Running head DISCUSSION POST 1 Chapter 20 .docx

Running head: DISCUSSION POST 1
Chapter 20: Cervical Cancer Screening and Diagnosis
Anita Opdycke
Regis College
Pathophysiology NURS 606
Terri Kanner
May 12, 2020
DISCUSSION POST 2

Chapter 20: Cervical Cancer Screening and Diagnosis
Diagnostic testing is important in early detection of cancer
(Hubert & VanMeter, 2018).
Hubert & VanMeter (2018), state that the examination of tumor
cells is the only definitive
method to diagnose cancer cells. Other tests should be used in
conjunction with cytologic tests
and to monitor treatment and follow up after a diagnosis is
made (Hubert & VanMeter, 2018).
Cytologic testing, are used to screen individuals as high risk, to
make a diagnosis, and to follow a
clinical plan of care or monitor (Hubert & VanMeter, 2018). To
make a diagnosis, clinicians use
histologic and cytologic examinations to gather cells that are
sent to a lab for further examination
(Hubert & VanMeter, 2018). In some cases, biopsies are
retrieved and in other cases exfoliative
cytology is used to make a dependable confirmation of
malignancy (Hubert & VanMeter, 2018).
For all tests, good technique and preservation of the sample is
key in obtaining an accurate
evaluation (Hubert & VanMeter, 2018). The Papanicolaou (Pap)
test is the standard of care for
screening, evaluating and diagnosing cervical cell changes that

can lead to cervical cancer
(Hubert & VanMeter, 2018).
Cervical dysplasia, or atypical glandular cells on cervical
cytology, are categorized based
on the degree of cellular change (Goodman & Huh, 2020). The
three main categories of cervical
intraepithelial lesions (CIN) include: CIN-1 or lesser
abnormalities, CIN 2 and CIN 3 (Goodman
& Huh, 2020). CIN-1 or lesser abnormalities includes atypical
cells of undetermined significance
(AS-CUS) and low grade squamous intraepithelial lesions
(LSIL) with HPV 16 or 18 infection,
or persistent HPV infection (Goodman & Huh, 2020). Low
grade CIN has a low potential to
progress to malignancy (cancer) but high grade CIN has a high
potential to develop into cancer
(Goodman & Huh, 2020). The Pap test has significantly
contributed to the decrease in invasive
cervical cancer incidence however every year there are 12, 000
new cases of invasive cervical
DISCUSSION POST 3

cancer are diagnosed in the U.S (Zhao, et al., 2014). Zhao, et
al. (2014) explored Factors
Associated with Reduced Accuracy in Papanicolaou Tests With
Invasive Cervical Cancer in an
effort to highlight the importance of accurate interpretation of
screening tests.
The study, Factors Associated with Reduced Accuracy in
Papanicolaou Tests With
Invasive Cervical Cancer, was published in Cancer
Cytopathology on May, 28, 2014. The
authors, Lichao Zhao, Nicolas Wentzensen, Roy Zhang, Terence
Dunn, Michael Gold, Sophia
Want, Mark Schiffman, Joan Walker and Rosemary Zuna
conducted research to explore and
evaluate the limiting factors in Pap tests from women who were
diagnosed with invasive cervical
cancer and to discuss ways to identify problematic cases in
clinical practice (Zhao, et al., 2014).
The literature was drawn from the discipline of oncology or the
study of cancer. The authors
conducted a cross sectional analysis of cytologic and HPV
results by studying 3003 women who
had a wide range of cervical lesions via the ThinPreP Pap test
and HPV genotyping (Zhao, et al.,

