Question

Please use this Case Study to complete the questions below.

KP – 68-year-old male

Dx – Colon Cancer – 5 days post-chemotherapy – 5FU and Leucovorin every 3 weeks.

Presents to the clinic today c/o of cough SOB, temp 100.5.

APN – determines the patient needs to be admitted. Direct admission to the oncology unit.

Past Medical History –

HTN

Elevated Cholesterol Levels

Depression

Asthma

A-Fib

Admitting Orders

1. Admit to Oncology Unit
2. R/O Infection
3. PIV – 1 Liter of D5 ½ NS at 75 cc/hr
4. Stat CXR
   1. EKG
   2. Blood Cultures
   3. CBC
   4. Chem Screen
   5. Lactic Acid Levels
5. Regular Diet
6. OOB with assistance
7. O2 at 3 Liters via NC

Med

Tylenol 650mg PO every 4 hours prn temp above 101

Hydrochlorothiazide 12.5 mg PO daily

Lipitor 20 mg PO daily

Lexapro 10 mg PO BID

Singular 10 mg PO daily

Ceftriaxone 1 gram in 100 cc of NS IVSS every 12 hours

Proventil 2.5 mg via Nebulizer every 4 hours as needed.

Questions

a) Brief description of the pathophysiology of this diagnosis: (Include source)

b) Possible treatment options for these diseases: (Include source)

c) Treatments received by the patient: (Include all current orders)

Medications:- Include: Dosages, classification, actions, side effects, and toxic effects.

d) Lab Data:

-CBC

-Electrolytes

-Cardiac Enzymes

-Drug Levels

-Culture Result

-Miscellaneous

-Interpretation of lab data (Relate to the reason for admission)

e) Physical Assessment findings:

-Neurological

-Cardiovascular

-Respiratory

-Gastrointestinal

-Musculoskeletal

-Genitourinary

-Skin

Identify 2 major nursing diagnoses for this patient.

i.

a. Nursing Diagnosis

b. Goal outcome/Criteria

c. Nursing Interventions: (Include rationale)

d. Variance/Evaluation

ii.

a. Nursing Diagnosis

b. Goal outcome/Criteria

c. Nursing Interventions: (Include rationale)

d. Variance/Evaluation

Answer 1

1.Adenocarcinoma is the most common type of colon cancer.Most colorectal cancers begin as adenomatous polyp that arise from mucosa lining of the lumen of the colon. As it grows, the cancer progress from the tip of polyp through the body and stalk. It becomers invasive and penitrates the muscularis mucosae, Once through the muscularis mucosae,tumor c ell gain access to the regional lumph nodes and vascular system,and can spread to distant sites.

The most common sites of metastasis are , regional lymph node, liver, lungs, and peritonium. Since the venous blood leaving the colon flows to the portal vein and inferior rectal vein, the liver and lung are common sites of metastasis. The cancer spread from liver to other sites, including the lungs,bones,and brain. The camncer can also spread directly into adjescent structures. The growing tumors can obstruct the bowel.Other complications are, bleeding, perforation, peritonitis and fistula formation (sourse.LEWIS,Medical surgical nursing ,2004)

2

People with colon cancers that have not spread to distant sites usually have surgery as the main or first treatment. Chemotherapy may also be used after surgery (called adjuvant treatment). Most adjuvant treatment is given for about 6 months.

Treating stage 0 colon cancer

Since stage 0 colon cancers have not grown beyond the inner lining of the colon, surgery to take out the cancer is often the only treatment needed. In most cases this can be done by removing the polyp or taking out the area with cancer through a colonoscope (local excision). Removing part of the colon (partial colectomy) may be needed if a tumor is too big to be removed by local excision.

Treating stage I colon cancer

Stage I colon cancers have grown deeper into the layers of the colon wall, but they have not spread outside the colon wall itself or into the nearby lymph nodes.

Stage I includes cancers that were part of a polyp. If the polyp is removed completely during colonoscopy, with no cancer cells at the edges (margins) of the removed piece, no other treatment may be needed.

If the cancer in the polyp is high grade (see Colorectal Cancer Stages for more on this), or there are cancer cells at the edges of the polyp, more surgery might be recommended. You might also be advised to have more surgery if the polyp couldn’t be removed completely or if it had to be removed in many pieces, making it hard to see if cancer cells were at the edges.

For cancers not in a polyp, partial colectomy ─ surgery to remove the section of colon that has cancer and nearby lymph nodes ─ is the standard treatment. You typically won't need any more treatment.

Treating stage II colon cancer

Many stage II colon cancers have grown through the wall of the colon, and maybe into nearby tissue, but they have not spread to the lymph nodes.

Surgery to remove the section of the colon containing the cancer (partial colectomy) along with nearby lymph nodes may be the only treatment needed. But your doctor may recommend adjuvant chemotherapy (chemo after surgery) if your cancer has a higher risk of coming back (recurring) because of certain factors, such as:

• The cancer looks very abnormal (is high grade) when viewed under a microscope.
• The cancer has grown into nearby blood or lymph vessels.
• The surgeon did not remove at least 12 lymph nodes.
• Cancer was found in or near the margin (edge) of the removed tissue, meaning that some cancer may have been left behind.
• The cancer had blocked off (obstructed) the colon.
• The cancer caused a perforation (hole) in the wall of the colon.

Not all doctors agree on when chemo should be used for stage II colon cancers. It’s important for you to discuss the pros and cons of chemo with your doctor, including how much it might reduce your risk of recurrence and what the likely side effects will be.

If chemo is used, the main options include 5-FU and leucovorin, oxaliplatin, or capecitabine, but other combinations may also be used.

