PANCREATIC CANCER Criteria

Introduction/Objectives 10%_____

Pathophysiology:

_____________ Etiology 10% _____

Symptomatology10%_____

Disease process5% _____

A Case Analysis Presented
Management 15% ______
to the Faculty of San Pedro College
Davao City Prognosis 10% ______

Discharge planning 10% ______

_____________ Nursing theory 10% ______

Review of Related Studies 10% ____

Reference 5% ________

In Partial Fulfilment of the Promptness 5% ________

Requirements in NCM 212 RLE
CANCER Rotation TOTAL:

Submitted to:

Josephine Magno, RN, MN

Clinical Instructor

By:

Michael Dame Canton

Shiyuki Goto
Johannah Glaze Juridico
Chelsy Mina Solis

September 12, 2020

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TABLE OF CONTENTS

I. INTRODUCTION AND OBJECTIVES................................................3

a. General objectives.........................................................................4
b. Specific objectives.........................................................................4
II. PATHOPHYSIOLOGY AND MANAGEMENT....................................5
i. Etiology..................................................................................... ...6-9
A. Diagram.....................................................................................10-11
B. Narrative Discussion..................................................................12-13
ii. Symptomatology.........................................................................13-14
iii. Diagnostic/Laboratory Confirmatory Test…….............................. 14
a. Physical assessment of affected system……………………….. 15
b. Medical Diagnostics……………………………………………….16-17
iv. Management….............................................................................18-19
a. Drug Studies……………………………………………………….20-25
v. Prognosis …………………………………………………………….. 26
III. DISCHARGE PLANNING.................................................................28-32
IV. RELATED NURSING THEORY....................................................... 33
V. REVIEW OF RELATED STUDIES/LITERATURES..........................34-35
VI. REFERENCES..................................................................................36

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I. INTRODUCTION AND OBJECTIVES

Pancreatic cancer is the fourth leading cause of cancer related death for both
men and women (following lung, colorectal and breast cancer), being responsible for
6% of all cancer-related deaths. It is very rare before the age of 45 years, and the
majority of patients present in or beyond the sixth decade of life. Exocrine pancreatic
cancer is characterized by early vascular dissemination and spread to regional lymph
nodes. Subclinical liver or lung metastases are present in most patients at the time of
the diagnosis, even when findings from imaging studies suggest localized disease.
Survival duration depends in the extent of the disease and the patient’s performance
status at diagnosis. The extent of disease is beast categorized as respectable stage
(stage 1 or stage 2) locally advanced stage (stage 3) or metastatic stage (stage 4).
Approximately 50% of patients with pancreatic cancer have jaundice at diagnosis as the
result of extrahepatic binary obstruction. If jaundice is not present, patient complaints
are often non-specific and include pain, fatigue, weight loss, hyperglycemia and
pancreatic exocrine insufficiency. The pain typical of locally advanced pancreatic cancer
is a dull, fairly constant pain localized to the middle and upper back owing to tumor
invasion of the celiac and mesenteric plexus. Pancreatic exocrine insufficiency, when
present, is due to obstruction of the pancreatic duct and commonly results in
malabsorption, steatorrhea and mild changes in stool frequency. Fatigue, weight loss
and anorexia are common even in the absence of mechanical gastric outlet obstruction.
The risk of pancreatic cancer increases as the extent of cigarette smoking increases.
Diabetes mellitus, chronic pancreatitis and hereditary pancreatitis are also associated
with pancreatic cancer. The pancreas can also be the site of metastasis from other
tumors. Cancer may develop in the head, body or tail of the pancreas; clinical
manifestations vary depending on the site and whether functioning insulin-secreting
pancreatic islet cells are involved. Approximately 70% of pancreatic cancers originate in
the head of the pancreas and give rise to a distinctive clinical picture (Zenner & Ashley,
2017). Functioning islet cell tumors, whether benign (adenoma) or malignant
(carcinoma), are responsible for the syndrome of hyperinsulinism. The symptoms are
typically non-specific, and patients usually do not seek medical attention until late in the

3
disease. Only about 7% of cases are diagnosed in early stages; 80% to 85% of patients
have advanced, unresectable tumor when first detected. As a result, pancreatic
carcinoma has only a 5% survival rate at 5 years regardless of the stage of diagnosis or
treatment (American Cancer Society, 2019)

General Objectives

At the end of the NCM 212 RLE, the student nurse of San Pedro College, BSN
3B Group 2, will be able to enhance the knowledge gained from the experience; apply
the interpersonal and communication skills in doing the management for Pancreatic
Cancer study; and develop sense of optimism and cooperativeness in the study. Thus,
that within the given week, the researcher will be able to discuss the disease process of
the client regarding pancreatic cancer comprehensively.

