This case study examines the care of a person with pancreatic cancer who was admitted to a private surgical ward for insertion of an ascitic drain. The article presents a student nurse's perspective of the nursing assessment, management and evaluation of the care provided to the patient. The student was supervised by a qualified nurse. A holistic patient-centred approach was adopted for the provision of patient care, incorporating a physical and psychological nursing assessment, management and evaluation. The decisions made by the student nurse, under the supervision of the qualified nurse, were based on evidence from the patient assessment, nursing literature, clinical guidance and hospital policies to support the care provided. The case study illustrates the care of a single patient and therefore the conclusions cannot be generalised (Alpi and Evans, 2019).
Overview of pancreatic cancer
The pancreas is located behind the stomach and has exocrine and endocrine glands with several functions, including breaking down carbohydrates, acids, fats and proteins and hormonal secretion of insulin, glucagon and somatostatin for the regulation of blood glucose (Widmaier et al, 2018). The most common type of pancreatic cancer is pancreatic adenocarcinoma, which affects 9 out of 10 patients, with the primary cancer starting in the exocrine ducts of the pancreas (Underhill et al, 2018).
The cause of pancreatic cancer is still not fully understood; however, according to Hicks et al (2016) there are several risk factors based on lifestyle choices, such as smoking, obesity, poor diet, diabetes and inactivity. There may also be a genetic element. There are no current screening methods for this disease, only prevention by reduction of lifestyle risk factors (Ilic and Ilic, 2016). Yadav and Lowenfels (2013) suggested that increased risks for developing pancreatic cancer include individuals who have had chronic pancreatitis, or a family history of chronic pancreatitis.
In 2018, there were 10 449 people living with pancreatic cancer in the UK, according to Pancreatic Cancer UK (2022), making it the 10th most common cancer. It is estimated that, in England, only 25.9% of people survive the first year after diagnosis and 7% survive 5 years (Pancreatic Cancer UK, 2022). Globally, in 2018, there were 458 918 newly diagnosed cases of pancreatic cancer and case numbers are expected to rise (Rawla et al, 2019).
Living with pancreatic cancer impacts on all aspects of an individual's life: physically, psychologically, emotionally, socially and financially. There are few signs and symptoms of pancreatic cancer but it can be asymptomatic, meaning it is often not diagnosed until the cancer is advanced, which leads to a poor prognosis despite treatment (Underhill et al, 2018). When diagnosed with any type of cancer, many patients tend to feel isolated as they do not want their family and friends to worry about them, and they face challenges related to communication with adult children, friends and coworkers about illness-related issues, and maintaining normality in these relationships (Porter et al, 2018).
Case study
In addition to the first author's personal experience as a student nurse on clinical placement engaging in patient care, under the direction and supervision of a nurse, a range of other data informed the case study, such as a patient interview, examination of the patient's medical records, and engagement with relevant literature (Figure 1).
Voluntary verbal consent was given by the patient in this case study. Written consent was not possible due to the patient's condition at the time. The student nurse obtained permission from the supervising qualified nurse and verbal consent was witnessed. Voluntary informed consent was guided by the World Declaration of Helsinki (World Medical Association, 2008) and the hospital's ethics process. For the purpose of the case study the pseudonym ‘Peter’ was selected in consultation with the patient and the supervising nurse. In keeping with Nursing and Midwifery Council's (2018)Code requirements, all identifiable data about Peter have been altered to protect his confidentiality and anonymity.
Patient overview
Peter is a divorced, white male living in north London, who has sustained a friendship with his ex-wife and two adult children. He claimed he was ‘supported at home’ by his friends and children. He was an accountant in his own family business, working with one of his children. At the time of illness he had taken a step back from working while his son took over the business, which ‘took the pressure off’.
Peter had been diagnosed with type 1 diabetes, at the age of 57 years. Six months later he was diagnosed with pancreatic cancer. Peter said he felt overwhelmed, and lacked understanding of the two conditions and how they interrelated and impacted on each another. Prior to this admission, Peter had been admitted to hospital for a Whipple procedure—the resection of the pancreatic head and surrounding area to include the duodenum, common bile duct and gall bladder (de Rooij et al, 2016). Unfortunately, this procedure was unsuccessful because his cancer was too advanced.
