Mapua Institute of the Technology

San Lorenzo School of Health Sciences

Makati City

A Case Study in NRS233L – BN04

Submitted to
Prof. Manzanas
School of Health Sciences
Mapua Institute of Technology - Makati

In Partial Fulfilment
of the Requirements
for NRS233L
Curative and Rehabilitative Nursing Care Management 1 – Part A (RLE)

Submitted by
De Guzman, Lora May
Fernandine, Patrick
Nicolas, Katherine Anne
Ramirez, Allison
Sison, Francis Michael
Tan, Joan Rae

February 24, 2005

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 TABLE OF CONTENTS

I. Overview 1
II. Profile of the Patient 2
III. Nursing Care Assessment 4
IV. Nursing Systems Review 5
V. Laboratory and Diagnostic Results 6
VI. Related Literature 11
VII. Anatomy and Physiology: Rectum 28
VIII. Pathophysiology: Rectal Adenocarcinoma 29
IX. Anatomy and Physiology: Pancreas 31
X. Pathophysiology: Diabetes Mellitus Type II 32
XI. Drug Study 36
XII. Concept Map 45
XIII. Nursing Care Plan 46
XIV. References 55
XV. Distribution of Work 56

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 I. OVERVIEW

Cancer is a cellular tumor that has properties of invasion and metastasis and is highly
anaplastic. It is localized within a system and in time would spread through-out the body. Rectal
cancer localizes within the rectum. It has three types depending on which layer of the rectum is
affected. The most common type of rectal cancer is the Adenocarcinoma wherein the cancer cells
originate from the mucosa or the inner layer of the rectum. Beside the different types of rectal
cancer, there are also different stages. Stage I involves only the first or second layer of the rectal
wall and no lymph nodes are affected. Stage II on the other hand, the cancer had reached the
mesorectum (fat surrounding the rectum) but no lymph nodes have been affected. Lastly stage III,
wherein the cancer cells have reached the lymph nodes.

This disease has several risk factors to indicate which individual are more likely to
develop rectal cancer. These includes the age (50 and above), lifestyle of the individual (smokers
are more prone than non-smoker), sex (male commonly get rectal cancer), positive family history
on colorectal cancer (first degree relative, parent, brother etc.) and diet of the individual (High-fat
diet which mostly consist of animal products are likely cause of rectal cancer).

Rectal cancer has many symptoms however some may be present without signs or any
symptoms. These are the symptoms to be aware of:

• Rectal bleeding
• Severe constipation or pain during defecating
• Stools appear to be narrow because of the blockage (pencil-thin stools)
• Sensation that the stool cannot be completely evacuated
• Unexplained weight loss

Treatment of rectal cancer depends on how deeply the cancer has invaded the rectal wall.
This could consist of surgery, medication (cancercidal drugs such as Capecitabine, Oxaliplatin
etc.) and chemotherapy or radiation therapy.

In the case of Msg. Julian E. Persia, he is a very likely candidate to have rectal cancer
since he passed two of the risk factors, which were his diet that consist mostly of animal products
and refined sugars (as he admitted that he usually takes 10 cups of rice per meal) and the other
one is sex where males are likely to develop rectal cancer than females.

His symptoms included rectal bleeding, narrow size stools, constipation and feeling of
incompletely expulsion of feces. Unfortunately the client wasn’t able to consult a doctor earlier
until his condition has worsened. For his condition had reached stage II, his treatment consist of
surgery (LAR), followed by chemotherapy and cobalt therapy to prevent the risk of the cancer to
recur again.

Lack of information about this type of disease is one of the factors why the client
condition progress. He wasn’t aware of the symptoms and the importance of early consultation.

8
 II. PROFILE OF THE PATIENT

Patient Profile:

Name: Persia, Julian E. Rank: Master Sergeant Ward: 5B

AFPSN #: 650825 Registration #: 700323
Age: 48 years old Sex: Male
Date of Birth: November 24, 1958 Place of Birth: Masbate
Civil Status: Married Religion: Roman Catholic
Race: Brown
Home Address: #94 29th Avenue, Extension East Rembo Makati City
Educational Attainment: High School Graduate

Client Complaint:

Take down Colostomy for Enclosure.

Diagnosis:

Rectal Adenocarcinoma Stage III; s/p Lower Anterior Resection, loop ileostomy (May
2005) S/P chemo C6 (Feb 2006) S/P Cobalt therapy (Nov 2005), DM Type II

Patient History:

Nine (9) months prior to consultation, the client experienced bloody stools. Self
medicated for hemorrhoids. The symptoms progressed to pencil-thin stools (the stools appeared
to be narrow so that it could pass through the blockage), constipation and feeling that the stools
are not completely evacuated.

On May of 2005, the patient consulted a physician and was diagnosed with Rectal
Adenocarcinoma Stage II. He was also diagnosed with Diabetes Mellitus. Within a month, the
client undergone Lower Anterior Resection (LAR), loop Ileostomy. The client then received six
(6) cycles of chemotherapy (Feb 2006) and twenty five (25) cycles of Cobalt therapy (Nov 2005).

On 2006, the client went to surgery for coloanal anastamosis.

Patient transferred to AFP Medical Center on January 12, 2007 for take down loop
ileostomy, admitted at Male Surgical Ward 5B. The findings in his recent CEA test were already
normal.

I. Pertinent Family Medical History:

(-) Tuberculosis (-) Cancer (-) Asthma (+) Hypertension

(- ) Diabetes Mellitus

II. Social History:

(-) smoker (+) occasional drinker

The patient has no family background on tuberculosis, cancer, asthma, hypertension and
Diabetes Mellitus. He doesn’t smoke and is an occasional alcoholic drinker.

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Narrative Summary:

The patient is Master Sergeant Persia, Julian E. Forty-eight years old and born on
November 24, 1958 at the province of Masbate. Married and devoted to the Catholic faith. He is
currently living at #94 29th Avenue, Extension East Rembo Makati City and has a house in
Davao.

The client has negative family background on tuberculosis, diabetes mellitus, asthma and
cancer. Hypertension runs in the family. He doesn’t smoke however he drinks occasionally.

Nine (9) months prior to consultation, the client experienced episodes of rectal bleeding
during defecation. Thinking it was only hemorrhoids; the client self-medicated and delayed to
seek medical assistance. After a few months the client noted pencil-thin stools (the stools
appeared to be narrow so that it could pass through the blockage), constipation and feeling that
the stools are not completely evacuated.

May of 2005, Msg. Persia consulted a physician and was diagnosed with Rectal
Adenocarcinoma Stage II besides this finding the client is also diagnosed with DM (Diabetes
Mellitus). His treatment consisted of surgery (Lower Anterior Resection) with loop ileostomy
done May of 2005, twenty-five (25) cycles of cobalt therapy (November of 2005) and six (6)
cycles of chemotherapy (February 2006). The client also had a coloanal anastamosis procedure on
2006.

On January 12, 2007, the patient was admitted to AFP Medical Center for take down
colostomy. After almost 2 years of ileostomy, the client is very enthusiastic to have it removed
although it has not affected his lifestyle and body image.

Several days upon admission, the patient experienced mild cramps in his upper left thigh
which resulted to pain and numbness. This condition progressed where inflammation was brought
about after administration of Levofloxacin, an anti-infective/antibiotic. The etiology of this
condition remains unknown, however several diagnostic tests were scheduled (e.g. x-ray and
bone scan) in order to find out what the problem is. The patient was also transfused with 2 units
of packed RBCs on February 15, 2007 due to his exacerbating anemia. He is currently on high
caloric diet and on medications including Eterocoxib, Insulin 30 ‘u’, Tramadol, Arcoxia,
Moriamin, Levofloxacin, Ferrous Sulfate, Pregabalin and Eperisone HCl.

10
 SAN LORENZO RUIZ HOSPITAL
Mapua Institute of Technology
School of Health Sciences
Buendia, Makati City

III. NURSING CARE ASESSMENT

I. PERSONAL
Name: Persia, Julian E. Rank: Master Sergeant AFSN: 650825
Age: 48 y/o Sex: Male Religion: Roman Catholic
Ward: Male Surgical Ward Bed #: Cubicle D-1
Home Address: 94 29th Avenue Extension, East Rembo, Makati City
Civil Status: Married Next to Kin: Persia, Adele (wife)
Educational Attainment: 4th Year High School
Language / Dialect Spoken: Bisaya / Cebuano

II. VITAL INFORMATION

A. Vital Signs
Temp: 36.9 PR: 88 bpm RR: 20 breaths/min BP: 100/70 HT: 5’8 WT: 138 lbs
B. Time of Admission: 1030H C. Reason for Admission: For take down of ileostomy

II. APPEARANCE ADMISSION

A. Physical
1. Body Built: Slender
2. Appearance: Untidy
3. Skin Integrity: With Lesions
B. Mental Status: Conscious and Coherent
C. Emotional Status: Worried
D. Level of Consciousness: Fully Awake

IV. HISTORY
A. Pertinent Family Medical History: HPN
B. Pertinent Surgical History: Had Previous Operation (loop ileostomy, low anterior resection, coloanal anastomosis)
C. Social History: Occasional Alcoholic
1. Occupation of Patient: MSG. Army Enlisted (non commission officer)
2. Sibling Rank: Eldest out of six (6) children
3. House: Owned
D. Behavior Attitudes Toward Illness: Depressed
E. Sleeping Patterns: Number of Sleeping hours – 8 to 10 hours/day
F. Elimination Patterns: Bowel Movement every 2-4 hours; Voiding every 4 hours
G. Personal Hygiene: Tepid Sponge Bath, Irregular Oral Care
H. Idiosyncrasies
1. Allergies: None
2. Preferences: Food, likes rice (about 1 kilo or 10 cups per meal) and fish, dislikes pork
3. Hobbies/Interests: Jogging, doing sports

6
 SAN LORENZO RUIZ HOSPITAL
Mapua Institute of Technology
School of Health Sciences
Buendia, Makati City

IV. NURSING SYSTEMS REVIEW

PUPILS SIZES IN MM ● ●● ●● ●
NEUROLOGICAL: GASTROINTESTINAL-GENITOURINARY:
PUPIL SIZE: 3mm R (+) L (+) REACTION: N/A R (+) L (+) ABDOMEN: Soft Firm Hard Distended Non-tender Tender
OTHERS: Pink, palpebral conjunctiva, anicteric sclerae______ BOWEL SOUNDS: Normal Hyperactive Hypoactive
EYES OPEN: Spontaneously to: Speech Pain None Absent
BEST VERBAL RESPONSE: Alert Oriented Confused N.G.T.: N/A Type Location Character
Lethargic Inappropriate words Incomprehensive sounds None DRAINS: N/A Type Location Character
BEST MOTOR RESPONSE: Obeys commands MAE Localizes Pain URINE: Color: Amber Yellow Character: Turbid
Voiding Has not voided Continent Incontinent Catheter
INTEGUMENTARY: OSTOMY: N/A Type: Loop Ileostomy Location: RUQ
VENOUS TEMP. Warm Cool Cold Clammy Diaphoretic Character : Pale, pinkish stoma
COLOR: Normal Pale Cyanotic Jaundice OTHERS: Tight sphincter, examining finger inserted up to 6 cm,
SKIN CONDITION: Moist Dry Cracked Sores (+) blood on examining finger______________________________
SKIN TURGOR: Normal Loose Tight Shiny
J.D.V.: N/A Flat Distended @ 0, 30, 60 _________________ angle DRESSINGS:
N/A ___________________________________________________
RESPIRATORY:
CHEST EXCURSION: Symmetrical Asymmetrical VASCULAR:
RESPIRATIONS: No distress S.O.B. Labored Use accessory Pulses 1+ 2+ D-Dopler Radial R (+) L (+)
muscles Ventilated Dorsalis pedis R (+) L (+)
0 @_________1/min/no Mist mask N/A _________ L_________% Post tibial R (+) L (+)
BREATH SOUNDS: Clear Rales Rhonchi Wheezing Diminished Edema: None
breath sounds ______________________________________________ Peripheral calf tenderness (+) (-) N/A
COUGH: Productive Non-productive Absent Homan’s sign (+) (-) N/A
Sputum N/A Color: ____ Consistency: ______ Amount: _______ Capillary Refill Normal Slow Rapid
TRACH DRNG: N/A ______________________________________
OTHER COMPLAINTS: Pain at the upper left thigh
with
CARDIAC: inflammation and numbness affecting his lower extremities
RHYTHM: Normal
HEART SOUNDS: Normal S S ACUITY: _______________________ RN: __________________
OTHERS: Fast, thready pulse______________________________

