Capitol University College of Nursing RECTAL PROLAPSE SECONDARY TO RECTAL NEW GROWTH PROBABLY MALIGNANT (NEOPLASM OR POLYPS) In partial fulfillment of the requirements Of RLE 7 1 st semester, SY 2010-2011 PRESENTED BY: Katrene Lequigan PRESENTED TO: Ma. Liwayway Salcedo, RN CLINCAL INSTRUCTOR
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Capitol University
College of Nursing
RECTAL PROLAPSE SECONDARY TO RECTAL NEW GROWTH PROBABLY
MALIGNANT
(NEOPLASM OR POLYPS)
In partial fulfillment of the requirements
Of RLE 7 1st semester, SY 2010-2011
PRESENTED BY:
Katrene Lequigan
PRESENTED TO:
Ma. Liwayway Salcedo, RN
CLINCAL INSTRUCTOR
AUGUST 2010
Table of Contents
Introduction……………………………………………………………………………..
Client’s Profile………………………………………………………………………….
Socio-demographic data……………………………………………………..
Vital Signs……………………………………………………………………..
Physical Assessment………………………………………………………...
Anatomy and Physiology…………………………………………………………….
Pathophysiology………………………………………………………………………
Laboratory Tests and Results……………………………………………………...
This portion of the case study will present the deviation from the abnormal
findings of the physical assessment presented in a cephalo-caudal approach.
These data are then considered in the making of the nursing care plan.
Head
Aspect of Consideration Findings
Hair Dry Hair
Eyes
Aspect of Consideration Findings
Conjunctiva Pale
Visual Acuity Nearsighted
Wears eyeglasses
Mouth
Aspect of Consideration Findings
Lips Pallor and dry
Teeth Missing teeth with dentures
Skin
Aspect of Consideration Findings
General color Pallor
Texture Rough
Moisture Dry
Abdomen
Aspect of Consideration Findings
Percussion Fluid wave
Bowel sounds Hyperactive
Elimination Pattern
Aspect of Consideration Findings
Usual bowel Pattern 3 -4 times per day, brown or green
colored stool, watery stool with
blood, pain at anal area during and
after defecation
Bowel sounds Hyperactive
Others: LBM
Problems before
August 19, 2010
Experienced constipation
Protruding mass at anal area proba-
bly rectal prolapse
Nutrition and Metabolic Pattern:
Weight: weight loss, from 57 kg to 43 kg
Activities of Daily Living /Mobility Status
0- Total independence 3- Assist with device and person
1- Assist with device 4- Total dependence
2- Assist with person
Feeding: 0 Meal Preparation: 4 Bed Mobility: 2
Bathing: 2 Cleaning: 4 Chair /toilet transfer: 2
Dressing; 2 Laundry: 4 Ambulation: 2
Grooming: 2 Toileting: 2 ROM: 0
Cognitive – Perceptual Pattern
Aspect of Consideration Findings
Appropriate behavior/ communication Need adequate rest due to weak-
ness
Emotional state Worried, irritable
Pain
at the anal area during and after defecation and occasional abdominal
pain during bedtime
pain scale of 3/10
Sexuality-Reproductive Pattern
Menstrual pattern: Menopause
LPM: 46 years old
Pregnancy History: home delivery, assisted by hilot
Anatomy and Physiology
The Large Intestine
The large intestine is about 1.5 m (5 ft) long and is characterized by the
following components:
The cecum is a dead-end pouch at the beginning of the large intestine,
just below the ileocecal valve.
The appendix (vermiform appendix) is an 8 cm (3 in) long fingerlike
attachment to the cecum that contains lymphoid tissue and serves
immunity functions.
The colon, representing the greater part of the large intestine, consists of
four sections: the ascending, transverse, descending, and sigmoid colons.