2014). The methods and materials for the study included
recruiting 3015 women, aged 18 and
older, referred for colposcopy from 2002-2010 into the Study to
Understand Cervical Cancer
Early Endpoints and Determinants (SUCCEED) and the National
Cancer Institute University of
Oklahoma Health Sciences Center Biopsy Study (Biopsy Study)
(Zhao, et al., 2014).
All women who were recruited had a spectrum of benign,
intraepithelial, and invasive
cervical neoplasia (Zhao, et al., 2014). Twelve participants were
excluded due to previous
surgical treatment for cervical neoplasia, non-cervical
neoplasm, pregnancy or HIV infection
(Zhao, et al., 2014). Each participant has a colposcopic visit as
their first visit, which also
included a ThinPrep Pap test (Zhao, et al., 2014). HPV
genotyping was also performed on the
specimens (Zhao, et al., 2014). Zhao, et al. (2014) noted that
all cases within this research study
attempted to mimic the normal screeing process (Zhao, et al.,
2014). As such, this study bias
DISCUSSION POST 4

could have caused some results that were diagnosed as
“abnormal” to have been classified as
“unsatisfactory” in a normal clinic setting (Zhao, et al., 2014).
This gap could have
underestimated the unsatisfactory rate for these women in a
clinical setting (Zhao, et al., 2014).
The results used the Pearson chi-square and Fisher exam test
and statistical significance was
assisgned to 2-sided probablity values <0.. The findings of the
study concluded that there was a
statistical significance demonstrating patients with cervical
cancer have a significantly higher
rate of unsatisfactory and limited quality Pap tests (Zhao, et
al., 2014). This poses a challenge
for providers to deliver timely treatment, especially in women
who do not obtain regular
screening (Zhao, et al., 2014). The major reasons leading to an
unsatisfactor test results included
scant cellularity, obscuring blood, and inflammation or the
presence of lubrication (Zhao, et al.,
2014).
Implications for further research include investigating the
incidence of falsely negative

PAP tests, particularly in women with adenocarcinoma,
decreasing testing intervals in women
over 30 or who have previous tested positive for HPV (Zhao, et
al., 2014). The information in
the article could be applied to advance nursing practice by
being aware of PAP technique,
adhering to best practice, ensure follow up for screeing for high
risk female populations, and
being aware of post-exam bleeding and/or a friable cervix and
the implications this may have on
the specimen collected (Zhao, et al., 2014). I would recommend
this article to a collegue and
classmate to further understand the classification of cervical
cell changes in the presence of HPV
genotype and the implications for progression to malignant
carcinoma.
DISCUSSION POST 5
References

Goodman, A., & Huh, W. (2020, April). Cervical Cytology
Evaluation. Retrieved from UptoDate:
https://www.uptodate.com/contents/cervical-cytology-
evaluation-of-atypical-and-
malignant-glandular-
cells?search=cervical%20dysplasia&topicRef=3215&source=rel
ated_link
Hubert, R. J., & VanMeter, K. C. (2018). Gould's
Pathophysiology for the Health Professions (6th
ed.). St. Louis: Elsevier.
Zhao, L., Wentzensen, N., Zhang, R., Dunn, T., Gold, T., Wang,
S., . . . Zuna, R. (2014). Factors
associated with reduced accuracy in Papanicolaou tests for
patients with invasive
cervical cancer. 1-8. Retrieved from
https://acsjournals.onlinelibrary.wiley.com/doi/epdf/10.1002/cn
cy.21443
Running head: HEALTH CARE QUALITY IMPROVEMENT
PROGRAMS
Ethics and Decision-Making in the VA Healthcare System
5

Ethics and Decision-Making in the VA Healthcare System
HS450: Strategic Planning and Organizational Development for
Health Care
Name
February 26, 2019
The Department of Veterans Affairs (VA) has had a tumultuous
time throughout its history with the processing of claims and
treatment of veterans. In 2009 President Barrack Obama put an
emphasis on fixing the issue. Current Army Chief of Staff
General Eric Shinseki was selected by President Obama as the
Secretary of the VA. General Shinseki’s primary role was to
implement 16 initiatives that would help alleviate the issues
within the VA. However under his leadership the VA had
different results than what was expected. In 2013 many major
news stations reported that veterans were experiencing delayed
care at the Williams Jennings Bryan Dorn Veterans Medical
Center in Columbia, SC. As a result of the delayed care six
veterans died. After an investigation many issues for found
including; low staff census, leadership turnover, lack of
understanding of roles, responsibilities and system processes,
and ineffective program coordination. In 2014, the Office of the
Inspector General (OIG) launched an investigation into these

