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Transcript
Pancreatitis
Overview
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Inflammation of the pancreas
Occurs in acute and chronic forms, with 10% to 15% mortality rate in the acute form
Irreversible tissue damage with the chronic form, which tends to progress to significant
pancreatic function loss
Possibly idiopathic, but sometimes associated with biliary tract disease, alcoholism,
trauma, and certain drugs
Pathophysiology
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The exact trigger or mechanism to initiate enzyme activation is unknown.
Common bile duct blockage from gallstones leads to reflux of juices back into the
pancreas after initial release.
Acute Pancreatitis
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Enzymes normally excreted into the duodenum by the pancreas are activated in the
pancreas or its ducts and start to autodigest pancreatic tissue. (See Necrotizing
pancreatitis.)
Consequent inflammation causes intense pain, third spacing of large fluid volumes,
pancreatic fat necrosis with consumption of serum calcium and, occasionally,
hemorrhage.
Chronic Pancreatitis
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Progressive inflammatory changes lead to permanent structural damage.
Exocrine and endocrine functions of the pancreas are disrupted.
Necrotizing pancreatitis
The illustration below shows the cell death and tissue damage in necrotizing pancreatitis.
Causes
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Idiopathic
Genetic mutations
Risk Factors
Acute Pancreatitis
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Alcohol abuse
Postendoscopic retrograde cholangiography
Abdominal trauma
Smoking
Obstruction of the ampulla
Hypertriglyceridemia
Hypercalcemia
Drugs, such as sulfonamides, diuretics, didanosine, and pentamidine
Infections such as mumps, hepatitis B, cytomegalovirus, Mycoplasma, and Aspergillus
Blunt or penetrating trauma
Abnormal organ structure
Chronic Pancreatitis
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Alcohol abuse
Genetic mutations
Ductal obstruction
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Systemic diseases, such as systemic lupus erythematosus and hypertriglyceridemia
Autoimmune response
Incidence
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Acute pancreatitis occurs in more than 200,000 people each year.
Chronic pancreatitis occurs in approximately 87,000 individuals each year.
Acute or chronic pancreatitis affects men slightly more commonly than women.
Acute pancreatitis can occur at any age; chronic pancreatitis commonly affects those
older than age 45.
Complications
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Diabetes mellitus
Massive hemorrhage
Shock and coma
Acute respiratory distress syndrome
Atelectasis and pleural effusion
Pneumonia
Paralytic ileus
GI bleeding or obstruction
Pancreatic abscess and cancer
Pseudocysts
Renal failure
Assessment
History
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Sudden, steady, intense epigastric pain centered close to the umbilicus and radiating to
the back, between the 10th thoracic and 6th lumbar vertebrae (acute); intermittent or
constant dull, severe pain in mid- to upper left abdomen, possibly radiating to the back
and lasting for several hours (chronic); improvement in pain when lying down (acute)
Pain aggravated by fatty foods, alcohol consumption (chronic), or walking or lying down
and relieved by sitting up or leaning forward (acute)
Nausea, vomiting
Weight loss (chronic)
Predisposing factor
History of alcohol or medication use
Bloating (acute)
Diarrhea (acute)
Physical Findings
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Hypotension
Tachycardia
Fever
Dyspnea, orthopnea
Pleural effusion
Generalized jaundice
Hypoactive bowel sounds
Cullen sign (bluish periumbilical discoloration)
Turner sign (bluish flank discoloration)
Steatorrhea (with chronic pancreatitis)
Abdominal tenderness, distention, rigidity, and guarding
Diagnostic Test Results
Laboratory
In Acute Pancreatitis
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Amylase (serum) level test and lipase test results are elevated.
White blood cell count is elevated; hematocrit may be elevated.
Bilirubin level test is elevated.
Transient hyperglycemia and glycosuria are present.
C-reactive protein test is elevated.
Amylase (urine) level test is increased.
Serum alanine aminotransferase level test, aspartate aminotransferase level test, and
alkaline phosphatase level test results are mildly elevated when alcoholic hepatitis or
choledocholithiasis is present.
In Chronic Pancreatitis
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Serum alkaline phosphatase level test and bilirubin level test results are elevated.