To manage his diabetes, Peter used long-acting insulin glargine, administering 18 units each morning. He said that he ‘never forgets or misses a dose’. Peter also took pancreatin, which is a supplement to compensate for reduced or absent exocrine secretion and assists with the digestion of protein, starch and fat (Joint Formulary Committee, 2022a). Peter described difficulty in taking this medication as he took several capsules, depending on the size of his meal. Pancreatin capsules are large and the Joint Formulary Committee (2022a) states that side effects of nausea and loss of appetite are common, which Peter experienced. He described himself as taking a responsible approach to his health and did not drink alcohol or smoke.
Peter's cancer treatment consisted of five cycles of chemotherapy. At the time of admission for insertion of an ascitic drain, he was due to commence the fifth and final cycle. He was hopeful and eager to meet with his oncologist to determine the next steps in treatment. Peter was admitted to the surgical ward for insertion of an ascitic drain because of the build-up of fluid in his abdomen.
Peter was a private patient, which included access to a consultant oncologist and endocrinologist. He was admitted to a private surgical ward for management of ascites because his consultant had made the decision to insert an ascitic drain, with the procedure scheduled for the day after admission. The student nurse met Peter on the ward before he went to theatre for surgery and provided post-surgery care on his return to the ward. This case study explores nursing assessment, management and evaluation, including physical and psychological perspectives, of Peter from a student nurse perspective.
Nursing assessment
In the advanced stages of pancreatic cancer, ascites—the accumulation of fluid in the abdomen—can be common (Hicks et al, 2016). There are several ways of treating this, such as insertion of an ascitic catheter drain, shunt or, in minor distention, diuretic medications (Rudralingam et al, 2017). All these treatments can have the common complication risk of infection (Hicks et al, 2016). Peter's ascitic drain was inserted in theatre early in the morning and when he returned to the ward the drain clamp had not been released as the treating consultant wanted the fluid output to be monitored by the nurse on the ward. The amount of fluid that had accumulated caused pressure on the abdomen, resulting in Peter experiencing acute pain, which was the focus of the nursing assessment.
Verbal or numerical pain rating tools are most appropriate for assessing acute pain, according to Dougherty et al (2015). Karcioglu et al (2018) described a numerical rating scale (NRS) used in acute settings and this tool was used in the clinical area where Peter was an inpatient. The NRS involves the patient verbally rating their pain along a scale of 0 to 10 (Table 1) (Karcioglu et al, 2018). When the student nurse administered the NRS to assess Peter's pain, he rated it as 8 out of 10, which equates to severe pain.
Table 1. Parameters of numerical pain scale
| Pain scale | Patient description |
|---|---|
| 0 | No pain |
| 1–3 | Mild pain |
| 4-6 | Moderate pain |
| 7-10 | Severe pain |
Source: Karcioglu et al, 2018
According to Karcioglu et al (2018), the NRS is commonly used in hospitals and patients tend to be familiar with this scale due to its straightforward nature, which also minimises the risk of misinterpretation. Although the NRS is commonly used by nurses assessing patients experiencing acute pain, there are limitations. It does not indicate the location, type, or history of pain to guide the nurse conducting a comprehensive assessment; to supplement NRS data, the nurse is required to ask the patient further questions (Morasco et al, 2018).
The Brief Pain Inventory could have been used to assess Peter's post-procedure pain (British Pain Society, 2019); nevertheless, this tool is reported to be more commonly used for patients experiencing chronic pain (Tan et al, 2004). For those experiencing pain related to their cancer condition, Schofield et al (2014) recommended the use of the Leeds Assessment of Neuropathic Symptoms and Signs. However, this assessment was not used because Peter's pain had resulted from the surgical intervention not his pancreatic cancer. Alternative visual assessments of patients' pain are the Wong-Baker Faces Scale and the Facial Expression Pain Scale (Arif-Rahu and Grap, 2010); both of which are typically used by nurses when a patient is unable to communicate or is unconscious. As Peter was able to communicate, these assessments were not considered appropriate and the NRS was deemed the most effective way of assessing his acute pain.