Specific Objectives

Specifically, by accomplishing it, the following are needed to be achieved.

a.) choose a client to be the subject of our case study.

b.) describe the concept through a well written introduction
c.) formulate specific, measurable, attainable, realistic and time bounded objectives.
d.) trace the pathophysiology of pancreatic cancer
e.) formulate a discharge plan subjective to the patient’s case.
f.) formulate nursing care plan’s applicable to the patient
g.) relate our case study to two nursing theories; and
i.) cite books, references and the internet website

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II. PATHOPHYSIOLOGY AND MANAGEMENT

i. ETIOLOGY

Etiology

I. Predisposing Present/Absent Justification

Factor
Family History Present The patient’s wife said that
the grandfather of her
husband died due to
pancreatic cancer. According
to studies, risk increases if a
person has two or more first-
degree relatives (parent,
sibling or child) who have had
the disease, a first-degree
relative who developed
pancreatic cancer before the
age of 50, or an inherited
genetic syndrome associated
with pancreatic cancer. The
risk increases if a greater
number of family members
are affected.  Approximately
10 percent of pancreatic
cancer cases are related to a
family history of the disease.
Age Absent The client’s age is 55 years
old. It was said that the
chance of developing
pancreatic cancer increase
with age. Most people
diagnosed with pancreatic
cancer are over the age 60.
Race Absent The client was a Filipino and

5
 according to studies African-
Americans have a higher
incidence of pancreatic
cancer compared to
individuals of Asia, Hispanic
or Caucasian descent.
Gender Present The client is male and
according to source, slightly
more men are diagnosed with
pancreatic cancer than
women. This may be linked to
higher smoking rates in men.

I. Precipitating Present/Absent Justification

Factor
Smoking Present The client’s wife said the
client started smoking at the
age of 25 until now.
According to studies,
smoking is a significant risk
factor and may cause about
20-30 percent of all exocrine
pancreatic cancer cases.
People who smoke cigarettes
are 2 times more likely to
develop pancreatic cancer
than people who have never
smoked
Diabetes Present The client has type 2
diabetes mellitus. Pancreatic
cancer is more likely to occur

6
 in people who have long
standing (over 5 years)
diabetes
Diet Present According to the wife, his
husband loves to ate street
foods. Street foods are prone
for acquiring hepatitis A.
Also, the client is often eating
fruits. A diet high in red and
processed meats is thought
to increase the risk of
developing pancreatic
cancer. A diet high in fruits
and vegetables may
decrease the risk.
Alcohol Present The client drinks alcoholic
beverages almost every day.
According to studies, the risk
of developing pancreatic
cancer is higher in people
who consume more than 3
alcoholic drinks daily
compared to those who do
not.
Environment Present The client has a farm and
exposed to pesticides and
other chemicals. Research
suggests that the exposure
to certain environmental
chemicals and heavy metals
may increase the risk of
developing pancreatic
cancer. These include beta-
naphthylamine, benzidine,
peticides, asbestos, benzene

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 and chlorinated
hydrocarbons.
Obesity Present The client’s BMI is 30 which
results to obesity. According
to studies, obese people
have a 20 percent increased
risk of developing the
disease compared to people
who are of normal weight.
The risk is even higher in
people who are obese during
early adulthood.
Chronic Pancreatitis and Present The client has chronic
Hereditary Pancreatitis pancreatitis 2 years ago and
according to studies, people
with chronic pancreatitis
have an increased risk of
developing pancreatic
cancer. Chronic pancreatitis
is common in individuals who
consume large amounts of
alcohol for many years.
Hereditary pancreatitis
causes recurrent episodes of
inflammation of the pancreas
that generally start by the
time a person is 20 years old.
The risk of developing
pancreatic cancer is even
higher in individuals who
have hereditary pancreatitis.

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A. DIAGRAM

9
 Precipitating Fx:
Predisposing Fx:
Smoking
Family History
Diabetes
Age
Diet
Gender
Alcohol
Race
Environment
Obesity
ETIOLOGY
Acinar cell

Low pH environment
Cathepsin - B activity
Trypsinogen activation

PATHOPHYSIOLOGY
Acute Pancreatitis

Gene mutation
Inflammation
PRSS, SPINK1, CFTR,
CTRC

Recurrent acute
pancreatitis

Pancreatic stellate cell

Inflammation
activation

Gene mutation
PRSS, SPINK1, CFTR,
CTRC

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 Defective autophagy

Fibrosis

Chronic pancreatitis
(Hereditary, familial, alcoholic, idiopathic)

SPINK1 Inflammation
Trypsin
Defective autophagy
Cathepsin-B+L
PRSS3
PANCREATIC
CANCER Oncogenic Kras
Loss of tumor
suppressors P16
and P53

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 METASTASIS

SIGNS & LAB FINDINGS

SYMPTOMS • C
• A T Scan
bdominal Pain • M
• W RI
eight Loss
• P
• J
aundice ET scan
• D • B
iarrhea iopsy (Frozen
• W Biopsy)
eakness • B
• P
alpable bladder

DIAGNOSIS AND STAGING

STAGE 1: 1A- T1,N0,M0 ; 1B- T2,N0,M0
STAGE 2: 2A- T3,N0,M0 ; 2B- T1,T2 or T3; N1,M0
STAGE 3: 3A- T4, Any N, M0
STAGE 4: Any T, Any N, M1

TREATMENT
• Su
rgery (Whipples
Procedure)
• Ch
emotherapy
• Ra

PROGNOSIS
Depends on the stage however average would
be 23-36 months. Patients are diagnosed in the
late stage due to non specific symptoms

