UNIVERSITY OF MAKATI COLLEGE OF ALLIED HEALTH STUDIES J.P.

Rizal Extension West Rembo, Makati City

Descending Colon to Rectosigmoid Mass with Multiple Seedings, probably Tuberculosis

A Clinical Abstract Presented to PROF. PAUL M. MARICA RN Clinical Instructor, College of Allied Health Studies, A.Y. 2012 2013

In partial fulfillment in the requirements for NCS 115 (Intensive Care Nursing) 1st Semester, A.Y. 2012 2013

Prepared by:

Barranda, Florable V. Bonifacio, Johannsen Mae L. Coronado, Jordan O.

July 18, 2012

INTRODUCTION The earliest written record regarding cancer is from 3000 BC in the Egyptian Edwin Smith Papyrus and describes cancer of the breast. Cancer however has existed for all of human history. Hippocrates (ca. 460 BC ca. 370 BC) described several kinds of cancer, referring to them with the Greek word carcinos (crab or crayfish). This name comes from the appearance of the cut surface of a solid malignant tumour, with "the veins stretched on all sides as the animal the crab has its feet, hence it derives its name". The Greek, Celsus (ca. 25 BC 50 AD) translated carcinos into the Latin cancer, also meaning crab and recommended surgery as treatment. Galen (2nd century AD) disagreed with the use of surgery and

recommended purgatives instead. These recommendations largely stood for 1000 years. The physician John Hill described tobacco snuff as the cause of nose cancer in 1761. This was followed by the report in 1775 by British surgeon Percivall Pott that cancer of the scrotum was a common disease among chimney sweeps. With the widespread use of the microscope in the 18th century, it was discovered that the 'cancer poison' spread from the primary tumor through the lymph nodes to other sites ("metastasis"). This view of the disease was first formulated by the English surgeon Campbell De Morgan between 1871 and 1874. Cancer or malignant neoplasm is a group of disease involving cells in the body which replicates and divides rapidly. Every part of our body which is composed of cells is prone to have neoplasm. Every time a cell undergoes apoptosis (cell death) the cell is subjected for mutation due to activation of proto- oncogene to oncogene which supresses the process of cell death. Thereby, cells are not replaced instead they replicate rapidly and eventually form a mass. Since everything in and out of our body is composed of cells every part is a candidate for neoplasm, just like the gastro intestinal tract specifically the rectosigmoid or colorectal area (the upper part of the sigmoid colon and lower part of the descending colon). Risk factors of Rectosigmoid or Colorectal Cancer are: 1. Age. People 50 and up are at high risk for the disease. 2. African-American race. African-Americans have a greater risk of colon cancer than do people of other races

3. Inherited syndromes that increase colon cancer risk. Genetic syndromes passed through generations of the family can increase your risk of colon cancer. These syndromes include familial adenomatous polyposis and hereditary nonpolyposis colorectal cancer, which is also known as Lynch syndrome. 4. Family history of colon cancer and colon polyps. The more likely to develop colorectal cancer if a parent, sibling or child with the disease. If more than one family member has colon cancer or rectal cancer, your risk is even greater. In some cases, this connection may not be hereditary or genetic. Instead, cancers within the same family may result from shared exposure to an environmental carcinogen or from diet or lifestyle factors. 5. Low-fiber, high-fat diet. Colon cancer and rectal cancer may be associated with diet low in fiber and high in fat and calories. Research in this area has had mixed results. Some studies have found an increased risk of colon cancer in people who eat diets high in red meat. 6. A sedentary lifestyle. Getting regular physical activity may reduce your risk of colon cancer. 7. Diabetes. People with diabetes and insulin resistance may have an increased risk of colorectal cancer. 8. Obesity. People who are obese have an increased risk of colon cancer and an increased risk of dying of colon cancer when compared with people considered normal weight. 9. Smoking. People who smoke cigarettes may have an increased risk of colon cancer. 10. Alcohol. Heavy use of alcohol may increase your risk of colon cancer. 11. Radiation therapy for cancer. Radiation therapy directed at the abdomen to treat previous cancers may increase the risk of colon cancer.

