Nursing Process Acute Pancreatitis Nursing Process Acute Pancreatitis

Nursing Process Acute Pancreatitis

Nursing Process Acute Pancreatitis

Assessment • History focussed on abdominal pain and discomfort, alcohol consumption • Gallstone colic • Anyother gastrointestinal problems • Respiratory status • Emotional and psychological status of the patient and his relativesl

Nursing diagnoses • Include pain related to inflammation, oedema, distentionof the pancreas, and peritoneal irritation • Ineffective breathing pattern related to severe pain pulmonary infiltrates, pleural effusion, and atelectasis • Altered nutrtional status • Impaired skin integrity related to poor nutritional status, bed rest, and multiple drains and surgical wound

Collaberative problems / potential complications • Fluid and electrolyte disturbances • Necrosis of the pancreas • Shock and multiple organ dysfuntion • Planning and goals: • Relief of pain and discomfort • Improved respiratory function, improved nutritional statusmaintenance of skin integrity • Absence of complications

• Nursing interventions • • • Relieving pain and discomfort – Meperidine Oral feeding withheld Parenteral fluids Electrolytes Fluid balance Nasogastric suction Relieve abdominal distention Oral hygiene Relieve dryness of the mouth Bed rest If there is no pain relief suspect haemorrhage in the pancreas

• Improving breath pattern • Semi-Fowler’s position • Frequent changes of postion to prevent atelectasis and pooling of respiratory secretions • Pulmonary assessment and monitoring of pulse oximetry or arterial blood gases • Patient is instructed in techniques of coughing and deep breathing to improve respiratory function and ecouraged and assisted to cough and deep breathe every 2 hours

Improving nutritional status • TPN • After acute syptoms subside, oral feedings are reintroduced gradually • Between acute attacks, the patient receives a diet high in carbohydrates and low in fat and proteins. Heavy meals are avoided, as are alcoholic beverages

Improving skin integrity • Skin breakdown likely • Pressure sores – guarded against • Drainage sites – protected • Use of special beds

Monitoring and managing potential complications • Abdominal girth assessed, skin turgor monitored • Be ready to combat circulatory collapse • Low levels of serum calcium and magnesium levels may occur and require prompt treatment. • Watch for early signs of neurologic dysfunction • cardiovascular, renal, and respiratory dysfunction • Keep the patient’s family informed and they must be allowed to spend some time with the patient.

Promoting home and community-based care • Repeat and reinforce the instructions given to the patient while he was acutely ill. • Instruct the family to recognize any complication or adverse situation and report promptly to the physician.

Continuing care • Referral for home care is often indicated • This enables the nurse to assess the patient’s physical and psychological status and compliance with therapeutic regimen. • Assess the home situation • Reinforce instructions about fluid and nutrition intake and avoidance of alcohol • Refer to alcoholics anonymous if needed