NURSING PROCESS:THE PATIENT WITH COLORECTAL CANCER
The nurse completes a health history to obtain information about fatigue, abdominal or rectal pain (eg, location, frequency, dura-tion, association with eating or defecation), past and present elim-ination patterns, and characteristics of stool (eg, color, odor, consistency, presence of blood or mucus).
Additional informa-tion includes a history of IBD or colorectal polyps, a family his-tory of colorectal disease, and current medication therapy. The nurse identifies dietary habits, including fat and fiber intake, as well as amounts of alcohol consumed. The nurse describes and documents a history of weight loss.
Assessment includes auscultating the abdomen for bowel sounds and palpating the abdomen for areas of tenderness, dis-tention, and solid masses. Stool specimens are inspected for char-acter and presence of blood.
Based on the assessment data, the major nursing diagnoses may include the following:
• Imbalanced nutrition, less than body requirements, related to nausea and anorexia
• Risk for deficient fluid volume related to vomiting and de-hydration
• Anxiety related to impending surgery and the diagnosis of cancer
• Risk for ineffective therapeutic regimen management re-lated to knowledge deficit concerning the diagnosis, the sur-gical procedure, and self-care after discharge
• Impaired skin integrity related to the surgical incisions (ab-dominal and perianal), the formation of a stoma, and fre-quent fecal contamination of peristomal skin
• Disturbed body image related to colostomy
• Ineffective sexuality patterns related to presence of ostomy and changes in body image and self-concept
Potential complications that may develop include the following:
• Intraperitoneal infection
• Complete large bowel obstruction
• GI bleeding
• Bowel perforation
• Peritonitis, abscess, and sepsis
The major goals for the patient may include attainment of opti-mal level of nutrition; maintenance of fluid and electrolyte bal-ance; reduction of anxiety; learning about the diagnosis, surgical procedure, and self-care after discharge; maintenance of optimal tissue healing; protection of peristomal skin; learning how to ir-rigate the colostomy and change the appliance; expressing feel-ings and concerns about the colostomy and the impact on himself or herself; and avoidance of complications.
The patient anticipating surgery for colorectal cancer has many concerns, needs, and fears. He or she may be physically debili-tated and emotionally distraught with concern about lifestyle changes after surgery, prognosis, ability to perform in established roles, and finances. Priorities for nursing care include preparing the patient physically for surgery, providing information about postoperative care, including stoma care if a colostomy is to be created, and supporting the patient and family emotionally.
Physical preparation for surgery involves building the patient’s stamina in the days preceding surgery and cleansing and steriliz-ing the bowel the day before surgery. If the patient’s condition permits, the nurse recommends a diet high in calories, protein, and carbohydrates and low in residue for several days before surgery to provide adequate nutrition and minimize cramping by decreasing excessive peristalsis. A full-liquid diet may be pre-scribed 24 to 48 hours before surgery to decrease bulk. If the pa-tient is hospitalized in the days preceding surgery, PN may be required to replace depleted nutrients, vitamins, and minerals. In some instances, PN may be given at home before surgery. Anti-biotics such as sulfonamides, neomycin, and cephalexin are ad-ministered the day before surgery to reduce intestinal bacteria. The bowel is cleansed with laxatives, enemas, or colonic irriga-tions the evening before and the morning of surgery.
For the patient who is very ill and hospitalized, the nurse measures and records intake and output, including vomitus, to provide an accurate record of fluid balance. The patient’s intake of oral food and fluids may be restricted to prevent vomiting. The nurse administers antiemetics as prescribed. Full or clear liquids may be tolerated, or the patient may be allowed nothing by mouth. A nasogastric tube may be inserted to drain accumulated fluids and prevent abdominal distention. The nurse monitors the ab-domen for increasing distention, loss of bowel sounds, and pain or rigidity, which may indicate obstruction or perforation. It also is important to monitor intravenous fluids and electrolytes. Monitoring serum electrolyte levels can detect the hypokalemia and hyponatremia that occur with GI fluid loss. The nurse observes for signs of hypovolemia (eg, tachycardia, hypotension, decreased pulse volume), assesses hydration status, and reports decreased skin turgor, dry mucous membranes, and concentrated urine.
The nurse assesses the patient’s knowledge about the diagno-sis, prognosis, surgical procedure, and expected level of func-tioning after surgery. It is important to include information about the physical preparation for surgery, the expected appear-ance and care of the wound, the technique of ostomy care (if ap-plicable), dietary restrictions, pain control, and medication management in the teaching plan (see Plan of Nursing Care 38-1). If the patient will be admitted the day of surgery, the physician’s office may arrange for the patient to be seen by an enterostomal therapist in the days preceding surgery.
