ASKEP KANKER KOLOREKTAL

MARIDI M. DIRDJO

Latar Belakang

Tipe kanker tersering ketiga dan penyebab kedua kematian akibat kanker

Pseseorang dengnriwayat keluarga kanker kolon atau ulcerative colitis beriko tinggi mengalami ini.

The American Cancer Society memerkirakan 135,400 kasus baru tiap tahun dan 56,700 meningga akibat colorectal cancer pd tahun 2001

Suatu penyakit dimana lapisan sel normal di kolon atau rektum yang mulai berubah dan berkembang tak terkontrol dan tidak lama kemudian meninggal

Biasanya dimulai sebagai polip nonkanker dan dengan berjalannya waktu menjadi kanker

Pengertian

Fungsi Kolon dan Rektum

Kolon dan rektum merupakan bagian dari usus besar (large intestine)

Fungsi utamanya usus besar adalah merubah isi perut cair menjadi feses yang padat

Faktor Risiko Kanker Kolorektal

Polip (suatu kelainan nonkanker atau pertumbuhan prakanker terkait dengan menua)

Umur Inflammatory bowel disease (IBD) Diet tinggi lemak jenus, seperti daging merah Riwayat diri atau keluarga menderita kanker Obesitas Merokok Lain-lain

Penyebab dari pada kanker Colon tidak diketahui. Diet yang dimakan dicurigai berperan.

Makanan-makanan yang pasti di curigai mengandung zat-zat kimia yang menyebabkan kanker pada usus besar.

Makanan tersebut juga mengurangi waktu peredaran pada perut,yang mempercepat usus besar menyebabkan terjadinya kanker.

Makanan yang tinggi lemak terutama lemak hewan dari daging merah,menyebabkan sekresi asam dan bakteri anaerob, menyebabkan timbulnya kanker didalam usus besar.

Daging yang di goreng dan di panggang juga dapat berisi zat-zat kimia yang menyebabkan kanker.

Diet dengan karbohidrat murni yang mengandung serat dalam jumlah yang banyak dapat mengurangi waktu peredaran dalam usus besar.

Beberapa kelompok menyarankan diet yang mengadung sedikit lemak hewan dan tinggi sayuran dan buah-buahan.

Makanan yang harus dihindari : Daging merah, Lemak hewan, Makanan berlemak, Daging dan ikan goreng atau panggang dan Karbohidrat yang disaring (example:sari yang disaring)

Etiologi

Hereditary Colorectal Cancer Syndromes: HNPCC

Hereditary non-polyposis colorectal cancer (HNPCC), sometimes called Lynch syndrome, accounts for approximately 5% to 10% of all colorectal cancer cases

The risk of colorectal cancer in families with HNPCC is 70% to 90%, which is several times the risk of the general population

People with HNPCC are diagnosed with colorectal cancer at an average age of 45

Genetic testing for the most common HNPCC genes is available; measures can be taken to prevent development of colorectal cancer

Hereditary Colorectal Cancer Syndromes: FAP

Familial adenomatous polyposis (FAP) accounts for 1% of colorectal cancer cases

People with FAP typically develop hundreds to thousands of colon polyps (small growths); the polyps are initially benign (noncancerous), but there is nearly a 100% chance that the polyps will develop into cancer if left untreated

Colorectal cancer usually occurs by age 40 in people with FAP

Mutations (changes) in the APC gene cause FAP; genetic testing is available

Yearly screening for polyps is recommended Attenuated familial adenomatous polyposis (AFAP) is

related to FAP; people have fewer polyps

Hereditary Colorectal Cancer Syndromes

Several other less common syndromes can increase a person’s risk of colorectal cancer

Talk with your doctor about finding a genetic counselor if you have a history of colorectal cancer in your family and family members developed cancer before age 50

For more information, visit www.plwc.org/genetics

Tumor terjadi ditempat yang berada dalam colon mengikuti kira-kira pada bagian  ( Sthrock 1991 a )  :

26 % pada caecum dan ascending colon 10 % pada transfersum colon 15 % pada desending colon 20 % pada sigmoid colon 30 % pada rectum

Patofisiologi

Typical sites of incidence and sympoms of colon cancer

Karsinoma Colon sebagian besar menghasilkan adenomatus polip. Biasanya tumor ini tumbuh tidak terditeksi sampai gejala-gejala muncul secara berlahan dan tampak membahayakan.

Penyakit ini menyebar dalam beberapa metode.Tumor mungkin menyebar dalam tempat tertentu pada lapisan dalam di perut,mencapai serosa dan mesenterik fat.

Kemudian tumor mulai melekat pada organ yang ada disekitarnya,kemudian meluas kedalam lumen pada usus besar atau menyebar ke limpa atau pada sistem sirkulasi.

