Pathophysiology

Introduction
The patient is Ann, a 70-year-old married female. She lives with her husband and has two daughters and one son. She worked as a midwifery nurse for 40 years. Ann underwent an open extended right hemicolectomy surgery in the operating theatre on 01/09/2015; postoperatively, she was moved to the surgical ward.
A preliminary examination indicated that Ann has smoked for 15 years. Mrs. Ann drinks alcohol white wine especially 3 to 5 glasses on special occasions and likes to eat potato more often when she watched TV. Since 2011, Ann been diagnosed with type 2 diabetic mellitus and treated with Metformin 500mg. Moreover, Ann’s past medical history indicates hyperlipidaemia managed with 40mg Simvastatin. Therefore, She also takes captopril 50 mg to treat hypertension. She is allergic to eggs, which result in swelling of the mouth. Ann has a family history of colon cancer in her father, and she has a past surgical history, with knee arthroscopy in 2011 and cholecystectomy in 2004. Ann came to the hospital regarding symptoms of lower abdominal pain, constipation and rectal bleeding.
She presented at the theatre at 0900 am and received general anaesthesia. She was in the supine position. The procedure lasted about 60 min and Ann was moved to recovery with an order of PCA (patient controlled analgesia) fentanyl 1000 mcg and instructions to wear Ted’s stockings on both legs to avoid deep vein thrombosis (DVT); moreover, IDC (indwelling catheter) patent.
Ann appeared fine on first day after surgery and demonstrated consistent stability. Her BP 110/ 72 mmHg, HR 64 beats/ minute, RR16 breath per minute and temperature was 36.9. Because Ann had PCA, she received 2L/min of oxygen through a nasal cannula; her oxygen saturation was 97%. The patient’s pain score was 3/10. Tests also included blood biochemistry and a complete blood count (CBC).
On postoperative day 2, Ann reported nausea and one instance of vomiting. The RN did a nursing assessment and found that there was no bowel movement and the abdomen was distended and reported to her surgeon. Post-hemicolectomy ileus was suspected; the care plan involved initiation of IVT with 4 mg of ondansetron to avoid dehydration.
Given the patient history, colorectal cancer, extended right hemicolectomy and postoperative ileus are discussed with procedure in this paper, followed by a description of the pathophysiology of colorectal cancer, diagnosis, nursing management of the condition is also discussed, including clinical nursing assessment, medical management; furthermore, patient education and discharge planning are considered. A research study is reviewed, and finally, a short summary is presented.

Discussion
In Australia, colorectal cancer has become the second major cause of cancer deaths.v It starts in the rectum or colon and advances gradually (Brown & Edwards 2012, p. 1152). According to Smeltzer et al. (2010, p. 1099), individuals aged over 50, those with inflammatory bowel disease and those with a family history greater rates of prevalencev. Colorectal cancer contains cancers of both the large intestine, the rectum and lower part of digestive tract (this is about 8-10 inches of the colon) (LeMone et al 2013, pp. 765-768). Its cause still needs to be determined, but 85% of colorectal tumours originate from small, noncancerous clumps of cells known as adenomatous polyps (Porth & Matfin 2009, p. 911). Parts of these polyps develop into cancerous tumours, and colorectal cancer occurs when tumours develop along the lining of the large intestine. The first 6 feet of the large intestine is known as the colon. As indicated in figure 1 below, this part is divided into four major sections: ascending colon, transverse colon, the sigmoid colon and descending colon (David et al 2011, p. 14). The ascending colon extends upwards on the right side of the abdomen while the descending colon continues downwards on the left side. On the other hand, the transverse colon derives its name from the fact that it goes across the body to the left side while the sigmoid colon is referred as such due to S-shape.