D, Indicates Deviation From Normal, Comments at the bottom

Comments:
Skin, Dry and Flaky, lack of hydration, nutrition, mobility, and exercise
Eyes, Jaundiced, impaired bilirubin processing.
Mouth, Dry Mucous Membranes, lack of hydration and nutrition
Brachial Pulse, Fast and thready secondary to Diabetes Mellitus
Abdomen, RUQ ileostomy

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 V. LABORATORY AND DIAGNOSTIC RESULTS

I. LABORATORY RESULTS

A. Hematologic Studies
Feb 13 07
Hemoglobin 106 M: 140-170 gms/L
Hematocrit 0.32 M: 0.42-0.51

Feb 11 07
Hemoglobin 93 M: 140-170 gms/L
Hematocrit 0.28 M: 0.42-0.51
RBC 3.32 M: 4.7-6.1x106/uL
WBC 29.0 M: 5000-10000/mm3

Feb 10 07
Hemoglobin 97 M: 140-170 gms/L
Hematocrit 0.28 M: 0.42-0.51
RBC 3.35 M: 4.7-6.1x106/uL
WBC 30.50 M: 5000-10000/mm3

Jan 13 07
Hemoglobin 124 M: 140-170 gms/L
Hematocrit 0.37 M: 0.42-0.51
RBC 4.14 M: 4.7-6.1x106/uL
WBC 16.0 M: 5000-10000/mm3

Jan 13 07
Blood Urea Nitrogen 9.51 (Integra) 2.78-7.64 mmol/L
Creatinine 7.5 (Integra) 6.2-10.6mmol/L

Interpretation:

Hemoglobin - is the iron-containing oxygen-transport metalloprotein in the red blood cells of the
blood. A low level of Hemoglobin may indicate anemia, recent hemorhage, or fluid retention,
causing hemodilution. in the case of MSG Persia, on February 11 2007 the hemoglobin level
declined to 93, together with low level of hematocrit and RBC was caused by anemia by blood
loss. One of the treatments given to MSG Persia to prevent further decline of this blood levels
was the transfusion of 2 U of PRBC. Ferrous sulfate was also given.

Hematocrit - is a measure of the proportion of blood volume that is occupied by red blood cells.
Low hematocrit level indicates anemia, or massive blood loss. This was the case of MSG Persia.

Red Blood cell - principal means of delivering oxygen from the lungs. A low RBC count may
indicate anemia, fluid overload, of hemorrhage beyond 24 hours.

8
White Blood cell - They are produced in the bone marrow and help to defend the body against
infectious disease and foreign materials as part of the immune system.An increased count
commonly signals infection. In the case of MSG Persia, inflammation sets in due to patient’s post
surgical wound, and compromised wound healing due to Diabetes mellitus and Colon cancer.
Antibiotic drugs were given to fight infection.

Blood Urea Nitrogen - test is a measure of the amount of nitrogen in the blood that comes from
urea. Urea is a substance secreted by the liver, and removed from the blood by the kidneys.
Elevated levels of BUN suggest renal disease, reduced renal blood flow, urinary tract obstruction
and increased protein catabolism ( burn ). In the case of MSG Persia this findings could be a sign
of chronic complication of Diabetes type 2.

Creatinine - is a breakdown product of creatine phosphate in muscle, and is usually produced at

a fairly constant rate by the body. Decreased urine creatinine levels may result from impaired
renal perfusion or from renal disease due to urinary tract obstruction. Increase level generally
have a little diagnostic significance.

B. Electrolyte Studies

Jan 15 07
Sodium 130 136-145 mmol/L
Potassium 4.3 3.5-5.1 mmol/L
Chloride 102 97-111 mmol/L

Interpretation:

Sodium - Sodium is the primary cation (positive ion) in extracellular fluids in animals and
humans. These fluids, such as blood plasma and extracellular fluids in other tissues, bathe cells
and carry out transport functions for nutrients and wastes. In MSG Persia’s case the metabolic
problems occuring in type 2 diabetes mellitus were increased fat mobilization, as ketones are
excreted simultaneously with sodium. This results to sodium depletion and metabolic acidosis
also affecting the acid-base balance.

C. Coagulation Studies

Jan 13 07
Activated Partial Thromboplastin 31.1 sec 26-39 sec
Clotting time 2’45’’ 2-7 min
Bleeding time 2’00’ 2-4 min

Interpretation:

Normal Findings

D. Fasting Blood Sugar

Feb 5 07
FBS 18.12mmol/L 3.9-5.8mmol/L

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Interpretation:

Fasting Blood sugar - type of blood test used to determine the amount of glucose in the blood.
12 hours after eating. Increase value taken from the patient will suggest Diabetes Mellitus. The
patient was diagnosed of to have Diabetes type 2 which is non insulin dependent. The patient is
taking insulin to prevent hyperglycemia since her glucose levels were extremely high.

E. Carcinoembryonic Antigen Test

Jan 22 07
CEA report
CEA 4.43 ng/mL 2.10-6.20 ( non-smoker )

Interpretation:

Carcinoembryonic Antigen - is a glycoprotein involved in cell adhesion. CEA is a substance

which is normally found only during fetal development, but may reappear in adults who develop
certain types of cancer. Once treatment for the cancer has begun, like in the case of MSG Persia,
CEA tests have a valuable role in monitoring the patient's progress. A decreasing CEA level
means therapy is effective in fighting the cancer. A stable or increasing CEA level may mean the
treatment is not working, and/or that the tumor is growing.

F. Urinalysis

Jan 13 07
Urinalysis
Sugar +3 Norma values : negative

Interpretation:

Urinalysis - is an array of tests performed on urine and one of the most common methods of
medical diagnosis. +3 of sugar in urine suggest glycosuria, caused by Diabetes mellitus.

G. Other Tests

Jan 13 07
Albumin Gen.2 33.4g/L 35-50.0 g/L
Glucose HK gen.3 12.19mmol/L 3.90-5.80 mmol/L

II. DIAGNOSTIC TESTS

A. Radiologic Report

10
Jan 26 07
Diagnostic Radiology (x-ray) section
Persia, Julian E.
Examination requested: Pelvis
Clinical Impression: Rectal Adeno CA
Radiologic report: 26 Jan 07: AP
No evident bone nor joint pathology seen on the projections taken Retained contrast
materials is noted on the right abdomen.

13 Jan 07
Rectal Adeno CA Stage III-C
The lungs are clear
Heart is at normal size
Aorta and pulmonary vascularity within normal limits
NORMAL FINDINGS

Jan 25 06
Examination CXR PA
Clinical Data PE
Chest: Normal Findings

B. Electrocardiogram

12 Jan 07
ECG report: No specific ST-T wave changes

C. Histopathology Report

May 26 05
Histopathology report
Gross: the specimen consists of rectum measuring 13x5.8x5.8 cm section shows an ulcerative
lesions with heaped up boarders measuring 4x3.5 cm. section shows gross infiltrations into the
subserosal area. II perirectal lymph nodes measuring from 0.3 to 0.5 cm are recovered.
Representative sections taken for the study.
A. Mass
B. Margin 1
C. Margin 2
D. Lymph nodes

11
Microscopic: Microsection reveal a malignant neoplasm composed of neoplastic glands in back
to back patterns. The glands are lined by columnar cells with pleomorphic dark nuclei and
moderate amount of cytoplasm. These are seen infiltrating the serosal area. All eleven perirectal
lymph nodes are negative for tumor metastasis. Surgical margins clear.

Diagnosis: Rectum segment of:

Well differentiated adeno carcinoma, astler coller B2 T3NOMX all II perirectallymph nodes
negative for tumor metastasis surgical margins clear.

May 16 05
Gross: the specimen consists of three pink white soft tissue fragments altogether measuring
0.5x.3 cm. entire specimen submitted for study

Micorscopic: Microsections reveal a malignant neoplasm composed of neoplastic glands in back

to back formations. The glands are lined by neoplastic columnar cells with enlarged, dark nuclei
and moderate amount of cytoplasm

Diagnosis: Adenocarcinoma, Rectal Mass

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 VI. RELATED LITERATURE

RECTAL CANCER

The rectum is the lower part of the colon that connects the large bowel to the anus. The
rectum’s primary function is to store formed stool in preparation for evacuation. Like the colon,
the 3 layers of the rectal wall are as follows:

 Mucosa: This layer of the rectal wall lines the inner surface. The mucosa is composed of
glands that secrete mucus to help the passage of stool.
 Muscularis propria: This middle layer of the rectal wall is composed of muscles that help
the rectum keep its shape and contract in a coordinated fashion to expel stool.
 Mesorectum: This fatty tissue surrounds the rectum.

In addition to these 3 layers, another important component of the rectum is the

surrounding lymph nodes (also called regional lymph nodes). Lymph nodes are part of the
immune system and assist in conducting surveillance for harmful materials (including viruses and
bacteria) that may be threatening the body. Lymph nodes surround every organ in the body,
including the rectum.

The most common type of rectal cancer is adenocarcinoma, which is a cancer arising
from the mucosa. Cancer cells can also spread from the rectum to the lymph nodes on their way
to other parts of the body.

A rectal adenocarcinoma arising from a villous adenoma

Illustration of Rectal Adenocarcinoma

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Causes

Rectal cancer usually develops over several years, first growing as a precancerous growth
called a polyp. Some polyps have the ability to turn into cancer and begin to grow and penetrate
the wall of the rectum.

The actual cause of rectal cancer is unclear. However, the following are risk factors for
developing rectal cancer:

 Increasing age
 Smoking
 Family history of colon or rectal cancer
 High-fat diet and/or a diet mostly from animal sources
 Personal or family history of polyps or colorectal cancer

Symptoms

Rectal cancer can cause many symptoms that require a person to seek medical
care. However, rectal cancer may also be present without any symptoms, underscoring the
importance of routine health screening. Symptoms to be aware of include the following:

 Bleeding

• Seeing blood mixed with stool is a sign to seek immediate medical

care. Although many people bleed due to hemorrhoids, a doctor should still be
notified in the event of rectal bleeding.
• Prolonged rectal bleeding (perhaps in small quantities that is not seen in the
stool) may lead to anemia, causing fatigue, shortness of breath, light-headedness,
or a fast heartbeat.

 Obstruction

• A rectal mass may grow so large that it prevents the normal passage of
stool. This blockage may lead to the feeling of severe constipation or pain when
having a bowel movement. In addition, abdominal pain or cramping may occur
due to the blockage.
• The stool size may appear narrow so that it can be passed around the rectal
mass. Therefore, pencil-thin stool may be another sign of an obstruction from
rectal cancer.
• A person with rectal cancer may have a sensation that the stool cannot be
completely evacuated after a bowel movement.

 Weight loss: Cancer may cause weight loss. Unexplained weight loss (in the absence of
dieting or a new exercise program) requires a medical evaluation.