allegations addressing two primary questions 1. Did the
facility’s electronic wait list (EWL) purposely omit the names
of veterans waiting for care and, if so, at whose direction? And
2. Were the deaths of any of these veterans related to delays in
care? The conclusion of the investigation resulted in the OIG
determining that there was evidence of improper scheduling in
the VA and the healthcare system. As a result of the
investigation General Shinseki resigned from office on May 30,
2014.
Ethical Decision Making Process
The ethical decision making process helps healthcare
professionals in making a sound judgment in regard to making a
proper ethical decision. Step one is to ask “What is the ethical
question?” In regard to issue at the VA the primary ethical issue
was the patients that were not listed on the Electronic Wait List
(EWL) but were still awaiting care. These individuals would be
waiting forever since their names were never on the actual list.
Step two is for you to ask yourself “What is your gut reaction?”
As an active duty U.S. Army Enlisted Soldiers my gut reaction
is pure disgust. There is no explanation for anyone not only
veterans but no one period to be waiting for care that they
would never receive. Step three is a research step and a point
where the facts are identified. The facts of the underlining
issues should have been identified at this point. The issues
should have been laid out and a plan to identify these issues
should begin at this moment. The fourth step is to ask “What are
the values at stake in the scenario?” This step should’ve been
one of the easiest in the VA case. Everyone has different values
but we all know what is right and what is wrong. In the VA case
it seems that everything was done wrong and to benefit
themselves and not the patients. Step five is to ask “What are
the options in this case?” The options were clear and that was to
find a solution that can provide veterans care in a timely
manner. In the sixth step you ask “What should I do?” This is
where an ethical decision should have been made by all
personnel who had a negative impact in the VA case. Many of

the people made the wrong choice for personal or professional
gain. Step seven is to ask “What justifies this choice?” Evidence
to support our choice is the proper way to support it. Without
the correct evidence an unethical decision is likely going to be
made. Finally step eight you ask “How could the ethical
problem have been prevented?” This is easier to ask after the
fact since we know the outcome. All healthcare professionals
should not have to decipher if something is right or wrong each
and every one of these individuals should be aware of what to
do and when to do it.
Two Policies/Standards
Upon researching about the issues in the VA more specifically
during the time that General Shinseki was the Secretary of the
VA many policies and procedure changes could have helped to
alleviate the issues. One of the policies I would have
implemented would have been to have one provider for a
specific number of patients. This would ensure there were
enough provider to care for the patients. When providers see to
many patients the providers begin to rush and that is when
mistakes begin to happen. This may not seem very cost effective
at first but the results of the policy would have outweighed the
cost associated with the policy. Additionally the second policy I
would have out in place would allow for the veterans to receive
care at another facility once they have been waiting for care for
an egregious amount of time. This would ensure that all patients
are receiving the appropriate amount of care in the appropriate
amount of time.
Two Alternative
Solution
s
At the time of his resignation General Shinseki made a quick

decision that may have seemed right in his mind but from the
outside looking in it seems as if he no longer wanted to be part
of the problem. He without a doubt could have done things
differently. I personally feel that he should have accepted
responsibility for the issues in the VA and then immediately
made changes within the VA. This would have been at the
healthcare administrator level. New administrator and leaders at
this pivotal positions could have without a doubt made a major
impact on the over success of the VA during his tenure. One of
the primary problems with the VA case is the focus on quantity
and not on quality. Healthcare quality cannot become collateral
damage when we are dealing with a large number of patients.
Another avenue that he could have approached is utilizing a
centralized Electronic Healthcare Records (EHR) this would
have provided everyone with oversight on how many patients
were being seen and how many needed to be seen going
forward.
ACHE Code of Ethics
The American College of Healthcare Executives (ACHE) Code
of Ethics can be applied to all healthcare systems including the
healthcare system of the VA Health System. Utilizing the ACHE
Code of Ethics will ensure that a centralized ethics system is
being shared across all of the healthcare professionals. The
ACHE Code of Ethics details the standards of all ethical
behavior for executives and administrators in the healthcare

