INTERFERENCES TO ELIMINATION NEEDS Cancer of the Colon Fecal Diversions Urinary Diversions 2009.
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Transcript of INTERFERENCES TO ELIMINATION NEEDS Cancer of the Colon Fecal Diversions Urinary Diversions 2009.
CANCER OF THE COLON
95% AdenocarcinomaAge: over 50 yearsFamily history: 1st degree relativeHave history of chronic inflammatory
bowel disease or polypsNO KNOWN CAUSE: 75% OF CASESRisk factors: diet high in fat, protein, beef,
and low in fiber
SYMPTOMSRIGHT
SIDED LESIONS:
Tumors can grow without disrupting bowel patterns
Dull abdominal painMelena (black tarry
stools)
SYMPTOMSLEFT
SIDED LESIONS
(transverse & descending colon)
ObstructionAbdominal painCrampingConstipationDistentionBright red blood in
stool
SYMPTOMSRECTAL
LESIONS
Tenesmus (ineffective painful straining at stool)
Rectal painFeeling of incomplete
evacuation after a bowel movement
Alternating constipation and diarrhea
Hematochezia: passage of red blood via the rectum
METASTASIS
Lymph nodesLiver by way of the bloodstreamALSO:
– Lungs– Brain– Bones– Adrenal glands
Peritoneal seeding during surgery
DIAGNOSTIC LABORTORY TESTS
Fecal occult blood test (FOBT): indicates bleeding in the GI tract
False positive: foods, vitamins, drugsfor 48 hours before test – AVOID : meat, horseradish, beets– AVOID: vitamin C, ASA, ibuprofen, corticosteroids,
salicylatesTwo stool samples tested on 3 consecutive daysNEGATIVE RESULTS DO NOT R/O COLON
CANCER
DIAGNOSTIC LABORATORY TESTS
Alkaline Phosphatase and SGOT to look for metastasis to the liver
Carcinoembryonic antigen (CEA level); elevations indicate advanced adenocarcinoma; – See this elevated in 70% of people– levels drop after removal of tumor; elevation
at a later date indicate recurrence
DIAGNOSTIC EVALUATION DONE IN THE FOLLOWING ORDER
Rectal Exam (50% of tumors palpable on digital exam)
Abdominal ExamBarium Enema (see polyps and small lesions)Sigmoidoscopy: (see lower colon, can do biopsy)***Colonoscopy: DEFINITIVE DX TESTCT scan confirms a masses and extent of disease
TREATMENT
Surgical Intervention: colon resection (removal tumor & lymph nodes
with reanastomosis)Colectomy (colon removal)Abdominal-perineal resection (removal of anus
and rectum with a permanent colostomyCould have laparoscopic surgery
Radiation/Chemotherapy
TYPES OF COLOSTOMIES
Ascending colostomy: done for right sided tumors
Transverse double barreled colostomy: can be done quickly for emergency intestinal obstruction; – 2 stomas– proximal closest to small intestine drains feces– the distal one drains mucous
TYPES OF COLOSTOMIES
Descending colostomy: Done for left sided tumors
Sigmoid colostomy:Done for rectal tumors
COLOSTOMY
Colostomies done on less than 1/3 of patients with colorectal cancer
DEFINED: surgical creation of an opening (stoma) into the colon
Temporary or permanentDrains the colon contents outside the bodyConsistency related to location in body
PREOP NURSING CARE
Adequate elimination of wastesReduce painMaintain fluid and electrolytesMaintain adequate nutritionReduce anxietyReview concerns about colostomy
BOWEL PREP
GOAL: to minimize bacterial growth and prevent complications
HOW: – 1-2 days clear liquids– Laxatives– Enemas– Ingests GoLYTELY: clears feces from colon– Oral or IV antibiotics day before surgery
POSTOP NURSING CARE
Maintain NGT to low suction 24-36 hrs (none for lap colon resection)– NPO, IV fluids, I & O
Maintain PCAAmbulateTEDS/ Sequential stockingsSQ HeparinProgress diet liquids to solids as tolerated
POSTOP NURSING CARE
Observe abdominal wound for infection, dehiscence, hemorrhage, edema
