A Case Study

On Chronic Progressive Disease Pancreatic Cancer

Presented to the faculty of College of Nursing and Midwifery

Southeast Asian College Inc.

#2 E Rodriguez Sr. Avenue, Quezon City

In Partial Fulfillment

Of the Requirements for the Degree

Bachelor of Science in Nursing

By

Otsuka, Dominuqe

Pasamonte, Kaylie Jamayca Marie

Pasco, Gerralene

Peralta, Frances Altessa

Racelis, Rodolfo Jr.

Ramones, Wilvhe Grace

Rosales, Karen

Vallada, Cheyserr Anne

Villaruz, Daniel

Visaya, Mar

4th yr / Group 44

Submitted to:

Mr. Melvin Mallo

ACKNOWLEDGEMENT

We, the students of Southeast Asian College Inc. College of Nursing, would like to give

the highest gratitude to Almighty God in which through Him, everything is possible.

To all the staff of the Veterans Memorial Medical Hospital and to the clinical instructor

namely: MR. Melvin Mallo, who helped us to grow in knowledge and experience to become

effective nurses in the future.

And to our parents, who are giving us all the love and support.

I. INTRODUCTION

Pancreatic Cancer

The pancreas is a six- to eight-inch long, slipper shaped gland located in the abdomen. It

lies behind the stomach, within a loop formed by the small intestine. Other nearby organs

includes the gallbladder, spleen, and liver. The pancreas has a wide end (head), a narrow end

(tail), and a middle section (body). A healthy pancreas is important for normal food digestion

and also plays a critical role in the body's metabolic processes. The pancreas has two main

functions, and each are performed by distinct types of tissue. The exocrine tissue makes up the

vast majority of the gland and secretes fluids into the other organs of the digestive system. The

endocrine tissue secretes hormones (like insulin) that are circulated in the bloodstream, and these

substances control how the body stores and uses nutrients. The exocrine tissue of the pancreas

produces pancreatic (digestive) juices. These juices contain several enzymes that help break

down proteins and fatty foods. The exocrine pancreas forms an intricate system of channels or

ducts, which are tubular structures that carry pancreatic juices to the small intestine where they

are used for digestion.

Pancreatic tumors are classified as either exocrine or endocrine tumors depending on

which type of tissue they arise from within the gland. Ninety-five percent of pancreatic cancers

occur in the tissues of the exocrine pancreas. Ductal adenocarcinomas arise in the cells that line

the ducts of the exocrine pancreas and account for 80% to 90% of all tumors of the pancreas.

Unless specified, nearly all reports on pancreatic cancer refer to ductal adenocarcinomas. Less

common types of pancreatic exocrine tumors include acinar cell carcinoma, cystic tumors that

are typically benign but may become cancerous, and papillary tumors that grow within the

pancreatic ducts. Pancreatoblastoma is a very rare disease that primarily affects young children.

Two-thirds of pancreatic tumors occur in the head of the pancreas, and tumor growth in this area

can lead to the obstruction of the nearby common bile duct that empties bile fluid into the small

intestine. When bile cannot be passed into the intestine, patients may develop yellowing of the

skin and eyes (jaundice) due to the buildup of bilirubin (a component of bile) in the bloodstream.

Tumor blockage of bile or pancreatic ducts may also cause digestive problems since these fluids

contain critical enzymes in the digestive process. Depending on their size, pancreatic tumors may

cause abdominal pain by pressing on the surrounding nerves. Because of its location deep within

the abdomen, pancreatic cancer often remains undetected until it has spread to other organs such

as the liver or lung. Pancreatic cancer tends to rapidly spread to other organs, even when the

primary (original) tumor is relatively small.

Sign and Symptoms

Pancreatic cancer is sometimes called a "silent killer" because early pancreatic cancer

often does not cause symptoms, and the later symptoms are usually nonspecific and varied.

Therefore, pancreatic cancer is often not diagnosed until it is advanced. Common symptoms

include:

Pain in the upper abdomen that typically radiates to the back (seen in carcinoma of the body

or tail of the pancreas)

Loss of appetite and/or nausea and vomiting

Significant weight loss

Painless jaundice (yellow skin/eyes, dark urine) when a cancer of the head of the pancreas

(about 60% of cases) obstructs the common bile duct as it runs through the pancreas. This

may also cause pale-colored stool and steatorrhea.

