The pancreas is a part of the endocrine system, and is located in the abdominal cavity surrounded by the liver, gallbladder, spleen, and stomach. The pancreas processes both exocrine and endocrine function. The exocrine function consists of the secretion of digestive enzymes into the duodenum through ducts. The enzymes digest starches and fats. The endocrine functions are a cluster of cells called the islets of Langerhans and only make up 2% of the pancreatic tissue. The islets of Langerhans is made up of three cells, alpha, beta, and delta.
There function is to secrete hormones and paracrine products. The most important hormones secreted are insulin, glucagon, and somatostatin. Alpha cells secrete glucagon, which increase blood glucose levels between meals. Beta cells secrete insulin, this is secreted when the level of glucose rises in the blood. Insulin stimulates cells to store nutrients to use between meals and at night to maintain blood glucose levels. Delta cells secrete somatostatin, after meals when blood glucose, fatty acids, and amino acids raise in the blood.

Pancreatic cancer is a highly malignant cancer. Tumors commonly originate from the epithelial cells of the pancreatic ductal system. This can happen in two ways, one that it has metastasized from a different part of the body, generally the lungs, breast, thyroid, kidneys, and skin. Second form is a primary tumor manly adenocarcinomas. Adenocarcinomas occur in secretory cells called glandular cells. These glandular cells line some organs within the endocrine system that make and release hormones in the lymphatic and venous system. Both system travel throughout the body and give opportunity to metastasis. The head of the pancreas is the most common place for cancer to form. Pancreatic cancer that starts on the tail and body metastasis to more places than if it first occurred on the head of the organ. These tumors are usually large and may be palpated, and metastases to the liver cause hepatomegaly.
Cancer of the tail and body metastasis to the retroperitoneal, vertebral column, spleen, adrenal glands, colon, or stomach. Cancer of the head of the pancreas are small lesions tumors that can cause compression and impair the function of the bile duct.
Regardless of the original site on the pancreas it spreads rapidly.

Manifestations
The clinical manifestation of pancreatic cancer depend on the location and extent of mastesasis. Onset of the disease is unspecific patients may complain of weakness, fatigue, nausea, and dull abdominal pain. After the disease progresses patients note clay colored stools, jaundice, glucose intolerance, splenomegaly, and hepatomegaly. Given the location of the pancreas the cancer is likely unknown until it is in the later stages of the disease. Patient experience fatigue, and weight loss, because of the tumors effect on the secretion of digestive enzymes. As the tumor grows it compresses the common bile duct and inhibits the secretion of bile. The bile consists of enzymes that digest fats and starches. Due to the lack of the digest enzymes in the bowel the food is not properly absorbed in the digestive track and malabsorption occurs. This manifestation causes weight loss and fatigue. Often the patient also experiences nausea and vomiting which further hinders the patient from getting proper nutrient to preform everyday activities. Bile secretion into the digestive track also gives the stool its brown color, the appearance of discolored stools is usually noticed by the patient and sends them to seek medical attention. Jaundice occurs when there is an increased amount of bilirubin in the blood, this occurs with liver involvement. The liver is the site of bilirubin breakdown and elimination into the stool. When the liver is affected by cancer it cannot excrete bilirubin effectively. A new diagnosis of Diabetes Militias can occur, due to the impaired function of the pancreas to secrete important hormones that control blood glucose.
Splenomegaly is caused by blood flow backing up into the spleen, caused by compression of the portal vein by the tumor. Hepatomegaly is caused by tumor growth on the liver.

Key Nursing assessment
Assess for pain given the rate of metastasize cancer could affect many organ and become very pain full. Assess the presents of Jaundice. If Jaundice is present it gives a good indicator that the cancer has spread to gallbladder and liver. Fatigue is common among these patients.
You will need a consult from PT, to assess their needs for assistance with mobility, ADL. Talk with patient about support system. Only 3% of individual’s diagnosed with pancreatic cancer live past 5 years. Most patient diagnosed pass away within the first year.

Risk Factors
The cause of pancreatic cancer is unknown, patient at risk are those between the age of 60 to
80 years old and with a history of smoking. Other factors for development of pancreatic cancer are Diabetes mellitus, chronic pancreatitis, food additives, industrial chemicals, and obesity.

Nutritional concerns
A patient with pancreatic cancer is at risk for many issues concerning diet. Due to the organs involved the patient may be experiencing nausea and vomiting. It is important that the patient stays well hydrated, because of the risk for electrolyte imbalance, caused by vomiting. The patient should be encouraged to eat 6 to 8 small meals a day including snacks. A digestive enzyme may be given to assist in digestive track. Improper diet can expose the patient to infection, skin breakdown, and weakened immune system. In the late progression of pancreatic cancer it may be necessary to have a jejunostomy or peripherally inserted central line (PICC) to deliver optimal nutrition. The PICC line is inserted into a vein in the arm and advanced to the superior vena cava. The IV fluid is sterile and contains all of the nutritional elements that are needed for the patient. The site of insertion needs to be kept clean, a sterile dressing is applied to the site. A jejunostomy is a surgically created opening through the abdominal wall into the jejunum, and is used for long term feeding. Jejunostomy is placed to prevent reflux and increase absorption of nutrition. In both method patient education is needed to prevent infection. As a nurse I will assess their tolerance for food, ask them what foods they prefer to eat. Offering food that appeal to the patient may increase the willingness to eat.

Activity Level
The patient may not have the energy to preform ADL’s due to increased fatigue from impaired nutrition status and pain. Assessment from PT maybe needed to facilitate the safety of the patient. Assessment of current diagnosis such as those that effect the bones, joints and muscles due to the increased incident in patients 60-80 years old. Plan to assist patient with activities when they have the most energy, conserve energy by clustering care and allowing adequate rest periods between activities. Allow patient to verbalize feelings about activity limitations.
The patient may have a difficult time with the need for assistance.

