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.

Learning Assign Time

Content Method REFERENCES EVALUATION
Outcomes student Frame

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
Purpose Clinic. Retrieved January 6, 2022, from
The goal of doing a Whipple procedure for cancer is: https://www.mayoclinic.org/tests-
- To remove the tumor and prevent it from growing and procedures/whipple-procedure/about/pac-
spreading to other organs. This is the only treatment that 20385054
can lead to prolonged survival and cure for most of these
tumors (Mayo Clinic, 2020).
Pancreaticoduodenectomy - StatPearls. (2021,
Types July 15). NCBI. Retrieved January 5, 2022, from
 Classical Whipple (CW) https://www.ncbi.nlm.nih.gov/books/NBK560
- It is the type of Whipple’s Procedure that is more 747/
extensive; entails the removal of the pancreatic head, the
duodenum, a section of the stomach, the gallbladder, and a
part of the bile duct.

 Pylorus sparing pancreatoduodenectomy (PSD)

- It is the type of WP where the part of the stomach is
spared (NCBI, 2021).

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. 

Although, the recent data related to the feasibility and the

shorter postoperative outcomes following both open and
laparoscopic approaches for pancreatoduodenectomy have
 suggested that the laparoscopic approach is associated with
shorter length of stay, less blood loss, and better lymph node
dissection.

However, the physicians around the globe are still hesitating in

the global adaptation of the laparoscopic strategy, which may be
most likely as a result of the highly challenging dissection and the
anastomosis in this procedure. Also, the oncological end results
following the open and laparoscopic strategy for Noronisa D.
 Develop pancreatoduodenectomy are still vague and even questionable Cabugatan Goodman, M. (n.d.). Outline for Whipple
insights on the (NBCI, 2021). Procedure for Carcinoma of the Pancreas - Part
outline of the 1. Journal of Medical Insight. Retrieved
surgical January 6, 2022, from
PROCEDURE OUTLINE
procedure https://jomi.com/article/15/whipple-
 Anesthesia procedure-carcinoma-pancreas/procedure-
particularly on
o epidural is placed for postoperative pain control outline
the order of
the procedure o General Anesthesia is given in the operating room.
 Positioning
o all bony prominences well padded.
 Exposure and Approach
o Abdominal midline incision extending from xiphoid to
just below umbilicus. An alternative is a right subcostal
incision
o Entire peritoneum is inspected including the surface of
the liver to insure no peritoneal metastasis. If found,
the procedure is aborted.
o Kocher maneuver performed
 Inspection/Identification of Structures behind Duodenum
 Cholecystectomy
o Gallbladder mobilized in retrograde fashion.
o Cystic artery cauterized and alternativel clipped.
o Cystic duct mobilized to insertion into common bile
duct.
 Management of porta hepatis
o Incise peritoneum overlying porta hepatis.
o Identify hepatic artery and common hepatic duct as it
 joins with cystic duct to form common bile duct.
o Mobilize common bile duct and transect just proximal
to the insertion of the cystic duct.
o Proline sutures placed on hepatic duct to prevent
retraction into liver.
 Mobilization and Division of Proximal Extent of Duodenum
o Pylorus and Perform Partial Omentectomy
o Divide Stomach 2 cm proximal to pyloric valve using
gastro-intestinal stapling device.
 Mobilization and Division of Jejunum
o Divide Jejunum with GI Stapler.
o The Ligament of Treitz is identified and 10 – 15cm distal
to this an appropriate vascular arcade is identified. The
Ligament of Treitz is then mobilized with dissection of
Shara 7 mins.
the 3rd and 4th portions of the duodenum.
Lailanie A.
 Develop  Mobilization and Division of Pancreas Ellison, E. C., & Robert M. Zollinger, J. (10th
Azis
understanding  Pancreatic, Biliary, & Gastrointestinal Reconstruction Edition). ZOLLINGER’S ATLAS OF SURGICAL
on how the o End to Side Pancreaticojejunostomy OPERATIONS. New York: Mc Graw Hill
patient is o End to Side CholedochoJejunostomy Education .
prepared for o Gastro-Jejunostomy
surgery such as o Jejunostomy Drains
the anesthesia
used, proper
position, and PATIENT PREPARATION
skin Patients will have had imaging including CT, MRI, and
preparation possibly endoscopic ultrasound prior to the procedure. Some
patients may have had biliary stents placed by an endoscopic or
transhepatic route. The electrolyte levels should be returned to
normal and particular care should be taken that the INR is normal,
and that renal function is not impaired, as shown by creatinine and
blood urea nitrogen levels. Patients with jaundice may have occult
vitamin K deficiency that may not become apparent until blood
loss occurs. Unexpected blood loss can be substantial so blood
should be available for transfusion as needed, preferably via a
central venous catheter. It is advisable to have a catheter in the
bladder in order to follow the postoperative hourly output of
 urine. Antibiotic therapy should be started prior to operation. This
is particularly important for patients with stents, as they are prone
to wound infections.

