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Pancreatic Head

mass
INTRODUCTION
•“It is a weariness disease to
preserve health by to strict a
regimen.” Our body is the
mirror of whatever lifestyle
we have. It is the one who
suffers on what we put
inside.
• Patient with pancreatic head mass develop
acute recurrent pancreatitis in childhood,
which usually progresses to chronic
pancreatitis and pancreatic cancer in early
adulthood. A consistent association has been
demonstrated between cigarette smoking and
excessive alcohol drinking for the
development of pancreatic cancer. Hereditary
pancreatitis is a genetic disease caused by a
mutation of a cationic trypsinogen gene. it is
more common on male than in female
because of lifestyle.
• Sixty percent of pancreatic cancers develop in
the pancreatic head; 40% develop in the body
and tail. The major symptoms include
abdominal pain, anorexia, weight loss, and
jaundice. The pain is located in the
epigastrium and has a quality characterized
as deep and boring. The pain may be
intermittent or constant, and is progressive.
Painless jaundice indicates a potentially
resectable lesion located in the pancreatic
head. A predominance of abdominal pain
suggests neural plexus involvement, location
in the tail, unresectability, and a poor
prognosis.
• The only potentially curative
therapy for pancreatic cancer is surgical
resection. The standard operation for
adenocarcinoma in the pancreatic head
or uncinate process is the
pancreaticoduodenectomy, or "Whipple
operation." The Whipple operation
involves resection of the pancreatic
head, duodenum, common bile duct,
distal stomach, and gallbladder.
• Pancreatic head mass has been a
common disease in people
unhealthy lifestyle. I want to know
more about this case and enhanced
my knowledge about it. I want to
be familiar about this case so that I
can implement appropriated
nursing actions to improve the
condition of my client.
OBJECTIVES
• General Objectives

• To gain knowledge on the certain disease (


Pancreatic Head Mass) aimed at as a part of
our course competency, also to provide us
complete learning experience that would help
us understand and increase the capability in
meeting the case as student nurses. To
enhance the nurses skills and to develop
nurses attitude towards caring and
communicating to patient with Pancreatic
Head Mass.
•Specific Objectives

• To know information about


pancreatic head mass.
• To know the signs and symptoms
of pancreatic head mass.
• To determine the complications
that caused by the disease.
• To enumerate the risk factors that
may cause by Pancreatic head mass
and the organs that are affected.
•To be knowledgeable enough
with regards to the tests and
treatment of the disease.
•To provide nursing care plan to
help patient recover.
•To evaluate level of patient’s
recovery.
•To think of nursing plans when
the client is discharged.
PATIENT’S
PROFILE
• Name: Patient X
• Age: 55 yrs. old
• Gender: Male
• Civil Status: Single
• Birthday: April 23, 1953
• Birthplace: Santol, Tanauan Batangas
• Nationality: Filipino
• Religion: Roman Catholic
• Chief Complaint: Abdominal Pain
• Date of Admission: June 29, 2008
• Date of Operation: July 4, 2008
• Attending Physician: Dr. Arellano, Gonzales,
Reyes, Ilagan
CLINICAL APPRAISAL
• A. Past Health History
• Patient X was born in their house
with normal delivery. He received all the
vaccine for his immunization since he was a
child. This is his first time to be hospitalized
for the reason of abdominal pain. He usually
uses analgesics for pain which can be bought
in any store of their barangay. He never
experienced any vehicular accidents because
their place is far from the city and only few
vehicles are seen in their place.
•B. Family History
• The family of Patient X
has a history of tumor. His
mother died because of tumor
in a part of gastrointestinal
area. His other relatives also
have cases of tumors.
•C. Personal History
• Patient X is fond of drinking
alcohol. He drinks alcohol 3-4 times
in a week. As his form of work, he
plants vegetables in their backyard.
He usually sleeps at 9 pm and
wakes up at 6 in the morning.
Watching TV is his form of
relaxation.
•D. Social History
• Patient X reached
Grade 4, he works as a
farmer in their place, Santol,
Tanauan Batangas with a
monthly income of 1000
pesos. He lives with his two
sisters in his mother’s house.
• E. Psychologic History
• Patient X experienced his
major stressor while he was resting
after work 3 months ago. He made
an eye to eye contact when
communicating but find it hard to
verbalize words because of his
condition. Despite if that, he still
can sleep and rests well.
•F. History of Present Illness
• 3 months ago, Patient X
experienced abdominal pain
associated with jaundice and
weight loss. He is first seen in the
private hospital for check-up and
referred to Batangas Regional
Hospital. He was admitted last
June 29 and had his surgery last
July 4, 2008.
PHYSICAL ASSESSMENT
SKIN
•Inspection

