Pancreatic Cancer
What is pancreatic cancer?
What are the risk factors?
Definition: Pancreatic cancer is a malignant neoplasm arising from pancreatic tissue, most commonly ductal adenocarcinoma originating in the exocrine pancreas. It is highly aggressive and often diagnosed at an advanced stage.
Risk factors: smoking (major modifiable risk factor),
chronic pancreatitis, diabetes mellitus, obesity, family history/genetic syndromes, age > 65, high-fat diet
What is peritonitis?
Describe the pathophysiology of peritonitis.
What are some risk factors for peritonitis?
Definition: Peritonitis is inflammation of the peritoneum, usually caused by bacterial infection due to perforation of abdominal organs, ischemia, trauma, or peritoneal dialysis contamination. It is a life-threatening emergency that can rapidly progress to sepsis.
Pathophysiology: Bacteria enter sterile peritoneal cavity (e.g., from perforation), there is an inflammatory response → increased capillary permeability. The body fluid shifts into peritoneal cavity → hypovolemia. Paralytic ileus develops. There is now a systemic inflammatory response → sepsis.
If untreated → septic shock and multi-organ failure.
Risk factors: appendicitis rupture, perforated ulcer, diverticulitis, bowel obstruction, abdominal trauma, peritoneal dialysis, post-abdominal surgery, cirrhosis with ascites (spontaneous bacterial peritonitis)
Define liver cancer
Describe the pathophysiology of liver cancer
What are some risk factors to develop liver cancer?
Definition: Liver cancer most commonly refers to hepatocellular carcinoma (HCC), a primary malignant tumor of hepatocytes. It frequently develops in clients with chronic liver disease and cirrhosis.
Patho: There is chronic inflammation → cirrhosis → cellular dysplasia.
There is a genetic mutation component that causes uncontrolled hepatocyte proliferation. Tumor replaces normal liver tissue → impaired function. There is increased portal pressure → ascites, varices. There is reduced protein synthesis → hypoalbuminemia. There is impaired clotting factor production → bleeding risk. Liver cancer is highly vascular → risk of hemorrhage and metastasis (lungs, bones).
Risk Factors: chronic hepatitis B or C infection, cirrhosis (any cause), alcohol-related liver disease, nonalcoholic fatty liver disease (NAFLD), aflatoxin exposure (cancer causing substances), hemochromatosis, male gender, diabetes
What is the definition of appendicitis?
Describe the pathophysiology of appendicitis
What are some risk factors of appendicitis?
Definition: appendicitis is acute inflammation of the vermiform appendix, usually caused by obstruction of the appendiceal lumen, leading to infection, ischemia, and possible perforation. It is a surgical emergency.
Patho: There is obstruction → increased intraluminal pressure which leads to venous congestion → edema. There is bacterial overgrowth. The ischemia leads to necrosis. If untreated → perforation → peritonitis → sepsis.
Pain progression: Visceral periumbilical pain → localized RLQ pain due to parietal peritoneum involvement.
Risk Factors: obstruction (fecalith most common), lymphoid hyperplasia (common in children/young adults), GI infections, family history
A client with chronic hepatitis has lab results:
ALT 220 U/L, AST 180 U/L. Which nursing action is priority?
A. Prepare for emergent dialysis
B. Assess for jaundice and RUQ pain
C. Administer potassium replacement
D. Restrict oral fluids
Answer: Assess for jaundice and RUQ pain
Rationale: Elevated ALT and AST indicate hepatocellular injury. The nurse should assess for clinical manifestations of liver dysfunction (jaundice, RUQ pain). Dialysis and potassium replacement are unrelated.
What are some client signs/symptoms?
S/S: depends on the location of the cancer in the pancreas (most occur in the head of pancreas).
Head of Pancreas: painless jaundice, clay-colored stools, dark urine, pruritus, weight loss, anorexia,
nausea and vomiting.
Cancer in the body/Tail: vague epigastric pain radiating to back, weight loss, new-onset diabetes.
Advanced Disease (cancer): ascites, hepatomegaly, fatigue, thromboembolic events (Trousseau syndrome)
What are some signs/symptoms (clinical manifestation) of peritonitis?
Clinical Manifestations are divided.
Early Signs: severe, sudden abdominal pain, pain worsens with movement, rigid, board-like abdomen, rebound tenderness, guarding, nausea/vomiting, fever
Progressive Signs: absent bowel sounds, abdominal distention, tachycardia, hypotension, oliguria, confusion (late), signs of septic shock
Peritoneal Dialysis–Related: cloudy dialysate, abdominal pain during infusion, fever
What are some treatments for the client with liver cancer?
Surgical Management: partial hepatectomy, liver transplantation (early-stage disease)
Localized Therapies: radiofrequency ablation (RFA); transarterial chemoembolization (TACE), percutaneous ethanol injection, systemic therapy, targeted therapy (e.g., sorafenib), immunotherapy (depending on stage)
Palliative Care: symptom management, ascites control (paracentesis)
What are some clinical manifestations of appendicitis?
