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Manuscript (Resource Unit) - Pancreaticoduodenectomy
Manuscript (Resource Unit) - Pancreaticoduodenectomy
Topic: Pancreaticoduodenectomy
General Objective: Within 45 minutes to 1 hour, the presenters will be able to provide information about pancreaticoduodenectomy to their target audience which is their co-
students.
At the end of the DISCUSSION Noronisa D. 15 Visual Aids General Surgery - Whipple Procedure The audience
presentation, the Definition Cabugatan mins. through (Pancreaticoduodenectomy). (n.d.). UCSF will be asked
audience must be Pancreaticoduodenectomy, also known as the Whipple PowerPoint General Surgery. Retrieved January 5, 2022, directly
able to: procedure, is a surgical procedure where the surgeon removes Presentation from related to
cancerous parts of the pancreas, duodenum, common bile duct, https://generalsurgery.ucsf.edu/conditions-- the topic and
Gain and if required, portions of the stomach (UCSF General Surgery, procedures/whipple-procedure- must be able
knowledge on n.d.). (pancreaticoduodenectomy).aspx to answer.
the This is to see
background of Indication: whether
pancreaticodu The Whipple Procedure is performed to treat the following there are
odenectomy conditions: areas of the
such as its discussion
indications, Cancer of the ampulla of Vater (Ampullary Cancer) that need
purpose, Cancer of the distal (lower portion) of the bile duct reinforcing
types, Chronic Pancreatitis or re-
approaches Duodenal cancer teaching.
Neuroendocrine (Islet Cell) Tumors
Pancreatic Cancer
Pancreaticoduodenectomy - StatPearls. (2021,
It is the surgical procedure of choice for the resectable and July 15). NCBI. Retrieved January 5, 2022, from
the borderline resectable pancreatic ductal adenocarcinomas. https://www.ncbi.nlm.nih.gov/books/NBK560
747/
This surgical procedure poses immense difficulties to the
surgeons due to the complex as well as highly difficult intra-
abdominal dissection and likewise the repair of the digestion
system. Due to its complex nature, this procedure has historically
been associated with higher mortality and perioperative
morbidity. (NCBI, 2021).
Whipple procedure. (2020, June 3). Mayo
Clinic. Retrieved January 6, 2022, from
Purpose
https://www.mayoclinic.org/tests-
The goal of doing a Whipple procedure for cancer is:
procedures/whipple-procedure/about/pac-
- To remove the tumor and prevent it from growing and
20385054
spreading to other organs. This is the only treatment that
can lead to prolonged survival and cure for most of these
tumors (Mayo Clinic, 2020). Pancreaticoduodenectomy - StatPearls. (2021,
July 15). NCBI. Retrieved January 5, 2022, from
Types
https://www.ncbi.nlm.nih.gov/books/NBK560
Classical Whipple (CW)
747/
- It is the type of Whipple’s Procedure that is more
extensive; entails the removal of the pancreatic head, the
duodenum, a section of the stomach, the gallbladder, and a
part of the bile duct.
Approach
The pancreaticoduodenectomy can be performed:
Laparoscopic
o This approach uses several incisions of one-quarter inch
or less
o The laparoscopic approach is associated with shorter
length of stay, less blood loss, and better lymph node
dissection
Open approach
o In more conventional open surgery, a single incision,
inches long or more, is made to access the abdomen.
Anesthesia
A nasogastric tube is inserted. General anesthesia with
endotracheal intubation is recommended.
Position
The patient is placed supine on the table with the feet slightly
lower than the head. Facilities should be available for performing a Shara 8 mins.
Minter, & Doherty. (June 2010). LANGE
cholangiogram or pancreaticogram. The abdomen is entered Lailanie A.
Current Surgical Procedures . The McGraw-Hill
Know the through a midline incision or bilateral subcostal "Chevron" Azis
Companies. (n.d.). Retrieved from
different OR incision, depending on surgeon preference.
https://www.rnpedia.com/nursing-notes/medi
equipment, cal-surgical-nursing-notes/
Skin Preparation
supplies, pancreaticoduodenectomy-whipple-
The skin should be shaved from the level of the nipples well out
instruments procedure/
over the chest wall and down over the abdomen, including the
involved in the
flanks.
procedure
including their
functions
COMPLETE OR EQUIPMENT, INSTRUMENTATION, AND
SUPPLIES WITH THEIR FUNCTIONS
Packs/ Drapes
Laparotomy pack
o Laparotomy Packs are specially designed to
contain surgical items needed to perform laparotomy
surgery in operating room, they are packed sterile to
save time and reduce the costs of operating room set-
up. Each laparotomy pack contains the surgical items
and a laparotomy drape. The laparotomy surgical drape
can absorb the flood when operating.
