Acupuncture and moxibustion (Acu-Moxa) treatment has helped some patients by reducing flatulence and bloating and improving stool consistency (Anastasi et al., 2009). Moxibustion is the use of herbs to facilitate healing. Encourage patients to try these therapies, especially if they can be reimbursed by insurance companies. Third-party payers are becoming more sensitive to the use of these proven therapies as adjuncts in holistic disease management.

Stress management is also an important part of holistic care. Suggest relaxation techniques, meditation, and/or yoga to help the patient decrease GI symptoms. If the patient is in a stressful work or family situation, personal counseling may be helpful. Based on patient preference, make appropriate referrals or assist in making appointments, if needed. The opportunity to discuss problems and attempt creative problem solving is often helpful. Teach the patient that regular exercise is important for managing stress and promoting regular bowel elimination.

Herniation

Pathophysiology

A hernia is a weakness in the abdominal muscle wall through which a segment of the bowel or other abdominal structure protrudes. Hernias can also penetrate through any other defect in the abdominal wall, through the diaphragm, or through other structures in the abdominal cavity.

The most common types of abdominal hernias (Fig. 59-2) are indirect, direct, femoral, umbilical, and incisional.

• An indirect inguinal hernia is a sac formed from the peritoneum that contains a portion of the intestine or omentum. The hernia pushes downward at an angle into the inguinal canal. In males, indirect inguinal hernias can become large and often descend into the scrotum.

• Direct inguinal hernias, in contrast, pass through a weak point in the abdominal wall (Fig. 59-3).

• Femoral hernias protrude through the femoral ring. A plug of fat in the femoral canal enlarges and eventually pulls the peritoneum and often the urinary bladder into the sac.

• Umbilical hernias are congenital or acquired. Congenital umbilical hernias appear in infancy. Acquired umbilical hernias directly result from increased intra-abdominal pressure. They are most commonly seen in obese people.

• Incisional, or ventral, hernias occur at the site of a previous surgical incision. These hernias result from inadequate healing of the incision, which is usually caused by postoperative wound infections, inadequate nutrition, and obesity.

FIG. 59-2 Types of abdominal hernias.

FIG. 59-3 A right direct inguinal hernia.

Hernias may also be classified as reducible, irreducible (incarcerated), or strangulated. A hernia is reducible when the contents of the hernial sac can be placed back into the abdominal cavity by gentle pressure. An irreducible (incarcerated) hernia cannot be reduced or placed back into the abdominal cavity. Any hernia that is not reducible requires immediate surgical evaluation.

A hernia is strangulated when the blood supply to the herniated segment of the bowel is cut off by pressure from the hernial ring (the band of muscle around the hernia). If a hernia is strangulated, there is ischemia and obstruction of the bowel loop. This can lead to necrosis of the bowel and possibly bowel perforation. Signs of strangulation are abdominal distention, nausea, vomiting, pain, fever, and tachycardia.

The most important elements in the development of a hernia are congenital or acquired muscle weakness and increased intra-abdominal pressure. The most significant factors contributing to increased intra-abdominal pressure are obesity, pregnancy, and lifting heavy objects.

Indirect inguinal hernias, the most common type, are most common in men because they follow the tract that develops when the testes descend into the scrotum before birth. Direct hernias occur more often in older adults. Femoral and adult umbilical hernias are most common in obese or pregnant women. Incisional hernias can occur in people who have undergone abdominal surgery.

Defects in the muscle wall result from weakened collagen or widened spaces at the inguinal ligament. These muscle weaknesses can be inherited or acquired as part of the aging process. Increases in intra-abdominal pressure as a result of pregnancy, obesity, abdominal distention, ascites, heavy lifting, or coughing can contribute to their occurrence.

Health Promotion and Maintenance

Even though the muscle weakness cannot be prevented, exercises can strengthen muscles. Obesity is considered a contributing factor because it causes increased intra-abdominal pressure. Weight control helps decrease the likelihood of hernias by decreasing pressure on the abdominal muscles. Heavy lifting and straining also increase intra-abdominal pressure and should be avoided.

Patient-Centered Collaborative Care

General postoperative care of patients having a hernia repair is the same as that described in Chapter 18 except that they should avoid coughing. To promote lung expansion, encourage deep breathing and ambulation. With repair of an indirect inguinal hernia, the physician may suggest a scrotal support and ice bags applied to the scrotum to prevent swelling, which often contributes to pain. Elevation of the scrotum with a soft pillow helps prevent and control swelling.

