Clinical Decision Making
Pathophysiology
Colon cancer is cancer that occurs in the digestive track, in the last part of the large intestine, the colon. It is more typical in older adults, but can occur at any age. The cancerous tissue usually starts as polyps on the inside of the colon. The polyps are usually benign. If they are not removed, they can eventually develop into cancer.
Colon cancer usually does not have many symptoms when it first begins. However, according to the Mayo Clinic (2019),some may develop as the disease progresses and they vary depending upon the size of the cancer and its location. One symptom is a change in bowel habits that includes diarrhea or constipation. Other symptoms include rectal bleeding or blood in stool, persistent abdominal discomfort such as cramps or gas, a feeling that the bowel does not empty completely, weakness or fatigue and unexplained weight loss (Mayo Clinic, 2019).
Pharmacology
The patient takes lisinopril for hypertension. Sinha (2019) of Drugs.com says that lisinopril is an ACE (angiotensin converting enzyme) inhibitor used to treat high blood pressure, congestive heart failure and to improve survival after a heart attack (Sinha, 2019). Some of the brand names for lisinopril include Zestril, Prinivil, and Qbrelis. ACE inhibitors prevent or impedes an enzyme (ACE) that prevents blood vessels from opening. When an ACE inhibitor impedes the enzyme, blood pressure is reduced. Lisinopril is prescribed for this patient because she has a history of hypertension.
Some of the side effects of lisinopril include lightheadedness, fever, sore throat, and high potassium which can cause nausea, weakness, tingly feelings, chest pain, irregular heartbeats, and loss of movement. Other possible side effects include kidney problems such as little or no urination, swelling in the feet and ankles, tiredness or shortness of breath, or liver problems such as nausea, upper stomach pain, itching, tiredness, loss of appetite, dark urine, clay-colored stools, and jaundice (Sinha, 2019). Possible drug interactions can occur with lisinopril and diuretics, lithium, gold injections for arthritis treatment, insulin or oral diabetes medicine, potassium supplements, medication that are prescribed to prevent organ transplant rejection including everolimus, sirolimus, tacrolimus, or temsirolimus and NSAIDS (Sinha, 2019).
Clinical Diagnostic Reasoning
Differential Diagnoses
Other possible diagnoses include Ulcerative Colitis, Bladder Cancer, or Crohn’s disease. Some of the symptoms are conducive to side effects of the lisinopril that the patient takes for hypertension such as the change in stool consistency, pain, and weight loss; however, that diagnosis does not account for the blood in the stool. Ulcerative colitis is caused by inflammation in the large intestines and can make a person more susceptible to colon cancer. Bladder cancer would not present with the blood in the stool, but perhaps in urine. Crohn’s disease is an inflammation of the digestive tract that can cause weight loss, diarrhea and pain, so it is a valid secondary diagnosis for the symptoms the patient has.
Priority Diagnosis Discussion
The diagnosis of colon cancer was made because of the symptoms including the alternating diarrhea and constipation she has suffered for the past 6 months, the weight loss and poor appetite, the bloating in her abdomen and the blood in her stool. She has refused colonoscopies in the past for cultural beliefs, which is the reason she now may have colon cancer. It is well known that colonoscopies can find and remove polyps before they develop into cancer. Many people are afraid or uncomfortable with the idea of having a colonoscopy. Bedin, et al. (2017) of the International Journal of Cancer point out that the ways to screen colon cancer are currently limited. “Colonoscopy represents the gold standard method for CRC detection and monitoring, but its usefulness as a screening tool is limited: the inability to detect lesions not actually reached by the endoscope, the cumulative risk of repeated screening colonoscopies and even more important, the low compliance of the population for this invasive procedure, are factors that have to be taken into account” (Bedin, et al., 2017, p. 1888). Perhaps the patient also never had the non-invasive kind of screening tests, fecal occult blood test (FOBT), which are widely used screening tests and have shown robust to be effective but have lower sensitivity. Therefore, follow-up screening by colonoscopy is recommended if the test comes back positive.
Rationale for Key Elements of the Plan of Care
Because the patient has notice blood in her stool, it is likely that the diagnosis of colon cancer is accurate and that it has advanced to cause the symptoms from which she suffers. The plan of care consists of having lab tests—CBC, CMP, renal function, liver biochemistry, CEA, CT scan of the abdomen, and a colonoscopy to confirm the diagnosis. Educating the patient in the reasons why she should go to a gastroenterologist for a colonoscopy may help to persuade her to do it especially by reassuring her that she will be anesthetized and will not feel any pain. The referral to the gastroenterologist is necessary regardless of the diagnosis based on the symptoms. A follow up after the patient sees the specialist is to confirm the diagnosis and to ensure that any new medications do not interfere with those she is already taking.