Prognosis
There is no cure for pancreatic cancer and it is the fourth leading cause of cancer deaths in the
United States. Treatment is centered on pain control palliative chemotherapy. Given the location of the pancreas, cancer is usually not diagnosed until it is a stage four. Pancreatic cancer spreads rapidly and is not usually not detected in the early stages. Classic sign is clay colored stool, and is a indication that it has metastasized to the liver. 75% to 80% of pancreatic cancers have spread at the time of diagnosis, and patient usually pass within a year of diagnosis. Even with radical surgical interventions prognosis is limited to 12 to 18 months.

Laboratory studies
Serum Bilirubin 0.1-1.2 mg/dL to monitor bilirubin levels associated with jaundice and suggests a liver disorder. Monitor for weakness and fatigue palpate for liver enlargement. Serum amylase 60-160 units/dL increased levels indicate pancreatic duct obstruction, necrosis of the liver. Blood sugar should be drawn 2hr after eating because sugar can decrease the amylase serum level. Check urine output, a decrease in urine can decrease level. Serum lipase 20-180 units/L increased levels indicate pancreatic cancer, obstruction of pancreatic ducted. Assess for abdominal pain, tell provider if pain persists and is uncontrolled this may also indicate acute pancreatitis. AST 8-35 units/L Increased levels indicate cancer of the liver, necrosis of the liver.
Explain the purpose of the test, and hold medication that may cause increase in level. ALT 10-35 units/L used to detect disorders of the liver. Assess for presents of jaundice, monitor medications that could falsely increase ALT levels. ALP 4.2-13 units/L to determine a liver or bone disorder. Monitor medication that increase ALP. Hemoglobin male 13.5-18 g/dL female
12/15 g/dL Decreased levels indicate cancer. Observe client for symptoms of anemia, check hematocrit level if hemoglobin is low, this may show internal bleeding. Hmeatocrit 0.40-0.54
Decreased levels indicate cirrhosis of the liver. Assess for sign of anemia.

Diagnostic test
Abdominal ultrasound and CT are used to differentiate a tumor from a cyst. ERCP allows visual diagnostic date. The normal assessment finding with these tests are the appearance of a normal pancreas free from masses.

Medications/ Treatments
The medical intervention for pancreatic cancer are to prevent tumor growth and decrease pain of the patient. Chemotherapy and radiation are used to treat pain and shrink tumors, but do not increase survival time. Kinase inhibitors block the kinase gene from binding to ATP, preventing cell division. These drugs focus on the cancer cells and have little effect on other cells in the body. Pain is controlled with opioid analgesics usually morphine. Morphine Sulfate classification analgesic narcotic dosage depends on progression of disease and may be administered as frequently as q30min to achieve desired affect. It can be given oral or intravenously. Peak and durations of medication vary by route of admission. PO route dosage
10-30m q4hr prn or 15-30mg sustained release. Intravenous is 2.5-15mg/70kg q2-4hrs or .08-
10mg/hr by continues infusion, may increase PRN to control pain or 5-10mg given epidurally q24hrs. Epidural (depodur only) 10-15mg as single dose 30min before surgery.
IM/subcutaneous 5-20mg q4hr PRN. Morphine sulfate is used to control severe pain associated with pancreatic cancer, and assists with dyspnea at end of life. Morphine binds to the same receptors as endogenous opioid peptides. This action blocks pain receptors around the body.
Assessment of vital signs with attention to respiration to observe for respiration depression.
Adverse effects include respiratory depression, bradycardia, constipation, urinary retention and dependency. Due to the poor prognosis of pancreatic cancer providers are not concerned with dependency of the medication. Morphine may cause false positives in labs in urine glucose.
Surgical management may include complete resection of the pancreas, this is only done if the tumors are small. Patient might have a partial pancreatectomy if the tumor is less than 3 cm in diameter. For larger tumors patients would undergo a radical pancreatectomy or whipple procedure. A whipple procedure is used for tumors that effect the head of the pancreas. This procedure involves removal of the head of the pancreas, the duodenum, a portion of the jejunum, the stomach, and gallbladder. Even with surgical intervention only 3% of patients diagnosed with pancreatic cancer survive past 5 yrs.

Patient Teaching
Assess patient’s support system before discharge. Addition care may be needed for client to be discharge home. If patient has had recent surgery you should teach patient and family the signs and symptoms of infection and potential complications that occur. Patient receiving morphine should be told of the risk for constipation. Patient receiving tube feeding need education on how much and how often to administer. It PICC line has been placed patient should watch for signs of infection. A visiting nurse service might be needed for dressing changes. Assess patient for stages of grief, given the prognosis it would be appropriate to talk with patient about end of life care. Patient may need a referral to hospice or suggest support groups. Encourage communication between patient and family. While it is a disease it effects the whole family, answer any questions the patient and family might have. Explain to family members that their own physical and emotional health is important. Tell them caring for a passing family member is may be stressful and they will need to focus on their own well being too.

Activity intolerance related to diagnosis of pancreatic cancer as evident by weakness and fatigue.
Patient will verbalize and use energy-conservation techniques.
Assist patient with planning of activities for times when they have the most energy.
Provide patient with adaptive equipment needed to assist with activity.
Teach patient and families signs of over activity.
Assess nutritional status.

Chronic pain related to metastasize of cancer as evident by patient report of pain.
Patient reports pain at a level acceptable to him/her.
Assess the patient’s expectation about pain relief.
Assess the appropriateness of the patient as a PCA candidate.
Eliminate additional stressors or sources of discomfort whenever possible.
Administer pain medication per MD order to facilitate comfort.

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