Amylase (serum) level test and lipase test results may be normal or decreased.
Serum glucose level is transiently elevated.
Lipid and trypsin levels in stools are elevated.
Complete blood count is normal.
Imaging
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Abdominal and chest radiography differentiate pancreatitis from other diseases that cause
similar symptoms; they also detect pleural effusions.
Computed tomography scanning (abdomen and pelvis) and ultrasonography (pancreas)
show increased pancreatic diameter, pancreatic calcification, pancreatic cysts, and
pseudocysts.
Diagnostic Procedures
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Endoscopic retrograde cholangiopancreatography (ERCP) shows pancreatic anatomy,
identifies ductal system abnormalities, and differentiates pancreatitis from other
disorders.
Treatment
General
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Emergency treatment of shock, as needed; vigorous I.V. replacement of fluid,
electrolytes, and proteins (acute)
Blood transfusions (for hemorrhage)
Nasogastric suctioning
Venous thromboembolism (VTE) prophylaxis
Diet
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Nothing by mouth (NPO)
Once crisis starts to resolve, oral feedings high in carbohydrate and low in fat and
protein, implemented gradually, for the acute form, or low in fat and high in protein and
calories for the chronic form
Total parenteral nutrition, if oral intake isn't tolerated
Alcohol and caffeine abstention
Activity
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As tolerated
Medications
Acute Pancreatitis
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Analgesics, such as meperidine hydrochloride (Demerol) I.V. or I.M (acute),
acetaminophen (Tylenol), and tramadol hydrochloride (Ultram); hydromorphone
hydrochloride (Dilaudid) or fentanyl citrate (Sublimaze) via patient-controlled analgesia
Antibiotics (acute), such as imipenem-cilastatin sodium (Primaxin) or meropenem
(Merrem IV)
Supplemental oxygen, as appropriate
Chronic Pancreatitis
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Analgesics, such as acetaminophen (Tylenol), acetaminophen oxycodone hydrochloride
(Percocet), acetaminophen hydrocodone bitartrate (Vicodin); morphine sulfate
continuous release or fentanyl transdermal system (Duragesic) for persistent pain
Pancreatic enzyme supplements
Octreotide acetate (Sandostatin) to reduce exocrine secretion
Medium-chain triglycerides for fat malabsorption
Fat-soluble vitamin supplementation
Insulin therapy to address glucose intolerance
Surgery
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Not indicated in acute pancreatitis unless complications occur
For chronic pancreatitis: Sphincterotomy, duct drainage, or pancreatectomy
Pancreaticojejunostomy
Endoscopic or percutaneous aspiration of pseudocysts (when symptomatic or larger than
7 cm)
Nursing Considerations
Nursing Diagnoses
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Acute pain
Anxiety
Chronic pain
Decreased cardiac output
Deficient fluid volume
Deficient knowledge: Disease process
Deficient knowledge: Treatment
Diarrhea
Disturbed body image
Hopelessness
Hyperthermia
Imbalanced nutrition: Less than body requirements
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Impaired comfort
Impaired gas exchange
Ineffective breathing pattern
Ineffective coping
Nausea
Risk for electrolyte imbalance
Risk for impaired skin integrity
Risk for injury
Risk for unstable blood glucose level
Risk-prone health behavior
Expected Outcomes
The patient will:
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verbalize feelings of increased comfort and decreased pain
express feelings of decreased anxiety and fear
maintain normal cardiac function and hemodynamic stability
relate an increased understanding of the disease process and treatment
maintain normal fluid volume and electrolyte balance
regain or maintain normal gastrointestinal motility
express positive feelings about self
participate in decisions about care
achieve adequate caloric and nutritional intake
maintain an effective breathing pattern and adequate gas exchange
maintain skin integrity
avoid complications and injury
maintain normal blood glucose levels
comply with a healthy life style.
Nursing Interventions
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Administer parenteral morphine or meperidine, as ordered; ensure patent I.V. access if
given I.V.
Give I.V. fluid therapy, as ordered.
Use nonpharmacologic measures to assist with pain relief, such as distraction, imagery,
and progressive muscle relaxation.
Administer pancreatic enzyme replacements with meals (chronic).
