Pancreatic Cancer: Pathophysiology and Health Deviations

Pancreatic Cancer

Pancreatic cancer is a silent killer and “is the fourth leading cause of death in the United States” (Reynolds and Folloder, 2014, p. 356). “Pancreatic cancer will often develop without clear early signs or symptoms, and the eventual manifestations will depend on the tumor location within the gland” (Reynolds and Folloder, 2014, p. 357). Pancreatic cancer is of significant concern for nursing because the signs and symptoms are very broad and can overlap with other disease processes. Pancreaticoduodenectomy is a treatment option for patients who can have the tumor removed. If the tumor is unable to be removed then their treatment options would either be systemic chemotherapy or chemoradiation. Educating the patient and caregivers about side effects of the treatment or therapy can help them to take immediate action for these adverse events.

The purpose of this paper is to educate on the anatomy and physiology or pancreatic cancer, describe the treatment of the patient, how a pancreaticoduodenectomy is effective but still has some consequences that the patient should be aware of. The subject, M.V., and the medical treatment received by this patient will be compared to the textbook management. M.V.’s health deviations that were present during the clinical setting and the nursing care provided will be discussed. The article Clinical Management of Pancreatic Cancer written by Reynolds and Folloder (2014) will be used to discuss the nursing practice and clinical management of patients who are diagnosed with pancreatic cancer.

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Basic Conditioning Factors

The patient M.V. was admitted on February 3rd, 2019 to Long Beach Memorial Medical Center (LBMMC). M.V.’s medical diagnosis was pancreatic cancer. Her medical doctor was Dr. Arguita, the responsible nurse was Andrew, and her coassigned nurse assistant was Belinda. M.V.’s surgery on February 6th, 2019, was a Whipple procedure which is also known as a pancreaticoduodenectomy, to treat pancreatic cancer. M.V. is a 61-year-old Hispanic female who is a retired certified nursing assistant (CNA). Her family roles are a wife, mother, grandmother, and daughter. She has no allergies and her previous medical history are hypertension and diabetes mellitus. M.V.’s code status was full while a patient at LBMMC.

According to Potter, Perry, Stockert, and Hall (2017), M.V.’s developmental level is Generativity versus Self-Absorption and Stagnation. This is the middle age adult developmental level where a person contributes in a positive way to their family and/or community. Stagnation is the opposite of this because this person is concerned only for them self and does not want to help the next generation. One could achieve generativity by contributing to the growth and development of the next generation by teaching, volunteering, or any other way to help in the community. If a person does not want to contribute to the development of the next generation they fall under stagnation. Stagnation is when a person is only worried about themselves and how they benefit from what they are doing at work, with friends and family, or will they benefit from helping others.

During clinical rotation, M.V. was asked what she enjoyed doing with her family, what she looked forward to once discharged, and any hobbies she had. M.V. shared that she enjoyed just being in the company of her mother, children, grandchildren, and husband. She goes to church and volunteers when asked. She enjoys taking her grandchildren to school and babysitting them while their parents are at work or school. She looked forward to being home and recovering with her family and also getting a new manicure and pedicure. She also shared that she just wanted to be home because that is where she knew she would get better quicker because some of her kids couldn’t make it to visit her in the hospital. M.V. has currently achieved generativity based on the definition given by Potter, Perry, Stockert, and Hall (2017).

Anatomy and Physiology of the Involved Organs

According to Hinkle and Cheever (2018), the pancreas, common bile duct, gallbladder, and duodenum are all the organs involved in the tumor of the head of the pancreas. The function of the pancreas is to produce enzymes to help with digestion in the exocrine system and produces hormones for blood glucose regulation in the endocrine system. The common bile duct carries bile from the gallbladder and empties the bile into the small intestine. The gallbladder stores bile, which is an enzyme that is produced by the liver, which then releases the bile through the common bile duct into the duodenum. The function of the duodenum is chemical digestion of the secretions from the pancreas, liver, and gallbladder which all mix with chyme from the stomach. The pancreas is located in the upper abdomen and is between the duodenum and spleen. The common bile duct is located at the end of the gallbladder and is attached to the head of the pancreas which then leads into the duodenum. The gallbladder is located below the liver. The duodenum is located anterior to the pancreas and is the beginning of the small intestine.

Pathophysiology

According to Hinkle and Cheever (2018), people that are at higher risk for pancreatic cancer are individuals that have a history of smoking cigarettes, diabetes, chronic pancreatitis, and any hereditary pancreatitis. “Pancreatic cancer is the fifth leading cause of cancer death in women” (Hinkle & Cheever, 2018, p. 1450). Hinkle and Cheever (2018), continue to explain that pancreatic cancer can occur at the head, body, or tail of the pancreas. Thy symptoms are not specific and patients do not seek treatment until it is late into the disease. Patients can present with pain in the abdomen, weight loss, and jaundice. The pain can sometimes move to the midback and can become severe over time. Metastasis can occur if the malignant cells from the pancreatic cancer go into the peritoneal cavity. Sometimes ascites can occur because of this metastasis. The onset of insulin deficiency, glucosuria, hyperglycemia, and an abnormal glucose tolerance is a very important sign that some patients will present with if the malignant cells have moved and caused metastasis. “There is no known biomarker specific to pancreatic cancer, but carbohydrate 19-9 (CA 19-9)…” (Reynolds and Folloder, 2014, p. 358).

