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colorectal carcinoma: 2nd most common in asia (clinical manifestation…
colorectal carcinoma: 2nd most common in asia
predisposing factor
inflammatory bowel disease (IBD
familial adenomatous 腺瘤 polyposis (FAP) lots of polyps
hereditary non-polyposis colon carcinoma
high fat low fiber diet
clinical manifestation
altered bowel habit
rectal bleeding
abdominal discomfort/ pain
iron deficiency anaemia
abdominal mass, right iliac fossa
unexplained weight loss, anorexia, fatigue
hepatomegaly if metastasis
ascites
no symptoms until advanced stage
investigation
fecal material from NG tube aspiration
digital rectal examination (DRE)
lab test
decrease sodium. potassium & chloride levels due to vomiting
WBC counts increase & C-reactive protein (CRP) to determine inflammatory process, necrosis, strangulation, peritonitis
serum amylase increase due to irritation of pancreas by bowel loop
CBC
increase
Carcinogenic Embryonic Antigen (CEA)
stool for occult blood
abdominal & chest XR
presence & location of small/ large intestinal distension, gas, fluid
'bird beak' lesion in colonic volvulus
foreign body visualization
contrast studies: Barium enema
identify colon obstruction/ intussusception in more proximal colon
identify site of tumour more accurately than colonoscopy
Barium/ Gastrografin meal & follow through to detect ileus
diagnostic test
colonoscopy with endorectal ultrasound
identify source of obstruction e.g. tumour/ stricture
confirm diagnosis with biopsy
resection of polyps
EUS (endoscopic ultrasound)
identify tumour site & staging
identify pelvic & perianal metastasis
CT scan
more accurate in determine level of intestinal obstruction
MRI: magnetic resonance imaging
more accurate determine the site of obstruction
detect metastasis in pelvis
PET scan
detect distant metastasis
radioisotope scan
locate rare tumour & cells & rapidly bleeding lesion
management
primary prevention
diet modification
screening for high risk individuals
genetic test to identify mutation
flexible sifmoidoscopy
polypectomy
prophylactic colorectal surgery:
total restorative proctocolectomy
chemoprevention under clinical
lifelong rectal surveillance: annual/ biennual colonoscopy
stent insertion 支架
decompress of obstruction
bowel resection
curative treatment
left/ right hemicolectomy
end -to-end
anastomosis of bowel
temporary diverting loop ostomy / double-barrel
Hartmann's procedure: 2 stages
1.
initial colonic resection
eith proximal bowel mobilized to perform colostomy & rectal pouch
subsequent closure of colostomy
& re-anastomosis of bowel
temporary/ permanent end colostomy
abdominoperineal (AP) resection
cancer involve anorectum
remove rectum & anus with permanent colostomy
end-colostomy
coloanal reservoir (total colectomy)
neodymium (laser Nd: YAG)
adjuvant therapy 輔助治療
chemotherapy
shrink tumour prior to surgical excision
eradicate 根除 tumour cells postoperatively
radiotherapy
palliative
pre-op nursing diagnosis
acute pain: obstruction, distension, strangulation
risk of deficient fluid volume: impaired fluid intake, vomiting, diarrhea
diarrhea/ constipation: onstruction
ineffective breathing pattern: abdominal distension, interfere normal lung expansion
risk of injury: severity * complications of illness
fear: life0threatening symptoms of intestinal obstruction
management
bowel decompression
NPO promote bowel rest
NG tube insertion
connect to BSB Q1H aspiration
monitor patency
note color, amount, characteristics of drainage
drain by gravity
note route of medication of prescribed
pain
anxiety lead to difficult to manage pain
address knowledge deficit but avoid overwhelming information
reinforce & explain intervention
promote relaxation & rest
determine & administer analgesia as appropriate
IM
opiates e.g. morphine
induce N/V
administer antiemetics
Hyoscine butylbromide, e.g. buscopan--> control colicky spasmodic pain
bowel preparation
low residue diet to reduce fecal content
fluid diet 1D pre-op
NPO 6-8hrs
administer prescribed medications
ducolax suppository
cathartics e.g. GoLytely p.o. 12-48 hrs pre-op
prophylactic antibiotics
cephalosporin (Zinacef)
aminoglycoside (neomycin)
sulfonamides (septrin)
post-op intervention
optimal nutrition: short bowel syndrome
enteral feeding
parenteral feeding
fluid & electrolyte balance
wound care
stoma care & bowel elimination
support +ve image
monitor & manage complications