Transcript Cancer of the Pancreas An Unfolding Case Study MJS

Cancer of the Pancreas
An Unfolding Case Study MJS
By: Kimberly Silver-Dunker
Case Study - MJS
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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
Teamwork & Communication
Definitions (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.
Team Huddle
“Teamwork & Collaboration”
Medication Reconciliation (Collected upon admission)
QSEN Competency: Teamwork and
Collaboration
Function effectively within nursing and inter•
professional teams, fostering open
communication, mutual respect, and shared
decision-making to achieve quality patient
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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.
Potential compromise of Patient Safety
QSEN Competency: Safety
Minimize 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.
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?
Initial Diagnosis
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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
Case Study - MJS
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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?
ERCP
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• Endoscopic Retrograde
Cholangiopancreatography (ERCP)
• Important Diagnostic Test
Endoscopic Retrograde Cholangiopancreatography (ERCP)
Case Study MJS
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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
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
Team Huddle
“Patient Centered Care”
QSEN Competency: Patient Centered Care
Recognize 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.
What treatment options will the patient have?
How can the nurse advocate for patient quality of
life?
How the nurse support patient decision making?
CA 19-9
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A risk factor associated with cancer
of the pancreas is
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Alcohol Intake
Cigarette Smoking
Exposure to asbestos
Increased dietary intake of milk and milk
products
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Cigarette smoking, high-fat diet, diabetes.
Alcohol intake is more associated with
pancreatitis
Signs and Symptoms?
PAIN - earliest and
most common
symptom
• weight loss
• G.I. Upset
• Jaundice
• Pruritus
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
Quality Improvement
& Evidence Based Care
QSEN Competency: Evidence-based Practice
Integrate 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.
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Surgery
Chemo
Radiation
Palliative care
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Chemotherapy
A patient’s experience with
Chemo & Radiation
“Rough Times”
What are the implications for
safety with chemotherapy
administration?
pancreatico- duodenectomy
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Pre-Op Surgery
How did they prepare MJS for a
16hour + Whipple Surgery?
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Post-Op Complications
Paralytic Illeus
GI Complications
Vomiting & Dehdration
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video
Post-Op Ileus & Drain
Management of Patient
Complications- Drain #2
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.
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?
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.