Hinkle and Cheever (2018), describe the medical management of pancreatic cancer depends on if it can be resectable and how localized is the tumor. If the tumor is resectable then the patient will undergo a very comprehensive procedure which is called the Whipple procedure. To remove the tumor completely is not possible sometimes due to two factors, one, how large the tumor has grown, and secondly, if the malignant cells have metastasized into the liver, lungs, or bones. If these factors occur then palliative measures will more than likely be the treatment option. Pancreatic tumors are resistant to basic radiation therapy, so the patient may need to be treated with chemotherapy and radiation.

Hinkle and Cheever (2018), advise that the nursing management for pancreatic cancer is pain management and assessing the nutritional requirements to help with improving the patient’s comfort level. Due to the pain that the patient may have because of the pancreatic cancer, opioids are used to help alleviate the pain. Patients who have severe and excruciating pain may need to be considered to have patient-controlled analgesia (PCA). Patients who are at the end of life may need to be referred to hospice care.

M.V. went to her primary care physician with a chief complaint of abdominal pain for two weeks. She also presented with nausea, vomiting, and diarrhea. M.V. then came to the emergency department Dr. Arguita admitted her with a diagnosis for abdomen pain. The emergency department ran a CBC that showed elevated liver function tests (LFTs) and a CT scan with findings of gallstones. Admitting physician, Dr. Argita, and the surgeon, Dr. Do, preoperatively diagnosed M.V. with gallstones and elevated LFTs (Long Beach Memorial Medical Center, 2019). The signs and symptoms that M.V. presented with correlate with the signs and symptoms Hinkle and Cheever (2018) described which was abdominal pain and her history of diabetes mellitus also put her at risk for pancreatic cancer.

M.V.’s preoperative diagnosis of gallstones was what lead to getting a biopsy done prior to continuing with removal of the gallstones. Intraoperatively, the biopsy findings were that of pancreatic cancer. Dr. Do proceeded with removing the gallstones and then the extensive Whipple procedure. (Long Beach Memorial Medical Center, 2019). The surgery resulted in the removal of the head of the pancreas and the rest of the pancreas was attached to the side of the jejunum. The common bile duct is attached to the side of the jejunum and the end of the stomach is sutured to the side of the jejunum as well (Hinkle & Cheever, 2018, p. 1452). The estimated blood loss was 100 milliliters. The intraoperative findings resulted in the postoperative diagnosis of pancreatic cancer.

Medical Orders

• Diet
• Activity

Nurse Responsibilities

NPO due to radiology procedure to insert a central venous catheter with placement of port.

Bedside commode with assistance

Notify MD if WBCs were still high to make the decision of proceeding with port placement

Saline lock

• Jackson Pratt drains – note color, amount, and characteristics of drainage
• G-tube enterostomy tube – note any infection, color, amount, and characteristics of drainage.

Note: (Long Beach Memorial Medical Center, 2019)

Medications

• Drug
• Dose
• Route
• Frequency
• Therapeutic effect
• Nursing responsibilities
• Relation to medical diagnosis
• amlodipine
• (Norvasc
• 5 mg
• PO
• Once daily
• Lower blood pressure.

Monitor blood pressure and pulse, intake and output, and daily weight. Assess for signs of angina.

M.V. has a history of hypertension. This does not relate to the medical diagnosis.

Antihypertensive to lower blood pressure by causing vasodilation.

cefoxitin (Mefoxin) 2 g in NS 100 mL

IVPB

Once daily

To prevent infection.

Assess for signs and symptoms of infection: surgical site. Assess WBC lab results. No labs to be drawn within 2 hours od administering this medication due to false increase of serum & urine creatinine.

M.V.’s Whipple procedure and her pancreatic cancer increase the risk of infection. Postoperative infection risks can be reduced when administering antibiotics.