Ethical and or Cultural Concerns
Provisions of the ANA Code of Ethics
The second provision of the ANA Code of Ethics for Nurses (2015) says, “The nurse’s primary commitment is to the patient, whether an individual, family, group, community, or population” (ANA, 2015, p. v). While this patient, in the past, has been reluctant to have a colonoscopy, she may now realize she has no choice because she has the symptoms of colon cancer. She is probably frightened by the diagnosis and probably still frightened about having such an invasive test; however, a nurse can explain to her exactly how the procedure will go, what sort of pain or discomfort to expect, and what she can expect after the procedure has been completed. The article referenced above by Bedin, et al. (2017) recounts a study in which a new type of non-invasive, more sensitive cancer screening method was tested with some success. In the future it may be that colonoscopies will not be required or only required if the non-invasive tests show positive signs of cancer. In the meantime, people still get colonoscopies all the time and survive. They have been life savers for many people, and the rate of colon cancer around the world has decrease because of this diagnostic tool. While some may interpret the second provision of the ANA Code of Ethics to say that the nurse should be all about doing what the patient wants, the nurse should be all about trying to save the patient’s life. If that means persuading the patient to have a colonoscopy, then the nurse should find ways to persuade the patient to have this lifesaving procedure.
Cultural Implications
Whatever the cultural belief the patient claimed to have that prevented her from having a colon cancer screening, it has now come back around to affect her life and possibly cause her death. While it is too late and just cruel to now chide the patient for not having a colonoscopy many years previous, this case should serve as motivation for nurses to find ways to persuade patients that having colonoscopies can save their lives. Nurses must exploit the fact that nursing is the most trusted occupation there is and teach patients about the necessity for being properly screened for colon cancer. Chang and Kelly (2007) of Urologic Nursing say, “To facilitate learning, nurses must implement effective patient teaching strategies. This process includes assessing and prioritizing learning needs, assessing learning styles, and implementing teaching strategies designed to address identified learning needs. As part of this process, cultural beliefs and literacy issues must be addressed” (Chang & Kelly, 2007, p. 411). Some of the information nurses can pass on to patients includes information about the different types of colon cancer screening that is available.
Several screening methods besides colonoscopy have been developed in recent years. The new blood-based screening tests have recently been approved that will basically reveal the same things that a colonoscopy would reveal without the invasiveness. Issa and Noureddine (2017) of the World Journal of Gastroenterology explain, “The non-invasive tests include stool and blood-based tests and radiologic tests. The stool-based tests . . . . are based on the concept of detecting blood or shredded cell debris by vascularized polyps, adenomas and cancers” (Issa & Noureddine, 2017, p. 5087). These tests are non-invasive and can be done in the privacy of the patient’s home, but they cannot detect and remove the polyps that can develop into tumors. Issa and Noureddine (2017) go on to describe the more invasive screening tests for colon cancer. “The radiologic examinations include double contrast barium enema, capsule endoscopy and Computed tomographic colonography (CTC). Their role revolves around radiographic visualization and identification of an advanced colonic polyp or cancer in addition to the possibility of detection of extra-colonic findings (by CTC)” (Issa & Noureddine, 2017, p. 5087). Issa and Noureddine (2017) also describe the newest types of colon cancer screening tools. “The newly emerged blood test (Epi procolon®) is a qualitative in vitro diagnostic polymerase chain reaction (PCR) test for the detection of mutated methylated septin9 DNA in EDTA plasma derived from patient whole blood specimens” (Issa & Noureddine, 2017, p. 5087). That means that those cancers that the older stool- and blood-based test do not detect can be detected, but the end result of cancer detection in these ways is that the patient must have a colonoscopy anyway. Nurses should advise patients to have a colonoscopy initially at the age of 50, and then go to the non-invasive types if they prove not to be at great risk for colon cancer. Avoiding any testing altogether is not a good idea as this patient’s diagnosis and cultural beliefs have revealed. Nurses must impress upon their patients the urgency and necessity of being properly screened even if it is an uncomfortable procedure.
Barriers to Care
This patient may have experienced several barriers to care. One of those is what the Care ATC (2019) article mentions: “It’s confusing” (Care ATC, 2019). Under that heading, the article places such things as “compliance regimens,” which means the patient must go about accessing the diagnostic tools the healthcare provider prescribes for them such as having a colonoscopy (Care ATC, 2019). If the patient does not comply, the provider cannot force the patient to comply even though it would be best for them to do so. This appears to be what has occurred with this patient.
Another barrier to care for this patient is her age group. Having colonoscopy screenings is so invasive in such a private part of a person’s body, this patient may have felt that she could not comply. Some people think differently than others about their bodies and what they are willing to allow others to do to their bodies. Perhaps the idea of a colonoscopy was outside of the range of invasiveness to which this patient was willing to concede. Unfortunately, such reluctance may have led to the colon cancer diagnosis.
This patient may also be a member of an ethnic minority. She may have different cultural beliefs that preclude invasive diagnostic methods such as colonoscopies. Scheppers, van Dongen, Dekker, Geertzend, and Dekker (2006) of Family Practice say, “Members of these groups are considered to practice different cultural norms and values from the majority culture and (often) a different mother tongue” (Scheppers, van Dongen, Dekker, Geertzend, & Dekker, 2006, p. 326). While it is unclear if this patient is an ethnic minority, it is possible that her cultural beliefs were responsible for her reluctance to have a colonoscopy rather than just an excuse for not doing so.
