Unit 3: Pancreatic Cancer Flashcards
Causes of Pancreatic Cancer
- cigarette smoking
- diets high in fat
- consumption of meat, fried foods, refined sugars, and nitrates (modifiable)
- diabetes
- chronic pancreatitis
- family hx of pancreatic cancer
- some occupational exposure to toxins (ex: gasoline)
Pathophysiology
- pancreatic tumors may be primary or metastatic, usually originating in the lung, breast, thyroid, kidneys, or skin
- b/c of the rapid growth of the adenocarcinomas in the pancreas, both exocrine and endocrine functions deteriorate as the tumor invades the pancreatic tissue
- pancreatic tumor, b/c of the proximity of other GI organs, may metastasize to the stomach, duodenum, gallbladder, and intestine
- cancer that invades the tail and body of the pancreas may metastasize to the liver via the splenic vein, and the patient may present with an abdominal mass and hepatomegaly
Clinical Presentation
- directly r/t the degree of pancreatic damage secondary to tumor growth
- may not manifest until significant damage has occurred
- pain (dull pain in epigastric area and back)
- jaundice (obstruction of bile duct)
- weight loss
How to Diagnose Pancreatic Cancer
- Ultrasound, CT scan, MRI, and/or ERCP to determine presence of mass
- Definitive diagnosis: through histopathology
- Tissue samples are collected by fine-needle biopsy or excisional biopsy through a laparotomy
- may also undergo angiography to determine involvement of vessels surrounding the pancreas
- once diagnosed, the tumor is staged according to the size, extent, lymph node involvement, and metastasis, and course of treatment is determined
Laboratory Values
- Elevated amylase
- Elevated total and direct bilirubin
- Elevated liver enzymes
- Fecal fat, trypsinogen, trypsin (enzyme that aids in the digestion of protein), and lipase may indicate how the pancreas is functioning and the need for pancreatic enzyme supplementation
Treatment for Pancreatic Cancer
- Adjuvant therapy; combined chemotherapy and radiation
- External beam radiation to the tumor and surrounding tissue over a 6-week period concurrent with 5-fluorouracil chemotherapy for up to 4 months help improve long-term survival
Surgical Management
- stage of cancer and the location of the tumor determine whether surgical intervention is an option
- surgical resection is potentially curable; only a small percentage qualify for surgical resection b/c of the latent nature of the clinical presentation
- may undergo surgery to relieve symptoms (palliative surgery), but excision of the tumor is not possible
- a celiac nerve block can be performed to decrease the pain associated with the tumors compression of the celiac nerves surrounding the aorta
- if tumor located in the head, neck, or uncinate process of the pancreas. patient ca undergo the Whipple procedure or pancreaticoduodenectomy
Celiac Nerve Block
can be performed to decrease the pain associated with the tumors compression of the celiac nerve surrounding the aorta
When is the cancer unresectable?
if the cancer has spread to distant lymph nodes or there is metastasis to the liver
The Patients can go under what procedures if the tumor is located in the head, neck, or uncinate process of the pancreas?
- Whipple Procedure
- Pancreaticoduodenectomy
Whipple Procedure
the head of the pancreas, distal stomach, spleen, gallbladder, common bile duct, portions of the duodenum, proximal jejunum, and lymph nodes are resected
Distal Pancreatectomy
- removal of the tail and part of the body of the pancreas
- done if the tumor is in the body or tail of the pancreas
What procedures can the patient undergo to reconstruct the GI tract?
- Pancreatojejunostomy
- Hepaticojejunostomy
- Gastrojejunostomy
Pancreaticojejunostomy
anastomosis of the pancreas to the jejunum
Hepaticojejunostomy
anastomosis of the hepatic duct to the jejunum
Gastrojejunostomy
anastomosis of the stomach to the jejunum
Vagotomy
- surgical resection of the vagus nerve
- done to decrease acid secretion in the stomach and decrease peptic ulcer formation
Postoperative Management of Surgical Procedures
- Monitored for exocrine insufficiency (lack of digestive enzymes to properly digest food) and insulin-dependent diabetes mellitus (DM I)
- NGT that is not to be manipulated
- Pain management via PCA
- Pulmonary interventions to encourage lung expansion
- Coughing and deep breathing to prevent pneumonia and atelectasis
- Abdominal assessment
Safety Alert: Post-op management for Whipple procedure or Pancreaticoduodenectomy
- NGTs are maintained post-op to decompress the stomach, prevent bloating, and remove gastric acid secretions to minimize pressure on the surgical site
- NGTs are placed intraoperatively and are not to be manipulated in any way
- a do not manipulate NGT sign is placed on the wall above the patients head
- NGTs are not to be repositioned, irrigated, or checked for placement b/c these actions can cause breakdown of the anastomotic site
- if a patient removes the NGT, it is not to be replaced by the nursing staff; member of surgical team is notified
Anastomosis
a connection made surgically between adjacent blood vessels, parts of the intestine, or other channels of the body, or the operation in which this is constructed
Connection Check: The nurse receives a patient from the OR after he undergoes a Whipple procedure. The nurse recognizes that this procedure is indicated for the patient who has which disorder? A. Acute pancreatitis B. Peritonitis C. Cholecystitis D. Pancreatic Cancer
D. Pancreatic Cancer
