CANCER OF THE GI SYSTEM AND ACCESSORY ORGANS
ASDN 228
ADULT MED-SURG
A. Pathophysiology and Manifestations
1. Occurrence is rare but high rate of mortality and morbidity
2. Men>women 2:1.
3. Increased incidence after age 40
4. Risk factors
a. Smoking
b. alcohol use
c. chewing tobacco
5. Signs and symptoms
a. Painless oral ulceration
b. irregular, ill-defined borders
c. Late symptoms difficulty speaking, swallowing or chewing
6. Any oral lesion that does not respond to treatment in 1-2 weeks should be evaluated.
B Diagnosis tests
1. Biopsy of lesion
2. CAT scan, MRI to assist in staging tumor/ check for mets
C Treatment
1. Surgery goal removal of lesion & Potentially cancerous surround tissue
a. Radical neck dissection for extensive cancer
Potentially disfiguring
Tracheostomy will be performed at the time of surgery
Entral feeding tube usually inserted during or before surgery
2. Radiation
3. Chemotherapy
D. Nursing Diagnosis
1. Risk for ineffective airway clearance related to oral surgery
Nursing care for tracheostomy review trach care
2. Risk for imbalanced nutrition: less than body requirements related to oral surgery
Nursing Care for entral feeding tube
a. Checking placement ph of aspirate is recommended over auscultation
ph <4 gastric placement
ph >7 respiratory placement
b. Elevate HOB 30 degrees during and 1 hour after feeding
c. Most common side effects aspiration and diarrhea
d. Check residual q 4 hours and water bolus as indicated
3. Impaired verbal communication
Nursing care: BEFORE SURGERY establish and practice an alternative communication
technique
4. Disturbed body image
I. CANCER OF THE ESOPHAGUS
A. Pathophysiology and Manifestations
1. Risk factors
a. Squamous cell carcinoma
More common in blacks than in whites
Cigarette smoking
Chronic alcohol use
b. Adenocarcinoma
More common in whites
Commonly associated with Barrett's esophagus
complication of Chronic GERD
2. Symptoms
a. Progressive dysphasia most common symptom
b. GERD-like symptoms
c. Regurgitation
d. Persistent cough
B. Diagnostic Tests
1. Barium swallow iden irregular mucosal patterns
2. Esophagoscopy direct visualization and obtain biopsy
3. x-ray, CAT scans or MRI to identify possible tumor metastases
4. Lab tests
CBC anemia, chronic blood loss
Liver function tests - elevated in liver metastases
Serum albumin low due to malnutrition
C. Treatments
1. Surgery resection of affected portion
2. Radiation
3. Chemotherapy
D. Nursing Diagnoses
1. Imbalanced nutrition: less than body requirements
2. Risk for ineffective airway clearance
3. Anticipatory grieving
II. CANCER OF THE STOMACH
A. Pathophysiology and Manifestation
1. H pylori infection is a major risk factor 35% to 89% can be attributed to this infection
2. Genetic disposition
3. Chronic gastritis, pernicious anemia, gastric polyps, smoked food and nitrates
4. Few symptoms
5. Early
Vague, including feelings of early satiety, indigestion, anorexiam ulcer like pain
6. Late
Weight loss, cachetic appearance, abdominal mass, blood in stools
B. Diagnostic tests
1. Endoscopy visualization and biopsy definitive diagnosis
2. CBC anemia often first sign
3. X-ray, CAT scan and MRI
C. Treatment
1. Surgery
Patrial gastrectomy removal of a portion of the stomach
Total gastrectomy removal of all of the stomach
Dumping Syndrome most common complication undigested
food rapidly enters the duodenum or jejunum. Peristalsis is stimulated
and intestinal motility is increased
Nasogastric tube will be placed in surgery intestinal decompression for. removal of
gastric acid to protect the surgical site and promote healing.