Sistem sirkulasi ini langsung masuk dari tumor utama melewati pembuluh darah pada usus besar melalui limpa, setelah sel tumor masuk pada sistem sirkulasi,biasanya sel bergerak menuju liver.

Tempat yang kedua adalah tempat yang jauh kemudian metastase ke paru-paru. Tempat metastase yang lain termasuk : Kelenjar Adrenal, Ginjal, Kulit, Tulang dan Otak

Patofisiologi

Colorectal Cancer and Early Detection

Colorectal cancer can be prevented through regular screening and the removal of polyps

Early diagnosis means a better chance of successful treatment

Screening should begin at age 50 for all “average risk” individuals or sooner if you have a family history of colorectal cancer, symptoms, or a personal history of inflammatory bowel disease

Screening Methods for Colorectal Cancer

Colonoscopy (currently the best way to prevent and detect colorectal cancer)

Virtual colonography

Sigmoidoscopy

Fecal occult blood test

Double contrast barium enema

Digital rectal examination

result of interplay between environmental and genetic factors

Central environmental factors:

diet and lifestyle

35% of all cancers are attributable to diet

50%-75% of CRC in the US may be preventable through dietary modifications

Development of CRC

consumption of red meat

animal and saturated fat

refined carbohydrates

alcohol

increased risk

Dietary factors implicated in colorectal carcinogenesis

dietary fiber

vegetables

fruits

antioxidant vitamins

calcium

folate (B Vitamin)

decreased risk

Dietary factors implicated in colorectal carcinogenesis

Tanda dan Gejala Kanker Kolorektal

weight loss

loss of appetite

night sweats

fever

rectal bleeding

change in bowel habits

obstruction

abdominal pain & mass

iron-deficiency anemia

Symptom lainya dari Kanker Kolorektal

A change in bowel habits: diarrhea, constipation, or a feeling that the bowel does not empty completely

Bright red or dark blood in the stool

Stools that appear narrower or thinner than usual

Discomfort in the abdomen, including frequent gas pains, bloating, fullness, and cramps

Unexplained weight loss, constant tiredness, or unexplained anemia (iron deficiency)

Menegakkan Diagnosis Kanker

Diagnosis is confirmed with a biopsy

Stage of disease is confirmed by pathologists and imaging tests, such as computerized tomography (CT scan)

Endoscopic ultrasound and magnetic resonance imaging (MRI) may also be used to stage rectal cancer

Colorectal Cancer Staging

Staging is a way of describing a cancer, such as the depth of the tumor and where it has spread

Staging is the most important tool doctors have to determine a patient’s prognosis

Staging is described by the TNM system: the size (the depth of penetration of the Tumor into the wall of the bowel), whether cancer has spread to nearby lymph Nodes, and whether the cancer has Metastasized (spread to organs such as the liver or lung)

The type of treatment a person receives depends on the stage of the cancer

TNM system

Primary tumor (T)

Regional lymph nodes (N)

Distant metastasis (M)

Staging of CRC

Stage 0 Colorectal Cancer

Known as “cancer in situ,” meaning the cancer is located in the mucosa (moist tissue lining the colon or rectum)

Removal of the polyp (polypectomy) is the usual treatment

Stage I Colorectal Cancer The cancer has grown

through the mucosa and invaded the muscularis (muscular coat)

Treatment is surgery to remove the tumor and some surrounding lymph nodes

Stage II Colorectal Cancer The cancer has grown

beyond the muscularis of the colon or rectum but has not spread to the lymph nodes

Stage II colon cancer is treated with surgery and, in some cases, chemotherapy after surgery

Stage II rectal cancer is treated with surgery, radiation therapy, and chemotherapy

Stage III Colorectal Cancer The cancer has spread to

the regional lymph nodes (lymph nodes near the colon and rectum)

Stage III colon cancer is treated with surgery and chemotherapy

Stage III rectal cancer is treated with surgery, radiation therapy, and chemotherapy

Stage IV Colorectal Cancer The cancer has spread

outside of the colon or rectum to other areas of the body

Stage IV cancer is treated with chemotherapy. Surgery to remove the colon or rectal tumor may or may not be done

Additional surgery to remove metastases may also be done in carefully selected patients

Coping With the Side Effects of Cancer and its Treatment

Side effects are treatable; talk with the doctor or nurse

Fatigue is a common, treatable side effect Pain is treatable; non-narcotic pain relievers are

available Antiemetic drugs can reduce or prevent nausea

and vomiting

Cancer Treatment: Surgery

Foundation of curative therapy

The tumor, along with the adjacent healthy colon or rectum and lymph nodes, is typically removed to offer the best chance for cure

May require temporary or (rarely) permanent colostomy (surgical opening in abdomen that provides a place for waste to exit the body)

