Colorectal cancer is one of the most common cancers in the world with the exact cause of illness unknown (Dulai et al., 2016). Multiple factors are associated with the disease that includes diet, smoking, genetics, and alcohol abuse (Okey, 2020). This paper will critically evaluate the case study of Amanda Johnson who has presented in the clinical setting with symptoms of lethargy and reduced exercise tolerance. The patient also notifies changes in the bowel movements. The patient has a history of increased consumption of red meat and consumes eight standard drinks in a week. Amanda was also a chronic smoker that was stopped 28 years ago. The patient is also anemic and has a family history of colorectal cancer. The patient has been suggested to undergo a colonoscopy due to the high risk of colorectal cancer chances. This paper will discuss the pathophysiology of illness concerning signs, symptoms, and risks associated with Amanda. The pharmacology of the medications that are being used for Amanda will also be analysed in this paper with a detailed discussion of the nursing care and discharge plan required for Amanda after completion of colonoscopy and medical assessment.


Colorectal cancer is a disease that originates in the epithelial cells of the colon or rectum due to uncontrolled cellular growth and proliferation (Lemoine et al., 2016). The pathophysiology of the condition is associated with the mutations in the Wnt signalling pathway that enhances the signalling and promotes cellular proliferation (Dulai et al., 2016). Genetics play a crucial role in the incidence of colorectal cancer in patients. Amanda has a family history of colorectal cancer with her father who passed away from the illness. The genetics of getting this disease is thus greater in Amanda making her prone to the illness. Other risk factors include increased consumption of red meat and chronic smoking. Amanda’s diet is rich in red meat that has been statistically associated with increased chances of colorectal cancer in the individuals (Dulai et al., 2016). Further, Amanda has a medical history of chronic smoking that has now been ceased, long term exposure to smoke can also result in increased chances of mutations, cellular damage, and hence increase the chances of colorectal cancer in the consumers (Lemoine et al., 2016). Alcohol consumption has been linked with colorectal cancer as it promotes cirrhosis resulting in tissue damage and polyp formation. Increased alcohol consumption thus increases the chances of an individual to develop colorectal cancer due to tissue and cell damage. Amanda consumes about eight drinks per week, making her vulnerable to the incidence of colorectal cancer.

Colorectal cancer is caused by abnormal proliferation of cells in the gastrointestinal tract, the cells grow and form a polyp or a benign tumour. The benign tumour transforms into metastatic tumour following the process of angiogenesis where the blood vessels are supplied (Adam & Tomat, 2016). The cells lose contact inhibition and divide in an uncontrolled manner driving cellular, molecular, and biochemical changes that induce cancer. Since the tumour growth obstructs the movement in the gastrointestinal tracts of the patient, blood is released in the stool due to tissue rupture causing pain and discomfort in the patient. Excessive blood loss in colorectal cancer can also result in anemia and is associated with symptoms like lethargy and reduced exercise tolerance as observed in the case of Amanda (Okey, 2020). Anemia is also associated in patients with colorectal cancer as the cancer cells form a tumor on or inside the blood vessels in the colon that carry the red blood cells (Okey, 2020).

This can cause bleeding and is one of the major causes of anemia. This is also deducible through the blood records of Amanda where her Hemoglobin is low at 85g/L when it should ideally be in the range of 115-105g/L (Adam & Tomat, 2016), The hematocrit levels in Amanda are low at 0.33ml?L that should be between 0.37-0.47ml/L (Okey, 2020), The WBC count is high with lowered RCC, MCV. And MCH reports in the client case study. The serum iron levels in the patient are low at 7icromol/L where they should be between 14-32 micromol/L (Adam & Tomat, 2016. The ferritin is low at 19microgram per Liter when it should be between 25-155 microgram per Liter (Adam & Tomat, 2016). These blood tests indicate that there has been blood loss in the body of Amanda causing anemia and ae linked with a high probability of colorectal cancer.


