Cancer of the Pancreas An Unfolding Case Study MJS

1. Cancer of the PancreasAn Unfolding Case Study MJS By: Kimberly Silver-Dunker

2. Case Study - MJS • 48 year old admit to ED • Weight loss of 40 lbs in 6 weeks • Presents with Jaundice, Elevated AST, ALT • Total Billirubin 9.8 • Elevated Amylase & Lipase • C/O RUQ pain radiating all over • C/O Severe itching (puritis) • C/O fatty stools, liquid consistency • PMH: None…healthy, ideal body weight, no smoking or alcoholic drinking

3. Teamwork & CommunicationDefinitions (QSEN) • Teamwork - a joint action by two or more people, in which each person contributes with different skills and expresses his or her individual interests and opinions to the unity and efficiency of the group in order to achieve common goals • Team – a small number of consistent people committed to a relevant shared purpose, • Interdisciplinary teams - individuals from at least two different disciplines who coordinate their expertise to deliver care to patients • Group – any collection of interconnected individuals working together for some purpose • Team Huddle – a small number of interdisciplinary healthcare members who meet at the beginning of a shift to collaborate and discuss the goals for the client within their care.

4. Team Huddle“Teamwork & Collaboration”Medication Reconciliation (Collected upon admission) QSEN Competency: Teamwork and CollaborationFunction effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care. • Lipitor 20 mg QD • MVI daily • Tylenol 500-100mg Q6 hours for itching pain PRN • Nurse notifies MD regarding itching. • MD and nurse collaborate regarding possible causes of itching. • The nurse decides to ask the patient’s daughter about the medications, because the healthcare proxy is not available.

5. Potential compromise of Patient Safety QSEN Competency: SafetyMinimize risk of harm to patients and providers through both system effectiveness and individual performance. • Are there any potential medication side effects that are concerning? • What strategies can a nurse do to identify a medication error during medication reconciliation? • Is it ok to verify the medication reconciliation with a family member who is not the health care proxy? Is this a include a HIPPA or almost HIPPA violation? • How can you maintain HIPPA and gather the information needed during admission intake? privacy.

6. Theory Burst“Evidence Based Practice” • Is this a gall bladder issue? • What are the clinical manifestations or assessment findings? • What are the diagnostics and treatment options? • What is the nursing care involved? • What is the current evidence from your text and the literature?

7. Initial Diagnosis To Start Video Click Here

8. Team Morning Huddle“Teamwork and Collaboration” • Who should be invited to the team huddle? What can the members contribute in this patient’s care? Discuss how the nursing assessment can be included during the morning huddle. • How can teamwork and communication be enhanced for this patient? • Diagnostics • Treatment Options • How can the nurse advocate during the huddle to interventions make the care more patient centered? • Pain • Skin Integrity • Nutrition

9. Case Study - MJS • MJS underwent an ERCP? • Current Total Billirubin 14.5 • How would you prep this patient? • What are the significant Findings? • What pre and post nursing interventions can be anticipated? • How can safety be ensured after conscious sedation • Based on current evidence what complications are associated with an ERCP?

10. ERCP Click Here to Start Video • Endoscopic Retrograde Cholangiopancreatography (ERCP) • Important Diagnostic Test

12. Endoscopic Retrograde Cholangiopancreatography (ERCP)

13. Case Study MJS • After ABD CT and ERCP • MJS has positive obstruction in the biliary tract • Stent is placed to drain the excessive bile • Current Billirubin is 18.6, increased Amylase & Lipase, as well as LFT’s • Pt continues to complain of “Severe Puritis” multiple skin abrasions on his arms and legs • C/O Anorexia with continued weight loss

14. Case Study MJS • MJS has ruled in for pancreatic CA (primarily in the head of the pancreas) • He is started on TPN for nutrition • Chemo and Radiation • Lotion for his itchy skin and arixtra for the puritis • Pre operative for Whipple Surgery

15. QSEN Competency: Patient Centered CareRecognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient preferences, values, and needs. Team Huddle“Patient Centered Care” What treatment options will the patient have? How can the nurse advocate for patient quality of life? How the nurse support patient decision making?

16. Start Video Click Here CA 19-9

17. A risk factor associated with cancer of the pancreas is • Alcohol Intake • Cigarette Smoking • Exposure to asbestos • Increased dietary intake of milk and milk products

18. B Cigarette smoking, high-fat diet, diabetes. Alcohol intake is more associated with pancreatitis

19. Signs and Symptoms? PAIN - earliest and most common symptom weight loss G.I. Upset Jaundice Pruritus

20. Treatment • Neither radiation or chemotherapy is effective --- extend life one year only • Surgical: Whipple Procedure need to take pancreatic enzymes for life ie. Viokase Allen Oldfather Whipple (1881-1963

21. Quality Improvement & Evidence Based Care QSEN Competency: Evidence-based PracticeIntegrate the best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal health care. • What can a nurse do to improve care for the oncology patient? • What is the role of the hospitals unit council or ethics committee? • Can the nurse advocate for this patient by going to the hospitals unit council? • What is the current Evidence in the literature for treatment options for oncology patients. • Surgery • Chemo • Radiation • Palliative care

22. Click Here to Start Video Chemotherapy A patient’s experience with Chemo & Radiation “Rough Times” What are the implications for safety with chemotherapy administration?

23. pancreatico- duodenectomy

24. Click Here to Start Video Pre-Op Surgery How did they prepare MJS for a 16hour + Whipple Surgery?

25. Click Here to Start Video Post-Op Complications Paralytic Illeus GI Complications Vomiting & Dehdration

26. Click here to start video Post-Op Ileus & Drain Management of Patient Complications- Drain #2

27. Case Study – MJS • MJS underwent a successful whipple procedure • Biliary Liver diversion completed • Head of the Pancreas removed and connected to the duodenum. • MJS remains on pancreatic enzymes and TPN until nutrition heals • T tube in place to drain excess bile in the short term • JP drain to bulb suction • He survived three years post diagnosis of Pancreatic CA • The videos which you have watched were taken 4 months before he died. He was very weak and tired at that time.

28. Family Huddle“Patient Centered Care” • What are the implications to increase patient centered care a patient facing cancer? • What ways can the nurse ensure safety in the care of this patient? • How can the nurse incorporate the family into this situation?

29. This case is dedicated to my Father! Thank you for giving your consent for this unfolding case study for many to learn about this disease to increase patient centered care, teamwork and collaboration, and practice with current evidence based medicine.