Long term management of client diagnosed with Colorectal Cancer Cancer is a leading cause of death worldwide and one of the four leading threats to human health and development along with cardiovascular diseases, chronic respiratory diseases and diabetes (WHO, 2011). It is estimated that cancer accounted for 13% of all deaths worldwide in 2008, of which colorectal cancer along with lung and breast cancers contributed to 45% of world’s total cancer mortality (Ferlay, et al. , 2010). Cancer continues to be a leading cause of mortality and morbidity in New Zealand accounting for one third of all deaths (MOH, 2012).
Colorectal cancer affects both Maori and non Maori populations in New Zealand and the incidence rate rank among the highest worldwide (Shah et al, 2011). The identity of the client in this case study is protected under the Privacy Act (1993). He will, hereafter, be known as Mr. S. The student in this assignment will critique the given case study (Appendix. A) and discuss the pathophysiology of colorectal cancer along with the interpretation of the information given (Appendix. A). An appropriate plan of care for Mr.
S diagnosed with colorectal cancer undergoing chemotherapy and the role of nurses in the management of people long term conditions are also discussed in this assignment. Background: Mr. S is a 68 year old man diagnosed with colorectal cancer undergoing his second course of chemotherapy in the outpatient clinic. He presented to the hospital with marked changes in his bowel habit with bright red blood per rectum and cramping abdominal pain in November, 2012. After detailed investigation, he has been diagnosed with stage for colon cancer with stomach and liver metastasis.
He underwent bowel resection in December, 2012 resulting in colostomy. His present concern includes abdominal discomfort, chronic fatigue, weakness, poor appetite, disturbed sleep and heart burn. His performance status is worsening and he needs assistance with his activities of daily living. He is a known hypertensive with family history of cancer and myocardial infarction. He is a non smoker and a non alcohol drinker with a very supportive family (Appendix. A). The author (Appendix. A) presented the case study with sufficient facts for planning a collaborative care plan for Mr. S.
Adequate information has been given regarding the presenting problems of the client along with recent investigations and current medications. The author also included the relevant family history as well as the past medical history of the client necessary to plan an appropriate care for Mr. S. However, the author hasn’t provided any information regarding the spiritual health of Mr. S. Spirituality and religion can be important to the well being of people with cancer, which enable them to cope with the disease in a better way (National Comprehensive Cancer Network, 2013). Knowledge regarding the sexual life of Mr.
S would have been relevant because research shows that, continuing sexual relationship is one of the major concerns for clients with colostomies and significant others ( Black, 1993). It is clear from the information given (Appendix. A) that, Mr. S has got an advanced stage of colorectal cancer. Therefore, Information on advanced directive of Mr. S would have been beneficial because advanced directive is a process of discussion and shared planning for future health care. It is focused on the individual and involves the person, family/whanau and the health care professionals responsible for their care as per the persons’ wish (MOH, 2011).
In order to develop a collaborative plan of care, an understanding of the pathophysiology of the presenting case is required. Colorectal Cancer. Cancer is a growing health concern in New Zealand and colorectal cancer is the second most common cancer registered for both men and women in New Zealand (MOH, 2012). Colorectal cancer (CRC), commonly known as colon cancer or bowel cancer is a malignant tumour arising from the inner walls of large intestine due to the uncontrolled growth of cells in the colon or rectum. The causes of colorectal cancer are complex but are usually a combination of inherited and environmental factors.
Most colorectal cancer occurs due to lifestyle and increasing age with only a minority of cases associated with underlying genetic disorders (Black, 1993; Nugent, 2012; Waitemata District Health Board, 2006). Factors that increase a person’s risk of colorectal cancer includes advancing age, family history of colorectal cancer and polyps, the presence of polyps in the large intestine, inflammatory bowel diseases, primarily chronic ulcerative colitis and high fat intake ( Nugent, 2012). Mr. S is 68 year old and had strong family history of cancer.
Apart from this he hasn’t got any other risk factors for colon cancer. He is a known hypertensive and had family history of hypertension and myocardial infarction which increases his risk for cardiovascular diseases (Appendix. A). Pathophysiology: Structurally the large intestine is a long tube comprised of four layers. The inner mucosal layer through which the undigested food travels, attached to the thin second layer, called the submucosa. The sub mucosal layer itself attached to a layer of muscle, the muscularis. The entire tube is surrounded by fibrous tissue called serosa.