industry. A clear cut code of ethics will undoubtedly lead to a
minimal number of unethical decisions made by healthcare
professionals. Ethics should be learned at the college level but
should also be refined as we progress into our professional
lives. Healthcare organization should be mandated to provide
ethical training on an annual basis in order to ensure the
mitigation of situation like that of the VA cases.
Overall the VA situation was a disaster for veterans, employees
of the VA, the VA, General Shinseki, President Obama and the
entire country. The whole situation could have been avoided if
the ethical decision making process was used. There were many
different tactics and techniques that could have been used by
General Shinseki in order to ensure these unethical decision
were avoided. Instead of putting in new policies and procedures
he decided to resign his position which I feel was the worst
thing he could have done. Many people quit or give up when
they are down, but a secretary of a major department within the
government should not do so. The ACHE is a great resource for
educating our current and future healthcare administrators on
ethics in healthcare. We should ensure we are utilizing all of the
resources to provide the patients not only of the VA but of all
healthcare with a good quality and ethical product. All of us as
future healthcare administrators should strive to learn from the
mistakes of the past and ensure we will be the best ethical
healthcare leaders of the future.

References
ACHE. 2017. ACHE Code of Ethics. Retrieved from
http://www.ache.org/abt_ache/code.cfm
Essentials of Strategic Planning in Healthcare, Harrison,
Jefferey P. retrieved from
https://purdueuniversityglobal.vitalsource.com/#/books/9781567
937916/cfi/0!/4/[email protected]:24.4
Ethical Decision-Making Guidelines and Tools, Jacqueline J.
Glover PhD retrieved from
http://samples.jbpub.com/9781284053708/Chapter2.pdf
Running head: CONGENITAL ANOMALIES 1

Congenital Anomalies
Jillian Zucco
Regis College, PMHNP
CONGENITAL ANOMALIES 2
Congenital Anomalies
The purpose of this assignment is to critique an article about a
topic covered in this
week’s reading material and discuss both the topic and the
article with classmates. The topic I
chose for this assignment is: congenital anomalies. Congenital
anomalies are genetic or inherited
disorders or developmental disorders that are present at birth. A

congenital anomaly can be
caused by a single-gene disorder, which is a mutation in one
gene in the ova or sperm that is
passed down to later generations. Mutations in body cells that
are not reproductive cells can
cause a disorder or dysfunction but cannot be passed down the
way mutations in reproductive
cells can (Vanmeter, 2014).
Chromosomal defects can also be the cause congenital
anomalies. During meiosis, DNA
fragments can be displaced or lost. This kind of error is what
usually causes chromosomal
anomalies and is more common when the mother is older than
age 35. Some congenital
disorders happen at birth, but do not have a genetic component.
These can occur from premature

birth, exposure to teratogenic agents, or a traumatic labor or
delivery. Teratogenic agents are
those that can damage the embryo or fetus and its development.
Some congenital anomalies are
caused by multiple genes, making them polygenic disorders
(Vanmeter, 2014).
The article I chose to critique is entitled “Dietary glycemic
index and glycemic load
during pregnancy and offspring risk of congenital heart defects:
a prospective cohort study.” It
was authored by Amalie Schmidt, Marie Lund, Giulia Corn,
Thorhallur Halldorsson, Nina Oyen,
Jan Wohfahrt, Sjurdur Olsen, and Mads Melbye, all of whom
are affiliated with reputable
institutions, such as the University of Bergen Department of
Global Public Health, Harvard TH
Chan School of Public Health, and Stanford University School

