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Mr. Schmidt’s Case
by
Gerry Altmiller, EdD, MSN, APRN
©Altmiller
Mr. Schmidt went to the ED C/O severe LUQ pain
radiating to his back and shoulder that started
suddenly four hours ago. He claims the pain
was aggravated by eating and was not relieved
when he vomited. He C/O nausea. He arrives
on the step down unit via stretcher lying in the
fetal position.
Physical assessment findings:
T 100.6, P 98, R 26, BP 102/64
Abdominal guarding
Bluish discoloration of the flanks
Ecchymosis of the umbilical area
Hypoactive Bowel sounds
Dyspnea, crackles in lungs, cyanosis
Jaundice
What else do you want to know?
©Altmiller
Mr. Schmidt’s immediate
orders:
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NPO
Bedrest
Morphine 5mg IV q 3 hours PRN
abdominal pain
IVF LR 125 cc/hr
NGT to LIS
©Altmiller
The laboratory personnel calls with results
from serum drawn in the ED and asks to
speak with Mr. Schmidt’s nurse. She explains
that she has a critical value report. What is
the procedure to be followed for a critical lab
value? Which of the following does the nurse
identify as abnormal?
Na 148
Chloride 99
Glucose 263
Potassium 5.3
Carbon Dioxide 25
BUN 20
Creatinine 0.9
Calcium 7.5
Magnesium 1.8
Phosphorus 3.8
©Altmiller
Critical Lab Values
Na 148
Chloride 99
Glucose 263
Potassium 5.3
Carbon Dioxide 25
BUN 20
Creatinine 0.9
Calcium 7.5
Magnesium 1.8
Phosphorus 3.8
©Altmiller
Diagnostic lab Findings
Serum Amylase 244
Serum Lipase 196
Urinary Amylase (24 hr) 4060
Random blood glucose 263
Serum Ca 7.5 (critical value)
Triglycerides 430
What other diagnostic tests could be done?
What diagnosis are you forming for
Mr. Schmidt?
©Altmiller
Acute Pancreatitis
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Acute inflammatory process ranging
from mild edema to severe hemorrhage
Prevalence
 Middle aged
 Effects men > women
Potentially life-threatening
Sequelae
may develop chronic
pancreatitis
©Altmiller
Etiology of Acute Pancreatitis
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Alcoholism
Gall bladder disease (biliary tract disease)
Trauma (post-abdominal surgery)
Post GI procedures (Endoscopic Retrograde
Cholangiopancreatography: ERCP)
Viral infections (mumps, coxsackievirus)
Penetrating duodenal ulcers, cysts, abscesses
Idiopathic
Medications (steriods, NSAIDS, thiazides, etc)
©Altmiller
The Pancreas
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Located behind the
stomach
Large, compound
gland consisting of
the head, body and
tail
Has endocrine and
exocrine functions
©Altmiller
Exocrine Function of the
Pancreas
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Pancreatic juice contains enzymes for
digesting fats, proteins, &
carbohydrates
Trypsin is the most abundant enzyme
Stored in its inactive form,
trypsinogen; activated by
enterokinase when released into the
small intestine via the pancreatic duct
©Altmiller
Endocrine Function of the
Pancreas
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Occurs in the islets of Langerhans
Beta cells secrete insulin
Alpha cells secrete glucagon
Delta cells secrete somatostatin
©Altmiller
Acute Pancreatitis
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Auto-digestion of the gland
The etiologic factors cause injury to the
pancreatic cells or activation of the
enzymes while still in the pancreas
Premature activation of trypsin which
begins to digest the pancreas
Elastase activated by trypsin and causes
hemorrhage by dissolving elastic fibers of
the blood vessels
©Altmiller
Acute Pancreatitis
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Phospholipase A also activated by trypsin,
and bile salts, causes fat necrosis within
the pancreas
Unknown whether alcohol causes increased
HCL acid production, which causes
pancreatic enzyme stimulation or if
regurgitation of duodenal contents into
the pancreatic duct causes the
inflammation
©Altmiller
What are the priority nursing
diagnosis?
©Altmiller
Nursing Diagnosis for
Pancreatitis
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Acute pain
Deficient fluid volume
Imbalanced nutrition: less than
body requirements
Ineffective therapeutic regimen
management
©Altmiller
Mrs. Schmidt comes to the nurse’s
station to tell the nurse that Mr.
Schmidt is complaining of severe
abdominal pain. The nurse goes to Mr.
Schmidt’s room to assess and
determines he requires pain medication.
The nurse goes to the medication
cabinet and selects Hydromorphone 10
mg dose, places it in a carpuject and
wastes 5 mg in the presence of another
nurse. As she is walking to Mr.
Schmidt’s room, she stops and takes a
time out. What does she discover?
©Altmiller
What is the nursing
responsibility for this near
miss?
What is the red rule regarding
medication administration?
©Altmiller
What is the nursing responsibility for this near
miss?
Discard hydromorphone with a witness
Complete incident/occurrence report
Report near miss to immediate supervisor
Medicate Mr. Schmidt with correct medication
and dose
What is the red rule regarding narcotic
administration?
Never administer medications without
reviewing MAR first; 3 checks of
medication
©Altmiller
Incident/Occurrence Reports
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Used to document any unusual occurrence
that results in or has potential to result in
harm to a patient, employee, or visitor
Should not be referred to in nursing notes
Used for quality improvement to identify risks
Records facts about an incident in case of
litigation
May be used in court as evidence
©Altmiller
What complications are you
concerned could occur for
Mr. Schmidt?
