Pathophysiology of pancreatic cancer
Most of the pancreatic cancer occurs between the age group of 60 and 80 years. The cause of pancreatic cancer is unknown; however, the incidence of pancreatic cancer is high with smokers. It is also associated with high calorie intake and nitrosamines, whose formation is enhanced with high temperatures as in frying. Diabetes is another risk factor but it is not clear whether cancer follows diabetes or diabetes follows cancer (Porth, 2002). In the above case study the patient already had diabetes for thirty – three years.
When normal cells are exposed to carcinogens, example, cigarette smoke, there is genetic damage to the DNA repair genes, resulting in DNA damage and eventually mutation of cell genes. A gene called K-ras is found to be altered in up to 95% of ductal carcinoma of the pancreas (Chernicky & Endy, 2008). These mutations of the gene leads to the activation of proto – oncogenes that promote normal cell growth and anti – oncogenes that inhibit growth. The result is unregulated cell growth and differentiation ending into a malignant neoplasm. The unregulated, cell growth results into proliferation of cells with a mass and because pancreas is an organ that lies just under the curvature of the stomach and deep within the abdomen the doctors usually miss an early diagnosis during the abdominal assessment. This cancerous process may arise in any part of the pancreas that is the head, body and the tail. Most of it occurs in the head. As cancer has no regard to normal anatomical boundaries, the proximity of the head of the pancreas to other abdominal structures like the common bile duct and the ampulla vater causes obstruction of these structures as neoplasm grows. The result is obstructive jaundice that occurs. Uncoordinated growth and lack of contact inhibition in neoplasm than have the ability to break loose because the cells are less well differentiated. As a result they can enter the circulatory circulation or lymphatic systems and form secondary malignant tumors at other sites (Porth, 2002). In our case study the liver is also affected.
The symptoms that Mrs. Brown presented with are the common manifestations of the pancreatic cancer. Abdominal pain, anorexia, rapid and progressive weight loss, nausea and jaundice are the most common ones. She presented with these symptoms when her cancer had well progressed and had metastasized because the onset of pancreatic cancer is insidious most of the time. Presence of jaundice usually indicates the progression of the disease to its late stage. Unfortunately there is no screening available for this cancer unlike other cancers (Bryant and Knights, 2007).
In Porth (2002), anorexia which is one of the main symptoms of pancreatic cancer occurs because of the exocrine function the pancreas plays in the body. From an anatomical view point, the pancreas passes its exocrine contents which contains enzyme lipase, protease and amylase for digestion of fats, proteins and carbohydrates respectively, through the pancreatic duct into the duodenum. In the normal physiological condition there is digestion of all three food groups in the duodenum by the pancreatic enzymes. However, in the pathological state, when there is pancreatic duct obstruction as the case study presents, obstruction to the flow of the pancreatic juices will cause poor absorption of food leading to weight loss. Apart from the malabsorption of nutrients that occur there is another phenomenon about weight loss. Cancer cachexia is the term that describes the weight loss and wasting of body fat and lean protein in cancer patients. Cachectin which is identical to Tumor Necrotic Factor (TNF) is released from the macrophages in response to tumor growth, causes anorexia by suppressing satiety centers causing early satiety. This contributes to fatigue and weakness and other psychosocial factors like depression. TNF is also an endogenous pyrogen that induces fever by its action on hypothalamic regulatory regions which probably explains SB’s fever TNF is also said to activate inflammatory response and coagulation system explaining why Mrs. Brown probably had a high WCC and elevated APTT.
Jaundice is the result of obstruction of the biliary tract and duodenum. This occurs when the hepatic or extrahepatic biliary tracts are occluded, causing decrease in flow of bile. Bile which is produced by the hepatocytes (liver cells) contains bilirubin (heme degradation product) and bile salts, whose function is to emulsify fats. The bile moves from the liver into the duodenum through biliary tract, into the common bile duct which passes through the head of the pancreas before passing through the ampulla of vater. Because of the obstruction of the common bile duct from the head of the pancreatic tumor the flow of bile together with bile salts is obstructed from entering the duodenum. As a result bilirubin is unable to empty into the duodenum and it backs up the biliary tree into the liver and crosses over into the blood in the systemic capillaries. It then binds to elastic tissue causing the characteristic color change of yellow skin and sclera and often causes debilitating pruritis. By the time the patient presents with jaundice the cancer has already metastasized and the prognosis is really poor whereby surgical resection of the tumor becomes impossible (Porth, 2002).
