Focus on Pancreatitis Relates to Chapter 44 Nursing

Acute Pancreatitis • An acute inflammatory process of the pancreas • Degree of inflammation

Acute Pancreatitis Etiology and Pathophysiology • Most common in middle-aged men and women •

Acute Pancreatitis Etiology and Pathophysiology (Cont’d) • Primary etiologic factors are • Biliary tract

Acute Pancreatitis Etiology and Pathophysiology (Cont’d) • Less common causes • Trauma (postsurgical, abdominal)

Acute Pancreatitis Etiology and Pathophysiology • Less common causes (cont’d) • Abscesses • Cystic

Acute Pancreatitis Etiology and Pathophysiology • Less common causes (cont’d) • Drugs • Corticosteroids

Acute Pancreatitis Etiology and Pathophysiology • Caused by autodigestion of pancreas • Etiologic factors

Acute Pancreatitis Fig. 44 -14 Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. ,

Acute Pancreatitis Etiology and Pathophysiology • Trypsinogen • Activated to trypsin by enterokinase •

Pancreatitis Etiology and Pathophysiology • Elastase • Activated by trypsin • Plays a major

Acute Pancreatitis Etiology and Pathophysiology • Phospholipase A • Plays a major role in

Acute Pancreatitis Etiology and Pathophysiology (Cont’d) Trypsin Elastase Edema, necrosis, hemorrhage Hemorrhage Phospholipase A

Acute Pancreatitis Etiology and Pathophysiology (Cont’d) • Alcohol • May stimulate production of digestive

Acute Pancreatitis Etiology and Pathophysiology (Cont’d) • Edematous pancreatitis • Mild and self-limiting •

Acute Pancreatitis Clinical Manifestations • Abdominal pain is predominant symptom • Pain located in

Acute Pancreatitis Clinical Manifestations • Abdominal pain (cont’d) • Sudden onset • Severe, deep,

Acute Pancreatitis Clinical Manifestations • Flushing • Cyanosis • Dyspnea • Edema • Nausea/vomiting

Acute Pancreatitis Clinical Manifestations (Cont’d) • Low-grade fever • Leukocytosis • Hypotension • Tachycardia

Acute Pancreatitis Clinical Manifestations (Cont’d) • Abdominal distention • Abnormal lung sounds • Crackles

Acute Pancreatitis Complications • Two significant local complications • Pseudocyst • Abscess Copyright ©

Acute Pancreatitis Complications (Cont’d) • Pseudocyst • Cavity surrounding outside of pancreas filled with

Acute Pancreatitis Complications • Pseudocyst (cont’d) • Nausea, vomiting, and anorexia • Elevated serum

Acute Pancreatitis Complications • Pancreatic abscess • A large fluid-containing cavity within pancreas •

Acute Pancreatitis Complications • Pancreatic abscess (cont’d) • High fever • Leukocytosis • Requires

Acute Pancreatitis Complications • Main systemic complications • Pulmonary • Pleural effusion • Atelectasis

Acute Pancreatitis Complications • Systemic complications (cont’d) • Cardiovascular • Hypotension • Tetany (caused

Acute Pancreatitis Diagnostic Studies • History and physical examination • Laboratory tests • Serum

Acute Pancreatitis Diagnostic Studies • Laboratory tests (cont’d) • Blood glucose • Serum calcium

Acute Pancreatitis Diagnostic Studies • Flat plate of abdomen • Abdominal/endoscopic ultrasound • Endoscopic

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc.

