Pancreatic HEad Mass

Pancreatic Head Mass

Submitted by:

4NU01

CABRAL, Nolan B.

October 13, 2015

Background

Sixty percent of pancreatic cancers develop in the pancreatic head; 40% develop in the body and tail. The major symptoms include abdominal pain, anorexia, weight loss, and jaundice. The pain is located in the epigastrium and has a quality characterized as deep and boring. The pain may be intermittent or constant, and is progressive. Painless jaundice indicates a potentially resectable lesion located in the pancreatic head. A predominance of abdominal pain suggests neural plexus involvement, location in the tail, unresectability, and a poor prognosis.

The only potentially curative therapy for pancreatic cancer is surgical resection. The standard operation for adenocarcinoma in the pancreatic head or uncinate process is the pancreaticoduodenectomy, or "Whipple operation." The Whipple operation involves resection of the pancreatic head, duodenum, common bile duct, distal stomach, and gallbladder.Pancreatic head mass has been a common disease in people unhealthy lifestyle. I want to know more about this case and enhanced my knowledge about it.

A. DEMOGRAPHIC DATA

Name: Patient Y.B

Address: Neuva Viscaya

Age: 74 years old

Gender: Female

Date and Time of Admission: N/A

Diagnosis: Pancreatic Head Mass

B. Chief Complaint:

Abdominal pain and discomfort

C. Present History of Illness:

Prior to admission, patient was having abdominal discomforts. She was then

diagnosed with diabetes and was sent home. 2 months prior to admission patient

then had an episode of extreme abdominal pain was sent back to the hospital.

Patient was then diagnosed for Pancreatic head mass. Patient was transferred to St.

Luke’s on September 14, 2015.

D. Family History of Illness

Patient’s family has history of hypertension and DM.

E. Social History

Patient does not smoke, drink alcohol or use recreational and illicit drugs.

F. Allergies

NKA

Vital Signs

Upon Admission

Temperature 37.6

Pulse rate 87

Respiratory rate 24

Blood pressure 150/100

O2 saturation 96%

Pain scale (VAS) --

Anatomy:

The pancreas is located retroperitoneal, posterior to the stomach in the inferior part of the left

quadrant. It has a head near the midline of the body and a tail that extends to the left where it

touches the spleen. It is a complex organ composed of both endocrine and exocrine tissues that

perform several functions. The endocrine part of the pancreas consist of pancreatic islets. The

islet cells produce insulin and glucagon, which are very important in controlling blood levels of

nutrients such as glucose and amino acids.The exocrine part of the pancreas is a compound

acinar gland . The acini produce digestive enzymes. Clusters of acini are connected by small

ducts, which join to form larger ducts, and a larger ducts join to form pancreatic duct. The

pancreatic duct joins the common bile duct and empties into the duodenum.The exocrine

secretions of the pancreas include HCO3, which neutralize the acidic chyme that enters the small

intestine from the stomach. The increased pH resulting from the secretion of HCO3 stops pepsin

digestion but provides the proper environment for the function of pancreatic enzymes. The

major proteolytic enzymes are trypsin, chymotrypsin and carboxypeptidase. These enzymes

continue the protein digestion that started in the stomach and pancreatic amylase continues the

polysaccharide digestion that begun in the oral cavity.

Pathophysiology:

PANCREAS

Head Body TailExocrine Endocrine

Pancreatic Cancer Formed

Regional Lymph Nodes

Liver

Lungs

DuodenumStomach

colon

Ductal epithelium

Acinar Cells

Connective Tissue

Lymphatic Tissue

Diagnostics:

HEMATOLOGY TEST

September 14, 2015

Test Results Normal values Clinical Significance

WBC Count 12.73/uL 5-10 Indicates bacterial infections

Hemoglobin 10.6 g/dL F: 12.0-16.0 Indicates anemia

Hematocrit 34.0 % F: 38.0-46.0 Indicates anemia

Platelet

Count

3483 u/L 150-450 103 u/L Within normal range

Segmenters

(%)

57.0 % 40.0-60.0 Within normal range

Lymphocyt

e (%)

21.0(%) 20.0-40.0 % Within normal range

Monocyte

(%)

1.0 % 2.0-8.0 % Within normal range

Eosinophil

(%)

6.8% 1.0-6.0 % Indicates allergic reactions

Basophil 0.8% 0.1-1.0 % Within normal range

Blood Chemistry

September 14, 2015

Tests Results Normal Value Clinical SignificanceGlucose 10.3 mmol/L 4.10-59.0 Indicates hyperglycemiaSodium 122.3mmol/L 137.0-145.0 Indicates renal

insufficiencyCreatinine 180.9

ummol/L71.0-133.0 Indicates renal function

Cholesterol 2.7 mmol/L 0.00-5.20 Within normal rangeDirect HDLC .6mmol/L 1.00-1.60 Indicates risks in CADLDL 1.20mmol/L 1.71 – 4.60 Within normal rangeVLDL .56mmol/L 0.00-1.03 Within normal rangePotassium 4.4ummol/L 3.50-5.10 Within normal range

Triglycerides 1.23mmol/L 00.-1.69 Within normal rangeUrea 24.3mmol/L 2.50-6.10 Indicates impaired renal

function

HbAlc

September 14, 2015

Tests Results Normal Value Clinical SignificanceHbAlc -7.5 % -4.2 – 6.2% Indicates DM

Drug Study:

Generic Name/Brand Name

Mechanism of Action Uses Contraindication

Side Effects Nursing intervention

Unasyn

Ampicilin Sodium and Sulbactam Sodium

Inhibits cell wall synthesis during bacterial multiplication.