At regular distances along the colon, the smooth muscle of the muscularis
layer causes the intestinal wall to gather, producing a series of pouches
called haustra. The epithelium facing the lumen of the colon is covered with
openings of tubular intestinal glands that penetrate deep into the thick
mucosa. The glands consist of absorptive cells that absorb water and
goblet cells that secrete mucus. The mucus lubricates the walls of the large
intestine to smooth the passage of feces. The colon is approximately five
feet (1.5 meters) in length, begins at the ileocecal valve, and ends at the
rectosigmoid junction. Arterial blood supply to the colon from cecum to
splenic flexure is through the superior mesenteric artery which gives rise to
the ileocolic, right colic, and middle colic arteries. The left and sigmoid
colon is supplied by the inferior mesenteric artery which gives rise to the left
colic and sigmoidal arteries. There can be several anatomic variations in
the colic arteries including absent middle colic artery, absent right colic
artery, common trunk for right and ileocolic artery, and the presence of an
Arc of Riolan between the middle and left colic artery. The colonic wall his-
tologically from lumen outward consists of: (1) a simple columnar epithe-
lium which forms crypts, (2) lamina propria, (3) muscularis mucosa, (4) sub-
mucosa, (5) muscularis propria formed by an inner circular and outer longi-
tudinal layer of smooth muscle, and (6) serosa. The typical colonic malig-
nancy is an adenocarcinoma. Once the neoplastic epithelial cells penetrate
the muscularis mucosa and into the submucosa, a malignant (the ability to
metastasize) adenocarcinoma is formed. The mainstay for treatment is op-
erative resection of the involved colonic segment along with the draining
lymph nodes located in the mesentery. Neoplastic cells confined by the
muscularis mucosa are termed carcinoma-in-situ or severe dysplasia and
are not as yet malignant thereby typically eliminating the need for segmen-
tal colonic resection.
The outer longitudinal smooth muscle of the colon thickens in three loca-
tions called tenia coli. The rectosigmoid junction is the point at which the three
tenia fan out and form a complete outer longitudinal layer. This anatomic point
has clinical significance. Carcinomas proximal to this point are colonic;
whereas distal tumors are rectal and as such may benefit from adjuvant radia-
tion therapy. Likewise, operative resection for classic sigmoid diverticular dis-
ease should include the rectosigmoid junction with the anastomosis located at
the upper rectum. The function of the colon is (1) absorption of water and elec-
trolytes, and (2) propulsion and storage of unabsorbed fecal waste for evacua-
tion. Approximately one liter of fluid chyme enters the cecum each day with an
average of only 100cc excreted in the feces. Parasympathetc innervation by
preganglionic vagal fibers and pelvic fibers result in colonic motility. Sympa-
thetic innervation by the superior mesenteric plexus, inferior mesenteric
plexus, and the hypogastric plexus inhibits colonic motility. It appears that the
major control of motility depends on the colonic wall intrinsic plexus (myenteric
or Auerbach’s/submucous or Meissner’s). An absence of intrinsic plexuses oc-
curs in Hirschsprung’s Disease resulting in tonic wall contraction and functional
obstruction.
The rectum is the last 20 cm (8 in) of the large intestine. The mucosa in the
rectum forms longitudinal folds called anal columns. 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 ex-
traperitoneal at its distal and posterior end. The epithelial lining or mucosa of
the rectum is of a simple columnar mucous secreting variety.
The anal canal, the last 3 cm (1 in) of the rectum, opens to the exterior at the
anus. An involuntary (smooth) muscle, the interior anal sphincter, and a
voluntary (skeletal) muscle, the external anal sphincter, control the release of
the feces through the anus. The anal canal begins a few centimeters proximal
to the classic and well visualized dentate line and it ends at the anal verge.
The anal canal is about 5 cm in length. Histologically the proximal end of the
anal canal is the point at which the columnar epithelium of the rectum becomes
a transitional epithelium. This epithelium transitions to a stratified squamous
variety at the dentate line. The distal most end of the anal canal is the anal
verge which is the point where the stratified squamous epithelium becomes
true skin marked by the presence of hair follicles and sweat glands. The anal
verge is readily identified by noting the point at which hair shafts are seen. The
anoderm is a term used to describe the zone between the dentate line and the
anal verge. Perianal skin then describes the anatomic area beyond the anal
verge. Malignancies of the perianal skin are typical skin cancers usually squa-
mous cell carcinomas. Anal canal carcinomas are described as epidermoid
carcinoma, squamous cell carcinoma, cloacogenic carcinoma, or baseloid car-
cinoma depending on their particular histologic features. The importance of lo-
cating and anatomically defining the particular malignancy of the anorectal re-
gion is in their treatment.
The functions of the large intestine include
Mechanical digestion. Rhythmic contractions of the large intestine produce
a form of segmentation called haustral contractions in which food residues
are mixed and forced to move from one haustrum to the next. Peristaltic
contractions produce mass movements of larger amounts of material.
Chemical digestion. Digestion occurs as a result of bacteria that colonize
the large intestine. They break down indigestible material by fermentation,
releasing various gases. Vitamin K and certain B vitamins are also
produced by bacterial activity.
Absorption. Vitamins B and K, some electrolytes (Na+ and Cl−), and most
of the remaining water is absorbed by the large intestine.
