Step1: Patient situation:
The first step in clinical reasoning is to describe the patient in the context of the clinical situation. Ms. Melody King, a 36-year-old female was presented for an emergency laparoscopic surgery for a ruptured appendix. She has a medical history of asthma and depression. Her medication list includes Ventolin, Seretide, Sertraline. Postoperatively, Melody developed peritonitis and was treated with antibiotics and analgesic. The biopsy results of Melody’s sample revealed the presence of adenocarcinoma. Melody will need to undergo a few most test, and till then continue her stay at the hospital. The diagnostic tests: CT scan of chest, abdomen, pelvis, MRI of abdomen and pelvis, blood tests for tumor markers CEA, CA-125 and CA-19-9, are prescribed for further evaluation.
Step 2: Collection of clues and information
The second step in the cycle of clinical reasoning is the collection clues and information about the patient condition. This is done through the review of literature and patient assessment. The following is the review of literature on adenocarcinoma, which was the major diagnosis made in the patient.
Review: Adenocarcinomas are very frequent in the appendix. It is a malignant epithelial neoplasm of the appendix (Gold, Neugut, & Arber, 2000). It is invasive and grows beyond the muscularis mucosae. Morphological variation from carcinoid to mucinous tumors can be seen in these carcinomas (Costa, Ivanova, & Esteves, 2016). Morphologically they resemble the colorectal carcinoma. While certain cases may show a well-differentiated adenoma, in others it is indistinguishable and can spread into the peritoneal cavity. Adenocarcinomas have been reported in 0.1% of appendectomies. Adenocarcinomas account for more than 50% of the malignant tumor affecting the appendix. It is common in males when compared to females. The mean age of diagnosis is around 65 years of age. Chronic ulcerative colitis increases susceptibility to adenocarcinoma of the appendix. Genetic susceptibility to diseases is also reported. Nevertheless, there is still a lack of evidence on the genes that cause this condition exclusively. (Abbruzzese, 2004)
The clinical symptom of adenocarcinoma of the appendix may be similar to that of acute appendicitis. Abdominal pain in the lower abdomen is a very common sign. In many cases, the adenoma-carcinoma may grow into an abdominal mass and persist, causing pain. When the disease spread to the peritoneum, it can cause psuedomyxoma peritonei, characterized by a large volume of mucus in the peritoneum (Gold, Neugut, & Arber, 2000). The diagnosis of adenoma-carcinoma is done by biopsy (Abbruzzese, 2004). CT-scan and blood biomarkers are used to identify the extent of invasion or tumor size. CT-scan will provide information on the extent of metastasis and stage of cancer (Abbruzzese, 2004). MRI can also provide information on the spread of cancer and tumor mass (Abbruzzese, 2004). Biomarkers can also be used to predict prognosis and response to treatment. CAE, CA 15-3 and CA 19-9, biomarkers are used to differentiate benign from malignant adenocarcinoma and also help to predict prognosis (Lee et al., 2013; Ghosh et al., 2012). The falling level of these tumor markers will suggest favorable response to treatment (Pablo Carmignani, Hampton, E. Sugarbaker, Chang, & H. Sugarbaker, 2004).
Patient assessment: In the case study, the presence of adenocarcinoma in the appendix was known from the biopsy. The patient presented for emergency surgery with acute abdominal pain and ruptured appendicitis. The rupture is usually confirmed through CT scan or Ultrasonography ("Appendicitis", 2016). WBC count is also elevated in cases of appendicitis (Wang, Lin, & Lin, 2016). The patient is recommended for CT scan, MRI and blood tumors marker, as a part of further assessment (Wang, Lin, & Lin, 2016). The patient is still young and the etiology is not entirely known. Nevertheless, it should be noted that Melody has been receiving treatment for depression and asthma. Though there is no conclusive scientific evidence, information from many internet sites have report ulcerative colitis as a side effect of Sertraline ("Could Zoloft cause Ulcerative colitis? - eHealthMe", 2016). Chronic ulcerative colitis is an important risk factor for adenocarcinoma (Kim, 2014). As the patient is young, the genetic cause of diseases should be suspected. The family history of cancer can be looked into. Information on the patients eating habit, BMI, vital sign and bowel activity can be useful. Pain assessment is also necessary for the patient.
Step 3: Processing of Information
The patient has symptoms similar to acute appendicitis. Though the exact etiology is unknown, the history of depression and drugs side provides clues on probable cause. The symptoms and course of diseases are consistent with the information presented in the literature review. The outcome of the patient can be known only after knowing the results of CT scan, MRI and blood biomarker levels. According to epidemiological information, the prevalence of adenocarcinoma is relatively higher in elderly and in males (Cancer.Net, 2012). Adenocarcinoma occurs incidentally in young females like Ms. Melody. The clinical presentation of the condition was similar to acute appendicitis. However, it is important to consider the possibility of adenocarcinoma in a patient who report for an appendectomy. It was surprising that the patient was positive for adenocarcinoma.