Clinical Manifestations:
Early appendicitis: Periumbilical pain (visceral pain), anorexia (classic early sign), nausea/vomiting (after pain onset), low-grade fever
Progression of appendicitis: pain migrates to RLQ (McBurney’s point), rebound tenderness, guarding, rigid abdomen, positive Rovsing’s sign, increased pain with movement, coughing
Late / Perforation: sudden relief of pain (rupture) which does not last long. This relief is followed by worsening pain. There is high fever, tachycardia. The client with this late stage of appendicitis will demonstrate signs of peritonitis
A client with alcohol-related liver disease has AST 300 U/L and ALT 120 U/L. Which interpretation is most accurate?
A. Normal finding
B. Pattern suggests alcoholic liver injury
C. Indicates acute kidney failure
D. Suggests pancreatic necrosis
Answer: Pattern suggests alcoholic liver injury
Rationale:
AST > ALT (often 2:1 ratio) is characteristic of alcoholic liver disease.
Discuss some of the pathophysiology of pancreatic cancer.
Pathophysiology of pancreatic cancer:
Most tumors are adenocarcinomas that start in the pancreatic ducts.
The tumor obstructs the common bile duct → jaundice. There is impaired enzyme flow.
There is local tumor invasion into the duodenum, stomach, major vessels and liver
There is early metastasis by way of the lymphatic system which causes a widespread throughout the bloodstream.
New onset hyperglycemia (diabetes)
What are some medical interventions and treatments?
What are some nursing management interventions and treatments?
Medical Management: broad-spectrum IV antibiotics (immediately), IV fluid resuscitation, electrolyte replacement, NG tube (bowel rest), oxygen therapy
Surgical Management: emergency surgery to repair perforation, drain abscess, remove necrotic tissue
Nursing Interventions
Assessment: frequent VS (monitor for shock), strict I&O, monitor abdominal girth, assess bowel sounds, monitor mental status
Interventions: maintain NPO status, administer IV antibiotics as prescribed, initiate large-bore IV access, monitor lab results, prepare for surgery, position in semi-Fowler’s to localize infection, pain management (carefully monitor masking of symptoms)
What types of nursing assessment can the registered nurse perform?
What are some nursing interventions?
Assessment: head to toe assessment, monitor liver function tests, assess for bleeding, measure abdominal girth, monitor mental status (hepatic encephalopathy), monitor I&O
Interventions: administer prescribed medications, manage ascites (diuretics, sodium restriction), provide nutritional support (high-calorie, moderate protein unless encephalopathy), prepare for procedures (biopsy, transplant), provide emotional support
What are some interventions and treatments?
Surgical Management: laparoscopic appendectomy (preferred), open appendectomy (if ruptured/complicated)
Medical Management: IV antibiotics (pre- and post-op), IV fluids, analgesics, client will be NPO
A client 24 hour post-appendectomy has c reactive protein (CRP) elevated. What is the nurse’s best action?
A. Document as expected inflammatory response
B. Start antibiotics independently
C. Restrict activity
D. Notify family immediately
Answer: Document as expected inflammatory response
Rationale:
CRP rises with inflammation. Mild elevation post-op is expected. Monitor trends.
What are the diagnostics?
What are some interventions and treatments?
Labs: elevated bilirubin (if bile duct obstruction), elevated alkaline phosphatase, mildly elevated AST/ALT, CA 19-9 tumor marker (not diagnostic but used for monitoring), hyperglycemia, low albumin
Imaging: CT scan (primary diagnostic test), MRI,
Endoscopic ultrasound (EUS), ERCP (for obstruction/stent placement), biopsy confirms diagnosis
Interventions & Treatment
Surgical Management: Whipple procedure (pancreaticoduodenectomy) for tumors in head; a distal pancreatectomy for body/tail tumors. A total pancreatectomy is rare. There is also palliative biliary bypass or stent placements
Chemotherapy: Gemcitabine, FOLFIRINOX regimen,
Targeted therapies (depending on mutation status)
Radiation Therapy: Adjunct or palliative
Pain Management: Opioids, celiac plexus block
Nutritional Support: high-calorie, high-protein diet, pancreatic enzyme replacement (pancrelipase), small frequent meals
Describe some diagnostic tests
Which medications are used to treat peritonitis?
Diagnostic Tests
Labs: elevated WBC, elevated lactate (sepsis indicator), electrolyte imbalances, blood cultures, elevated CRP, peritoneal fluid analysis (if PD or ascites)
Imaging: abdominal CT (preferred), abdominal X-ray (free air with perforation), ultrasound (ascites/abscess)
Medication: broad-spectrum IV antibiotics (e.g., piperacillin-tazobactam, ceftriaxone + metronidazole), IV fluids (NS or LR),
Vasopressors (if shock), analgesics, antiemetics
For PD-related peritonitis: intraperitoneal antibiotics
Name some diagnostic tests performed for the client with liver cancer
Diagnostic Tests
Labs: elevated alpha-fetoprotein (AFP), elevated AST/ALT, elevated bilirubin, prolonged PT/INR, low albumin, thrombocytopenia
Imaging: abdominal ultrasound (screening in cirrhosis), CT scan with contrast, MRI, liver biopsy (confirmation)
How is appendicitis diagnosed?