Trousseau sign, in which blood clots form spontaneously in the portal blood vessels, the deep

veins of the extremities, or the superficial veins anywhere on the body, is sometimes

associated with pancreatic cancer.

Diabetes mellitus, or elevated blood sugar levels. Many patients with pancreatic cancer

develop diabetes months to even years before they are diagnosed with pancreatic cancer,

suggesting new onset diabetes in an elderly individual may be an early warning sign of

pancreatic cancer.

Clinical depression has been reported in association with pancreatic cancer, sometimes

presenting before the cancer is diagnosed. However, the mechanism for this association is not

known

Predisposing factors

Risk factors for pancreatic cancer include 

Age

Obesity

Diabetes

Chronic pancreatitis has been linked, but is not known to be causal.

Family history

Helicobacter pylori infection

Precipitating Factors

Smoking

Excessive alcohol intake

Occupational exposure to certain pesticides

II. OBJECTIVES

To be able to find out factors that causes pancreatic cancer. To be able to determine the age group that has higher risk of acquiring pancreatic cancer To be able to determine ways on how to prevent having pancreatic cancer.

III. ANATOMY AND PHYSIOLOGY

The pancreas is an elongated, tapered organ located across the back of the abdomen,

behind the stomach. The right side of the organ (called the head) is the widest part of the organ

and lies in the curve of the duodenum (the first section of the small intestine). The tapered left

side extends slightly upward (called the body of the pancreas) and ends near the spleen (called

the tail).

The pancreas is made up of two types of tissue:

Exocrine tissue

The exocrine tissue secretes digestive enzymes. These enzymes are secreted into a

network of ducts that join the main pancreatic duct, which runs the length of the

pancreas.

Endocrine tissue

The endocrine tissue, which consists of the islets of Langerhans, secretes hormones into

the bloodstream.

Functions of the pancreas:

The pancreas has digestive and hormonal functions:

The enzymes secreted by the exocrine tissue in the pancreas help break down

carbohydrates, fats, proteins, and acids in the duodenum. These enzymes travel down the

pancreatic duct into the bile duct in an inactive form. When they enter the duodenum,

they are activated. The exocrine tissue also secretes a bicarbonate to neutralize stomach

acid in the duodenum.

The hormones secreted by the endocrine tissue in the pancreas are insulin and glucagon

(which regulate the level of glucose in the blood), and somatostatin (which prevents the

release of the other two hormones).

IV. THEORETICAL FRAMEWORK

“ Florence Nightingale Environmental Theory”

Nightingale is viewed as the mother of modern nursing. She synthesized information

gathered in many of her life experiences to assist her in the development of modern nursing. Her

contribution to the nursing profession was her “Environmental Theory” in which the nurse’s role

is to place the client in the best position for nature to act upon him, thus encouraging healing.

Nightingale viewed the manipulation of the physical environment as a major component

of nursing care. She identified ventilation and warmth, light, noise, variety, bed and bedding,

cleanliness of the rooms and walls, and nutrition as major areas of the environment the nurse

could control. When one or more aspects of the environment are out of balance, the client must

use increased energy to counter the environmental stress. These stresses drain the client of

energy needed for healing. These aspects of physical environment are also influenced by the

social and psychological environment of the individual.

name of patient

I as a student nurse and part of the medical field, has the role of providing nursing care

with the help of the institutions and personnel involve to cure the illness and lower down the

factors causing the patient’s disease with the help of Nightingale’s Environmental Theory.

VI. PATIENT PROFILE

Name: Pt. F

Age: 79 y/o

Sex: Female

CS: Married,

Address: 2811, Benita St. Gagalangin, Tondo Manila

Occupation: Unemployed

Religion: Roman Catholic

Dialect: Tagalog

Dates of Admission: October 18, 2010

Time of Admission: 10:30 am

Admitting Physician: Dr. Paolo Delos Reyes

Admitting Diagnosis:

Final Diagnosis: Chronic Progressive Disease Pancreatic Cancer

VII. NURSING HISTORY

VIII. 13 AREAS OF ASSESSMENT

Areas of assessment

The patient is conscious and coherent with difficulty to response immediately.