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Exams and Tests

Appropriate colorectal screening leading to the detection and removal of precancerous

growths is the only way to prevent this disease. Screening tests for rectal cancer include the
following:

 Fecal occult blood test (FOBT): Early rectal cancer may damage blood vessels of the
rectal lining and cause small amounts of blood to leak into the feces. The stool
appearance may not change. The fecal occult blood test requires placing a small amount
of stool on a special paper that is provided by a doctor. The doctor then applies a
chemical to that paper to see if blood is present in the stool sample.
 Endoscopy: During endoscopy, a doctor inserts a flexible tube with a camera at the end
(called an endoscope) through the anus and into the rectum and colon. During this
procedure, the doctor can see and remove abnormalities on the inner lining of the colon
and rectum.

If rectal cancer is suspected, the tumor can be physically detected through either digital
rectal examination (DRE) or endoscopy.

 A digital rectal examination is performed by a doctor using a lubricated gloved finger

inserted through the anus to feel the cancer on the rectal wall. Not all rectal cancers can
be felt this way, and detection is dependent on how far the tumor is from the anus. If an
abnormality is detected by a digital rectal examination, then an endoscopy is performed
for further evaluation of the cancer.
 Flexible sigmoidoscopy is the insertion of a flexible tube with a camera on the end
(called an endoscope) through the anus and into the rectum. An endoscope allows a
doctor to see the entire rectum, including the lining of the rectal wall.
 Rigid sigmoidoscopy is the insertion of a rigid optical scope inserted through the anus
and into the rectum. Rigid sigmoidoscopy is usually performed by either a
gastroenterologist or a surgeon. The advantage of rigid sigmoidoscopy is that a more
exact measurement of the tumor’s distance from the anus can be obtained, which may be
relevant if surgery is required.
 Colonoscopy; a flexible endoscope is inserted through the anus and into the rectum and
colon. A colonoscopy allows a doctor to see abnormalities in the entire colon, including
the rectum.

Once an abnormality is seen with endoscopy, a biopsy specimen is obtained using the
endoscope and sent to a pathologist. The pathologist can confirm that the abnormality is a cancer
and needs treatment. A person may experience small amounts of bleeding after a biopsy is
performed. If this bleeding is heavy or lasts longer than a few days, a doctor should be notified
immediately.

A chest x-ray and a CT scan of the abdomen and pelvis are most likely performed to see
whether the cancer has spread further than the rectum or surrounding lymph nodes.

Routine blood studies are performed to assess how a person might tolerate the upcoming
treatment.

15
Treatment

Medications

The following chemotherapy drugs may be used at various points during therapy:

 5-Fluorouracil (5-FU): This drug is given intravenously either as a continuous infusion

using a medication pump or as quick injections on a routine schedule. This drug has
direct effects on the cancer cells and is often used in combination with radiation therapy
because it makes cancer cells more sensitive to the effects of radiation. Side effects
include fatigue, diarrhea, mouth sores, and hand-and-foot syndrome (redness, peeling,
and pain in the palms of the hands and the soles of the feet).
 Capecitabine (Xeloda): This drug is given orally and is converted by the body to a
compound similar to 5-FU. Capecitabine has similar effects on cancer cells as 5-FU and
can be used either alone or in combination with radiation therapy. Side effects are similar
to intravenous 5-FU.
 Oxaliplatin (Eloxatin): This drug is given intravenously once every 2 or 3 weeks.
Oxaliplatin has recently become the most common drug to use in combination with 5-FU
for the treatment of metastatic rectal cancer. Side effects include fatigue, nausea,
increased risk of infection, anemia, and peripheral neuropathy (tingling or numbness of
the fingers and toes). This drug may also cause a temporary sensitivity to cold
temperatures up to 2 days after administration. Inhaling cold air or drinking cold liquids
should be avoided if possible after receiving oxaliplatin.
 Irinotecan (Camptosar, CPT-11): This drug is given intravenously once every 1-2
weeks. Irinotecan is also commonly combined with 5-FU. Side effects include fatigue,
diarrhea, increased risk of infection, and anemia. Because both irinotecan and 5-FU cause
diarrhea, this symptom can be severe and should be reported immediately to a doctor.
 Bevacizumab (Avastin): This drug is given intravenously once every 2-3 weeks.
Bevacizumab is an antibody to vascular endothelial growth factor (VEGF) and is given to
reduce blood flow to the cancer. Bevacizumab is used in combination with 5-FU and
irinotecan or oxaliplatin for the treatment of metastatic rectal cancer. Side effects include
high blood pressure, nose bleeding, blood clots, and bowel perforation.
 Cetuximab (Erbitux): This drug is given intravenously once every week. Cetuximab is
an antibody to epidermal growth factor receptor (EGFR) and is given because rectal
cancer has large amounts of EGFR on the cell surface. Cetuximab is used alone or in
combination with irinotecan for the treatment of metastatic rectal cancer. Side effects
include an allergic reaction to the medication and an acnelike rash on the skin. Clinical
trials are underway to evaluate this antibody for the treatment of localized rectal cancer.

Medications are available to alleviate the side effects of chemotherapy and antibody
treatments. If side effects occur, an oncologist should be notified so that they can be addressed
promptly.

Surgery

Surgical removal of a tumor is the cornerstone of curative therapy for localized rectal
cancer. In addition to removing the rectal tumor, removing the fat and lymph nodes in the area of
a rectal tumor is also necessary to minimize the chance that any cancer cells might be left behind.

16
 However, because the rectum is in the pelvis and is close to the anal sphincter (the
muscle that controls the ability to hold stool in the rectum), rectal surgery can be difficult. With
more deeply invading tumors and when the lymph nodes are involved, chemotherapy and
radiation therapy are usually included in the treatment course to increase the chance that all
microscopic cancer cells are removed or killed.

Four types of surgeries are possible, depending on the location of the tumor in relation to
the anus.

 Transanal excision: If the tumor is small, located close to the anus, and confined only to
the mucosa (innermost layer), then performing a transanal excision, where the tumor is
removed through the anus, may be possible. No lymph nodes are removed with this
procedure. No incisions are made in the skin.

 Mesorectal surgery: This surgical procedure involves the careful dissection of the tumor
from the healthy tissue. Mesorectal surgery is being performed mostly in Europe.

 Low anterior resection (LAR): When the cancer is in the upper part of the rectum, then
a low anterior resection is performed. This surgical procedure requires an abdominal
incision, and the lymph nodes are typically removed along with the segment of the
rectum containing the tumor. The two ends of the colon and rectum that are left behind
can be joined, and normal bowel function can resume after surgery.

 Abdominoperineal resection (APR): If the tumor is located close to the anus (usually
within 5 cm), performing an abdominoperineal resection and removing the anal sphincter
may be necessary. Lymph nodes are also removed during this procedure. With an
abdominoperineal resection, a colostomy is necessary. A colostomy is an opening of the
colon to the front of the abdomen, where feces are eliminated into a bag.

Other Therapy

Radiation therapy uses high-energy rays that are aimed at the cancer cells to kill or
shrink them. For rectal cancer, radiation therapy may be used either before surgery (neoadjuvant
therapy) or after surgery (adjuvant therapy), usually in conjunction with chemotherapy.

The goals of radiation therapy are as follows:

 Shrink the tumor to make its surgical removal easier (if given before surgery).

 Kill the remaining cancer cells after surgery to reduce the risk of the cancer returning or
spreading.

 Treat any local recurrences that are causing symptoms, such as abdominal pain or bowel
obstruction.

Typically, radiation treatments are given daily, 5 days a week, for up to 6 weeks. Each
treatment lasts only a few minutes and is completely painless; it is similar to having an x-ray film
taken.

17
 The main side effects of radiation therapy for rectal cancer include mild skin irritation,
diarrhea, rectal or bladder irritation, and fatigue. These side effects usually resolve soon after the
treatment is complete.

CHEMOTHERAPY

The term chemotherapy, which is sometimes shortened to chemo, refers to the use of
medications to treat cancer. Cancer cells tend to divide rapidly. Chemotherapy works by
interfering with the way cells divide, thereby preventing the cancer from spreading - and
sometimes even curing the disease by helping to get rid of all the cancer cells in the body.

There are many different ways chemo medications are given, this includes:

 Intravenously (IV). A needle is inserted into a vein and the medicine flows from an IV
bag or bottle into the bloodstream. Chemo can also be delivered intravenously through a
catheter, a thin flexible tube that is placed in a large vein in the body.

 Orally. The person getting treatment swallows a pill, capsule, or liquid form of chemo
medication.

 By injection. Using a needle or syringe, the drugs are injected into a muscle or under the
skin.

 Intrathecally. A needle is inserted into the fluid-filled space surrounding the spinal cord
and the chemo drugs are injected into the spinal fluid.

Port Inserted in Vein for Chemotherapy

A. Port

B. Catheter

C. Tubing

D. Superior Vena Cava

E. Pulmonary Vein

F. Aorta

G. Heart

18
Some of the side effects of chemotherapy are:

 Fatigue. It's quite common for people who are having chemotherapy to feel very tired.
Some people feel extremely tired all of a sudden and may be exhausted even after
sleeping or resting.

 Discomfort and pain. Some people may feel a little discomfort when the catheter or IV
needle is put in the skin. Chemo treatments may also cause nerve problems and burning,
numbness, tingling, or shooting pain in the fingers and toes. Certain types of chemo
medications also cause mouth pain, headaches, muscle pains, and stomach pains.

 Skin changes. People who are receiving chemo treatments may find their skin becomes
red, sensitive, or irritated. People who receive radiation therapy before having
chemotherapy may notice that involved skin may turn red, blister, and peel once chemo
begins. This is known as "radiation recall."

 Hair loss and scalp problems. Some people who get chemo lose their hair. It may
become thinner and then fall out completely or in
clumps. People who are receiving chemo may lose
hair all over their bodies, including the head, face,
arms and legs, underarms, and pubic area. Most
people who lose their hair during chemotherapy find
that it grows back once treatment has ended, usually
within 3 months.

 Mouth, gum, and throat sores. Chemotherapy may

cause sores in the mouth, gums, and throat, or cause a
person's gums to become irritated and bleed. A
doctor may prescribe a mouth rinse or other products to
reduce pain, dryness, and irritation. People who are
receiving chemotherapy treatments should get
regular dental checkups and follow their dentist's advice on how to brush their teeth
during chemotherapy.

 Stomach problems. People receiving chemotherapy may feel sick, not feel like eating, or
throw up during the course of their treatment. They may also have loose bowel
movements or become constipated.

 Central nervous system problems. Chemotherapy may also cause temporary confusion
and depression in some people.

 Kidney and bladder problems. Some chemo drugs can irritate or damage the bladder or
kidneys.

 Blood problems. Having chemo may cause certain blood problems:

19
 • Anemia. Having chemo can affect the red blood cells, the blood cells that are
made in the bone marrow and carry oxygen to the rest of the body. This can
cause anemia, a low number of red cells in a person's blood.

• Bleeding problems. Some types of chemo drugs may also cause problems with
platelets, which are needed to help blood clot. Platelet problems can make it easy
for a person to bleed and become bruised. Blood transfusions are sometimes
given to help remedy these problems.

• Increased risk of infection. In addition to red blood cell and platelet problems,
people who get chemo may have lowered numbers of white blood cells. White
blood cells are part of the immune system and help the body to fight infections.
As a result, people getting chemotherapy are more vulnerable to infection.
Because of their suppressed immune systems, it's important for these people to
avoid crowds and to stay away from people they know who have infections like
colds or the flu. This doesn't mean that teens getting chemo need to hide in their
rooms, though. Doctors encourage people who are getting chemo to maintain
contact with friends. And, although they usually ask patients to check in before
going to a place where there will be lots of people, doctors usually give teens the
go-ahead to attend social functions. One way to prevent infection is frequent
hand washing.