Give some nursing treatment/action for the client with appendicitis
What teaching points can you share with this client?
Diagnostic Tests
Labs: elevated WBC, elevated CRP, urinalysis (to rule out UTI), pregnancy test (females of childbearing age)
Imaging: abdominal CT (most accurate), ultrasound (children/pregnancy), MRI (pregnancy alternative)
Nursing assessment: complete head to toe, monitor VS (fever, tachycardia), assess abdominal pain location, monitor WBC, observe for signs of rupture, monitor I&O
Interventions: maintain NPO, initiate IV fluids, administer antibiotics as prescribed, avoid heat to abdomen (may cause rupture), do NOT give laxatives or enemas, prepare for surgery
Post-op: Encourage early ambulation, monitor incision, advance diet gradually
Teaching Points
Pre-op: report worsening pain, remain NPO, avoid heating pad use
Post-op: incision care, signs of infection (redness, drainage, fever), avoid heavy lifting for several weeks, gradual return to activity, complete antibiotic course
If rupture occurred: longer recovery, monitor for abscess formation
A client’s CRP continues to rise 72 hours after surgery, and temperature is 38.9°C (102°F). What does this most likely indicate?
A. Normal healing
B. Postoperative infection
C. Dehydration
D. Electrolyte imbalance
Answer: Postoperative infection
Rationale:
Persistent CRP elevation + fever suggests infection.
What are some nursing actions?
What are some teaching points you can provide for the client with pancreatic cancer?
Nursing Interventions: monitor VS, glucose levels, head to toe assessment, assess for jaundice progression, monitor stool color and urine changes, pain assessment & management, monitor nutritional status (weight, albumin), administer pancreatic enzymes with meals, monitor post op complications which are delayed gastric emptying, pancreatic fistula, post op infection, hemorrhage
Client Teaching includes reporting jaundice, dark urine, clay stools, continue importance of enzyme replacement with meals, eat high-protein, high-calorie diet, blood glucose monitoring, smoking cessation, if on chemo, educate on chemo side effects, implement neutropenia, report and treat nausea and vomiting, manage fatigue with frequent rest periods.
Post-Whipple procedure: eat small frequent meals, avoid high-fat foods, educate on lifelong enzyme supplementation (if indicated)
What are some teaching points/Health promotion for the client with peritonitis?
What are some expected outcomes for the client with peritonitis?
Client Teaching/Health promotion: report severe abdominal pain immediately, complete full antibiotic course.
If on peritoneal dialysis: use sterile technique, report cloudy effluent, monitor for fever, avoid delaying treatment of appendicitis/diverticulitis, importance of follow-up care.
Expected outcomes: stable VS, adequate urine output (>30 mL/hr), decreasing WBC, reduced abdominal rigidity, no progression to sepsis
Which medications can the registered nurse anticipate for the client with liver cancer?
Name a few teaching points for the client with liver cancer
What are some health promotion points you can provide for the client with liver cancer?
Medications: Sorafenib (targeted therapy),
Immunotherapy agents, diuretics (spironolactone, furosemide), lactulose (if encephalopathy), analgesics, antiemetics
Client Teaching: avoid alcohol completely, maintain follow-up appointments, report bleeding, report mental status changes, monitor weight daily (ascites), adhere to sodium-restricted diet, importance of hepatitis treatment, medication adherence
Post-Transplant Teaching: lifelong immunosuppressants, infection prevention
Health Promotion: hepatitis B vaccination, screening for hepatitis C, early treatment of chronic liver disease, avoid alcohol abuse, maintain healthy weight, routine ultrasound screening in cirrhosis (every 6 months)
Which medications do you anticipate giving the client with appendicitis?
Medications: Broad-spectrum IV antibiotics (e.g., ceftriaxone + metronidazole), analgesics (opioids, acetaminophen), antiemetics, IV fluids (NS, LR)
Health Promotion: early evaluation of abdominal pain, avoid delaying care, educate about classic symptom progression, maintain hydration, encourage prompt medical care in children and older adults (atypical symptoms common)
A client taking metronidazole for C. difficile infection asks about alcohol use. What is the best response?
A. “Alcohol is safe in small amounts.”
B. “Avoid alcohol during treatment and for at least 3 days after.”
C. “Alcohol improves drug absorption.”
D. “Drink alcohol only with food.”
Answer: “Avoid alcohol during treatment and for at least 3 days after.”
Rationale:
Metronidazole + alcohol causes disulfiram-like reaction (flushing, tachycardia, nausea).