care plan : cancer of the small intestine, colon, or rectum

[John]

Test6-11careplancancerofthesmallintestine,colon,orrectum.doc

CANCER OF THE SMALL INTESTINE, COLON, OR RECTUM

Data Base

A.     Etiology and pathophysiology

1.    Tumor causes narrowing of lumen of bowel, ulcerations, necrosis, or perforation

2.    Predisposing factors include familial polyps, chronic ulcerative colitis, and bowel stasis, ingestion of food additives, and a high-fat low-fiber diet

3‘ Cancer of the colon is more common inmales, and incidence increases after 50 years of age

4‘ Cancer of the small intestine is rare; adenocar­cinoma of the large intestine is relatively common

B.     Clinical findings

1.    Subjective: abdominal discomfort or pain; weakness and fatigue

2.    Objective

a.    Alterations in usual bowel function (constipation or diarrhea or alternating constipation and diarrhea); pencil- or ribbon-shaped stool

b.   Abdominal distention

c.   Weight loss

d.   Frank or occult blood in stool; secondary anemia

e.   Digital examination detects any palpable masses

f.     Proctosigmoidoscopy visualizes the bowel directly and determines the presence of abnormalities; permits biopsy

g.   Cytologic examination of tissue from GI tract detects malignant cells

h.    Elevated alkaline phosphatase and aspartate aminotransferase (AST) levels detect metastasis to the liver

i.      Elevated serum carcinoembryonic antigen (CEA) may indicate carcinoma of the colon

C.    Therapeutic interventions

1.Surgical intervention to remove the mass and restore bowel function (e.g., colostomy, hemicolectomy, abdominal perineal resection)

2.    Radiation in nonsurgical situations may be used to limit symptoms; may be used

preoperatively to reduce size of tumor or postoperatively to limit metastases

3.    Chemotherapy to reduce the lesion and limit metastases

4.    Preparation for surgery

a.    Antibiotics (e.g., neomycin or sulfonamides) to reduce bacteria in the bowel

b.   Type and cross-match of blood for transfusions to correct anemia

c.   Vitamin supplements to improve nutritional status

d.   Gastric or intestinal decompression

e.   Bowel preparation

Nursing Care of Clients with Cancer of Small Intestine, Colon, or Rectum

A.    Assessment

1.    Detailed history of symptoms and risk factors

2.    Stool for frequency, color, consistency, shape

3.    Weight for baseline data

4.    Areas of abdominal discomfort on palpation

5.    Presence and extent of bowel sounds

B.    Analysis/Nursing Diagnoses

1.    Acute and chronic pain related to trauma of surgery and pathologic processes

2.    Anxiety related to treatments and prognosis

3.    Disturbed bodv image related to alteration in GI structure and function

4.    Deficient fluid volume related to losses through ostomy

5.    Imbalanced nutrition: less than body requirements related to malabsorption

6.    Risk for impaired skin integrity related to fecal irritation

C. Planning/Implementation

1.    Observe vital signs, increasing abdominal pain, nausea, and vomiting to detect early signs of complications

2.    Monitor patency of gastric or intestinal tube; instill or irrigate with notmal saline as ordered; note the amount and character of drainage

3.    Implement mechanical cleansing and intestinal antisepsis preoperatively

4.Administer chemotherapeutic drugs if ordered; observe for significant side effects such as stomatitis, dehydration, nausea and vomiting, diarrhea, leukopenia

5.Administer electrolyte and parenteral fluid replacement as ordered in situations of bleeding, vomiting, and/or obstruction

6.Administer progressive diet as ordered; assess tolerance; teach dietary modifications to client and family, including non-gas-forming foods, avoidance of stimulants, adequate fluid intake; diet should be as close to the client’s normal as possible

7.Teach the importance of diet in supporting the body's natural defenses; emphasize high-nutrient-dense foods from the fruit, vegetable, cereal grain, and legume groups with some lean meat, fish, and poultry; encourage client to eat as great a variety of foods as can be tolerated; vitamin and mineral supplements can be encouraged, especially the immune-stimulating factors

8.    Provide pre- and postoperative care for colon surgery (see pre- and postoperative care in Ulcerative Colitis)

9.Assess the client's reaction to the colostomy, recognizing that it will depend on how the client sees it affecting lifestyle， physical and emotional status, social and cultural background, and place and role in the family; client may demonstrate the stages of grieving

10.   Provide colostomy care (see Colostomy Irrigation in Related Procedures); encourage involvement in colostomy care as soon as physical and emotional status permits

11.Recognize that the client with a cecostomy or colostomy is especially sensitive to gestures, odors, and facial expressions

12.Teach the client and family care of the colostomy, measures to facilitate acceptance and adjustment, resumption of activities (including sexual), and the need for regular medical supervision

13.Teach the client that colostomy c4ainage begins in 3 to 4 days and can be controlled by following a regular irrigation schedule and dietary modifications; adequate uninterrupted time for procedure is necessary

14.Arrange for follow-up care with community agencies as required (e.g., public health, home care programs, Cancer Society, ostomy resource person)

15.    Teach the need to periodically dilate the stoma to prevent status

D.    Evaluation/Outcomes

1.    Maintains adequate fluid and electrolyte balance

2.    Resumes a regular pattern of bowel elimination

3.    Client or family member demonstrates ability to perform ostomy care

4.    Discusses feelings concerning diagnosis, prognosis, and ostomy

5.    Maintains nutritional status