Defecation. Mass movement of feces into the rectum stimulates a
defecation reflex that opens the internal anal sphincter. Unless the external
and sphincter is voluntarily closed, feces are evacuated through the anus.
Pathophysiology
Predisposing Factors: refer to figure A
Precipitating Factors: refer to figure B
Rectal new growth (neoplasm or Polyps)
Pathologic Report: positive for malignancy
Intramucosal epithelial lesion
Uncontrollable cell formation
Developed chronically in the rectum
Invading of muscularis mucosa, regional lymph
nodes at the rectum, vascular structure
Invading of distant site especially liver
Formation of bowel mass of tissue arises
from bowel wall
Fatty liver grade II
Electrolyte imbalance
Nausea/
vomiting
White mucus secretions
Blood in stool
Weight loss
Abdominal pain
and cramps
Diarrhea
Watery stool
Prolonged constipation and
straining
Anemia of intestinal track lesion
Rectal prolapsed
Constrict the intestinal lumen
Protrudes into the lumen and grow slowly (large)
Prolapsed through the anus
Partial obstruction
Attack immune system
Predisposing Factors (figure A.)
Etiologic Factors Actual Rationale
Age: common in person at all ages with mean age of 50 years old and above
Patient X is an elderly, most likely she is more prone on having rectal prolapsed secondary to rectal neoplasm, age 56 years old
Elderly person tend to be more at risk on developing rectal prolapsed secondary to rectal neoplasm
Gender: Recent studies found out that the female is most commonly affected to it, with multiple pregnancies
Patient X’s gender is female with 9 children
Women are more prone to develop cancer than men.
Lifestyle: impaired physical activity; high fat diet, spicy-food lover
Problem: constipation and straining
Patient X has limited physical activity and eats fatty and spicy foods
Patient X experienced prolonged straining before due to constipation
Foreign studies found out that impaired physical activity, high fat diet, spicy food lover greatly and prolong straining increase the risk of developing the disease
Precipitating Factors (figure B.)
Etiologic Factors Actual Rationale
Developing abnormal buildup of polyps or neoplasm in the rectum
Patient X experienced constipation, abdominal pain, and blood in the stool, watery stool, vomiting and fever, protruded mass in the rectum
1 year prior to admission sudden onset of rectal bleeding associated with severe pain and gradually protruding mass
Laboratory Result
Hematology Report
8/3/10 8/8/10 8/9/10 8/12/10 8/13/10 8/17/10
WBC
5.0-10.0 10^3/uL
13.6 12.4 14.3 19.5
RBC
4.2-5.4 10^6/uL
2.87 3.61 3.86 3.21
Hgb 12.0-16.0 g/dL
10.9 7.2 8.2 9.4 10.0 8.3
Hct 37.0-47.0 %
33.5 23.1 25.1 29.0 30.9 26.1
MCV 82.0-98.0 fL
76.5 80.5 80.3 80.1 81.3
MCH 27.0-31.0 pg
24.9 25.1 26.0 25.9 25.9
RDW-CV 12.0-17.0 %
21.4 21.6
PDW 9.0-16.0 fL
7.4 7.2 7.1 6.9 6.9
MPV 8.0-12.0 fL
7.6 7.5 7.5 7.4 7.4
Platelet 150-400 10^3/uL
640 532 450 468 510
Lymphocyte
17.4-48.2 %
15.4 11.3
Eosinophils 1.0-3.0 %
0.5 0.2
Neutrophil 43.4-76.2 %
78.2
Monocyte 4.5-10.5 %
11.6
WBC Increase in various infections.
RBC Decreased RBC is usually seen in anemia of any cause with the possible exception of thalassemia minor, where a mild or borderline anemia is seen with a high or borderline-high RBC.
HGB A low hemoglobin is referred to as anemia; nutritional deficiency (iron, vitamin B12, folate)
HCT A low hematocrit is referred to as being anemic; nutritional deficiency (iron, vitamin B12, folate)
MCV Microcytic/hypochromic anemia (decreased MCV) Iron deficiency (com-mon); Anemia of chronic disease (uncommonly microcytic)
MCH Microcytic/hypochromic anemia (decreased MCH) Iron deficiency (com-mon); Anemia of chronic disease (uncommonly microcytic)
RDW-CV The RDW may also be useful in monitoring the results of hematinic therapy for iron-deficiency or megaloblastic anemias.
MPV Mean platelet volume (MPV) is a machine-calculated measurement of the average size of your platelets. New platelets are larger, and an increased MPV occurs when increased numbers of platelets are being produced. MPV gives your doctor information about platelet production in your bone marrow.