Anti-Bacterial Contraindicated to patients hypersensitive to drug or other penicillin.Use cautiously in patients with other drug allergies ( especially to cephalosporins) because of possible cross-sensitivity, and in those with mononucleiosis because of high risk of maculopapular rash.

CV: thrombophlebitis, vein irritationGI: diarrhea, Nausea, pseudomembranous colitis,vomiting, stomatitis, gastritis, black hairy tongue, enterocolitis.HEMATOLOGIC: agranulocytosis, leucopenia, anemia, eosinophilia.SKIN: pain at injection site.OTHER: hypersensitivity reaction,anaphylaxis,overgrowth of non susceptible organisms.

Ask patient about allergic reactions to penicillin. Obtain specimen of culture and sensitivity test.In patient with impaired renal function, decrease dosage.. Monitor liver function test results during therapy, especially in patients with impaired liver function.If large doses are given or if therapy is prolonged, bacterial and fungal superinfectiton may occur, especially in elderly, debilitated or immunosuppresssed patient.




Captopril

Capoten

nhibits ACE, preventing conversion of angiotensin I to angiotensin II, a potent vasoconstrictor. Less angiotensin II decreases peripheral arterial resistance, decreasing aldosterone secretions, which reduces sodium and water retention and lowers blood pressure.

> Hypertension> Diabetic nephropathy> Heart failure> left ventricular dysfunction after acute MI.

>Contraindicated in patients hypersensitive to drug or other ACE inhibitors.> Use cautiously in patients with impaired renal function or serious autoimmune disease, especially systemic lupus erythematous, and in those who have been exposed to other drug that affect WBC counts or immune response.

CNS: dizziness, fainting, headache, fatigue, fever.CV: tachycardia, hypotensionGI: abdominal pain, anorexia, constipation, dry mouth, nausea and vomiting.METABOLIC: hyperkalemiaRESPIRATORY: dry, non productive cough.OTHER: angioedema

> Monitor patients BP and PR frequently.> Elderly patients may be more sensitive to drug’s hypotensive effects.> Assess patient for signs of angioedema.> Drug causes more frequent occurrence of cough, compared with other ACE inhibitors.> Don’t confuse Captopril with Capitrol.




Metronidazole

Flagyl

> Direct-acting trichomonacide and amebicide that works inside and outside the intestines. It’s thought to enter the cells of microorganisms that contain nitroreductase, forming unstable compounds that bind to DNA and inhibit synthesis causing cell death.

> Amebic Liver abscess> Intestinal amebiasis>Trichomoniasis> Refractory trichomoniasis> Bacterial infections caused by anaerobic organisms.>To prevent postoperative infection in contaminated and potentially contaminated colorectal surgery. > Bacterial Vaginosis> Use cautiously in patients who take hepatotoxic drugs or have hepatic disease or alcoholism.

>Contraindicated in patients hypersensitive to drug or other ACE inhibitors.> Use cautiously in patients with impaired renal function or serious autoimmune disease, especially systemic lupus erythematous, and in those who have been exposed to other drug that affect WBC counts or immune response.

CNS: headache, fever, dizziness, incoordination, confusion, irritability, depression, weakness, insomia.CV: edema, flushing, EENT: rhinitis, sinusitis, pharyngitisGI: nausea, abdominal pain, stomatitis, vomiting, diarrhea, constipation, dry mouth.GU: darkened urine, polyuriaOTHER: decreased libido, overgrowth of non susceptible organism.

> Monitor liver function test results carefully in elderly patients.> Observe patient for edema, especially if he’s receiving corticosteroids,> Record number and character of stools when drug is used to treat amebiasis..

DRUG MECHANISM OF ACTION

INDICATION CONTRAINDICATION ADVERSE EFFECTS

NURSING RESPONSIILITIES

Generic Name:Isophane Insulin

Brand name:Humulin N

Classification:Anti-diabetic

Dosage:70/30

Insulin is a hormone secreted by beta cells of the pancreas that, by receptor-mediated effects, promotes the storage of the body’s fuels, facilitating the transport of metabolites and ions (potassium) through cell membrane sand stimulating the synthesis of glycogen from glucose, of fats from lipids, and proteins from amino acids.