In the immediate postoperative period, male patients who have had an inguinal hernia repair may experience difficulty voiding. Encourage them to stand to allow a more natural position for gravity to facilitate voiding and bladder emptying. Urine output of less than 30 mL per hour should be reported to the surgeon. Techniques to stimulate voiding such as allowing water to run may also be used. A fluid intake of at least 1500 to 2500 mL daily prevents dehydration and maintains urinary function. A “straight” or intermittent catheterization is required if the patient cannot void.

Most patients have uneventful recoveries after a hernia repair. Surgeons generally allow them to return to their usual activities after surgery, with avoidance of straining and lifting for several weeks while subcutaneous tissues heal and strengthen.

Provide oral instructions and a written list of symptoms to be reported, including fever, chills, wound drainage, redness or separation of the incision, and increasing incisional pain. Teach the patient to keep the wound dry and clean with antibacterial soap and water. Showering is usually permitted in a few days.

NCLEX Examination Challenge

Physiological Integrity

A nurse is caring for a client 1 day after an open hernia repair surgery. Which assessment finding will the nurse report to the surgeon immediately?

A. Pain in the incisional area

B. Blood pressure of 130/82 mm Hg

C. Bronchovesicular breath sounds

D. Rigid, board-like abdomen

Colorectal Cancer

Pathophysiology

Colorectal refers to the colon and rectum, which together make up the large intestine, also known as the large bowel. Colorectal cancer (CRC) is cancer of the colon or rectum and is a major health problem worldwide. In the United States, it is one of the most common malignancies.

Most CRCs are adenocarcinomas, which are tumors that arise from the glandular epithelial tissue of the colon. They develop as a multi-step process, resulting in a number of molecular changes, such as loss of key tumor suppressor genes and activation of certain oncogenes that alter colonic mucosa cell division. The increased proliferation of the colonic mucosa forms polyps that can transform into malignant tumors. Most CRCs are believed to arise from adenomatous polyps that present as a visible protrusion from the mucosal surface of the bowel (McCance et al., 2010).

Tumors occur in different areas of the colon, with about two thirds occurring within the rectosigmoid region. The percentages in Fig. 59-4 indicate an increased incidence of cancer in the proximal sections of the large intestine over the past 35 years.

FIG. 59-4 The incidence of cancer in relation to colorectal anatomy.

Colorectal cancer (CRC) can metastasize by direct extension or by spreading through the blood or lymph. The tumor may spread locally into the four layers of the bowel wall and into neighboring organs. It may enlarge into the lumen of the bowel or spread through the lymphatics or the circulatory system. The circulatory system is entered directly from the primary tumor through blood vessels in the bowel or via the lymphatics. The liver is the most frequent site of metastasis from circulatory spread. Metastasis to the lungs, brain, bones, and adrenal glands may also occur. Colon tumors can also spread by peritoneal seeding during surgical resection of the tumor. Seeding may occur when a tumor is excised and cancer cells break off from the tumor into the peritoneal cavity. For this reason, special techniques are used during surgery to decrease this possibility.

Complications related to the increasing growth of the tumor locally or through metastatic spread include bowel obstruction or perforation with resultant peritonitis, abscess formation, and fistula formation to the urinary bladder or the vagina. The tumor may invade neighboring blood vessels and cause frank bleeding. Tumors growing into the bowel lumen can gradually obstruct the intestine and eventually block it completely. Those extending beyond the bowel wall may place pressure on neighboring organs (uterus, urinary bladder, and ureters) and cause symptoms that mask those of the cancer. Chapter 23 discusses cancer pathophysiology in more detail.

Etiology and Genetic Risk

The major risk factors for the development of colorectal cancer (CRC) include being older than 50 years, genetic predisposition, personal or family history of cancer, and/or diseases that predispose the patient to cancer such as familial adenomatous polyposis (FAP), Crohn’s disease, and ulcerative colitis (McCance et al., 2010). Only a small percentage of colorectal cancers are familial and transmitted genetically.

Genetic/Genomic Considerations

People with a first-degree relative (sister, sibling, or child) diagnosed with colorectal cancer (CRC) have three to four times the risk for developing the disease. An autosomal dominant inherited genetic disorder known as familial adenomatous polyposis (FAP) accounts for 1% of CRCs. FAP is the result of one or more mutations in the adenomatous polyposis coli (APC) gene (McCance et al., 2010). In these very young patients, thousands of adenomatous polyps develop over the course of 10 to 15 years and have nearly a 100% chance of becoming malignant. By 20 years of age, most patients require surgical intervention, usually a colectomy with ileostomy or ileoanal pull-through, to prevent cancer. Chemotherapy may also be used for cancer prevention.