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13
B. NARRATIVE DISCUSSION

The pancreas is a glandular organ of the digestive system consisting of (a) an endocrine
component which secretes insulin, glucagon, and somatostatins, and (b) an exocrine
component that produces numerous digestive enzymes and iso-osmotic alkaline fluid which is
released into the small intestine every day. The exocrine pancreas is composed of both acinar
and ductal cells; acinar cells (or acini) are responsible for synthesis, storage and secretion of
both active (amylase, lipase) and inactive enzymes (zymogens; trypsinogen). This results in
release of pancreatic enzymes into the small intestine. These normal physiological responses
can be altered by many factors that can ultimately lead to pathological responses and
development of pancreatitis and pancreatic cancer. Acute pancreatitis (AP) is a clinical
syndrome which begins with acute injury to the pancreas. The most common causes of
pancreatitis include alcohol, gallstones, toxins, and trauma, with a small number of cases
remaining idiopathic. These factors initiate distinct changes in pancreatic physiology causing
pathological activation of digestive enzymes within acinar cells, decreased pancreatic enzyme
secretion, increased inflammatory responses and ultimately cell death. Traditionally, chronic
pancreatitis, CP was thought of as a separate disease but years of research have concluded
that AP, recurrent AP and CP can be part of the same disease continuum. If the attack is severe
enough it could activate macrophage dependent stellate cells which ultimately lead to fibrosis,
particularly if there is a continuous stimulus causing interplay between pro-inflammatory and
anti-inflammatory pathways. Thus CP develops due to complex interactions between an
impaired immune response to low grade inflammation and environmental factors that decrease
the threshold for recurrent AP like alcohol intake and smoking. CP has long been thought of as
a strong risk factor for pancreatic cancer. Pancreatic cancer is an extremely aggressive,
invariably deadly disease without any improvements in patient outcome over the last 2 decades.
Pancreatic cancer is not prevalent in patients under 20 years of age; the median age at onset is
71 years. Hereditary pancreatitis is a severe risk factor for pancreatic cancer with a lifetime risk
of developing pancreatic cancer of 40–55%. Smoking increases the risk of cancer in these
patients and lowers the median age of diagnosis from 71 in non-smokers to 56 in smokers
(Howes et al., 2014). Although our knowledge of underlying mechanisms of pancreatitis and
pancreatic cancer have advanced in the past few years much remains unknown. Recent studies
have strongly implicated smoking, alcohol, and obesity as common etiological factors in
pancreatitis-to-cancer pathways. At the cellular level, aberrant zymogen activation, particularly
through mutations in trypsinogen, can lead to repeat bouts of AP. This can result in low grade

14
inflammation, autophagy, stellate cell activation, and fibrosis, culminating in chronic disease.
Furthermore, oncogenic Kras mutations and modifications of tumor suppressor genes (p16 and
p53) may all contribute to progression from CP to PDAC. Development of multiple drugs that
target various aspects of this complex tapestry of cellular pathways will be paramount in halting
disease initiation and progression. From there on, intensive treatment is followed based on the
staging and diagnosis of the Pancreatic adenocarcinoma. Whipples procedure is usually
advised in order to achieve higher mortality rates and is also comanaged with therapy
afterwards. Therefore, prognosis would depend mainly on the staging, however an average
mortality rate would be from 23-36 months. This is mainly because patients are diagnosed in the
late stage due to non specific symptoms.

ii. SYMPTOMATOLOGY

Signs / Symptoms Present Rationale

Abdominal Pain ✔ This is probably caused by a tumor that has
formed in the body or tail of the pancreas
because it can press on the spine. (Hopkins J,
2016)
Weight loss ✔  Pain and fatigue cause them to lose interest in
food. (Huhmann M, 2015)
Jaundice ✔ Jaundice is caused by the buildup of bilirubin, a
component of bile produced by the liver. This can
occur when a tumor blocks the bile duct connecting
the pancreas to the liver. (Scholten J, 2018)
Diarrhea ✔ Arise as a result of pressure from a pancreatic cyst
or tumor on the stomach or the small intestine that
causes a block in the digestive tract. (Surge C,
2016)
Weakness ✔ Pancreatic cancer can cause feelings of extreme
tiredness or weakness in the limbs. (Chandra R,
2015)
Palpable ✔ When the cancer blocks the bile duct, it can lead to
gallbladder a buildup of bile in the gallbladder. (Chandra R,
2015)
Constipation ✔ Caused by insufficient amount of
pancreatic enzymes in the intestines. (Rosecrans
G, 2017)
Hematemesis or ✔ Direct infiltration into the surrounding organs which
melena include the bile duct, duodenum, stomach, jejunum
and colon. (Takada R, 2015)

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 Vomiting ✔ Nausea and vomiting can occur during later stages
if a pancreatic tumor has grown sufficiently large to
block a portion of the digestive tract (usually the
duodenum). (Bethesda M, 2018)
Migratory ✔ Migratory thrombophlebitis, also called Trousseau
thrombophlebitis syndrome or thrombophlebitis migrans, is a clot that
moves around the body, often from one leg to
other. It's often linked to an underlying cancer,
especially of the pancreas or lung. (Fisic E, 2018)

iii. DIAGNOSTIC/LABORATORY CONFIRMATORY TEST

Diagnostic Tests

a. PHYSICAL ASSESSMENT OF THE AFFECTED SYSTEM

GENERAL

Clients with pancreatic cancer typically report the gradual onset of nonspecific symptoms
such as anorexia, malaise, nausea, fatigue, and mid epigastric or back pain. Significant weight
loss is also a characteristic feature of pancreatic cancer. Mid epigastric pain is a common
symptom of pancreatic cancer, with radiation of the pain to the midback or lower-back region
sometimes occurring. Radiation of the pain to the back is worrisome, as it indicates
retroperitoneal invasion of the splanchnic nerve plexus by the tumor. Weight loss may be
related to cancer-associated anorexia and/or subclinical malabsorption from pancreatic exocrine
insufficiency caused by pancreatic duct obstruction by the cancer. Patients with malabsorption
usually complain about diarrhea and malodorous, greasy stools. Nausea and early satiety from
gastric outlet obstruction and delayed gastric emptying from the tumor may also contribute to
weight loss.