The most common cancers of the large intestine (adenocarcinoma) arise from the inner mucosal layer. These cells are exposed to toxins from food and bacteria along with mechanical wear and tear and are constantly dying off and being replaced. Cancer of colon and rectum occurs when the process of this normal replacement of lining cells goes away (Nugent, 2012). For reasons that are poorly understood, these cells begin to divide and grow independently, leading to the uncontrolled proliferation of abnormal cells. As these abnormal cells grow and divide, they can lead to growths within the olon called polyps. Polyps are precancerous tumours that grow slowly over years and do not spread. Additional genetic mutation of these polyps further destabilizes the cells and invades other layers of large intestine and becomes cancerous (Black, 1993; Nugent, 2012). Once formed, the colorectal cancer grows in two ways. First the cancer can grow locally by invading the adjacent structures, making the mass called the primary tumour which is harder to remove. Local extension leads to symptoms such as pain or fullness, including blockages of the colon and nearby structures.
Second the cancer begins the process of metastasis by shedding numerous cells a day into the blood stream and lymphatic system that can cause cancers to form in distinct locations. Colorectal cancers most commonly spread first to the local lymph nodes. Once local lymph nodes are involved, spread to the liver, the abdominal cavity, and the lung are the next most common destinations of metastatic spread (Black, 1993; Nugent, 2012; Waitemata District Health Board, 2006). It is clear from the information given that, (Appendix. A) Mr. S has stomach and liver metastasis and the local lymph nodes are also involved.
Symptoms of colorectal cancer. Symptoms of colorectal cancer are numerous and often asymptomatic. Depending on the location, size and type of cancer symptomatic presentation may indicate a relatively advance tumour. The symptoms of colorectal cancer are often due to the growth of the tumour into the lumen of the intestine or adjacent structures (American Cancer Society, 2012; Black, 1993). Right sided lesions are larger and cause iron deficiency anaemia due to the slow loss of blood over a long period of time and causes fatigue, weakness, and shortness of breath.
Cancers of the left colon are more likely to cause partial or complete bowel obstruction, resulting in constipation, diarrhoea, narrowed stool, abdominal pain, cramps and bloating. Bright red blood in the stool may also indicate lesions of the lower colon or in the rectum (Black, 1993; Nugent, 2012). Mr. S presented with marked changes in his bowel habit with bright red blood per rectum along with sharp cramping abdominal pain, indicative of lesions in the lower colon or in rectum (Appendix. A). What tests can be done to detect colon cancer?
Diagnostic tests are often performed when an individual exhibits the signs and symptoms of colorectal cancer or laboratory studies suggest a cancer may be present. A complete blood count (CBC) is a standard diagnostic test that determines the amount of red and white blood cells in the blood and helps to determine whether the patient has an infection or anaemia (American Cancer Society, 2012; Black, 1993; Nugent, 2012). Anaemia can be a sign of cancer and is often a side effect of chemotherapy. Barium enema x-ray or colonoscopy is also performed to confirm the diagnosis and locate the cancer.
A barium enema involves x-ray imaging of the colon and the rectum after the patient is given an enema containing barium. The barium outlines the large intestine and the tumours and other abnormalities appear as dark shadows on x-rays (Nugent, 2012). Colonoscopy is a procedure in which a long, flexible viewing tube is inserted into the rectum to inspect the inside of the entire colon. If colon polyps are found, they are usually removed through the colonoscope which prevents the future development of colon cancer from these polyps.
Since colorectal cancer tends to spread to distinct organs staging tests usually includes Computerized tomography (CT) scans, Positron emission tomography (PET) scans, and Magnetic resonance imaging (MRI) studies (Black, 1993; Nugent, 2012; Waitemata District Health Board, 2006). Sometimes “tumour marker” blood test called carcinoembryonic antigen (CEA) may also be performed. CEA is a protein produced by some colon and rectal cancer cells as well as other cancers. For those who have CEA levels higher than 5. 0 mcg/l, the test is indicative of cancer.
For smokers as well as patients with advanced cancer the CEA values are likely to be very high (Nugent, 2012; Medical Health Tests, 2012). According to the information given (Appendix. A), the blood count with differential chemistries of Mr. S were within normal limits. He underwent colonoscopy, which demonstrated an obstructive lesion in his sigmoid colon. His CT scan confirmed lesions in the stomach and multiple liver lesions have been ruled out on his PET scan. Apart from this his carcinoembryonic antigen level was also high (200ng/mg).