As well as assessing the physical aspect of Peter's pain, the student nurse also considered the psychosocial aspect of his pain as part of a conducting patient-centred holistic assessment (Riva et al, 2011). When a patient experiences pain, Dougherty et al (2015) indicated that the psychosocial aspect of care should be assessed, such as the patient's mood, wellbeing, and relationships. By using questions to gently probe the patient's feelings, the nurse can gain an understanding about the mindset of the patient. Peter told the student nurse he felt he had a ‘low mood’ due to his long-term condition and he believed his mood state was exacerbated by the acute pain he was experiencing. Although a mental health diagnosis was not recorded in the medical history, the student nurse asked further questions to gather more information about Peter's reported low mood. It was uncertain how long Peter had lived with a low mood, he could not outline a time frame, he just described feeling persistently low in mood in recent days.
The student nurse used the Baseline Assessment Tool for Depression in Adults (National Institute for Health and Care Excellence (NICE), 2009) to conduct a psychosocial assessment. The student nurse explored with Peter his interests, motivation, appetite, ideas of self-worth, insomnia and energy levels. By gathering information about Peter's stated low mood, while providing physical care, the student nurse was able to update the supervising qualified nurse and treating medical officer for a more informed assessment. The Baseline Assessment Tool for Depression in Adults (NICE, 2009) is based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (American Psychiatric Association, 1994), but the assessment criteria are different; the DSM-IV for use by a doctor, whereas the Baseline Assessment Tool for Depression can be used by any health professional (NICE, 2009). According to Truschel (2019), the Baseline Assessment Tool for Depression in Adults (NICE, 2009) is recommended for use across the UK to ensure that health professionals take a standardised approach.
After gathering further data about Peter's self-reported low mood, the student nurse handed over to the supervising nurse and treating medical officer, and Peter was medically assessed. This assessment indicated that Peter was not suffering from depression based on criteria that his symptoms had not persisted for longer than 2 weeks (NICE, 2009). However, Peter was medically assessed as experiencing low mood. The medical and nursing assessment data informed the nursing management of Peter's care needs.
Nursing management
The pain Peter was experiencing was due to the pressure from the fluid build-up in his abdomen. This was managed pharmacologically and non-pharmacologically. The student nurse observed the administration of a prescribed controlled medication for pain relief by the supervising nurse.
The Joint Formulary Committee (2022b) states that adults with acute pain can be prescribed 10 ml of morphine every 4 hours delivered orally or by subcutaneous or intramuscular injection and this can be adjusted according to the patient's response. The medical officer prescribed 5-10 ml of morphine to be delivered orally every 4 hours. The supervising nurse planned to administer 5 ml of morphine as an initial dose, as prescribed and in keeping with recommended dosage for patients in acute pain (Joint Formulary Committee, 2022b). Peter was reluctant to take the full dose because he was concerned about being sick or too drowsy when his sons came to visit that evening. The student nurse explained that, should he feel nauseated, the medical team could prescribe an anti-emetic medication and taking the morphine would mean that his pain would be controlled for his sons' visit later in the evening. The management of starting with a low dose and titrating if the pain continues is supported in the literature (Lee et al, 2015).
Peter required observation because of the opiate medication, which can have an adverse effect on respiration, causing respiratory depression, and he was monitored every 30 minutes, in line with good practice (Jungquist et al, 2017). The student nurse was responsible for observing Peter's vital signs: respiration rate, depth of breath and pulse oximetry. Jungquist et al (2017) recommended that vital signs are taken at least once per hour because this is one method of early detection of any further deterioration. Monitoring every 30 minutes provided an opportunity to ensure Peter's pain was being effectively managed.
Non-pharmacological nursing management involved fluid draining to relieve Peter's abdominal pain (NICE, 2018). The student nurse unclamped the drain and completed a fluid balance chart to record that 4000 ml of fluid had drained over the course of 3 hours since surgical insertion.
