Faculty of nursing

Zagazig university

For patient with

COLORECTAL CANCER
Prepared by
Aya abd elfadeil elsayed
Supervised by

Dr/ Nadia Mohammed Taha

Dr/Fathia Atia
Dr/Elham hamad
Dr/Howaida kameel
Dr/Maha desoky
phd
first semester
)2019(

1
Out lines
Biographic data
Admission data
Chief complain
Medical diagnosis
Present illness
Past medical &surgical history
Child health history
Family history
Health pattern
Diagnostic procedure &lab test
Medication
Disease process
Nursing care plan

2
 Case study

Sociodemographic data:

-Special unit: surgical department

-Patient's name: Mohammed Mohsen
ebrahim
-Bed no: 5
-Date of admission: 25-11-2019
-Age: 45years old -Sex: male
-Level of education: Bachelor of Commerce -Occupation: banker
-Marital status: married -Religion: Muslim

Present history:

- Diagnosis / Present illness: colorectal cancer

- Chief complaints on admission: recurrent difficulty micturation
and recurrent constipation
- Associated signs and symptoms: throbbing pain, bleeding per rectum
and itching
- Onset / Duration / Frequency: begin gradual and become continuous
for several days
- Predisposing factors: increasing by examination, tobacco smoking, heavy meal
- Relieving measures and its effects: relieving with medication

3
 Past history:

-Medical:

No past medical history for any chronic

disease

-Surgical:
Name of surgery: Herniotomy
Duration: since 10years ago

-Allergy history: no allergic effect

Child health history (if applicable):
 Birth history :- The patient was born in 24/ 8/ 1958
 Growth and development : Normal without any retardation , he has no problem or
disease related to growth and development
 Immunization history :- The patient said that " he takes all immunization "
 Childhood disease: Pt said that "as any child fever, tonsillitis, cough, diarrhea,
constipation and anemia, sometimes he suffers from bronchitis but he recovered from it.
Family history:-
 Age and health status of living grand parents, parents, sibling, uncle.
 Age and cause of death of decreased close first class relatives.
Name Age Health status
Grand parent Die since 1o years Die without any
disease " normal death

Her Father Die at age of 50years Die normal with out

old. any disease.

Her Mother Die at the age of 53 Die normal with out

years old any disease.

Uncle He has one uncle 82 Diabetic patient,

years old hypertensive patient ,
still live
His son :-
El said 17 years old
Hussien All of them is still

4
 Asmaa 13 years old alive and with normal
health.
20 years old

Family history:

- Diagnosis / Relation: no similar condition

-Life style habit: smoking

Patient's Physical Assessment:

1. Respiratory system: breathing NAD

2. Circulatory system : heart NAD
3. Peripheral vascular: NAD
4. Neurological assessment: Weakness and fatigue
5. Gastrointestinal system: nausea, vomiting and anorexia
6. Urinary system: NAD
7. Muscle skeletal system: weakness muscle
8. Skin assessment: NAD
9. Head / hair: headache, hair loose
8. Eyes: blurred vision
9. Ears: NAD
10. Nose: NAD
11. Mouth: fungal infection and sore throat
12. Neck: NAD
13. Activity and rest: hypoactive and restlessness

5
Definition of disease:
 Colorectal cancer defined as:
 Cancer of the colon and rectum
 A malignant tumor arising from the inner wall of the large
intestine
 A malignant disease of the colon and/or rectum which often
begins as a polyp
 A malignancy that arises from the inner lining of the colon. Most,
if not all, of these cancers develop from colonic polyps. Removal
of these precancerous polyps can prevent colon cancer.

Path physiology of disease:

According to WHO Cancer is a leading cause of death worldwide,

accounting for an estimated 9.6 million deaths in 2018. The most
common cancers are: Lung (2.09 million cases) then Breast (2.09
million cases) and Colorectal (1.80 million cases) While The most
common causes of cancer death are cancers of: Lung (1.76 million
deaths) then Colorectal (862 000 deaths).