The medications that have been prescribed for Amanda are helpful multiple illnesses and health conditions of the patient and thus prevent polypharmacy (Brown et al., 2016). These medications are:


Methotrexate is a folic acid derivative that functions as a folic acid antagonist (Friedman & Cornstein, 2019). The drug functions through cellular inhibition of enzyme dihydrofolate reductase through the activity of competitive inhibition by binding an inactivation the active site of the enzyme. Through this inhibition, the reduction of dihydrofolate to tetrahydrofolate is caused which in turn obstructs the DNA synthesis and cell replication in a cascade. The drug is provided in cancer treatment to control the unregulated cell proliferation and cell growth and also for autoimmune health conditions like rheumatoid arthritis (Brown et al., 2016). The medicine is metabolized through folypolyglutamate synthase in the liver and tissues. The methotrexate, therefore, inhibits the enzyme responsible for nucleotide synthesis and prevents the cell division. This limits the anti-inflammatory actions of the drug and prevents proliferation in the cancerous cells and autoimmune response of the body (Faghfoori et al., 2020). The enzymes in the cell replication cycle that are affected by this drug include “dihydrofolate reductase, thymidylate synthase, aminoimidazole carboxamide ribonucleotide transformylase (AICART), and amido phosphoribosyltransferase” (Brown et al., 2016). Amanda has been given this medication as it helps in preventing cancer tumour growth in her body and for effective management of rheumatoid arthritis and thus a dose of 7.5mg at weekly basis has been recommended for the patient.

Paracetamol Ibuprofen PRN

Ibuprofen is a non-selective inhibitor of enzyme cyclooxygenase that is required for prostaglandin synthesis (Moore & Scheiman, 2018). The synthesis occurs through the arachidonic acid pathway that is inhibited by this drug. This helps in pain management and reducing inflammation in the body of the patient in illnesses like rheumatoid arthritis. Prostaglandins are produced at the site of injuries and bleeding in the body. Through this medication, the pain and inflammation at the site of injury are reduced (Pain, 2018). In cancer patients, it is used to control the pain and inflammation that is caused by uncontrolled cellular growth and proliferation. The drug falls in the category of nonsteroidal anti-inflammatory drugs (NSAIDs) (Moore & Scheiman, 2018). Use of these drugs has also been known to have an impact on cancer control in the prostate and colon cancers. The drug ahs an inhibitory impact on tumour survival and angiogenesis that helps in limiting the cancer growth and help in the management of cancer in the patients (Pain, 2018). The pain management through Ibuprofen will also be helpful in the management of pain caused by Rheumatoid arthritis diagnosed in Amanda.


Ramipril acts as an ACE (Angiotensin-converting enzyme) inhibitor in the animals. The angiotensin-converting-enzyme is a peptidyl dipeptidase that catalyses the conversion of Angiotensin I to Angiotensin II, that is a vasoconstrictor substance in nature (Shi et al., 2016). Further, Angiotensin II also stimulates the release of aldosterone by the adrenal cortex and impacts the inflammatory reactions in the body in illnesses like cancer and autoimmune disorders like rheumatoid arthritis (Ganesan et al., 2018). The medication is converted in the liver through a de-esterification reaction into its active form, that is, ramiprilat. The ACE inhibitors are used in the inflammatory response in the body as they are known to limit the risk of uncontrolled tissue growth and inflammation development. The medication is however is commonly used for patients with hypertension (Chauhan & Ahmed, 2019). Amanda has a medical history of hypertension and this drug is being used for control of same. Patients with ACE inhibitor drugs for hypertension management have a reduced rate of colon cancer formation and risk and thus use of medication will also help in management and prevention from the condition in Amanda (American Heart Association, 2020). The dosage of 5mg to be consumed daily has been prescribed to the patient.

Nursing Care

Pre-Procedure Care and Instructions for Amanda

Colonoscopy is an invasive procedure and thus special considerations should be followed before the procedure. These considerations include following a special diet before the commencement of the procedure (Zhuang et al., 2017). A few days before the procedure the patient is advised to start eating a low fibre diet. The patient is instructed to not consume solid foods one day before the exam and consumes clear liquids before the procedure. This is suggested as opaque foods and liquids can hinder with the imaging procedure of colonoscopy and thus limit the application of the medical procedure for derivative results (McCommons et al., 2016). On the day of the procedure, the patient is advised not to consume anything two hours prior to the procedure. The rationale for these precautions is to ensure clear imaging results that may be hindered due to the food consumption and result in a lack of identification of small polyps or cancers in the intestinal tract of the patient (Morowitz, 2017). Bowel preparation is also instructed before the colonoscopy procedure Bowel clearing diarrhea is recommended before the commencement of colonoscopy in the patient for clear imaging of the tract facilitated through the clear intestinal tract (Liu et al., 2018).