Instrumentation
Supplies/ Equipment
Basin set
o It is a shallow basin with different shape base and
sloping walls used in medical and surgical wards to
receive soiled dressings and other medical waste.
Blades – (2) #10, (1) #15
o Blades #10: a large vurved cutting edge, which
represents a more traditional blade shape. It is used for
cutting soft tissue, typically with large incisions.
o Blade #15: Ideal for making short, precise incisions
because of its small, curved cutting edge.
Electrosurgical unit; suction
o (bovie) is a surgical device used to incise tissue, destroy
tissue through desiccation, and to control bleeding by
causing the coagulation of blood.
Hemoclips/ surgiclips
o Used for applying clips to small vessels in all branches
of surgery.
Dissector sponges
o Used whenever tissue is needed to be abrasively, yet
gently, removed from neighboring organs, vessels, or
arteries.
Needle counter
o Designed to aid in accounting for used, disposable
surgical sharps during a procedure.
Internal staples
o Used to deliver staples to tissues inside the body during
surgery for: removing part of an organ (resection),
cutting through and sealing organs and tissues
(transection).
Drains – for retractors: Penrose 1 inch.
o It lets blood and other fluids move out of the area of Norhanessah 10
the surgery. M. Dalupang mins.
For drainage: HemoVac, Jackson Pratt, etc Vera, M. (2014). Preoperative Phase.
Obtain o This is a fine tube with many holes at the end, which is Nurselabs.
learnings on attached to an evacuated glass bottle providing suction. https://nurselabs.com/preoperative-
the It is used to drain blood under the skin. phase/
perioperative Sutures – surgeon’s preference
nursing o Surgical threads that are used to repair cuts
responsibilities (lacerations). Also used to closed incisions from
of Whipple’s surgery.
Procedure Solutions – saline, water
o It used to clean wounds, clear sinuses, and treat
dehydration.
Medications – Hemostatic agents, etc.
o Used as an adjunct or alternative to standard surgical
techniques to manage bleeding from surgical surfaces.
PREOPERATIVE:
Physiologic Assessment
Before any treatment is initiated, a health history is
obtained, and a physical examination is performed
during which vital signs are noted and a data base is
establish for future comparisons. Example: Age,
health history and perform physical examination,
Fluid and Electrolyte Imbalance, Drug and alcohol
use, Respiratory status, Cardiovascular status and
etc.
Gerontologic Considerations
Monitor older patients undergoing surgery for
subtle clues that indicate underlying problems since
elder patients have less physiologic reserve than
younger patients.
Monitor also elderly patients for dehydration,
hypovolemia, and electrolyte imbalances.
Psychological Assessment
Explore the client’s fears, worries and concerns.
Encourage patient verbalization of feelings.
Provide information that helps to allay fears and
concerns of the patient.
Give empathetic support.
Provide Informed consent
Reducing Anxiety and Fear
Provide psychosocial support.
Be a good listener, be empathetic, and provide
information that helps alleviate concerns.
During preliminary contacts, give the patient
opportunities to ask questions and to become
acquainted with those who might be providing care
during and after surgery.
Acknowledge patient concerns or worries about
impending surgery by listening and communicating
therapeutically.
Explore any fears with patient, and arrange for the
assistance of other health professionals if required.
Teach patient cognitive strategies that may be
useful for relieving tension, overcoming anxiety,
and achieving relaxation, including imagery,
distraction, or optimistic affirmations.
Managing Nutrition and Fluids
Provide nutritional support as ordered to correct
any nutrient deficiency before surgery to provide
enough protein for tissue repair.
Instruct patient that oral intake of food or water
should be withheld 8 to 10 hours before the
operation (most common), unless physician allows
clear fluids up to 3 to 4 hours before surgery.
Inform patient that a light meal may be permitted
on the preceding evening when surgery is
scheduled in the morning, or provide a soft
breakfast, if prescribed, when surgery is scheduled
to take place after noon and does not involve any
part of the GI tract.
In dehydrated patients, and especially in older
patients, encourage fluids by mouth, as ordered,
before surgery, and administer fluids intravenously
as ordered.
Monitor the patient with a history of chronic
alcoholism for malnutrition and other systemic
problems that increase the surgical risk as well as
for alcohol withdrawal (delirium tremens up to 72
hours after alcohol withdrawal).