Cancer of the colon and rectum is predominantly (95%) Aden

carcinoma (i.e., arising from the epithelial lining of the intestine) It may
start as a benign polyp but may become malignant, invade and destroy
normal tissues, and extend into surrounding structures. Cancer cells
may migrate away from the primary tumor and spread to other parts of
the body (most often to the liver) and Colon cancer is preventable and
curable. It is preventable by removing the precancerous colon polyps. It
is curable if detected early when it can be surgically removed before it
has spread to other parts of the body. If screening and surveillance
programs were practiced universally, there would be a tremendous
reduction in the incidence and mortality of colon cancer.

6
 Etiology:

According to patient According to literature

 The exact cause of colon and
rectal cancer is still unknown
 But risk factors have been identified
as:
 Low-fiber and high-fat diet
 Older age:. About 90 percent of
people diagnosed with colon cancer
are older than 50. Colon cancer can
occur in younger people, but it occurs
much less frequently.

7
  A personal history of
colorectal cancer or polyps:.
If you've already had colon
cancer or adenomatous
polyps, you have a greater risk
of colon cancer in the future.
 Inflammatory intestinal
conditions: Long-standing
inflammatory diseases of the
colon, such as ulcerative
colitis and Crohn's disease,
can increase your risk of
 A sedentary lifestyle colon cancer.
 Inherited syndromes that
increase colon cancer risk:
Genetic syndromes passed
through generations of your
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.
 Family history of colon
cancer and colon polyps:
You're more likely to develop
colon cancer if you have 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.

8
9
  Low-fiber and high- fat diet:
Colon cancer and rectal cancer
may be associated with a diet
low in fiber and high in fat and
calories. Some studies have
found an increased risk of colon
cancer in people who eat diets
high in red meat and processed
meats.
 A sedentary lifestyle: If you're
inactive, you're more likely to
develop colon cancer. Getting
 Smoking regular physical activity may
reduce your risk of colon
cancer.
 Diabetes: People with
diabetes and insulin resistance
may have an increased risk of
colon cancer.
 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.
 Smoking: People who
smoke cigarettes may have
an increased risk of colon
cancer.
 Alcohol: Heavy use of
alcohol may increase your
risk of colon cancer.
Radiation therapy for
cancer: Radiation therapy
directed at the abdomen to
treat previous cancers may
increase the risk of colon
cancer.

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Clinical manifestations:
According to patient According to literature
Signs and symptoms of colon cancer
include:

 Recurrent constipation • A change in your bowel habits,

including diarrhea or constipation or
a change in the consistency of your
stool for more than a couple of
weeks(The most common)

 Bleeding per rectum

• Rectal bleeding or blood in your
stool (the second most common
symptom)

• Persistent abdominal discomfort,

such as cramps, gas or pain

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 • A feeling that your bowel doesn't
• Weakness or fatigue empty completely after a bowel
movement

• Unexplained weight loss

• Weakness or fatigue
• Anorexia
• Unexplained weight loss

• unexplained anemia,

• Anorexia

Complications:

According to patient According to literature

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 • Tumour growth may
cause partial or complete
bowel obstruction.

• Extension of the tumor

and ulceration into the
surrounding blood vessels
• Abscess formation, result in haemorrhage

• . Perforation
,
• Abscess formation,

• peritonitis

• Sepsis and shock may

occur.

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 Diagnostic Measures:

Lab Investigation:

According to literature According to patient

Lab investigation Patient Results Normal Range Comment

Kidney function test :

.
blood urea nitrogen 13mg/dl 6-20mg/dl Within normal
(BUN)
creatinine 0.5mg/dl 0.5-1mg/dl Within normal

Uric acid 4.1 3.5-7.2 Within normal

Complete blood count

(CBC)
WBC 5500k/l 4000-11000k/l With normal range
RBC 3.2million/cumm 4-5millio/cumm Low value
HGB 9.3gm/dl 13-18m/dl Low value

Liver function test:

Albumin 3.2gm/dl 3.5-5.5gm/dl With normal range

AST 15u/l 0-35u/ml With normal range

ALT 1lu/ml 5-35u/ml With normal range

Total billirubin 0.4gm/dl 0.3-1 gm/dl With normal range

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 Radiological Examination:

According to literature According to patient

Type of examination Check for what done Patient's result
 Using a scope to
examine the inside of
your colon.
(Colonoscopy )
 Using dye and X-rays All done Colorectal cancer
to make a picture of
your colon. A barium
enema allows your
doctor to evaluate
your entire colon
with an X-ray.
 -Using multiple CT
images to create a
picture of your colon.