• hydrocodone/ acetaminophen
• (Norco)
• 7.5-325 mg
• PO
• q 4 hours PRN
• 1 tab for pain (4-6)
• 2 tabs for pain (7-10)

For pain management

Do not exceed 4 g/day. Assess blood pressure, pulse, respiratory rate, and bowel function. If the respiratory rate is 60

• 65-99
• 136-145
• 3.5-5.1
• 8.5-10.1
• 15-37 u/L
• 13-56 u/L
• 45-117 u/L
• 0.2-1.0 mg/dL
• 73-393
• 2-37
• 6.0
• 14.3
• 43.1
• 223
• 6
• 0.76
• >60
• 126
• 139
• 3.9
• 9.3
• 445
• 811
• 232
• 2.1
• 315
• 32 (02/07/19)
• 11.6
• 9.5
• 29.4
• 332
• 8
• 0.67
• >60
• 167
• 137
• 3.6
• 7.9
• 37
• 59
• 152
• 0.4
• UTZ
• CT
• Abdomen

MRCP without contrast

Note: (Long Beach Memorial Medical Center, 2019), (Pagana, Pagana, & Pagana, 2015)

When diagnosing M.V. with gallstones as stated before the main lab values and tests to determine this diagnosis were the CT scan and the CBC. On her admission date February 3rd, 2019, her LFTs which consist of the enzymes that are found in the liver, that include alanine transaminase (ALT), aspartate transaminase (AST), alkaline phosphatase, and bilirubin. M.V.’s ALT levels were elevated at 811, AST levels were elevated at 445, alkaline phosphatase levels were elevated at 232, and bilirubin levels were elevated at 2.1 (Pagana, Pagana, & Pagana, 2017). The LFTs check to see how well the liver is working. The CT scan also solidified the diagnosis with its findings of gallstones obstructing the common bile duct (Long Beach Memorial Medical Center, 2019).

Health Deviations

Balance Between Solitude and Social Interaction

Health deviations brought on by pancreatic cancer. The patient may not be able to interact in a social environment due to pain and would be in solitude. The pain from pancreatic cancer can inhibit a patient from meeting these universal needs. The psychosocial concerns for these patients would be about relieving the pain.

Maintenance of Sufficient Intake of Air

Health deviation brought on by pancreatic cancer. The patient may hyperventilate as a response to pain. Hyperventilation causes a release of carbon dioxide quickly which stimulates an increase in respiratory rate which leads to respiratory alkalosis (Potter, Perry, Stockert, & Hall, 2017). This can be a consequence of insufficient intake of air because the brain won’t have enough air to profuse which then the patient may have a lack of consciousness. Pancreatic cancer is effected more because the heart rate and blood pressure will increase as a response to pain.

Maintenance of Sufficient Intake of Food and Water

Health deviation brought on by pancreatic cancer. The malabsorption of nutrients and fat-soluble vitamins can obstruct the common bile duct can decrease the secretions of bile which aids in the breakdown of chyme from the stomach. Pancreatic cancer can lead to anorexia because of discomfort and pain in the abdominal area (Hinkle & Cheever, 2018).

Maintenance of Sufficient Elimination of Water.

Health deviation brought on by pancreatic cancer. Ascites is common in these patients. There for monitoring for any abdominal cavity swelling and distention is very important. These signs and symptoms can further look into any metastasized cells of pancreatic cancer (Hinkle & Cheever, 2018).

Maintenance of Balance Between Activity and Rest

Health deviation brought on by pancreatic cancer. Immobility due to the presence of pain that is caused by the pancreatic cancer. Acute pain can affect the patient’s ability to walk or rest comfortably. When patients are uncomfortable and in pain, sleeping patterns are disrupted.

Promotion of Normalcy

Health deviation brought on by pancreatic cancer. Normalcy is affected by the pain from pancreatic cancer. Routine lifestyle activities are limited. Patients are not comfortable with body movements and become malaise when getting up and using the toilet. Weight loss can occur due to the abdominal pain from pancreatic cancer as well. Resting would be affected if the pain is not able to be controlled by opioid drug therapy.

Prevention of Hazards

Health deviation brought on by pancreatic cancer. The pain brought on by pancreatic cancer causes the patient to be very cautious of how one moves. Patients guard and move to a comfortable position to maintain a level of relief.

Nursing Diagnosis

The priority nursing diagnosis for M.V. is acute pain related to surgical incision, secondary to the Whipple procedure, as evidenced by numeric pain scale of 6/6/4 and verbal report of pain that she felt in the lower abdominal region. M.V.’s goal on February 14th, 2019 for this nursing diagnosis was that she will state a pain less than six within one hour of administering Norco. The nursing interventions to help M.V. to reach this goal was to reassess her pain level in one hour, to administer the Norco prescription as needed for the pain every four hours according to the parameters, advise deep breathing exercise (Ladwing, Ackley, & Makic, 2017).

The potential complication for M.V. in regards to the pancreatic cancer is paralytic ileus (Potter, Perry, Stockert, & Hall, 2017). The nurse will monitor, manage, minimize paralytic ileus and collaboratively intervene to reach this goal. The nurse will monitor the signs and symptoms which are nausea, vomiting, constipation, loss of appetite, inability to pass gas, and the distention of the abdomen (Mestrovic, 2018). The nurse will manage paralytic ileus by a drug treatment with alvimopan or stimulate the bowel movement with prescribed lactulose or neostigmine (Mestrovic, 2018). The nurse will minimize paralytic ileus by getting M.V. to ambulate at least three times per shift, encourage patient to report any changes in her pain level, and encourage fluid intake.