INTERFERENCES TO ELIMINATION NEEDS

Cancer of the ColonFecal DiversionsUrinary Diversions2009

CANCER OF THE COLON

95% 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 patterns

Dull abdominal painMelena (black tarry

stools)

SYMPTOMSLEFT

SIDED LESIONS

(transverse & descending colon)

ObstructionAbdominal painCrampingConstipationDistentionBright red blood in

stool

SYMPTOMSRECTAL

LESIONS

Tenesmus (ineffective painful straining at stool)

Rectal painFeeling of incomplete

evacuation after a bowel movement

Alternating constipation and diarrhea

Hematochezia: passage of red blood via the rectum

METASTASIS

Lymph nodesLiver by way of the bloodstreamALSO:

– Lungs– Brain– Bones– Adrenal glands

Peritoneal seeding during surgery

DIAGNOSTIC LABORTORY TESTS

Fecal occult blood test (FOBT): indicates bleeding in the GI tract

False positive: foods, vitamins, drugsfor 48 hours before test – AVOID : meat, horseradish, beets– AVOID: vitamin C, ASA, ibuprofen, corticosteroids,

salicylatesTwo stool samples tested on 3 consecutive daysNEGATIVE RESULTS DO NOT R/O COLON

CANCER

DIAGNOSTIC LABORATORY TESTS

Alkaline Phosphatase and SGOT to look for metastasis to the liver

Carcinoembryonic antigen (CEA level); elevations indicate advanced adenocarcinoma; – See this elevated in 70% of people– levels drop after removal of tumor; elevation

at a later date indicate recurrence

DIAGNOSTIC EVALUATION DONE IN THE FOLLOWING ORDER

Rectal 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

TREATMENT

Surgical 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 surgery

Radiation/Chemotherapy

TYPES OF COLOSTOMIES

Ascending colostomy: done for right sided tumors

Transverse double barreled colostomy: can be done quickly for emergency intestinal obstruction; – 2 stomas– proximal closest to small intestine drains feces– the distal one drains mucous

TYPES OF COLOSTOMIES

Descending colostomy: Done for left sided tumors

Sigmoid colostomy:Done for rectal tumors

COLOSTOMY

Colostomies done on less than 1/3 of patients with colorectal cancer

DEFINED: surgical creation of an opening (stoma) into the colon

Temporary or permanentDrains the colon contents outside the bodyConsistency related to location in body

PREOP NURSING CARE

Adequate elimination of wastesReduce painMaintain fluid and electrolytesMaintain adequate nutritionReduce anxietyReview concerns about colostomy

BOWEL PREP

GOAL: to minimize bacterial growth and prevent complications

HOW: – 1-2 days clear liquids– Laxatives– Enemas– Ingests GoLYTELY: clears feces from colon– Oral or IV antibiotics day before surgery

POSTOP NURSING CARE

Maintain NGT to low suction 24-36 hrs (none for lap colon resection)– NPO, IV fluids, I & O

Maintain PCAAmbulateTEDS/ Sequential stockingsSQ HeparinProgress diet liquids to solids as tolerated

POSTOP NURSING CARE

Observe abdominal wound for infection, dehiscence, hemorrhage, edema

Splint abdominal incision during C & DBObserve perineal wound for bleeding, infection,

necrosisTeach colostomy care

POSTOP NURSING CARE CONTINUED

Teach 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 MANAGEMENT

from 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 common

Assess peristomal skin (no excoriation)

POSTOP COLOSTOMY CARE

CALL MD FOR: Signs of ischemia/necrosis: dark red,

purplish, black color, dry, firm, flaccidUnusual bleedingSeparation of stoma from wall

WOUNDS

For AP resection: perineal wound has JP drains

Serosanguineous drainage seen 1-2 moHealing takes 6-8 moPhantom rectal sensations commonRectal pain/itching common: benzocaine,

sitz baths

POSTOP COLOSTOMY CARE

Starts working 2-4 days postop May see lots of gas initially Stool initially liquid then becomes normal based on

location

– Ascending colon: liquid

– Transverse colon: pasty

– Descending colon: solid Stoma shrinks 6-8 wks after surgery: measure once week Wafer opening 1/8-1/16 inch larger than stoma pattern to

prevent constriction

COLOSTOMY CARE

When washing skin around stoma avoid moisturizing soaps; interferes with adhesion of appliance

Skin prep applied before putting on appliance to protect skin

Change bag if there is leakageSigmoid colostomy: irrigation regulates

elimination, but can be through diet

COMPLICATIONS OF COLOSTOMY

Prolapse of the stoma (due to obesity)Perforation (due to improper stoma

irrigation)Stoma retractionFecal impactionSkin irritationPulmonary complications

ILEOSTOMY

DEFINED: surgical creation of an opening into the ileum or small intestines usually by means of an ileal stoma on the abdominal wall

Permanent 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 NURSING

Intensive 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 folds

Teaching about ileostomy

POSTOPERATIVE NURSING

Observe 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 wall

Done 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 valve

Urine is drained by a catheter

URETEROSIGMOIDOSTOMY

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

CUTANEOUS URETEROSTOMY

Bringing detached ureter through abdominal wall

Attaching ureter to an opening in the skin