The therapist helps determine the optimal site for the stoma and provides teaching about care. If the patient is hospitalized before the day of surgery, the staff enterostomal therapist is involved in the pre-operative teaching. All procedures are explained in language the patient understands.
Patients anticipating bowel surgery for colorectal cancer may be very anxious. They may grieve about the diagnosis, the impend-ing surgery, and possible permanent colostomy. Patients under-going surgery for a temporary colostomy may express fears and concerns similar to those of a person with a permanent stoma. All members of the health care team, including the enterostomal therapy nurse, should be available for assistance and support. The nurse’s role is to assess the patient’s anxiety level and coping mechanisms and suggest methods for reducing anxiety such as deep-breathing exercises and visualizing a successful recovery from surgery and cancer. Other supportive measures include pro-viding privacy and teaching relaxation techniques to the patient. Time is set aside to listen to the patient who wishes to talk, cry, or ask questions. The nurse can arrange a meeting with a spiritual advisor if the patient desires or with the physicians if the patient wishes to discuss the treatment or prognosis. To promote patient comfort, the nurse projects a relaxed, professional, and empa-thetic attitude. See Nursing Research Profile 38-1 about the importance of spiritual well-being for patients with colorectal cancer.
The patient undergoing a colostomy may find the anticipated changes in body image and lifestyle profoundly disturbing. Be-cause the stoma is located on the abdomen, the patient may think that everyone will be aware of the ostomy. The nurse helps reduce this fear by presenting facts about the surgical procedure and the creation andmanagement of the ostomy. If the patient is recep-tive, the nurse can use diagrams, photographs, and appliances to explain and clarify. Because the patient is experiencing emotional stress, the nurse may need to repeat some of the information. The nurse provides time for the patient and family to ask questions; the nurse’s acceptance and understanding of the patient’s concerns and feelings convey a caring, competent attitude that promotes confidence and cooperation. Consultation with an enterostomal therapist during the preoperative period can be extremely helpful, as can speaking with a person who is successfully managing a colostomy. The United Ostomy Association provides useful in-formation about living with an ostomy through literature, lec-tures, and exhibits. Visiting services by qualified members and rehabilitation services for new ostomy patients are provided.
Postoperative nursing care for patients undergoing colon resec-tion or colostomy is similar to nursing care for any abdominal surgery patient, including pain management dur-ing the immediate postoperative period. The nurse also monitors the patient for complications such as leakage from the site of the anastomosis, prolapse of the stoma, perforation, stoma retraction, fecal impaction, skin irritation, and pulmonary complications as-sociated with abdominal surgery. The nurse assesses the abdomen for returning peristalsis and assesses the initial stool characteris-tics. It is important to help patients with a colostomy out of bed on the first postoperative day and encourage them to begin par-ticipating in managing the colostomy.
The nurse teaches all patients undergoing surgery for colorectal cancer about the health benefits to be derived from consuming a healthy diet. The diet is individualized as long as it is well bal-anced and does not cause diarrhea or constipation. The return to normal diet is rapid.
A complete nutritional assessment is important for patients with a colostomy. The patient avoids foods that cause excessive odor and gas, including foods in the cabbage family, eggs, fish, beans, and high-cellulose products such as peanuts. It is important to determine whether the elimination of specific foods is causing any nutritional deficiency. Nonirritating foods are substituted for those that are restricted so that deficiencies are corrected. The nurse advises the patient to experiment with an irritating food sev-eral times before restricting it, because an initial sensitivity may de-crease with time. The nurse can help the patient identify any foods or fluids that may be causing diarrhea, such as fruits, high-fiber foods, soda, coffee, tea, or carbonated beverages. Paregoric, bis-muth subgallate, bismuth subcarbonate, or diphenoxylate with at-ropine (Lomotil) help control the diarrhea. For constipation, prune or apple juice or a mild laxative is effective. The nurse sug-gests fluid intake of at least 2 L of fluid per day.
The nurse frequently examines the abdominal dressing during the first 24 hours after surgery to detect signs of hemorrhage. It is im-portant to help the patient splint the abdominal incision during coughing and deep breathing to lessen tension on the edges of the incision. The nurse monitors temperature, pulse, and respiratory rate for elevations, which may indicate an infectious process. If the patient has a colostomy, the stoma is examined for swelling (slight edema from surgical manipulation is normal), color (a healthy stoma is pink or red), discharge (a small amount of ooz-ing is normal), and bleeding (an abnormal sign).
If the malignancy has been removed using the perineal route, the perineal wound is observed for signs of hemorrhage. This wound may contain a drain or packing, which is removed grad-ually. Bits of tissue may slough off for a week. This process is hastened by mechanical irrigation of the wound or with sitz baths performed two or three times each day initially. The condition of the perineal wound and any bleeding, infection, or necrosis are documented.