Obtain fingerstick blood glucose levels and administer insulin, as ordered (chronic).
Encourage the patient to express his feelings and concerns; provide emotional support.
Maintain NPO status until pain and tenderness resolve and GI motility returns.
Assist with insertion or insert a nasogastric (NG) tube for decompression; provide NG
tube care; maintain NG suction, as ordered; observe the characteristics of NG tube
drainage.
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Administer enteral or parenteral nutrition, as ordered. When oral intake is allowed,
provide small, frequent meals; advance the diet, as tolerated.
Obtain daily weights.
Insert an indwelling urinary catheter, if indicated, to evaluate urine output and renal
function.
Position the patient with the head of the bed elevated to ease the work of breathing;
encourage coughing and deep breathing and incentive spirometry; administer
supplemental oxygen, as indicated by oxygen saturation levels via pulse oximetry.
Reposition the patient every two hours, and provide skin care to prevent pressure ulcer
formation.
Apply antiembolism stockings or sequential compression stockings to prevent VTE.
Obtain specimens for laboratory testing to evaluate pancreatic enzyme levels, glucose
levels, and overall fluid and electrolyte status.
Prepare the patient with chronic pancreatitis and his family for possible surgery.
Monitoring
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Vital signs
NG tube function and drainage
Respiratory status
Acid-base balance
Serum glucose level
Amylase and lipase levels
Fluid and electrolyte balance
Daily weight
Pain level and effectiveness of interventions
Nutritional status and metabolic requirements
Renal function
Postoperative status, as appropriate
Associated Nursing Procedures
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Alignment and pressure-reducing device application
Antiembolism stocking application, knee-length
Antiembolism stocking application, thigh-length
Assessment techniques
Blood glucose monitoring
Blood pressure assessment
Cardiac monitoring
Health history interview and physical assessment
Incentive spirometry
Indwelling urinary catheter (Foley) care and management
Indwelling urinary catheter (Foley) insertion, female
Indwelling urinary catheter (Foley) insertion, male
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Indwelling urinary catheter (Foley) removal
Informed consent
IV bag preparation
IV bolus injection
IV catheter insertion
IV catheter removal
IV dressing change
IV pump use
IV secondary line drug infusion
IV solution change
IV tubing change
Intake and output assessment
Nasogastric tube insertion
Nasogastric tube irrigation
Nasogastric tube monitoring
Nasogastric tube removal
Oral care
Oxygen administration
Pain assessment
Pain management
Pressure ulcer prevention
Pulse assessment
Pulse oximetry
Relaxation and stress management techniques
Respiration assessment
Safe medication administration practices, general
Sequential compression therapy
Standard precautions
Stool specimen collection, random
Surgical wound dressing application
Temperature assessment
Urine specimen collection, random
Venipuncture
Weight measurement
Wound assessment
Patient Teaching
General
Be sure to cover:
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disorder, possible underlying causes, diagnostic tests, and treatment, including the need
for I.V. fluids, NPO status, and pain control, as appropriate
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identification and avoidance of acute pancreatitis triggers
dietary needs, including small, frequent meals that are high in carbohydrates and low in
fat and protein (acute pancreatitis) or small, low-protein, high-calorie meals (chronic
pancreatitis), and appropriate food choices
signs and symptoms of recurrence of pancreatitis and the need to notify the practitioner
immediately
prescribed medication therapy, such as pancreatic enzyme supplements as treatment for
chronic pancreatitis; the need to take pancreatic enzymes before or with meals and snacks
technique for insulin administration, if appropriate, for the patient with chronic
pancreatitis
importance of abstaining from alcohol ingestion
need for smoking cessation
need for continued follow-up, including laboratory testing to evaluate the effectiveness of
therapy.
Discharge Planning
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Refer the patient to appropriate community resource and support services, as needed.
Refer the patient to an alcohol rehabilitation program or smoking cessation program, as
appropriate.