Once you've finished chemo, it's still important to visit the doctor for follow-up
appointments. During these checkups, the doctor will want to know how you're feeling and
whether you're experiencing any side effects. He or she will also check to see whether there are
any signs of the cancer coming back.

RADIATION THERAPY

Radiation therapy, sometimes called radiotherapy, x-ray therapy radiation treatment,

cobalt therapy, electron beam therapy, or irradiation uses high energy, penetrating waves or
particles such as x rays, gamma rays, proton rays, or neutron rays to destroy cancer cells or keep
them from reproducing.

Radiation therapy is a local treatment. It is painless. The radiation acts only on the part of
the body that is exposed to the radiation. This is very different from chemotherapy in which drugs
circulate throughout the whole body. There are two main types of radiation therapy. In external
radiation therapy a beam of radiation is directed from outside the body at the cancer. In internal
radiation therapy, called brachytherapy or implant therapy, where a source of radioactivity is
surgically placed inside the body near the cancer.

Purpose

The purpose of radiation therapy is to kill or damage cancer cells. Radiation therapy is a
common form of cancer therapy. It is used in more than half of all cancer cases. Radiation
therapy can be used:

20
 • alone to kill cancer
• before surgery to shrink a tumor and make it easier to remove
• during surgery to kill cancer cells that may remain in surrounding tissue after the surgery
(called intraoperative radiation)
• after surgery to kill cancer cells remaining in the body
• to shrink an inoperable tumor in order to and reduce pain and improve quality of life.
• in combination with chemotherapy

Radiation therapy can cause anemia, nausea, vomiting, diarrhea, hair loss, skin burn,
sterility, and rarely death. However, the benefits of radiation therapy almost always exceed the
risks. Patients should discuss the risks with their doctor and get a second opinion about their
treatment plan.

The outcome of radiation treatment varies depending on the type, location, and stage of
the cancer. For some cancers such as Hodgkin's disease, about 75% of the patients are cured.
Prostate cancer also responds well to radiation therapy. Radiation to painful bony metastases is
usually a dramatically effective form of pain control. Other cancers may be less sensitive to the
benefits of radiation.

The patient is positioned and consulted by the

technologist prior to radiotherapy. The "upside down L"
device is a linear accelerator, which delivers high energy
x-rays directly to the tumor.

Gamma Rays and Cobalt Therapy Systems

Gamma rays are another form of photons used in radiotherapy. Gamma rays are produced
spontaneously as certain elements (such as radium, uranium, and cobalt 60), which release
radiation as they decompose, or decay. Each element decays at a specific rate and gives off
energy in the form of gamma rays and other particles. X-rays and gamma rays have the same
effect on cancer cells.

Many of the original cobalt gamma ray systems have been replaced with linear
accelerators. Cobalt systems can not deliver the higher power radiation that is possible with a
linear accelerator, and thus may not be as effective at destroying cancerous tumor. Also, the
radiation produced by a linear accelerator can be turned on and off, whereas the cobalt system
consists of a radioactive source material which is always on.

ILEOSTOMY

An ileostomy is an opening made into the small bowel, the ileum. The resulting opening
is called a stoma from the Greek word meaning "mouth". Initially after surgery, the stoma tends
to be quite swollen due to the handling of the bowel. The size may decrease, however, this will
occur over a period of time often taking up to six weeks. The bowel is not unlike the inside of our

21
mouths. The stoma is red, soft, and moist. The stool from an ileostomy stoma contains many
harsh enzymes. If stool should come in contact with skin, irritation can occur. To avoid this
problem, the surgeon will construct the stoma so that it protrudes approximately 2.5 mm from the
skin and well into the opening of the appliance.

Ileostomies are necessary where disease or injury has rendered the large intestine
incapable of safely processing intestinal waste, typically because the colon has been wholly
removed. An ileostomy may also be necessary in the treatment of colorectal cancer; one
example is a situation where the tumor is causing a blockage. In such a case the ileostomy may be
temporary, as the common surgical procedure for colorectal cancer is to reconnect the remaining
sections of colon or rectum following removal of the tumor provided that enough of the rectum
remains intact to preserve sphincter function.

The stoma can be either a loop or an end portion of the ileum. Through the opening, the
bowel is turned back on itself almost like a cuff and stitched to the skin. The loop ileostomy will
have two openings - the top opening called the proximal opening where stool is passed and the
distal opening or bottom opening that is connected to the resting portion of bowel. An ileostomy
may be temporary or it may be permanent. Ileostomies are usually located in the right lower
quadrant of the abdomen.

End Ileostomy Loop Ileostomy

22
Loop Ileostomy

This type of ileostomy is formed by bringing a loop of ileum on to the skin surface
through a small incision on the right-hand side of the abdomen.
To prevent the loop of bowel slipping back inside the abdomen, a "bridge" is placed under the
loop. A small incision is made in the loop of the bowel which will allow the faeces (stools) to be
passed to the outside. A drainable stoma appliance - which covers the ileostomy and adheres to
the abdomen - is used to collect the faeces. The "bridge" supporting the loop of bowel will be
painlessly removed after 5-10 days. The skin and muscle will keep the ileostomy in place on their
own.

CREATION OF A LOOP ILEOSTOMY

The person with an ileostomy has no voluntary control over the passage of stool or gas
because, unlike the anus, the stoma has no sphincter muscle. As a result, an external appliance
must be worn at all times.

The stool from an ileostomy is initially quite loose. It may take 24-48 hours before the
ileostomy will start to function. Prior to that, there may be bloody drainage present in the
appliance. Once the ileostomy starts to function, the contents may be loose, thin, watery and
greenish looking. This is know as bile. Ileostomy stool will always be loose because the colon,
large bowel, has either been removed or bypassed with the surgery and less water and salt is
absorbed. As the small bowel adapts to this change (which takes several weeks), the stool should

23
gradually thicken to a porridge or toothpaste consistency. The stool from an ileostomy should
never be formed. Changes in the consistency of the stool will vary during the course of a day
depending upon the types and quantities of fluids and foods consumed. You might find that stool
will pass into your appliance anywhere from 1 ½ to 4 hours after eating and drinking.

ANASTOMOTIC STRICTURE

Anastomotic stricture: (A) Gastrografin swallow, (B) anastomotic stricture with a diameter of
approximately 5 mm, and (C) dilation with a through-the-scope balloon dilator.

In this photo, you can see the balloon dilator catheter which has been passed through the center
channel of the colonoscope. Under direct vision, the deflated cigar-shaped balloon is carefully
placed to straddle the stricture. The balloon is then inflated with water. As it inflates and becomes
wider, the narrow ring is stretched and becomes more open. The balloon dilators come in a
variety of sizes. The larger the size the larger the diameter of the balloon. Dividing the size (like

24
45F) by 3 gives you the approximate width of the balloon. So a 54F balloon is about 18
millimeters wide.

After the balloon dilator was deflated and removed, the stricture
is seen to be more open. The patient was advised to begin a high
fiber diet to help keep the stricture from reclosing.

After dilation was completed, the thinner pediatric colonscope was

easily passed beyond the stricture and the entire remaining colon was
examined. She was relived that no additional polyps or cancer were
present within the colon. She is to return every three years to be
rechecked.

COLOANAL ANASTOMOSIS

It is expected during colorectal or coloanal anastomosis surgery, depending on the

disease, either the upper part of the rectum (colorectal anstomosis) or the entire rectum is
removed through an incision in the abdomen. If the entire rectum is removed, the surgeon
connects the colon to the anus (coloanal anastomosis).

Generally, if more than half of the rectum is removed, a colon pouch ("J-pouch") is
created. The J-pouch becomes a reservoir for waste and replaces the function of the rectum that
was removed. The surgeon constructs the pouch from about 2-4 inches of colon (large intestine)
and attaches it to the remaining rectum or to the anal muscle if the entire rectum has been
removed.

In many cases, a temporary "loop" ileostomy is created. This allows waste to be diverted
into an external pouch, while the surgical area heals without the danger of irritation or infection
from bacteria in stool. The loop construction of the stoma allows for a simpler reversal of the
ostomy with less pain and a shorter recovery time.

25
Difference between Colorectal Anastomosis and Coloanal Anastomosis

Colorectal Anastomosis

 Disease is limited to the upper half of the rectum

 Only the diseased portion of the rectum is removed. The colon (large intestine) is
connected to the remaining rectum
 Temporary loop ileostomy only occasionally necessary if the area of the bowel
connection is low, if there has been an infection, or if you had radiation to the surgical
area because of the rectal cancer

Coloanal Anastomosis

 Extensive disease or disease involvement of the lower rectum

 The entire rectum is removed-leaving the anal muscle intact. The colon (large intestine) is
connected directly to the anal muscle
 Temporary loop ileostomy is usually created because the connection is extremely low-
and the colon is actually sewn to the anal muscle

DIABETES MELLITUS TYPE II

Type 2 diabetes used to be called 'non-insulin-dependent diabetes mellitus' or adult-onset

diabetes. It differs from type 1 diabetes in that the body makes some insulin, but not enough; also,
the body can't use the insulin efficiently.

During digestion, the body breaks down carbohydrates from foods such as bread, rice,
pasta, vegetables, fruits and dairy products into various sugar molecules. One of these sugar
molecules is glucose, a main source of energy. Glucose is absorbed directly into the bloodstream
after eating, but it can't enter the cells without the help of insulin.

The pancreas — a gland located just behind your stomach — produces insulin
continuously. When the blood sugar increases after eating, insulin production also increases. The
extra insulin "unlocks" the cells to more sugar, which provides the body with energy and helps
maintain a normal level of sugar in the blood.

The liver also plays a key role in maintaining a normal blood sugar level. If there is more
glucose than the cells need for energy, the body can remove the excess from your bloodstream
and store it in your liver as glycogen. Then, when glucose levels become low, the body can tap
into the stored glucose and release it into the bloodstream.

When the pancreas is functioning normally, the amount of glucose in the blood fluctuates
in response to a number of factors, including the type of food a person eats, exercise, stress and
infections. But the complex relationship between insulin, glucose, the liver and other hormones
ensures that the blood sugar stays within set limits.

In type 2 diabetes, the pancreas makes some insulin, but one or two other problems
develop:

26
  The muscles and body tissue become resistant to insulin.
 The pancreas doesn't make enough insulin.

When the cells become resistant to insulin, they refuse to accept it as the key that unlocks
the door for sugar. As a result, sugar accumulates in your bloodstream. That is exactly why the
cells become insulin resistant remains uncertain, although excess weight, inactivity and fatty
tissue seem to be important factors.

Unlike Type 1 diabetes, there is little tendency toward ketoacidosis in Type 2 diabetics,
though it is not unknown. Complex and multifactorial metabolic changes lead to damage and
function impairment of many organs, most importantly the cardiovascular system in both Types.
This leads to substantially increased morbidity and mortality in both Type 1 and Type 2 patients,
but the two have quite different origins and treatments despite the similarity in complications
which often confuse even diabetics.

Clinical Manifestation and Pathophysiology

Genetic factors, usually polygenic, are present in most patients. However, environmental
factors such as obesity, lack of exercise and a sedentary lifestyle are thought by most observers to
lead to insulin resistance. Certainly not all type 2 diabetics have a family history of the condition.
Insulin resistance means that body cells do not respond appropriately when insulin is present.

Other important contributing factors:

• increased hepatic glucose production (e.g., from glycogen degradation), especially at
inappropriate times
• decreased insulin-mediated glucose transport in (primarily) muscle and adipose tissues
(receptor and post-receptor defects)
• impaired beta-cell function—loss of early phase of insulin release in response to
hyperglycemic stimuli
• Cancer survivors who received allogenic Hematopoeitic Cell Transplantation (HCT) are
3.65 times more likely to report type 2 diabetes than their siblings. Total body irradiation
(TBI) is also associated with a higher risk of developing diabetes.