Assess color, amount and odor of gastric drainage, Initially will be
bright red, becomes dark, then clear or greenish-yellow. CHANGES indicate
potential complication infection, hemorrhage or obstruction
Abdominal assessment for return of bowel sounds, distention
Encourage ambulation - stimulates peristalsis
2. Radiation or chemotherapy for lymphatic or metastatic spread
3. Prognosis is poor due to late diagnosis
D. Nursing Diagnosis
Imbalanced Nutrition: less than body requirements
Nursing care for gastrostomy/jeujunostomy tube
Surgically placed in stomach. Assess tube placement by pH
aspirate of <5 indicates gastric
aspirate of 7 or greater intestinal placement
Stoma care evaluate site for S&S infection
Tube feeding formulas may coat the inside of tube and clog
Regular irrigation with water as indicated
Oral care prevent dry, cracked mucous membranes
Risk for dehydration related to fluid and electrolyte imbalance secondary to NG tube
Nursing care:
Maintain intravenous fluids which NG suction is in place
Patient is losing e-lyte rich fluids through NG tube
Anticipatory grieving
III. CANCER OF THE GALLBLADDER
A. Pathophysiology and Manifestation
1. Primary cancer of gallbladder are rate
2. Usually affect people over age 65 women>men
3. Symptoms
Pain and palpable mass in RUQ
4. Metastasize by direct extension to liver and blood and lymph system
5. Advanced stage by diagnosis
B. Treatment
1. Surgery may be done if not to far advanced
2. Palliative care and comfort care is priority
IV. CANCER OF THE LIVER
A.Pathophysiology and manifestation
1.Primary liver cancer is uncommon in US
2. Common in parts of Asia and Africa , linked to chronic hepatitis B or C infection
3. Men>women. 50 & 60s
4. Advanced stage by diagnosis
5. Metastasis to liver from primary tumors of lung, breast, and GI tract are common
6. Symptoms
Early -Masked by presence of cirrhosis or chronic hepatitis
Late -Weakness, anorexia, weight loss, fatigue and malaise, fever of unknown origin
Abdominal pain and a palpable mass in the RUQ are common
B. Diagnosis
1. CAT scans and MRI
2. Liver biopsy
3. AFP levels rise in most clients with hepatocellular cancer
C. Treatment
1.Surgery best chance for survival
2. Liver transplant in some cases
4. Radiation shrink tumor
5. Chemotherapy direct continuous hepatic arterial infusion with implanted pump
D. Nursing Diagnosis
Pain
Altered nutrition
Anticipatory grieving
V. CANCER OF THE PANCREAS
A. Pathophysiology and manifestations
1. One of the most lethal cancers
2. Incidence increases after age 50
3. Slightly higher in women than men
4. Risk factors
Smoking major risk factor
Exposure to industrial chemicals or environmental toxins
High fat diet
Chronic pancreatitis
Diabetes mellitus
5. Symptoms
Slow onset
Anorexia, nausea, eight loss, flatulence, dull epigastric pain
Pain increases in severity as tumor grows
B. Diagnosis
CAT scans, MRI
C. Treatment
1. Surgery
Whipples procedure pancreatoduodenectomy
2. Radiation and chemotherapy in addition to surgery.
VI. CANCER OF BOWEL AND COLORECTAL CANCER
A. Pathophysiology and manifestations
1. Occurs most frequently after age 50 and continues to rise with age
2. Risk factors
Genetic factors strongly linked to family history of disease
Polyps of colon and/or rectum
inflammatory bowel disease
exposure to radiation
Diet high animal fat and calorie intake
3.Nearly all begin as adenomatous polyps
4. Develop in the rectum and sigmoid colon most commonly
6. Symptoms
``` Blood in the stools usually first symptom
Change in bowel habits, either diarrhea or constipation
Pain, anorexia and weight loss in advanced disease
B. Diagnosis
Lab tests
CBC anemia chronic blood loss
Fecal occult blood detect blood in the feces
CEA (carcinoembryonic antigen) tumor marker detected in clients with
colorectal cancer. No specific for colorectal cancern and does not
detect early-stage cancer, NOT used as a screening measure. Used
to estimate prognosis, monitor treatment and detect recurrence
Sigmoidoscopy or colonoscopy primary diagnostic tool visualization and biopsy
CAT scan or MRI metastasis
TNM classification for colorectal cancer Stages cancer according to depth of Tumor,
Amount of lymph Nodes involved and distant Metastasis Stage I to
Stage IV
C. Treatment
1. Surgery treatment of choice
Surgical resection - with anastomosis of ends of remaining bowel
Tumors of rectum adbominoperineal resection with colostomy
Laser photocoagulation Small tumors or palliative for advanced tumors to
remove obstruction
2. Radiation - adjunct especially for rectal tumors
3. Chemotherapy adjunct therapy
4. Medication
Antiemetics
Zofran - developed for nausea secondary to chemo
D. Nursing Diagnosis
1. Pain
2. Imbalanced nutrition : less than body requirements
3. Anticipatory grieving
4. Risk for sexual dysfunction
5. Disturbed body image
VII. NURSING CARE OF THE CANCER PATIENT ON CHEMOTHERAPY
A. Identify and manage toxic effects of drugs
1. Onset of toxicity
Nausea, vomiting, diarrhea, hair loss, skin changes, anorexia and fatigue
2. Organ toxicity
nephrotoxicity, neurotoxicity or cardiac toxitity
3. Care for access sites
4. Dispose of used equipment and secretions safely
5. Diet management
Increase fluids to flush out drugs
Small frequent meals
Nutritional supplements ensure
Food diary to document daily intake
Tailor food plan to clients needs
B. Nursing Diagnosis
1. Anxiety
2. Risk for infection
3. Imbalanced Nutrition: less than body requirements
4. Impaired tissue integrity
5. Risk for injury
6. Anticipatory grieving
VIII. HOME CARE
A. Teaching
1. Care of incision and feeding tube or entral venous line
2. Maintaining nutrition and preventing complications of surgery such as
cumping syndrome
3. Pain management
B. Referrals
1. Home care agencies
2. Cancer support groups
3. Hospice as indicated