Signs and Symptoms In its early stage, colorectal cancer usually produces no symptoms. The most likely warning signs include:

Changes in bowel movements, including persistent constipation or diarrhea, a feeling of not being able to empty the bowel completely, an urgency to move the bowels, rectal cramping, or rectal bleeding

Dark patches of blood in or on stool; or long, thin, "pencil stools" Abdominal discomfort or bloating Unexplained fatigue, loss of appetite, and/or weight loss Pelvic pain, which occurs at later stages of the disease.

Diagnostic Tests 1. Fecal occult blood. Test the presence of microscopic or invisible blood in the stool, or feces. Fecal occult blood can be a sign of a problem in the digestive system, such as a growth, or polyp, or cancer in the colon or rectum. If microscopic blood is detected, it is important for doctors to determine the source of bleeding to properly diagnose and treat the problem. 2. Colonoscopy is an outpatient procedure during which the large bowel (colon and rectum) is examined from the inside. Colonoscopies are usually used to evaluate symptoms like abdominal pain, rectal bleeding, or changes in bowel habits. They are also used to screen for colorectal cancer. 3. Imaging tests are also used to screen for and detect colorectal cancer. These tests use technologies that visualize body organs and present them like a picture. Imaging tests are also used to determine how far the cancer has spread or how well it is responding, or has responded, to treatment. While some tests still use X-rays, newer technologies use radioactivity (in very tiny doses), ultrasound, or magnetic fields to obtain the pictures. 4. Other test like Barriun Enema Screening for Colorectal cancer, Flexible Sigmoidoscopy, Proctoscopy for Rectal Cancer.

Treatments Colorecatal cancer just like any other cancer is treated in three ways slash, burn or poison. Some says that colorectal cancer should be treated according to its stage (www.cancer.org).

Stage 0 Since these cancers have not grown beyond the inner lining of the colon, surgery to take out the cancer is all that is needed. This may be done in most cases by polypectomy (removing the polyp) or local excision through a colonoscope. Colon resection (colectomy) may occasionally be needed if a tumor is too big to be removed by local excision. Stage I These cancers have grown through several layers of the colon, but they have not spread outside the colon wall itself (or into the nearby lymph nodes). Partial colectomy surgery to remove the section of colon that has cancer and nearby lymph nodes is the standard treatment. Stage II Many of these cancers have grown through the wall of the colon and may extend into nearby tissue. They have not yet spread to the lymph nodes.Surgery (colectomy) may be the only treatment needed. But the doctor may recommend adjuvant chemotherapy (chemo) if the cancer has a higher risk of coming back.

Stage III In this stage, the cancer has spread to nearby lymph nodes, but it has not yet spread to other parts of the body. Surgery (partial colectomy) followed by adjuvant chemo is the standard treatment for this stage. The FOLFOX regimen is the most common chemotherapy combination, although some doctors may prefer 5-FU and leucovorin, or capecitabine alone based on your health needs. Doctors may also advise radiation therapy if your surgeon thinks some cancer cells might have been left behind after surgery. In people who aren't healthy enough for surgery, radiation therapy and/or chemotherapy may be options.

Stage IV The cancer has spread from the colon to distant organs and tissues such as the liver, lungs, peritoneum, or ovaries. In most cases surgery is unlikely to cure these cancers. However, if only a few small areas of cancer spread (metastases) are present in the liver or lungs and they can be completely removed along with the colon cancer, surgery may help the patient live longer and may even cure him/her. Chemo is typically given as well, before and/or after surgery. In some cases, hepatic artery infusion may be used if the cancer has spread to the liver.