INSERT_HANDOUTS
Resources
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Alcoholics Anonymous: www.aa.org
American Pancreatic Association: www.american-pancreatic-association.org
Digestive Disease National Coalition: www.ddnc.org
National Digestive Diseases Information Clearinghouse: http://digestive.niddk.nih.gov
National Pancreas Foundation:http://pancreasfoundation.org
American Gastroenterological Association: http://www.gastro.org/patientcenter/digestive-conditions/pancreatitis
Selected References
1. Ahmed Ali, U., et al. (2015). Endoscopic or surgical intervention for painful obstructive
chronic pancreatitis. Cochrane Database of Systematic Reviews, 2015(3), CD007884.
(Level I)
2. Dorlon, M., et al. (2013). Increase in postoperative insulin requirements does not lead to
decreased quality of life after total pancreatectomy with islet cell autotransplantation for
chronic pancreatitis. The American Surgeon, 79(7), 676–680.
Abstract | Complete Reference
3. Freedman, S. D. Clinical manifestations and diagnosis of chronic pancreatitis in adults.
(2014). In: UpToDate, Whitcomb, D. C. (Ed.). Retrieved from: www.uptodate.com
4. Freedman, S. D. Complications of chronic pancreatitis. (2013). In: UpToDate,
Whitcomb, D. C. (Ed.). Retrieved from: www.uptodate.com
5. Freedman, S. D., & Lewis, M. D. Etiology and pathogenesis of chronic pancreatitis in
adults. (2013). In: UpToDate, Whitcomb, D. C. (Ed.). Retrieved from:
www.uptodate.com
6. Freedman, S. D. Treatment of chronic pancreatitis. (2013). In: UpToDate, Whitcomb, D.
C. (Ed.). Retrieved from: www.uptodate.com
7. Gardner, T. B. (2015). “Acute pancreatitis” [Online]. Accessed April 12, 2015 via the
Web at http://emedicine.medscape.com/article/181364-overview
8. Gelrud, A., & Whitcomb, D. C. Hypertriglyceridemia-induced acute pancreatitis. (2015).
In: UpToDate, Friedman, L. S. (Ed.). Retrieved from: www.uptodate.com
9. Herdman, T. H., & Kamitsuru, S. (Eds.). (2014). NANDA International Nursing
Diagnoses: Definitions & Classification 2015–2017. Oxford: Wiley Blackwell.
10. Huffman, J. L. (2015). “Chronic pancreatitis” [Online]. Accessed April 12, 2015 via the
Web at http://emedicine.medscape.com/article/181554-overview
11. Khoury, G. (2013). “Emergent management of pancreatitis” [Online]. Accessed April 20,
2014 via the Web at http://emedicine.medscape.com/article/775867-overview
12. Lim, C. L., et al. (2015). Role of antibiotic prophylaxis in necrotizing pancreatitis: A
meta-analysis. Journal of Gastrointestinal Surgery, 19(3), 480–491. (Level I)
Abstract | Complete Reference
13. Nettina, S. (2014). Lippincott manual of nursing practice (10th ed.). Philadelphia, PA:
Wolters Kluwer.
14. Njgaard, C., et al. (2013). Update of exocrine functional diagnostics in chronic
pancreatitis. Clinical Physiology and Functional Imaging, 33(3), 167–172.
Abstract | Complete Reference
15. Ona, X. B., et al. (2013). Opioids for acute pancreatitis pain. Cochrane Database of
Systematic Reviews, 2013(7), CD009179. (Level I)
16. Phillip, V., et al. (2013). Time period from onset of pain to hospital admission and
patients' awareness in acute pancreatitis. Pancreas, 42(4), 647–654.
Abstract | Complete Reference
17. Swaroop Vege, S. Clinical manifestations and diagnosis of acute pancreatitis. (2014). In:
UpToDate, Whitcomb, D. C. (Ed.). Retrieved from: www.uptodate.com
18. Swaroop Vege, S. Etiology of acute pancreatitis. (2013). In: UpToDate, Whitcomb, D. C.
(Ed.). Retrieved from: www.uptodate.com
19. Swaroop Vege, S. Management of acute pancreatitis. (2014). In: UpToDate, Whitcomb,
D. C. (Ed.). Retrieved from: www.uptodate.com
20. Swaroop Vege, S. Predicting the severity of acute pancreatitis. (2013). In: UpToDate,
Whitcomb, D. C. (Ed.). Retrieved from: www.uptodate.com