• > slightly yellowish in color

• > Abnormal; may indicate high


level of bilirubin in the blood.
•Palpation

•> temperature within normal


range

•Normal
HEAD

•Inspection

•>Symmetrical in shape

•> Normal
HAIR
• Inspection

• > without infestation of lice


• >combined black and white hair
• > with normal

• > Normal
SCALP

•Inspection

•> absence of abrasion

•> Normal
EYES
• EYE BROWS
•Inspection

•> symmetrically aligned

•> Normal
•EYE LASHES
•Inspection

•> with normal distribution

•> Normal
•PUPIL
•Inspection

•> constricts to penlight

•> Normal
•CONJUNCTIVA

• Inspection

• > slightly yellowish in color

• > Abnormal: may indicate high


bilirubin level in the blood
EARS

•AURICLE
• Inspection

• > Symmetrically aligned

• > Normal
• EAR CANAL

•Inspection

•> Symmetrically aligned

•> Normal
NOSE

•Inspection
•> Presence of NGT

•>Abnormal; may indicate


NPO
LIPS
•Inspection

•> slightly dry

•> Abnormal: may indicate low


fluid intake through mouth
TEETH

•Inspection

•> presence of dental cavities

•> Abnormal: may indicate poor


oral hygiene.
TONGUE

•Inspection

•> positioned centrally

•> Normal
TONSIL

•Inspection

•> positioned centrally

•> Normal
LYMPH NODES

•Palpation

•> not palpable

•> Normal
SHOULDER

•Inspection

•>level shoulder

•> Normal
CHEST

•Inspection

•> Symmetrical chest expansion

•> Normal
ABDOMEN
•Inspection

• > Presence of sutured wound and


Jackson Pratt

• > Abnormal; may indicate


undergone operation
UPPER EXTREMITIES
• HANDS

• Inspection

• > thin to touch

• > Normal
NAILS
•Inspection
•> convex curvature
•> Normal
•> slightly dirty
•> Abnormal; may indicate poor
personal hygiene
LOWER EXTREMITIES

•Inspection/ palpation

•> no edema

•> Normal
•Summary:
• Almost all the body parts in physical
assessment are normal expect from
some abnormalities such as yellowish
discoloration in the skin and
conjunctiva, slightly dry lips, presence
of dental cavities, presence of
nasogastric tube, presence of sutured
wound and Jackson Pratt in the
stomach and slightly dirty nails.
ANATOMY AND
PHYSIOLOGY
• The pancreas is located retroperitoneal,
posterior to the stomach in the inferior part of
the left quadrant. It has a head near the
midline of the body and a tail that extends to
the left where it touches the spleen. It is a
complex organ composed of both endocrine
and exocrine tissues that perform several
functions. The endocrine part of the pancreas
consist of pancreatic islets. The islet cells
produce insulin and glucagon, which are very
important in controlling blood levels of
nutrients such as glucose and amino acids.
• The exocrine part of the pancreas is a
compound acinar gland . The acini
produce digestive enzymes. Clusters of
acini are connected by small ducts,
which join to form larger ducts, and a
larger ducts join to form pancreatic
duct. The pancreatic duct joins the
common bile duct and empties into the
duodenum.
• Function of the Pancreas

• The exocrine secretions of the


pancreas include HCO3, which
neutralize the acidic chyme that enters
the small intestine from the stomach.
The increased pH resulting from the
secretion of HCO3 stops pepsin
digestion but provides the proper
environment for the function of
pancreatic enzymes.
• The major proteolytic enzymes
are trypsin, chymotrypsin and
carboxypeptidase. These enzymes
continue the protein digestion that
started in the stomach and
pancreatic amylase continues the
polysaccharide digestion that
begun in the oral cavity.
PATHOPHYSIOLOGY
•Pancreatic cancer can arise from
both the exocrine and endocrine
portions of the pancreas. Of
pancreatic tumors, 95% develop
from the exocrine portion of the
pancreas, including ductal
epithelium, acinar cells,
connective tissue, and
lymphatic tissue.
• Approximately, 75% of all
pancreatic carcinomas occur within
the head or neck of the pancreas.
15-20% occur in the body of the
pancreas and 5-10% occur in the
tail. Typically, pancreatic cancer
first metastasizes to regional lymph
nodes, then to the liver and less
commonly to the lungs. It can also
directly invade surrounding
visceral organs such as the
duodenum, stomach and colon.
•As in other organs, chronic
inflammation is a predisposing
factor in the development of
pancreatic cancer. Patients with
chronic pancreatitis from
alcohol, especially those with
familial forms, have much
higher incidence and an earlier
age of onset on pancreatic
carcinoma.
PANCREAS