Tea colored urine is also due to high bilirubin in the blood which causes increased filtration of bilirubin by the kidneys into the urine giving it the dark coloration. Obstruction of bile flow into the duodenum also causes decreased fat emulsification because of low or absent bile salts causing decreased fat digestion and absorption resulting in high fecal fat excretion. According to Porth (2002) if there is obstruction to the ampulla of vater there will be more fecal fat excretion because now the excretion of pancreatic enzyme especially lipase for fat digestion is also affected. Hence if there is no lipase there will be no fat digestion. The term to describe this condition is steatorrhoea whereby you have loose, pale, fatty, floating offensive bowel motions, the condition that Mrs. Brown presented with.
Mrs. Brown presented with most of the complications arising from pancreatic cancer like obstruction of the duodenum and biliary ducts. She also presented to the ED, with PR bleeding which is one of the complications due to pancreatic cancer. PR bleeding is due to gastrointestinal hemorrhage when the growing tumor compresses and erodes the portal venous system causing frank bleeding. Fever, another complication is a life threatening condition which can occur when there is neutropenia (low neutrophil count) resulting from cancer which makes the person more prone to infection. Mrs. Brown also has the tendency to develop malignant ascitis which can result from liver metastasis. From ascitis she can develop respiratory problems, heart failure due to pulmonary edema caused by the diffusion of the peritoneal fluid intravascularly. Splenomegaly can be caused by the encasement of the splenic vein by the tumor. Glucose intolerance can be facilitated even though she already has the history of it. As the tumor grows it can cause gastric outlet obstruction leading to nausea and vomiting. Another complication of pancreatic cancer is migratory thrombophlebitis which is the presence of several blood clots along the veins. Pain can get intolerable when there is invasion to the autonomic nerves of the pancreas by the tumor. Spinal cord compression from expanding tumor can cause irreversible paraplegia (Chernicky & Endy, 2008).
According to the case study presented there are several problems that need addressing for Mrs. Brown. However, three nursing diagnosis according to priority will be discussed. According to Lee and Bishop (2004), “priority diagnosis is those nursing diagnosis… if not managed now, will deter progress to achieve outcomes or negatively affect the client’s functional status”p.15. Hence, first nursing diagnosis is fluid volume deficit, relating to nausea, vomiting and PR bleeding as manifested by dry skin and mucous membrane and increased heart rate. Anticipatory short term goal for Mrs. Brown will be that she will verbalize relief from nausea and vomiting, will demonstrate normal heart beat of ≤ 100 beats/min, absence of blood in stool and exhibit an elastic skin turgor and moist mucous membrane within the end of my shift of seven and a half hours. Nursing implementations included keeping Mrs. Brown Nil By Mouth (NBM) as keeping the stomach empty will reduce the urge to vomit so that more fluids are not lost. Assured patient has a patent, intravenous access site available for administration of medications. Administration of Intravenous Fluids (IVF) was commenced to maintain fluid and electrolyte balance. Vital signs were monitored every two hourly because of Physiological Unstable Person (PUP) of 2. This was done to monitor cardiovascular changes. According to Brown and Edwards (2008), “When there is mild to moderate fluid volume deficit, compensatory mechanism include sympathetic nervous stimulation of the heart and peripheral vasoconstriction,”p. 354. As a result there is increased heart rate. If the homeostatic mechanism is not able to compensate then hypotension can occur and the person can have weak pulses eventually leading to hypovolemic shock (Brown and Edwards, 2008). Accurate intake and output of fluids in the 24hr fluid balance chart to detect an imbalance between intake and output was also monitored and documented so that appropriate interventions can be made. For output recordings recorded the urine output and vomitus. Monitored respiratory changes every two hours because respiration rate increases due to decreased tissue perfusion and resultant hypoxia (Brown & Edwards, 2008). Weight measurement was done in the morning as it was done previously to ensure correct measurement (body weight changes reflect changes in body fluid volume). Administered antiemetic maxalon that relieves nausea and vomiting by blocking dopamine receptors in the chemoreceptor trigger zone (Bryant & Knights, 2007). Monitored Blood glucose regularly so that uncontrolled diabetes can be detected and prevent further fluid loss through diuresis. Abdomen region was assessed for skin turgor and mucous membrane for signs of dehydration. If there is delay to the return of the pinched skin to its shape the person has a diminished skin turgor (Brown & Edwards, 2008). Urine sample was examined for color and amount as concentrated urine denotes fluid deficit. Urine sample was then sent to the lab for evaluation for increased specific gravity which is the test for dehydration (Brown & Edwards, 2008). Assessed the signs and symptoms of PR bleeding by examining the feces. Presence of frank blood was text paged to the Health surgeon for medical intervention so that appropriate action can be taken to avoid further deterioration on fluid balance resulting in hypovolemia.
