Focus on Pancreatitis Relates to Chapter 44 Nursing
- Slides: 80
Focus on Pancreatitis (Relates to Chapter 44, “Nursing Management: Liver, Pancreas, and Biliary Tract Problems” in the textbook) Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc.
Acute Pancreatitis • An acute inflammatory process of the pancreas • Degree of inflammation varies from mild edema to severe necrosis. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 2
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. • African American rate 3 times higher than that of whites Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 3
Acute Pancreatitis Etiology and Pathophysiology • Primary etiologic factors are • Biliary tract disease • Most common in women • Alcoholism • Most common in men • Hypertriglyceridemia Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 4
Acute Pancreatitis Etiology and Pathophysiology • Less common causes • Trauma (postsurgical, abdominal) • Viral infection • Penetrating duodenal ulcer • Cysts • Idiopathic causes Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 5
Acute Pancreatitis Etiology and Pathophysiology • Less common causes (cont’d) • Abscesses • Cystic fibrosis • Kaposi sarcoma • Metabolic disorders • Vascular diseases • Postop GI surgery Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 6
Acute Pancreatitis Etiology and Pathophysiology • Less common causes (cont’d) • Drugs • Corticosteroids • Thiazide diuretics • Oral contraceptives • Sulfonamides • NSAIDs Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 7
Acute Pancreatitis Etiology and Pathophysiology • Caused by autodigestion of pancreas • Etiologic factors • Injury to pancreatic cells • Activation of pancreatic enzymes Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 8
Acute Pancreatitis Fig. 44 -13. Pathogenic process of acute pancreatitis. GI, Gastrointestinal. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 9
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 © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 10
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 © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 11
Acute Pancreatitis Etiology and Pathophysiology • Phospholipase A • Plays a major role in autodigestion • Activated by trypsin and bile acids • Causes fat necrosis Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 12
Acute Pancreatitis Etiology and Pathophysiology Trypsin Edema, necrosis, hemorrhage Elastase Hemorrhage Phospholipase A Fat necrosis Kallikrein Edema, vascular permeability, smooth muscle contraction, shock Lipase Fat necrosis Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 13
Acute Pancreatitis Etiology and Pathophysiology • Alcohol • May stimulate production of digestive enzymes • Increases sensitivity to hormone cholecystokinin • Stimulates production of pancreatic enzymes Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 14
Acute Pancreatitis Etiology and Pathophysiology • Edematous pancreatitis • Mild and self-limiting • Necrotizing pancreatitis • Degree of necrosis correlates with severity of manifestations. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 15
Acute Pancreatitis Fig. 44 -14. In acute pancreatitis, the pancreas appears edematous and is commonly hemorrhagic (H). Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 16
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 © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 17
Acute Pancreatitis Clinical Manifestations • Abdominal pain (cont’d) • Sudden onset • Severe, deep, piercing, steady • Aggravated by eating • Onset when recumbent • Not relieved by vomiting Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 18
Acute Pancreatitis Clinical Manifestations • Flushing • Cyanosis • Dyspnea • Edema • Nausea/vomiting • Bowel sounds decreased or absent Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 19
Acute Pancreatitis Clinical Manifestations • Low-grade fever • Leukocytosis • Hypotension • Tachycardia • Jaundice • Abdominal tenderness Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 20
Acute Pancreatitis Clinical Manifestations • Abnormal lung sounds • Crackles • Discoloration of abdominal wall Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 21
Acute Pancreatitis Complications • Two significant local complications • Pseudocyst • Abscess Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 22
Acute Pancreatitis Complications • Pseudocyst • Cavity surrounding outside of pancreas filled with necrotic products and liquid secretions • Abdominal pain • Palpable epigastric mass Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 23
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 © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 24
Acute Pancreatitis Complications • Pancreatic abscess • A large fluid-containing cavity within the pancreas • Results from extensive necrosis in the pancreas • Upper abdominal pain • Abdominal mass Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 25
Acute Pancreatitis Complications • Pancreatic abscess (cont’d) • High fever • Leukocytosis • Requires surgical drainage Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 26
Acute Pancreatitis Complications • Main systemic complications • Pulmonary • Pleural effusion • Atelectasis • Pneumonia Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 27
Acute Pancreatitis Complications • Systemic complications (cont’d) • Cardiovascular • Hypotension • Tetany (caused by hypocalcemia) Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 28
Acute Pancreatitis Diagnostic Studies • Laboratory tests • Serum amylase • Serum lipase Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 29