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 Shara 8 mins.
lower than the head. Facilities should be available for performing a Lailanie A.
cholangiogram or pancreaticogram. The abdomen is entered Azis Minter, & Doherty. (June 2010). LANGE
 Know the through a midline incision or bilateral subcostal "Chevron" Current Surgical Procedures . The McGraw-Hill
different OR incision, depending on surgeon preference. Companies. (n.d.). Retrieved from
equipment, https://www.rnpedia.com/nursing-notes/medi
supplies, Skin Preparation cal-surgical-nursing-notes/
instruments The skin should be shaved from the level of the nipples well out pancreaticoduodenectomy-whipple-
involved in the over the chest wall and down over the abdomen, including the procedure/
procedure flanks.
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.

 Transverse Lap sheet

 Four folded towels
Instrumentation

 Major Lap tray

o Is a tray that contains or hold the surgical instruments
needed to perform a surgical procedure.
 Biliary instruments
 Intestinal tray
o It is a tray used to hold the intestinal instruments which
is used to assist the management of bleeding, biopsies
and dilation and gastrointestinal surgery.
 Harrington retractors
o It provides deep retraction within a cavity without
disturbance of more superficial structures. Also used
for delicate organs such as the lobes of the liver.
 Hemoclip/Surgiclip
o Used for applying clips to small vessels in all branches
of surgery.
 Internal stapling instruments
o Are medical devices that may be used in place of
sutures. It can close large wounds or incisions more
quickly and be less painful than stitches for patients. It
is often used in minimally invasive surgery.

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
the surgery. Norhanessah 10
 For drainage: HemoVac, Jackson Pratt, etc M. Dalupang mins.
o This is a fine tube with many holes at the end, which is
 Obtain Vera, M. (2014). Preoperative Phase.
attached to an evacuated glass bottle providing suction.
learnings on Nurselabs.
It is used to drain blood under the skin.
the https://nurselabs.com/preoperative-
 Sutures – surgeon’s preference
perioperative phase/
o Surgical threads that are used to repair cuts
nursing
(lacerations). Also used to closed incisions from
responsibilities
surgery.
of Whipple’s
 Solutions – saline, water
Procedure
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.
PERIOPERATIVE NURSING RESPONSIBILTIES
The first phase in which the patients decide for the surgery
intervention up to the transfer in the operating room

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).

o Clarify teaching and learning as needed. Provide

psychologic support for client and family. The client Vera, M. (2014) Intraoperative
Phase.Nurselabs.
 and family faced with a diagnosis of pancreatic https://nurselabs.com/
cancer may require reinforcement of teaching as intraoperative.com/intraoperative-
anxiety, fear, and possible denial can interfere with phase/
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.
 There should be no interference with the patient’s Rijal, S. (2018) Post-operative Care in
respiration as a result of pressure of the arms on the chest pancreatitis: Nursing Interention.
or constriction of the neck or chest caused by a gown. Arcada University of Applied
 The nerves of the client must be protected from undue Sciences.https//www.thesus.fi>handleP
pressure. Serious injury or paralysis may result from DF Post-operative care in pancreatitis:
improper positioning of the arms, hands, legs or feet. Nursing intervention – Thesus
 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.