 Medical management according to literature

 The patient with symptoms of intestinal obstruction

is treated with IV fluids and nasogastric suction.
 If there has been significant bleeding, blood component
therapy may be required.
 Treatment for colorectal cancer depends on the stage of
the disease (Chart 38-9) and consists of surgery to
remove the tumor
 , supportive therapy, and adjuvant therapy
 . Patients who receive some form of adjuvant therapy,
which may include chemotherapy, radiation therapy,
immunotherapy, or multimodality therapy, typically
demonstrate delays in tumor recurrence and increases
in survival time

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 Staging of Colorectal Cancer Dukes' Classification–Modified Staging
System
Class A: Tumor limited to muscular mucosa and sub mucosa
Class B1: Tumor extends into mucosa
Class B2: Tumor extends through entire bowel wall into serosa or
pericolic fat, no nodal involvement
Class C1: Positive nodes, tumor is limited to bowel wall
Class C2: Positive nodes, tumor extends through entire bowel wall
Class D: Advanced and metastasis to liver, lung, or bone Another staging
system, the TNM (tumor, nodal involvement, metastasis) classification,
may be used to describe the anatomic extent of the primary tumor,
depending on:

 Size, invasion depth, and surface spread

 Extent of nodal involvement
 Presence or absence of metastasis

.
Adjuvant Therapy:
The standard adjuvant therapy administered to patients with Dukes' class
C colon cancer is the 5-fluorouracil plus levamisole regimen. Patients
with Dukes' class B or C rectal cancer are given 5-fluorouracil and high
doses of pelvic irradiation. Mitomycin is also used. Radiation therapy is
used before, during, and after surgery to shrink the tumor, to achieve
better results from surgery, and to reduce the risk of recurrence. For
inoperative or unresectable tumors, radiation is used to provide
significant relief from symptoms. Intracavitary and implantable devices
are used to deliver radiation to the site. The response to adjuvant therapy
varies.

 Medical Management according to patient:

No Drug name Route Dose / Frequency

1 Zantac Iv 3ml/ every 8h
2 Unacin Iv 1.5gm/every 12h
3 Flagyle Iv 100mg /every 8h
4 Glucose 5% Iv 500mg/every 8h
5 Ringer Iv 500mg/every 8h

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  Surgical Management:

According to literature According to patient

 Surgery is the primary treatment for most
colon and rectal cancers. It may be curative
or palliative
 Surgical procedures include the following:
Not done
 Segmental resection with anastomosis (ie,
removal of the tumor and portions of the bowel
on either side of the growth, as well as the blood
vessels and lymphatic nodes)

 Abdominoperineal resection with permanent

sigmoid colostomy (ie, removal of the tumor and
a portion of the sigmoid and all of the rectum and
anal sphincter)
 Temporary colostomy followed by segmental
resection and anastomosis and subsequent
reanastomosis of the colostomy, allowing initial
bowel decompression and bowel preparation
before resection

 Permanent colostomy or ileostomy for

 Permanent colostomy or ileostomy
palliation of unrespectable obstructing lesions
for palliation of unrespectable
 Construction of a coloanal reservoir called a
obstructing lesions
colonic J pouch, which is performed in two steps.
A temporary loop ileostomy is constructed to
divert intestinal flow, and the newly constructed J
pouch (made from 6 to 10 cm of colon) is
reattached to the anal stump. About 3 months after
the initial stage, the ileostomy is reversed and
intestinal continuity is restored. The anal sphincter
and therefore continence are preserved.