Splint abdominal incision during C & DBObserve perineal wound for bleeding, infection,
necrosisTeach colostomy care
POSTOP NURSING CARE CONTINUED
Teach high fiber, high roughage dietTeach to avoid foods that cause excessive odor
and gas (broccoli, brussel sprouts, cauliflower, cucumbers, mushrooms, peas, cabbage, eggs, fish, beans, garlic, turnips, fish, peanuts, chewing gum, smoking, beer, skipping meals)
Teach foods that avoid odors: buttermilk, cranberry juice, parsley, yogurt. – Charcoal filters, pouch deodorizers, breath mint in
pouchTeach to avoid foods that cause diarrhea (fruits,
soda, coffee, tea, carbonated beverages)
POSTOP COLOSTOMY MANAGEMENT
from OR with ostomy pouch in place or petrolatum gauze over stoma covered by
dry sterile dressing; pouch laterAssess color and integrity stoma: moist, reddish pink, protrude from
abdominal wall 3/4 inch, small amt of bleeding at stoma common
Assess peristomal skin (no excoriation)
POSTOP COLOSTOMY CARE
CALL MD FOR: Signs of ischemia/necrosis: dark red,
purplish, black color, dry, firm, flaccidUnusual bleedingSeparation of stoma from wall
WOUNDS
For AP resection: perineal wound has JP drains
Serosanguineous drainage seen 1-2 moHealing takes 6-8 moPhantom rectal sensations commonRectal pain/itching common: benzocaine,
sitz baths
POSTOP COLOSTOMY CARE
Starts working 2-4 days postop May see lots of gas initially Stool initially liquid then becomes normal based on
location
– Ascending colon: liquid
– Transverse colon: pasty
– Descending colon: solid Stoma shrinks 6-8 wks after surgery: measure once week Wafer opening 1/8-1/16 inch larger than stoma pattern to
prevent constriction
COLOSTOMY CARE
When washing skin around stoma avoid moisturizing soaps; interferes with adhesion of appliance
Skin prep applied before putting on appliance to protect skin
Change bag if there is leakageSigmoid colostomy: irrigation regulates
elimination, but can be through diet
COMPLICATIONS OF COLOSTOMY
Prolapse of the stoma (due to obesity)Perforation (due to improper stoma
irrigation)Stoma retractionFecal impactionSkin irritationPulmonary complications
ILEOSTOMY
DEFINED: surgical creation of an opening into the ileum or small intestines usually by means of an ileal stoma on the abdominal wall
Permanent or TemporaryAllows for drainage of fecal matter (effluent)
from the ileum to the outside of the bodyDrainage is liquid and occurs at frequent intervals
PREOPERATIVE NURSING
Intensive fluids, blood and protein replacementAntibioticsLow residue dietAbdomen marked for proper placement of stoma
by surgeon or enterostomal therapist usually in the RLQ 2 inches below the waist crease away from skin folds
Teaching about ileostomy
POSTOPERATIVE NURSING
Observe stoma: pink to bright red and shinyFecal drainage begins 72 hours after surgery and is
continuous draining into an ileostomy bagStrict I&O of urinary and fecal outputMaintain IV fluids; watch for electrolyte losses (Na
and K)NGT initiallyAfter NGT removal, sips of clear liquids with
progression to low residue diet Early ambulation
ILEAL CONDUIT URINARY DIVERSION (ILEAL LOOP)
Oldest of the urinary diversion proceduresA portion of the ileum becomes a conduitUrine is diverted by implanting the ureter
into a loop of ileum that is led out through the abdominal wall
Done when bladder has to be removed for cancer of the bladder
CONTINENT ILEAL URINARY RESERVOIR (KOCK POUCH)
Transplanting the ureters to an isolated segment of ileum (pouch) with a nipple like one way valve
Urine is drained by a catheter
URETEROSIGMOIDOSTOMY
Ureters are surgically implanted into the sigmoid colon allowing urine to flow through the colon out of the rectum