Diagnosing an adenocarcinoma without a surgery is quite challenging. The presence of a mucocele of the appendix provides a hint for appendiceal tumor (Wang, Lin, & Lin, 2016). CT scan can reveal nodular masses of tumors. MRI can also reveal spread of tumor cells. The peritoneal cavity is usually contaminated with tumors cell in a ruptured appendicitis. The patient reported for peritonitis soon after the operation which was treated with antibiotics. The progress of the patient needs to be monitored. The patient is treated as a high-risk candidate and her condition has to be regularly monitored. The six physiological parameters like respiratory rate, oxygen saturation, temperature, systolic blood pressure, pulse rate, the level of consciousness, will be regularly monitored. The course of post-operative care will vary with the kind of complication seen in this patient. Infusion fluid, antibiotic therapy, non-steroidal anti-inflammatory therapy and prokinetic treatment are part of the normal post-operative care. The surgical wound will be monitored to avoid infection and promote healing. The surgical wound will heal by granulation, following suture removal.
Step 4: Problem and issues
The patient was presented with ruptured appendicitis and there is always the complication of post-surgical infection in such patients (Margenthaler et al., 2003). Though the patient has presented for an acute appendicitis, the histological assessment revealed the presence of adenocarcinoma. The presence of tumor tissue near the suture site of the intestine can affect the wound healing process. It would be problematic, if the tumor has metastasized to the nearby lymph node, as well (Ruoff et al., 2011). The nearby lymph node will be assessed for metastasis. The tumor is also likely to spread to the nearby peritoneum. Information on metastasis and the size of tumors mass in the body is required for staging of tumors (Ruoff et al., 2011). The patient can be discharged, only when her condition becomes stable and when she can be given a recommendation about future treatment protocol. The survival rate for less aggressive adenocarcinoma is 95%. (Cancer.Net, 2012). Advanced stages of appendiceal adenocarcinoma have the poor prognosis. Likewise, the presence of tumor cell beyond the visceral peritoneum also indicates poor prognosis (Cancer.Net, 2012). Complete removal of primary tumor mass and absence of metastasis can enable longer period of diseases free survival (Ito et al., 2004).
Another problem that will arise, is the psychological need for support. The patient is already having a history of depression. The news on cancer can leave the patient aghast. As the patient is recovering under post-operative care, the news about cancer can affect the patient's mental wellbeing.
Step 5: Establish a goal
The goal of treatment will be to identify changes that can be incorporated to improve the physical and mental wellbeing of the patient. The overall nursing goal for the patient is to lower pain and improve comfort. It will include medication or other treatment strategies, counseling, and assistance that will help to handle the disease in a better way. The patient has to be discharged in a good condition and recommendation for disease management will be provided.
Step 6: Take Action
The nurse may have to visit the patient frequently and provide her constant reassurance. The news of adenocarcinoma can be devastating. Frequent contact with the patient will help in building trust. The patient should be provided reliable information about her condition so that no misunderstanding can occur in the future. The client will be encouraged to share her feelings about her condition, treatment, life situation and prognosis. While staying in the hospital, the nurses can assist the patient with grooming and other hygienic needs. The other goal is to monitor the patient, administer medicine and document the progress noticed in the patient. Once the diagnosis is made, treatment decided and discharge plan is made, the nurse needs to communicate the advantages and disadvantages of the plan so that the patient can arrive at an informed decision. Patient consent and cooperation will be needed for all interventional procedure done in the hospital. The nurse has to provide a sound information on the need for consent and the importance of the intervention. The degree of analgesic is planned, based on the intensity of pain. ONC nurses who are authorized to directly provide chemotherapy care will work out the dose, safety, and management of the adverse effects, before administering the medicine. Fatigue is a very important side effect of chemotherapy. Nurse manger will also coordinate care between different discipline. For example, the patient will need assistance from pain management team, clinical psychiatry team, oncology, and gastrointestinal team. Plans for communication and visit can be planned in discussion with the patient.
Step 6: Evaluate outcome
The condition of the patient is evaluated by regular follow-up. The patient will be encouraged to talk about their feeling on treatment and its effect on general well-being. Diagnostic tests can be done at recommended intervals to evaluate the regression and spread of tumors.