Figure 1: Structure of the colon (MedicineNet.com 2015)
Colectomy is a surgical procedure, which involves removing one side of the colon also known as hemicolectomy ( Silver Spring 2012, p. 31). For this particular patient, the procedure will involve a right hemicolectomy or removing the right side of the colon and attaching the remaining part to the small intestines. During surgery, there are significant arteries been discussed and explained with the surgeon during the procedure should be protected from injury, as follows:
1- The superior mesenteric artery: It is delivering blood to ascending colon, cecum and appendix (Moini 2015, p. 407)
2- Inferior mesenteric artery: It deliveries blood to the distal large intestine, starting from the mesial transfer colon to the rectum (Moini 2015, p. 407)
.3- Median sacral artery It is hard to see, it supplies blood to coccyx and sacrum (Moini 2015, p. 408)
A condition in which there is no intestinal peristalsis or bowel sounds following abdominal surgery is known as postoperative ileus (Carroll & Alavi 2009, p. 47).

Some life style factors could be the reason in Ann’s adenocarcinoma:
According to Leun (2012, p. 190), a fatty diet increases the risk of adenocarcinoma, as fatty acids and cholesterol will likely break down. Gradually, the derived chemicals react with the lining of the large bowel, resulting in mutation of the cells, which then develop into cancer.
Other studies have linked cigarette smoking with an increased risk of colorectal cancer (Longo, Reddy & Audisio 2014, p. 17), as smokers inhale carcinogens (cancer-causing agents) such as benzopyrene from cigarettes. Benzopyrene damages the DNA, thereby lowering the body’s ability to repair subsequent damage to the cells.v
Consumption of alcohol can also be linked to adenocarcinoma. Alcohol damages body tissues in several ways; in the rectum and colon, bacteria may convert alcohol into large volumes of acetaldehyde, which has been associated with cancer in lab animals (Lewis 2014, p. 453). Alcohol has also been linked to decreased folate intakes in the body. Low folate levels may result in a weakened ability to repel risks associated with breast and colorectal cancer.
Pathophysiology
Tumours in the large intestine can range from benign growths to cancer. These are classified into three major groups, as follows (Braun & Anderson 2007, p. 173): no neoplastic polyps, neoplastic polyps (adenomatous polyps) and cancers (usually carcinoma, i.e. arising from epithelium). Adenomatous polyps longer than 1 cm are associated with an increased risk of cancer. If not removed early enough, they may become cancerous (Braun & Anderson 2007, p. 174). The development of cancer occurs through the following six major stages (Finkel 2011, p. 14). See figure 2
a) treatment. This time, it may affect the colon or another part of the body.
Figure 2: Stages of colorectal cancer:
a) Stage 0 also known as Duke A stage, cancer is in its earliest stage and mostly confined within the mucosa lining of the colon.
b) Stage I (Duke B stage)-cancerous cells have grown through the inner layer of the colon. To be precise, the growth of the cancerous cells is yet to spread beyond the wall of the colon
c) Stage II (Duke C Stage)-the cancerous cells have penetrated into the walls of the colon albeit they are yet to reach nearby lymph nodes
d) Stage III (Duke D stage)- although the nearby lymph nodes have been infected, the growth is yet to affect other parts of the body
e) Stage IV (Duke E stage)- the effects of the cancerous growth have spread to other parts of the body such as the liver and the ovary
f) Recurrent stage- in this stage, cancer is considered to have returned after the previous treatment. This time, it may affect the colon or still another part of the body.
Large tumours along the lining of the colon or rectum may obstruct the movement of the bowel contents. This causes constipation, bowel discomfort and rectal bleeding (Beck et al. 2011, p. 703)

Diagnostic tests
Faecal occult blood test: Ann had this test on 21/3/2015 and the result was positive. The aim of this test is to identify blood in the stool that cannot be seen with the eye (Yang Tan 2012, p. 10).
Colonoscopy: Ann had a colonoscopy procedure on 17/8/2015 which showed a large polyp in the splenic flexure (Check Appendix 1). This procedure involves inserting a camera into the colon, taking a biopsy and removing the polyps (Porth & Matfin 2009, p. 945).
CBC: All Ann’s results were in the normal range (Check Appendix 2).
Blood biochemistry: No results were abnormal range and the health professionals were happy with this (Check Appendix 3).

