A CASE STUDY ON COLON MASS

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A Related Learning Experience Research Work

Presented to Mrs. Cristin G. Ungab

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In Partial Fulfilment of the Requirements in BSN 4

Related Learning Experience (RLE) NCM 106

By

Mishael A. Dawame

June 2016

ACKNOWLEDGEMENT

The success and final outcome of this case study required a lot of guidance and

assistance from many people and I was extremely fortunate to have got this all along

the completion of my case study. Whatever I have done is only due to such guidance

and assistance and I would not forget to thank them.

First and foremost, I would like to thank our loving Creator who made us curious

being, who loves to explore his creation and for giving me the opportunity to have this

case study. Without Him, I can’t do anything.

My deepest gratitude is to our Clinical Instructor Ma’am Cristin G. Ungab. I have

been amazingly fortunate to have an advisor who gave me the freedom to explore on

my own, and at the same time the guidance to recover when our steps faltered. Ma’am

taught me how to question thoughts and express ideas. Her patience and support

helped me overcome many crisis situations and finish this case study.

Most importantly, none of this would have been possible without the love and

patience of my family. My immediate family to whom this case study is dedicated to, has

been a constant source of love, concern, support and strength all these years.

INTRODUCTION

Colon cancer is cancer of the large intestine (colon), the lower part of your

digestive system. Rectal cancer is cancer of the last several inches of the colon.

Together, they're often referred to as colorectal cancers. Most cases of colon cancer

begin as small, noncancerous (benign) clumps of cells called adenomatous polyps.

Over time some of these polyps become colon cancers.Polyps may be small and

produce few, if any, symptoms. For this reason, doctors recommend regular

screening tests to help prevent colon cancer by identifying and removing polyps

before they become colon cancer.This annual report provides the estimated numbers

of new cancer cases and deaths in 2015, as well as current cancer incidence,

mortality, and survival statistics and information on cancer symptoms, risk factors,

early detection, and treatment. In 2015, there will be an estimated 1,658,370 new

cancer cases diagnosed and 589,430 cancer deaths in the

US. http://www.who.int/mediacentre/factsheets/fs297/en/ date Retrieved: June 25,

2016

Colorectal cancer is among the top five most common cancers in the Philippines

today. However, recent statistics show that the Philippines has a higher colorectal

cancer mortality than other countries. In February 2010, the World Health

Organization predicted that the number of cancer deaths worldwide would increase from

7.6 million to 17 million deaths in 2030. In the Philippines, cancer ranked third in the list

of leading  causes of death  in the country in 2010, with the following as the ten top

causes of cancer deaths in the country for that same year.

http://www.philstar.com/cebu-lifestyle/2015/05/04/1451051/top-10-common-cancers-

philippines/ Date Retrieved: June 25, 2016

OBJECTIVES

General Purpose

The primary concern of this study is to further enhance understanding of Colon

mass in congruence with learned concepts, as well as broaden the knowledge of the

patient who are suffering from this type of illness and those people who are high risk of

acquiring this kind of disease.

Specific Objectives

This study seeks answers to the following questions:

1. What are the etiologies of Colon mass?

2. What are the Signs and Symptoms of Colon mass?

3. What is the pathophysiology of Colon mass?

4. What is the effective management for Colon Mass?

5. To identify the clients primary problem and formulate effective nursing care plan

II. ASSESSMENT

A. BIOGRAPHICAL DATA

NAME: Mr. C Attending Physician: Dr. Magallen

AGE: 46years old Admission Date/Time: June 19, 2016/ 12:12 PM

Gender: Male Nationality: Filipino

ADDRESS: MAGSAYSAY EXTENSION, SOBRECAREY STREET, TAGUM CITY

DAVAO DEL NORTE

RELIGION: Roman Catholic

OCCUPATION: SOLDIER

STATUS: Married

AGENCY: Bishop Joseph Regan Memorial Hospital - St. Jude

Admitting Diagnosis: Colon Mass; To Consider Malignancy

B.CHIEF COMPLAINT

“SAKIT AKONG TIYAN, SA TUO DAPIT” AS VERBALIZED

“DILI JUD KOKATULOG UG TARONG, TUNGOD SA SAKIT SA AKONG TIYAN” AS

VERBALIZED

C.HISTORY OF PRESENT ILLNESS

Patient C was admitted on June 19, 2016 at 12:12 Pm at BISHOP JOSEPH REGAN

MEMORIAL HOSPITAL he came to the hospital together with his wife. According to him

prior to his admission he was able to experienced severe pain on his abdomen at right

lower quadrant. They immediately went to the hospital to seek medical advice.

