Brian Jones (aged 50) presented to his GP with a nine month (9/12) history of a change in his bowel habits, abdominal pain and fatigue. His GP ordered Faecal Occult Blood testing which confirmed the presence of blood in Brian’s stool. Following this, Brian’s GP referred him to a gastrointestinal specialist. The specialist recommended Brian have a colonoscopy. During the colonoscopy, a biopsy was taken of a lesion located in Brian’s rectum. The biopsy results confirmed a Stage IIA rectal carcinoma. Brian was admitted to hospital for an abdomino-perineal resection and the formation of a colostomy.
Brian returned to the surgical ward postoperatively. On his return, Brian has a patient controlled analgesia (PCA) infusion of 50mgs of Morphine in 50ml NaCl running at 4mL/hr, 0.9% NaCl (Sodium Chloride) IVI running at 125mL/hr via an IVC in his left arm, a sigmoid colostomy with a small amount of haemoserous fluid evident, 2 x Haemovac drains in situ on suction with 100mls frank blood in total, a nasogastric (NG) tube in situ on free drainage with 4/24 aspirations, an indwelling urinary catheter (IDC) with 50mls of urine output, regular medications ordered
• metronidazole (Flagyl) IVI 500mgs in 100mLs 8/24
• paracetamol (Panadol) 1g IVI 6/24,
• enoxaparin (Clexane) 40mgs sub cutanously daily, and
• metoclopramide (Maxalon) 10mgs 8/24 PRN.
1. Describe the pathogenesis of Brian’s colorectal cancer from the initial cellular mutation to the diagnosis of stage IIA colorectal cancer
2. Describe two (2) modifiable and three (3) non-modifiable risk factors for colorectal cancer and explain how these risk factors may have contributed to the development of Brian’s colorectal cancer
3. a) Describe the action and mechanism of action of metronidazole (Flagyl) in relation to its administration to Brian.
b) Describe the action and mechanism of action of Morphine in relation to its administration to Brian.
4. Discuss the nursing responsibilities with associated rationales in relation to administering Morphine to Brian.
1. The development of cancer in the colon or rectum is known as colorectal cancer. It is also known as bowel cancer, rectal cancer or colon cancer. The abnormal growth of cell and blood present in stool is the main problem of this disease. The symptoms and signs of colorectal cancer are hepatomegaly, enlarged lymph nodes, loss of appetite, jaundice, pain in the hip or buttock, severe abdominal pain, breathing problems and buildup of fluid in abdomen. Three symptoms are common in Brian Jone. And his general physician referred him to a gastrointestinal specialist. After examining the biopsy results confirmed a stage IIA carcinoma (National Cancer Institute, 2015) .
Pathogenesis of Brian’s colorectal cancer:
Stage 0:
Fig1: Pathogenesis of stage zero colon cancer of Brian Jone. Colon wall shows abnormal cell growth
For this stage In the inner most layer of mucosa of colon wall the abnormal growth of cells are seen. This abnormal growth of cells produce cancer and then spread througt out the colon. The other name of zero stage is carcinoma in situ.
Stage I:
Fig2: Pathogenesis of stage I colon cancer of Brian Jone. From the colon wall it is spread to the muscle layer. Colon cancer.
In this stage the colon cancer is already produced. It is formed in the inner most layer of mucosa of colon wall in stage I. In this stage the cancer is spread over the colon. It has spread from the inner most layer of mucosa of colon wall to the submucosal layer which is found under the mucosa.
Stage IIA:
Fig3: Pathogenesis of stage IIA colon cancer of Brian Jone.
There are three parts of this stage :IIA, IIB and IIC. Brian has stage IIA rectal carcinoma. In stage IIA through the colon wall’s muscle wall it has spread to the serosa’s outer most layer of the colon wall.