The student nurse assisted Peter to wash, change into clean clothes and sit out of bed, all of which are recommended strategies to helping improve a patient's feelings of low mood (Wiese, 2011). This type of management aimed to help Peter feel more motivated to renew his interest in activities of daily living and in engaging socially with his family, an approach supported by others (Kenner, 2018). By sitting out of bed, Peter was more active throughout the day, which also aimed to improve his quality of sleep during the night. Insomnia is a known contributing factor to low mood (Triantafillou et al, 2019). Time spent with Peter helping him wash and dress gave the student nurse an opportunity to build a therapeutic nurse-patient relationship, which is considered fundamental in nursing (Stevenson et al, 2004; Kornhaber et al, 2016). This nurse-patient relationship enabled the student nurse to engage in an open discussion about how Peter was feeling and explore other possible reasons or triggers for his low mood. Research shows that 76% of patients with pancreatic cancer develop mental health concerns after their diagnosis (Mayr and Schmid, 2010).
Nursing evaluation
Evaluating nursing actions and interactions is a crucial aspect of practice and Peter's care was evaluated by the student nurse, under the supervision of a qualified nurse.
Non-pharmacological evaluation consisted of the ascitic drain being monitored by the student nurse over the shift and 6000 ml was drained over 8 hours and recorded on a fluid balance chart. As the large amount of fluid drained from the peritoneal cavity, the distention of Peter's abdomen decreased (Rudralingam et al, 2017), which resulted in his pain decreasing and improving his ability to mobilise.
The administration of 20 mg of morphine by the supervising qualified nurse over the length of the shift resulted in Peter's acute pain being effectively managed. This was evident by the student nurse repeating the NRS assessment. Peter's pain was initially rated at 8 (severe) and this subsequently reduced to 2 (mild) (Karcioglu et al, 2018). Towards the end of the student's shift Peter described his pain as ‘tolerable’ and indicated that he no longer wanted the morphine administered as he did not want the drowsy side effects. Instead, he preferred to continue with his analgesia of paracetamol as prescribed for pain, 1 g every 4-6 hours orally, which he had been taking prior to admission. For some patients, stopping the morphine could be problematic because, morphine, like many other analgesics, is most effective when taken at prescribed regular intervals. If this is stopped the patient is at risk of their pain returning and needing to recommence the process of pain assessment and management (Sessler et al, 2008). The student nurse explained the mechanism of analgesia to Peter, but he declined the morphine because of its associated drowsiness and nausea, which are common side effects of morphine and other opioids (Murphy et al, 2022).
Peter's motivation to eat and drink, mobilise and engage in conversations in the clinical area were noted to improve as his pain decreased. Good nutrition and mobilising can lead to an increase in energy and motivation, which can have an impact on the mood of people living with cancer (Vijayvergia and Denlinger, 2015).
The student nurse reflected on the care of Peter and concluded that his needs had been met during his stay: his pain and low mood had been acknowledged and recorded, analgesia provided and the cause of the pain treated through draining fluid from his abdomen. He had been given the chance to talk about his feelings and helped to wash, change and mobilise, which improved his mood.
Conclusion
This case study has outlined the fundamental role that a student nurse can have in carrying out the assessment, management and evaluation of a patient for improved health outcomes, such as eliminating pain and improving mood, as demonstrated in the case of Peter. The assessment of acute pain using the NRS was suitable due to the straightforwardness of the tool, and its familiarity, and because it allows immediate understanding of the pain being experienced. There are more advanced methods for pain assessment, but these were not appropriate for use with the patient in this case study. A psychosocial aspect of this patient's case was the patient's low mood, which was associated with his experience of pain and was therefore managed through pain relief and ascites drainage. This allowed the patient to mobilise, wash and eat, all factors that improved his mood.
Receiving surgical treatment for cancer ascites via a drain insertion meant that the patient could be discharged home to wait for his final treatment cycle of chemotherapy for pancreatic cancer.
KEY POINTS
- Pancreatic adenocarcinoma affects the exocrine ducts
- Surgical intervention for ascites drainage may be required
- A range of post-surgical pharmacological and non-pharmacological nursing interventions can help to improve the lives of those affected
- Person-centred holistic nursing care extends beyond physical care and includes the psychological wellbeing of the patient
- Credible evidence should inform nursing practice to ensure the best possible patient experience
CPD reflective questions
- Think about the symptoms of pancreatic cancer and how these are best managed
- What is the nurse's/student nurse's role in assessing, managing, and evaluating post-surgical acute pain experienced by a patient with pancreatic cancer?
- How can you provide holistic patient-centred care for a patient with pancreatic cancer?