Biographical Data Patient Name Age Gender Religion Address Hospital Date of Admission : Patient ED : 59 years old : Female : Roman Catholic : Makati City : Ospital Ng Makati : July 5, 2012

History of Present Illness One year prior to admission, the patient noted episodes of gross hematochezia (bright red blood) with associated left lower quadrant abdominal pain, stabbing in quality, 10/10 in pain scale, not associated with food intake or relieved by medications, no vomiting or fever. She consulted at the Outpatient Department (OPD) and underwent a Computer Tomographic Scan (CT Scan) showing a colonic mass for which a colonoscopy was warranted. Due to various familial reasons (death of an immediate family member), the patient deferred the procedure. 8 months prior to admission, the patient again developed the same abdominal pain but with no hema tochezia this time. She also noticed severe weight loss over the past months ( not quantified) with anorexia and intermittent diarrhea. The patient then sought consultation at the

OPD but colonoscopy was deferred again. She was given pain medications and taught follow up consults after that 2 week prior to admission the patient developed constipation in addition to her left lower quadrant abdominal pain. According to her, she always needs suppository to help her defecate. She sought consultation at the OPD for which colonoscopy was done showing around 70 % obstruction of the colonic lumen. She was advised for admission for further work up and elective surgery Review of Systems Has easy fatigability, anorexia, weight loss, generalized weakness, no fever Has occasional difficulty of breathing, no cough, colds, dyspnea, syncope No chest pain, palpitations, orthopnea No dysuria, frequency, urinary symptoms No heat/cold intolerance, polyuria, polydipsia, polyphagia

Past Medical History and Surgical History The patient has no known illness/condition like Diabetes Mellitus, asthma, or hypertension. She has no known allergies to foods or medications.

Family Medical History The patients mother has Diabetes Mellitus and hypertension while his father died with lung cancer. Pulmonary tuberculosis and Asthma is not present in the family.

Personal and Social History She does not smoke, and does not drink alcoholic beverages; she also denies usage of illicit/illegal drugs.

OB-Gyne History: The patients OB scoring is G2P2 2002; all through Caesarian Delivery due to cephalopelvic disproportion but without complications; currently the patient is on menopause. Surgical Procedures done to the patient Explolartory Laparotomy; Transverse loop Colonostomy; Peritoneal Seeding and Mysenteric Lymph node biopsy was done to the client; with post-operative diagnosis of Descending colon to Rectosigmoid mass with multiple seeding probably Tuberculosis. During the perioperative phase of the surgery, the patient was given Ceftriaxone 2 g TIV OD as antibiotic prophylaxis, before the surgery. Our client is also under Epidural Anesthesia and General Anesthesia during the surgery and she has a midline laparotomy incision carried down to the peritoneum. Findings of the exploration includes, minimal ascites (fluid was obtained); multiple seedings were noted all over the colon, concentrating most at the descending colon up to the pelvis forming a huge, hard mass that is adherent to the left ureter, peritoneum and posterior wall of the uterus; a 1.5 cm caseation (necrotic degeneration of a bodily tissue to a soft, cheesy like state) of a mesenteric lymph node; the liver was adherent to the anterior abdominal wall by multiple seedings; no definite mass noted; ad no other lesions seen. Medical Procedures after the Surgery Right after the surgery the patient was transferred from the OR to the Post Anesthesia Care Unit and is critically monitored and once stable will be transferred to the ward. Upon receiving the patient oxygen therapy was provided and is immediately hooked with a monitoring machine that takes the clients vital signs digitally. News orders from the doctors are followed including positioning for the client and her medication which includes: 1. Tramadol 50 mg TIV every 6 hours PRN for pain 2. Ceftriaxone 500 mg TIV (SIVP) OD ANST (-) 3. Pantoprazole 40 mg TIV OD while on NPO 4. Ketorolac 30 mg IV every 6 hours ANST (-) for 20 hours

5. Morphine Sulfate 0.02 % low Via epidural catheter 6. Metronidazole 500 mg/ vial

Course in the Post-Anesthesia Care Unit (PACU)