After nursing interventions of seven hours the nursing care was evaluated and it was found that Mrs. Brown was able to maintain an adequate fluid volume as evidenced by moist mucous membranes and good skin turgor. Mrs Brown also verbalised of having no nausea and vomiting at the end of my shift.
Second nursing diagnosis is chronic pain relating to obstruction of the duodenum and biliary tract secondary to pancreatic cancer as manifested by patient not able to relax and facial grimacing. Mrs. Brown will verbalize pain relief approximately within four hours of interventions and will display relaxed facial expressions. To help Mrs. Brown achieve her goals, her pain was assessed using COLDSPA. That is character, onset, location, duration, severity, pattern and associated symptoms. This is done to aid diagnosis and find underlying cause of pain and assist in treatment choice. The assessment on pain intensity was documented at regular intervals. According to Brown and Edwards (2008) the rationale for doing this is that systematic, ongoing assessment and documentation provide direction for the pain treatment plan. Utilized pain scale (0 – 10) for pain intensity whereby 0 is no pain and 10 is the least pain. Pain intensity scale is useful to objectify discomfort, assess effectiveness of pain – relieving measures (Brown & Edwards, 2008). Mrs. Brown had a pain of “8” on pain scale of 1 – 10. Provided analgesics tramadol and severedol as required on a prn basis according to the physicians order as untreated pain can have a negative effect on the physical wellbeing of the patient and may subject Mrs. Brown to unnecessary anxiety and depression. Evaluation of the analgesia given on regular basis was also done to identify whether adequate pain relief has been given or adjustments to pain management needs to be done. Comfort and reassurance was offered by staying with the patient when the pain occurred to alleviate fears of pain. Provided education on the need for analgesia before pain becomes severe to avoid unnecessary pain and provide overall well being. Alternative pain relief measures like relaxation and deep breathing was also suggested as other means to control pain. Suggested diversional activities like music and watching television to distract from pain. Evidence has showed that music can help control pain in some patients (Lim & Locsin, 2006). At the end of the shift patient still reported a dull pain of “6” on the pain scale of 1 – 10. As a result goal was not met and the health officer was text paged to review pain medication.
Third nursing diagnosis is Fatigue relating to anemia as evidenced by low hemoglobin count of 75g/l and spells of dizziness. Mrs. Brown will demonstrate moderate exercise and activity without fatigue and dizziness within seven hours. The possible cause of fatigue for Mrs. Brown is anemia as a result she was transfused with two units of red blood cells. Advised Mrs. Brown on adequate diet of small frequent meals for imbalance nutrition as it is one of the causes of fatigue. Encouraged Mrs. Brown to increase activities to gradually build tolerance this will prevent exhaustion and will not have a detrimental effect on her (Brown & Edwards, 2008). After the end of my shift Mrs. Brown verbalized that she was able to take a shower without much exhaustion.
