Colorectal cancer, commonly known as colon cancer, arises when polyps in the large intestine become cancerous. This condition’s risk escalates with age, with the majority of diagnoses occurring in individuals over 50. However, there’s a growing trend of colorectal cancer in younger adults aged 20 to 49, often linked to unhealthy eating habits, inactive lifestyles, obesity, family history, alcohol consumption, and lack of physical activity.
Complications from colon cancer can be severe, including metastasis, obstruction, perforation, fistula formation, and peritonitis.
This article delves into the crucial role of nursing in managing colon cancer, focusing specifically on nursing diagnoses, assessments, interventions, and care plans.
The Nursing Process in Colon Cancer Care
The management of colon cancer is closely tied to the tumor’s pathologic stage and typically involves a combination of surgery, chemotherapy, and radiation therapy. Nurses are integral throughout this journey, from initial screening to treatment and long-term follow-up.
Nurses are vital in identifying symptoms suggestive of colon cancer, educating patients about risk factors, providing comprehensive support during various treatment phases, and ensuring patients understand and adhere to their treatment plans.
Comprehensive Nursing Assessment for Colon Cancer
The nursing assessment is the foundational step in providing patient-centered care. It involves gathering holistic data – physical, psychosocial, emotional, and diagnostic. This section outlines both subjective and objective data pertinent to colon cancer.
Review of Health History
1. Identifying General Symptoms: Colon cancer often develops insidiously, with symptoms potentially absent until the disease progresses. Common signs and symptoms include:
- Fatigue
- Unexplained Weight Loss
- Abdominal Pain
- Blood in Stool
- Changes in Bowel Habits
- Bloating
- Diarrhea
- Constipation
2. Determining Bowel Habits: Any alterations in stool consistency, color, shape, and frequency warrant attention. Early indicators can also include lethargy, blood in the stool, and unintentional weight loss.
3. Tracking Family History: A detailed family history is crucial for identifying potential familial patterns and increased risk. Frequent screenings are essential for individuals with a family history of colon cancer or advanced polyps, especially in first-degree relatives (parents, siblings, or children) diagnosed before age 45.
4. Identifying Risk Factors: Several factors can increase the risk of colon cancer:
-
Modifiable Risk Factors:
- Obesity: Significantly increases colon and rectal cancer risk, particularly in men. Maintaining a healthy weight is a preventative measure.
- Physical Inactivity: A sedentary lifestyle raises colon cancer risk. Regular, moderate physical activity can mitigate this risk.
- Diet: High consumption of processed meats (hot dogs, deli meats, bacon) increases risk due to chemicals in salted, smoked, or cured meats. Low vitamin D, low fruit and vegetable intake, low fiber, and high-fat diets are also contributing factors.
- Smoking: Long-term tobacco use significantly elevates the risk of colorectal cancer and related mortality.
- Alcohol Consumption: Moderate to excessive alcohol intake is linked to increased colorectal cancer risk.
-
Non-Modifiable Risk Factors:
- Age: Risk increases significantly after age 50.
- Family History: Genetic predispositions.
- Personal History of Colorectal Polyps or Cancer: Increased recurrence risk.
- Inflammatory Bowel Disease (IBD): Chronic inflammation increases risk.
- Race/Ethnicity: African Americans have a higher incidence rate.
5. Reviewing Treatment History: Prior radiation therapy to the abdomen for other malignancies increases colon cancer risk.
Physical Assessment
1. Performing a Physical Examination: In early stages, physical findings may be subtle (fatigue, weight loss) or even normal. More advanced cases may present with:
- Rectal Bleeding
- Palpable Abdominal Mass
- Liver Enlargement (Hepatomegaly)
- Jaundice (yellowing of skin and eyes)
- Anemia (pallor)
- Ascites (fluid accumulation in the abdomen)
- Enlarged Abdominal Organs
- Edema (fluid accumulation, especially in legs and ankles)
2. Digital Rectal Exam (DRE): Assist the healthcare provider with DRE to palpate for rectal abnormalities. This exam, while limited in detecting colon cancer higher in the colon, can identify masses in the rectum and lower sigmoid colon.