Acute Pancreatitis Diagnostic Studies • Laboratory tests (cont’d) • Liver enzymes • Blood glucose • Triglycerides • Bilirubin • Serum calcium Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 30
Acute Pancreatitis Diagnostic Studies • Abdominal/endoscopic ultrasound • X-ray • Contrast-enhanced CT scan • Endoscopic retrograde cholangiopancreatography (ERCP) Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 31
Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 32
Acute Pancreatitis Diagnostic Studies • Endoscopic ultrasound • Magnetic resonance cholangiopancreatography (MRCP) • Chest x-ray Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 33
Acute Pancreatitis Collaborative Care • Objectives include • Relief of pain • Prevention or alleviation of shock • ↓ of pancreatic secretions • Fluid/electrolyte balance • Prevention/treatment of infection • Removal of the precipitating cause Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 34
Acute Pancreatitis Collaborative Care • Conservative therapy • Supportive care • Aggressive hydration • Pain management • IV morphine • Combined with antispasmodic agent • Management of metabolic complications • Minimizing stimulation Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 35
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) Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 36
Acute Pancreatitis Collaborative Care • Conservative therapy (cont’d) • Suppression of pancreatic enzymes • NPO • NG suction • Prevent infections Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 37
Acute Pancreatitis Collaborative Care • Surgical therapy indicated if • Presence of gallstones • Uncertain diagnosis • Unresponsive to conservative therapy • Abscess, pseudocyst, or severe peritonitis Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 38
Acute Pancreatitis Collaborative Care • Surgical therapy • ERCP • Endoscopic sphincterotomy • Laparoscopic cholecystectomy Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 39
Acute Pancreatitis Collaborative Care • Drug therapy • IV morphine • Nitroglycerin or papaverine • Antispasmodics • Carbonic anhydrase inhibitors • Antacids • Histamine (H 2) receptor blockers Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 40
Acute Pancreatitis Collaborative Care • Nutritional therapy • NPO status initially to reduce pancreatic secretion • IV lipids • Monitor triglycerides. • Small, frequent feedings • High-carbohydrate, low-fat, high-protein diet Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 41
Acute Pancreatitis Collaborative Care • Nutritional therapy (cont’d) • Supplemental fat-soluble vitamins • No alcohol Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 42
Acute Pancreatitis Nursing Assessment • Health history • Biliary tract disease • Alcohol use • Abdominal trauma • Duodenal ulcers • Infection • Metabolic disorders Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 43
Acute Pancreatitis Nursing Assessment • Medication usage • Thiazides, estrogens, corticosteroids, NSAIDs • Surgical procedures • Nausea/vomiting • Dyspnea • Severe pain Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 44
Acute Pancreatitis Nursing Assessment • Physical examination findings • Fever • Jaundice • Discoloration of abdomen/flank • Tachycardia • Hypotension • Abdominal distention/tenderness Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 45
Acute Pancreatitis Nursing Assessment • Abnormal laboratory findings • ↑ serum amylase/lipase • Leukocytosis • Hyperglycemia • Hyperlipidemia • Hypocalcemia • Abnormal ultrasound/CT/ERCP Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 46
Acute Pancreatitis Nursing Diagnoses • Acute pain • Deficient fluid volume • Imbalanced nutrition: Less than body requirements • Ineffective self-health management Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 47
Acute Pancreatitis Planning • Overall goals • Relief of pain • Normal fluid and electrolyte balance • Minimal to no complications • No recurrent attacks Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 48
Acute Pancreatitis Nursing Implementation • Health promotion • Assessment of predisposing factors • Early diagnosis/treatment of cholelithiasis • Elimination of alcohol intake Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 49
Acute Pancreatitis Nursing Implementation • Acute intervention • • • Monitoring vital signs IV fluids Observation of side effects of medications Assessment of respiratory function Pain assessment and management • Frequent position changes • Side-lying with HOB elevated 45 degrees • Knees up to abdomen Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 50
Acute Pancreatitis Nursing Implementation • Acute intervention (cont’d) • Fluid/electrolyte balance • Blood glucose monitoring • Monitoring for signs of hypocalcemia • Tetany (jerking, irritability, twitching) • Numbness around lips/fingers • Positive Chvostek’s or Trousseau’s sign • Monitoring for hypomagnesemia Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 51
Acute Pancreatitis Nursing Implementation • Acute intervention (cont’d) • NG tube care • Frequent oral/nasal care • Observation for signs of infection • Wound care • Observation for paralytic ileus, renal failure, mental changes Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 52
Acute Pancreatitis Nursing Implementation • Ambulatory and home care • Physical therapy • Counseling regarding abstinence from alcohol, caffeine, and smoking • Assessment of narcotic addiction Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 53
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 © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 54