PLATELET Thrombocytosis is seen in many inflammatory disorders and myelo-proliferative states, as well as in acute or chronic blood loss, hemolytic anemias, carcinomatosis, status post-splenectomy, post- exercise, etc.
LYMPHOCYTE Lymphopenia is characteristic of AIDS. It is also seen in acute in-fections, Hodgkin's disease, systemic lupus, renal failure, carcinomatosis, and with administration of corticosteroids, lithium, mechlorethamine, methysergide, niacin, and ionizing irradiation. Of all hematopoietic cells lymphocytes are the most sensitive to whole-body irradiation, and their count is the first to fall in radia-tion sickness.
EOSINOPHILS Eosinopenia is seen in the early phase of acute insults, such as shock, major pyogenic infections, trauma, surgery, etc. Drugs producing eosinopenia include corticosteroids, epinephrine, methysergide, niacin, niaci-namide, and procainamide.
NEUTROPHIL Neutrophilia is seen in any acute insult to the body, whether infec-tious or not. Marked neutrophilia (>25,000/µL) brings up the problem of hemato-logic malignancy (leukemia, myelofibrosis) versus reactive leukocytosis, including "leukemoid reactions." Laboratory work-up of this problem may include expert re-view of the peripheral smear, leukocyte alkaline phosphatase, and cytogenetic analysis of peripheral blood or marrow granulocytes. Without cytogenetic analy-sis, bone marrrow aspiration and biopsy is of limited value and will not by itself establish the diagnosis of chronic myelocytic leukemia versus leukemoid reac-tion.
MONOCYTE Monocytosis is seen in the recovery phase of many acute infec-tions. It is also seen in diseases characterized by chronic granulomatous inflam-mation (TB, syphilis, brucellosis, Crohn's disease, and sarcoidosis), ulcerative colitis, systemic lupus, rheumatoid arthritis, polyarteritis nodosa, and many
hematologic neoplasms. Poisoning by carbon disulfide, phosphorus, and tetra-chloroethane, as well as administration of griseofulvin, haloperidol, and methsux-imide, may cause monocytosis.
Blood Chemistry Result
8/3/10 8/9/10 8/12/10 8/17/10
Glucose 59.9-110.1 mg/dL
117.7 129.0
BUN 4.5-23.5 mg/dL
33.8
Albumin 3.70-5.20 g/dL
2.77 2.65
Blood Sugar 60-110 mgs. %
117.7
Potassium 3.5-5.3 mmol/L
2.99
GLUCOSE Hyperglycemia can be diagnosed only in relation to time elapsed after meals and after ruling out spurious influences (especially drugs, including caffeine, corticosteroids, estrogens, indomethacin, oral contraceptives, lithium, phenytoin, furosemide, thiazides, thyroxine, and many more). Previously, the diagnosis of diabetes mellitus was made by demonstrating a fasting blood glucose >140 mg/dL (7.8mmol/L) and/or 2-hour postprandial glucose >200 mg/dL (11.1 mmol/L) on more than one occasion.
BUN Decreased serum urea nitrogen (BUN) is seen in high carbohydrate/low protein diets, states characterized by increased anabolic demand (late pregnancy, infancy, acromegaly), malabsorption states, and severe liver damage.
ALBUMIN Decreased serum albumin is seen in states of decreased synthesis (malnutrition, malabsorption, liver disease, and other chronic diseases), increased loss (nephrotic syndrome, many GI conditions, thermal burns, etc.), and increased catabolism (thyrotoxicosis, cancer chemotherapy, Cushing's disease, familial hypoproteinemia).
POTASSIUM Decreased levels of potassium indicate hypokalemia. Decreased levels may occur in a number of conditions, particularly: dehydration, vomiting, diarrhea, deficient potassium intake (rare).
Examination Results
8/3/10 8/12/10 8/17/10
Prothrombin Activity (Therapeutic range: 0-20 %)
100 % 76 % 88.6 %
APTT (activated partial thrombin time) Normal rate: 23.4-38.5 sec
41.1 secs.
Protime (Normal rate: 10.2-15.2 sec.)
16.4 sec.
PROTHROMBIN ACTIVTY A prolonged, or increased, PT means that your blood is taking too long to form a clot. This may be caused by conditions such as liver disease, vitamin K deficiency or a coagulation factor deficiency.