Diagnostic Procedures
1. Encouraging Screening Tests: Routine screening is a powerful tool for early detection and prevention. Early detection significantly improves treatment outcomes as tumors are often smaller, localized, and easier to treat.
2. Assisting with Screenings: Screening tests are categorized into:
-
Stool-based Tests: Detect cancerous traces in stool. Less invasive but require more frequent execution.
- Fecal Immunochemical Test (FIT): Detects blood in stool using antibodies.
- Guaiac-based Fecal Occult Blood Test (gFOBT): Uses chemical reaction to detect hidden blood. Less specific, cannot identify blood origin.
- Stool DNA Test: Detects hidden blood and abnormal DNA segments from cancer or polyp cells.
-
Visual (Structural) Examinations: Examine colon and rectum structure for abnormalities.
- Colonoscopy: Visualizes the entire colon and rectum using a flexible tube with a camera. Allows for polyp removal and biopsy.
- CT Colonography (Virtual Colonoscopy): CT scan of the colorectal region detecting polyps or cancer. Creates 3D images; non-invasive, no sedation needed.
- Flexible Sigmoidoscopy: Similar to colonoscopy but examines only the rectum and lower colon.
3. Blood Sample Testing: Blood tests can provide supportive diagnostic information.
- Complete Blood Count (CBC): Detects anemia from chronic tumor bleeding.
- Liver Enzymes: May be elevated in cases of liver metastasis (hepatomegaly).
- Tumor Markers: Carcinoembryonic antigen (CEA) is the most common tumor marker for colon cancer, though not always elevated in early stages and not specific to colon cancer.
4. Biopsy Samples: Biopsy samples from colonoscopy or surgery are crucial for definitive diagnosis and staging. Further lab tests on biopsies classify cancer stage and guide treatment.
5. Reviewing Imaging Findings: Imaging provides crucial information about tumor location, size, and spread.
- Computed Tomography (CT or CAT) Scan: Assesses for metastasis to liver, lungs, or other organs.
- CT-guided Needle Biopsy: Obtains tissue samples for cancer screening, especially for suspected metastasis in lungs or liver.
- Ultrasound: Imaging of the colorectal region using sound waves.
- Magnetic Resonance Imaging (MRI) Scan: Detailed images of colon tissues, useful for visualizing tumors and polyps, particularly for rectal cancer staging.
- Chest X-ray: Detects lung metastasis.
- Positron Emission Tomography (PET) Scan: Often combined with CT scans to locate metabolically active cancerous cells, helpful for staging and recurrence detection.
6. Determining Cancer Stage: Staging (0-IV) indicates cancer extent and guides treatment. Stage 0 is earliest, Stage IV signifies metastasis. TNM staging (Tumor, Nodes, Metastasis) is commonly used.
Image: Microscopic view of colon cancer cells, illustrating the cellular abnormalities associated with the disease.
Nursing Interventions for Colon Cancer Patients
Nursing interventions are vital for patient recovery and well-being throughout the colon cancer journey.
Assisting with Cancer Treatment
1. Evaluating Therapies: Treatment strategies are tailored to cancer stage, location, and patient-specific needs. Surgery, chemotherapy, and radiation are common modalities. Nurse navigators play a crucial role in guiding patients through treatment.
2. Preparing for Surgical Procedures: Surgical resection is primary for localized colon cancer. Surgical options include:
- Laparoscopic Surgery: Minimally invasive approach.
- Open Resection: Traditional surgery for more complex cases.
- Temporary or Permanent Colostomy: May be necessary depending on tumor location and extent.
- Radiofrequency Ablation or Cryotherapy: For liver or lung metastasis, destroying cancer cells with heat or cold.
3. Educating on Adjuvant and Neoadjuvant Therapy:
- Neoadjuvant Therapy: Given before primary treatment (usually surgery) to shrink tumors, making resection easier and potentially improving outcomes.
- Adjuvant Therapy: Given after primary treatment to eliminate remaining cancer cells and reduce recurrence risk. Recommended for Stage III and high-risk Stage II colon cancer.
Adjuvant Therapy Examples:
- Chemotherapy: Systemic drugs to kill cancer cells, often post-surgery.
