Colorectal cancer, commonly known as colon cancer, arises when abnormal growths, or polyps, in the large intestine become cancerous. This condition poses a significant health concern, with risk escalating with age, particularly affecting individuals over 50. However, there’s a concerning rise in cases among younger adults aged 20 to 49, linked to factors like unhealthy dietary habits, sedentary lifestyles, obesity, family history of the disease, alcohol consumption, and lack of physical activity.
If left unaddressed, colon cancer can lead to severe complications, including metastasis (spread to other body parts), bowel obstruction, perforation, fistula formation, and peritonitis.
This guide delves into the crucial role of nursing in managing colon cancer, from initial screening to ongoing care and prevention. Nurses are integral throughout the patient journey, participating in screening processes, treatment administration, and follow-up care. They are vital in identifying early symptoms, educating patients about risk factors, providing support during various treatments, and ensuring patients understand and adhere to their care plans.
Nursing Process in Colon Cancer Care
Effective management of colon cancer is dictated by the tumor’s pathologic stage and often involves a combination of surgery, chemotherapy, and radiation therapy. Nurses are central to patient care, starting from early detection through screening to treatment and long-term preventive strategies.
Nurses are crucial in spotting symptoms suggestive of colon cancer and advising patients about their individual risk profiles. They offer essential support throughout diverse treatment approaches and deliver patient education to foster understanding and treatment adherence.
Nursing Assessment for Colon Cancer
The nursing assessment forms the cornerstone of care. During this phase, nurses gather comprehensive data encompassing physical, psychosocial, emotional, and diagnostic aspects. This section will outline both subjective and objective data pertinent to colon cancer.
Review of Health History
1. Identify General Symptoms: Colon cancer often progresses slowly, with symptoms potentially emerging only in advanced stages. Common signs and symptoms include:
- Fatigue
- Unexplained weight loss
- Abdominal pain
- Blood in the stool
- Changes in bowel habits
- Bloating
- Diarrhea
- Constipation
2. Determine Bowel Habits: Any alterations in stool consistency, color, shape, and frequency warrant attention. Early indicators of colon cancer may also include lethargy, blood in the stool, and unintentional weight loss.
3. Track Family History: A detailed family history is essential for identifying potential genetic predispositions. Increased screening frequency is recommended for individuals with a family history of colon cancer or advanced polyps, especially in first-degree relatives (parents, siblings, or children). The risk is further elevated if the affected family member was diagnosed before age 45.
4. Identify Risk Factors: Several factors increase the risk of colon cancer:
- Modifiable Risk Factors:
- Obesity: Obesity is a significant risk factor for colon and rectal cancer, particularly in men. Maintaining a healthy weight is crucial for risk reduction.
- Physical Inactivity: Lack of physical activity increases colon cancer risk. Regular, moderate-intensity exercise can help mitigate this risk.
- Diet: Diets high in processed meats (hot dogs, deli meats, bacon), salted, smoked, or cured meats, and low in fruits, vegetables, and fiber elevate the risk. Low vitamin D levels are also implicated.
- Smoking: Long-term tobacco use significantly increases the likelihood of developing and dying from colorectal cancer.
- Alcohol Consumption: Moderate to excessive alcohol intake is linked to an increased risk of colorectal cancer. Even modest drinking may pose some risk.
5. Review Treatment History: Prior radiation therapy to the abdomen for other cancers can increase the risk of colon cancer.
Physical Assessment
1. Perform Physical Examination: In the early stages, physical exam findings may be subtle or normal, possibly including fatigue or weight loss. More advanced cases might present with:
- Rectal bleeding
- Palpable abdominal mass
- Liver enlargement (hepatomegaly)
- Jaundice (yellowing of skin and eyes)
- Anemia (low red blood cell count)
- Pallor (pale skin)
- 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 a DRE. This procedure involves inserting a lubricated, gloved finger into the rectum to palpate for any abnormalities.