The physiologic and metabolic alterations depend upon the percentage of loss of insulin
action. Since adipose tissue is very sensitive to insulin affects, there maybe enough insulin to

27
prevent lipolysis and promote fat storage. Fat distribution is often more central in the upper part
of the body.
Typical clinical features that is common
o Polyuria and thirst
o Recurrent and blurred vision
o Paresthesias
o Fatigue
o Vulvovaginitis in women

28
 The exact mechanism that leads to insulin resistance and impaired insulin secretions in
type 2 diabetes are unknown. To overcome insulin resistance and to prevent the build up of
glucose in the blood, increased amounts of insulin must be secreted to maintain the glucose level
at normal or slightly elevated level. Diabetic ketoacidosis does not typically occur in type 2
diabetes because it is associated with a slow (over years), progressive glucose intolerance the
onset of type 2 diabetes may go undetected for many years. For most patients (approximately
75%) type 2 diabetes is detected incidentally (e.g. when routine laboratory tests or
ophthalmoscopic examinations are performed). One consequence of undetected diabetes is that
long term diabetes complications (e.g. eye disease, peripheral neuropathy, peripheral vascular
disease) may have developed before the actual diagnosis of diabetes is made. Because insulin
resistance is associated with obesity, the treatment of type 2 diabetes is weight loss. Exercise is
also important in enhancing the effectiveness of insulin. Oral antidiabetic agents maybe added if
diet and exrcise are not successful.

Acute complications

Hyperglycemia the hallmark of DM may result from alteration in insulin secretion,

impaired insulin action, combination of both of these changes. As a result of hyperglycemia there
are several physiologic manifestations: the glucose level can be greater than the reabsorptive
capacities of the renal tubules, resulting in glucosuria. This promotes an osmotic diuresis with
loss of both fluids and electrolytes. This demonstrates clinically with both polyuria and nocturia.
Excessive loss of fluids stimulates thirst and polydipsia. Glucosuria can result in a significant loss
of calories since glucose loss can exceed 75 gm/day. Decreased responsiveness in the satiety
center of the hypothalamus promotes polyphagia. Plasma osmolality is increased as a result of
hyperglycemia this can promote changes in the water content of the lens of the eye leading to
blurred vision. Glucosuria increases the incidence of candidal infections.

Chronic Complications

Nephropathy
Diabetes is the leading cause of end stage renal disease in the U.S. Diabetic Nephropathy
is the result of an alteration in the glomerular function. It is characterized by proteinuria,
hypertension and progressive renal insufficiency.

Retinopathy
It is the result of microvascular changes associated with hyperglycemia. Two distinct
patterns develop in DM retinopathy: 1) non-proliferative or background retinopathy and 2)
proliferative retinopathy. The changes associated with non-proliferative retinopathy include
microaneurysm, exudates and retinal edema. Proliferative retinopathy includes neovascularization
with the growth of new capillaries.

Treatment

Diabetes mellitus type 2 is a chronic, progressive disease that cannot now be cured. There
are two main goals of treatment of the disease:
1. reduction of mortality and concomitant morbidity (from assorted diabetic complications)
2. preservation of quality of life

The first goal can be achieved through close glycemic control (ie, blood glucose levels);
the reduction effect in diabetic complications has been well demonstrated in several extensive

29
clinical trials and is thus well established. The second goal is often addressed (in developed
countries) by support and care from teams of diabetic health workers (physician or PA, nurse,
dietitian, certified diabetic educator, ...). Knowledgeable patient participation is vital and so
patient education is a crucial aspect of this effort.

Type 2 is initially treated by adjustment in diet and exercise, and by weight loss,
especially in obese patients. The amount of weight loss which improves the clinical picture is
sometimes modest (5–10 lb); this is almost certainly due to currently poorly understood aspects
of fat tissue chemical signalling (especially in visceral fat tissue in and around abdominal organs).
In many cases, such initial efforts can substantially restore insulin sensitivity.

The next step, if necessary, is treatment with oral antidiabetic drugs (oral agents "OA"s):

30
• the sulfonylureas
• biguanides (metformin)
• thiazolidinediones
• α-glucosidase inhibitors
(acarbose, miglitol)
• meglitinides (nateglinide,
repaglinide and their
analogues)
• exenatide

31
 If these fail to help (or stop helping), insulin therapy may be necessary, usually as an adjunct to
oral medication therapy, to maintain normal glucose levels. The term non-insulin-dependent diabetes
is thus inaccurate and misleading. The classification, or type, of diabetes is determined by the
underlying cause of the diabetes, not the type of therapy that is used to treat the diabetes. Many
patients with type 2 diabetes will progress to insulin therapy to control of blood glucose levels, but
these patients are still type 2 diabetics.
 VII. ANATOMY AND PHYSIOLOGY

RECTUM

The rectum is the terminal portion of the large intestine beginning at the confluence of the
three tenia coli of the sigmoid colon and ending at the anal canal. Generally the rectum is 15 cm in
length, is intraperitoneal at its proximal and anterior end, and is extraperitoneal at its distal and
posterior end. The epithelial lining or mucosa of the rectum is of a simple columnar mucous secreting
variety. Therefore, the characteristic malignancy of the rectum is an adenocarcinoma.

Anatomy and Physiology: Rectum and Anal Canal

 VIII. PATHOPHYSIOLOGY

RECTAL ADENOCARCINOMA

Adenocarcinoma, the most common type of rectal cancer, arises from an adenomatous polyp
or gland.

In the normal mucosa of the bowel and the rectum, the surface epithelium regenerates
approximately every 6 days. But in some cases, a loss of function of a gene called adenomatous
polypsis coli (APC) which is a tumor suppressor protein causes the increased cell division which
produces abnormalities in K-ras oncogene (which influence proliferation, differentiation,
transformation, and apoptosis of cell ) in the early stages and p53 mutations (Tumor suppressor gene
of any normal cell) in later stages. The loss of tumor suppressor function prevents apoptosis and
gives the cell eternal life eventually producing adenomas (benign polyps). Some polyps remain very
small while others continue to enlarge. Risk of developing cancer increases with the number and size
of polyps you have. Adenomas larger than two centimeters have a 30-50 percent chance of being
cancerous. Most polyps remain benign but about 1 in 10 will turn into cancer.

Though the actual cause of rectal cancer is unclear, risk factors were identified in the
development of rectal cancer namely increasing age (greater than 50 years), smoking, family history
of colon or rectal cancer, personal or family history of polyps or inflammatory bowel diseases (e.g.
ulcerative colitis), and diet.

A diet high in saturated animal fat, particularly dairy products and red meat increases
colorectal cancer risk because the digestion of fats requires the activity of normal bile acids that
irritate and damage cells lining the colon. Consequently, bile acids activate factors associated with
abnormal growth of these cells, resulting in an increased risk of colorectal cancer.

Low folate intake, especially when combined with alcohol consumption and a low-protein
diet, increases colorectal cancer risk because dietary folate influences DNA methylation, synthesis,
and repair. Abnormalities in these DNA processes enhance cancer development, particularly in
rapidly growing tissues such as the colorectal mucosa.

Cancer cells in a tumor like to eat glucose and will alter the metabolism of the body to get
more. They do this by increasing liver gluconeogenesis from amino acids, which leads to a loss of
muscle tissue from the skeleton and internal organs. Insulin resistance is increased so that glucose will
not be as able to enter healthy cells.

The rectum is also surrounded with lymph nodes which are part of the immune system and
assist in conducting surveillance for harmful materials. Cancer cells can also spread from the rectum
to the lymph nodes on their way to other parts of the body.

Pathogenesis of Rectal Adenocarcinoma

 Regeneration of surface epithelium
tissue in the rectum

Loss of function of APC (adenomatous R/t diet and

polypsis coli) gender

Abnormalities in K-RAS oncogene

Affecting the cells

Proliferation Differentiation Transformation Prevents P-53 mutation

apoptosis

Rectal Production of
Adenocarcinoma adenomas

Rectal Mass
↑ no. and size of
polyps

Bleeding Obstruction

Pain Pencil-thin stools

 IX. ANATOMY AND PHYSIOLOGY

PANCREAS

The pancreas is a glandular organ that secretes digestive enzymes and hormones. In humans,
the pancreas is a yellowish organ about 7 in. (17.8 cm) long and 1.5 in. (3.8 cm) wide. It lies beneath
the stomach and is connected to the small intestine at the duodenum (see digestive system). Most of
the pancreatic tissue consists of grapelike clusters of cells that produce a clear fluid (pancreatic juice)
that flows into the duodenum through a common duct along with bile from the liver. Pancreatic juice
contains three digestive enzymes: tryptase, amylase, and lipase that, along with intestinal enzymes,
complete the digestion of proteins, carbohydrates, and fats, respectively. Scattered among the
enzyme-producing cells of the pancreas are small groups of endocrine cells, called the islets of
Langerhans that secrete two hormones, insulin and glucagon. The pancreatic islets contain several
types of cells: alpha-2 cells, which produce the hormone glucagon; beta cells, which manufacture the
hormone insulin; and alpha-1 cells, which produce the regulatory agent somatostatin. These hormones
are secreted directly into the bloodstream, and together, they regulate the level of glucose in the
blood. Insulin lowers the blood sugar level and increases the amount of glycogen (stored
carbohydrate) in the liver; glucagon has the opposite action. Failure of the insulin-secreting cells to
function properly results in diabetes, which can occur in two major forms, the division being between
juvenile onset and onset in maturity.

Anatomy and Physiology: Digestive System-Pancreas

 X. PATHOPHYSIOLOGY

DIABETES MELLITUS TYPE II

The pathogenesis of type 2 diabetes mellitus differs significantly from that of type 1. A
limited beta cell response too hyperglycemia appears to be a major factor in its development. Beta
cells chronically exposed to high blood levels of glucose become progressively less efficient when
responding to further glucose elevations. This phenomenon, termed desensitization, is reversible by
normalizing glucose levels. The ration of proinsulin (a precursor to insulin) to insulin secreted also
increases

A second pathophysiologic process in type 2 diabetes mellitus is resistance to the biologic

activity of insulin in both the liver and peripheral tissues. This state is known as insulin resistance.
People with type 2 diabetes have a decreased sensitivity to glucose levels, which results to continued
hepatic glucose production, even with high blood glucose levels. This is coupled with an inability of
muscle and fat tissues to increase glucose uptake. The mechanism causing peripheral insulin
resistance is not clear; however, it appears to occur after insulin binds to a receptor on the cell surface.

Insulin is a building (anabolic) hormone. Without insulin, three major metabolic problems
occur: (1) decreased glucose utilization, (2) increased fat mobilization, and (3) increased protein
utilization.

Decreased Glucose Utilization

In diabetes, cells that require insulin as a carrier for glucose can take in only about 25% of the
glucose they require for fuel. Nerve tissues, erythrocytes, and the cells of the intestines, liver and
kidney tubules do not require insulin for glucose transport. However adipose tissue, along with
skeletal and cardiac muscles does require insulin for glucose transport. Without adequate amounts of
insulin, much of the ingested glucose cannot be used.

With adequate amounts of insulin, blood glucose levels rise. This elevation continues because
the liver cannot store glucose as glycogen without sufficient insulin levels. In an attempt to restore
balance and return blood glucose levels to normal, the kidney excretes the excess glucose. Glucose
appears in the urine (glucosuria). Glucose excreted in the urine acts as an osmotic diuretic and causes
excretion of increased amounts of water resulting in fluid volume deficit.