Treating stage III colon cancer

Stage III colon cancers have spread to nearby lymph nodes, but they have not yet spread to other parts of the body.

Surgery to remove the section of the colon with the cancer (partial colectomy) along with nearby lymph nodes, followed by adjuvant chemo is the standard treatment for this stage.

For chemo, either the FOLFOX (5-FU, leucovorin, and oxaliplatin) or CapeOx (capecitabine and oxaliplatin) regimens are used most often, but some patients may get 5-FU with leucovorin or capecitabine alone based on their age and health needs.

Radiation therapy and/or chemo may be options for people who aren’t healthy enough for surgery.

Treating stage IV colon cancer

Stage IV colon cancers have spread from the colon to distant organs and tissues. Colon cancer most often spreads to the liver, but it can also spread to other places like the lungs, brain, peritoneum (the lining of the abdominal cavity), or to distant lymph nodes.

In most cases surgery is unlikely to cure these cancers. But if there are only a few small areas of cancer spread (metastases) in the liver or lungs and they can be removed along with the colon cancer, surgery may help you live longer. This would mean having surgery to remove the section of the colon containing the cancer along with nearby lymph nodes, plus surgery to remove the areas of cancer spread. 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.

If the metastases cannot be removed because they're too big or there are too many of them, chemo may be given before any surgery (neoadjuvant chemo). Then, if the tumors shrink, surgery to remove them may be tried. Chemo would then be given again after surgery. For tumors in the liver, another option may be to destroy them with ablation or embolization.

If the cancer has spread too much to try to cure it with surgery, chemo is the main treatment. Surgery might still be needed if the cancer is blocking the colon or is likely to do so. Sometimes, such surgery can be avoided by putting a stent (a hollow metal or plastic tube) into the colon during a colonoscopy to keep it open. Otherwise, operations such as a colectomy or diverting colostomy (cutting the colon above the level of the cancer and attaching the end to an opening in the skin on the belly to allow waste out) may be used.

If you have stage IV cancer and your doctor recommends surgery, it’s very important to understand the goal of the surgery ─ whether it's to try to cure the cancer or to prevent or relieve symptoms of the disease.

Most people with stage IV cancer will get chemo and/or targeted therapies to control the cancer. Some of the most commonly used regimens include:

• FOLFOX: leucovorin, 5-FU, and oxaliplatin (Eloxatin)
• FOLFIRI: leucovorin, 5-FU, and irinotecan (Camptosar)
• CAPEOX or CAPOX : capecitabine (Xeloda) and oxaliplatin
• FOLFOXIRI: leucovorin, 5-FU, oxaliplatin, and irinotecan
• One of the above combinations plus either a drug that targets VEGF, (bevacizumab [Avastin], ziv-aflibercept [Zaltrap], or ramucirumab [Cyramza]), or a drug that targets EGFR (cetuximab [Erbitux] or panitumumab [Vectibix])
• 5-FU and leucovorin, with or without a targeted drug
• Capecitabine, with or without a targeted drug
• Irinotecan, with or without a targeted drug
• Cetuximab alone
• Panitumumab alone
• Regorafenib (Stivarga) alone
• Trifluridine and tipiracil (Lonsurf)

The choice of regimens depends on several factors, including any previous treatments you’ve had and your overall health.

If one of these regimens is no longer working, another may be tried. For people with certain gene changes in their cancer cells, another option after initial chemotherapy might be treatment with an immunotherapy drug such as pembrolizumab (Keytruda).

For advanced cancers, radiation therapy can also be used to help prevent or relieve symptoms such as pain. It may shrink tumors for a time, but it's not likely to cure the cancer. If your doctor recommends radiation therapy, it’s important that you understand the goal of treatment.

Treating recurrent colon cancer

Recurrent cancer means that the cancer has come back after treatment. The recurrence may be local (near the area of the initial tumor), or it may be in distant organs.

Local recurrence

If the cancer comes back locally, surgery (often followed by chemo) can sometimes help you live longer and may even cure you. If the cancer can’t be removed surgically, chemo might be tried first. If it shrinks the tumor enough, surgery might be an option. This would again be followed by more chemo.

Distant recurrence

If the cancer comes back in a distant site, it's most likely to appear in the liver first. Surgery might be an option for some people. If not, chemo may be tried to shrink the tumor(s), which may then be followed by surgery to remove them. Ablation or embolization techniques might also be an option to treat some liver tumors.

If the cancer has spread too much to be treated with surgery, chemo and/or targeted therapies may be used. Possible regimens are the same as for stage IV disease.

For people whose cancers are found to have certain traits on lab tests, another option might be treatment with immunotherapy.

Your options depend on which, if any, drugs you had before the cancer came back and how long ago you got them, as well as your overall health. You may still need surgery at some point to relieve or prevent blockage of the colon or other local problems. Radiation therapy may be an option to relieve symptoms as well.

(sourse-Libutti SK, Salz LB, Willett CG, Levine RA. Chapter 57: Cancer of the colon. In: DeVita VT, Lawrence TS, Rosenberg SA, eds. DeVita, Hellman, and Rosenberg’s Cancer: Principles and Practice of Oncology. 10th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2015)

patient medications

(5 days post-chemotherapy – 5FU and Leucovorin every 3 weeks.)

Tylenol 650mg PO every 4 hours prn temp above 101

Hydrochlorothiazide 12.5 mg PO daily

Lipitor 20 mg PO daily

Lexapro 10 mg PO BID

Singular 10 mg PO daily

Ceftriaxone 1 gram in 100 cc of NS IVSS every 12 hours

Proventil 2.5 mg via Nebulizer every 4 hours as needed.