-Treatment of type 2 diabetes mellitus that cannot be controlled by diet or oral drugs. -Treatment of severe ketoacidosis.-Treatment of adults with diabetes who require basal insulin for control of hyperglycemia.

Contraindicated with allergy to pork products (varies with preparations; human insulin notcontraindicated with pork allergy).

Endo : hypoglycemiaLocal : lipoatrophy, lipohypertrophy, pruritus, edema, swelling

-Assess for symptoms of hypoglycemia (anxiety, restlessness, mood changes, confusion, drowsiness, nausea).-Monitor blood glucose every 6 hours during therapy.-Be aware that some patients may develop insulin resistance and require large insulin doses to control symptoms of diabetes.-Monitor serum glucose level to assess effectiveness of drug and dosage.

DRUG MECHANISM OF ACTION

INDICATION CONTRAINDICATION ADVERSE EFFECTS

NURSING RESPONSIILITIES

Generic Name:FeSO4 + FA

Brand Name:

Classification:Enzymatic mineral and Iron preparationStency; Vitamins

essential component in the formation of hemoglobin, myoglobin and enzymes. It isnecessary for effective erythropoiesis and transport or utilization of oxygen

-The prevention or treatment of ironand folate deficiency anemia due to inadequate diet, malabsorption pregnancy, and blood loss.

Patients receiving repeated blood transfusions; anaemia not due to iron and folate deficiency

-Dizziness-N & V-Nasal Congestion-Dyspnea-Hypotension-CHF-MI-Muscle cramps-Flushing

-Advise patient to take medicine as prescribed.-Caution patient to make position changes slowly to minimize orhtostatic hypotension.-Advise patient to consult physician if irregular heartbeat, dyspnea, swelling of hands and feet and hypotension occurs.-Inform patient that angina attacks may occur 30 min. after administration due to reflex tachycardia.• Encourage patient to comply with additional intervention for hypertension like proper diet, regular exercise, lifestyle changes and stress management.

Nursing Care Plans:

Assessment Diagnosis Planning Intervention Rationale EvaluationObjective:-Presence of wound scarring-Facial Grimace-Vas of 8/10

Paint r/t post sx Short Term Goal: Patient will be able to lower pain scale to 4/10

Long Term Goal:Patient will be able to maintain low vas and demonstrates pain relieving exercises

-Monitor V/S

-Asses Pain

-Instruct distraction techniques

-Explain reason why there is pain

Collaborative:-Give pain medications as ordered (paracetamol)

-Get baseline data and see fluctuations in v/s to see if patient is in pain

-To evaluate what kind of pain and its frequency

-A good non-pharmacologic way to relieve pain

-Patient will be able to understand the reason for pain

-Alleviate pain

Goal is met.

Assessment Diagnosis Planning Intervention Rationale EvaluationObjective:-Presence of melena-Post surgery- Low Hbg count

Risk for deficient fluid volume related to active fluid loss

Short Term Goal: -Patient will maintain urine output >30cc/hr-Patient will demonstrate good skin turgor.>Patient CBC result will be normal

Long Term Goal:Patient will maintain adequate fluid and electrolyte balance

-Weigh daily

-Monitor intake and output

-Monitor Skin turgor

-Monitor vital signs. Evaluate peripheral pulses, capillary refill-Observed temperature and mucous membranes

-Monitor urine

-Encourage increased fluid intake to 3000 mL per day as individually appropriate or tolerated.

-Monitor laboratory studies (CBC, electrolytes, serum albumin)

-Sensitive measurement of fluctuations in fluid balance- To find out the balance of fluids in the body that is needed for daily metabolism

- To find out the less interstitial fluid / loss can lead to loss of skin elasticity-Reflects adequacy of circulating volume

-Dry mucous membranes which are an indicator of dehydration-The reduced amount of urine as indicators of reduced fluid in the body-Assists in maintenance of fluid requirements

-Provides information about level of hydration and corresponding deficits

Goal is met.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATIONObjective:-VAS of 8/10-facial grimace-cannot perform ADLs alone-with limited range of motion-immobility-body weakness

Activity intolerance Short term:After 8 hrs of nursing intervention patient will demonstrate increased tolerance to activity.

1. Monitor vital signs and record.

2. Assess ability to perform ADL.

3. Assess physical mobility status.

4. Assist patient to do ADLs.

5. Assist to do active range of motion exercise.6. Promote rest and comfort. 7. Emphasize importance of frequentambulation.8. Administer medications as prescribed.

1. to help determine patient’s current health status2. to determine the capacity of patient in doing ADLs3. To know if there is change in patient’s physical condition4. to minimize fatigue and to evaluate his capabilities in doing ADL5. to maximize full strength

6. to conserve energy7. to promote circulation

8. to relieve pain

Goal partially met. Pt demonstrated increased tolerance to activity by getting out of bed still with assistance but without any abnormal changes in vital signs.

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Pancreatic HEad Mass