 Intensive monitoring by the nurses to detect the post-

operative complications.
Patients are kept on a continuous surveillance monitoring
of the vital signs for the first 2-3 hours depending on the
observations. Then the vital signs are taken continuously
every hour or within the interval if necessary, when shifted
to the wards. Preventing complications is rather sensible
 then treating them too late.
 Post-operative nausea and vomiting (PONV) is the most
incidence side effect of operation even above pain.
Nurses use both pharmacological and non-
pharmacological ways to treat PONV.
Pharmacological interventions used by the nurses to
prevent or reduce the risk of PONV includes drugs with
antiemetic properties such as Ondansetron, granisetron,
dolasetron, steroids, phenothiazines, butyrophenones,
benzamides etc. Good therapeutic measures to
communicate with the patients, reassurance and a positive
rapport, psychological interventions are commonly used
non-pharmacological interventions by the nurses.
 Post-operative pain management.
Pain relief is important to achieve good physical and
mental health. While accessing the post-operative pain,
health care nurses ask questions about the onset and
pattern, location, quality, intensity, aggravating and
relieving factors, treatment history, effect and barriers to
pain assessment. Several scales were validated and
published to assess postoperative pain. Interventions for
pain management includes both pharmacological and non-
pharmacological ways. Non-pharmacological techniques
include distraction, physical therapy, TENS (transcutaneous
Electrical Nerve Stimulation), acupressure, etc.
pharmacological interventions include nonopioids [e.g.
paracetamol, Non-steroidal anti-inflammatory drugs
(NSAIDs), clonidine], opioids (e.g. morphine, meperidine,
and hydromorphone), local anesthetics and other drugs
prescribed by doctors.
 Post-operative Nutrition
Increase cortisol level after the surgery leads to the protein
and muscle depletion therefore early nutrition plays a very
important role in the recovery role of patients after
surgery. Enteral and parenteral nutrition together with the
supplements such as omega-3 fatty acids, arginine,
glutamine, and selenium with probiotics and prebiotics
 help to reduce inflammation and infection. Enteral
nutrition preserves gut function, reduces hypermetabolic
function, maintains effective immune system and increases
the survival rate after surgery.
 Early mobilization
Helps to improve functional independence, psychological
well-being, level of consciousness, cardiovascular and
respiratory system. It also helps to avoid patients pain and
ileus. It is important to motivate or encourage patient for
early mobilization such as walking. Norhanessah 20
Patient who can walk a significant distance on the first 7 M. Dalupang mins.
days of surgery enables them to perform better physical
activities later after the recovery.
 Wound care
 Learn three (3) The wound from the incision site needs to be clean and dry Vera,M. (2020). 8+Pancreatitis Nursing care
different as possible. Nurses can give pain medication in regular plans.Nurselabs.
nursing care basis to make the patient comfortable. Instruct patient to https://murselabs.com/pancreatitis-nursing-
plans for avoid taking shower, using swimming pool and sauna after care-plans/
patient who surgery as it can be harmful and infectious. Instruct patient
has undergone to eat nutritious food high in protein, vitamin c and zinc
Whipple’s helps in wound healing process. Added protein
Procedure supplements and multivitamins further helps wound to
heal.
 Fluid balance
The main aim of the fluid balance in surgical patients is to
maintain the homeostatic of the body by maintaining both
the intracellular and extracellular spaces of the cell. Nurses
might use 0.9% sodium chloride, 5% dextrose or Hartman’s
solution (Ringer’s lactate solution) as prescribe by the
surgeons. Hypovolemic shock after surgery needs to be
treated with restoring adequate tissue perfusions.
Excessive blood loss needs to be restored with blood
transfusion.
 Catheters and drainage
Early removal of urinary catheters significantly reduces the
chance of urinary tract infection, pain, and uncomfortable
feeling to the patient. nurses need to make sure that the
 patients can urinate by themselves before leaving the
hospital.

NURSING CARE PLANS

NURSING DIAGNOSIS #1
Acute pain related to obstruction of pancreatic, biliary ducts as
evidence by self-focusing, grimacing, distraction/guarding
behaviors

CUES

Subjective cues

“Masakit po ang tahi ko” as verbalized by the patient

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

After nursing intervention, the patient will report pain

relieve/controlled.

 Will follow prescribed therapeutic regimen

 Will demonstrate use of methods that provide relief
INTERVENTIONS

 Investigate verbal reports of pain, noting specific location

and intensity (0-10 scale). Note factors that aggravate and
relieve pain.
 Maintain bedrest during acute attack. Provide quiet, restful
environment.
 Promote position of comfort one side with knees flexed,
sitting up and leaning forward.
 Provide alternative comfort measures (back rub),
encourage relaxation techniques (guided imagery,
visualiazation) quiet diversional activities (TV, radio).
 Keep environment free of food odors.
 Administer analgesics in timely manner (smaller, more
frequent doses).
 Maintain meticulous skin care, especially in presence of
draining abdominal wall fistulas.
 Administer medication as indicated: Narcotic analgesics:
meperidine (Demerol), fentanyl (Sublimaze), pentazocine
(Talwin); Sedatives: diazepam (Valium); antispasmodics:
atropine; Antacids: Mylanta, Maalox, Amphojel, Riopan;
Cimetidine (Tagamet), ranitidine (Zantac), famotidine
(Pepcid) Withhold food and fluid as indicated. Maintain
gastric suction when used.