D.PAST MEDICAL HISTORY

Mr. C was able to confirm he had been completely vaccinated. On December 28,

2015 he undergone major operation which is Cholecystectomy. He have no known

allergies to foods and drugs. There’s no previous accident encountered by him.

FAMILY, SOCIAL AND PERSONAL HISTORY

E.1 Personal History:

Mr. C is the eldest among 3 siblings, Mr. C finished his course at University OF

BICOL with the degree of BACHELOR OF SCIENCE IN NURSING. When he passed

the nursing licensure examination he worked at Canada as an ER nurse. He came back

to the Philippines and applied in the Philippine Army as a soldier, his current position as

of now is a lieutenant colonel. Her mother died due to ovarian cancer at the age of 71

years old, and his father has Diabetes. He verbalized his uncle diagnosed with Colon

Cancer.According to him, he started to drink alcohol at the age of 14 years old and

loves to eat fatty foods and vegetables until he was diagnosed with colon mass. He was

also fun of reading books and newspaper..

F. PATIENT NEED ASSESSMENT

1. PHYSIOLOGICAL NEED

I. Oxygenation

BP: 110/600 mmHg PR: 80 bpm RR: 20cpm

Lungs (per auscultation)

Symmetry of chest expansion: normal

Lung sound: No adventitious sounds heard upon auscultation

Breathing character and pattern: normal rate and rhythm

Cardiac Status:a dynamic precordium; no heaves and thrills; no murmurs; regular

cardiac rate and rhythm

Capillary Refill: with capillary refill of <2 seconds

Skin Character and color: brown in color and dry

Life supporting Apparatus: IVF: D5LR 1L at 140cc/hr infusing well at Left metacarpal

vein. And Blood transfusion line.

Other Observations: Cyanosis not noted. Nailbeds and conjunctivae are pale in color.

Not in respiratory distress

II. Temperature Maintenance

Temperature: 36.4 °C

His skin is warm and dry to touch.

III. Nutritional Status

Height/Weight: 5'9 feet/ 74 KgsAmount of food consumed: Whole meal served

Prescribed diet: Diet as Tolerated Eating pattern: Eats 3x a day

Skin character: Poor skin turgor

Intake: IVF: 300cc Water: 1000ml

IV. Elimination

Defecated 10x a day, as claimed with watery stool and urinates 5x within the shift,

yellowish in color urine, no foul odor noted.

V. Rest-Sleep

Sleep (Pattern, amount of sleep): Bed Time: 2:00am, Waking up: 4:00am, 2 hours

Problems (as verbalized): “Dilijudkokatulogugtarong, tubgodsasakitsaakongtiyan”

VI. Stimulation-Activity

Work: Soldier

Recreation / Pastime: Bonding with family

Hobbies / vices: Reading newspaper and watching TV

2. SAFETY-SECURITY NEED

Neuro VS: both eyes are symmetrical, iris constricted to 3mm when stimulated by light,

both hands are strong, both legs are strong.

Mental Status: Conscious, Responsive, Coherent

3. LOVE-BELONGING NEED

Have 5 children; has good relationship with them. Living with wife and has a good

relationship with her.

4. SELF-ESTEEM NEED

He is aware about his condition and is willing to recover, for his family and

especially to his wife.

5. SELF-ACTUALIZATION NEED

He realized that things right now are not the way it used to be, he accepted that due

to his old age he is now weak and will lessen the intensity of his daily work and will now

focus more on his health.