Hereditary nonpolyposis colorectal cancer (HNPCC) is another autosomal dominant disorder and accounts for a small percentage of all colorectal cancers. HNPCC is also caused by gene mutations, including MLH1 and MLH2. People with these mutations have an 80% chance of developing CRC at an average of 45 years of age. They also tend to have a higher incidence of endometrial, ovarian, stomach, and ureteral cancers (Nussbaum et al., 2007). Genetic testing is available for both of these familial CRC syndromes. Refer patients for genetic counseling and possible testing if the patient prefers.

The role of infectious agents in the development of colorectal and anal cancer continues to be investigated. Some lower GI cancers are related to Helicobacter pylori, Streptococcus bovis, JC virus, and human papilloma virus (HPV) infections.

There is also strong evidence that long-term smoking, increased body fat, physical inactivity, and heavy alcohol consumption are risk factors for colorectal cancer (American Cancer Society [ACS], 2010). A high-fat diet, particularly animal fat from red meats, increases bile acid secretion and anaerobic bacteria, which are thought to be carcinogenic within the bowel. Diets with large amounts of refined carbohydrates that lack fiber decrease bowel transit time.

Incidence/Prevalence

Colorectal cancer (CRC) is the third most common cause of cancer death in the United States (ACS, 2010). It is not common before 40 years of age, but the incidence in younger adults is slowly increasing, most likely due to increases in HPV infections (Stubenrauch, 2010). The overall incidence of CRC has decreased over the past 10 years, most likely as a result of increased cancer screenings. The disease is most common in African Americans, and their survival rate is lower than that of Euro-Americans (Caucasians). The possible reasons for this difference include less use of diagnostic testing (especially colonoscopy), decreased access to health care, cultural beliefs, and lack of education about the need for early cancer detection (Good et al., 2010; Hamlyn, 2008).

Health Promotion and Maintenance

People at risk can take action to decrease their chance of getting CRC and/or increase their chance of surviving it. For example, those whose family members have had hereditary CRC should be genetically tested for FAP and HNPCC. If gene mutations are present, the person at risk can collaborate with the health care team to decide what prevention or treatment plan to implement.

Teach people about the need for diagnostic screening. When an adult turns 40 years of age, he or she should discuss with the health care provider about the need for colon cancer screening. The interval depends on level of risk. People of average risk who are 50 years of age and older, without a family history, should undergo regular CRC screening. The screening includes fecal occult blood testing (FOBT) and colonoscopy every 10 years or double-contrast barium enema every 5 years. People who have a personal or family history of the disease should begin screening earlier and more frequently (National Comprehensive Cancer Network, 2008). Teach all patients to follow the American Cancer Society recommendations for CRC screening listed in Chart 59-1.

Chart 59-1 Best Practice for Patient Safety & Quality Care

Screening Recommendations for Men and Women Ages 50 Years and Older at Average Risk for Colorectal Cancer

PROCEDURE: CHOICE OF ONE OF THE FOLLOWING	INTERVAL AFTER SCREENING INITIATED AT AGE 50 YEARS	COMMENTS
FOBT and sigmoidoscopy	Every 5 years	FOBT procedure: two or three samples from three consecutive bowel movements obtained at home; tested by physician or nurse
OR
Double-contrast barium enema	Every 5 years
OR
Colonoscopy	Every 10 years

FOBT, Fecal occult blood testing.

Teach patients, regardless of risk, to modify their diets as needed to decrease fat, refined carbohydrates, and low-fiber foods. Encourage baked or broiled foods, especially those high in fiber and low in animal fat. Teach people the hazards of smoking, excessive alcohol, and physical inactivity. Refer patients as needed for smoking- or alcohol-cessation programs, and recommend ways to increase regular physical exercise.

Patient-Centered Collaborative Care

Assessment

History

When taking a history, ask the patient about major risk factors, such as a personal history of breast, ovarian, or endometrial cancer (which can spread to the colon); ulcerative colitis; Crohn’s disease; familial polyposis or adenomas; polyps, or a family history of CRC. Also assess the patient’s participation in age-specific cancer screening guidelines. Ask about whether the patient uses tobacco and/or alcohol. Assess the patient’s usual physical activity level.

Ask whether vomiting and changes in bowel habits, such as constipation or change in shape of stool with or without blood, have been noted. The patient may also report fatigue (related to anemias), abdominal fullness, vague abdominal pain, or unintentional weight loss. These symptoms suggest advanced disease.