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.

 Meperidine is usually effective in relieving pain and may be

preferred over morphine, which can have a side effect of
biliary-pancreatic spasms. Paravertebral block has been
used to achieve prolonged pain control. Note:Pain in
patients whohave recurrent or chronic pancreatitis
episodes may be difficult to manage because they may
become dependent on the narcotics given for pain control.
 Potentiates action of narcotic to promote rest and to
reduce muscular and ductal spasm, thereby reducing
metabolic needs, enzyme secretions. Neutralizes gastric
acid to reduce production of pancreatic enzymes and to
reduce incidence of upper GI bleeding.
 Decreasing secretion of HCl reduces stimulation of the
pancreas and associated pain.
 Limits and reduces release of pancreatic enzymes and
resultant pain.
 Prevents accumulation of gastric secretions, which can
stimulate pancreatic enzyme activity.

EVALUATION

After nursing intervention, the patient reports pain

relieve/controlled.

 follows prescribed therapeutic regimen

 Demonstrate use of methods that provide relief

NURSING DIAGNOSIS #2
Risk for infection

CUES
Subjective Cues:

“Mainit ang aking pakiramdam” as verbalized by the patient.

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

Imbalanced Nutrition: Less than body requirements related to loss

of digestive enzymes and insulin (related to pancreatic outflow
obstruction) as evidenced by reported inadequate food intake.

CUES
SUBJECTIVE CUES

“Wala akong ganang kumain” as verbalized by the patient.

OBJECTIVE CUES

 Temp: 37°C
 BP: 110/80 mm Hg
 PR: 85 bpm
 RR: 18 cpm
 Weight loss

OBJECTIVES

 After nursing interventions patient will be able to

demonstrate progressive weight gain toward goal of
 normalization of laboratory values.
 Will experience no signs of malnutrition.

 Will demonstrate behaviors, lifestyle changes to regain

and/or maintain appropriate weight.

INTERVENTIONS

 Assess abdomen, noting presence and character of bowel

sounds, abdominal distension, and reports of nausea.
 Provide frequent oral care.
 Assist patient in selecting food and fluids that meet
nutritional needs and restrictions when diet is resumed.
 Observe color, consistency and amount of stools. Note
frothy consistency and foul odor.
 Note signs of increased thirst and urination or changes in
mentation and visual acuity.
 Test urine for sugar and acetone.
 Maintain NPO status and gastric suctioning in acute phase
 Administer hyperalimentation and lipids, if indicated.
 Resume oral intake with clear liquids and advance diet
slowly to provide high-protein, high-carbohydrate diet,
when indicated.
 Provide medium-chain triglycerides (MCTs) (MCT,
Portagen).
Administer medications as indicated:

 Vitamins: A,D,E,K.
 Replacement enzymes: pancreatin (Dizymes), pancrelipase
(Viokase, Cotazym).
 Monitor serum glucose.
 Provide insulin as appropriate.

RATIONALE

 Gastric distention and intestinal atony are frequently

present, resulting in reduced and absent bowel sounds. Noronisa D. 15
 Return of bowel sounds and relief of symptoms signal Cabugatan mins.
readiness for discontinuation of gastric aspiration (NG
tube).
 Decreases vomiting stimulus and inflammation and
irritation of dry mucous membranes associated with
 Acquire latest dehydration and mouth breathing when NG is in place.
information Yasin, T., Wattoo, N., Butt, Q., Safdar, K., &
 Previous dietary habits may be unsatisfactory in meeting
regarding Asif, M. (2021). ANALYSIS OF FACTORS
current needs for tissue regeneration and healing. Use of
Whipple’s ASSOCIATED WITH DELAYED GASTRIC
gastric stimulants (caffeine, alcohol, cigarettes, gas-
Procedure EMPTYING AFTER WHIPPLE’S
producing foods), or ingestion of large meals may result in
through a PROCEDURE. PAFMJ, 71(Suppl-1), S235-39.
excessive stimulation of the pancreas and recurrence of
summary of https://doi.org/10.51253/pafmj.v71iSuppl-
symptoms.
two academic 1.2951
 Steatorrhea may develop from incomplete digestion of fats.
journals
 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

 After nursing interventions patient demonstrates

progressive weight gain toward goal of normalization of
laboratory values.
 Experience no signs of malnutrition.
Uddin, M. S. An Evaluation of the Whipple’s
 Demonstrate behaviors, lifestyle changes to regain and/or Procedure: A Retrospective Study in Dhaka,
maintain appropriate weight. Bangladesh.