Insulin Deficiency

Decreased Increased hepatic Impaired beta cell

glucose-induced glucose production function
insulin secretion
Hyperglycemia
Decreased tissue
responses to
insulin Decreased cellular Post-receptor defect
glucose uptake

Insulin resistance

Relationship between insulin resistance and insulin secretion in type 2 diabetes mellitus
Increased Fat Mobilization

In type 1 diabetes and occasionally severe stress in type 2 diabetes, the body turns fat stores
for energy. Fat metabolism causes breakdown products called ketones to form. Ketones accumulate in
the blood and are excreted through the kidneys and lungs. Ketone levels can be measured in the blood
and urine; high levels can indicate uncontrolled diabetes.

Ketones interfere with the body’s acid-base balance by producing hydrogen ions. The pH
can decrease and metabolic acidosis can develop. In addition, when ketones are excreted, sodium is
also eliminated, resulting in sodium depletion and further acidosis. The excretion of ketones also
increases osmotic pressure, leading to increased fluid loss. Also, when fats are the primary source of
energy, body lipid levels can increase to five times normal, leading to atherosclerosis.

Increased Protein Utilization

Lack of insulin leads to protein wasting. In healthy people, proteins are constantly being
broken down and rebuilt. In people with type 1 diabetes, without insulin to stimulate protein
synthesis, the balance is altered, which leads to increased catabolism (destruction). Amino acids are
converted to glucose in the liver, further elevating glucose levels. If this condition goes untreated,
clients with type 1 diabetes appear emaciated. The pathophysiological processes of diabetes continue,
leading to many acute and chronic complications.

Normal Glucose Metabolism

During digestion, the sugar (glucose) in the food you eat is absorbed into your bloodstream. Insulin
from your pancreas allows glucose into your cells, where it provides energy for your body. Excess
glucose is stored in your liver as glycogen.
 Pathogenesis of DM Type 2

Type 2 diabetes develops when the pancreas doesn't produce enough insulin or your cells become
resistant to insulin.

GI Tract
Pancreas Gastrointestinal absorption of
Impaired Insulin Secretion Glucose

Hyperglycemia

Liver Muscle
Increased Basal hepatic Decreased insulin-
glucose production stimulated glucose uptake
 XI. DRUG STUDY

BRAND NAME/
GENERIC MECHANISM OF ADVERSE NURSING
CHEMICAL NAME/ INDICATION CONTRAINDICATION
NAME ACTION EFFECTS CONSIDERATIONS
AVAILABILITY
Eperisone Hcl Brand Name/s: Myonal Skeletal muscle •Improvement of • Patients with a history • Shock and Since symptoms or side
relaxation thru: myotonic of hypersensitivity to anaphylactoid effects may occur,
Chemical Name: • Inhibition of conditions any ingredients of the reactions patients should be
1-(4-ethylphenyl)-2- experimentally- •Spastic paralysis drug • Oculo-muco- carefully observed. If
methyl-3-(1- induced muscle cutaneous these occurs, treatment
piperidyl)propan-1-one rigidity syndrome should be discontinued
• Suppression of (Stevens- and appropriate
Availability: spinal reflexes Johnson measures taken.
Tablets: 50 mg • Reduction of syndrome) and
muscle spindle toxic epidermal Since the elderly often
sensitivity via γ- necrolysis (Lyell have a physiological
motor syndrome) hypofunction, it is
• Neurons • Hepatic: advisable to take
Elevation of measures, such as
Vasodilatation and AST (GOT), reduction in dosage
Augmentation of ALT(GPT) and under careful
blood flow Al-P, etc. supervision.
• Renal:
Analgesic action and Proteinuria and It is advisable to avoid
inhibition of the pain elevation of the administration of
reflex in the BUN MYONAL to nursing
spinal cord • Hematologic: mothers. When
Anemia MYONAL must be used,
Facilitation of breastfeeding should be
• Psychoneuro-
voluntary movement discontinued during
logic:
treatment.
Sleepiness,
insomnia,
headache and
numbness in the
extremities
• GI: N/V,
anorexia,
stomach

Etoricoxib Brand Name/s: Arcoxia Arcoxia reduces pain • Osteoarthritis: • History of
and inflammation by 60 mg hypersensitivity to the
Chemical Name: blocking COX-2, an • Rheumatoid active substance or to
sodium 5- enzyme in the body. arthritis: 90 mg any of the excipients
( difluoromethoxy)- 2- • Acute gouty • Active peptic ulceration
[[( 3,4- dimethoxy- 2- arthritis: 120 mg or active gastro-
pyridinyl) methyl] intestinal (GI) bleeding.
sulfinyl]- 1 H- • Pregnancy and lactation
benzimidazole • Severe hepatic
sesquihydrate dysfunction (serum
albumin <25 g/l or
Availability: Child-Pugh score 10).
Tablet: 60 mg, 90 mg, 120 • Estimated renal
mg creatinine clearance <30
ml/min.
• Children and
adolescents under 16
years of age.
• Inflammatory bowel
disease.
• Congestive heart failure
(NYHA II-IV).
• Patients with
hypertension whose
blood pressure has not
been adequately
controlled.
• Established ischaemic
heart disease, peripheral
arterial disease and/or
cerebrovascular disease
discomfort,
abdominal pain,
diarrhea,
constipation and
thirst
• GI: Nausea, Etoricoxib may mask
diarrhea, fever and other signs of
dyspepsia and inflammation.
upper abdominal
pain. Caution should be
• Others: Edema, exercised when co-
dizziness, administering etoricoxib
hypertension, with warfarin or other
headache, oral anticoagulants
fatigue and
increases in liver The use of etoricoxib, as
enzymes. with any medicinal
product known to inhibit
cyclo-
oxygenase/prostaglandin
synthesis, is not
recommended in women
attempting to conceive.
ARCOXIA tablets
contain lactose. Patients
with rare hereditary
problems of galactose
intolerance, the Lapp
lactase deficiency or
glucose-galactose
malabsorption should not
take this medicine.
Ferrous Brand Name/s:
sulfate Apo-Ferrous Sulfate,
Feosol†, Feratab, Fer-Gen-
Sol‡, Fer-Iron drops‡, Fer-
In-Sol†, Fero-Gradumet†
Chemical Name:
FeSo4
Availability:
(about 20% elemental
iron; dried an powdered,
its about 32% elemental
iron)
Capsules: 150 mg, 159 mg
(dried), 190 mg (dried),
250 mg, 390 mg
Capsules (extended-
release): 150 mg (dried),
160 mg (dried)
Drops: 75 mg/ 0.6 ml, 125
mg/ ml
Elixir: 220 mg/ 5 ml
Solution: 75 mg/ 0.6 ml,
300 mg/ 5 ml
Syrup: 90 mg/ 5ml
Tablets: 195 mg, 300 mg,
325 mg, 187mg (dried),
200 mg (dried)
Tablets (extended-release):
160 mg (dried), 525 mg)
Gliclazide Brand Name/s:
Diamicron MR®
Class
Anti-diabetic agent:
hypoglycemic agent
Chemical effect: •Iron deficiency: • Contraindicated in • GI: nausea, Inform patients that as
provides elemental adults: 300 mg patients with primary epigastric pain, few as three drops can
iron, an essential ferrous sulfate hemochromatosis, vomiting, cause poisoning on
component of P.O. bid to qid or hemosiderosis, constipation, children.
hemoglobin 1 extended- hemolytic anemia diarrhea, black
Therapeutic effect: release capsule (unless iron deficiency stool, anorexia If patient misses dose,
relieves iron- (160 to 525 mg) anemia is also present), • Others: tell patient to take it as
deficiency ferrous sulfate peptic ulcer disease, suspension and soon as he remembers
P.O daily to bid. regional enteritis, or drops may but not to double the
•Children aged 2 an ulcerative colitis, and in temporarily dose.
older: 3 mg/ kg those receiving repeated stain teeth.
ferrous sulfate blood transfusions. Advise the patient to
P.O. daily in • Use cautiously in long- avoid certain foods that
three or four term basis may impair oral iron
divided doses absorption, including
daily. yogurt, cheese, eggs,
milk, whole-grain breads
an cereals, tea, and
coffee.
Teach dietary measures
for preventing
constipation.
Bind to plasma • Type 2 diabetes • Stress before and during • Hypoglycemia, Instruct patient to take
membranes of surgery, ketosis, severe gastrointestinal drug with food to
functional beta cells in Therapeutic trauma, fever, disturbance, skin decrease incidence of
the pancreas causing a Effects: infections, pregnancy, reactions, gastric upset
decrease in potassium •Decreased hypo/ diabetes complicated by hematological
permeability and hyperglycemic recurrent episodes of disorders, hepatic If ketonuria, acidosis,
membrane episodes ketoacidosis or coma. enzyme rises increased glycosuria or
 Chemical Name: depolarization. This •HbA1 within • Juvenile, growth onset, serious side effects occur,
3-(7-azabicyclo[3.3.0]oct- leads to an increase desired range <7 insulin dependent or withdraw the med.
7-yl)-1-(4-methylphenyl) intracellular calcium •Prevention of brittle diabetes
sulfonyl-urea and subsequent release target organ • Impaired endocrine, Be prepared to treat if
from insulin- damage renal or liver function. client develops severe
Availability: containing secretory •Knowledge/ hypoglycemia
Tablet: 30 mg granules. control of
diabetes Review prescribed drugs
The sulfonylureas •Adherence to to ensure none interact.
enhance beta-cell exercise, drug,
response rather than and diet therapy Assessment:
change the sensitivity Note any previous
of beta-cells to experience with
glucose. sulfonylureas and the
outcome