I. PHYSICAL ASSESSMENT

General Survey

Received lying on bed, awake, responsive and coherent. Has a life supporting

apparatus attached; IVF. With clean and tidy bed and bed linens, things on the side of

the bed are properly arranged, room is humid with adequate lighting, pleasant smell,

and minimal noise.

REVIEW OF SYSTEMS

Integumentary System

No jaundice noted, no cyanosis noted. Skin is brown in color, with poor skin turgor.

HEENT (HEAD, EYES, NOSE, NECK, THROAT)

HEAD

Head is normal in size, symmetric, round erect and in midline. No head and scalp

lesion noted. With smooth and fine white hair evenly distributed, no dandruff noted.

EYES

Patient’s eyes are symmetrical; sclera is white in color. No eye discharges noted.

Eyebrows and eyelashes are equally distributed. Conjunctivae is pale in color. Swelling

and lesions not noted. With dark circles on the orbital are noted. Both eyes are alert.

EARS

Mr.C can hear clearly. Client’s ears are both symmetrical; No discharges observed, no

lesions, wounds or discoloration noted upon inspection.

NOSE

Nostril are symmetrical, normally red nasal mucosa with no drainage. The color is

the same as the rest of the face.

NECK

Short, no tracheal deviations felt upon placing a finger along one side of the

trachea. No swollen lymph nodes upon palpation.

THROAT

Lips is dry and without lesions or swelling. Tongue is pinkish and is free of

swelling and lesions. The buccal mucosa of Mr. C appears pink and dry, without lesions.

Tonsils are present and they are normally pink and symmetric. No exudates, swelling or

lesions was present.

Pulmonary System

No Adventitious breath sound noted; symmetrical chest expansion. There’s an

equal rise and fall of the chest with a rate of 20 cycles per minute. Breathing character

and pattern is on normal rate and rhythm. Not in respiratory distress.

Cardiovascular System

Upon auscultation there is no blowing and murmurs heard. Regular cardiac rate and

rhythm. He has a blood pressure of 110/80 and pulse rate of 80 beats per minute.

Capillary refill is less than 2 seconds.

Gastrointestinal System

Smooth, flat, umbilicus centrally located, no splenomegaly, no hepatomegaly, with

scar present on his abdomen.

Musculoskeletal System

Symmetrical structure; No lesions noted. Arms are able to move through active ROM.

Feet are symmetrical in shape.

Genito-urinary System

Defecated 10x a day with watery stool and urinates 5x within the shift, yellowishin

color, no foul odor noted.

Neurologcial Status

No neurologic deficits, no auditory and visual hallucination.

COURSE IN THE WARD

Date & Shift

Assessment

Medical Management

Rationale Nursing Intervention

Rationale

6/20/16 D: Received lying on bed, awake, conscious and coherent. with IVF #4D5LR 1L @ 140cc/° infusing well at Left basilic vein

Intravenous therapy as ordered;D5LR 1L SFSR x2

Hypertonic solutions are those that have an effective osmolarity greater than the body fluids. This pulls the fluid into the vascular by osmosis resulting in an increase vascular volume. It raises intravascular osmotic pressure and provides

-IV tube checked.-IV site checked.-IV rate check.

-To check tube patency- To check for any swelling and discoloration.- To calculate the amount that will be infused.

fluid, electrolytes and calories for energy..

8:00 am

D: Temp:36.4 PR:80bpm RR:20cpm BP:110/80

-Vital signs monitored and regulated

To monitor vital signs and assess for any unusualities

6/21/1673 Shift8:05 am

D: Received lying on bed, awake, conscious and coherent.with D5LR 1L@ 140cc/° on KSS with ongoing blood transfusion of 1 unit fresh whole blood A+ with serial no 8200-002078-2 and expiry date of july 7, 2016 infusing well @ Left Basilic vein

Transfusion Therapy:Secure 3 units fresh whole blood as ordered

Blood is transfused either as whole blood (with all its parts) or, more often, as individual parts. The type of blood transfusion you need depends on your situation.an illness that stops your body from properly making a part of your blood, you may need only that part to treat the illness.

- Check the VS before, during and after

- Monitor for the reactions.

-To have baseline data-

9:00AM

D: for Chest X-ray

Chest x-ray as ordered.