The most characteristic sign of pancreatic carcinoma of the head of the pancreas is painless
obstructive jaundice. Clients with this sign may come to medical attention before their tumor
grows large enough to cause abdominal pain. These clients usually notice a darkening of their
urine, lightening of their stools before they or their families notice the change in skin
pigmentation. Pruritus may accompany and often precedes clinical obstructive jaundice. Pruritus
can often be the patient's most distressing symptom.

SKIN AND EYES

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 Jaundice is yellowing of the eyes and skin. Most people with pancreatic cancer (and
nearly all people with ampullary cancer) will have jaundice as one of their first symptoms.
Jaundice is caused by the buildup of bilirubin, a dark yellow-brown substance made in the liver.
Normally, the liver releases a liquid called bile that contains bilirubin. Bile goes through the
common bile duct into the intestines, where it helps break down fats. It eventually leaves the
body in the stool. When the common bile duct becomes blocked, bile can’t reach the intestines,
and the amount of bilirubin in the body builds up.

ABDOMEN

Pain in the abdomen is common in pancreatic cancer. Cancers that start in the body or tail of
the pancreas can grow fairly large and start to press on other nearby organs, causing pain.
Clients with pancreatic cancer usually have palpable abdominal mass at region 2 and 3.
Epigastric, left hypochondriac and umbilical area has a solid palpable abdominal mass by 3
inches’ deep ranging from pancreas to duodenum indicates for whipples procedure.

 b. MEDICAL DIAGNOSTICS

Complete Blood Count

- Blood tests are used to check your blood cell levels (blood count), how well your liver
and kidneys are working, and your general health. If you have jaundice a blood test
will show how severe the jaundice is. Blood tests can also check for tumor markers
that show up in the blood. Tumor markers are chemical substances produced by
cancers. CA19-9 is a marker that may be used to help diagnose pancreatic cancer.

Exam Name Normal Definition Interpretation

Range
Hemoglobin Male: 13-18 Hemoglobin is the Increased Hemoglobin: Anemia
g/dL protein molecule in red Decreased Hemoglobin:
Female: 12-16 blood cells that carries polycythemia, dehydration
g/dL oxygen from the lungs
to the body's tissues

17
 and returns carbon
dioxide from the
tissues back to the
lungs.
RBC Male: 4.6- Red blood cell is a Increased RBC: Sleep apnea,
12
6.2x10 cells/L cellular component of pulmonary fibrosis.
Female: 4.2- blood that carries Decreased RBC: Anemia.
5.9x1012cells/L oxygen from the lungs
to the tissues.
MCV 80-100fL It is the average Increased MCV: liver disease,
volume of red blood macrocytic anemia
cells. Decreased MCV: iron deficiency
anemia, macrocytic anemia
WBC 4.3-10.8x109/L White blood cells Increased WBC: autoimmune
(WBCs), also called disease, bone marrow failure,
leukocytes or Leukocytosis
leucocytes, are the Decreased WBC: bacterial
cells of the immune infection, Leukopenia.
system that are
involved in protecting
the body against both
infectious disease and
foreign invaders.
Platelet 165-415x109/L Platelets also known Increased Platelet: Risk of
as thrombocytes, are uncontrolled bleeding, Dengue and
small, colorless leukemia.
fragments in the blood Decreased Platelet:
that form clots and Thrombocytosis.
prevent bleeding.

 Biopsy

Biopsy is a procedure to remove a small sample of tissue for examination under a

microscope. Most often the tissue is collected during EUS by passing special tools through

18
 the endoscope. Less often, a sample of tissue is collected from the pancreas by inserting a
needle through your skin and into your pancreas (fine-needle aspiration).

 Endoscopic ultrasound (EUS)

An ultrasound device to make images of your pancreas from inside your abdomen. The
device is passed through a thin, flexible tube (endoscope) down your esophagus and into
your stomach in order to obtain the images.

 Magnetic Resonance Imaging.

MRI scans use radio waves and strong magnets instead of x-rays to make detailed images
of parts of your body. Most doctors prefer to look at the pancreas with CT scans, but an MRI
might also be done.

 CT (computerized tomography) scan

- A CT scan uses x-rays to create a 3D picture of the pancreas and the organs around it.
If you have jaundice  and suspected pancreatic cancer, or have had another scan that
showed a problem with your pancreas, you should be offered a CT scan.

 ERCP (endoscopic retrograde cholangio-pancreatography)

- An ERCP (endoscopic retrograde cholangio-pancreatography) is sometimes used to
diagnose problems with the pancreas. It is usually used if your bile duct is blocked, to
insert a small tube (called a stent) into the bile duct to unblock it. The bile duct is the
tube that carries fluid (bile) from the liver to the duodenum (the first part of the small
intestines). View our diagram of the pancreas and surrounding organs. 

iv. MANAGEMENT

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ORDER DEFINITION RATIONALE
Biliary-enteric A common surgical procedure To relieve the jaundice
anastomosis (BEA) performed for the management

(Surgical Management) of biliary obstruction or leakage that

results from a variety of benign and
malignant diseases.
Total Pancreatomy  Removal of the pancreas. This surgery might be an option if
(Surgical Management) the cancer has spread
throughout the pancreas but can
still be removed.
Pancreaticoduodenectom Removing the head of the pancreas, Removes a tumor offers the best
y or Whipple procedure the first part of the small intestine chance for long-term control of
(Surgical Management) (duodenum), the gallbladder and the all pancreatic cancer types.

bile duct.