Nursing management
The nurse examined the patient and evaluated her health status. For the detection of bowel obstruction, the abdomen was examined for returning peristalsis and bowel sounds. The abdominal wound was also checked for signs of infection or bleeding. Vital signs were recorded after every one hour to check for deterioration or infection (Smeltzer et al. 2010, p. 1104), and as a hospital protocol with patient on PCA. The patient was weighed daily to monitor fluid status. Since she had a history of type 2 diabetes, blood glucose level monitoring was important to prevent hyperglycaemia or hypoglycaemia (Smeltzer et al., 2010). The patient was provided with suitable hydration through intravenous therapy. Signs of dehydration were assessed via the fluid balance chart (Tollefson 2010, p. 58-73). DVT was prevented by assuring that the elastic stockings were put on by the nurse (Kehlet 2008, p. 556).

Situation/background: The patient demonstrated an ineffective breathing pattern related to postoperative pain and analgesia. She had abdominal pain from bowel surgery.

Assessment: BP 133/76 mmHg, HR 77 beats/min, RR 17 breath/min, Spo2 96% with 2L O2 via nasal mask, T 36.7°C. U/O 46 mL/h; normal colour, no sign of hematoma. The wound site showed no sign of infection, bleeding or ooze. The patient was encouraged to breathe deeply and coughing excessive.

Recommendations: Ann was encouraged to get out of bed to prevent complications like pneumonia (Dewit and Kumagai 2013, p. 678). PCA was monitored (Naloxone medication would be administered if Ann overdosed on analgesics). Following hospital protocol, the patient needed to be observed each hour because she was on PCA fentanyl 1000 mcg. Any other analgesic medication needed to be ceased while on PCA. She was encouraged to chew gum to improve her bowel sounds by increasing the amount of digestive juice. Any oral food needed to be avoided to prevent vomiting. She needed to be assisted in breathing and coughing effectively to clear secretions and improve lung function (Brown and Edwards 2012, p. 431).

Ann was subjected to some other assessments to prevent complications, including the following:
1. CNS: The pain score and sedation score were 3/10 and 0/3, respectively. The patient was oriented and alert;
2. CVS: This showed absence of oedema, BP 133/876, temperature 36.6°C, Spo2 98% with 2L of O2 via nasal mask, RR 17 and HR 77 beats/min;
3. Mobility: The patient was able to move independently with a frame;
4. Endocrine: BGL was recorded as 6.5 mmol/l.
5. ADLs: The patient could execute routine activities like dressing, eating and bathing;
6. Integument: The skin was moist with no sores. Cannulation was done on the left cubital fossa; the cannula was patent on the 2nd day. The midline abdominal wound was clean and dry.
7. GIT: This showed the absence of nausea, no bowel movement and a soft abdomen.
8. U/O: This was 46 ml/h with no sign of blood in the urine.

Medical management
Metformin 500 mg, orally: The drug was given to improve the glycaemic condition of the patient, who had been diagnosed with type 2 diabetes mellitus (Tizian 2013, p. 237). It is antihyperglycemic agent, which acts through reducing the generation of hepatic glucose and absorption of glucose in intestine thereby improving insulin sensitivity (Mckenna and Mirkov 2012, p.728)
Common side effects (Tizian 2013, p. 237):
? Anorexia
? Nausea
? Diarrhoea
? Abdominal bloating

Simvastatin 40 mg, orally once daily: the purpose of this drug is to minimize the levels of LDL and triglycerides in the blood and increase the level of HDL (Fisher 2012, p. 20). Simvastatin inhibits 3-hydroxy-3-methylglutaryl-coenzyme A. Common side effects (Tizian 2013, p. 889):
? Abdominal pain
? Elevated CPK and liver enzyme
? Constipation
? Asthenia

Captopril 50 mg: Its ACE drug inhibitor to reduce the blood pressure. It works by inhabit the angiotensin 1 to convert to angiotensin 2, that happen when the lung realise angiotensin enzyme (Tizian 2013, p. 360). Common side effect (Tizian 2013, p. 361):
? Chest pain
? Palpitation
? Drop blood pressure
? Dry mouth

Ondansetron 4 mg, IV: It is common for cancer patients to experience nausea and vomiting after chemotherapy or radiation treatment (Aronson 2012, p. 560). Ondansetron is inherently a selective serotonin 5-HT3-receptor antagonist and antiemetic agent. Common side effects (Tazian 2013, p. 285):
? Fatigue
? Dizziness
? Insomnia