Document any stress

Note if taking oral

contraceptives;
effectiveness is lessened
by oral hypoglycemic
agents
Insulin Brand Name/s: Increases glucose • Moderate to severe • Contraindicated in • Metabolic: Dosage is always
Actrapid‡, Actrapid transport across diabetic patients with history of hypoglycemia, expressed in USP units.
Penfill‡, Humulin, muscle and fat cell ketoacidosis or systemic allergic hyperglycemia, Use only the syringes
Humulin R Regular U-500 membranes to reduce hyperosmolar reaction to pork when hypomagnesemia calibrated for the
(concentrated), Hypurin glucose level. Helps hyperglycemia porcine-derived , hypokalemia. particular concentration
Neutral‡, Iletin II, convert glucose to (regular insulin) products are used or • Skin: rash, of insulin given.
Novolin, Novolin R glycogen; triggers • Mild diabetic hypersensitivity to any urticaria,
PenFill, Novolin R amino acid uptake and ketoacidosis component of pruritus, Don't use insulin that
Prefilled, Velosulin B conversion to protein (regular insulin) preparation. swelling, redness, changes color or becomes
in muscle cells; • Newly diagnosed • Contraindicated during stinging, warmth clumped or granular in
Chemical Name: stimulates triglyceride diabetes (regular episodes of at injection site. appearance.
(S)-2,5-Diaminopentanoic formation and inhibits insulin) hypoglycemia. • Other:
Acid Monohydrochloride release of free fatty lipoatrophy, Check expiration date on
acids from adipose lipohypertrophy, vial before using
• Control of
Availability: tissue; and stimulates hypersensitivity contents.
hyperglycemia
 Injection (human): 100 lipoprotein lipase reactions,
units/ml (Humulin R, activity, which with Humalog and anaphylaxis. Usual administration
Novolin R, Novolin R converts circulating longer-acting route is S.C. For proper
PenFill, Novolin R lipoproteins to fatty insulin in patients S.C. administration,
Prefilled, Velosulin BR) acids. with type 1 & 2 pinch a fold of skin with
diabetes fingers at least 3 inches
(7.6 cm) apart, and insert
needle at a 45- to 90-
degree angle.
Lactulose Brand Name/s: Taken orally and •Used to treat • May cause rupture of • Common Note the length of time it
Generlac®, Cephulac®, reaches the large constipation. abdomen or intestinal Adverse Effects: takes for the laxative to
Cholac®, Constilac®, bowel without being hemorrhage in severe Distension, take effect and give it so
Enulose®, Acilac®, absorbed into the •Also used in the abdominal pain that flatulence, that the result of the
Heptalac®, Actilax®, bloodstream. treatment of a might be cause by intestinal cramps, laxative will not interfere
Dulphalac specific disorder appendicitis, enteritis, diarrhea, fluid & with the client’s rest or
Here, it is degraded by of brain function ulcerative colitis, electrolyte digestion and absorption
Class the normal bacteria caused by many diverticulitis, intestinal imbalance of nutrients.
Laxative found in the bowel, different types of obstruction.
and this changes the liver disease • Uncommon Administer at agreeable
Chemical Name: pH, making it more • Undiagnosed abdominal Adverse Effects: temperature.
4-O-(beta)-D- acidic. pain Nausea,
Galactopyranosyl-D- vomiting, Assessment:
fructofuranose This has two effects: • Children under age of anorexia, Note indications for
• to increase the two. increased thirst. therapy: length of time
Availability: amount of water in and causes; stool
Tablet: 30 ml the bowel, which characteristics;
makes the stools effectiveness.
softer and allows
defecation to occur. With abdominal pain and
• to remove harmful discomfort, note location
ammonia from the and type of discomfort.
system and expel it
in faeces, Note stage of health,
preventing the brain activity level and general
from being exposed nutritional status.
to it
List other drugs that may
contribute to constipation
Levofloxacin Brand Name/s: Levaquin,
Tavanic, Cavit, Floxel
Class:
Fluoroquinolones
Chemical Name:
(-)-(S)-9-fluoro-2,3-
dihydro-3-methyl-10-
(4-methyl-1-piperazinyl)-
7-oxo-7H-pyrido
[1,2,3-de]-1,4-
benzoxazine-6-carboxylic
acid
Availability:
Tablets: 250, 500, 750 mg
Oral Solution: 25 mg/mL
Injection: levofloxacin in
D5W
Multivitamin Brand Name/s: Moriamin
and Amino Forte
Acid
Supplement Class:
Multivitamins/with
Minerals
Contents:
5-oxyanthranilic acid 0.2
mg, Ca pantothenate 5 mg,
folic acid 0.2 mg, l-
isoleucine 5.9 mg, l-
acetyltryptophan 5 mg, l-
leucine 18.3 mg, l- lysine
HCl 25 mg, l- methionine
18.4 mg, nicotinamide 20
mg, l- phenylalanine 5 mg,
l- threonine 4.2 mg, l-
The fluorine molecule • Large number of • Hypersensitivity to the • GI: N&V, Document indications for
confers increased gram positive and quinolone group of diarrhea, therapy, symptoms, and
activity against gram gram negative antibiotics. abdominal pain results.
negative organisms as infections • Tendonitis or tendon or discomfort,
well as broadens the rupture associated with painful mouth, Discontinue at first sign
spectrum against gram quinolone use heartburn, of allergic reaction
positive organism. • Lactation dyspepsia,
• Children less than 18 flatulence, Document soft
Antibacterial agents years if age constipation tissue/extremity injury;
by interfering with assess achilles tendon for
DNA gyrase and
• CNS: headache, drug induced injury
malaise, lethargy,
topoisomerase IV.
fatigue,
Monitory VS, I&O,
drowsiness,
CBC, cultures and liver
somnolence,
and renal function
depression
studies.
• Dermatologic:
rashes, pruritus
Supplies vitamins and • Malnutrition, • None. • Hypervitaminosis Document indications for
amino acids protein & vit (large dose). therapy, clinical
necessary for many deficiencies presentation and
processes in the body. • Anemia offending agents
• Convalescence,
restoration & Have a full nutritional
maintenance of assessment by a
body resistance registered dietician.
• Pregnancy &
lactation Assess metabolic panel
and vitamin levels
indicated.
• Adjuvant in the
therapy of peptic Teach client to comply
ulcer & TB with diet
recommendations.
Avoid self medicating
 valine 6.7 mg, vit A 2,000 with vitamin supplements
iu, vit B1 5 mg, vit B12 1
mcg, vit B2 3 mg, vit B6 Instruct patient that
2.5 mg, vit C 20 mg, vit D Moriamin may be taken
200 iu, vit E 1 mg with or without food
(May be taken w/ meals
Availability: for better absorption or if
Tablet form GI discomfort occurs).
Pregabalin Brand Name/s: Lyrica The drug works by • Neuropathic pain • Contraindicated in • Body as a Whole: Patients should be
attaching to a part of associated with patients with known Accidental advised to take LYRICA
Chemical Name: the over-firing nerve diabetic peripheral hypersensitivity to Injury, pain as prescribed. Abrupt or
(S)-3-(aminomethyl)-5- cells. This is thought neuropathy pregabalin or any of its • GI: Increased rapid discontinuation
methylhexanoic acid to help to reduce the components. appetite, dry may result in insomnia,
pain signals that cause • Postherpetic mouth, nausea, headache, or
Availability: the symptoms of neuralgia constipation diarrhea. Patients should
Capsules: 25, 50, 75, 100, diabetic nerve pain. • Metabolic: be counseled that
150, 200, 225, and 300 mg Weight gain, LYRICA may cause
peripheral edema edema and weight gain.
LYRICA may reduce • CNS: Dizziness,
the nerve pain that can somnolence, Diabetic patients should
prevent the enjoyment euphoria, ataxia, be instructed to pay
of everyday activities. tremor, abnormal particular attention to
gait skin integrity while being
• Vision: Blurred treated with LYRICA.
vision, diplopia,
abnormal vision
Tramadol Hcl Brand Name/s: Ultram, Unknown. A centrally •Moderate to • Contraindicated to •CNS: dizziness, Use in extreme caution in
Zamadol, Zydol acting synthetic moderately patient hypersensitive to vertigo, headache, patients with severe
analgesic compound severe pain drug and in those with somnolence, CNS cardiac disease. Use
Chemical Name: not chemically related acute intoxication from stimulation, cautiously in patients
(±)cis-2- to opiates. Drug is alcohol, hypnotics, asthenia, anxiety, with severe mental
[(dimethylamino)methyl]- thought to bind opioid centrally active confusion, depression, suicidal
1-(3-methoxyphenyl) receptors and inhibit analgesics, opioids, or coordination tendencies, or history of
cyclohexanol reuptake of psychotropic drugs. disturbance, drug abuse.
hydrochloride norepinephrine and euphoria,
serotonin. nervousness, sleep Alert: Note two strengths
Availability: disorder. of oral liquid form.
Tablets: 50 mg •CV: vasodilation Double-check dose,
•EENT: visual especially when giving to
disturbances children.
•Musculoskeletal:
hypertonia To minimize unpleasant
•GU: urine taste and stomach
retention, urinary irritation, dilute or give
frequency, with liquid.drug should
menopausal be taken after meals.
symptoms,
proteinuria. Monitor BUN levels;
•GI: nausea, large doses may raise
constipation, BUN levels.
vomiting, Don’t give drug for 48
dyspepsia, dry hours after fluorometric
mouth, diarrhea, test.
abdominal pain,
anorexia,
flatulence
•Respiratory:
respiratory
depression
• Skin: pruritus,
diaphoresis,
rash
 Medications taken at AFPMC:

Gliclazide The patient has type 2 diabetes mellitus and is given gliclazide, an anti-
diabetic drug, 30 mg OD with breakfast. Gliclazide acts by restoring first
peak of insulin secretion thus increasing insulin sensitivity of the patient.
The medication will decrease hypo/ hyperglycemic episodes and keep
HbA1 within desired range.
Insulin After continuous blood glucose monitoring and consequently increased
blood glucose level (529 as of February 1, 2007), the gliclazide was
discontinued and replaced by 30 units of insulin every day (8 units every
6 hours) together with diabetic diet to reduce glucose level.
Ferrous Sulfate Ferrous sulfate was given to resolve the signs and symptoms of anemia
because the patient has relatively a low hemoglobin count. Ferrous
sulfate with restore serum iron levels and improve levels of fatigue.
Lactulose Lactulose is a laxative and was given to MSG Persia to be able to clear
his colon in preparation for the series of x-ray and ct scan.
Tramadol Tramadol is an opiate agonist (analgesic) given to the patient to reduce
the chronic (moderate to severe) pain that he is experiencing associated
with stage 3 rectal adenocarcinoma along with his new complaint
regarding the numbness and inability to mobilize his left thigh which
affected his lower extremities.
Eterocoxib Eterocoxib is a non-steroidal anti-inflammatory (analgesic) drug given
to the patient to improve symptoms, reduce pain and inflammation.
Pregabalin The patient is given Pregabalin, for drug for neuropathic pain, to reduce
the pain signals that cause the symptoms of diabetic nerve pain.
Multivitamin and Amino The patient is given multivitamins with minerals to supply the body with
Acid Supplement the deficiency. Vitamins are important substances required for normal
metabolism. It is essential for promoting growth, health and life.
Levofloxacin The patient is suspected to have cellulitis in his left thigh. Cellulitis is
the inflammation of subcutaneous connective tissue caused by bacterial
infection. Levofloxacin is a broad spectrum antibiotic, effective against a
number of gram-positive and gram-negative bacteria. It is prescribed for
a wide range of infections before the specific causal organism is known.
If the causal organism is identified, levofloxacin may be discontinued
and the patient may be switched to an antibiotic with a narrower
spectrum of activity.
Eperisone HCl This drug is given to the patient because of its analgesic action that
inhibits the pain reflex in the spinal cord and also aids in the facilitation
of voluntary movement of the patient.
 XII. CONCEPT MAP

Comfort measures,
LEGEND: relaxation techniques
█ Patient Info
█ Assessment Data Analgesic
█ Nursing Diagnoses s
█ Nursing Interventions Pain Mgt.
█ Nursing Outcomes (NIC)
Plan

Pain Level (NOC)

Pain Evaluate Pain Control (NOC)

Admin.
Plain LR
Plan Fluid and Continuo
Rectal Adenocarcinoma Stage III; S/P Electrolyte Mgt. us
Lower Anterior Resection, loop (NIC) monitorin
ileostomy (May 2005) g
S/P chemo C6 (Feb 2006) S/P Cobalt Deficient
therapy (Nov 2005), DM Type II Fluid Evaluate
Volume Fluid Balance (NOC)

Client Assess
Insulin
Therapy
Hyperglycemia Mgt. BG
Plan (NIC) M
Family History (?)
Diet (+)
Gender (+)
MSG Julian E. Persia Imbalanced
48 year old, 5 foot 8 inch, 138 lb Nutrition: Less Evaluate Nutritional
man who has been diagnosed than Body Status
Clinical
with rectal adenocarcinoma and Requirements (NOC)
Manifestations
type 2 diabetes mellitus for the
past 2 years.