Cholecystojejunostomy Anastomosis of the gallbladder Jaundice can be relieved by

(Surgical Management) and the jejunum. diverting the bile flown into the
jejunum if the tumor cannot be
excised

Administer Medications Chemotherapy drugs help destroy, To get rid of all the cancer and
(Medical Management) shrink, or control those malignant keep it from coming back. 
cells.

Chemotherapy Type of cancer treatment that uses one To kill fast-growing cells in your
(Medical Management) or more anti-cancer drugs as part of a body.
standardized chemotherapy regimen.

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Intravenous Therapy Is a therapy that delivers fluids directly To support oral hydration and

(Medical Management) into a vein. will replace the fluid loss.

Sanitation Eating and living in a sanitary Prevent further complications

(Nursing Management) environment helps prevent further
contamination from surroundings.

Promoting Comfort The easing or alleviation of a person's For reducing the negative impact
(Nursing Management) of hospitalization
feelings of grief or distress.

DRUG STUDIES

Generic name: Fluorouracil

Brand name: Adrucil, Fluoroplex, Carac

Efudex

Drug classification: Antineoplastic, Antimetabolite

Mode of action: Inhibits DNA & RNA synthesis leading to death of rapid-growing neoplastic
cells. Cell-cylcle-S-phase specific.

Suggested dose:

Advanced colorectal cancer

21
Adult: IV bolus 300-500 mg/m2/day 3 4-5 days q28 days or 600-1500 mg/m2 qwk or every
other wk; continuous IV infusion: 300-1000 mg/ m2/day 3 4-5 days q4wk or 300 mg/m2/day

2 indefinitely; high dose 3000-3400 mg/m over

24-72 hr F

Breast cancer

Adult: IV bolus 400-600 mg/m2 on days 1 and 8 of every cycle with cyclophosphamide and

2 methotrexate or 600 mg/m on day 1 with cyclo-

phosphamide and methotrexate q21-28 days

Pancreatic cancer

Adult: IV bolus 600 mg/m2 on day 1, 8, 29, 36 with DOXOrubicin and q8wk

Actinic/solar keratoses

Adult: TOP 1% cream/SOL 1-2 3/day or 2%- 5% SOL for hands

Superficial basal cell carcinoma

Adult: TOP 5% cream/SOL 2 3/day 3 3-12 wk

Indications:

Systemic: cancer of breast, colon, rectum, stomach, pancreas;

Topical: superficial basal cell carcinoma; multiple actinic keratoses

Contraindications:

Pregnancy or breastfeeding

Hypersensitivity

Poor nutritional status

Serious infections

Bone marrow depletion

Side effects:

Loss of appetite

Headache

22
Nausea

Vomiting

Diarrhea

Mouth inflamation and sores

Myelosuppression

Hair loss

Sensitivity of skin to sunlight (photosensitivity)

Hand-foot syndrome

Red, itchy skin rash

Sore throat

Inflammation of the esophagus

Low white blood cell counts (leukopenia)

Adverse effects:

CNS: Lethargy, malaise, weakness, acute cerebellar dysfunction

CV: Myocardial ischemia, angina

EENT: Epistaxis, light intolerance, lacrimation

GI: Anorexia, stomatitis, diarrhea, nausea, vomiting, hemorrhage, enteritis, glossitis

HEMA: Thrombocytopenia, leukopenia, myelosuppression, anemia, agranulocy- tosis

INTEG: Rash, fever, photosensitivity, ana- phylaxis

Drug interactions:

Drug-drug : Bone marrow depressants (including other antineoplastics): additve to bone

marrow depression

Ironetecan : Dehydration, neutropenia, sepsis

Leucovorin calcium : Increased risk of fluorouracil toxicity

Live-virus vaccines: Decreased antibody reponse to vaccine, increased risk of adverse reaction

Drug-behaviors : Sun exposure- increased risk of phototoxicity

23
Nursing responsibility:

1. Give fluids IV or PO before chemotherapy to hydrate patient

2. Give antiemetic 30-60 min before giving product to prevent vomiting, and prn for several
days thereafter; antibiotics for prophylaxis of infection
3. Provide liquid diet: carbonated beverages; gelatin may be added if patient is not
nauseated or vomiting
4. Monitor ECG; watch for ST-T wave changes, low QRS and T, possible dysrhythmias
(sinus tachycardia, heart block, PVCs)
5. Assess buccal cavity q8hr for dryness, sores or ulceration, white patches, oral pain,
bleed- ing, dysphagia; obtain prescription for viscous lidocaine (Xylocaine)
6. Assess tachypnea, ECG changes, dyspnea, edema, fatigue; identify dyspnea, crackles,
unproductive cough, chest pain, tachypnea
7. Monitor renal function studies: BUN, creati- nine, serum uric acid, urine CCr before,
during therapy; I&O ratio; report fall in urine output to ,30 ml/hr
8. Monitor temp q4hr (may indicate beginning of infection)
9. Monitor liver function tests before, during therapy (bilirubin, AST, ALT, LDH) as needed
or monthly; jaundice of skin, sclera, dark urine, clay-colored stools, itchy skin,
abdominal pain, fever, diarrhea
10. Assess for bleeding: hematuria, stool guaiac, bruising or petechiae, mucosa or orifices
q8hr; inflammation of mucosa, breaks in skin
11. Instruct patient to report signs of anemia (fatigue, headache, irritability, faintness)
12. Instruct patient to report signs of stomatitis (bleeding, white spots, ulcerations in the
mouth); tell patient to examine mouth daily, to report symptoms; viscous lidocaine
(Xylocaine) may be used
13. Teach patient to avoid crowds, persons with known infections
14. Advise patient to avoid vaccinations during therapy, to use sunscreen or stay out of the
sun to prevent burns; about hair loss; explore use of wigs or other products until hair
regrowth occurs

Reference:

Skidmore, (2015). Flourouracil. Mosby’s Drug Guide for Nursing Students, Eleventh Edition.