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 Ideal nursing care plan for patient with
colorectal cancer

Assessment
Ascending (Right) Colon Cancer
 Occult blood blood in stool
 Anemia
 Anorexia and weight loss
 Abdominal pain above umbilicus
 Palpable mass
Distal Colon/ Rectal Cancer
 Rectal bleeding
 Change bowel habits
 Constipation or diarrhea
 Pencil or ribbon shaped stool
 Tenesmus
 Sensation of incomplete

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 Nursing diagnosis Expected outcomes Nursing Intervention Rationale Evaluation

Pain related to Report maximal  Determine pain Information provides Patient become more
tissue injury pain relief/control history (location of baseline data to evaluate relaxed and control his
from tumor with minimal pain, frequency, effectiveness of pain as evidenced by
invasion and the interference with duration, and interventions. Pain of decrease level of anxiety.
surgical incision ADLs. intensity using more than 6 mo
and Side effects Follow prescribed numeric rating duration constitutes
of various pharmacological scale (0–10 scale), chronic pain, which
cancer therapy regimen. or verbal rating may affect therapeutic
agent. Demonstrate use of scale (“no pain” to choices. Recurrent
relaxation skills and “excruciating pain”) episodes of acute pain
diversional and relief measures can occur within
activities as used. Believe chronic pain, requiring
indicated for patient’s report. increased level of
individual situation.  Administer intervention. Note: The
chemotherapy pain experience is an
agents as ordered, individualized one
provide care for the
composed of both
client receiving
physical and emotional
chemotherapy.
responses.
 Provide care for
the client receiving
radiation therapy.
 Provide care for
the client with
bowel surgery.
 Analgesic
administration
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  Anxiety reduction
 Environmental
management.

Imbalanced Demonstrate stable 1. Conduct a complete 1. Patients react  Patient Consumes a

nutrition; less than weight/progressive nutritional assessment differently to healthy diet:
body requirements weight gain toward to identify any foods certain foods
related to anorexia, goal with that may increase because of  Avoids foods and
nausea, vomiting normalization of peristalsis by irritating individual fluids that cause
and avoidance of laboratory values the bowel. sensitivity. diarrhea
foods that may and be free of signs  Substitutes no
cause GI discomfort of malnutrition. 2. Advise the patient to irritating foods and
as manifested by Verbalize avoid food products 2. Cellulose food fluids for those that
weight loss understanding of with a cellulose or products are the no are restricted
individual hemicellulose base digestible residue
interferences to (nuts, seeds). of plant foods.
adequate intake. They hold water,
Participate in 3. Recommend provide bulk, and
specific moderation in intake of stimulate
interventions to certain irritating fruits elimination.
stimulate such as prunes, grapes,
appetite/increase and bananas. 3. These fruits tend to
dietary intake. increase the
4. Encourage open quantity of effluent.
communication
regarding anorexia. 4. Often a source of
emotional distress,
5. Insert and maintain NG especially for SO
or feeding tube for who wants to feed
enteric feedings, or patient frequently.
central line for total When patient

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 parenteral nutrition refuses, SO may
(TPN) if indicated. feel rejected or
frustrated.

5. In the presence of
severe malnutrition
(loss of 25%–30%
body weight in 2
mo) or if patient
has been NPO for 5
days and is unlikely
to be able to eat for
another week, tube
feeding or TPN
may be necessary
to meet nutritional
needs.
Deficient patient will 1. Ascertain whether the 1. Fear of a repeated  Patient Acquires
knowledge about Understands the patient has had a negative information about
the surgical surgical process and previous surgical experience diagnosis, surgical
procedure and the necessary experience and ask for increases anxiety. procedure,
preoperative preoperative recollections of positive Talking about the preoperative
preparation as preparation and negative experience with a preparation
manifested by impressions. nurse helps clarify Projects a positive
verbalizing 2. Determine what misconceptions attitude toward
inaccurate information the surgeon and helps the the surgical
information gave the patient and patient ventilate procedure
family and whether it any repressed
was understood. Clarify emotions. Positive
and elaborate as experiences are  Repeats in own
necessary. reinforced. words information
2. Clarification given by the

21
 3. Determine whether the prevents surgeon
stoma is permanent or misunderstandin
temporary. Be aware of gs and alleviates
the patient's prognosis if anxiety
carcinoma exists. 3. Knowledge, for
4. Use pictures or some, alleviates
drawings to illustrate the anxiety because
location and appearance fear of the
of the surgical wounds unknown is
(abdominal, perineal) decreased. Others
and the stoma if the choose not to know
patient is receptive. because it makes
5. Explain that them more anxious
oral/parenteral
antimicrobials will be
administered to cleanse
the bowel
preoperatively. 4. Antimicrobials and
Mechanical cleansing mechanical cleansing
may also be required. reduce intestinal
6. Assist the patient during bacterial flora
nasogastric/nasoent eric
intubation. Measure
drainage from the tube. 5. Nasoenteral
intubation is used for
decompression and
drainage of
gastrointestinal
contents before
Anxiety related to patient describe a 1. Provide information 1. Emotional  Patient Feels
the loss of bowel reduction in level of about expected bowel adjustment is less anxious
control as anxiety experienced function: facilitated if through:

22
manifested by -Characteristics of adequate
patient restlessness effluent information is
and anxious -Frequency of provided at the
discharge level of the o Expresse
2. Teach the patient how learner. s
to prepare the 2. Adequate fit is concerns
appliance for an necessary for and fears
adequate fit. successful use of freely
a. Choose the drainage the appliance.
appliance that will a. The appliance
provide a secure fit opening should be
around the stoma. larger than the
Measure the stoma size stoma for an Uses coping
with a measuring guide adequate fit. measures to
provided by the ostomy Available brands manage stress
equipment manufacturer come in different
and compare with the sizes to fit the
opening on the pouch. stoma.
About 3-mm (1/8-in) Adjustments are
clearance should be made as
provided around the necessary.
stoma. b. The appliance is
b. Remove any plastic ready to apply
covering that protects directly to the
the appliance adhesive. skin or skin
Note: The pouch is protector.
applied by pressing the
adhesive for 30 seconds
to the skin or skin
barrier.
3. Demonstrate how to 3. Manipulation of
change the appliance the appliance is

23
 before leakage occurs. a learned motor
Be aware that the skill that
elderly person may requires
have diminished vision practice
and difficulty handling and positive
equipment reinforcement.
4. When appropriate,
demonstrate how to
irrigate the colostomy
(usually on the 4th–5th 4.Colostomy
day). Recommend that irrigation is used
irrigation be performed to regulate the
at a consistent time, passage of fecal
depending on the type material;
of colostomy. alternatively the
bowel can be
allowed to
evacuate naturally
Risk for deficient patient will Estimate fluid intake .1 1. Provides
fluid volume Attainment of fluid :and output indication of  Patient
related to anorexia balance a. Strict intake fluid balance. Maintains fluid
and vomiting and and output balance
increased loss of b. Daily weights .b. gain/loss of 1
fluids and L of fluid is
electrolytes from GI reflected in a  Maintains
tract body weight normal serum
change of 2.2 lb. and urinary
Assess serum and .2 values for
urinary values of sodium and
.sodium and potassium Sodium is the potassium
major electrolyte Normal skin
regulating water turgor

24
 balance.
Vomiting results Surface of
Observe and record .3 in decreased tongue is pink,
skin turgor and the urinary and with a moist
appearance of the serum sodium mucous
.tongue levels. Urinary membrane
sodium values,
in contrast to
serum values,
reflect early,
sensitive
changes in
sodium balance.
Sodium works
in conjunction
with potassium,
which is also
decreased with
vomiting.
3. Adequate
hydration is
reflected by the
skin's ability to
return to its
normal shape
after being
grasped between
the fingers.
Note: In the
older person, it
is normal for the
return to be

25
 delayed.
Changes in the
mucous
membrane
covering the
tongue are
accurate and
early indicators
of hydration
status.
Risk for Maintain usual 1. Ascertain usual 1. Data required as
Constipation/Diarrh bowel elimination habits. baseline for future Patient
ea may be related consistency/pattern. 2. Assess bowel sounds evaluation of improved as
to Irritation of the Verbalize and record bowel therapeutic needs evidenced by
GI mucosa from understanding of movements (BMs) and effectiveness. Maintain usual
either factors and including frequency, 2. Defines bowel
chemotherapy or appropriate consistency (particularly problem (diarrhea, consistency/pat
radiation therapy; interventions/solutio during first 3–5 days of constipation). tern.
malabsorption of fat ns related to Vinca alkaloid therapy). Note:
Verbalize
Hormone-secreting .individual situation 3. Monitor I&O and Constipation is
understanding
tumor, carcinoma of weight. one of the earliest
of factors and
colon 4. Encourage adequate manifestations of
appropriate
Poor fluid intake, fluid intake (2000 mL neurotoxicity.
interventions/so
low-bulk diet, lack per 24 hr), increased 3. Dehydration,
lutions related
of exercise, use of fiber in diet; regular weight loss, and
to individual
opiates/narcotics exercise. electrolyte
situation.
5. Provide small, frequent imbalance are
meals of foods low in complications of
residue (if not diarrhea.
contraindicated), Inadequate fluid
maintaining needed intake may
protein and potentiate