- sent to x-rat room per wheelchair

1:00 PM

D- complained of right lower quadrant abdominal pain upon moving and exertion @ rate pain as 7/10 in a scale of 1-10

Nubain 5mg IV q 6 hours PRN as ordered.

Relief of moderate to severe pain.

-1. Referred to NOD.

2. .Reassess patients level of pain at least 15 and 30 minutes after parenteral administration

III.LABORATORY AND DIAGNOSTIC EXAMINATIONS

BLOOD CHEMISTRY

ELECTROLYTES

Lab Exam Normal Value

Result Implication

S.SODIUM 136.00- 145.00 mmol/ L

137 Sodium levels may get too low if your body is losing too much water and electrolytes. It may also be a symptom of certain medical conditions.http://www.healthline.com/health/hyponatremia#Overview1

S. POTASSIUM 3.50- 5.00mmol/L

4.1

S. CALCIUM (ionized)

1.12- 5.00mmol/L

1.15

S.CHLORIDE 96.00-106.00mmol/L

S.MAGNESIUM 0.70-1.05mmol/L

S.PHOSPHORUS 0.80-1.50mmol/L

Date: June 19, 2016 Time: 3:02 PM

HEMATOLOGY REPORT

Date: June 19,2016 Time: 3:00 PM

Lab Exam Normal Value Result

Implication

Hemoglobin Male: 134.00-160g/LFemale:120.00-150.00g/L

103 Interpretation: Below normal. Implication: Nutrition need, rest and sleep

Reference: http://healthyeating.sfgate.com/diet-person-suffering-low-hemoglobin-9801.html

Hematocrit Male:0.40- 0.54Female:0.36-0.45

0.31 Interpretation: Below normal range Implication: Nutrition needReference:http://www.livestrong.com/article/420635-diet-changes-that-can-help-low-hematocrit-levels/

Leucoocyte No. Concentration

5.00-10.00 X 10^9/L

10.8

Segmenters 0.40-0.60 0.59

Lymphocytes 0.25-0.40 0.21 Interpretation: Below Normal rangeImplication: Nutrition need; to boost immune system, infection mgt.Reference: //www.wikihow.com/Increase-Lymphocytes

Monocytes 0.01-0.12 0.17Eosinophils 0.01-0.05 0.02Basophils 0.005 0.01Stabs 0.01-0.05Thrombocytes

150.00-440.00 X 10^9/L

372.0

PROTHROMBIN TIME/ ACTIVATED PARTIAL THROMBOPLASIN

TIME JUNE, 20, 2016/ 11:19PM

PROTHROMBIN TIME

UNKNON PLASMA

13.2 SECONDS

CONTROL PLASMA

13.1 SECONDS

INR 1.13

% ACTIVITY 94.4 %

ACTIVATED PARTIAL THROMBOPLASTIN TIME

UNKNOWN PLASMA

26.8 SECONDS

CONTROL PLASMA

27.9 SECONDS

DIGESTIVE ENDOSCOPY UNIT

COLONOSCOPY RESULT

DATE/ JUNE 11, 2016FINDINGS:THE SCOPE WAS INSERTED UP TO THE ASCENDING AREA. A LARGE FUNGATING FRIABLE MASS WAS SEEN AT THE ASCENDING MULTIOLE BIOPSIES WERE TAKEN AND SENT FOR HISTOPATHOLOGIC STUDIES. THERE WAS DIFFICULT PASSING THE SCOPE BEYOND THE MASS.THE REST OF THE COLON HAD GOOD DISTENSIBILITY ON AIR INSUFFLATION. THE COLONIC MUCOSA APPERED SMOOTH, SHINY AND PINKISH WITH NO, ULCER NOR POLYPS SEEN.THE HEMORRHIODAL VESSELS WERENOT ENGORGED.COMPLICATIONS: NONEBIOPSY: SENT TO MDMRCDIAGNOSIS: COLONIC MALIGNANCY, ASCENDING

