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Colorectal Cancer (CRC) and Anaemia 

This assessment is based on the case study regarding colorectal cancer and anaemia of a 56 year old lady named Amanda Johnson. She was presented to her GP with the complains of lethargy, reduced exercise tolerance, and altered bowel habits. When the patient was asked about her diet and other activities she stated that her diet is rich in red meat and she is more dependent on the processed foods and drinks. On this she also revealed that she drinks approx. 8 standard drinks per week. She also stated that she had a habit of smoking but prior to the birth of her first child she gave up smoking. On examination of her complete blood profile she was found anaemic. The key issues that were found from her vitals showed that she is at stage 2 hypertension as her blood pressure ranges 164/86 mm Hg. Also, this issue of hypertension was diagnosed already 3 years ago. The patient also has high heart rate as it has been reported that her HR is 92 BPM and 92 is a bit high than normal. Patient’s weight is 96 Kg and this shows that she is obese. Along with this the patient has a family history of bowel cancer. The patient also has rheumatoid arthritis which is confined to her hands. On complete blood profile it was revealed that she has lesser Hb and hematocrit, reduced RCC, MCV, MCH, and MCHC along with a considerable low amount of serum iron and ferratin.

Pathophysiology could be understood as the mechanism that underlying the disease prognosis. Traditionally, colorectal cancer development has been considered as an ordered process that encompasses of three main phases i.e., initiation, promotion, and progression. Later on, it was seen that the epithelial cells of normal colonic gets transformed by the histopathologic. The adenomatous polyps is a stage in carcinogenic process that is considered as an intermediate stage, this adenoma gets transformaed in to colorectal cancer that leads to the mutations in APC and K-ras. The mutation in p53 mutation leads to trigger the malignancy (Kuipers et al., 2015). Colorectal Cancer is the cancer that affects the caecum, colon and rectum. Both genetic as well as the environmental factors could be the reason behind the development of colorectal cancer. What exactly happens is the mutation that results into the colorectal cancer. This happens when the mutation in APC leads the Colonic epithelium to get Dysplastic aberrant crypt foci as a result of which the Development of initial adenoma occurs with the mutation in K-ras initial adenoma levels up to the Intermediate adenoma and as soon as the Mutation in DCC occurs it the stage of late adenoma comes and this results in the mutation of p53 that leads to the colorectal cancer, some other alteration results into the metastasis of the cancer (Kuipers et al., 2015).

The diagnosis of the colorectal cancer involves few tests that can confirm if the patient has colorectal cancer or not. The first way to diagnose colorectal cancer is via complete blood count. This test helps in measuring various types of cells in the patient’s blood. It will also reveal if the patient also has anemia. Because it has been seen that patients who have colorectal cancer often becomes anemic (Li, 2018). The other way of diagnosis is by colonoscopy. Colonoscopy allows looking and having an insight to the entire colon and rectum while a patient is sedated (Swiderska et al., 2013) In biopsy removal of a small portion of tissue would be done and examined under a microscope (Swiderska et al., 2013). The another way of diagnosis is the molecular testing of the tumor. In this the identification of the specific proteins, genes, and other factors that are specific to the tumor is done (Sepulveda et al., 2017). Computed tomography scan have also been used in the scan helps in taking the pictures of the inside the body via x-rays. This shows if any abnormalities or tumors are present (Li, 2018). Magnetic resonance imaging (MRI) with help of magnetic fields provide the detailed images of the body that are produced and this helps in the measurement of the size of the tumor (Li, 2018). Endorectal MRI also helps in scan of the pelvis that can happen in the patients surviving with rectal cancer as it helps in seeing if the tumor has been spread into the nearby organs. The next assessment could be chest x-ray. This helps to see if cancer has been spread to the lungs, but more often a CT scan of the lungs is done since it tends to give more detailed pictures.

As it has been discussed earlier in the pathophysiology that the Colorectal cancer is generally caused because of the abnormal growth of the cells in the colon or rectum. These cells leads to the development of tumors either on or in the blood vessels of the colon and the blood vessels carry RBCs (Vayrynen et al., 2018). It has been reportedly seen that these tumors results into the bleeding and an excessive loss of healthy RBCs, Amanda’s complete blood profile reports has clearly shown that her RBC count is decreased and this decrement in the amount of RBCs and iron causes anemia (Vayrynen et al., 2018). There were certain other factors that have been seen in considerable low amount and the rationale for how these factors that can cause anaemia and they were: Haemoglobin (Hb) was 85g/L, Hematocrit (Hct) 0.33mL/L, RCC 3.0L, MCV 65 Fl, MCH 25 pg, MCHC 237 g/L, and Serum Iron 7 micromol/L. The patient has low serum iron level and lack of serum iron and iron is needed to produce haemoglobin, lesser the production of haemoglobin results into the reduction of RBCs. As, RBCs is directly linked with oxygen, the body tissues and organs does not get enough oxygen and this leads to anaemia. Patient’s diet is also one of the reason behind it as it is high in red meat.