Diagnostic Procedures for Colon Cancer
1. Encourage Screening Tests: Regular screening is a powerful tool in preventing and detecting colorectal cancer early when it’s most treatable. Early detection often reveals smaller, localized tumors that are easier to manage.
2. Assist with Screenings: Screening tests are categorized into:
-
Stool-based Tests: These tests detect cancerous indicators in stool samples. They are less invasive but require more frequent administration.
- Fecal Immunochemical Test (FIT): Uses antibodies to detect blood in the stool.
- Guaiac-based Fecal Occult Blood Test (gFOBT): Employs a chemical reaction to identify hidden blood in stool, but it cannot pinpoint the blood’s origin.
- Stool DNA Test: Analyzes stool for hidden blood and specific abnormal DNA segments from cancer or polyp cells.
-
Visual (Structural) Examinations: These procedures examine the structure of the colon and rectum for abnormalities.
- Colonoscopy: A flexible tube with a light and camera is inserted into the anus to visualize the entire colon and rectum. Polyps or suspicious areas can be biopsied or removed during this procedure.
- CT Colonography (Virtual Colonoscopy): A CT scan of the colorectal region detects abnormal tissue like polyps or cancer, creating 3D images of the colon and rectum’s interior. It’s less invasive and usually doesn’t require sedation.
- Flexible Sigmoidoscopy: Similar to colonoscopy but examines only the lower part of the colon using a sigmoidoscope.
3. Blood Tests: Blood samples are analyzed for:
- Complete Blood Count (CBC): Detects anemia, which can result from chronic bleeding from the tumor.
- Liver Enzymes: May be elevated if liver metastasis (spread) has occurred, causing liver enlargement.
- Tumor Markers: Substances produced by cancer cells, such as Carcinoembryonic Antigen (CEA), can be detected in the blood and may be elevated in colon cancer.
4. Biopsy: Tissue samples obtained during colonoscopy or surgery are sent for laboratory examination to confirm cancer diagnosis, determine cancer stage, and guide treatment decisions.
5. Imaging Findings Review:
- Computed Tomography (CT) Scan: Helps assess if colon cancer has spread to the liver, lungs, or other organs.
- CT-guided Needle Biopsy: A CT scan guides needle insertion to obtain a tissue sample for biopsy, useful for assessing metastasis in organs like the lungs or liver.
- Ultrasound: Uses sound waves to create images of the colorectal region.
- Magnetic Resonance Imaging (MRI) Scan: Provides detailed images of soft tissues in the colon, helping visualize tumors, polyps, or abnormal tissues.
- Chest X-ray: Detects potential spread of colon cancer to the lungs.
- Positron Emission Tomography (PET) Scan: Often combined with CT scans to identify cancerous cells and assess the extent of cancer spread.
6. Cancer Staging: Staging determines the extent of cancer in the body, influencing treatment strategies and prognosis. Stages range from 0 (earliest) to IV (metastatic).
Nursing Interventions for Colon Cancer
Nursing interventions are critical to patient recovery and well-being. This section outlines essential nursing interventions for patients with colon cancer.
Assist With Cancer Treatment
1. Evaluate Therapies Based on Stage and Patient Needs: Treatment approaches are tailored to the cancer stage, location, and individual patient factors. Surgery, chemotherapy, and radiation therapy are common modalities. Nurse navigators often guide patients through their treatment journey.
2. Prepare for Surgical Procedures: Surgical resection is the primary treatment for localized colon cancer. Other surgical options include:
- Laparoscopic surgery (minimally invasive)
- Temporary or permanent colostomy (creating an opening in the abdomen for waste removal)
- Radiofrequency ablation or cryotherapy (for liver or lung metastases)
3. Educate on Adjuvant Therapy: Adjuvant therapy aims to prevent cancer recurrence by eliminating any remaining cancer cells post-surgery.
- Neoadjuvant therapy: Given before primary treatment (usually surgery) to shrink the tumor.