REVIEW OF ANATOMY AND PHYSIOLOGY

Gastrointestinal tract

Is an organ system responsible for transporting and digesting foodstuffs,

absorbing nutrients, and expelling waste. The tract consists of the stomach and

intestines, and is divided into the upper and lower gastrointestinal tracts. The GI tract

includes all structures between the mouth and the anus, forming a continuous

passageway that includes the main organs of digestion, namely, the stomach, small

intestine, and large intestine. In contrast, the human digestive system comprises the

gastrointestinal tract plus the accessory organs of digestion (the tongue, salivary

glands, pancreas, liver, and gallbladder) The GI tract

releases hormones from enzymes to help regulate the digestive process. These

hormones, including gastrin, secretin, cholecystokinin, and ghrelin, are mediated

through either intracrine or autocrine mechanisms, indicating that the cells releasing

these hormones are conserved structures throughout evolution. The colon is about six

feet long and has four parts namely the ascending colon, transverse colon, the

descending colon, and the sigmoid colon. Beyond the sigmoid colon is the rectum and

the anus. The colon from cecum to the mid-transverse colon is also known as the right

colon. The remainder is known as the left colon.

The ascending colon, on the right side of the abdomen, is about 12.5 cm long. It is the

part of the colon from the cecum to the hepatic flexure (hepatic means liver). The

transverse colon extends from the hepatic flexure to the splenic flexure(near the

spleen). The descending colon extends from the splenic flexure to the beginning of the

sigmoid colon. The sigmoid colon starts after the descending colon and ends before the

rectum. The name sigmoid means S-shaped.

The rectum is about eight inches and connects the sigmoid colon with the anal canal.

The anal canal is 2.5 - 4 centimeters long. It's situated between the rectum and

anus.The functions of the Colon are absorption of water and minerals and the formation

and elimination of feces. The small intestine absorbs the nutrients from the food and

pours the leftover sludge into the cecum. This sludgy waste then moves from the cecum

to the colon for further processing. The colon absorbs water from the sludge while

transporting it toward the rectum. The colon stores the waste material until it is time for it

to be evacuated. The colon moves the waste material through by involuntary wavelike

contractions, made possible by smooth muscles within the colon wall, a process which

is referred to as peristalsis.The urge to defecate is signaled by the propulsion of feces

from the sigmoid colon to rectum. Distention of the rectum causes relaxation of the

internal anal sphincter (involuntary sphincter). For defecation to proceed, the external

anal sphincter must voluntarily relax. Defecation is facilitated by squatting or sitting and

by increasing intra-abdominal pressure.

SYMPTOMATOLOGY

SYMPTOMS ACTUAL SYMPTO MS

IMPLICATION

A change in your bowel habits.

Long-term constipation, diarrhea, or a change in the size of the stool may be a sign of colon cancer. Pain when passing urine, blood in the urine, or a change in bladder function (such as needing to pass urine more or less often than usual) could be related to bladder or prostate cancer. Report any changes in bladder or bowel function to a doctor.

http://www.cancer.org/cancer/cancerbasics/signs-and-symptoms-of-cancer

Rectal bleeding or blood in your stool

Unusual bleeding can happen in early or advanced cancer. Coughing up blood may be a sign of lung cancer. Blood in the stool (which can look like very dark or black stool) could be a sign of colon or rectal cancer.

http://www.cancer.org/cancer/cancerbasics/signs-and-symptoms-of-cancer

Persistent abdominal discomfort, such as

Pain may be an early symptom with some cancers like bone cancers or testicular cancer. A headache that does not go away or get better with treatment

cramps, gas or pain

may be a symptom of a brain tumor. Back pain can be a symptom of cancer of the colon, rectum, or ovary. Most often, pain due to cancer means it has already spread (metastasized) from where it started.

http://www.cancer.org/cancer/cancerbasics/signs-and-symptoms-of-cancer

Weakness or fatigue

Fatigue is extreme tiredness that doesn’t get better with rest. It may be an important symptom as cancer grows. But it may happen early in some cancers, like leukemia. Some colon or stomach cancers can cause blood loss that’s not obvious. This is another way cancer can cause fatigue.