He came to AFPMC for Energy Mgt.

enclosure of ileostomy (NIC)
Several days upon admission, the Nervous System Plan
patient experienced mild cramps Headache (+)
in his upper left thigh which Cardiovascular
Pain and numbness in the Fatigue Evaluate Endurance
resulted to pain, inflammation
and numbness. lower extremities – upper (NOC)
He states a feeling of weakness left thigh (+)
and lacks interest in food. Respiratory
(?)
ze
He has managed his diabetes by Aseptic
Gastrointestinal
aly Plan Infection technique
“avoiding sweets like cakes and
(?) Control (NIC)
An
pies,” but has not been doing
Musculoskeletal Antibiotics
routine blood glucose checks. Risk for
Poor muscle tone (+)
Skin Infection
Laboratory Studies
Blood sugar is elevated Poor skin turgor (+) Knowledge: Infection
Sugar positive in his urine Dry mucous membranes (+) Control (NOC)
Evaluate
↓ Hgb, Hct, RBC and WBC Diagnostic Tests
count Serum glucose elevated (+)
CEA level within normal range Serum osmolality (?)
↓ Na level +3 sugar in urine Risk for Surveillance
Decreased Na level (+) Ineffective Plan (NIC)
Peripheral
Tissue
Perfusion
Circulation
Evaluate Status (NOC)
 SAN LORENZO RUIZ HOSPITAL
Mapua Institute of Technology
School of Health Sciences
Buendia, Makati City

XIII. NURSING CARE PLAN

MSG. Julian E. Persia
Rectal Adenocarcinoma Stage III; S/P Lower Anterior Resection (May 2005)
S/P chemo C6 (Feb 2006) S/P Cobalt therapy C25 (Nov 2005), DM Type II

NURSING
CUES NURSING GOALS INTERVENTIONS RATIONALE EVALUATION
PROBLEM/DIAGNOSIS
Subjective: Pain of unknown origin After giving the Pain Management Pain Level (NOC)
related to obstruction of a appropriate (NIC)
• The patient nerve pathway and intervention(s), the • The client
verbalized, “Ang inflammation client will: Independent Nursing reports maximal
sakit talaga ng Interventions: pain relief.
kaliwang hita ko. • Verbalize lessening
Hindi ko na siya of pain. • Provide information • Promotes problem Pain Control
maigalaw sa sobrang • Appear relaxed and and anticipatory solving, helps (NOC)
sakit, apektado tuloy able to sleep/rest guidance regarding reduce pain
ang ibabang katawan appropriately. causes of discomfort associated with • The client
ko. Dahil sa sakit, and appropriate anxiety and fear of relates pain
hindi ko na kaya interventions. the unknown, and relief measures
makalakad mag-isa.” provides a sense of that are
control. effective.
Objective: • Provide the non • Relaxes muscles,
pharmacologic and redirects
• Guarding and comfort measures attention away
restricted movement (e.g. massage, TSB) from painful
• Facial mask of pain and diversional sensations.
• Poor muscle tone activities (e.g. Promotes comfort,
• Self-focusing music, reading). and reduces
• Pain scale (7) Emphasize the unpleasant
importance of the distractions,
presence and enhancing sense of
participation of the well-being.
partner as needed.
• Encourage use of • Enables patient to
stress management participate actively
skills or com- in nondrug
plementary treatment of pain
therapies (e.g., and enhances
relaxation sense of control.
techniques, Pain produces
visualization, stress and, in
guided imagery, conjunction with
biofeedback, muscle tension and
laughter, music, internal stressors,
aromatherapy, and increases patient’s
therapeutic touch). focus on self,
which in turn
increases the level
of pain.

Collaborative
Nursing
Interventions:

• Administer • Promotes comfort,

analgesics as which improves
indicated. psychological
status and
enhances mobility.

Subjective: Deficient Fluid Volume related After 3-5 day(s) of Fluid and Electrolyte Fluid Balance
 to osmotic diuresis from therapy, the client will Management (NIC) (NOC)
• The patient states, hyperglycemia be able to:
“Parati akong Independent Nursing
nakakaramdam ng • Demonstrate Interventions: • The client
uhaw kasabay ng adequate hydration achieves
panghihina.” as evidenced by • Assess peripheral • Indicators of level adequate
stable vital signs, pulses, capillary of hydration, hydration upon
Objective: palpable peripheral refill, skin turgor adequacy of evaluating the
pulses, good skin and mucous circulating efficiency of the
• Poor skin turgor turgor and capillary membranes. volume. therapy.
• Dry mucous refill, etc. • Maintain fluid • Maintains
membranes intake of at least hydration or
• Hypotension 2500 mL/day within circulating
(usually patient’s BP cardiac tolerance volume.
is 90/60 mmHg) when oral intake is
• Tachycardia (PR resumed.
usually 90-110) • Promote
• Slow capillary refill comfortable • Avoids
• Blood glucose levels environment. Cover overheating, which
usually ranges from patient with light could promote
250-500 mg/dL sheets. further fluid loss.
(insulin
insufficiency)
Collaborative
Nursing
Interventions:

• Administer fluids as • Type and amount

indicated: Isotonic of fluid depend on
(0.9%) or lactated degree of deficit
Ringer’s solution and individual
without additives. patient response.
• Monitor laboratory
 studies as indicated,
e.g.:
Hct; • Assesses level of
hydration and is
often elevated
because of
hemoconcentration
associated with
osmotic diuresis.
Serum osmolality; • Elevated because
of hyperglycemia
and dehydration.
Sodium • May be decreased,
reflecting shift of
fluids from the
intracellular
compartment
(osmotic diuresis).
Subjective: Imbalance Nutrition: Less Throughout the Hyperglycemia Nutritional
than Body Requirements hospital stay, the Management (NIC) Status (NOC)
• According to the related to insulin insufficiency client will:
patient, “Minsan Independent Nursing
wala akong gana • Ingest appropriate Interventions: • The client is
kumain, lagi kasing amounts of able to take in
oatmeal kinakain ko calories/nutrients. • Ascertain patient’s • Identifies deficits sufficient
para maiwasan ang • Display usual dietary program and and deviations amount of
pagtaas ng glucose energy level. usual pattern; from therapeutic calories and
ko.” compare with recent needs. nutrients.
• Feels weak intake. • The client shows
• Identify food • If patient’s food usual energy
Objective: preferences, preferences can be level and reports
including incorporated into that weakness
• Poor muscle tone ethnic/cultural the meal plan, has diminished.
• Weight loss (from needs. cooperation with
143 lbs to 138 lbs) dietary
requirements may
be facilitated after
discharge.
• Include the • Promotes sense of
significant other in involvement;
meal planning as provides
indicated. information for SO
to understand
nutritional needs
of patient.

Collaborative
Nursing
Interventions:

• Perform fingerstick • Bedside analysis

glucose testing. of serum glucose
is more accurate
(displays current
levels) than
monitoring urine
sugar, which is not
sensitive enough
to detect
fluctuations in
serum levels and
can be affected by
patient’s
individual renal
threshold or the
presence of
 urinary retention
or renal failure.
• Administer regular • Regular insulin
insulin 30 ‘u’ as has a rapid onset
indicated. and thus quickly
helps move
glucose into cells.
• Provide diet of • Complex
approximately 60% carbohydrates
carbohydrates, 20% (e.g., corn, peas,
proteins, 20% fats in carrots, broccoli,
designated number dried beans, oats,
of meals/snacks. apples) decrease
glucose levels or
insulin needs,
reduce serum
cholesterol levels,
and promote
satiation. Food
intake is scheduled
according to
specific insulin
characteristics
(e.g., peak effect)
and individual
patient response.
Subjective: Fatigue related to altered body After a week, the Energy Management Endurance
chemistry: insulin insufficient client will be able to: (NIC) (NOC)
• Pt. said, “Ang dami
kong hindi magawa • Verbalize an Independent Nursing • The client is
dahil sa karamdaman increase in energy Interventions: able to
ko, buti na lang level. participate
nariyan si misis para • Display improved • Discuss with patient • Education may efficiently in his
 asikasuhin ako. Siya ability to participate the need for activity. provide motivation desired activities
nagpupunas at in desired activities. Plan schedule with to increase activity and states an
nagpapakain sa akin. patient and identify level even though increase in his
Hinang-hina talaga activities that lead to patient may feel level of energy.
ang katawan ko, fatigue. too weak initially.
nadagdagan pa ng • Alternate activity • Prevents excessive
pamamanhid ng with periods of fatigue.
kaliwang hita ko.” rest/uninterrupted
sleep.
Objective: • Monitor pulse, • Indicates
respiratory rate, and physiological
• Blood glucose levels BP before/after levels of tolerance.
usually ranges from activity.
250-500 mg/dL • Discuss ways of • Patient will be able
(insulin conserving energy to accomplish
insufficiency) while bathing, more with a
transferring, and so decreased
on. expenditure of
energy.
• Increase patient • Increases
participation in confidence
ADLs as tolerated. level/self-esteem
and tolerance
level.
Risk for Infection related to Throughout the Infection Control Knowledge:
high glucose levels and hospital stay, the (NIC) Infection Control
decreased leukocyte function client will: (NOC)
Independent Nursing • Patient may be
• Identify Interventions: admitted with • The client is free
interventions to infection, which from infection
prevent/reduce risk • Observe for signs of could have and uses
of infection. infection and precipitated the interventions to
• Demonstrate inflammation, e.g., ketoacidotic state, prevent
techniques, lifestyle fever, flushed or may develop a development of
changes to prevent ppearance, wound nosocomial an infection.
development of drainage, purulent infection.
infection. sputum, cloudy
urine.
• Promote good • Reduces risk of
handwashing by cross-
staff and patient. contamination.
• Maintain aseptic • High glucose in
technique for IV the blood creates
insertion procedure, an excellent
administration of medium for
medications, and bacterial growth.
providing
maintenance/site
care. Rotate IV sites
as indicated.
• Provide • Peripheral
conscientious skin circulation may be
care; gently impaired, placing
massage bony areas. patient at
Keep the skin dry, increased risk for
linens dry and skin irritation or
wrinkle-free. breakdown and
infection.
• Encourage adequate • Decreases
dietary and fluid susceptibility to
intake infection.
(approximately3000 Increased urinary
mL/day if not flow prevents
contraindicated by stasis and aids in
cardiac or renal maintaining urine
dysfunction). pH/acidity,
 reducing bacteria
growth and
flushing organisms
out of system.

Collaborative
Nursing
Interventions:

• Administer • Early treatment

antibiotics (e.g. may help prevent
levofloxacin) as sepsis.
appropriate.
Risk for Ineffective Peripheral Throughout the Surveillance (NIC) Circulation
Tissue Perfusion related to hospital stay, the Status (NOC)
immobility client will: Independent Nursing
Interventions: • The client has
• Maintain perfusion warm/dry skin,
as individually • Monitor vital signs. • Indicators of present
appropriate, e.g., Palpate peripheral circulatory peripheral pulses
skin warm/dry, pulses routinely; adequacy. and VS within
peripheral pulses evaluate capillary • Prevents excessive normal range.
present/strong, vital refill and changes in fatigue.
signs within mentation. Note 24- Risk Control
acceptable range. hr fluid balance. (NOC)
• Demonstrate • Encourage frequent • Stimulates • The client shows
behaviors to range of motion circulation in the ways in
improve/maintain (ROM) exercises for lower extremities; improving
circulation. legs and ankles. reduces venous circulation.
stasis.
• Assess for Homans’ • Indicators of
sign, redness, and thrombus
edema of calf. formation, but may
not always be
present.
 XIV. REFERENCES

 Black, J. & Hawkes, J. 2005. Medical Surgical Nursing: Clinical Management for
Positive Outcomes. 7th ed. Elsevier Saunders.
 Carpenito-Moyet, L. 2004. Nursing Care Plans & Documentation: Nursing Diagnoses
and Collaborative Problems. 4th ed. Lippincott Williams & Wilkins.
 Doenges, M., Moorhouse, M. & Murr, A. 2006. Nursing Care Plans: Guidelines for
Individualizing Client Care Across the Life Span. 7th ed. Philadelphia: FA Davis.
 Ignatavicius, D. & Workman, L. 2006. Medical Surgical Nursing: Critical Thinking for
Collaborative Care. 5th ed. Elsevier Saunders.
 Textbook of Medical-Surgical Nursing 10th edition by: Suzanne C. Smeltzer, Brenda G.
Bare
 Focus on Pathophysiology by: Barbara L. Bullock, Reet L. Henze
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