Acute Pancreatitis Diagnostic Studies (Cont’d) • CT of pancreas • Magnetic resonance cholangiopancreatography (MRCP)

Acute Pancreatitis Collaborative Care • Objectives include • Relief of pain • Prevention or

Acute Pancreatitis Collaborative Care (Cont’d) • Conservative therapy • Supportive care • Aggressive hydration

Acute Pancreatitis Collaborative Care • Conservative therapy (cont’d) • Shock • Plasma or plasma

Acute Pancreatitis Collaborative Care • Conservative therapy (cont’d) • Suppression of pancreatic enzymes •

Acute Pancreatitis Collaborative Care • Surgical therapy indicated if • Presence of gallstones •

Acute Pancreatitis Collaborative Care • Surgical therapy (cont’d) • ERCP • Endoscopic sphincterotomy •

Acute Pancreatitis Collaborative Care (Cont’d) • Drug therapy • IV morphine • Nitroglycerin or

Acute Pancreatitis Collaborative Care (Cont’d) • Nutritional therapy • NPO status initially to reduce

Acute Pancreatitis Collaborative Care • Nutritional therapy (cont’d) • Supplemental fat-soluble vitamins • Supplemental

Acute Pancreatitis Nursing Assessment • Health history • Biliary tract disease • Alcohol use

Acute Pancreatitis Nursing Assessment (Cont’d) • Medication usage • Thiazides, estrogens, corticosteroids, NSAIDs •

Acute Pancreatitis Nursing Assessment (Cont’d) • Physical examination findings • Fever • Jaundice •

Acute Pancreatitis Nursing Assessment (Cont’d) • Abnormal laboratory findings • ↑ Serum amylase/lipase •

Acute Pancreatitis Nursing Diagnoses • Acute pain • Deficient fluid volume • Imbalanced nutrition:

Acute Pancreatitis Planning • Overall goals • Relief of pain • Normal fluid and

Acute Pancreatitis Nursing Implementation • Health Promotion • Assessment of predisposing factors • Early

Acute Pancreatitis Nursing Implementation (Cont’d) • Acute Intervention • Monitor vital signs • IV

Acute Pancreatitis Nursing Implementation • Acute Intervention (cont’d) • Fluid/electrolyte balance • Blood glucose

Acute Pancreatitis Nursing Implementation • Acute Intervention (cont’d) • NG tube care • Frequent

Acute Pancreatitis Nursing Implementation • Ambulatory and Home Care • Physical therapy • Counseling

Acute Pancreatitis Nursing Implementation • Ambulatory and Home Care (cont’d) • Dietary teaching •

Acute Pancreatitis Nursing Implementation • Expected outcomes • Maintains adequate fluid volume • Maintains

Acute Pancreatitis Nursing Implementation • Expected outcomes (cont’d) • Describes therapeutic regimen • Expresses

Chronic Pancreatitis • Continuous, prolonged inflammatory, and fibrosing process of the pancreas • Pancreas

Chronic Pancreatitis Etiology and Pathophysiology • May follow acute pancreatitis • May occur in

Chronic Pancreatitis Etiology and Pathophysiology (Cont’d) • Chronic obstructive pancreatitis • Associated with biliary

Chronic Pancreatitis Etiology and Pathophysiology (Cont’d) • Chronic calcifying pancreatitis • Inflammation • Sclerosis

Chronic Pancreatitis Etiology and Pathophysiology • Chronic calcifying pancreatitis (cont’d) • Most common form

Chronic Pancreatitis Etiology and Pathophysiology • Chronic calcifying pancreatitis (cont’d) • Ducts are obstructed

Chronic Pancreatitis Etiology and Pathophysiology • Chronic calcifying pancreatitis (cont’d) • Calcification is followed

Chronic Pancreatitis Clinical Manifestations • Abdominal pain • Located in the same areas as

Chronic Pancreatitis Clinical Manifestations (Cont’d) • Constipation • Mild jaundice with dark urine •

Chronic Pancreatitis Clinical Manifestations (Cont’d) • Complications • Pseudocyst formation • Bile duct or

Chronic Pancreatitis Clinical Manifestations • Complications (cont’d) • Splenic vein thrombosis • Pseudoaneurysms •

Chronic Pancreatitis Diagnostic Studies • Confirming diagnosis can be challenging • Based on signs/symptoms,