http://www.cancer.org/cancer/cancerbasics/signs-and-symptoms-of-cancer

Unexplained weight loss

Most people with cancer will lose weight at some point. When you lose weight for no known reason, it’s called an unexplained weight loss. An unexplained weight loss of 10 pounds or more may be the first sign of cancer. This happens most often with cancers of the pancreas, stomach, esophagus (swallowing tube), or lung.

http://www.cancer.org/cancer/cancerbasics/signs-and-symptoms-of-cancer

ETIOLOGY OF THE DISEASE

ETIOLOGY ACTUAL SYMPTOMS

IMPLICATION

Older age.  The great majority of people diagnosed with colon cancer are older than 50. Colon cancer can occur in younger people, but it occurs much less frequently.

http://www.mayoclinic.org/diseases-conditions/colon-cancer/symptoms-causes/dxc-20188239

African-American race.

African-Americans have a greater risk of colon cancer than do people of other races.

http://www.mayoclinic.org/diseases-conditions/colon-cancer/symptoms-causes/dxc-20188239

Family history   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.

http://www.mayoclinic.org/diseases-conditions/colon-cancer/symptoms-causes/dxc-20188239

 Lifestyle If you're inactive, you're more likely to develop colon cancer. Getting regular

physical activity may reduce your risk of colon cancer.

http://www.mayoclinic.org/diseases-conditions/colon-cancer/symptoms-causes/dxc-20188239

Low-fiber, high-fat diet.

 Colon cancer and rectal cancer may be associated with a 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 and processed meat.

http://www.mayoclinic.org/diseases-conditions/colon-cancer/symptoms-causes/dxc-20188239

Diabetes People with diabetes and insulin resistance may have an increased risk of colon cancer.

http://www.mayoclinic.org/diseases-conditions/colon-cancer/symptoms-causes/dxc-20188239

Smoking People who smoke may have an increased risk of colon cancer.

http://www.mayoclinic.org/diseases-conditions/colon-cancer/symptoms-causes/dxc-20188239

PATHOPHYSIOLOGY

Predisposing Factors

Age Gender Hereditary

Precipitating Factors

Lifestyle

Abnormal proliferate of cell in the colon area

Arising from epithelial lining of the intestine

Signs and Symptoms:

a.) Rectal Bleeding

b.)Bloody stool

c.)Abdominal Pain

d.)weakness

e.)Diarrhea

Polyps occur

if treatedif untreated

Continue increase in size Surgical Mgt.

-Colonoscopy-Chemotherapy

-Radiation

Nursing Mgt.

- Monitoring of VS - Administration of drugs

ordered-Instructed to increase oral fluid

Written Pathophysiology

Surgical Mgt.

-Colonoscopy-Chemotherapy

-Radiation

Nursing Mgt.

- Monitoring of VS - Administration of drugs

ordered-Instructed to increase oral fluid

Metastases of cancer cells in other organs.

Proliferation of cancer cells in that area

Formation of new tumor

Complications occur

DEATH

Colorectal cancer, disease characterized by uncontrolled growth of cells within

the large intestine(colon) or rectum (terminal portion of the large

intestine). Colon cancer (or bowel cancer) and rectal cancer are sometimes referred to

separately. Colorectal cancer develops slowly but can spread to surrounding and distant

tissues of the body. Chronic inflammatory bowel diseases such as Crohn

disease or ulcerative colitis are associated with colorectal cancer, as is the presence of

a large number of noncancerous polyps along the wall of the colon or rectum. Other risk

factors include physical inactivity and a diet high in fats. Those who have previously

been treated for colorectal cancer are also at increased risk of recurrence. Certain gut

bacteria, including species of Fusobacterium, have been implicated in colorectal

cancer; Fusobacteriumare present at increased levels in colorectal cancer patients and

can trigger inflammatory responses associated with tumour growth and progression.

Because colorectal cancer is a disease of the digestive tract, many of the symptoms are

associated with abnormal digestion and elimination. Symptoms include episodes

of diarrhea or constipation that extend for days, blood in the stool, rectal bleeding,

jaundice, abdominal pain, loss of appetite, andfatigue. Because these symptoms

accompany a variety of different illnesses, a physician should be consulted to determine

their cause.