Cancer Treatment: Chemotherapy

Drugs used to kill cancer cells

Typical medications include fluorouracil (5-FU), oxaliplatin (Eloxatin), irinotecan (Camptosar), and capecitabine (Xeloda)

A combination of medications is often used

Types of Chemotherapy

Adjuvant chemotherapy is given after surgery to maximize a patient’s chance for cure

Neoadjuvant chemotherapy is given before surgery

Palliative chemotherapy is given to patients whose cancer cannot be removed to delay or reverse cancer-related symptoms and substantially improve quality and length of life

Cancer Treatment: Radiation Therapy

The use of high-energy x-rays or other particles to destroy cancer cell

Used to treat rectal cancer, either before or after surgery

Different methods of delivery

External-beam: outside the body

Intraoperative: one dose during surgery

New Therapies: Antiangiogenesis Therapy

“Starves” the tumor by disrupting its blood supply

This therapy is given along with chemotherapy

Bevacizumab (Avastin) was approved by the U.S. Food and Drug Administration (FDA) in 2004 for the treatment of stage IV colorectal cancer

New Therapies: Targeted Therapy

Treatment designed to target cancer cells while minimizing damage to healthy cells

Cetuximab (Erbitux) was approved by the FDA in 2004 for the treatment of advanced colorectal cancer

Riwayat: Sejarah dari keluarga terhadap Ca Colon, Radang usus besar, Penyakit Crohn’s, Familial poliposis dan Adenoma

perubahan kebiasaan pada usus besar seperti diare dengan atau tanpa darah pada feces klien mungkin merasa perutnya terasa penuh, nyeri atau berat badan turun

Tanda-tanda Ca Colon tergantung pada letak tumor.Tanda-tanda yang biasanya terjadi adalah :Perdarahan pada rektal, Anemia dan Perubahan feces

Hal pertama yang ditunjukkan oleh Ca Colon adalah : - teraba massa - pembuntuan kolon sebagian atau seluruhnya - perforasi pada karakteristik kolon dengan distensi abdominal

dan nyeri

Pengkajian

Ketidakseimbangan nutrisi : Kurang dari kebutuhan tubuh s/d perkembangan sel kanker yang cepat, mual dan mutah.

Nyeri b/d obstruksi tumor pada usus besar skunder terhadap penekanan organ yang lainnya.

Kecemasan b/d penyakit yang mengancam kehidupan dan pengobatannya.

Ketidakefektifan pemeliharaan kesehatan b/d kurangnya pengetahuan tentang proses penyakit, program diagnosa dan rencana pengobatan.

Ketidakefektifan koping keluarga : Kompromi b/d gangguan pada peran, perubahan gaya hidup dan ketakutan pasien terhadap kematian.

Gangguan konsep diri: body image b/d perubahan penampilan

Diagnosis Keperawatan

Ketidakseimbangan nutrisi : Kurang dari kebutuhan tubuh s/d perkembangan sel kanker yang cepat,

mual dan mutah.

NOC Pemulihan selera makan

Status nutrisi

NIC Terapi nutrisi Pentahapan diet Manajemen nutrisi Menejemen kelainan

makan Menejemen cairan Monitoring nutrisi Bantuan peningkatan BB Konseling nutrisi Pembelajaran: diet yang

diajurkan/ diperbolehkan

Nyeri kronik b/d obstruksi tumor pada usus besar skunder terhadap penekanan organ

yang lainnya

NOC

Tingkat kenyamanan

Kontrol nyeri

Nyeri: efek disruptif

NIC

Manajemen nyeri Manajemen obat

Terapi relaksasi sederhana

Manajemen obat

Modifikasi perilaku Peningkatan kemampuan

koping

Kecemasan b/d penyakit yang mengancam kehidupan dan

pengobatannya.NOC

Tingkat kecemasan

Kontrol diri kecemasan

NIC

Penurunan kecemasan Teknik menenangkan diri Peningkatan kemampuan

koping Penurunan kecemasan Mendengarkan aktif Petunjuk antisipasi Humor

Ketidakefektifan pemeliharaan kesehatan b/d kurangnya pengetahuan tentang proses penyakit,

program diagnosa dan rencana pengobatan

NOC

Perilaku peningkatan kesehatan

Perilaku mencari kesehatan

NIC

Pendidikan kesehatan Bantuan modifikasi diri Peningkatan kemampuan

koping Konseling Dukungan pengambilan

keputusan Penfasilitasan

tanggungjawab diri Penfasilitas belajar

Follow-Up Care

Doctor’s and nurse’s visits Serial carcinoembryonic antigen (SEA)

measurements are recommended Colonoscopy one year after removal of

colorectal cancer Surveillance colonoscopy every three to five

years to identify new polyps and/or cancers