- Radiation Therapy: High-energy rays to kill cancer cells, can be used pre- or post-surgery.
- Targeted Therapy: Drugs targeting specific abnormalities in cancer cells to inhibit growth.
- Biological Therapy (Immunotherapy): Stimulates the body’s immune system to fight cancer cells.
4. Administering Palliative Therapy: For non-surgical patients with advanced cancer, palliative systemic chemotherapy manages symptoms and improves quality of life. Palliative care focuses on symptom relief and comfort, alongside other treatments.
5. Managing Treatment Side Effects: Cancer and its treatments cause side effects by affecting healthy tissues. Common side effects include:
- Neutropenia (low white blood cell count)
- Lymphedema (lymph node fluid buildup)
- Alopecia (hair loss)
- Nausea and Vomiting
- “Chemo Brain” (cognitive difficulties)
- Pain
- Blood Clots
- Fatigue
- Loss of Appetite (Anorexia)
- Depression
- Constipation or Diarrhea
Image: Illustration depicting chemotherapy administration, a common treatment modality for colon cancer, emphasizing the role of intravenous delivery.
Instructing on Ostomy Care
1. Teaching Ostomy Care: Surgical resection may result in an ostomy, connecting the colon to the skin via a stoma. Nurses monitor the ostomy for complications (bleeding, ischemia, retraction, prolapse).
2. Ostomy Nurse Referral: Living with an ostomy requires adjustment. Ostomy nurses educate on pouch application, skin care, appliance sizing, cleaning, and pouch management.
3. Avoiding Gas-Forming Foods: Certain foods increase gas, bloating, diarrhea, constipation, and odor. These include beans, cabbage, carbonated drinks, coffee, and beer. Advise gradual introduction of new foods to assess tolerance.
4. Managing Body Image Concerns: Colostomies can impact self-esteem. Educate patients that pouches are concealable under clothing and pouch covers are available.
5. Avoiding Contact Sports and Heavy Lifting: Patients should consult their healthcare provider before resuming heavy lifting or contact sports post-surgery to prevent complications.
Managing Pain
1. Administering Pain Medications: Pain management depends on severity and location. Over 70% of colon cancer patients experience pain. Options include:
- Over-the-counter pain relievers (acetaminophen, aspirin, ibuprofen)
- Oral and IV opioids (hydromorphone, morphine, oxycodone)
- Antidepressants (for neuropathic pain)
- Anti-seizure drugs (for neuropathic pain)
- Steroids (to reduce inflammation)
- Rectal suppositories (for local rectal pain)
2. Non-Pharmacological Pain Treatments: Acupuncture, massage, physical therapy, stress reduction, meditation, and hypnosis can complement medication. Medical marijuana may be an option in some regions.
3. Managing Treatment Side Effects: Pain medication side effects (constipation, nausea, insomnia) require management through medications, diet, aromatherapy, or dosage adjustments.
4. Sitz Baths: Warm sitz baths can relieve rectal pain.
Assisting the Patient in Coping
1. Addressing Thoughts and Feelings: Cancer diagnosis is emotionally challenging. Nurses provide support, listen to concerns, and offer reassurance.
2. Presenting Treatment Options: Informed decisions require understanding treatment benefits, risks, and uncertainties. Nurses help patients make optimal choices.
3. Involving Family and Caregivers: Family support is crucial. Include loved ones as the patient desires, as they provide emotional support and influence decisions.
4. Counseling Referral: Mental health professionals specialized in chronic or terminal illnesses can assist patients and families in coping with the emotional burden of cancer.
Educating on Risk Factors and Prevention
1. Managing Modifiable Risk Factors: While no guaranteed prevention exists, managing risk factors (smoking, diet, alcohol, inactivity) reduces risk.
2. Recommending Regular Screenings: Screening detects polyps before they become cancerous. Routine screening (stool tests, colonoscopy) is recommended for ages 45-75.
3. Lifestyle Modification: Diet rich in fruits and vegetables, limited processed meats, weight management, exercise, moderate alcohol, and smoking cessation are preventative measures.
4. Encouraging Supplements: Magnesium, calcium, and vitamin D may reduce colon cancer risk.
5. Hormone Therapy Consultation: Hormone therapy (estrogen replacement) may lower colorectal cancer risk in women; discuss with a healthcare provider.