26
 carbohydrates (eggs., constipation.
cooked cereal, bland 4. May reduce
cooked vegetables). potential for
constipation by
improving stool
consistency and
stimulating
peristalsis; can
prevent
dehydration
associated with
diarrhea.
5. Reduces gastric
irritation. Use of
low-fiber foods
can decrease
irritability and
provide bowel rest
when diarrhea
present.
Disturbed body patient will 1. Encourage the 1. Free expression of
image related to Attainment of a patient to verbalize feelings allows the  Patient
colostomy as positive self- feelings about the patient the Expresses
manifested by concept stoma. Offer to be opportunity to feelings and
verbalization about present when the verbalize and concerns about
altered function of stoma is first viewed identify concerns. self through:
body part and touched. Expressed
concerns can be
therapeutically -Gradually
addressed by increases
health care team participation in
2. Suggest that the members. stoma and
27
 spouse or significant 2. Helps patient to
other view the stoma. overcome fears peristomal skin
3. Offer counselling, if about partner's care
desired. response.
4. Arrange for a visit 3. Provides
with an ostomate opportunity for - Discusses
additional support. feelings related
4.Ostomates can offer to changed
support and share appearance
mutual feelings and
experiences
Anticipatory  Identify and 1. Expect initial shock 1. Few patients are
Grieving May be express feelings and disbelief fully prepared • Continue
related to appropriately. following diagnosis for the reality of normal life
 Continue normal of cancer the changes that activities,
Anticipated loss of life activities, and traumatizing can occur. looking
physiological well- looking procedures 2. Knowledge toward/plannin
being , change in toward/planning (disfiguring surgery, about the g for the future,
lifestyle, for the future, colostomy, grieving process one day at a
Perceived potential one day at a amputation). reinforces the time.
death of patient time. 2. Assess patient and SO normality of
Possibly evidenced  Verbalize for stage of grief feelings and
by understanding of currently being reactions being
Changes in eating the dying experienced. Explain experienced and
habits, alterations in process and process as can help patient
sleep patterns, feelings of being appropriate. deal more
activity levels, supported in 3. Provide open, effectively with
libido, and grief work. nonjudgmental them.
communication environment. Use 3. Promotes and
patterns therapeutic encourages
Denial of potential communication skills realistic dialogue
loss, choked of Active-Listening, about feelings

28
feelings, anger acknowledgment, and and concerns.
so on. 4. Patient may feel
4. Encourage supported in
verbalization of expression of
thoughts or concerns feelings by the
and accept understanding
expressions of that deep and
sadness, anger, often conflicting
rejection. emotions are
Acknowledge normal and
normality of these experienced by
feelings. others in this
5. Be aware of mood difficult
swings, hostility, and situation.
other acting-out 5. Indicators of
behavior. Set limits ineffective
on inappropriate coping and need
behavior, redirect for additional
negative thinking. interventions.
6. Reinforce teaching Preventing
regarding disease destructive
process and actions enables
treatments and patient to
provide information maintain control
as appropriate about and sense of self-
dying. Be honest; do esteem.
not give false hope 6. Patient and SO
while providing benefit from
emotional support. factual
information.
Individuals may
ask direct