- Adjuvant therapy: Recommended for stage III (node-positive) and high-risk stage II colon cancer.
Examples of adjuvant therapies:
- Chemotherapy: Drugs to kill cancer cells, often used after surgery, especially if cancer is advanced or has spread to lymph nodes.
- Radiation therapy: High-energy rays to destroy cancer cells, used before surgery to shrink large tumors or after surgery to eradicate remaining cells.
- Targeted therapy: Drugs targeting specific abnormalities in cancer cells to inhibit their growth.
- Biological therapy (Immunotherapy): Utilizes the body’s immune system to fight cancer cells.
4. Administer Palliative Therapy: For non-surgical patients with advanced cancer, palliative systemic chemotherapy can manage symptoms and improve quality of life. Palliative care focuses on symptom relief and enhancing patient comfort, alongside any curative treatments.
5. Manage Treatment Side Effects: Cancer treatments can cause side effects by affecting healthy tissues. Common side effects include:
- Neutropenia (low white blood cell count)
- Lymphedema (swelling due to lymph node blockage)
- Alopecia (hair loss)
- Nausea and vomiting
- “Chemo brain” (cognitive difficulties)
- Pain
- Blood clots
- Fatigue
- Loss of appetite (anorexia)
- Depression
- Constipation or diarrhea
Instruct on Ostomy Care
1. Teach Ostomy Care: Surgical resections may result in an ostomy, connecting the colon to the skin through a stoma. Nurses must monitor the ostomy for complications like bleeding, ischemia, retraction, and prolapse.
2. Refer to Ostomy Nurse: An ostomy nurse provides specialized education on ostomy care, including pouch application, skin protection, appliance sizing, cleaning, and pouch emptying.
3. Advise on Diet: Certain foods can cause gas, bloating, diarrhea, constipation, and digestive issues. Foods to be cautious with include:
- Beans
- Cabbage
- Carbonated beverages
- Coffee
- Beer
Gas-producing and odorous foods can cause pouch swelling and unpleasant smells. Patients should try new foods at home first to understand their digestive effects.
4. Address Body Image Concerns: Colostomies can impact body image and self-esteem. Educate patients that pouches can be discreetly worn under clothing and pouch covers are available.
5. Caution Against Heavy Lifting and Contact Sports: Patients should consult their healthcare provider before engaging in heavy lifting or contact sports post-surgery to allow for proper incision healing and prevent complications.
Manage Pain
1. Administer Pain Medications: Pain management strategies depend on pain severity and location. Over 70% of colon cancer patients experience pain. Medications may include:
- Over-the-counter pain relievers (acetaminophen, aspirin, ibuprofen)
- Oral and IV opioids (hydromorphone, morphine, oxycodone)
- Antidepressants
- Anti-seizure drugs
- Steroids
- Rectal suppositories
2. Offer Non-Pharmacological Pain Relief: Complementary therapies such as acupuncture, massage, physical therapy, relaxation techniques, meditation, and hypnosis can be beneficial. Medical marijuana may be an option in some regions.
3. Manage Pain Treatment Side Effects: Pain medications can cause side effects like constipation, nausea, and insomnia. Nurses help manage these through medications, diet adjustments, aromatherapy, or medication adjustments.
4. Sitz Baths for Rectal Pain: Warm water sitz baths can provide relief for patients experiencing rectal pain.
Assist the Patient in Coping
1. Discuss Thoughts and Feelings: A cancer diagnosis is emotionally challenging. Nurses should assess patient concerns and offer empathetic listening and support.
2. Present Treatment Options Clearly: Patients need to understand treatment options, including benefits, risks, and uncertainties, to make informed decisions. Nurses facilitate this process by providing comprehensive information.
3. Involve Family and Caregivers: Family and caregivers provide crucial emotional and practical support. Include them in care discussions as per the patient’s wishes.
4. Refer to Counseling: Mental health professionals specializing in chronic or terminal illnesses can offer valuable support to patients and families navigating the emotional challenges of cancer.