Head Body Tail


Exocrine Endocrine

Pancreatic Cancer
Formed
Ductal epithelium

Regional Lymph Acinar Cells


Nodes

Connective Tissue
Liver

Lungs Lymphatic Tissue

Duodenum
Stomach
colon
NURSING CARE PLAN
ASSESSMENT

•S> “ Malala pa ang ubo


ko,” as verbalized by the
patient.
•O > presence of productive
cough.
•> difficulty vocalizing.
•> excessive sputum
•> RR= 28 bpm
•> restless
•> weak
NURSING DIAGNOSIS

•> Ineffective airway


clearance related to presence
of secretions in the bronchi.
SCIENTIFIC EXPLANATION
• > Pulmonary complications
following surgery are associated
with significant morbidity and
have been shown to increase the
length of hospitalization. Efforts
have been focused on the
minimization of postoperative risk
factors, such as prolonged bed rest
and inadequate pain control, and
on the routine use of incentive
spirometry.
PLANNING
•> After 3 hours of nursing
intervention, the client will
be able to maintain better
airway patency.
INTERVENTION RATIONALE
• > Monitored • >To note the
respiration and inactive respiratory
breath sounds,
noting rate and distress and/ or
sound. ( tachypnea, accumulation of
stridor, crackels and secretions.
wheezes).
• > To open or
maintain open
• > Positioned head
appropriate for age/ airway in at-rest or
condition. compromised
individual.
• > Elevated head of • >To take advantage
the bed and changed of gravity
position every 2 decreasing pressure
hours. on the diaphragm
and enhancing
• > Encouraged deep drainage of/
breathing and ventilation to
coughing exercises. different lung
segments.
• > To maximize
effort.
• > Observe signs • > To identify
and symptoms of infectious process/
infection promote timely
(increased intervention.
dyspnea with
onset of fever,
change in sputum
color, amount or
character.)
• > Performed • > To enhance the
bronchial tapping client’s capability to
expectorate
secretions.
EVALUATION

•The client maintained better


airway patency and
expectorated secretions readily.
ASSESMENT

•S> “Nilalagnat ako.” as


verbalized by the patient.
•O> temperature= 39 degrees
Celsius
•> warm to touch
•>RR= 29 bpm
•> weak
•> restless
NURSING DIAGNOSIS

•Increased in body
temperature related to tissue
trauma secondary to
removal of IV.
SCIENTIFIC EXPLANATION

• Fever is a common, fast and easy


measurable sign of inflammation and
infection. An increase in body
temperature often coincides with the
liberation of microbiological products
or live bacteria into the circulation.
During sepsis, hyperthermia may also
occur.
PLANNING

•After 2 hours of nursing


interventions, the client's
temperature will decrease from
39 degrees Celsius to 38 degrees
Celsius.
INTERVENTION RATIONALE

• > Monitored • > To have a


vital signs. guide for
• > Monitored all nursing actions
sources of fluid to be taken.
loss such as • > Potentiates
urine, vomiting fluid and
and diarrhea. electrolytes
losses.
• > Noted absence/ • >Evaporation is
presence of decreased by
sweating as body environmental
attempts to factors as high
increase heat loss humidity and
by evaporation, high ambient
conduction and temperature, as
diffusion. well as body
factors producing
loss of ability to
sweat or sweat
glands
dysfunction.
• > Performed • > Heat loss by
tepid sponge evaporation
bath. and conduction.
• > Maintained • >To reduce
bed rest. metabolic
demands/oxyg
en
consumption.
EVALUATION

•> Body temperature


decreased form 39 degrees
Celsius to 38 degrees
Celsius.
ASSESSMENT

•S> “ Medyo sumasakit ang


tahi ko,” as verbalized by the
patient.
•O> limited mobility
•> facial grimace
•> PR= 88 bpm
•> BP= 140/90 mmHg
•> with sutured wound on
hypogastric region.
•> Pain Scale= 6 out of 10.
NURSING DIAGNOSIS