Chronic Pancreatitis Diagnostic Studies (Cont’d) • Laboratory tests • Serum amylase/lipase • May be

Chronic Pancreatitis Diagnostic Studies • Laboratory tests (cont’d) • Mild leukocytosis • Elevated sedimentation

Chronic Pancreatitis Diagnostic Studies • CT • MRI • MRCP • Transabdominal ultrasound Copyright

Chronic Pancreatitis Diagnostic Studies (Cont’d) • Endoscopic ultrasound • Secretin stimulation test • Assess

Chronic Pancreatitis Collaborative Care • Prevention of attacks • During acute attack, follow acute

Chronic Pancreatitis Collaborative Care (Cont’d) • Bland low-fat, high-carbohydrate diet • Bile salts •

Chronic Pancreatitis Collaborative Care (Cont’d) • Pancreatic enzyme replacement • Acid-neutralizing and acid-inhibiting drugs

Chronic Pancreatitis Collaborative Care (Cont’d) • Surgery • Indicated when biliary disease is present

Chronic Pancreatitis Nursing Management • Focus is on chronic care and health promotion •

Case Study Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of

Case Study • 63 -year-old female enters the emergency department with nausea, vomiting, epigastric

Case Study (Cont’d) • Pain began 24 hours ago • She is divorced, retired,

Case Study (Cont’d) • Vital signs • Blood pressure 100/70 mm Hg • Heart

Discussion Questions 1. What are the possible causes of pancreatitis? 2. What is her

Discussion Questions (Cont’d) 3. What labs are the most important to monitor in acute