Three Priority Social Determinants of Health for Patient
Three social determinants of health that may have affected this patient and made it more likely that she would contract colon cancer include her socioeconomic status, the environment in which she lives, and access to healthcare. The Center for Disease Control and Prevention (CDC) (2018) explains, “People with a low SES are less likely to get cancer screening tests. So their cancer is often found at a later stage, when it causes symptoms. Even if their cancer is treated, patients are less likely to survive cancer that’s found after it has advanced” (CDC, 2018). Another factor that may be the case for this patient is that she is an ethnic minority. These patients may not have health insurance, and may not get cancer screenings because they do not speak English well, they are afraid of the screening, they may not be able to take time off from work or they may not have transportation to the healthcare facilities (CDC, 2018). Finally, this patient may have worked in a profession or lived in an area where she was exposed to carcinogens, which may be a factor in her situation.
Health Care Policy or Advocacy Initiatives
An intervention that may help to overcome some of the social determinants of health for this patient is a computer-tailored intervention for cancer screening that addresses each patient’s issues specifically. Rawls (2017), who presented this cancer screening tool at the 28th International Nursing Research Congress, calls her initiative a program of research focused on promoting screening behaviors (Rawls, 2017). In her presentation at the conference, Rawls (2017) explained that tailoring information for each patient will make it more relevant to them and be more likely to produce the desired behavioral change such as compliance with cancer screenings (Rawls, 2017, p. 4).
Evidence Based Practice
What could have made this patient comply with preventative cancer screenings?
Beyond the social determinants of health, other issues such as availability of health insurance, affordability of health care and cultural issues that prevented her from seeking cancer screenings may have played a role in this patient’s reluctance to get a colonoscopy so that her diagnosis could have been prevented. Bedin, et al. (2017) point out that there are other forms of colon cancer screening besides the colonoscopy are available, which may have helped in this patient’s case, but colonoscopy can remove polyps that are present that may form tumors, Other methods of screening only detect that cancer is present. Also, these newer less invasive forms of screening have not been around long as Issa and Noureddine (2017) discuss. This patient should have been screened several years ago. Rawls (2017) describes how research can help to tailor education to individual patients so that they may be more likely to comply with colon cancer screenings.
Self-Reflection
This patient is an example of someone who seems to have fallen through the cracks of the healthcare system. She should have gotten screened prior to the diagnosis, but refused colonoscopies. Other forms of screening could have been offered, and she may have been more likely to comply with the less invasive forms, but perhaps they were not offered especially since the less invasive screenings are newer innovations. This patient’s sad diagnosis is an incentive for nurses to find ways to persuade patients to comply with colon cancer screenings.
Advanced Practice Practitioner Role Analysis
Advanced Practice Practitioner Role Analysis: Identify the specific person that drove this plan of care and developed the management, while including detail in how you advocated for the patient. It is entirely possible, and desirable, that you drove the development of the plan of care. Include how an individualized approach was applied to this patient’s care. Also include how you identified your advocacy for the role of the Nurse Practitioner.
References
ANA. (2015). Nurses Code of Ethics. Retrieved from Nursing World: https://www.nursingworld.org/c...
Bedin, C., Enzo, M. V., Del Bianco, P., Pucciarelli, S., Nitti, D., & Agostini, M. (2017). Diagnostic and prognostic role of cell‐free DNA testing for colorectal cancer patients. International Journal of Cancer, 140(8), 1888-1898. Retrieved from https://onlinelibrary.wiley.co...
Care ATC. (2019). 3 Common Barriers to Quality Medical Care. Retrieved from Care ATC: https://www.careatc.com/ehs/3-...
CDC. (2018, July 5). Factors That Contribute to Health Disparities in Cancer. Retrieved from Center for Disease Control and Prevention: https://www.cdc.gov/cancer/hea...
Chang, M., & Kelly, A. E. (2007). Patient Education: Addressing Cultural Diversity and Health Literacy Issues. Urological Nursing, 27(5), 411-417. Retrieved from https://pdfs.semanticscholar.o...
Issa, I. A., & Noureddine, M. (2017). Colorectal cancer screening: An updated review of the available options. World Journal of Gastroenterology, 23(28), 5086-5096. Retrieved from https://www.ncbi.nlm.nih.gov/p...
Mayo Clinic. (2019, April 16). Colon Cancer. Retrieved from Mayo Clinic: https://www.mayoclinic.org/dis...
Rawls, S. M. (2017). Computer-Tailored Interventions to Increase Cancer Screening: Building a Program of Research. 28th International Nursing Research Congress (pp. 1-29). Dubin: Sigma Theta Tau International. Retrieved from https://sigma.nursingrepositor...
Scheppers, E., van Dongen, E., Dekker, J., Geertzend, J., & Dekker, J. (2006). Potential barriers to the use of health services among ethnic minorities: a review. Family Practice, 325-348. Retrieved from https://watermark.silverchair....
Sinha, S. (2019, May 1). Lisinopril. Retrieved from Drugs.com: https://www.drugs.com/lisinopr...