Management of Colorectal cancer. Surgical removal of the tumour is the most common initial treatment for colon cancer. In patients with rectal cancer sometimes the rectum is permanently removed resulting in a colostomy on the abdominal wall through which solid waste from colon is excreted. Following the surgery depending upon the extent of metastasis chemotherapy is also recommended. Whereas, radiation therapy is limited to the treatment of rectal cancer (Black, 1993; Nugent, 2012; Waitemata District Health Board, 2006). . Mr.
S had radiation therapy in the outpatient clinic followed by the surgical removal of the tumour (bowel resection) resulted in the formation of a colostomy. He also completed a course of chemotherapy and started on his second round of chemotherapy (Appendix. A). Management Plan for Mr. S: The health care needs of people with long term condition are diverse. The main aim of health care provider’s in the management of people with long term illness is to identify and help the patients to meet their needs in order to improve their quality of life (NHC, 2007).
The aim of the management plan for Mr. S is to reduce his sufferings as much as possible and thereby increase his level of functional ability. The role of family/whanau in meeting a wide range of emotional and physical needs of people with long term conditions is vital. When involving in care planning family/whanau may also support behaviour and lifestyle changes (NHC, 2007). From the information given, Mr S lives with his family and has got very supportive family members.
A family meeting would help the nurse to assess their understanding of the client’s medical condition. Research shows that, during an assessment process, the nurse brings special knowledge and skills and the client brings self knowledge and perception of problems. The information collected during this process helps the nurse to interpret the requirements of the client and the family and to communicate an effective patient centred management plan (King, 2007). It is clearly evident from the information given that, Mr.
S is undergoing his second course of chemotherapy in outpatient clinic and his main concerns includes increasing fatigue, weakness, poor appetite, heart burn and sleep disturbances. Research shows that, every person experiences the side effects from chemotherapy differently, both physically and emotionally. Chemotherapy can make people feel tired and cause taste and appetite changes along with mouth sores and discomfort (Cancer Resource Centre, California, 2013). One of the most important goals for the nurse is to help Mr.
S to understand the role of chemotherapy in the management of colon cancer including its possible side effects. The nurse needs to take every effort to help Mr. S to overcome these side effects of chemotherapy and thereby minimise his sufferings. How to manage these side effects? Increasing fatigue and feeling tired are one of the main concerns of Mr. S. An understanding of the fact that these are common among people receiving chemotherapy will help Mr. S to cope effectively. Encouraging the family member to offer assistance with his cares will help Mr.
S to save his energy by ensuring adequate rest. Light exercises, such as walking should be encouraged as per his tolerance (Cancer Council, NSW, 2013). In consultation with the client, family and general practitioner the nurse can send referral to ‘Nurse Maude’ home care services. The support workers provide assistance with needs including personal grooming, bathing, colostomy care, mobility needs and meals (Nurse Maude, 2013). A small frequent meal along with adequate water intake is important for Mr. S to regain the energy.
Adding flavours to the food like sugar, honey, cheese and salt will make the meal more attractive. Mr. S should be encouraged to take a low fat diet and helping him to reduce the intake of coffee, chocolate, citrus fruits, red capsicum, and tomato helps to prevent heartburn (Cancer Council, NSW, 2013). Intake of fruits and vegetables helps Mr. S to supplement vitamins and add roughage to the diet which in turn helps him to prevent constipation. Mr. S and his family may enjoy participating in an ‘Appetite for Life programme’ that gives advice on healthy food options.
The nurse can discuss this option with the client and the family. According to the information given, Mr. S needs assistance with the activities of daily living with worsening performance status. Minimising the possible complication associated with colostomy should be another important goal for the nurse. The nurse need to assess the client’s emotional and mental attitude towards the colostomy before attempting to teach colostomy self care and pace the teaching towards the client’s level of acceptance (Black, 1993). Mr.
S should be taught to examine the stoma followed by how to apply the pouch to the stoma correctly. Emptying the bag requires careful consideration and the nurse need to assess the client’s ability to change the bag. The nurse should ensure the involvement of family so that they can assist Mr. S with the colostomy care as and when required. Research shows that, flatus is an embarrassing problem faced by people with colostomies apart from diarrhoea (Black, 1993). Therefore, Mr. S should be taught how to muffle the passage of gas from their colostomies.
Liaising with the district nurses and community stoma nurses will also help to eliminate the associated complication by ensuring specialist care (Cornin, 2005). It is the responsibility of the nurse to help Mr. S to understand the role of medications and the importance of taking prescribed medications. The nurse need to provide relevant information to Mr. S regarding his current medications that those medications will help him to reduce his abdominal discomfort and improves his sleep quality (Appendix. A). Thus, the nurse can ensure his compliance to medications.