Elsevier; St. Louis, Missouri. 63043 P. 443-445

Schull, P.D., (2013). Flutamide. McGraw-Hill Nurse’s Drug Handbook, Seventh Edition. P.

517-519

Medscape, (2020). Adrucil (fluorouracil) dosing, indications, interactions, adverse effects, and
more. Retrieved on September 8, 2020 from https://reference.medscape.com/drug/adrucil-
fluorouracil-342092

Paclitaxel

Generic Name: Paclitaxel

24
Brand Name: Abraxane

Drug Classification: Anti-neoplastic or cytotoxic

Mode of Action: Increases action of tubulin dimers; stabilizes existing microtubules;

inhibits their disassembly; interferes with late G2 mitotic phase.

Suggested Dose: IV: ADULTS, ELDERLY: 125 mg/m2 on days 1, 8, 15 of each 28-

day cycle. (Administer gemcitabine immediately after Abraxane.)

Indication: - Breast Cancer - Ovarian Cancer

- Kaposi’s Sarcoma - Pancreatic Cancer

- Non-small lung cell cancer - Head & neck cancer

- Peritoneal Cancer - Lung Cancer

Contraindications: - Hypersensitivity - Severe neutropenia

Side Effects: - Diarrhea - Alopecia

- Nausea - Vomiting

- Myalgia - Arthralgia

- Peripheral Neuropathy - Mucositis

- Pain and redness at injection site

Adverse Effects: - Anemia - Leukopenia

- Thrombocytopenia - Severe Hypersensitivity

- Severe Hypotension - Angioedema

- Neutropenia - Peripheral Neuropathy

- Hepatic Impairment

25
Drug Interaction: - CYP3A4, CYP2C8 inhibitors may increase concentration/effects.

- Live virus vaccines may potentiate virus replication, increase

vaccine side effects, decrease pt’s antibody response to vaccine.

- LAB VALUES: May elevate serum alkaline phosphatase, bilirubin,

ALT, AST, triglycerides.

Nursing Responsibilities:

1. Check blood counts, particularly neutrophil, platelet count

2. Monitor CBC, vital signs

3. Monitor for hematologic toxicity (fever, sore throat, signs of local infections, unusual

bleeding/ bruising)

4. Avoid IM injections, rectal temperatures, other traumas that may induce bleeding

5. Educate patient that hair loss is reversible but new hair growth may have different

color, texture.

6.Report any signs of bleeding, dyspnea, sore throat

7. Instruct patient not to receive any vaccinations without advice of health care

professional.

References:

o Karch, M. (2015). Lippincott’s Nursing Drug Guide. New York: Wolter’s Kluwer.

o Nursing 2020 Drug Handbook. (2019). Philadelphia: Wolter’s Kluwer Health.

o Skidmore-Roth, L. (2019). Mosby’s 2019 Nursing Drug Reference. St. Louis,

Missouri: Elsevier. A

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v. PROGNOSIS

Pancreatic cancer survival rates have been improving from decade to decade,
although the disease is still considered largely incurable. According to the American
Cancer Society, for all stages of pancreatic cancer combined, the one-year relative
survival rate is 20%, and the five-year rate is 7%. These low survival rates are
attributable to the fact that fewer than 20% of patients’ tumors are confined to the
pancreas at the time of diagnosis; in most cases, the malignancy has already
progressed to the point where surgical removal is impossible. In those cases where
resection can be performed, the average survival rate is 23 to 36 months. The overall
five-year survival rate is about 10%, although this can rise as high as 20% to 35% if the
tumor is removed completely and when cancer has not spread to lymph nodes. Plus,
Tumor size also appear to impact survival rates. The larger the tumor, the less likely it is
to be cured by resection. However, even large tumors may be removed and a number
of patients with tumors greater than 4-5 cm appear to have been cured by surgery.
There is increasing evidence that the best pancreatic cancer outcomes are achieved at
major medical centers with extensive experience, those that perform more than 20
Whipple procedures annually. About 15 to 20 percent of all pancreatic tumors are
resectable. These include stage I and stage II tumors. Rarely, locally advanced stage III
tumors, which are typically considered unresectable, are characterized as “borderline”
and may be removed if the patient has access to an experienced, highly trained
surgeon. As for Stage IV pancreatic cancer, it has a five-year survival rate of 1 percent.

27
The average patient diagnosed with late-stage pancreatic cancer will live for about 1
year after diagnosis. In patients where a cure is not possible, progression of the disease
may be accompanied by progressive weakness, weight loss, and chronic pain. Effective
techniques for pain management are widely available today and used by physicians
experienced in the care of pancreatic cancer patients. The techniques include nerve
blocks and various drugs that can be taken by mouth or injection. There are also a
variety of effective techniques available to treat bile duct obstruction which may produce
jaundice and stomach obstruction caused by growth of the tumor. Both surgical and
non-surgical techniques may be effective. As for the physical status post surgery,
consuming right nutrition and keeping physically active under the circumstances will
impact how a patient tolerates the side effects of treatment and the symptoms of
pancreatic cancer. Younger patients tend to do better since they have fewer other
conditions that may limit recovery, but even older patients can positively impact their
prognosis by focusing on nutrition and exercise.