APTT A prolonged PTT means that clotting is taking longer to occur than expected and may be caused by a variety of factors (see the list below). Often, this suggests that there may be a coagulation factor deficiency or a specific or nonspecific inhibitor affecting the body’s clotting ability. Coagulation factor deficiencies may be acquired or inherited. Several factors are Vitamin K dependent. If a person has liver disease, for instance, or more rarely a Vitamin K deficiency, he may have one or more factor deficiencies. Inherited factor deficiencies may affect the quantity and/or function of the factor produced.
PROTIME The prothrombin time (PT) test measures how long it takes for a clot to form in a sample of blood. In the body, the clotting process involves a series of sequential chemical reactions called the coagulation cascade, in which coagulation or “clotting” factors are activated one after another and result in the formation of a clot. Prothrombin is one of the coagulation factors produced by the liver. One of the final steps of the cascade is the conversion of prothrombin (factor II) to thrombin. The PT test evaluates the integrated function of the coagulation factors that comprise the extrinsic and common pathways of the coagulation cascade, including factors I (fibrinogen), II (Prothrombin), V, VII and X. It evaluates the body’s ability to produce a clot in a reasonable amount of time and, if any of these factors are deficient, the PT will be prolonged.
Clinical Data: Circumferential mass 5cm from the anal verge per proctosigmoidoscopy findings: Scout film shows minimal gas filled bowel loops within the abdomen without air fluid levels. The flank stripes and psoas shadows are distinct. No definite mass, organomegaly and intra-abdominal calcification is seen. Minimal spurs are seen along the lumbar spine margins. The rest of the visualised osseuos structures are intact.
Subsequent fillins following introduction of barium mixture into the ano via F24 catheter show ascert of barium from the rectum up to the cecum with minimal passage into the terminal ileum (as visualised in the decubitus study). There is a large mucosal irregularity with shouldering pattern with approximate widest diameter of 8cm noted in the rectum. No other mucosal irregularity, mass lesion effect is seen.
Post evacuation film show moderate retention of barium.
Impression:
1. Large area of mucosal irregularity with shouldering pattern in the area of the rectum—suggestive of a neoplastic process, likely malignant.
2. Moderate barium retention
3. Lumbar spondylosis
Lower gastrointestinal (GI) tract radiography, also called a lower GI or barium enema, is an x-ray examination of the large intestine, also known as the colon. This examination evaluates the right or ascending colon, the transverse colon, the left or descending colon, the sigmoid colon and the rectum. The appendix and a portion of the distal small intestine may also be included.
An x-ray (radiograph) is a noninvasive medical test that helps physicians diagnose and treat medical conditions. Imaging with x-rays involves exposing a part of the body to a small dose of ionizing radiation to produce pictures of the inside of the body. X-rays are the oldest and most frequently used form of medical imaging.
The lower GI uses a special form of x-ray called fluoroscopy and a contrast material called barium or a water soluble iodinated contrast.
Fluoroscopy makes it possible to see internal organs in motion. When the lower gastrointestinal tract is filled with barium, the radiologist is able to view and assess the anatomy and function of the rectum, colon and sometimes part of the lower small intestine.
A physician may order a lower GI examination to detect: benign tumors (such as polyps). cancer.
causes of other intestinal illnesses.
The procedure is frequently performed to help diagnose symptoms such as: chronic diarrhea. blood in stools.
Images of the small bowel and colon are also used to diagnose inflammatory bowel disease, a group of disorders that includes Crohn's disease and ulcerative colitis.
Ultrasound Report: August 10, 2010
Findings:
The liver appears normal in size but with echogenic parenchyma. No mass or calcification seen. Intrahepatic bile ducts and common bile duct are non-dilated.
Gallbladder is normal in size. Its wall is not thickened. No intraluminal mass or lithiasis seen.
Pancrease is unremarkable.
Diagnosis:
1. Fatty liver grade II
2. Non-remarkable UTZ findings in the gallbladder and pancrease.
Ultrasound imaging, also called ultrasound scanning or sonography, involves exposing part of the body to high-frequency sound waves to produce pictures of the inside of the body. Ultrasound exams do not use ionizing radiation (as used in x-rays). Because ultrasound images are captured in real-time, they can show the structure and movement of the body's internal organs, as well as blood flowing through blood vessels.
Ultrasound imaging is a noninvasive medical test that helps physicians diagnose and treat medical conditions.
An abdominal ultrasound produces a picture of the organs and other structures in the upper abdomen.
A Doppler ultrasound study may be part of an abdominal ultrasound examination.
Doppler ultrasound is a special ultrasound technique that evaluates blood flow through a blood vessel, including the body's major arteries and veins in the abdomen, arms, legs and neck.
Abdominal ultrasound imaging is performed to evaluate the: kidneys liver