Educate on Risk Factors and Prevention
1. Manage Modifiable Risk Factors: While there’s no guaranteed way to prevent colon cancer, managing modifiable risk factors like smoking, diet, alcohol, and physical activity can significantly reduce risk.
2. Recommend Regular Screenings: Polyps typically take 10-15 years to become cancerous. Regular screenings, starting at age 45-75, can detect and remove polyps before cancer develops.
3. Lifestyle Modifications: Encourage a diet rich in fruits and vegetables, reduced processed meat intake, weight management, regular exercise, limited alcohol consumption, and smoking cessation.
4. Consider Supplements: Magnesium, calcium, and vitamin D may reduce colon cancer risk.
5. Hormone Therapy Discussion: Hormone replacement therapy (estrogen) has been linked to lower colorectal cancer rates in women. Discuss this with healthcare providers if relevant.
Nursing Care Plans for Colon Cancer
Once nursing diagnoses are identified, care plans prioritize assessments and interventions to achieve short-term and long-term patient care goals. Below are examples of nursing care plans for colon cancer.
Death Anxiety
Patients with colon cancer, especially those with advanced stages, are at higher risk of death anxiety. While a normal response to diagnosis, it can lead to stress and depressive symptoms requiring intervention.
Nursing Diagnosis: Death Anxiety
Related to:
- Anticipation of pain
- Anticipation of suffering
- Awareness of imminent death
- Depressive symptoms
- Discussions on death
- Low self-esteem
- Nonacceptance of mortality
- Uncertainty about afterlife
- Uncertainty about higher power
- Uncertainty of prognosis
As evidenced by:
- Concern about impact of death on family
- Deep sadness
- Fear of loneliness
- Fear of pain during dying
- Fear of premature death
- Fear of prolonged dying
- Fear of separation from loved ones
- Fear of suffering during dying
- Fear of dying process
- Fear of unknown
- Powerlessness
- Negative thoughts about death and dying
Expected outcomes:
- Patient will express feelings about dying openly.
- Patient will discuss realistic goals regarding condition and prognosis.
Assessment:
1. Psychosocial Maturity: Consider psychosocial maturity, as females may experience higher death anxiety. This helps tailor support.
2. Fear of Death and Grief Stage: Assess fear of death and grief stage to understand emotional state and provide appropriate psychosocial support.
3. Cultural/Religious Beliefs: Understand cultural/religious beliefs, as strong faith can influence coping mechanisms. Support patient’s sources of peace.
Interventions:
1. Therapeutic Communication: Use therapeutic communication to build rapport.
2. Life Planning Assistance: Support life planning to improve end-of-life care, reduce stress, and promote satisfaction.
3. Acknowledge Negative Feelings: Normalize fear, anger, and denial. Allow expression of emotions to validate patient feelings.
4. Encourage Life Review and Reminiscence: Facilitate life review to find meaning, reduce stress, and accept the situation.
5. Mental Health/Spiritual Services: Refer to chaplains or mental health counselors for emotional and spiritual support.
Diarrhea
Changes in bowel habits, including diarrhea, are common symptoms of colon cancer.
Nursing Diagnosis: Diarrhea
Related to:
- Disease process
- Colorectal tumor
- Tumor fluid leakage
As evidenced by:
- Abdominal cramping
- Abdominal pain
- Bowel urgency
- Dehydration
- Blood in stool
- Hyperactive bowel sounds
Expected outcomes:
- Patient will maintain perianal area skin integrity.
- Patient will use prescribed medications to manage diarrhea.