When focused on the Pharmacology, Amanda was given certain medication. She was prescribed and Methotrexate 7.5mg orally once a week, Paracetamol and Ibuprofen PRN, and Ramipril 5mg daily. And, Methotrexate is considered as one of the most effectual medications and is always considered as doctor’s first choice to prescribe the patient with rheumatoid arthritis (RA) in order to treat it. t helps to ease the symptoms such as joint redness, fatigue, pain, and swelling and in preventing the damage to patient’s organs and joints. The Mechanism of action entails that Methotrexate works by interrupting the process that leads to the RA inflammation. And, which inflammation damages the patient’s joints and organs with time. So, disrupting this process helps in easing the symptoms and in preventing the damage to patient’s organs and joints. The normal dosage is 7.5 to 10 milligrams each week (Weinblatt, 2013). Patient with rheumatoid arthritis encounters pain and in this case painkiller such as paracetamol, Ibuprofen, &Ramipril. They are prescribed in order to bring relieve to the patient encountering pain of rheumatoid arthritis. They are not used to treat the inflammation, but they are used to relieve the pain. Mechanism of action: these drugs tends to inhibit the enzymes COX-1 and COX-2 through metabolism .This in turn results into the inhibition of the formation of phenoxyl radicals from a tyrosine residue. In addition to this, paracetamol selectively leads to the inhibition of the synthesis of prostaglandins. This leads to reduce the pain and fever of the patient (Ngo & Bajaj, 2020).

Specific nursing care interventions would start from Securing an informed consent. It is the duty of the nurses to make sure that the patient or his family member has signed the form of informed consent form (Sanguinetti et al., 2015). It is followed by Obtaining an entire medical history of the patient. It is very important to check any bleeding histories regarding the patient, checking her medications, any allergies, or any important information that is related to the current complaint (Jung at al., 2017). The next nursing care interventions would be the establishment of an IV line. Informing the patient about the IV line is important and to tell her that a tranquilizer would be administered prior to the procedure (Kumar, Kelleher & Sigle, 2013). The next intervention would be ensuring that the patient has obeyed all the aspects of bowel preparation. In a study presented by Hopchik& Jones, (2015) explaining the patient the significance of cleaning large intestine so that it could be viewed clearly. It is important to educate the patient for maintaining a clear-liquid diet for the period of 24 to 48 hours before the test. Nothing should be given orally and a laxative should be given. Providing information regarding the colonoscope is also considered to be an intervention that helps in assuring the patient regarding the colonoscope that it is well lubricated in order to ease the insertion, that it initially feels cool, and that he may feel an urge to defecate when it’s inserted and advanced (Lee et al., 2014). The final intervention was instructing the patient for empting her bladder prior to the procedure. It is important as well as comfortable for the patient to void immediately prior to the procedure (Windpessl, Christoph & Wallner, 2017).

Patient’s discharge education could be understood as educating the patient regarding their post-discharge medication and care. For this a well planned and executed hospital discharge is very important as this will help the patient in continuing her recovery. Multidisciplinary collaboration, communication, and coordination play an important role throughout from the admission to the discharge. In a multidisciplinary collaborative, communicative, and coordinative manner the education regarding the post-discharge aspects must be given to the patients. Along with the patient post discharge education must also be given to the patient’s family and her caregivers. This would assure the speedy post discharge recovery of the patient (Sheikh et al., 2018). This is accomplished by a team of providers from diverse specialties. The first patient discharge educating intervention that would be taken will be assisting the client in planning as well as prioritizing the activities of daily living. This will help the client in maximizing her time in order to accomplish certain important activities. The second intervention would be assisting Amanda in order to develop a schedule regarding her daily activity and rest: there is a need to respect the body’s requirement for the increased rest by the patient. So, this plan would help the patient in balancing her periods of activity with her periods of rest and in this way the patent will be able to achieve desired activities without adding levels to fatigue. And, Instructing the patient regarding her medications that would help her in stimulating the production of RBC in her bone marrow as the patient is anaemic: hematological growth factor, and recombinant human erythropoietin tends to increase the hemoglobin and reduces the need for the transfusion of RBC transfusions (Lithner et al., 2015).

From this case study assessment it could be understood that there are various factors that could cause colorectal cancer and later on can also cause anaemia. However, having diet rich in iron can help in reducing the chances of anaemia. Effective nursing interventions can help the patient in addressing the medical complications of the patients effectively with ease. Along with this effective patient discharge education is also important as it leads to fasten the recovery post-discharge and will make the patient understand about his own care.

References for Amanda Johnson Case Study

Hopchik, J., & Jones, M. (2015). Colonoscopy Bowel Preparation Instructions. Federal practitioner for the Health Care Professionals of the VA, DoD, and PHS32(3), 35–37.