Discharge Education

The Nursing and Midwifery Board of Australia (2018) identifies patient education as a critical component of nursing care. Discharge education is critical as it helps in the process of recovery and assists in the self-management of the clinical conditions of the patient. Effective discharge education also limits the risk of hospitalizations in the care settings and improves the quality of life for the patients. After the process of colonoscopy, Amanda should be provided with the following instructions at the time of discharge: It is suggested that the patient does not drive for 24 hours and does not lift heavy weights (Zhuang et al., 2017). The patient can slowly resume daily activities. The patient should also be educated that gas and discomfort after the procedure can result in bloating and should be relieved through moving on the left side and using a heating pad on the abdomen. The patient is advised to take small walks. The bowel movement often restores within 48-72 hours in the patients after the procedure however, in case of any major discomfort or concern, clinical assistance should be sought by Amanda (Liu et al., 2018).

The patient should be instructed to immediately seek medical help in case of black and tarry stools observed after the procedure, presence of blood in stool and vomiting and nausea. Extreme cramps in belly and chest pain should also be brought to medical attention (Zhuang et al., 2017). Amanda also needs to bring in lifestyle changes and cease the consumption of alcohol and improve diet intake with limited consumption of red meat (Morowitz, 2017). The patient should also be educated regarding medication adherence and complications associated with the health condition. Regular medical assessments as per the colonoscopy results should be ensured for Amanda to ensure application of required interventions for her health and well-being (McCommons et al., 2016).


This paper discusses the case scenario of a 75-year-old patient, Amanda Johnson who has been scheduled for the process of colonoscopy due to current medical symptoms, biochemical results, and family history of colorectal cancer. This paper provides a succinct discussion on the pathophysiology of colorectal cancer in focus on Amanda by relating the biochemical results and the experienced symptoms of the patient due to the health condition. The risks of development of colorectal cancer in Amanda have also been identified. This paper also discusses the pharmacology of medications prescribed to Amanda and discusses the pre and post colonoscopy education plan for Amanda with details about precautions that need to be followed before the procedure along with the considerations to be followed after discharge.


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American Heart Association (2020). Common hypertension medications may reduce colorectal cancer risk. Hypertension, 2020; doi:10.1161/HYPERTENSIONAHA.120.15317

Brown, P. M., Pratt, A. G., & Isaacs, J. D. (2016). Mechanism of action of methotrexate in rheumatoid arthritis, and the search for biomarkers. Nature Reviews Rheumatology, 12(12), 731-742.

Chauhan, M., & Ahmad, F. (2019). Ramipril. Biomedicine & Pharmacotherapy, 108, 1338-1346.

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Faghfoori, M. H., Nosrati, H., Rezaeejam, H., Charmi, J., Kaboli, S., Johari, B., & Danafar, H. (2020). Anticancer effect of X-Ray triggered methotrexate conjugated albumin coated bismuth sulfide nanoparticles on SW480 colon cancer cell line. International Journal of Pharmaceutics, 582, 119320.

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Ganesan, D., Holkar, A., Albert, A., Paul, E., Mariakuttikan, J., & Selvam, G. S. (2018). Combination of ramipril and rutin alleviate alloxan induced diabetic nephropathy targeting multiple stress pathways in vivo. Biomedicine & Pharmacotherapy, 108, 1338-1346.

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Nursing and Midwifery Board of Australia (2018). Code of conduct. Retrieved from:


Okey, J. (2020) Pathophysiology of colorectal cancer. Cancer Prevention Research, 9(12), 887-894.

Pain, D. N. (2018). Acetaminophen for IV Infusion see Pain page 340 Ibuprofen for IV Infusion see Pain page 340 acetaminophen (B)(G) see Fever page 157 aspirin (D)(G) see Fever page 158. The APRN’s Complete Guide to Prescribing Pediatric Drug Therapy 2019, 367.

Shi, J. H., Pan, D. Q., Jiang, M., Liu, T. T., & Wang, Q. (2016). Binding interaction of ramipril with bovine serum albumin (BSA): Insights from multi-spectroscopy and molecular docking methods. Journal of Photochemistry and Photobiology B: Biology, 164, 103-111.

Zhuang, H., Wang, L., Jinghua, L. I., Liu, J., Liu, Y., & Yan, Y. (2017). Application of language intervention to alleviate the discomfort of patients during the colonoscopy process. Chinese Journal of Practical Nursing, 33(19), 1458-1461.

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