If the client wants to know more about the medications, a referral to the Canterbury Community Pharmacy Group can be made. Research shows that, continuing sexual relationships are one of the major concern for clients with cancer and significant others. There is no physical reason the client cannot enjoy normal sexual relationships (Black, 1993). The author (Appendix. A) has not provided any information regarding the sexual life of Mr. S. However, the nurse can provide this information to Mr. S as he lives with his wife.
Spirituality and religion can be important to the well being of people with cancer, which enable them to cope with the disease in a better way. “Patients who rely on their faith or spirituality tend to experience increased hope and optimism, freedom from regret, higher satisfaction with life, and feelings of inner peace. In addition, patients who practice a religious tradition or are in touch with their spirituality tend to be more compliant with treatment and live a healthier lifestyle” (National Comprehensive Cancer network, 2013). The author (Appendix. A) has not provided any information regarding the spirituality of Mr.
S. If Mr. S has got any spiritual beliefs and needs the nurse can help him to meet those needs that can have a direct effect on his quality of life. Addressing all these issues may increase the sleep for Mr. S. If sleep quality does not improve, cognitive behavioural therapy can be beneficial which helps Mr. S to learn healthy sleep hygiene. If problem still persists the nurse can in consultation with the patient, family and GP send referral to a psychologist or a sleep specialist (Delsigne, 2013). It is crystal clear from the information given that, (Appendix. A) Mr. S has got an advanced stage of colorectal cancer.
Therefore, it is the responsibility of the nurse to review and revise his wishes at the end of life with the active involvement of his family. Starting the conversation early strengthen the clients relationship with the health care team. Planning ahead to settle legal and financial affairs helps the client and family to concentrate on the emotional aspects of the clients illness (American Society of Clinical Oncology, 2011). Therefore, the nurse can create an advanced directive for Mr. S. It is a legally binding set of instructions that provide information regarding the kind of medical treatment Mr.
S wants at the time when he is not able to make those decisions by his own (MOH, 2011). Thus, the nurse can make sure that the client believes and values are incorporated into his future health care. The role of nurse in caring for people with cancer is multifacrotial. The nurse must be sensitive to the emotional aspect of their client’s illness, be skilled with the technical aspects of care (such as in chemotherapy), be available to teach both client and significant others about the disease process and treatments, and be a client advocate.
If the client denies treatment, the nurse must put all his or her skills to meet the client’s current and anticipated needs. If treatment is no longer an option for a client, the nurse is there to provide care for the client and perhaps significant others (Black, 1993). Conclusion: An increase in the incidence of long-term diseases like cancer and cardiovascular diseases is making new demands on healthcare systems and internationally new models of care are being developed to ensure patients with long-term conditions receive the most appropriate care.
Cancer is a leading cause of death worldwide and a growing health concern in New Zealand. Colorectal cancer being a leading cause of death in New Zealand, health promotion and primary prevention activities need to give special emphasis on early detection of cancer risks among the general population through health literacy and which in turn help them to lead a healthy lifestyle. The health care services need to be patient centred and the people, whanau and communities must be empowered to take the responsibility of their own health.
Nurses are in an ideal position to identify the population at risk following a population health approach which has the potential to not only improve the health status, but to contribute to the overall sustainability of the health care system.
References: American society of clinical Oncology (2011). Advanced Directives. Cancer. Net. Retrived from: http;//www. cancer. net/coping/end -life-care/advance-directives Black. J. M. , & Jacob. E. M. (1993). Luckmann and sorensen’s Medical- Surgical Nursing: A psychological Approach. Philadelphia, USA: Saunders Company. 651-1657, 474-525. Cancer Resource centre (2013). Coping with chemotherapy University of California, San Francisco Medical Center. Retrieved from:http://www. ucsfhealth. org/education/coping_with_chemothe rapy/ Cronin. E. (2005). Best practice in discharging patients with a stoma Nursing times. Net, 101(47), 67. Retrieved from: http://www. nursingtimes. net/best-practice-in-discharging-patients-with- a-stoma/203531. article. Delsigne. J. (2013). Managing sleep disorders in Cancer Patients. Oncolog, 58(2), retrieved from: http://www2. mdanderson. org/depts/Oncolog/articles/13/2-feb/2-13-2. html F