Step 7: Reflection and process of learning
Every case, in spite of a known diagnosis, has a number of unique features that offers the opportunity for the nurse to learn and develop. The treatment and nursing plans are made considering the needs of the patient. The case is an opportunity to learn about the progress made in the management of adenocarcinoma. Though much of the information about the etiology is unknown, the response of the patient to treatment can vary. Today we have many advanced treatment options like radiosurgery and immunotherapy that hold the promise of cancer cure and survival even for patients with advanced stages of cancer.
Conclusion:
Following the final step, the cycle of clinical reasoning once again come back to the patient situation. This cycle of reasoning can guide the day to day activity of the nurse in the clinic. It helps develop a clear perspective about the disease in the light of current evidence and sets clear communication goals. Communicating the goals clearly is important in helping the patient understand their options. The goal of treating adenocarcinoma is to prolong the life of the patient and support them in achieving a normal healthy life.
References
Abbruzzese, J. (2004). Gastrointestinal oncology (p. 566). New York: Oxford University Press.
Appendicitis. (2016). WebMD. Retrieved 24 August 2016, from http://www.webmd.com/digestive-disorders/digestive-diseases-appendicitis
Cancer.Net,. (2012). Appendix Cancer - Treatment Options | Cancer.Net. Cancer.Net. Retrieved 24 August 2016, from http://www.cancer.net/cancer-types/appendix-cancer/treatment-options
Costa, M., Ivanova, E., & Esteves, J. (2016). Adenocarcinoma of the appendix detected by colonoscopy. Acta Clinica Belgica, 71(3), 190-191. http://dx.doi.org/10.1080/17843286.2015.1105610
Could Zoloft cause Ulcerative colitis? - eHealthMe. (2016). Ehealthme.com. Retrieved 24 August 2016, from http://www.ehealthme.com/ds/zoloft/ulcerative%20colitis/
Ghosh, I., Bhattacharjee, D., Das, A., Chakrabarti, G., Dasgupta, A., & Dey, S. (2012). Diagnostic Role of Tumour Markers CEA, CA15-3, CA19-9 and CA125 in Lung Cancer. Indian Journal Of Clinical Biochemistry, 28(1), 24-29. http://dx.doi.org/10.1007/s12291-012-0257-0
Gold, J., Neugut, A., & Arber, N. (2000). ADENOCARCINOMA OF THE APPENDIX. Annals Of Cancer Research And Therapy, 8(1-2), 25-34. http://dx.doi.org/10.4993/acrt1992.8.25
Guivarc’h, M. (2008). Adenocarcinoma of the Appendix. Digestive Surgery, 1(1), 45-49. http://dx.doi.org/10.1159/000171638
Ito, H., Osteen, R., Bleday, R., Zinner, M., Ashley, S., & Whang, E. (2004). Appendiceal Adenocarcinoma: Long-Term Outcomes After Surgical Therapy. Diseases of The Colon & Rectum, 47(4), 474-480. http://dx.doi.org/10.1007/s10350-003-0077-7
Kim, E. (2014). Colorectal cancer in inflammatory bowel disease: The risk, pathogenesis, prevention and diagnosis. World Journal of Gastroenterology, 20(29), 9872. http://dx.doi.org/10.3748/wjg.v20.i29.9872
Lee, J., Park, S., Park, J., Cho, J., Kim, S., & Park, B. (2013). Elevated levels of serum tumor markers CA 15-3 and CEA are prognostic factors for diagnosis of metastatic breast cancers. Breast Cancer Res Treat, 141(3), 477-484. http://dx.doi.org/10.1007/s10549-013-2695-7
Margenthaler, J., Longo, W., Virgo, K., Johnson, F., Oprian, C., & Henderson, W. et al. (2003). Risk Factors for Adverse Outcomes After the Surgical Treatment of Appendicitis in Adults. Annals Of Surgery, 238(1), 59-66. http://dx.doi.org/10.1097/01.sla.0000074961.50020.f8
Pablo Carmignani, C., Hampton, R., E. Sugarbaker, C., Chang, D., & H. Sugarbaker, P. (2004). Utility of CEA and CA 19-9 tumor markers in diagnosis and prognostic assessment of mucinous epithelial cancers of the appendix. Journal of Surgical Oncology, 87(4), 162-166. http://dx.doi.org/10.1002/jso.20107
Ruoff, C., Hanna, L., Zhi, W., Shahzad, G., Gotlieb, V., & Saif, M. (2011). Cancers of the Appendix: Review of the Literatures. International Scholarly Research Notices, 2011. Retrieved from http://dx.doi.org/10.5402/2011/728579
Wang, H., Lin, C., & Lin, C. (2016). An appendix adenocarcinoma mimicking appendicitis. Advances in Digestive Medicine, 3(2), 73-75. http://dx.doi.org/10.1016/j.aidm.2015.11.002