The patient is observed for signs and symptoms of complications. It is important to frequently assess the abdomen, including de-creasing or changing bowel sounds and increasing abdominal girth, to detect bowel obstruction. The nurse monitors vital signs for increased temperature, pulse, and respirations and for decreased blood pressure, which may indicate an intra-abdominal infectious process. It is important to report rectal bleeding im-mediately because it indicates hemorrhage. The nurse monitors hematocrit and hemoglobin levels and administers blood com-ponent therapy as prescribed. Any abrupt change in abdominal pain is reported promptly. Elevated white blood cell counts and temperature or symptoms of shock are reported because they may indicate sepsis. The nurse administers antibiotics as prescribed.
Pulmonary complications are always a concern with abdomi-nal surgery; patients older than 50 years of age are at risk, espe-cially if they are or have been receiving sedatives or are being maintained on bed rest for a prolonged period. Two primary pul-monary complications are pneumonia and atelectasis. Frequent activity (eg, turning the patient from side to side every 2 hours), deep breathing, coughing, and early ambulation can reduce the risks for these complications. Table 38-6 lists possible postoper-ative complications.
The incidence of complications related to the colostomy is about one half that seen with an ileostomy. Some common com-plications are prolapse of the stoma (usually from obesity), per-foration (from improper stoma irrigation), stoma retraction, fecal impaction, and skin irritation. Leakage from an anastomotic site can occur if the remaining bowel segments are diseased or weak-ened. Leakage from an intestinal anastomosis causes abdominal distention and rigidity, temperature elevation, and signs of shock. Surgical repair is necessary.
The colostomy begins to function 3 to 6 days after surgery. The nurse manages the colostomy and teaches the patient about its care until the patient can take over. The nurse teaches skin care and how to apply and remove the drainage pouch. Care of the peristomal skin is an ongoing concern because excoriation or ul-ceration can develop quickly. The presence of such irritation makes adhering the ostomy appliance difficult, and adhering the ostomy appliance to irritated skin can worsen the skin condition. The effluent discharge and the degree to which it is irritating vary with the type of ostomy. With a transverse colostomy, the stool is soft and mushy and irritating to the skin. With a descending or sigmoid colostomy, the stool is fairly solid and less irritating to the skin. Other skin problems include yeast infections and aller-gic dermatitis.
If the patient wants to bathe or shower before putting on the clean appliance, micropore tape applied to the sides of the pouch will keep it secure during bathing. To remove the appliance, the patient assumes a comfortable sitting or standing position and gently pushes the skin down from the faceplate while pulling the pouch up and away from the stoma. Gentle pressure prevents the skin from being traumatized and any liquid fecal contents from spilling out. The nurse advises the patient to protect the peri-stomal skin by then washing the area gently with a moist, soft cloth and a mild soap. Soap acts as a mild abrasive agent to re-move enzyme residue from fecal spillage. The patient should re-move any excess skin barrier. While the skin is being cleansed, a gauze dressing can cover the stoma, or a vaginal tampon can be inserted gently to absorb excess drainage. After cleansing, the pa-tient pats the skin completely dry with a gauze pad, taking care not to rub the area. The patient can lightly dust nystatin (Myco-statin) powder on the peristomal skin if irritation or yeast growth is present.
Smoothly applying the drainage appliance for a secure fit re-quires practice and a well-fitting appliance. Patients can choose from a wide variety of appliances, depending on their individual needs.
The stoma is measured to determine the correct size for the pouch; the pouch opening should be about 0.3 cm (1⁄8 in) larger than the stoma. After the skin is cleansed according to the previously described procedure, the patient applies the peristomal skin barrier (ie, wafer, paste, or powder). Mild skin irritation may require dusting the skin with karaya or Stomahesive powder be-fore attaching the pouch. The patient removes the backing from the adherent surface of the appliance, and places the bag down over the stoma for 30 seconds. The patient empties or changes the drainage appliance when it is one-third to one-fourth full so that the weight of its contents does not cause the appliance to sep-arate from the adhesive disk and spill the contents. Most appli-ances are disposable and odor resistant; commercially prepared deodorizers are available.
For some patients, colostomy appliances are not always nec-essary. As soon as the patient has learned a routine for evacua-tion, bags may be dispensed with, and a closed ostomy appliance or a simple dressing of disposable tissue (often covered with plastic wrap) is used, held in place by an elastic belt. Except for gas and a slight amount of mucus, nothing escapes from the colostomy opening between irrigations. Colostomy plugs that expand on insertion to prevent passage of flatus and feces are available.