Physical Assessment/Clinical Manifestations

The clinical manifestations of CRC depend on the location of the tumor. However, the most common signs are rectal bleeding, anemia, and a change in stool consistency or shape. Stools may contain microscopic amounts of blood that are not noticeably visible, or the patient may have mahogany (dark)-colored or bright red stools (Fig. 59-5). Gross blood is not usually detected with tumors of the right side of the colon but is common (but not massive) with tumors of the left side of the colon and the rectum.

FIG. 59-5 Common causes of lower gastrointestinal bleeding.

Tumors in the transverse and descending colon result in symptoms of obstruction as growth of the tumor blocks the passage of stool. The patient may report “gas pains,” cramping, or incomplete evacuation. Tumors in the rectosigmoid colon are associated with hematochezia (the passage of red blood via the rectum), straining to pass stools, and narrowing of stools. Patients may report dull pain. Right-sided tumors can grow quite large without disrupting bowel patterns or appearance because the stool consistency is more liquid in this part of the colon. These tumors ulcerate and bleed intermittently, so stools can contain dark or mahogany-colored blood. A mass may be palpated in the lower right quadrant, and the patient often has anemia secondary to blood loss.

Examination of the abdomen begins with assessment for obvious distention or masses. Visible peristaltic waves accompanied by high-pitched or “tinkling” bowel sounds may indicate a partial bowel obstruction from the tumor. Total absence of bowel sounds indicates a complete bowel obstruction. Palpation and percussion are performed by the advanced practice nurse or other health care provider to determine whether the spleen or liver is enlarged or whether masses are present along the colon. The examiner may also perform a digital rectal examination to palpate the rectum and lower sigmoid colon for masses. Fecal occult blood screening should not be done with a specimen from a rectal examination because it is not reliable.

Psychosocial Assessment

The psychological consequences associated with a diagnosis of colorectal cancer (CRC) are many. Patients must cope with a diagnosis that instills fear and anxiety about treatment, feelings that life has been disrupted, a need to search for ways to deal with the diagnosis, and concern about family. They also have questions about why colon cancer affected them, as well as concerns about pain, possible disfigurement, and possible death. In addition, if the cancer is believed to have a genetic origin, there is anxiety concerning implications for immediate family members.

Laboratory Assessment

Hemoglobin and hematocrit values are often decreased as a result of the intermittent bleeding associated with the tumor. For some patients, that may be the first indication that a tumor is present. CRC that has metastasized to the liver causes liver function tests to be elevated.

A positive test result for occult blood in the stool (fecal occult blood test [FOBT]) indicates bleeding in the GI tract. These tests can yield false-positive results if certain vitamins or drugs are taken before the test. Remind the patient to avoid aspirin, vitamin C, and red meat for 48 hours before giving a stool specimen. Also assess whether the patient is taking anti-inflammatory drugs (e.g., ibuprofen, corticosteroids, or salicylates). These drugs should be discontinued for a designated period before the test. Two or three separate stool samples should be tested on 3 consecutive days. Negative results do not completely rule out the possibility of CRC.

Carcinoembryonic antigen (CEA), an oncofetal antigen, is elevated in many people with CRC. The normal value is less that 5 ng/mL or 5 mcg/L (SI units) (Pagana & Pagana, 2010). This protein is not specifically associated with the colorectal cancer, and it may be elevated in the presence of other benign or malignant diseases and in smokers. CEA is often used to monitor the effectiveness of treatment and to identify disease recurrence.

Imaging Assessment

A double-contrast barium enema (air and barium are instilled into the colon) or colonoscopy provides better visualization of polyps and small lesions than a barium enema alone. These tests may show an occlusion in the bowel where the tumor is decreasing the size of the lumen.

Computed tomography (CT) or magnetic resonance imaging (MRI) of the chest, abdomen, pelvis, lungs, or liver helps confirm the existence of a mass, the extent of disease, and the location of distant metastases. CT-guided virtual colonoscopy is growing in popularity and may be more thorough than traditional colonoscopy. However, treatments or surgeries cannot be performed when a virtual colonoscopy is used.

Other Diagnostic Assessment

A sigmoidoscopy provides visualization of the lower colon using a fiberoptic scope. Polyps can be visualized, and tissue samples can be taken for biopsy. Polyps are usually removed during the procedure. A colonoscopy provides views of the entire large bowel from the rectum to the ileocecal valve. As with sigmoidoscopy, polyps can be seen and removed, and tissue samples can be taken for biopsy. Colonoscopy is the definitive test for the diagnosis of colorectal cancer. These procedures and associated nursing care are discussed in Chapter 55.