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III. DISCHARGE PLANNING

Discharge Planning

Method Health teachings Rationale

Medication 1. Antibiotics. 1. Helps to treat or prevent a
2. Pancreatic enzymes. bacterial infection.
3. Insulin. 2. Helps your body digest
4. Prescription of pain protein, carbohydrates, and
medicine. fats in your food.
5. Encourage patient to 3. To help balance blood
take their medicine as sugar levels.
directed. 4. Ask their healthcare
provider how to take this
medicine safely. Some
prescription pain medicines
contain acetaminophen. Do
not take other medicines that
contain acetaminophen
without talking to their
healthcare provider. Too
much acetaminophen may
cause liver damage.
Prescription pain medicine
may cause constipation. Ask

29
 their healthcare provider how
to prevent or treat
constipation.
5. Contact their healthcare
provider if they think the
medicine is not helping or if
there are side effects. Inform
the health care provider if the
patient is allergic to any of
the medicine. Keep a list of
the medicines, vitamins, and
herbs you take. Include the
amounts, and when and why
they should take them.
Instruct them to bring the list
or the pill bottles to follow-up
visits. Carry the medicine list
with you in case of an
emergency.

Exercise 1. Relaxation breathing 1.Research shows that

2. Aerobic exercise relaxation breathing can help
3. Stretching reduce stress and anxiety
4. Strength training during recovery. When
people feel stressed, they
usually take quick, shallow
breaths. During relaxation
breathing, the goal is to
breathe slowly and deeply.
Being aware of your breath
can have a calming effect
and allow you to focus your
energy toward healing.
2. Aerobic exercise helps

30

Treatment 1.Right time at the right
interval of the medicines
given should be observed to
obtain optimum effects.
2. Explain the current health
status to patient’s family.
3.If there are any unusuality’s
contact the healthcare
provider immediately
Hygiene 1.Good personal hygiene
such as taking a bath daily,
brushing teeth three times a
day, hand washing before
and after eating and after
using the toilet.
Outpatient 1. Consult the primary health
care provider regularly for
follow-up.
2. Encourage the family to
ask questions if it needs
clarification.
31
maintain your cardiovascular
system
3. Stretching regularly can
gradually improve your
posture, range of motion, and
flexibility.
4. It is important to including
stretching after your
strengthening exercises in
order to assist in recovery
and minimize muscle and
joint pain.
1. To obtain optimal effects of
the drugs.
2. To make sure that proper
managements and
precautions are done in
rendering care to the patient
upon discharge.
3. To modify the treatment
and add interventions if
needed.
maintaining good personal
hygiene can prevent illness
and infection
1. Enables the physician and
the patient to monitor and
evaluate progress of
recovery.
2. Avoids misunderstanding
on orders made by physician
 3. Set or plan care or
activities with client.
Diet 1. Eat a variety of fruits and
vegetables every day.
2. Eat small, frequent meals can help fight against cancer.
throughout the day.
3. Choose protein-rich
foods such as eggs, beans,
lean meats.
4. Avoid alcohol intake.
5. Encourage the patient to
drink liquids as directed.
32
thus contributing to fast
recovery and the prevention
of developing complications
through wrong
managements.
3. This gives a message to
that patient can handle
situation and enhancing self-
concept.
1. Fruits and vegetables offer
the body antioxidants, which
2. Eating frequent small
meals will ensure your body
is getting enough calories,
protein, and nutrients to
tolerate treatment. Smaller
meals may also help to
reduce treatment-related side
effects such as nausea.
3. Protein helps the body to
repair cells and tissues. It
also helps your immune
system recover from illness.
4. Alcohol may contribute to
dehydration, can lower the
abilities of your immune
system, and provides no
beneficial nutrients.
5. Drinking enough fluids
during cancer treatment is
important for preventing
dehydration.
Reference:

https://pearlpoint.org/i-have-pancreatic-cancer-what-should-i-eat/#:~:text=Aim%20to%20eat
%20a%20minimum,cause%20stomach%20pain%20or%20discomfort.

https://www.drugs.com/cg/pancreatic-cancer-discharge-care.html

https://www.fairview.org/sitecore/content/Fairview/Home/Patient-
Education/Articles/English/d/i/s/c/h/Discharge_Instructions_After_Treatment_for_Cancer_of_the
_Pancreas_86294

IV. RELATED NURSING THEORY

Care, Cure, Core Nursing Theory by Lydia Hall

The theory emphasizes the role of nurses, and is focused on

performing the task of nurturing patients. This theory is very applicable in
the case of pancreatic cancer. Since the patient doesn’t have the ability to
take care of themselves, nursing care should be rendered with the help of
other medical professional to achieve the goal of care. On this case, the
patient needs assistance in which serves as an opportunity for nurses to
extend the care to meet the physical and emotional needs. Provision of
care allows nurses to acquire knowledge about the treatment and the

33
disease itself. The patient and a nurse should develop close relationship to
promote good communication in dispensing information specifically health
teaching while intimate physical care is given.

V. REVIEW OF RELATED LITERATURE

Title: Pancreatic cancer in 2017: Rebooting pancreatic cancer knowledge and treatment
options.