Nursing Management: Assessment and Analysis
- patients with pancreatic cancer present w/ nonspecific clinical manifestations that can be attributed to a variety of GI disturbances
- pain, jaundice, fatigue, anorexia, and weight loss
- vague, nonspecific abdominal and epigastric pain
- pain described as dull and intermittent that sometimes increases in intensity with eating and movement
- jaundice develops in a pattern that is first seen in the mucous membranes, then palms of the hands, and eventually generalized
- complain of pale, greasy stools, which is attributed to a tumor that blocks digestive enzyme release
- pruritis (itching) starting with the palms of the hands, then generalized
- dark-amber urine d/t the accumulation of bilirubin
Nursing Diagnoses
- Pain: acute or chronic r/t the pressure caused by the pancreatic mass
- Imbalanced nutrition: less than body requirements r/t malabsorption and anorexia
- Anxiety r/t cancer diagnosis
Nursing Assessments
- Vital Signs
- Fluid intake and output
- Serum glucose
- Weight
- Muscle mass
- Pain location, intensity, duration
- Abdomen
- Skin color
- Pruritis
- Post-op assessment
Assessments: Vital Signs
- tachycardia r/t to fever and pain
- elevated BP r/t pain and anxiety
- fever r/t infection d/t blocked bile ducts
Assessment: Fluid Intake and Output
- daily intake and output monitor fluid volume status and prevent dehydration
- with the development of ascites, there may be a fluid shift from the intravascular space
Assessment: Serum Glucose
-elevated b/c of impaired insulin secretion d/t tumor or d/t removal of the pancreas, which secretes insulin
Assessment: Weight
-weight loss d/t anorexia d/t presence of tumor and malabsorption
Assessment: Muscle Mass
-cachexia (weight loss) secondary to loss of muscle mass is common b/c of decrease appetite and altered protein metabolism
Assessment: Pain location, intensity, duration
- important to note location, intensity, and duration of pain that is cased by the pancreatic tumor compressing surrounding organs and nerves
- pain may radiate to the back b/c of compression of nerves
Assessment: Abdomen
distention and enlargement of the abdomen b/c of presence of ascites
Assessment: Skin color
jaundice d/t tumor obstruction of bile flow
Assessment: Pruritis
accumulation of bile salts under the skin causes itching
Assessments: Postoperative Assessment
post-op monitor vital signs, pain, glucose, NGT output, abdominal assessment, and surgical site
Nursing Actions for Pancreatic Cancer
- Provide Intravenous (IV) fluids
- Maintain NPO
- NGT to low suction
- Never manipulate NGT
- Administer insulin
- Encourage coughing and deep breathing and the use of incentive spirometer or flutter valve every hour while wake
- Administer analgesics and antiemetics
- Nutritional supplements
Actions: Provide IV fluids
hypovolemia occurs b/c of third-space losses in the retroperitoneum from autodigestion of the pancreas and capillary leak
Actions: Maintain NPO status
until the return of GI function post-op, then slowly introduce a diet with clear liquids, and then advance to a regular diet to decrease strain on the surgical site
Actions: NGT to low suction
decompresses stomach b/c postoperative abdominal distention and decreased GI motility can place strain on the surgical anastomosis
Actions: Never manipulate NGT
NGTs are placed by the surgeon, and manipulation can increase the risk of anastomotic breakdown
Actions: Never manipulate NGT
NGTs are placed by the surgeon, and manipulation can increase the risk of anastomotic breakdown
Actions: Administer insulin
pancreatic cancer affects the ability of the pancreas to produce and secrete insulin, leading to hyperglycemia
Actions: Encourage coughing, deep breathing, and use of incentive spirometry every hour while awake
prevents atelectasis, improves oxygenation, and prevents post-op pneumonia
Actions: Administer analgesics an antiemetics as ordered
- Pain management post-op for incisional pain and discomfort
- Pre-operative pain management for pain caused by tumor compression
Actions: Nutritional Supplements
help improve calorie input, prevent weight loss, and promote postoperative surgical wound healing
-high-calorie, high-protein supplements
Patient Teachings
- Post-operative care: what to expect after surgery, pain management
- Medication regimens; know side effects, pain meds may increase risk of constipation and increase pressure and discomfort in abdominal cavity
- Diet and nutrition; supplements to increase caloric intake, maintain weight, and promote wound healing after surgery
- Signs and Symptoms of hyperglycemia and hypoglycemia
- Disease symptoms, progression, diagnostic procedures, and interventions
- Coping skills, palliative care, and support groups
Evaluating Care Outcomes
- the diagnosis of pancreatic cancer generally occurs in a late stage of the disease, and often the patient does not have a prolonged life expectancy
- w/ surgical candidates, it is imperative that they are made aware of the postoperative requirements and restrictions
- b/c diagnosis caries a devastating prognosis, it is important for the healthcare providers to direct the patient to and encourage the use of support systems and self-help books
- encourage patient to be knowledgeable about the disease, treatment, interventions, and restrictions
Connection Check: The nurse assesses for which finding in a patient with a positive Cullen’s sign?
A. Periumbilical bruising
B. Rebound tenderness
C. RUQ pain with radiation to the shoulder
D. Flank bruising
A. Periumbilical bruising