Nursing Care Plans for Colon Cancer
Nursing care plans prioritize assessments and interventions based on identified nursing diagnoses, guiding short-term and long-term care goals. Examples for colon cancer include:
Death Anxiety
Patients with colon cancer, especially advanced stages, are at higher risk of death anxiety. This is a normal response, but can lead to stress and depression requiring intervention.
Nursing Diagnosis: Death Anxiety
Related to:
- Anticipation of Pain and Suffering
- Awareness of Imminent Death
- Depressive Symptoms
- Discussions about Death
- Low Self-Esteem
- Nonacceptance of Mortality
- Uncertainty about Afterlife and Prognosis
As evidenced by:
- Expressing Concern about Impact of Death on Family
- Deep Sadness
- Fear of Loneliness, Pain, Premature Death, Prolonged Dying, Separation, Suffering, Unknown
- Powerlessness
- Negative Thoughts about Death and Dying
Expected Outcomes:
- Patient will openly express feelings about dying.
- Patient will discuss realistic goals regarding condition and prognosis.
Assessment:
1. Psychosocial Maturity: Assess psychosocial maturity as it influences coping mechanisms and support needs. Women may experience higher death anxiety.
2. Fear of Death and Grief Stage: Evaluate fear of death and grief stage to tailor psychosocial support.
3. Cultural/Religious Beliefs: Understand cultural and religious beliefs as they impact coping and provide spiritual comfort.
Interventions:
1. Therapeutic Communication: Use therapeutic communication to build rapport and trust.
2. Life Planning Assistance: Assist with advanced care planning to improve end-of-life care and reduce stress.
3. Acknowledge Negative Feelings: Normalize fear, anger, and denial as natural responses to loss.
4. Life Review and Reminiscence: Encourage life review to promote acceptance and reduce distress.
5. Mental Health/Spiritual Services: Refer to chaplains or counselors for emotional and spiritual support.
Diarrhea
Changes in bowel habits, including diarrhea, are common colon cancer symptoms.
Nursing Diagnosis: Diarrhea
Related to:
- Disease Process
- Colorectal Tumor
- Tumor Fluid Leakage
As evidenced by:
- Abdominal Cramping and Pain
- Bowel Urgency
- Dehydration
- Blood in Stool
- Hyperactive Bowel Sounds
Expected Outcomes:
- Patient will maintain perianal skin integrity.
- Patient will use prescribed medications to manage diarrhea.
Assessment:
1. Defecation Patterns: Assess frequency, consistency, and associated symptoms (bloating, pain, urgency).
2. Stool Characteristics: Note blood, odor, or pus, which may indicate infection or trauma.
3. Abdominal Assessment: Inspect, auscultate, palpate, and percuss abdomen. Expect hyperactive bowel sounds.
Interventions:
1. Intake and Output Monitoring: Monitor for dehydration risk due to diarrhea.
2. Fluid Intake Encouragement: Promote adequate fluid intake to improve bowel consistency and hydration.
3. Dietitian Referral: Refer to a dietitian for dietary guidance to manage diarrhea and ensure nutritional needs are met.
4. Perianal Skin Care: Instruct on gentle cleaning, medicated wipes, and barrier creams to prevent skin breakdown.
5. Medication Administration: Administer antidiarrheal medications as prescribed.
Dysfunctional Gastrointestinal Motility
Colon cancer can disrupt gastrointestinal motility due to nerve and tissue damage.
Nursing Diagnosis: Dysfunctional Gastrointestinal Motility
Related to:
- Inflammatory Process
- Disease Process
- Malnutrition
- Sedentary Lifestyle
- Stressors
- Anxiety
- Changes in Eating Habits
As evidenced by:
- Abdominal Pain and Cramping
- Absence of Flatus
- Altered Bowel Sounds
- Diarrhea
- Distended Abdomen
- Difficulty Defecating
- Nausea and Vomiting
Expected Outcomes:
- Patient will be free from abdominal distention, cramping, and pain.
- Patient will have active bowel sounds and at least three formed stools per week.