of Medicine. The article was
published this year, 2020, in The American Journal of Clinical
Nutrition. The purpose of this
article was research- to examine the relationship between mid-
pregnancy dietary glycemic index,
glycemic load, and the risk of congenital heart defects in the
baby. The article does not include a
formal literature review, but the introduction section provides
information already published
about the topic from previous studies, mostly in the discipline
of medicine. The journals cited
from are mostly medical journals on the topics of pediatrics,
epidemiology, and diabetes. The

authors identify a research gap by stating that only one other
study exists that assesses the risks
between glycemic index and heart defects. The first aim of the
study was to investigate the
association between glycemic index and glycemic load during
pregnancy and offspring risk of
congenital heart defects using a food-frequency questionnaire,
and the second aim was to
investigate the association between high intake of sugary
beverages and offspring risk of
congenital heart defects (Schmidt, 2020). The study design is a
prospective cohort study. Women
were recruited at antenatal visits to their primary care providers
to participate in 2 phone
interviews. Women in the Danish National Birth Cohort were
recruited and invited to fill out
food-frequency questionnaire. Discharge and outpatient

diagnoses from hospital encounters were
collected from the National Patient Register. Maternal and fetal
characteristics related to
pregnancy and birth were collected form the Medical Birth
Register. Statistical analyses were
performed to determine the association between glycemic index,
glycemic load, and congenital
heart defects as well as the association between sugary
beverages and congenital heart defects.
The sample size included 101,042 pregnancies, which seems
sufficient for the project (Schmidt,
2020).
The researchers found no significant association between
glycemic index and glycemic
load during pregnancy and congenital heart defects. The
researchers found a significant

association between high intake of sugary carbonated beverages
and congenital heart defects. It
was concluded that high dietary glycemic index in pregnancy
does not increase the offspring risk
of congenital heart defects, but that sugary carbonated
beverages pose a moderate risk of
offspring heart defects. The authors do not state any
implications for further research but since
this seems to be only the second study on this topic, further
research is necessary to confirm
these findings. APRNs should apply this knowledge when
assessing, treating, and educating
expecting mothers. Expecting mothers should be instructed to
limit their intake of sugary

carbonated beverages like soda. I would recommend this article
to others, since it appears to be
new information.
Congenital heart defects can be caused by both genetic and
environmental factors,
making them multifactorial congenital anomalies (Vanmeter,
2014). Environmental factors are
often modifiable. As APRNs, it is our responsibility to educate
patients about modifiable risk
factors and encourage healthy decisions. This knowledge of
congenital anomalies as well as this
new information about sugary carbonated beverages posing a
risk for congenital heart defects are
important for us to relay to our patients regardless of our
specialty area as nurse practitioners. It
is worth noting that another article I found concludes that a

higher maternal body mass index is
related to increased risk of offspring congenital heart defects
(Liu, 2019). It is possible that many
of the women in the first study who consume sugary carbonated
beverages have a higher BMI,
and that a higher BMI poses the risk and not the sugary
carbonated beverages alone. Regardless,
we must educate pre- and perinatal patients to make healthy
decisions including cutting down on
sugary carbonated beverage consumption.

References
Liu, X., Ding, G., Yang, W., Feng, X., Li, Y., Liu, H., Zhang,
Q., Ji, L., & Li, D. (2019).
Maternal body mass index and risk of congenital heart defects
in infants: A dose-
response meta-analysis. BioMed Research International, 2019,
1315796.
Schmidt, A. B., Lund, M., Corn, G., Halldorsson, T. I., Øyen,
N., Wohlfahrt, J., Olsen, S. F., &
Melbye, M. (2020). Dietary glycemic index and glycemic load
during pregnancy and
offspring risk of congenital heart defects: a prospective cohort
study. The American
Journal of Clinical Nutrition, 111(3), 526–535.
VanMeter, K. C., & Hubert, R. J. (2014). Gould's
pathophysiology for the health professions. St.

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