Nursing+Process

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 * Applying the Nursing Process**
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=Assessment= Cancer of the pancreas has been called a **“silent” disease**; one reason for the poor survival rate is that cancer is often not detected during its early stages because of its insidious onset. The signs and symptoms are vague and frequently disregarded, or they are attributed to some minor ailment. **Abdominal pain** is a common sign of advanced pancreatic cancer. Cancer of the body of the pancreas impinge on the celiac ganglion, causing pain. Unplanned **weight loss** and **epigastric pain that may radiate to the back** are common complaints. REMINDER: Listen carefully to your patient.


 * Ask the patient to describe the type and intensity of the pain and also aggravating and relieving factors. Patients often report a dull intermittent pain that has become more intense. Eating and activity often precipitate pain, whereas lying supine or sitting up and bending forward may offer relief.


 * Question the patient as to the presence of any nausea and vomiting (especially that worsens after eating), anorexia, flatulence, diarrhea, constipation, or unusual fatigue.


 * Inspect the patient for the presence and extent of jaundice, which is the presenting symptom in 80% to 90% of patients with cancer of the pancreatic head. The jaundice may have preceded or followed the onset of pain, but it usually progresses along a distinctive pattern: beginning on the mucous membranes, then on the palms of the hands, and finally becoming generalized.


 * If the cancer blocks the release of pancreatic juices into the intestines, the patient may have difficulty digesting fatty foods; this will result in pale, bulky, greasy stools that tend to float in the toilet.


 * Assess for the presence of pruritus and dark urine, which is caused by a build up of bilirubin in the skin and blood, respectively.


 * Early tumors can usually not be palpated but auscultate, palpate, and percuss the abdomen. If the tumor involves the body and tail of the pancreas, an abdominal bruit may be heard in the left upper quadrant (indicating involvement of the splenic artery) and a large, hard mass may be palpated in the subumbilical or left hypochondrial region. Note the presence of liver or spleen enlargement. Dullness on percussion may indicate the presence of ascites or gallbladder enlargement.


 * Assess for the presence of irritability, depression, and personality changes. The sudden onset of characteristic symptoms can precipitate these emotional responses. Families and patients often display profound grief and disbelief on receiving the diagnosis of pancreatic cancer and a poor prognosis. Assess the specific feelings and fears of the patient and family and also the support systems available and previous coping strategies.


 * NOTE:** These assessment notes are intended to assist in the initial and ongoing assessment of your patient. It is critical that assessment and the nursing process is applied continually throughout the care of your patient and NOT only at the initial planning phase.

=Primary Nursing Diagnosis=

Pain (chronic and acute) related to the effects of tumor invasion and surgical incision.

=Interventions & Treatment Plans=

Surgery, radiotherapy, and chemotherapy are the major treatment modalities for pancreatic cancer. Below are some notes/facts on each of the procedures. It is important to understand the background of each procedure in order to plan quality care for your patient.


 * A **distal pancreatectomy**, used more often with islet cell tumors than with exocrine cancer, removes only the tail of the pancreas or the tail and part of the body. The __spleen is also removed__.


 * A **total pancreatectomy** or a **pancreatoduodenectomy** (**Whipple procedure**) is __used when cure is the objective__. In a total pancreatectomy, the entire pancreas and spleen are removed. The Whipple procedure involves removal of the head of the pancreas, distal stomach, gallbladder, pancreas, spleen, duodenum, proximal jejunum, and regional lymph nodes. The __procedure induces exocrine insufficiency and insulin-dependent diabetes__. A pancreatojejunostomy, hepaticojejunostomy, and gastrojejunostomy are performed with the Whipple procedure to reconstruct the gastrointestinal (GI) system.


 * A **vagotomy** is usually done in both procedures to __decrease the risk of peptic ulcer__.

=Postoperative Nursing Care=
 * Careful postoperative management is essential for providing comfort and reducing surgical mortality.
 * Observe vital signs, prothrombin times, drainage from drains, and wounds for signs of infection, hemorrhage, or fistula formation.
 * Report immediately any evidence of increasing abdominal distension; shock; hematemesis, bloody stools; or bloody, gastric, or bile-colored drainage from incision sites.
 * Vitamin K injections and blood components may be needed.