Assessment:
1. History and Physical Assessment: Assess for bowel habit changes, rectal bleeding, abdominal pain, fatigue, and weight loss.
2. Bowel Sounds Assessment: Assess bowel sounds for hypoactivity or hyperactivity, which can indicate motility issues or obstruction. High-pitched sounds may suggest obstruction.
3. Diagnostic Studies Review: Review fecal occult blood tests, CT/PET scans, and colonoscopy results for abnormalities.
Interventions:
1. High-Fiber Diet: Encourage high-fiber foods to aid bowel movement and improve motility.
2. Exercise Encouragement: Promote exercise to stimulate peristalsis and improve motility.
3. Adequate Fluid Intake: Ensure sufficient fluid intake to soften stool and improve transit time.
4. Surgical Intervention Preparation: Prepare patient for possible colon resection to remove tumors and restore function.
5. Ostomy Care and Education: Provide ostomy care and educate patients and families on ostomy management if colostomy is performed.
Ineffective Tissue Perfusion
Colon cancer can lead to ineffective tissue perfusion due to tumor growth, obstruction, and complications.
Nursing Diagnosis: Ineffective Tissue Perfusion
Related to:
- Disease Process
- Cancer Progression
- Gastrointestinal Tract Damage
- Inflammatory Process
As evidenced by:
- Abdominal Pain and Tenderness
- Abdominal Distension
- Hypoactive Bowel Sounds
- Nausea and Vomiting
- Change in Bowel Habits
- Diarrhea or Constipation
- Bloody Stool
- Absence of Flatus
Expected Outcomes:
- Patient will remain free from perfusion complication signs (rectal bleeding, distension, vomiting, severe pain).
- Patient will have active bowel sounds without abdominal pain or bloating.
Assessment:
1. Abdominal Assessment: Thoroughly assess for masses, distension, ascites, and hepatomegaly (liver metastasis).
2. Diagnostic Studies Review: Assess blood tests for anemia and review colonoscopy, sigmoidoscopy, barium enema, and CT scan findings.
3. Bowel Sounds Assessment: Auscultate for bowel sounds; high-pitched or absent sounds may indicate obstruction.
Interventions:
1. Radiation Therapy Assistance: Assist with radiation therapy to control tumor growth and reduce perfusion complications.
2. Surgical Tumor Removal Preparation: Prepare patient for surgical resection to improve tissue perfusion.
3. Chemotherapy Administration: Administer adjuvant chemotherapy post-surgery to prevent recurrence and perfusion issues.
4. Prompt Intervention for Complications: Act quickly if peritonitis, obstruction, or perforation are suspected (severe pain, distension, fever, loss of bowel movements, vomiting).
Risk for Infection
Colon cancer patients are at increased risk of infection due to tumor invasion, necrotic tissue, and immunosuppression from chemotherapy.
Nursing Diagnosis: Risk for Infection
Related to:
- Chemotherapy
- Disease Process
- Surgical Interventions
- Colostomy
- Immunosuppression
As evidenced by:
Risk diagnosis, evidenced by risk factors, not signs and symptoms.
Expected Outcomes:
- Patient will remain free from infection.
- Patient will demonstrate infection control measures.
- Patient will demonstrate ostomy care (if applicable).
Assessment:
1. Risk Factor Assessment: Identify factors increasing infection risk (disease, chemotherapy, surgery, colostomy).
2. Vital Signs and Labs: Monitor vital signs and lab values (neutropenia, leukocytosis, fever, hypotension) for infection indicators.
Interventions:
1. Hand Hygiene: Emphasize and practice handwashing before and after patient care.
2. Isolation Precautions: Implement isolation during chemotherapy or radiation to prevent infection transmission.
3. Avoid Alcohol and Smoking: Advise abstinence from alcohol and smoking to optimize immune function.
4. Antibiotic Administration: Administer prophylactic antibiotics as ordered, especially for surgery or chemotherapy.
5. Incision and Ostomy Care Education: Instruct on proper incision and ostomy care to prevent infection at surgical sites.
Image: Illustration emphasizing handwashing with soap and water as a critical measure for infection prevention in healthcare settings and at home.
References
References as provided in the original article would be listed here.