RELATED JOURNAL/RESEARCH ON
PANCREATICODUODENECTOMY

1) Analysis of Factors Associated with Delayed Gastric

Emptying After Whipple’s Procedure

 Objective: To assess the frequency and analyze

associated factors of delayed gastric emptying among
the patients undergoing Whipple’s procedure at
surgical unit of a tertiary care center in Pakistan.

 Study Design: Cross sectional study.

 Place and Duration of Study: Pak Emirates Military
Hospital and Combined Military Hospital Rawalpindi,
Pakistan, Apr 2018 to Mar 2019.
 Methodology: A prospective study was conducted on
80 patients of both the genders who underwent
Whipple’s procedure at the surgical unit of
 abovementioned hospitals. Delayed gastric emptying
was diagnosed based on the criteria as defined by the
International Study Group of Pancreatic Surgery by the
consultant surgeons involved. Factors studied in our
analysis included age, gender, smoking, presence of co
morbidities, perioperative blood transfusion, sepsis,
operative time and BMI.
 Results: Out of 80 patients included in the final
analysis, 61 (76.25%) were male and 19 (23.75%) were
female. Mean age of patients included in our study was
46.31 ± 6.711 years. Thirty-six (45%) patients had
delayed gastric emptying while 44 (55%) did not meet
the criteria as mentioned above. With binary logistic
regression we found that presence of sepsis and high
BMI had a strong relationship (p-value <0.05) with
delayed gastric emptying after the Whipple’s
procedure.
 Conclusion: Delayed gastric emptying is a common
phenomenon among the patients undergoing
Whipple’s procedure. High BMI and post-operative
sepsis constitute the group which is at the highest risk
of developing this post-operative complication in our
study.

2) An Evaluation of The Whipple’s Procedure: A

Retrospective Study In Dhaka, Bangladesh

 Abstract Background: Basically, the Whipple’s

procedure also known as pancreaticoduodenectomy is
an operation to remove the head of the pancreas, the
first part of the small intestine (duodenum), the
gallbladder and the bile duct. The Whipple’s procedure
is the most common operation for periampullary
neoplasms like distal bile duct cancer, ampullary
cancer, duodenal cancer and in chronic pancreatitis
involving head, pancreatic injury and some benign
lesions in pancreaticoduodenal junction. Aim of the
 study: The aim of this study was to evaluate the
Whipple’s procedure in Bangladesh.

 Methods: This retrospective study was conducted in

Department of Hepatobiliary, Pancreatic and Liver
Transplant Surgery, Bangabandhu Sheikh Mujib
Medical University (BSMMU) and several private
hospitals in Dhaka, Bangladesh during the period from
January 2010 to December 2019. Three hundred and
fifty (350) cases of Whipple’s procedures performed at
BSMMU from January 2010 to December 2019 were
selected to analyze. A predesigned questioner was used
in collecting data, SPSS version 16 was used to analyze
data and several tales and charts were used to
disseminate the findings.

 Result: In this study, we found in 143 patient’s

adenocarcinomas of pancreas were associated which
was the highest in ratio (40.86%). Then
adenocarcinoma of duodenum, solid pseudo papillary
neoplasm of pancreas, cholangiocarcinoma of terminal
CBD, chronic pancreatitis, and serous adenoma of
pancreas was found in 101 (28.86%), 46 (13.14%), 39
(11.14%), 28 (8%) and 21 (6%) cases respectively. We
found 10 cases of mortality which was 2.86% of the
total patients. As the causes of mortality, we found
septicemia associated shock due to pancreatic/biliary
leak, hemorrhage, and respiratory complication in
1.43%, 0.86% and 0.57% patients respectively.

 Conclusion: We have concluded that, applying of

ultrasonic scalpel, avoidance of preoperative stenting
experience of surgeon and supporting staff has led to
decrease in operative duration and blood loss.
Pulmonary complications and septicemia secondary to
anastomotic leakage are the most common causes of
morbidity and mortality