Assessment:
1. Defecation Patterns: Assess patterns and related symptoms (bloating, pain, urgency) to guide interventions.
2. Stool Characteristics: Evaluate stool for blood, odor, pus, which may indicate complications.
3. Abdominal Assessment: Inspect, auscultate, palpate, and percuss abdomen. Expect increased bowel sounds with diarrhea.
Interventions:
1. Monitor Intake and Output: Diarrhea can cause dehydration. Monitor fluid balance.
2. Encourage Fluid Intake: Adequate fluids improve stool consistency and hydration.
3. Dietitian Referral: Consult dietitian for specialized meal plans to ensure nutritional intake and manage symptoms.
4. Perianal Skin Care: Instruct on proper hygiene, use of medicated wipes and barrier creams to prevent skin breakdown.
5. Administer Medications: Antidiarrheal medications as prescribed to manage symptoms.
Dysfunctional Gastrointestinal Motility
Colon cancer can disrupt gastrointestinal motility due to tumor impact on nerves and tissues.
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
- Abdominal cramping
- Absence of flatus
- Altered bowel sounds
- Diarrhea
- Distended abdomen
- Difficulty defecating
- Nausea
- 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 persistent bowel changes, rectal bleeding, abdominal pain, fatigue, weight loss.
2. Bowel Sounds: Assess bowel sounds for hypoactivity or high-pitched sounds, indicating motility issues.
3. Diagnostic Studies: Review fecal occult blood tests, CT/PET scans, and colonoscopy results for abnormalities and tumor presence.
Interventions:
1. High-Fiber Diet: Encourage high-fiber foods to aid digestion and improve motility.
2. Exercise: 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: Prepare for potential colon resection to remove tumor and restore function.
5. Ostomy Care and Education: Provide ostomy care and educate patient if colostomy is performed to preserve bowel function.
Ineffective Tissue Perfusion
Colon cancer can lead to ineffective tissue perfusion due to tumor growth and complications like obstruction.
Nursing Diagnosis: Ineffective Tissue Perfusion
Related to:
- Disease process
- Cancer progression
- Damage to GI tract
- Inflammatory process
As evidenced by:
- Abdominal pain
- Abdominal 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, absence of abdominal pain and bloating.
Assessment:
1. Abdominal Assessment: Assess for masses, distension, ascites, hepatomegaly (liver metastasis).
2. Diagnostic Studies: Review blood tests for anemia, colonoscopy, sigmoidoscopy, barium enema, and CT scans for abnormalities.
3. Bowel Sounds: Assess bowel sounds for high-pitched sounds (partial obstruction) or absence (complete obstruction).
Interventions:
1. Assist in Radiation Therapy: Prepare patient for radiation to control tumor growth and improve perfusion.
2. Prepare for Surgery: Assist with surgical resection to remove tumor and improve tissue perfusion.
3. Administer Chemotherapy: Provide adjuvant chemotherapy to prevent recurrence and perfusion problems.
4. Prompt Intervention for Complications: Act quickly for suspected peritonitis, obstruction, or perforation (severe pain, distension, fever, vomiting).
Risk for Infection
Colon cancer and its treatment increase infection risk due to tissue invasion, immunosuppression, and surgical procedures.
Nursing Diagnosis: Risk for Infection
Related to:
- Chemotherapy
- Disease process
- Surgical interventions
- Colostomy
- Immunosuppression
As evidenced by:
(Risk diagnosis – no current symptoms, interventions are preventative)
Expected outcomes:
- Patient will remain free from infection.
- Patient will demonstrate infection control precautions.
- Patient will demonstrate ostomy care.
Assessment:
1. Risk Factors: Identify factors increasing infection risk (disease, chemo, radiation, surgery, colostomy).
2. Vital Signs and Labs: Monitor vital signs and lab values (neutropenia, leukocytosis) for infection indicators (fever, chills, hypotension).
Interventions:
1. Hand Hygiene: Practice and encourage thorough hand washing.
2. Isolation During Treatment: Isolate patients during chemotherapy or radiation to minimize exposure to pathogens.
3. Avoid Alcohol and Smoking: Advise against alcohol and smoking to support immune function.
4. Administer Antibiotics: Provide prophylactic antibiotics as ordered.
5. Incision and Ostomy Care Education: Instruct on proper incision and ostomy care to prevent infection.