Jung, J. W., Park, J., Jeon, G. J., Moon, Y. S., Yang, S. Y., Kim, T. O., Jung, E. T., & Kim, H. C. (2017). The effectiveness of personalized bowel preparation using a smartphone camera application: A randomized pilot study. Gastroenterology Research and Practice2017, 4898914. https://doi.org/10.1155/2017/4898914

Kuipers, E. J., Grady, W. M., Lieberman, D., Seufferlein, T., Sung, J. J., Boelens, P. G., van de Velde, C. J., & Watanabe, T. (2015). Colorectal cancer. Nature Reviews. Disease Primers1, 15065. https://doi.org/10.1038/nrdp.2015.65

Kumar, A. S., Kelleher, D. C., & Sigle, G. W. (2013). Bowel preparation before elective surgery. Clinics in Colon and Rectal Surgery26(3), 146–152. https://doi.org/10.1055/s-0033-1351129

Laar, M., Pergolizzi, J. V., Jr, Mellinghoff, H. U., Merchante, I. M., Nalamachu, S., O'Brien, J., Perrot, S., & Raffa, R. B. (2012). Pain treatment in arthritis-related pain: beyond NSAIDs. The Open Rheumatology Journal6, 320–330. https://doi.org/10.2174/1874312901206010320

Lee, S. H., Park, Y. K., Lee, D. J., & Kim, K. M. (2014). Colonoscopy procedural skills and training for new beginners. World Journal of Gastroenterology20(45), 16984–16995. https://doi.org/10.3748/wjg.v20.i45.16984

Li D. (2018). Recent advances in colorectal cancer screening. Chronic Diseases and Translational Medicine4(3), 139–147. https://doi.org/10.1016/j.cdtm.2018.08.004

Li D. (2018). Recent advances in colorectal cancer screening. Chronic Diseases and Translational Medicine4(3), 139–147. https://doi.org/10.1016/j.cdtm.2018.08.004

Lithner, M., Klefsgard, R., Johansson, J., & Andersson, E. (2015). The significance of information after discharge for colorectal cancer surgery-a qualitative study. BMC Nursing, 14, 36. https://doi.org/10.1186/s12912-015-0086-6

Ngo VTH, Bajaj T. Ibuprofen. [Updated 2020 May 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK542299/

Sanguinetti, J. M., Lotero Polesel, J. C., Iriarte, S. M., Ledesma, C., Canseco Fuentes, S. E., & Caro, L. E. (2015). Informed consent in colonoscopy: A comparative analysis of 2 methods. Revista de Gastroenterologia de Mexico80(2), 144–149. https://doi.org/10.1016/j.rgmx.2015.03.001

Sepulveda, A. R., Hamilton, S. R., Allegra, C. J., Grody, W., Cushman-Vokoun, A. M., Funkhouser, W. K., Kopetz, S. E., Lieu, C., Lindor, N. M., Minsky, B. D., Monzon, F. A., Sargent, D. J., Singh, V. M., Willis, J., Clark, J., Colasacco, C., Rumble, R. B., Temple-Smolkin, R., Ventura, C. B., & Nowak, J. A. (2017). Molecular Biomarkers for the Evaluation of Colorectal Cancer: Guideline From the American Society for Clinical Pathology, College of American Pathologists, Association for Molecular Pathology, and American Society of Clinical Oncology. The Journal of Molecular Diagnostics: JMD19(2), 187–225. https://doi.org/10.1016/j.jmoldx.2016.11.001

Sheikh, H., Brezar, A., Dzwonek, A., Yau, L., & Calder, L. A. (2018). Patient understanding of discharge instructions in the emergency department: do different patients need different approaches?. International Journal of Emergency Medicine, 11(1), 5. https://doi.org/10.1186/s12245-018-0164-0

Swiderska, M., Choromańska, B., Dąbrowska, E., Konarzewska-Duchnowska, E., Choromańska, K., Szczurko, G., Myśliwiec, P., Dadan, J., Ladny, J. R., & Zwierz, K. (2014). The diagnostics of colorectal cancer. Contemporary Oncology (Poznan, Poland)18(1), 1–6. https://doi.org/10.5114/wo.2013.39995

Väyrynen, J. P., Tuomisto, A., Väyrynen, S. A., Klintrup, K., Karhu, T., Mäkelä, J., Herzig, K. H., Karttunen, T. J., & Mäkinen, M. J. (2018). Preoperative anemia in colorectal cancer: Relationships with tumor characteristics, systemic inflammation, and survival. Scientific Reports8(1), 1126. https://doi.org/10.1038/s41598-018-19572-y

Weinblatt M. E. (2013). Methotrexate in rheumatoid arthritis: A quarter century of development. Transactions of the American Clinical and Climatological Association124, 16–25.

Windpessl, M., Schwarz, C., & Wallner, M. (2017). "Bowel prep hyponatremia" - A state of acute water intoxication facilitated by low dietary solute intake: case report and literature review. BMC Nephrology18(1), 54. https://doi.org/10.1186/s12882-017-0464-2

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