Bibliography: Semaan, A., & Maitra, A. (2018). Pancreatic cancer in 2017: Rebooting
pancreatic cancer knowledge and treatment options. Nature Reviews.Gastroenterology &
Hepatology, 15(2), 76-78. doi:http://dx.doi.org/10.1038/nrgastro.2017.182

Reaction:

Worldwide, both the incidence and death rates of pancreatic cancer are increasing. Evaluation
of pancreatic cancer burden and its global, regional, and national patterns is crucial to policy
making and better resource allocation for controlling pancreatic cancer risk factors, developing
early detection methods, and providing faster and more effective treatments. The article shows
that pancreatic cancer has a very poor prognosis, with a 5-year survival rate of only 6% and 80–
85% of patients with pancreatic cancer diagnosed at a stage when the tumor is unresectable.

It is also show in this article that during the past decade, emerging high throughput genomic
technologies have generated large amounts of data with apparently inconsistent results, owing

34
to tumor heterogeneity and low individual patient prevalence of distinct mutations. Although the
predominant question in pancreatic cancer research in 2014 was whether stroma was friend or
foe, the focus of research in 2015 has been the identification and validation of diagnostic
biomarkers. If the findings reported in 2015 can be reproduced in the clinical setting, tests based
on glypican- 1 hold promise for the early detection of pancreatic cancer, at least in high-risk
cohorts. Organoid models of PDAC are an improvement on previous preclinical models for the
study of disease pathogenesis and treatment response. In addition, pooling large data sets
enables the identification of cancer-specific signatures that are predictive of disease outcome,
potentially paving the way to precision medicine. It remains to be seen whether these research
efforts will be able to alter the pessimistic projections for the burden of pancreatic cancer. I
strongly agree with the article since it was giving us an update and knowledge about pancreatic
cancer and what are its treatment options all throughout the years.

TITLE: Characteristics of early‐onset pancreatic cancer and its association with familial
pancreatic cancer and hereditary pancreatic cancer syndromes

REFERENCE:
Eguchi, H., Kobayashi, S., Gotoh, K., Noda, T., & Doki, Y. (2020). Characteristics of
early‐onset pancreatic cancer and its association with familial pancreatic cancer
and hereditary pancreatic cancer syndromes. Annals of Gastroenterological
Surgery. Retrieved on September 5, 2020 from
http://dx.doi.org/10.1002/ags3.12326

REACTION:

This study reported the clinical characteristics of early-onset pancreatic cancer

and its association with familial pancreatic and hereditary pancreatic cancer syndromes.
The incidence of pancreatic cancer is high among individual in their 60’s to 70’s of age
but low in those in their 50’s or younger. Familial pancreatic cancer is defined as
pancreatic cancer who have two or more first-degree relatives with the same disease.
The study presented that at the young age, people may develop pancreatic cancer that
they might acquire from their family or termed as familial pancreatic cancer and
hereditary pancreatic cancer syndromes.

The study also mentioned that smoking plays a significant role in the incidence of
early-onset pancreatic cancer (EOPC). Piciucchi et al defined the onset of pancreatic
cancer at an age of 50 or younger as early-onset of pancreatic cancer and compared
the characteristics of 25 patients suffering from early-onset of pancreatic cancer with

35
268 patients with later-onset pancreatic cancer (LOPC). They reported that if a person
started smoking at a young age are primary risk factors of EOPC and that there was no
significant difference in the incidence of familial pancreatic cancer and hereditary
pancreatic cancer syndromes.

Accordng to studies, approximately 10% of pancreatic cancer patients reported

that they have a family history. Medical examination for pancreatic cancer among
subjects in a familial pancreatic cancer, family line may be effective. Heriditary
pancreatic cancer syndromes exemplify hereditary tumors which later on develop into
pancreatic cancer. Hereditary pancreatitis was defined as inflammation of the pancreas,
usually recurrent from childhood. In relation to carcinogenesis, these gene mutations
are thought to cause continuous chronic pancreatitis from childhood, leading to the
formation of precancerous lesions.

In addition, the study helps widen the knowledge of individual about the major
risk factor of pancreatic cancer. Also, it will help nurses included student nurses to use
information more effectively, stay updated, and offer quality patient care.

VI. REFERENCES

Gonzalo, A., (2019). Lydia Hall: Care, Cure, Core Nursing Theory. Retrieved on
September 9, 2020 from https://nurseslabs.com/lydia-e-halls-care-cure-core-theory/

(n.a) (2019, November 13). Pancreas – Cancer. Retrieved September 12, 2020, from
https://www.cdc.gov/shigella/general-information.html

(n.a). (2020, February 3). Acute Pancreatitis (Discharge Care) - What You Need to
Know. Retrieved September 12, 2020, from https://www.drugs.com/cg/acute-
pancreatitis-discharge-care.html

Alter, D. (2019, October 28). Cancer. Retrieved September 12, 2020, from
https://labtestsonline.org/conditions/Cancer

Bo, X. (2018, February 20). 10 dead in Pancreatic Cancer in S. Philippines. Retrieved

September 12, 2020, from http://www.xinhuanet.com/english/2018-
02/20/c_136986457.html

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Buff, S. (2018, September 3). Pancreatic Cancer: Symptoms, Treatment, and More.
Retrieved September 12, 2020, from https://www.healthline.com/health/digestive-
health/pancreatitis

Felman, A. (2017, June 23). Pancreatic Cancer: Treatment, symptoms, and causes.
Retrieved September 12, 2020, from
https://www.medicalnewstoday.com/articles/171193

Murray, F. W. (2015, May). V. The Surgical Treatment of Pancreatic Cancer. Retrieved

September 12, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1425453/

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