©Altmiller
Complications:
Pancreatic Pseudocyst or Abscess
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Cavity continuous with, surrounding or within the
pancreas fills with necrotic products and liquid
secretions
Leakage of enzymes inflame adjacent tissues
Sx: abdominal pain, N&V, palpable epigastric mass,
anorexia, persistently amylase levels,
Leukocytosis, Fever
May be visible on abdominal CT scan
May resolve or rupture causing peritonitis
Rx: prompt surgical drainage to prevent sepsis
©Altmiller
Systemic Complications:
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Pulmonary: pleural effusion, atelectasis,
pneumonia which are all caused by enzyme
induced inflammation from the passage through
transdiaphragmatic lymph channels. Pt can
develop ARDS
CV: Hypotension & shock due to hemorrhages
into pancreas or activated enzymes forming
kinins which cause vasodilation, capillary
permeability,&
vascular tone
Neuro: Tetany due to hypocalcemia
©Altmiller
At this time, what patient
outcomes/goals do you want
for Mr. Schmidt?
©Altmiller
Goals
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Relief of pain
Prevention or alleviation of shock
Reduction of pancreatic secretions
Normal fluid & electrolyte balance
Removal of the precipitating causes
Prevention of complications
Prevention of recurrent attacks
©Altmiller
How will you stablize Mr.
Schmidt?
©Altmiller
Collaborative Care
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Aggressive hydration with LR or volume
expanders (dextran, albumin)
CVP readings to guide fluid replacement
Dopamine to
systemic vascular resistance
(SVR) for ongoing hypotension
Pain Management: may use MSO4 with an antispasmotic
Management of metabolic complications
©Altmiller
What collaborative interventions
can be done to resolve Mr.
Schmidt’s pancreatitis?
©Altmiller
Collaborative Care
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Minimize pancreatic stimulation
 NPO
 NGT to suction
 H2 blocking agents or Proton pump
inhibitors
 Antacids
Prevent infections as necrotic pancreatic
tissue is a good medium for growth
May require peritoneal lavage or dialysis
©Altmiller
Nursing Care
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Monitor vital signs
IV fluids to correct volume deficit and
combat hypotension
Assess respiratory function (potential ARDS)
Cough & deep breathe, IS
Frequent mouth care
NGT to LWS- check patency and placement
©Altmiller
Nursing Care
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Assess for fever as prone to infection
Monitor for signs of hypocalcemia
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Assess for Chvostek or Trousseau signs
Monitor lab values
Monitor blood glucose
Control pain & restlessness
Position for comfort; flexed, semi-fowlers
©Altmiller
Collaborative Care:
Nutritional Therapy
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NPO status initially to reduce pancreatic secretion
As pancreatitis resolves, small, frequent feedings
High-carb, low-fat, high-protein diet
Bland diet
No alcohol or caffeine (stimulants)
Supplemental fat-soluble vitamins
Supplemental commercial liquid preparations
TPN
©Altmiller
For what reasons might Mr.
Schmidt require surgical
intervention?
©Altmiller
Collaborative Care:
Surgical Therapy Indications
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Presence of gallstones
 ERCP, laproscopic cholecystectomy
to decrease potential for recurrence
Uncertain diagnosis
Unresponsive to conservative therapy
Abscess, pseudocyst or severe
peritonitis
©Altmiller
Later that evening, the
nurse is called to the phone
for an inquiry about Mr.
Schmidt. The caller
identifies herself as Mr.
Schmidt’s sister. She wants
to know his condition. What
should the nurse tell the
caller?
©Altmiller
Confidentiality
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Protecting & maintain privacy of all patient
information whether spoken, written or saved
in computer
Includes confirmation that a patient is
admitted to institution
Health Insurance Portability and
Accountability Act (HIPAA)
 Disclosure requires signed authorization
from patient
©Altmiller
What teaching does Mr.
Schmidt require prior to
discharge?
©Altmiller
Home Care & Health
Promotion
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Assessment for predisposing factors
Treatment of cholelithiasis
Physical therapy for loss of muscle reserve &
strength during extended hospitalization
Counseling regarding abstinence from alcohol,
caffeine, and smoking
Dietary teaching: high carb, low-fat diet
Teach signs of infection
Teach about medications
Indications that pancreatitis is becoming a chronic
condition
©Altmiller
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How will Mr. Schmidt know if his
condition is becoming chronic
pancreatitis?
©Altmiller
Clinical Manifestations of
Chronic Pancreatitis
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Heavy, gnawing feeling,
burning and cramp-like
in LUQ or mid-epigastic
area
Malabsorption & weight
loss
Constipation
Steatorrhea
Mild jaundice with dark
urine
Diabetes mellitius
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Increased serum amylase
Increased serum bilirubin
Increased alkaline
phosphatase
Mild leukocytosis
Elevated sedimentation rate
Hyperglycemia
Arteriography or X-ray shows
fibrosis and calcification
ERCP indicates biliary disease
(chronic obstructive or chronic
calcifying pancreatitis)
©Altmiller
How is Chronic pancreatitis
managed?
©Altmiller
Collaborative Care for Chronic Pancreatitis
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Prevention of attacks
Relief of pain with analgesics
Control of pancreatic exocrine and endocrine
insufficiency
Bland, low-fat, high-carb, high-protein diet
Pancreatic enzyme replacement
 Pancreatin or pancrelipase
Bile salts to absorption of fat soluble vits (A, D, E, K)
Control of Diabetes if it develops
Total elimination of alcohol
Acid-neutralizing and acid-inhibiting drugs
Surgery indicated when biliary disease is present or if
obstruction or pseudocyst develops
©Altmiller