•Pain related to tissue


trauma secondary to
operation.
SCIENTIFIC EXPLANATION
• Unpleasant sensory from actual or
potential tissue damage; sudden or
slow onset of any intensity from
mild to severe. Pain is a signal that
something is wrong. It is due to
infection and increased number of
white blood cells on the sight of
incision to fight microorganisms
that will enter on the sutured
wound and prevent sepsis.
INTERVENTION RATIONALE
• > To have a guide
• > Monitored vital
signs. for nursing actions
to be taken.
• > Observed non
verbal cues/ pain • > Observations
behaviors and other may/may not be
objective defining congruent with
characteristics. verbal reports or
maybe only
indicator present
when client is
unable to verbalize.
• > Provided comfort • > To promote non
measures pharmacological
(therapeutic touch, pain management.
repositioning, use of
heat/cold packs),
quite environment
and calm activities.
• > Encouraged use of • > To distract
relaxation attention and reduce
techniques such as tension.
focused breathing
and imaging.
EVALUATION

• The pain decreased to a


tolerable level allowing
the patient to mobilize wit
minimal assistance.
DRUG STUDY
NAME OF THE DRUG
• Generic Name:
• Unasyn

• Brand Name:
• Ampicilin Sodium and Sulbactam
Sodium
CLASSIFICATION ON
ACTION

•Inhibits cell wall synthesis


during bacterial
multiplication.
INDICATIONS

•Intra-abdominal,
gynecologic, and skin
structure infections caused
by susceptible strains.
CONTRAINDICATIONS
• Contraindicated to patients
hypersensitive to drug or other
penicillin.
• Use cautiously in patients with
other drug allergies ( especially to
cephalosporins) because of possible
cross-sensitivity, and in those with
mononucleiosis because of high
risk of maculopapular rash.
ADVERSE REACTION
• CV: thrombophlebitis, vein irritation
• GI: diarrhea, Nausea,
pseudomembranous colitis,vomiting,
stomatitis, gastritis, black hairy tongue,
enterocolitis.
• HEMATOLOGIC: agranulocytosis,
leucopenia, anemia, eosinophilia.
• SKIN: pain at injection site.
• OTHER: hypersensitivity
reaction,anaphylaxis,overgrowth of non
susceptible organisms.
NURSING RESPONSIBILITY

• Ask patient about allergic reactions


to penicillin. Obtain specimen of
culture and sensitivity test.
• In patient with impaired renal
function, decrease dosage.
• In children, don’t use I.M. route.
• Monitor liver function test results
during therapy, especially in
patients with impaired liver
function.
• If large doses are given or if
therapy is prolonged, bacterial and
fungal superinfectiton may occur,
especially in elderly, debilitated or
immunosuppresssed patient.
MONITORING PARAMETERS

• May increase alkaline phosphatase,


bilirubin, creatinine and LDH
levels.
• May increase eosinophil count.
May decrease granulocyte, platelet
and WBC count.
•May alter results of urine
glucose tests that use cupric
sulfate, such as Benedict
reagent and clinitest.
NAME OF DRUGS

•Generic Name:
•Captoril
•Brand Name:
•Capoten
CLASSIFICATION ON
ACTION
• > Inhibits ACE, preventing
conversion of angiotensin I to
angiotensin II, a potent
vasoconstrictor. Less angiotensin II
decreases peripheral arterial
resistance, decreasing aldosterone
secretions, which reduces sodium
and water retention and lowers
blood pressure.
INDICATIONS

•> Hypertension
•> Diabetic nephropathy
•> Heart failure
•> left ventricular dysfunction
after acute MI.
CONTRAINDICATIONS
• > Contraindicated in patients
hypersensitive to drug or other ACE
inhibitors.
• > Use cautiously in patients with
impaired renal function or serious
autoimmune disease, especially
systemic lupus erythematous, and in
those who have been exposed to other
drug that affect WBC counts or immune
response.
ADVERSE REACTION
• CNS: dizziness, fainting, headache,
fatigue, fever.
• CV: tachycardia, hypotension
• GI: abdominal pain, anorexia,
constipation, dry mouth, nausea
and vomiting.
•METABOLIC: hyperkalemia
•RESPIRATORY: dry, non
productive cough.
•OTHER: angioedema
NURSING RESPONSIBILITY
• > Monitor patients BP and PR
frequently.
• > Elderly patients may be more
sensitive to drug’s hypotensive
effects.
• > Assess patient for signs of
angioedema.
•> Drug causes more frequent
occurrence of cough, compared
with other ACE inhibitors.
•> Don’t confuse Captopril with
Capitrol.
MONITORING PARAMETERS

• > May increase alkaline


phosphatase, bilirubin and
potassium levels. May decrease
hemoglobin level and hematocrit.
• > May decrease granulocyte,
platelet, RBC and WBC counts.
• > May decrease granulocyte,
platelet, RBC and WBC counts
NAME OF DRUGS