Analysis

The priority problems for patients with colorectal cancer (CRC) include:

1. Potential for colorectal cancer metastasis

2. Grieving related to cancer diagnosis

The patient with colorectal cancer (CRC) is expected to not have the cancer spread to vital organs. Thus the patient’s life expectancy will be increased and the quality of life will be improved. However, if metastasis is present, the desired outcome is to ensure that the patient is as comfortable as possible and pain is well-managed.

Interventions

Although surgical resection is the primary means used to control the disease, several adjuvant (additional) therapies are used. Adjuvant therapies are administered before or after surgery to achieve a cure, if possible, and to prevent recurrence.

Nonsurgical Management

The type of therapy used is based on the pathologic staging of the disease. Several staging systems may be used. The American Joint Committee on Cancer (AJCC) system uses this broad staging classification and description:

• Stage I—Tumor invades up to muscle layer

• Stage II—Tumor invades up to other organs or perforates peritoneum

• Stage III—Any level of tumor invasion and up to 4 regional lymph nodes

• Stage IV—Any level of tumor invasion; many lymph nodes affected with distant metastases

Radiation Therapy

The administration of preoperative radiation therapy has not improved overall survival rates for colon cancer, but it has been effective in providing local or regional control of the disease. Postoperative radiation has not demonstrated any consistent improvement in survival or recurrence. However, as a palliative measure, radiation therapy may be used to control pain, hemorrhage, bowel obstruction, or metastasis to the lung in advanced disease. For rectal cancer, unlike colon cancer, radiation therapy is almost always a part of the treatment plan. Reinforce information about the radiation therapy procedure to the patient and family, and monitor for possible side effects (e.g., diarrhea, fatigue). Chapter 24 describes the general care of patients undergoing radiation therapy.

Drug Therapy

Adjuvant chemotherapy after primary surgery is recommended for patients with stage II or stage III disease to interrupt the DNA production of cells and improve survival. The drugs of choice are IV 5-fluorouracil (5-FU) with leucovorin (LV) (folinic acid), capecitabine (Xeloda), or a combination of drugs referred to as FOLFOX. The most frequently used FOLFOX combination for metastatic CRC is 5-FU (fluorouracil), leucovorin, and oxaliplatin (Eloxatin), a platinum analog. These drugs cannot discriminate between cancer and healthy cells. Therefore common side effects are diarrhea, mucositis, leukopenia, mouth ulcers, and peripheral neuropathy.

Bevacizumab (Avastin) is the first antiangiogenesis drug to be approved for advanced CRC. This type of drug reduces blood flow to the growing tumor cells, thereby depriving them of necessary nutrients needed to grow. It is usually given in combination with other chemotherapeutic agents.

Cetuximab (Erbitux), a monoclonal antibody, may also be given for advanced disease. This drug works by blocking factors that promote cancer cell growth. Cetuximab is usually given in combination with another drug.

Intrahepatic arterial chemotherapy, often with 5-FU, may be administered to patients with liver metastasis. Patients with CRC also receive drugs for relief of symptoms, such as opioid analgesics and antiemetics.

Surgical Management

Surgical removal of the tumor with margins free of disease is the best method of ensuring removal of CRC. The size of the tumor, its location, the extent of metastasis, the integrity of the bowel, and the condition of the patient determine which surgical procedure is performed for colorectal cancer (Table 59-1). Many regional lymph nodes are removed and examined for presence of cancer. The number of lymph nodes that contain cancer is a strong predictor of prognosis. The most common surgeries performed are colon resection (removal of the tumor and regional lymph nodes) with reanastomosis, colectomy (colon removal) with colostomy (temporary or permanent) or ileostomy/ileoanal pull-through, and abdominoperineal (AP) resection. A colostomy is the surgical creation of an opening of the colon onto the surface of the abdomen. An AP resection is performed when rectal tumors are present. The surgeon removes the sigmoid colon, rectum, and anus through combined abdominal and perineal incisions.

TABLE 59-1 SURGICAL PROCEDURES FOR COLORECTAL CANCERS IN VARIOUS LOCATIONS

Right-Sided Colon Tumors

• Right hemicolectomy for smaller lesions

• Right ascending colostomy or ileostomy for large, widespread lesions

• Cecostomy (opening into the cecum with intubation to decompress the bowel)

Left-Sided Colon Tumors

• Left hemicolectomy for smaller lesions

• Left descending colostomy for larger lesions

Sigmoid Colon Tumors

• Sigmoid colectomy for smaller lesions

• Sigmoid colostomy for larger lesions

• Abdominoperineal resection for large, low sigmoid tumors (near the anus) with colostomy (the rectum and the anus are completely removed, leaving a perineal wound)