Acute Pancreatitis Nursing Implementation • Expected outcomes • Have adequate pain control • Maintain adequate fluid volume • Be knowledgeable about treatment regimen • Get help for alcohol dependence, if appropriate Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 55
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 © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 56
Chronic Pancreatitis Etiology and Pathophysiology • May follow acute pancreatitis • May occur in the absence of any history of an acute condition • Two major types • Chronic obstructive pancreatitis • Chronic nonobstructive pancreatitis Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 57
Chronic Pancreatitis Etiology and Pathophysiology • Chronic obstructive pancreatitis • Associated with biliary disease • Most common cause of this type • Inflammation of the sphincter of Oddi associated with cholelithiasis • Other causes include • Cancer of ampulla of Vater, duodenum, or pancreas Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 58
Chronic Pancreatitis Etiology and Pathophysiology • Chronic nonobstructive pancreatitis • Inflammation • Sclerosis • Mainly in the head of the pancreas and around the pancreatic duct • Most common form of chronic pancreatitis Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 59
Chronic Pancreatitis Clinical Manifestations • Abdominal pain • Located in the same areas as in acute pancreatitis • Heavy, gnawing feeling; burning and cramplike • Abdominal tenderness • Malabsorption with weight loss Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 60
Chronic Pancreatitis Clinical Manifestations • Constipation • Mild jaundice with dark urine • Steatorrhea • Frothy urine/stool • Diabetes mellitus Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 61
Chronic Pancreatitis Clinical Manifestations • Complications include • Pseudocyst formation • Bile duct or duodenal obstruction • Pancreatic ascites • Pleural effusion Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 62
Chronic Pancreatitis Clinical Manifestations • Complications (cont’d) • Splenic vein thrombosis • Pseudoaneurysm • Pancreatic cancer Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 63
Chronic Pancreatitis Diagnostic Studies • Confirming diagnosis can be challenging. • Based on signs/symptoms, laboratory studies, and imaging Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 64
Chronic Pancreatitis Diagnostic Studies • Laboratory tests • Serum amylase/lipase • May be ↑ slightly or not at all • ↑ serum bilirubin • ↑ alkaline phosphatase Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 65
Chronic Pancreatitis Diagnostic Studies • Laboratory tests (cont’d) • Mild leukocytosis • Elevated sedimentation rate • ERCP • Visualization of pancreatic/common bile duct • Stool samples Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 66
Chronic Pancreatitis Diagnostic Studies • CT • MRI • MRCP • Transabdominal ultrasound • EUS Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 67
Chronic Pancreatitis Diagnostic Studies • Secretin stimulation test • Assessment of degree of pancreatic function • Not useful in diagnosis Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 68
Chronic Pancreatitis Collaborative Care • Prevention of attacks • During acute attack, follow acute therapy. • Relief of pain • Control of pancreatic exocrine and endocrine insufficiency Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 69
Chronic Pancreatitis Collaborative Care • Bland low-fat, high-carbohydrate diet • Bile salts • Help absorption of fat-soluble vitamins • Prevent further fat loss • Control of diabetes • No alcohol Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 70
Chronic Pancreatitis Collaborative Care • Pancreatic enzyme replacement • Acid-neutralizing and acid-inhibiting drugs Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 71
Chronic Pancreatitis Collaborative Care • Surgery • Indicated when biliary disease is present, or if obstruction or pseudocyst develops • Diverts bile flow or relieves ductal obstruction Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 72
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 © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 73
Audience Response Question The nurse explains to a patient with an episode of acute pancreatitis that the most effective means of relieving pain by suppressing pancreatic secretions is the use of: 1. Antibiotics. 2. NPO status. 3. Antispasmodics. 4. H 2 R blockers or proton pump inhibitors. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 74
Case Study Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 75
Case Study • 63 -year-old woman 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 © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 76
Case Study • Pain began 24 hours ago. • She is divorced and retired, and smokes a half-pack of cigarettes a day. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 77
Case Study • Vital signs • Blood pressure 100/70 • Heart rate 97 • Respiratory rate 30 • Temperature 100. 2°F • She is diagnosed with acute pancreatitis and is admitted to the medical-surgical unit. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 78
Discussion Questions 1. What are the possible causes of pancreatitis? 2. What is her priority of care? Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 79
Discussion Questions 3. What laboratory tests are the most important to monitor in acute pancreatitis? 4. What patient teaching should you do with her? Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 80
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