Slides: 82

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Focus on Pancreatitis (Relates to Chapter 44, “Nursing Management: Liver, Pancreas, and Biliary Tract Problems” in the textbook) Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis • An acute inflammatory process of the pancreas • Degree of inflammation varies from mild edema to severe necrosis Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Etiology and Pathophysiology • Most common in middle-aged men and women • Severity of the disease varies according to the extent of pancreatic destruction • Can be life-threatening • African American rate three times higher than for whites Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Etiology and Pathophysiology (Cont’d) • Primary etiologic factors are • Biliary tract disease • Most common: Gallbladder disease • Alcoholism Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Etiology and Pathophysiology (Cont’d) • Less common causes • Trauma (postsurgical, abdominal) • Viral infections (mumps, coxsackievirus HIV) • Penetrating duodenal ulcer • Cysts • Idiopathic Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Etiology and Pathophysiology • Less common causes (cont’d) • Abscesses • Cystic fibrosis • Kaposi’s sarcoma • Metabolic disorders • Vascular diseases • Postop GI surgery Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Etiology and Pathophysiology • Less common causes (cont’d) • Drugs • Corticosteroids • Thiazide diuretics • Oral contraceptives • Sulfonamides • NSAIDs Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Etiology and Pathophysiology • Caused by autodigestion of pancreas • Etiologic factors • Injury to pancreatic cells • Activate pancreatic enzymes Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Etiology and Pathophysiology • Trypsinogen • Activated to trypsin by enterokinase • Inhibitors usually inactivate trypsin • Enzyme can digest the pancreas and can activate other proteolytic enzymes Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Pancreatitis Etiology and Pathophysiology • Elastase • Activated by trypsin • Plays a major role in autodigestion • Causes hemorrhage by producing dissolution of the elastic fibers of blood vessels Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Etiology and Pathophysiology • Phospholipase A • Plays a major role in autodigestion • Activated by trypsin and bile acids • Causes fat necrosis Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Etiology and Pathophysiology (Cont’d) Trypsin Elastase Edema, necrosis, hemorrhage Hemorrhage Phospholipase A Fat necrosis Kallikrein Edema, vascular permeability, smooth muscle contraction, shock Lipase Fat necrosis Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Etiology and Pathophysiology (Cont’d) • Alcohol • May stimulate production of digestive enzymes • Increases sensitivity to hormone cholecystokinin • Stimulates production of pancreatic enzymes Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Etiology and Pathophysiology (Cont’d) • Edematous pancreatitis • Mild and self-limiting • Necrotizing pancreatitis • Degree of necrosis correlates with severity of manifestations Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Clinical Manifestations • Abdominal pain is predominant symptom • Pain located in the left upper quadrant • Pain may be in the midepigastrium • Commonly radiates to the back Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Clinical Manifestations • Abdominal pain (cont’d) • Sudden onset • Severe, deep, piercing, steady • Aggravated by eating • Not relieved by vomiting Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Clinical Manifestations • Flushing • Cyanosis • Dyspnea • Edema • Nausea/vomiting • Bowel sounds decreased or absent Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Clinical Manifestations (Cont’d) • Low-grade fever • Leukocytosis • Hypotension • Tachycardia • Jaundice • Abdominal tenderness Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Clinical Manifestations (Cont’d) • Abdominal distention • Abnormal lung sounds • Crackles • Discoloration of abdominal wall Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Complications (Cont’d) • Pseudocyst • Cavity surrounding outside of pancreas filled with necrotic products and liquid secretions • Abdominal pain • Palpable epigastric mass Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Complications • Pseudocyst (cont’d) • Nausea, vomiting, and anorexia • Elevated serum amylase • May resolve spontaneously within a few weeks or may perforate, causing peritonitis • Treatment: Internal drainage procedure Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Complications • Pancreatic abscess • A large fluid-containing cavity within pancreas • Results from extensive necrosis in the pancreas • Upper abdominal pain • Abdominal mass Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Complications • Pancreatic abscess (cont’d) • High fever • Leukocytosis • Requires surgical drainage Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Complications • Main systemic complications • Pulmonary • Pleural effusion • Atelectasis • Pneumonia Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Complications • Systemic complications (cont’d) • Cardiovascular • Hypotension • Tetany (caused by hypocalcemia) Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Diagnostic Studies • History and physical examination • Laboratory tests • Serum amylase • Serum lipase • 2 -hour urinary amylase and renal amylase clearance Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Diagnostic Studies • Laboratory tests (cont’d) • Blood glucose • Serum calcium • Triglycerides Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Diagnostic Studies • Flat plate of abdomen • Abdominal/endoscopic ultrasound • Endoscopic retrograde cholangiopancreatography (ERCP) • Chest x-ray Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Diagnostic Studies (Cont’d) • CT of pancreas • Magnetic resonance cholangiopancreatography (MRCP) Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Collaborative Care • Objectives include • Relief of pain • Prevention or alleviation of shock • ↓ of pancreatic secretions • Fluid/electrolyte balance • Removal of the precipitating cause Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Collaborative Care (Cont’d) • Conservative therapy • Supportive care • Aggressive hydration • Pain management • IV morphine • Combined with antispasmodic agent • Management of metabolic complications • Minimizing stimulation Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Collaborative Care • Conservative therapy (cont’d) • Shock • Plasma or plasma volume expanders (dextran or albumin) • Fluid/electrolyte imbalance • Lactated Ringer’s solution • Ongoing hypotension • Vasoactive drugs: Dopamine (Intropin) • ↑ Systemic vascular resistance Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Collaborative Care • Conservative therapy (cont’d) • Suppression of pancreatic enzymes • NPO • NG suction • Prevent infections • Peritoneal lavage or dialysis • Remove kinin and phospholipase A exudate Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Collaborative Care • Surgical therapy indicated if • Presence of gallstones • Uncertain diagnosis • Unresponsive to conservative therapy • Abscess, pseudocyst, or severe peritonitis Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Collaborative Care • Surgical therapy (cont’d) • ERCP • Endoscopic sphincterotomy • Laparoscopic cholecystectomy Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Collaborative Care (Cont’d) • Drug therapy • IV morphine • Nitroglycerin or papaverine • Antispasmodics • Carbonic anhydrase inhibitor • Antacids • Histamine (H 2) receptor Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Collaborative Care (Cont’d) • Nutritional therapy • NPO status initially to reduce pancreatic secretion • IV lipids • Monitor triglycerides • Small, frequent feedings • High-carbohydrate, low-fat, high-protein diet • Bland diet Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Collaborative Care • Nutritional therapy (cont’d) • Supplemental fat-soluble vitamins • Supplemental commercial liquid preparations • Parenteral nutrition • No caffeine or alcohol Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Nursing Assessment • Health history • Biliary tract disease • Alcohol use • Abdominal trauma • Duodenal ulcers • Infection • Metabolic disorders Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Nursing Assessment (Cont’d) • Medication usage • Thiazides, estrogens, corticosteroids, NSAIDs • Surgical procedures • Nausea/vomiting • Dyspnea • Severe pain Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Nursing Assessment (Cont’d) • Physical examination findings • Fever • Jaundice • Discoloration of abdomen/flank • Tachycardia • Hypotension • Abdominal distention/tenderness Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Nursing Assessment (Cont’d) • Abnormal laboratory findings • ↑ Serum amylase/lipase • Leukocytosis • Hyperglycemia • Hyperlipidemia • Hypocalcemia • Abnormal ultrasound/ CT/ ERCP Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Nursing Diagnoses • Acute pain • Deficient fluid volume • Imbalanced nutrition: Less than body requirements • Ineffective therapeutic regimen management Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Planning • Overall goals • Relief of pain • Normal fluid and electrolyte balance • Minimal to no complications • No recurrent attacks Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Nursing Implementation • Health Promotion • Assessment of predisposing factors • Early diagnosis/treatment of cholelithiasis • Eliminate alcohol intake Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Nursing Implementation (Cont’d) • Acute Intervention • Monitor vital signs • IV fluids • Observe for side effects of medications • Assess respiratory function • Pain assessment and management • Frequent position changes • Side-lying with HOB elevated 45 degrees • Knees up to abdomen Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Nursing Implementation • Acute Intervention (cont’d) • Fluid/electrolyte balance • Blood glucose monitoring • Monitor for signs of hypocalcemia • Tetany (jerking, irritability, twitching) • Numbness around lips/fingers • Positive Chvostek or Trousseau sign • Monitor for hypomagnesemia Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Nursing Implementation • Acute Intervention (cont’d) • NG tube care • Frequent oral/nasal care • Observe for signs of infection • Wound care • Observe for paralytic ileus, renal failure, mental changes Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Nursing Implementation • Ambulatory and Home Care • Physical therapy • Counseling regarding abstinence from alcohol, caffeine, and smoking • Assessment of narcotic addiction Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Nursing Implementation • Ambulatory and Home Care (cont’d) • Dietary teaching • High-carbohydrate, low-fat diet • Patient/family teaching • Signs of infection, high blood glucose, steatorrhea • Medications/diet Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Nursing Implementation • Expected outcomes • Maintains adequate fluid volume • Maintains weight appropriate for height • Food and fluid intake adequate to meet nutritional needs Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Acute Pancreatitis Nursing Implementation • Expected outcomes (cont’d) • Describes therapeutic regimen • Expresses commitment to lifestyle