The purpose of irrigating a colostomy is to empty the colon of gas, mucus, and feces so that the patient can go about social and busi-ness activities without fear of fecal drainage. A stoma does not have voluntary muscular control and may empty at irregular intervals. Regulating the passage of fecal material is achieved by irrigating the colostomy or allowing the bowel to evacuate naturally with-out irrigations. The choice often depends on the individual and the type of the colostomy. By irrigating the stoma at a regular time, there is less gas and retention of the irrigant. The time for ir-rigating the colostomy should be consistent with the schedule the person will follow after leaving the hospital. Chart 38-9 delineates the irrigating procedure.
The patient is encouraged to verbalize feelings and concerns about altered body image and to discuss the surgery and the stoma (if one was created). A supportive environment and a supportive attitude on the nurse’s part are crucial in promoting the patient’s adaptation to the changes brought about by the surgery. If applicable, the patient must learn colostomy care and begin to plan for incorporating stoma care into daily life. The nurse helps the patient overcome aversion to the stoma or fear of self-injury by providing care and teaching in an open, ac-cepting manner and by encouraging the patient to talk about his or her feelings about the stoma.
The nurse encourages the patient to discuss feelings about sexu-ality and sexual function. Some patients may initiate questions about sexual activity directly or give indirect clues about their fears. Some may view the surgery as mutilating and a threat to their sexuality; some fear impotence. Others may express worry about odor or leakage from the pouch during sexual activity. Al-though the appliance presents no deterrent to sexual activity, some patients wear silk or cotton covers and smaller pouches during sex. Alternative sexual positions are recommended, as well as alternative methods of stimulation to satisfy sexual drives. The nurse assesses the patient’s needs and attempts to identify specific concerns. If the nurse is uncomfortable with this or if the patient’s concerns seem complex, it is appropriate for the nurse to seek assistance from an enterostomal therapy nurse, sex coun-selor or therapist, or advanced practice nurse.
Patient education and discharge planning require the combined efforts of the physician, nurse, enterostomal therapist, social worker, and dietitian. Patients are given specific information, in-dividualized to their needs, about ostomy care and signs and symptoms of potential complications. Dietary instructions are es-sential to help patients identify and eliminate irritating foods that can cause diarrhea or constipation. It is important to teach pa-tients about their prescribed medications (ie, action, purpose, and possible side effects).
The nurse reviews treatments (eg, irrigations, wound cleans-ing) and dressing changes and encourages the family to partici-pate. Because the hospital stay is short, the patient may not be able to become proficient in stoma care techniques before dis-charge. Many patients need referral to a home care agency and the telephone number of the local c hapter of the American Can-cer Society. The home care nurse goes to the home to provide fur-ther care and teaching and to assess how well the patient and family are adjusting to the colostomy. The home environment is assessed for adequacy of resources that allow the patient to ac-complish self-care. A family member may assume responsibility for purchasing the equipment and supplies needed at home.
Patients need very specific directions about when to call the physician. They need to know which complications require prompt attention (ie, bleeding, abdominal distention and rigidity, diarrhea, fever, wound drainage, and disruption of suture line). If radiation therapy is planned, the possible side effects (ie, anorexia, vomiting, diarrhea, and exhaustion) are reviewed.
Ongoing care of the patient with cancer and a colostomy often ex-tends well beyond the initial hospital stay. Home care nurses man-age ostomy follow-up care, manage the assessment and care of the debilitated patient, and coordinate adjuvant therapy. The home care visits also provide the nurse with opportunities to assess the patient’s physical and emotional status and the patient’s and fam-ily’s ability to carry out recommended management strategies. Visits from an enterostomal therapy nurse are available to the pa-tient and family as they learn to care for the ostomy and work through their feelings about it, the diagnosis of cancer, and the future. Some patients are interested in and can benefit from involvement in an ostomy support group.
Expected patient outcomes may include the following:
• Consumes a healthy diet
a) Avoids foods and fluids that cause diarrhea
b) Substitutes nonirritating foods and fluids for those that are restricted
• Maintains fluid balance
a) Experiences no vomiting or diarrhea
b) Experiences no signs or symptoms of dehydration
• Feels less anxious
a) Expresses concerns and fears freely
b) Uses coping measures to manage stress
• Acquires information about diagnosis, surgical procedure, preoperative preparation, and self-care after discharge
a) Discusses the diagnosis, surgical procedure, and post-operative self-care
b) Demonstrates techniques of ostomy care
• Maintains clean incision, stoma, and perineal wound
• Expresses feelings and concerns about self
a) Gradually increases participation in stoma and peri-stomal skin care
b) Discusses feelings related to changed appearance
• Discusses sexuality in relation to ostomy and to changes in body image
• Recovers without complications
a) Is afebrile
b) Regains normal bowel activity
c) Exhibits no signs and symptoms of perforation or bleeding
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