QSENCaseStudy1.ppt

Cancer of the Pancreas

An Unfolding Case Study MJS
By: Kimberly Silver-Dunker

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

117.bin

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.

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Team Huddle

“Teamwork & Collaboration”

Medication Reconciliation (Collected upon admission)
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.

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 care.

Potential compromise of Patient Safety

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.

QSEN Competency: Safety

Minimize risk of harm to patients and providers through both system effectiveness and individual performance.

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
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

Endoscopic Retrograde Cholangiopancreatography (ERCP)
Important Diagnostic Test

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Go through like an EGT, and go up through the common bile duct via back flow
Lengthly procedure because they try to get up into the common bile duct. They inject contrast media and is a difficult procedure

Endoscopic Retrograde Cholangiopancreatography (ERCP)

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Inject into the biliary tree contrast media

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

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”
What treatment options will the patient have?
How can the nurse advocate for patient quality of life?
How the nurse support patient decision making?
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.

CA 19-9

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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

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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
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

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.

Chemotherapy

A patient’s experience with
Chemo & Radiation
“Rough Times”
What are the implications for safety with chemotherapy administration?
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pancreatico- duodenectomy

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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Post-Op Ileus & Drain

Management of Patient Complications- Drain #2

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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.