Received patient at 6:45PM, lying on bed and sleeping; with oxygen supply via face mask regulated @5LPM; with an IVF of D5LR hooked at Right hand and infusing well at 42gtts/min; with IVF of D5W x KVO for CVP line at the antecubital area (subclavian); with colostomy bag on the Left part of her abdomen, well intact; with Foleys catheter ; vital signs taken and recorded as follows Temp: 36.3 OC , BP: 130/90 mmHg, PR: 85 bpm, RR: 20 cpm, O2 Sat: 99 % and CVP of 6 cm of Water. At Around 7 PM patient is still sleepy and unable to move or race her extremities , vital signs are reassessed and recorded as follows Tem: 36.3, BP: 130/90, PR: 83 bpm, RR: 23 cpm, O2 Sat: 99 %, and CVP reading of 6-7 cm of water. At exactly 7:15 PM the patient is still sleepy but she was able to move her upper and lower limbs, vital signs are taken and recorded as follows Tem: 36.7, BP: 130/90, PR: 83 bpm, RR: 22 cpm, O2 Sat: 99 %, and CVP reading of 6-7 cm of water. Around 7:30 PM the patient is still sleepy but she was able to move her upper and lower limbs, vital signs are taken and recorded as follows Tem: 36.7, BP: 130/90, PR: 86 bpm, RR: 22 cpm, O2 Sat: 99 %, and CVP reading of 6-7 cm of water.

II. Identified problems with Interventions and Evaluation

1. Ineffective Breathing Pattern related to muscle weakness Interventions Asses the patients breathing the rate, depth and effort of breathing. Position the client on semi Fowler position. Provide the patient with Oxygen supplementation via face mask 5-6 lpm. Provide comfort and promote rest. May instruct the patient to do deep breathing exercises if tolerated Evaluation: Goal met. Significant improvement on the rate of breathing of the client was noted. 2. Acute Pain related to Post-surgical incision Interventions Assess pain including location, characteristics, onset/duration, frequency and severity Note the location of the surgical procedure Monitor vital signs Provide comfort measures to the client Diversional activities are implemented. Encouraged patient the use of relaxation exercises such as deep breathing exercises Evaluation: Goal Met. The pain felt by the client was lessened from 7/10 to 5/10 which indicates that the therapeutic approach was effective. 3. Impaired physical mobility related to presence of surgical incision. Interventions Monitor vital signs every 15 minutes Determine presence of complications related to immobility. Keep patient comfortable on bed. Reposition the patient every 2 hours. Provide for safety measures as indicated by individual situation, including environmental management and fall prevention. Evaluation: Goal met. The plan of care for the patient was attained and kept the patient comfortable on bed. 4. Risk for injury related to decreased level of consciousness.

Interventions Provide privacy, and inform the patient to every nursing care to be done. Ensure that side rails are padded and kept in raised position. Monitor the patients vital signs every 15 minutes. Assess clients muscle strength, gross and fine motor coordination to identify risk for falls. Identify interventions and safety devices to promote safe environmental and individual safety. Evaluation: Goal met. The patient did not experience any injury.

5. Risk for Infection related to inadequate primary defenses Interventions Assess the incision site of the client to check for bleeding Note risk factors for occurrence of infection such as the catheter, skin integrity and the contraptions of the client Monitor vital signs Provide preventive measures (hand washing, gloving) Draining of urine output from the catheter Evaluation: Goal Met. Provided preventive measures to help reduce the risk factors which can lead to infection.

6. Risk for impaired skin integrity related to physical immobility. Interventions Assess skin routinely, noting moisture, color, and elasticity. Massage body prominences and use proper positioning, turning, lifting, and transferring techniques when moving client to prevent friction or shear injury. Reposition the patient at least once every two hours. Monitor vital signs every 15 minutes. Provide adequate clothing or covers; protect from drafts to prevent vasoconstriction. Provide protection by use of pads, pillows, foam mattress to increase circulation and limit or eliminate excessive tissue pressure. Evaluation: Goal met. After 1- 2 hours of nursing interventions, the patient prevented of having a pressure ulcers.