Skin: warm to touch, dry, rough, good turgor, (-) jaundice, (-) lesions

Hair: dry, evenly distributed

Eyes: parallel and evenly placed, non protruding with an scant amount of secretions, both

eyes bright and clean with pale conjunctiva

Ears: symmertical

Nose: symmetrical, straight with septum at the midline and not tender, and there is no

discharge

Lips: dry and pale. With soft voice

Neck: no neck vien distention, no anterior neck mass with trachea at the midline

Back: with spine at the midline

Abdomen: flat, skin is intact, with sunken umbilicus

A. Health Perception

Subjective: client’s daughter verbalized as secondary source, “ malusog naman sya dati,di sya

nagkakasakit. Nung nadiagnosed lang sya nung sakit nya saka sya nahospital. Mahalaga sa kanya

ang kalusugan nya.

Objective: The patient is ------ year old female with a well developed body posture, can’t do

facial expression well, not confident. ------- bp.

Analysis: Management of Therapeutic Regimen, effective: Individual

B. Nutritional- Metabolic Pattern

Subjective: The patient verbalized, “Kumakain ako ng gulay, karne, at isda. Paborito ko ang

adobong babot at paksiw nab angus…

Client’s daughter verbalized as secondary source, “lahat kami,kumakain ng gulay…

Objective: Dry skin, no lesion. Skin pinch goes back normally. Weak in appearance.

Analysis: Risk for altered nutrition; less than body requirements r/t inability to ingest food, lack

of adequate nutrition as evidenced by dry skin and being weak.

C. Elimination Pattern

Subjective: client’s daughter verbalized as secondary source, “ normal ang pagdumi nya. Isang

beses sa isang araw.

Objective: Dry skin, skin pinch goes back normally

Analysis: ready for enhancement – Elimination Pattern

D. Activity- Exercise Pattern

Subjective: client’s daughter verbalized as secondary source, “ araw araw sya nag eexercise

dati nung wala pa syang sakit. Sa umaga nga pagpasok nya sa trabaho dina sya

sumasakay..,nilalakad nya nalng para dw exercise nya na din yun. Ngayon eh di nya na kaya

bumangon dahil sa sakit nya,limitado n nga din ang kanyang paggalaw,din a makatayo…

Objective: with limitation in ROM of joints, with DOB and difficulty in standing.

Analysis: Fatigue r/t poor physical condition

E. Sexuality- Reproductive Pattern

Subjective: client’s daughter verbalized as secondary source, “ masaya sya sa pagiging asawa.

Walo nga kmi na anak nya. matagal nang patay ang tatay ko.

Objective: The patient is well developed according to her age.

Analysis: Readiness for enhancement Sexual- reproductive pattern

F. Sleep- Rest Pattern

Subjective: client’s daughter verbalized as secondary source, “ di ata sya makatulog ng maayos

dahil sa sakit nya,madalas sya inaantok.”

Objective: The patient is sleepy and with presence of eye bugs. She is weak in appearance.

Analysis: Sleep deprivation r/t prolonged discomfort as manifested awakening earlier than

desired and daytime drowsiness.

G. Sensory- Cognitive Pattern

Subjective: client’s daughter verbalized as secondary source, “ nahihirapan na sya gumalaw

pero nakakausap parin naman ng maayos kaya lang nahihirapan na din sya. Hindi na nga lang

sya makakilos ng maayos,dyan nalang sya sa higaan nya.

Objective: The patient’s able to hear my voice clearly and accurately. Absence of obvious

delusions, hallucinations, or thought disorders together with the presence of insight, good

judgment, and socially appropriate appearance.

Analysis: Ready for enhancement Sensory- Cognitive Pattern

H. Role- Relationship Pattern

Subjective: The patient verbalized as secondary source, “kasama nya kami sa bahay. Maayos

naman an gaming samahan.

Objective: Patient was accompanied by her daughter in the room. She was visited by her other

children and friends.

Analysis: Ready for enhancement Family Processes

I. Self- Perception – Self- Concept Pattern

Subjective: client’s daughter verbalized as secondary source, “hindi sya masyado nag iisip ng

kung anu- ano. Masayahin sya.

Objective: The patient maintains fixed eye contact with smile.

Analysis: Ready for enhancement Self- perception – Self- concept Pattern

J. Coping – Stress- tolerance Pattern

Subjective: client’s daughter verbalized as secondary source, “ pinag uusapan naman naming

pag me problema sa bahay.

Objective: Patient appears with no other altering of behavior.

Analysis: Readiness for enhanced coping

K. Value- belief Pattern

Subjective: client’s daughter verbalized as secondary source, “Roman Catholic kami. Dati

madalas sya magsimba,ngayon di na namin magawa.