Discharge planning for continuity of care will include discharge medications and prescriptions (pain medication and nitrofurantoin) given to the patient and the purpose of the drug therapy, proper dosage and routes and potential adverse effects are to be explained to the patient. Ensure health education is provided on adequate rest and short period of exercise to compensate for fatigue. To ensure that cancer society liaison nurse referral has been made for regular support. Discharge planning will also include assurance that Mrs. Browns has the understanding of the outcome of the disease and understanding of self- management plan including building activity tolerance. Also education on the possible complications, signs and symptoms of the disease and when to notify the physician is understood. To provide address of the cancer society information nurses for the patient and the family to seek information and service if needed. Also to provide address of the support group which would be helpful for the patient’s wellbeing when sharing experiences with people who are in similar situation. There are several in the Auckland region, example, the ostomy society. Discharge planning also includes the assurance that the patient has the dietician, the social worker, the palliative nurse, and the Pacific Islander Support input.
Reflection
Caring of Mrs. Brown has been the most rewarding experience for me whereby she has been my first nurse – client contact of a person who has been diagnosed with a terminal illness. She has helped me to gain insight as to how to deal with challenging situations of emotional and psychological turmoil. She has also helped me question my interpersonal skills and acquiring skills when dealing with multidisciplinary team members. I am going to reflect on one of the challenging situations that I was faced with while caring for Mrs. Brown. Upon being told about her illness, Mrs. Brown, asked me how could God do this to her as she was a religious women and always attended church functions with her husband who is a church minister. I was quite speech less and did not know how to respond to her question. At one instance she became physically emotional and that was the time that I realized that I lacked the skills to console her. I was so relieved when my preceptor came to relieve me and I saw her deal with the situation so appropriately.
At that instance I realized how important interpersonal skill is in managing challenging situations. The skills identified were listening, empathy, adopting a non – judgemental approach and motivation. Because of my lack of education on dealing with loss and grief, I decided to search the relevant literature on ways that nurses can help the patient and their family into dealing with this psychological and psychosocial problem. According to Crisp and Taylor (2005), nurses use the theoretical frameworks to guide them in assessing the special needs of the patient. One of the nursing models used by nurses is the Kubler- Ross’s stage theory. This theory describes the stages a patient goes through when faced with loss and grief. The stages being denial, anger, bargaining followed with depression and then acceptance of the disease. However the patient can demonstrate any stage at any given time. From the question that Mrs.Brown put forward to me, I could identify that she was going through the anger phase of the Kubler-Ross’s stage theory. To get Mrs. Brown to the acceptance stage, the most appropriate way to deal with it, which according to Crisp and Taylor (2005), is an open and honest therapeutic communication.
Having searched the relevant literature on therapeutic communication and loss and grief, I now feel that that I have the knowledge, skills and understanding to cope with situations that I first deemed challenging. However, I do feel that challenging situations come at different times at different level and competence in dealing with it evolves with time and experience.
Reference
Brown, D. & Edwards, H. (Eds.). (2008). Lewis’s medical-surgical nursing.
Assessment and management of clinical problems. (2nd ed.) Sydney, Australia:
Elservier, Mosby.
Bryant, B., & Knights, K. (2007). Pharmacology for health professionals. (2nd
ed.). Sydney: Elsevier.
Chernecky, C. C., & Endy, K. M. (2008). Acute care oncology nursing (2nd ed.).
Marrickville, Australia: Elsevier.
Crisp. J., & Taylor, C. (Eds.). (2005). Potter & Perry’s fundamentals of
nursing (2nd Australasian ed.). Marrickville, Australia: Elsevier
Australia
Huether, S. & McCance, K. (Eds.). (2004). Understanding pathophysiology. (2nd ed.).
Philadelphia: Elsevier, Mosby.
Lim, P. H., & Locsin, R. (2006). Music as nursing intervention for pain in five Asian
countries. International Nursing Review 53(3), Retrieved May 20, 2009, from
CINAHL database.
Ministry Of Health (2008). Incidence of pancreatic cancer. Retrieved on May 19, 2009
from http://www.moh.govt.nz/moh.nsf/82f4780aa066f8d7cc2570bb006b5d4d/8
e1d731682cab3d9cc256c7e00764a23/$FILE/29-pancreatic.pdf
Porth, C. M. (2002). Pathophysiology: Concepts of Altered health status (6th
ed.). Philadelphia: Lippincott Williams & Wilkins.
.
