psychosocial issues, sexual concerns & grief mgmt

  14. Prostate Cancer Brunner, pp. 1516-1530

  15. 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 98%

  16. Risk Factors • >50 y.o. • African American (twice as likely) • Family hx (father or brother twice as likely) • High fat diet, high red meat intake, Vitamin A supplements, low intake of fruits and vegs • Positive HPC1, BRCA1 and BRCA2 gene mutations

  17. 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 weakness, and perineal or rectal discomfort • Anemia, nausea, wt loss

  18. 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.

  19. Diagnostics • DRE reveals hard, nodular, asymmetrical gland • PSA>4 (not all elevations are cancer). For screening and monitoring success of tx • UA, CBC, Alkaline phosphatase • Transrectal US with needle bx • CT, MRI, bone scan

  20. Medical Management of Prostate Cancer • Depends on stage • Pharmacologic: androgen deprivation therapy or androgen antagonist therapy. Accomplished by giving meds such as Lupron (testicular suppression of androgen), or Eulexin (adrenal suppression). • External beam or brachytherapy (internal radiation with seed implants)—with or without surgery • Cryotherapy—liquid nitrogen placed into prostate • Watchful waiting—more common in elderly

  21. 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. 1525, Figure 49-4 • May also be done laproscopically and with nerve-sparing procedure • Orchiectomy may also be done if late stage (produces androgen suppression)

  22. Complications • Urinary incontinence • Erectile dysfunction • Hemorrhage • Urinary retention • Infection • Dehiscence • DVT and PE

  23. 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

  24. 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

  25. 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

  26. 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 • Management of ED—Viagra and penile implants

  27. Breast Cancer Brunner, pp. 1481-1503

  28. Overview * Factors used to help differentiate benign from malignant tumors include age, number of lumps, shape, consistency, mobility, tenderness, retraction. • BSE qmo beginning at age 20, but malignant lesions may not be palpable for 10 years; therefore mammography baseline 35-40 and qyr after 40. • Mutated cell doubles q30d; 30 doubling times for lump to get to 1 cm when it can become apparent

  29. Breast Cancer Statistics • Most common 2nd to skin cancer • Highest death rate 2nd to lung cancer • Over 200,000 new cases; almost 41,000 deaths each year • Incidence is increasing; deaths decreasing especially among young women • Localized cancers without node involvement have 5-yr survival rate of 98%

  30. Etiology and Risk Factors • Table 48-3 on p. 1483 shows gender, age, fa hx, personal hx, hormonal influences, parity, obesity, dietary factors, radiation exposure, and complicated benign disease as risk factors • Mutations in genes BRCA 1 and 2 increase risk, but can be reduced by having ovaries removed.

  31. Protective Factors and Prevention Strategies • Full-term pregnancy before age 30 • Breastfeeding (delays exposure to estrogen) • Exercise after menopause • Close surveillance with high risk patients using MRI • Tamoxifen or Evista for high risk patients • Prophylactic mastectomy

  32. Types of Breast Cancer • Ductal Carcinoma in Situ (noninvasive) • Confined to ducts • Mostly treated by simple mastectomy with radiation • Tamoxifen x 5 yrs for prophylaxis

  33. Types cont’d • Invasive Carcinoma—Most serious: • Infiltrating ductal –80% of all breast cancers; very hard on palpation; more likely to metastasize to lung, bone, liver, brain; poorest prognosis. • Infiltrating lobular—10-15%; arise from thickened areas and may occur at several sites; may spread to above areas and meninges; poor prognosis.

  34. Types cont’d • Invasive Carcinoma—Better outcomes: • Medullary—5%; encapsulated and large; fair prognosis. • Mucinous—3%; slow growing; good prognosis • Tubular—2%; metastasis rare; excellent prognosis

  35. Types cont’d • Invasive Carcinoma—Rare, serious types: • Inflammatory—1-3%; causes pain, redness, enlarged and firm breast, edema, nipple retraction; attention is sought early; spreads quickly; chemo, radiation, surgery • Paget’s Disease—1%; ductal type; scaly lesion, burning, itching around nipple-areola area; bx is needed for dx; tx as above

  36. Assessment (Chart 48-1, p. 1474) • Nontender • Fixed • Hard • Irregular border • Retraction • Dimpling • Usually upper outer quad • Lymphs, bone, lung sites most common sites of metastasis

  37. Diagnostics • BSE: includes inspection & palpation • Mammography • US • MRI (for women at high risk) • Biopsy: definitive; can reveal type and stage and whether tumor is estrogen dependent

  38. Breast Self-Exam (BSE), p. 1475-6 • Examine monthly , preferably after period, beginning at age 20 • Clinical exam q3yr 20-40; qyr after 40 • Examine in shower with soap and water • Look at breasts in mirror, then raise arms • Put hands on hips; then lean forward • Use a method to palpate entire breast tissue, including tail of Spence

  39. Mammography • Detects tumors using x-ray even before they are palpable (usually 1 cm-10 years) • Can show early cancer tissue changes if compared to previous x-rays • Yearly mammography starting at 40 (talk with MD if high-risk)

  40. Staging • Most women are Stage 2 @ time of dx • Survival Rates depend on: • Hormone receptors • Growth factor receptors (HER-2) • Tumor differentiation, size • Proliferation (number) • DNA content • Axillary node involvement

  41. Management

  42. Other Management • Hormone suppression by oophrectomy, removal of pituitary gland, or adrenal glands • Radiation (internal and external)—only in breast conserving procedures or with chest wall involvement • Pharmacologic—Hormones if tumor is hormone dependent; Antineoplastics—3 of 5 drugs being used

  43. Preop Nursing Management • Education about dx procedures, meds, postop wound care, managing chemo SEs, prosthetics • Physician will discuss treatment options and reconstruction • Emotional support—Use therapeutic communication and education to address many fears and anxieties r/t death, reoccurrence, txs, relationships, and finances

  44. Postop Nursing Management • Pain management (paresthesia is common) • Meds • Arm elevation • Drain management • Management of incision and dressing • Arm exercises (1491) • Emotional support • Education for home management

  45. Preventing Postop Complications • Hematoma—indicates internal hemorrhage. Monitor x 12h—if forms, call MD immediately • External hemorrhage • Infection—incision, etc. • Lymphedema—occurs more often in pts who have had axillary node dissection compared to sentinel node dissection • Injury and trauma to arm

  46. Radiation • External beam—most common • Brachytherapy with implant into lumpectomy site • Intraoperative radiation therapy (IORT)—intense radiation to surgical site after lump is removed

  47. Chemotherapy • Cytoxan, methotrexate, and fluorouracil regimen is most common • Taxol may be added for axillary node involvement • Hormonal therapy with Tamoxifen (estrogen blocker) for premenopausal women; Arimidex (enzyme inhibitor that prevents estrogen from forming) for postmenopausal • Targeted therapy using Herceptin which inactivates the HER-2 protein that makes tumor grow

  48. Reconstruction • Enables women to maintain a sense of wholeness and to balance other breast • Some women prefer prosthetics • In most cases, can be done immediately or within one year of mastectomy • Done in stages • More successful if women have realistic expectations and have reconstruction done as soon as possible

  49. Types of Reconstructive Surgery • Saline implant: • Temporary implant placed inside pectoralis muscle with port attached for injecting saline over a period of weeks. When tissue is stretched enough, permanent one is placed. • Advantages—office visits and OP surgery, less complications. • Disadvantages—less natural looking, synthetic material used

More Related