Vera, M. (2014) Intraoperative
Phase.Nurselabs.
o Clarify teaching and learning as needed. Provide
https://nurselabs.com/
psychologic support for client and family. The client
intraoperative.com/intraoperative-
and family faced with a diagnosis of pancreatic
phase/
cancer may require reinforcement of teaching as
anxiety, fear, and possible denial can interfere with
learning.
o Maintain in semi-Fowler’s position. Semi-Fowler’s
position facilitates lung expansion and reduces
stress on the anastomosis and suture line.
o Maintain low gastrointestinal suction. If drainage is
not adequate, obtain an order to irrigate, using
minimal pressure. Do not reposition nasogastric
tube. Pressure within the operative area from
retained secretions increases intraluminal pressure
and places stress on the suture line. Forceful
irrigations and repositioning of the nasogastric tube
may disrupt the suture line.
INTRAOPERATIVE:
The second phase where the patient is transferred in operating
room, administered with anesthesia, the ongoing procedure of
surgery up to transfer of the recovery room.
Administration of anesthesia
The following are nursing assessment after anesthesia:
Monitoring vital signs.
Observe patient and record the time when motion and
sensation of the legs and the toes return.
Side Effects
Some numbness or reduced feeling in part of your body
(local anesthesia)
Nausea and vomiting.
A mild drop in body temperature.
Positioning
The nurse should have an idea which patient position is
required for a certain surgical procedure to be performed.
There are lots of factors to consider in positioning the
patient which includes the following:
Patient should be in a comfortable position as possible
whether he or she is awake or asleep.
The operative area must be adequately exposed.
The vascular supply should not be obstructed by an
awkward position or undue pressure on a part.
Rijal, S. (2018) Post-operative Care in
There should be no interference with the patient’s
pancreatitis: Nursing Interention.
respiration as a result of pressure of the arms on the chest
Arcada University of Applied
or constriction of the neck or chest caused by a gown.
Sciences.https//www.thesus.fi>handleP
The nerves of the client must be protected from undue
DF Post-operative care in pancreatitis:
pressure. Serious injury or paralysis may result from
Nursing intervention – Thesus
improper positioning of the arms, hands, legs or feet.
Shoulder braces must be well padded to prevent
irreparable nerve injury.
Patient safety must be observed at all times.
In case of excitement, the patient needs gentle restraint
before induction.
Safety is the highest priority.
Simultaneous placement of feet. This is to prevent
dislocation of hip.
Always apply knee strap.
Arms should not be more than 90°
Prepare and apply cautery pad. Cautery is used to stop
bleeding.
POSTOPERATIVE:
The last phase in which the patient is transferred in recovery room
up to the releasing in the hospital.
NURSING DIAGNOSIS #1
Acute pain related to obstruction of pancreatic, biliary ducts as
evidence by self-focusing, grimacing, distraction/guarding
behaviors
CUES
Subjective cues
Objective cues
Vital signs:
Temp: 37.4 °C
BP: 110/80 mm Hg
PR: 80 bpm
RR: 12 cpm
Facial grimace
Body malaise
Pain scale of 7
OBJECTIVES
INTERVENTIONS
RATIONALE
Pain is often diffuse, severe, and unrelenting in acute or
hemorrhagic pancreatitis. Severe pain is often the major
symptoms in patients with chronic pancreatitis. Isolated
pain in the RUQ reflects involvement of the head of the
pancreas. Pain in the left upper quadrant (RUQ) suggests
involvement of the pancreatic tail. Localized pain may
indicate development of pseudocysts or abscesses.
Decreases metabolic rate and GI stimulation and
secretions, thereby reducing pancreatic activity.
Reduces abdominal pressure tension, providing some
measure of comfort and pain relief.
Note: Supine position often increases pain.
Promotes relaxation and enables patient to refocus
attention; may enhance coping.
Sensory stimulation can activate pancreatic enzymes,
increasing pain.
Severe and prolonged pain can aggravate shock and is more
difficult to relieve, requiring larger doses of medication,
which can mask underlying problems and complications
and may contribute to respiratory depression.
Pancreatic enzymes can digest the skin and tissues of the
abdominal wall, creating a chemical burn.
EVALUATION
NURSING DIAGNOSIS #2
Risk for infection
CUES
Subjective Cues:
Objective Cues:
Vital Signs:
Temp: 38°C
BP: 120/85
RR: 20 cpm
PR: 90 bpm
Warm to touch
Pallor
Shivering
OBJECTIVES
After nursing interventions patient will achieve timely
healing, be free of signs of infection.
Will be afebrile.
Will participate in activities to reduce risk of infection.
INTERVENTIONS
Use strict aseptic technique when changing surgical
dressings or working with IV lines, indwelling catheters and
tubes, drains. Change soiled dressings promptly.
Stress importance of good handwashing.
Observe rate and characteristics of respirations, breath
sounds. Note occurrence of cough and sputum production.