Objective: No presence of rosary inside his room

Analysis: Risk for impaired Religiosity r/t life transitions.

X. DRUG STUDY

DRUG STUDYClassification Indication Action Contraindication Adverse Effect Nursing

ConsiderationBrand Name:Tramadol Hydrochloride

Generic Name:Ultram

Route:P.O

Dosage:50 mg

Frequency:q.i.d

Moderate to moderately severe pain

Unknown. A centrally acting synthetic analgesic compound not chemically related to opioids.

Serious hypersensitivity reaction can occur, usually after the first dose.

Patient with history of anaphylactic reaction to codeine and other opioids may be at risk

CNS: dizziness, headache, somnolence, vertigo, seizure, anxiety.

CV: vasodilation

G.I: Constipation, nausea, vomiting, abdominal pain.

Monitor bowel and bladder function. Anticipate need for laxative.

Monitor patients at risk for seizures.

Withdrawal symptoms may occur if drug is stopped abruptly. Reduce dosage gradually.

DRUG STUDYClassification Indication Action Contraindicatio

nAdverse Effect

Nursing Consideration

Brand Name:Omeprazole

Generic Name:Losec

Route:P.O

Dosage:20mg

Frequency:o.d

Symptomatic gastroesophageal reflux disease without esophageal lesions.

Erosive esophagitis and accompanying symptoms caused by GERD.

Inhibits activity of acid (proton) pump and binds to hydrogen-potassium adenosine triphosphatase at secretory surface of gastric parietal cells to block formation of gastric acid.

Contraindicated in patients hypersensitive to drug or its components.

Use cautiously in patients with barter syndrome, hypokalemia, and respiratory alkalosis.

CNS: asthenia, dizziness, headache

G.I: abdominal pain, constipation, diarrhea.

Musculoskeletal: back pain

Respiratory: Cough, upper respiratory tract infection.

Dosage adjustment may be necessary.

Gastrin level rises in most patients during the first 2 weeks of therapy.

Tell patient to swallow tablets or capsules whole and not to open, crush or chew them.

Caution patient to avoid hazardous activities if he gets dizzy.

XI. NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATIONSubjective:“nanghihina na siya hidi na siya nagreresponse sa gamot niya?”as verbalized by the daughter of the patient.

Objective:

-change in eating habits

-alteration in sleep pattern

-decrease activity level

-loss of physical ability

-decrease in communication pattern.

Death related to anticipated loss of physiological well being.

After 1 hrs. of nursing intervention the significant others will identify and express feelings of sadness effectively.

Facilitate development of trusting relationship with the family

Provide open, non-judgmental environment. Use therapeutic communication skills of active listening, acknowledgement and so on.

Encourage verbalization of thoughts or concerns and accept expression of sadness, anger, rejection. Acknowledge normality of these feelings.

Reinforce teaching regarding disease process and treatments and provide information as requested or appropriate about dying.

Be honest; do not give false hope while providing emotional

Trust is necessary before family can feel free to open personal lines of communication with the hospice team and address sensitive issues.

Promotes and encourages realistic dialogue about feelings and concerns.

Significant others may feel supported in expression of feelings by the understanding that deep and often conflicting emotions are normal and experienced by others in this difficult

After 1 hrs. of nursing intervention the significant others was able to identify and express feelings of sadness effectively.

support.

Assist significant others to identify strength in its self or situation and support systems.

situation. Family

benefit from factual information.

Honest answers promote trust and provide reassurance that concern information will be given.

Recognizing these resources provides opprtuniy to work true feelings of grief.

XII. BIBLIOGRAPHY

Brunner, Emerson, Ferguson and Suddarth (2000). Textbook of Medical-Surgical

Nursing – 2nd ed. Blackwell Scientific Publication, Oxford & Edinburg.

Damico, C.M.& Zalewski, K. A.(Eds.). (2008). Nursing 2008 Drug Handbook 28 ed.

Lippincott Willams & Wilkins

Smeltzer, Bare, Hinkle and Cheever (2007). Brunner and Suddarh’s textbook of Medical-

Surgical Nursing – 11 ed. Lippincott Williams & Wilkins.

MIMS Philippines 103 ed. (2005). CMP Medica Publications.

Snell, Richard. Clinical Anatomy 8th edition.

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