2. Risk factors are the risk by which the chance of getting disease enhances. The risk factors are different for different diseases. By the researchers it is found that there are many risk factors for colorectal cancer. The risk factors are not everything for a patient. Central deposition of adiposity, excess body weight and physical inactivity are the modifiable risk factors of coloractal colon cancer. There are many risk factors which produces colon cancer. Those are life style related factors, certain type of diets, physical inactivity, obesity, smoking, alcoholism, age, personal history of colorectal cancer, personal history of inflammatory bowel disease, family history of colorectal cancer, inherited syndromes. Modifiable risk factors of colorectal cancer are life style related factors,certain type of diets, obesity, physical inactivity, alcoholism, smoking etc. For Brian Jones all are applicable. The life style of Brian Jones or habit to consume alcohol or obesity may be controlled by him. So this all are modifiable risk factors for colorectal cancer of Brian Jones. Non – modifiable risk factors of colorectal cancer are age, personal history of inflammable bowel disease, personal history of colorectal cancer, family history of colorectal cancer, inherited syndromes etc. As we know Brian Jone had a history of nine month of a change in his bowel habits. This is the main reason and most imporatantly it helps to enhance the chance of colorectal cancer of Brian Jones (Cancer.org, 2015). The family history of colorectal cancer is not a modifiable risk factor. So if there was any family history of cancer of Brian jones then it was not possible to control by the Brian Jones. In some cases the colorectal cancer is produced by inherited gene defects or mutation. The chances of colorectal cancer is increase after age 50. As we know Brian Jones is 50 years old. So this is a also a possible reason for the colorectal cancer of Brian Jones.
3 a) Anaerobic bacteria and protozoa are killed by metronidazole. It is an antibiotic belongs to nitromidazole group. The metronidazole was prescribed intravenous infusion (IVI) 500mgs in 100 mls 8/24. Metronidazole with metoclopramide has so many drug intaractions over the time. The toxicity is enhanced by the administration of the metronidazole over time.
Fig4: mechanism of action of metronidazole.
b) Morphine is prescribed to Brian Jones post operatively for pain remove(Australianprescriber.com, 2015). The pharmacological action of morphine is produced by the receptor which are present on the neuronal cell membranes. Neurotransmitter release is inhibited by the presynaptic action of morphines. In the nervous system neurotransmitter release is the major effect. Morphine drugs are pharmacologically worked by the opoid receeptors. Three types of opoid receptors are found, m, k and d. All the receptors are cojugated by G- protein. The pharmacology of opoid receptor is characterised by the opoid receptors.
4. The administration of morphine should be controlled by the nurse. There are some standard procedure which offer safety of a patient for administering the intravenous morphine and it will offer the relief from pain(Morphine, 2012). Morphine is called as ‘good standard’ opoid analgesic in management of pain. Some guidelines are produced for appropriate and safe administration of morphine intravenously. The nurse should be trained properly for administering the morphine intravenously(WENDLING, 2009). The responsibility directly goes to the clinical mangement team. In the case of Brian Jones the nurse sholud monitered the administration of morphine as well as the dose of morphine. First of all the morphine is prescribed for the severe pain. And it is the responsibility of nurse to check proper dose and the route of administration of morphine which is written is the prescription(The New Gold Standard in Infusion Nursing, 2011). The result or side effects is monitored by the paient. If the pain is less the dose will less. Same case is for the Brian Jones. If he reports to the nurse that he feels better than before then the dose will reduce(Duse, Davià and White, 2009). It is the responsibility of nurse to check the contraindications of morphine. The doctor prescribed four drugs to Brian post operatively. It is the responsibility of nurse to confirm the interactions of the drugs with morphine(Golembiewski, 2003). The nurse should monitor all the factors: respiratory rate, observation of infusion site, medication identification, response totherapy, confirmation of dosage, level of consciousness, side effect profile etc.
References
Australianprescriber.com, (2015). Opioids – mechanisms of action – Australian Prescriber. [online] Available at: https://www.australianprescriber.com/magazine/19/3/63/5 [Accessed 6 Mar. 2015].
Cancer.org, (2015). What are the risk factors for colorectal cancer?. [online] Available at: https://www.cancer.org/cancer/colonandrectumcancer/detailedguide/colorectal-cancer-risk-factors [Accessed 6 Mar. 2015].
Duse, G., Davià, G. and White, P. (2009). Improvement in Psychosocial Outcomes in Chronic Pain Patients Receiving Intrathecal Morphine Infusions. Anesthesia & Analgesia, 109(6), pp.1981-1986.
Golembiewski, J. (2003). Morphine and hydromorphone for postoperative analgesia: Focus on safety.Journal of PeriAnesthesia Nursing, 18(2), pp.120-122.
Morphine. (2012). Reactions Weekly, &NA;(1394), p.32.
National Cancer Institute, (2015). Colon Cancer Treatment (PDQ®). [online] Available at: https://www.cancer.gov/cancertopics/pdq/treatment/colon/Patient/page2#figure_261_e [Accessed 6 Mar. 2015].
The New Gold Standard in Infusion Nursing. (2011). Journal of Infusion Nursing, 34(1), p.11.
WENDLING, P. (2009). New Pain Guideline Takes Aim at NSAID Use in the Elderly. Clinical Psychiatry News, 37(7), p.20.
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