Clexane 40 mg, subcutaneous injection: This drug falls under the class of medicines known as low-molecular-weight heparins. It was administered to prevent blood clotting following the operation (Agrawal 2015, p. 261). The drug was injected under the skin once a day. Common side effect (Tazian 2013, p. 187):
? Haemorrhage
? Peripheral oedema
? Urticaria

Oxycodone 10 mg, orally PRN: This was administered to reduce severe pain when subjected to oral analgesic (Clark & Dionne 2012, p. 72). The health professional ceased the medication while Ann was on the PCA analgesic to avoid a dose higher than the therapeutic range and possible toxicity. Some known side effects:
? Diarrhoea
? Constipation
? Mild itching
? Nausea
Patient education
In this context, the goal of patient education was to provide Ann with sufficient information about her diagnosis and how to resume normal living. After the surgery, Ann needs regular medical screening to ensure proper healing (Francis 2011, p. 8). In addition, she should ensure that her diet comprises plenty of fibre, fruits and vegetables, while eliminating alcohol and meats (Hasan 2011, p. 17). Although moderate exercise is recommended, Ann should avoid strenuous activities, which could critically affect the healing process.
Patients are often given with booklets detailing how to manage their health and providing links for online help, such as for the Bowel Cancer Australia website (Rubin, Constine & Marks 2013, p. 265). This will benefit both Ann and her relatives and friends, who will learn how to take care of cancer patients.

Discharge planning
For discharge, it is necessary to brief the patient on how to take the prescribed medications outlined in the schedule, follow-up appointment at the hospital. Considering that Ann had just been operated on, it was also appropriate to include family or friends to brief them on matters such as mobility and toileting issues related to the patient (Francis 2011, p. 8).
A new trend is for nurses to use technology to keep in touch with patients (Stanhope & Lancaster 2014, p. 404). In this case, the patient or her family members should maintain contact with nurses via cell phones or email to help them adhere to the post–colorectal cancer healthcare plan. In this way, the patient can also report any unusual experience during her post-recovery care at home.

Article discussion
Isaacson et al. (2013, p.12) emphasised the importance of nursing care for patients after hemicolectomy to promote rapid recovery and quicker discharge from the hospital. They reported that the greatest postoperative complication for hemicolectomy patients is pain management; postoperative patients therefore require scheduled pain management to control severe pain and pain intensity. This may involve both pharmacological and non-pharmacological interventions, as non-pharmacological have been reported to increase the efficacy of pharmacological pain management interventions. Isaacson et al. (2013, p.12) recommended massage, repositioning, ensuring a calm environment and allowing the patient to listen to music.
Isaacson et al. (2013, p.12) reported that hemicolectomy patients face the risk of infection at the surgical site. Nurses should not remove the surgical dressing before 24–48 hours post-surgery. Moreover, the surgical site should be kept dry and clean after removal of the dressing.
The authors also mentioned that postoperative patients might have activity intolerance. In this case, cancer may have emotionally weakened the patient. Therefore, adequate rest should be allowed for the patient to recover and to prevent fatigue. In addition, nurses should educate the patient to empower her to engage in self-care. The nurse should arrange follow-up visits at the time of discharge.
In conclusion of the article, the appropriate management of pain and maintaining the hygiene of the patient are necessary for rapid recovery from hemicolectomy. Proper nursing can provide the appropriate comfort for the patient via emotional and psychological support.

Summary and conclusion
The patient was presented with rectal bleeding, frequent bowel motion and abdominal pain. Specific post-operative care has been given to patient after open extended right hemi-colectomy. Pharmacological treatment was given to patient and IVT with a fluid chart was monitoring to maintain hydration.
Verbal and written information has been given to educate the patient about the how to manage her life with after discharging with bowel cancer. Medicine schedule and follow-up appointment at the hospital managed. The quality of patient’s medical and personal experience has been improved through quality nursing care, suitable education and appropriate discharge planning. Role of nurses in managing and accessing the important nursing care with hemicolectomy for pain management has been discussed by the article.

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