changes Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Pancreatitis • Continuous, prolonged inflammatory, and fibrosing process of the pancreas • Pancreas becomes destroyed as it is replaced by fibrotic tissue • Strictures and calcifications can also occur Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Pancreatitis Etiology and Pathophysiology • May follow acute pancreatitis • May occur in absence of any history of acute condition • Two major types • Chronic obstructive pancreatitis • Chronic calcifying pancreatitis Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Pancreatitis Etiology and Pathophysiology (Cont’d) • Chronic obstructive pancreatitis • Associated with biliary disease • Most common cause • Inflammation of the sphincter of Oddi associated with cholelithiasis • Other causes include • Cancer of ampulla of Vater, duodenum, or pancreas Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Pancreatitis Etiology and Pathophysiology (Cont’d) • Chronic calcifying pancreatitis • Inflammation • Sclerosis • Mainly in the head of the pancreas and around the pancreatic duct Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Pancreatitis Etiology and Pathophysiology • Chronic calcifying pancreatitis (cont’d) • Most common form of chronic pancreatitis • May be referred to as alcohol-induced pancreatitis Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Pancreatitis Etiology and Pathophysiology • Chronic calcifying pancreatitis (cont’d) • Ducts are obstructed with protein precipitates • Precipitates block the pancreatic duct and eventually calcify Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Pancreatitis Etiology and Pathophysiology • Chronic calcifying pancreatitis (cont’d) • Calcification is followed by fibrosis and glandular atrophy • Pseudocysts and abscesses commonly develop Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Pancreatitis Clinical Manifestations • Abdominal pain • Located in the same areas as in acute pancreatitis • Heavy, gnawing feeling; burning and cramp-like • Abdominal tenderness • Malabsorption with weight loss Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Pancreatitis Clinical Manifestations (Cont’d) • Constipation • Mild jaundice with dark urine • Steatorrhea • Frothy urine/stool • Diabetes mellitus Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Pancreatitis Clinical Manifestations (Cont’d) • Complications • Pseudocyst formation • Bile duct or duodenal obstruction • Pancreatic ascites • Pleural effusion Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Pancreatitis Clinical Manifestations • Complications (cont’d) • Splenic vein thrombosis • Pseudoaneurysms • Pancreatic cancer Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Pancreatitis Diagnostic Studies • Confirming diagnosis can be challenging • Based on signs/symptoms, laboratory studies, and imaging Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Pancreatitis Diagnostic Studies (Cont’d) • Laboratory tests • Serum amylase/lipase • May be ↑ slightly or not at all • ↑ Serum bilirubin • ↑ Alkaline phosphatase Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Pancreatitis Diagnostic Studies • Laboratory tests (cont’d) • Mild leukocytosis • Elevated sedimentation rate • ERCP • Visualize pancreatic/common bile duct Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Pancreatitis Diagnostic Studies (Cont’d) • Endoscopic ultrasound • Secretin stimulation test • Assess degree of pancreatic function • Not useful in diagnosis Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Pancreatitis Collaborative Care • Prevention of attacks • During acute attack, follow acute therapy • Relief of pain • Control of pancreatic exocrine and endocrine insufficiency Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Pancreatitis Collaborative Care (Cont’d) • Bland low-fat, high-carbohydrate diet • Bile salts • Help absorption of fat-soluble vitamins • Prevent further fat loss • Control of diabetes • No alcohol Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Pancreatitis Collaborative Care (Cont’d) • Pancreatic enzyme replacement • Acid-neutralizing and acid-inhibiting drugs Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Pancreatitis Collaborative Care (Cont’d) • Surgery • Indicated when biliary disease is present or if obstruction or pseudocyst develops • Divert bile flow or relieve ductal obstruction Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Chronic Pancreatitis Nursing Management • Focus is on chronic care and health promotion • Dietary control • No alcohol • Control of diabetes • Taking pancreatic enzymes • Patient and family teaching Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Case Study • 63 -year-old female enters the emergency department with nausea, vomiting, epigastric pain, left upper quadrant pain • She claims the pain is severe, sharp, and boring and radiates through to her midback Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Case Study (Cont’d) • Pain began 24 hours ago • She is divorced, retired, and smokes a half-pack of cigarettes a day Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Case Study (Cont’d) • Vital signs • Blood pressure 100/70 mm Hg • Heart rate 97 beats/min • Respiratory rate 30 breaths/min • Temperature 100. 2°F • She is diagnosed with acute pancreatitis and admitted to the medical-surgical unit Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Discussion Questions 1. What are the possible causes of pancreatitis? 2. What is her priority of care? Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.

Discussion Questions (Cont’d) 3. What labs are the most important to monitor in acute pancreatitis? 4. What patient teaching should you do with her? Copyright © 2010, 2007, 2004, 2000, Mosby, Inc. , an affiliate of Elsevier Inc. All Rights Reserved.