•Generic Name:
• Metronidazole
•Brand Name:
•Flagyl
CLASSIFICATION OF
ACTION
• > Direct-acting trichomonacide and
amebicide that works inside and
outside the intestines. It’s thought
to enter the cells of microorganisms
that contain nitroreductase,
forming unstable compounds that
bind to DNA and inhibit synthesis
causing cell death.
INDICATIONS

•> Amebic Liver abscess


•> Intestinal amebiasis
•>Trichomoniasis
•> Refractory trichomoniasis
•> Bacterial infections caused by
anaerobic organisms.
•>To prevent postoperative
infection in contaminated and
potentially contaminated
colorectal surgery.
•> Bacterial Vaginosis
CONTRAINDICATIONS

•> Contraindicated in patients


hypersensitive to drug or other
nitroimidazole derivatives.
•> Use cautiously in patients
with history of CNS disorder,
or retinal and visual field
changes.
•> Use cautiously in patients
who take hepatotoxic drugs or
have hepatic disease or
alcoholism.
ADVERSE REACTION

•CNS: headache, fever,


dizziness, incoordination,
confusion, irritability,
depression, weakness, insomia.
•CV: edema, flushing,
•EENT: rhinitis, sinusitis,
pharyngitis
•GI: nausea, abdominal pain,
stomatitis, vomiting, diarrhea,
constipation, dry mouth.
•GU: darkened urine, polyuria
•OTHER: decreased libido,
overgrowth of non susceptible
organism.
NURSING RESPONSIBILITY

• > Monitor liver function test results


carefully in elderly patients.
• > Observe patient for edema,
especially if he’s receiving
corticosteroids,
• > Record number and character of
stools when drug is used to treat
amebiasis.
MONITORING PARAMETERS

•> May decrease WBC and


neutrophil counts.

•> May falsely decrease


triglycerides and
aminotransferase levels.
PROGNOSIS
• Some patients with
Pancreatic head mass that is
resectable ( can be surgically
removed) are cured.
However, cure rates are
significantly less than 50%.
• In our case study, the patient
experienced early signs and symptoms
of abdominal pain associated with
jaundice and weight loss. When he was
admitted in the hospital, he also
experienced vomiting. He underwent
hematology and ultrasound for whole
abdomen and left hemithorax. He also
underwent biopsy of the pancreas and
operation of gastrojejunostomy. The
improvement of his condition was seen
several days after the operation.
• His condition was improved but not
enough for him to be discharge in the
hospital. He is still not allowed to eat
or drink anything through mouth. He
still have nasogastric tube where he
takes his medications, and a Jackson
Pratt connected to his area where body
fluids are build. But because of
immeasurable support of his sister and
other relatives, our patient still fights
and show signs that he will be well
soon.
DISCHARGED
PLANNING
MEDICATION
• M Instruct the client to take his medication
>

such as Captopril, Metronidazole,


Cefoxitin and Esomeprazole.
• >Reinforce importance of medication
compliance to patient and his relatives: it’s
time, route, dosage, frequency and duration.
• >Advice to report unusual
manifestations and side effects of drug to
physician.
ENVIRONMENT/EXERCISE

E > Instruct the patients relative to


provide calm and non stressful
environment.
> Provide environment with normal room
and body temperature.
> Maintain clean and safe environment.
> Encourage patient to have mild exercise.
TREATMENT

T> Teach patient how to


manage pain regarding his
sutured wound.
HEALTH
TEACHING/HYGIENE

H> Explain to patient’s relative


regarding disease and its
manifestations.
>Discuss possible complications of
disease and its signs and symptoms.
>Instruct the client to have proper
hygiene.
>Discuss the importance of
proper personal hygiene.
> Encourage the patient to do
proper hand washing before and
after eating and whenever it is
necessary.
OUT PATIENT FOLLOW UP

O> Inform relatives and patient


regarding the importance of
compliance on follow up.
DIET
D> Encourage the patient to increase fluid intake and
eat nutritious foods such as fruits and vegetables.
> Instruct the patient to avoid salty and fatty foods.
> Instruct the patient to avoid smoking and
alcoholic beverages.
SPIRITUAL

S > Encourage patient’s relative


to seek spiritual support.
> Encourage the patient to hold
his faith in God.
BIBLIOGRAPHY
• Kozier, Barbara, Fundamentals of Nursing, 7th Edition,
Gentzler Company, 2002
• Brunner and Suddarth’s Textbook of Medical-surgical
Nursing, 11th Edition , Volume I.
• Doenges, Marilyn G., Nurses Pocket Guide, 10th
Edition, Stamper Company., 2003
• Brener, Toby E., Nursing 2007 Drug Handbook 27th
Edition, Little John Company., 2007
• Internet:
• http://www.google.com.ph
• http://www.yahoo.com