 * Monitor GI drainage from the nasogastric (NG) or gastrostomy tubes carefully**. These tubes are strategically placed during surgery to decompress the stomach and prevent stress on the anastomosis sites.
 * Maintain the tube’s patency by preventing kinks or dislodgment;
 * maintain suction at the prescribed level (usually low continuous suction for an NG tube).
 * Secure gastrostomy tubes in a dependent position.
 * Monitor the color, consistency, and amount of drainage from each tube. The presence of serosanguineous drainage is expected, but clear, bile-tinged drainage or frank blood could indicate disruption of an anastomosis site and should be reported immediately.
 * Do **NOT** irrigate the NG or gastrostomy tube without specific orders. When irrigation is ordered, gently instill 10 to 20 mL of normal saline solution to remove an obstruction.

Because **postoperative nutritional requirements** for adequate tissue healing approximate 3000 calories per day, parenteral hyperalimentation is often ordered.
 * Monitor the blood and urine glucose levels every 6 hours, and administer insulin as needed.
 * Once oral food and fluids are allowed, the patient is placed on a bland, low-fat, high-carbohydrate, high-protein diet.
 * Administer pancreatic enzyme supplements (pancrelipase [Viokase, Cotazym] and lipase for metabolism of long-chain triglycerides) with each meal and snack.
 * Observe and report any evidence of diarrhea or frothy, floating, foul-smelling stools (an indication of steatorrhea) because an adjustment in the enzyme replacement therapy may be needed.

A **combination of adjuvant chemotherapy** and **radiation therapy** with surgery may increase survival time 6 to 11 months. Most patients receive chemotherapy and radiation therapy on an outpatient basis. **Palliative surgical procedures** can be used to relieve the obstructive jaundice, duodenal obstruction, and severe back pain that are characteristic of advanced disease.


 * Provide emotional support and information as treatment goals and options are explored.** Patients newly diagnosed with pancreatic cancer are often in shock, especially when the disease is diagnosed in the advanced stages.
 * Encourage the patient and family to verbalize their feelings surrounding the diagnosis and impending death.
 * Allow for the time needed to adjust to the diagnosis, while helping the patient and family begin the grieving process.


 * Help family members** identify the extent of physical home care that is realistically required by the patient. Arrange for visits by a home health agency. Suggest the family seek supportive counseling (hospice, grief counselor), and if necessary, make the initial contact for them. Local units of the American Cancer Society offer assistance with home care supplies and support groups for patients and families.


 * Following any surgical procedure, direct care toward preventing the associated complications.**
 * Use the sterile technique when changing dressings and emptying wound drainage tubes.
 * Place the patient in a semi-Fowler position to reduce stress on the incision and to optimize lung expansion.
 * Help the patient turn over in bed, and perform coughing, deep-breathing, and leg exercises every 2 hours to prevent skin breakdown and pulmonary and vascular stasis.
 * Teach the patient to splint the abdominal incision with a pillow to minimize pain when turning or performing coughing and deep-breathing exercises.
 * As soon as it is allowed, help the patient get out of bed and ambulate in hallways three to four times each day. **Be alert** for the sudden onset of chest pain or dyspnea (or both), which could indicate the presence of a pulmonary embolism.


 * Continually assess pain.** As the disease progresses and pain increases, large doses of narcotic analgesics may be needed. Instruct the patient on the effective use of the pain scale and to request pain medication before the pain escalates to an intolerable level. Consider switching as-needed pain medication to an around-the-clock dosing schedule to keep pain under control. Encourage the patient and family to verbalize any concerns about the use of narcotics, and stress that drug addiction is not a consideration.

=Discharge & Homecare Notes=


 * Reinforce the need for small, frequent meals.
 * Warn against overeating at any one meal, which places too great a demand on the pancreas, and stress limiting caffeine and alcohol.
 * Instruct the patient to **inspect stools daily** and report to the physician any signs of steatorrhea.
 * Teach the patient and family the **care related to surgically induced diabetes**: symptoms and appropriate treatment for hypoglycemia and hyperglycemia, procedure for performing blood glucose monitoring, administration of insulin injections.
 * Teach the patient or significant other to change the dressing over the abdominal incision and empty the drains daily (if present).


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