29
 questions about
death, and honest
answers promote
trust and provide
reassurance that
correct
information will
be given.
Sexual dysfunction Attainment of 1. Encourage the patient 1. Expressed needs  Patient Expresses
related to altered satisfactory sexual to verbalize concerns help the therapist fears and
body image performance and fears. The sexual develop a plan of concerns
partner is welcomed to care.
participate in the 2. Avoid patient
discussion. embarrassment
2. Recommend with the visual  Discusses
alternative sexual appearance of alternative sexual
positions. the stoma.Avoid positions
3. assistance from a sexual peristomal skin
therapist, enterostomal irritation
therapist. secondary to Accepts
friction. services of a
3. Some patients professional
need professional counselor
sexual
counselling.
Risk for impaired Maintenance of skin 1. Provide information 1. Peristomal skin  Patient
skin integrity integrity about signs and should be slightly Describes
related to irritation symptoms of irritated pink without appearance of
of the peristomal or inflamed skin. Use abrasions and healthy skin
skin by the effluent pictures if possible. similar to that of  Correctly
2. Teach patient how to the entire cleanses the skin
cleanse the peristomal abdomen.  Successfully
30
 skin gently. 2. Mild friction with applies a skin
3. Demonstrate how to warm water and a barrier
apply a skin barrier gentle soap  Gently removes
(powder, gel, paste, cleanses the skin the drainage
wafer). and appliance
minimizes without skin
4. Demonstrate how to irritation and Damage
remove the pouch. possible  Demonstrates
abrasions. intact skin
Patting the skin around the
dry prevents colostomy stoma
tissue trauma.
3. Skin barriers
protect the
peristomal skin
from enzymes and
bacteria.
4. Gently separate
adhesive from
the skin to avoid
irritation. Never
pull!
Risk for infection patient will recover 1-Monitor Patient
related to without temperature; report recover
colostomy and complication and temperature without
surgical wound exhibit no signs and elevation. complication:
symptoms of -2Observe for redness,
infection tenderness, and pain As exhibit no
around the surgical signs or
wound. symptoms of
3- Assist in infection
establishing local

31
drainage.
4- Obtain specimen of
drainage material for
culture and sensitivity
studies

5- Observe for sudden

drainage of profuse
serous fluid from wound.
6-Cover wound area with
sterile towels held in
place with binder.
-Prepare patient
immediately for
surgery

7- Monitor for evidence

of constant or
generalized abdominal
pain, rapid pulse, and
elevation of temperature.
8- Prepare for tube
decompression of
bowel.
9- Administer fluids and
electrolytes by IV route as
prescribed.
10-Administer antibiotics
as prescribed

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collaborative Problems/Potential Complications
Potential complications that may develop include the following:

 Intraperitoneal infection
 Complete large bowel obstruction
 GI bleeding
 Bowel perforation
 Peritonitis, abscess, and sepsis

Complication (general Nursing Intervention

complication)
Paralytic illus -Initiate or continue nasogastric
intubation as prescribed

.
-Prepare patient for x-ray study.
Ensure adequate fluid and
electrolyte replacement

-Administer prescribed antibiotics

if patient has symptoms of
peritonitis

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Mechanical obstruction

.- Assess patient for intermittent

colicky pain, nausea, and vomiting.

Intra-abdominal Septic Conditions

Complication Nursing intervention

Peritonitis -Evaluate patient for nausea,
hiccups, chills, spiking fever,
tachycardia.
-Administer antibiotics as
prescribed.
-Prepare patient for drainage
procedure.
-Administer parenteral fluid and
electrolyte therapy as prescribed.
-Prepare patient for surgery if
condition deteriorates
Abscess formation
-Administer antibiotics as
prescribed.
-Apply warm compresses as
prescribed.
-Prepare for surgical drainage.
Surgical Wound Complications

Complication Nursing intervention

Infection -Monitor temperature; report
temperature elevation.
-Observe for redness, tenderness,
and pain around the surgical
wound.
-Assist in establishing local
drainage.
-Obtain specimen of drainage
material for culture and sensitivity
studies
Wound disruption
.- Observe for sudden drainage of
profuse serous fluid from wound.
-Cover wound area with sterile
towels held in place with binder.
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 -Prepare patient immediately for
surgery

-Monitor for evidence of constant

Intraperitoneal infection and
or generalized abdominal pain,
abdominal wound infection
rapid pulse, and elevation of
temperature.
-Prepare for tube decompression of
bowel.
-Administer fluids and electrolytes
by IV route as prescribed.
-Administer antibiotics as
prescribed

Anastomotic Complications

Complication Nursing intervention

Dehiscence of anastomosis -Prepare patient for surgery

Fistulas
-Assist in bowel decompression.
-Administer parenteral fluids as
prescribed to correct fluid and
electrolyte deficits.

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