Encourage frequent position changes, deep breathing, and
coughing. Assist with ambulation as soon as stable.
Observe for signs of infection:
Fever and respiratory distress in conjunction with jaundice;
Increased abdominal pain, rigidity and rebound
tenderness, diminished and absent bowel sounds;
Increased abdominal pain and tenderness, recurrent fever
(higher than 101°F), leukocytosis, hypotension,
tachycardia, and chills.
Obtain culture specimens (blood, wound, urine, sputum, or
pancreatic aspirate).
Administer antibiotic therapy as indicated: cephalosporins,
cefoxitin sodium (Mefoxin); plus aminoglycosides:
gentamicin (Garamycin), tobramycin (Nebcin).
RATIONALE
Limits sources of infection, which can lead to sepsis in a
compromised patient. Note: Studies indicate that
infectious complications are responsible for about 80% of
deaths associated with pancreatitis.
Reduces risk of cross-contamination.
Fluid accumulation and limited mobility predispose to
respiratory infections and atelectasis. Accumulation of
ascites fluid may cause elevated diaphragm and shallow
abdominal breathing.
Enhances ventilation of all lung segments and promotes
mobilization of secretions.
Cholestatic jaundice and decreased pulmonary function
may be first sign of sepsis involving Gram-negative
organisms.
Suggestive of peritonitis.
Abscesses can occur 2 wk or more after the onset of
pancreatitis (mortality can exceed 50%) and should be
suspected whenever patient is deteriorating despite
supportive measures.
Identifies presence of infection and causative organism.
Broad-spectrum antibiotics are generally recommended for
sepsis; however, therapy will be based on the specific
organisms cultured.
EVALUATION
After nursing interventions patient achieves timely healing,
be free of signs of infection.
Is afebrile. Participates in activities to reduce risk of
infection.
NURSING DIAGNOSIS #3
CUES
SUBJECTIVE CUES
OBJECTIVE CUES
Temp: 37°C
BP: 110/80 mm Hg
PR: 85 bpm
RR: 18 cpm
Weight loss
OBJECTIVES
INTERVENTIONS
RATIONALE
Noronisa D. 15
Gastric distention and intestinal atony are frequently Cabugatan mins.
present, resulting in reduced and absent bowel sounds.
Return of bowel sounds and relief of symptoms signal
readiness for discontinuation of gastric aspiration (NG
tube).
Acquire latest Decreases vomiting stimulus and inflammation and
information irritation of dry mucous membranes associated with Yasin, T., Wattoo, N., Butt, Q., Safdar, K., &
regarding dehydration and mouth breathing when NG is in place. Asif, M. (2021). ANALYSIS OF FACTORS
Whipple’s Previous dietary habits may be unsatisfactory in meeting ASSOCIATED WITH DELAYED GASTRIC
Procedure current needs for tissue regeneration and healing. Use of EMPTYING AFTER WHIPPLE’S
through a gastric stimulants (caffeine, alcohol, cigarettes, gas- PROCEDURE. PAFMJ, 71(Suppl-1), S235-39.
summary of producing foods), or ingestion of large meals may result in https://doi.org/10.51253/pafmj.v71iSuppl-
two academic excessive stimulation of the pancreas and recurrence of 1.2951
journals symptoms.
Steatorrhea may develop from incomplete digestion of fats.
May warn of developing hyperglycemia associated with
increased release of glucagon (damage to [beta] cells) or
decreased release of insulin (damage to [beta] cells).
Early detection of inadequate glucose utilization may
prevent development of ketoacidosis.
Prevents stimulation and release of pancreatic enzymes
(secretin), released when chyme and HCl enter the
duodenum.
IV administration of calories, lipids, and amino acids should
be instituted before nutrition and nitrogen depletion is
advanced.
Oral feedings given too early in the course of illness may
exacerbate symptoms. Loss of pancreatic function and
reduced insulin production may require initiation of a
diabetic diet.
MCTs are elements of enteral feedings (NG or J-tube) that
provide supplemental calories and nutrients that do not
require pancreatic enzymes for digestion and absorption.
Replacement required because fat metabolism is altered,
reducing absorption and storage of fat-soluble vitamins.
Used in chronic pancreatitis to correct deficiencies to
promote digestion and absorption of nutrients.
Indicator of insulin needs because hyperglycemia is
frequently present, although not usually in levels high
enough to produce ketoacidosis.
Corrects persistent hyperglycemia caused by injury to cells
and increased release of glucocorticoids. Insulin therapy is
usually short-term unless permanent damage to pancreas
occurs.
EVALUATION
RELATED JOURNAL/RESEARCH ON
PANCREATICODUODENECTOMY