The pathologic assessment of colorectal cancer is based on tumor depth, lymph node involvement, and metastasis staging. The location and staging of colorectal cancer determines the patient's candidacy for surgical colon resection. The purpose of colon resection is to remove involved lymph nodes, determine if the cancer has spread, and to restore bowel continuity for normal bowel function. Oral antibiotics and polyethylene glycol lavage solution are administered prior to surgery to decrease the amount of colonic and rectal bacteria that contribute to postoperative infection and abscess formation. A permanent colostomy is indicated for patients whose entire rectum are surgically removed.
Radiation therapy may be done in combination with surgery and chemotherapy in patients with colorectal cancer. For patients with metastatic cancer, radiation therapy is a palliative measure to decrease the size of tumor and provide symptomatic pain relief.
Chemotherapy may be administered to shrink the tumor prior to surgery in patients diagnosed with colorectal cancer. Chemotherapeutic agents may also be given after colon resection and as palliative treatment if the patient is not a candidate for resection surgery. The goal of patients with stage IV cancer is to control the spread of tumors. Examples of chemotherapy drugs include 5-fluorouracil (5-FU), folinic acid (leucovorin), and oxaliplatin (Eloxatin).
For 24-48 hours prior to diagnostic or surgical procedures, the patient is placed on a clear liquid diet in order to cleanse the bowel. In addition, the patient is instructed to drink 4L of oral polyethylene glycol (Miralax) lavage solution the evening before the procedure. Since the solution may be difficult to drink and cause nausea and bloating, encourage the patient to drink the solution and discuss with the health care provider about supplementing the solution with magnesium citrate solution or bisacodyl tablets. Educate the patient that clear or clear-yellow liquid stool indicates a cleared colon.
Early detection through cancer screenings initiate early treatment and help decrease mortality rates. Regular colorectal cancer screening is recommended in both males and females over 45 years old. Due to an increased risk, screening is recommended for African Americans starting at 40 years old. If the individual's first degree relative had colon cancer, colonoscopies are initiated at 40 years old and repeated every 5 years. Screening techniques include colonoscopies, fecal occult blood tests, flexible sigmoidoscopies, and double-contrast barium enemas.
If the entire rectum is surgically removed, a colostomy is required for stool elimination. Providing instructions for colostomy care is critical for preventing infection, maintaining adequate fluid and electrolyte balance, and minimizing odor (refer to the Picmonic on "Colostomy Care"). Key points include education regarding pouch changes, skin care, and stoma care. Refer the patient to a wound, ostomy, and continence (WOC) nurse for teaching and follow-up colostomy care.
Since patients with or without stomas may experience diarrhea, constipation, or incontinence, dietary changes may help control bowel complications. For postoperative ostomy patients diagnosed with colorectal cancer, a dietary consult with a registered dietician will help the patient choose foods that are less likely to cause diarrhea and odor. Encourage the patient to drink at least 3L of fluids a day to prevent dehydration and fluid and electrolyte imbalance.
Addressing altered body image is critical in the patient with a permanent ostomy. The patient may experience anxiety or depression. Emotional support and education helps the patient cope with and manage the new stoma.
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