Problem: Abdominal Pain Nursing Diagnosis: acute pain r/t biologic agents (pancreatic inflammation and enzyme leakage)

Cause Analysis: Abdominal pain and tenderness and back pain results from irritation and edema of the inflamed pancreas, which stimulate the nerve endings, increased tension on the pancreatic capsule and obstruction of the pancreatic ducts also contribute to the pain.
Cues Subjective: P- supine position Q- dull and boring R- abdomen & lower back pain S- 7/10 T- continuous Objective: STO: After 3 hours of effective nursing intervention, patient will report decrease amount and frequency of pain. LTO: After 3 days of effective nursing intervention, client will report pain relief or controlled. Objectives Intervention Independent: Investigate verbal reports of pain, noting specific location and intensity. Maintain bed rest during acute attack, provide quiet, restful environment. Promote position of comfort (e.g. on one side with knees flexed, sitting up and leaning forward) Provide alternative comfort measures (e.g. back rub), encourage relaxation techniques (e.g. guided imagery, visualization), quite diversional activities (e.g. TV, radio) Keep environment free of food odors. Rationale STO: Pain is often diffuse, severe and unrelenting in acute or hemorrhagic pancreatitis. Decreases metabolic rate and GI stimulation/secretions, thereby reducing pancreatic activity. Reduces abdominal pressure/tension, providing some measure of comfort and pain relief. Note: Supine position often increases pain.\ After 3 hours of effective nursing care the client reported decrease in amount of frequency of pain as evidenced by no guarding behavior. LTO: After 3 days of effective nursing care the patient reported relieved pain as evidenced by absence of facial grimace. Evaluation

Swollen or tender abdomen Vomiting Guarding behavior Vital signs Pallor

Sensory stimulation can activate pancreatic enzymes, increasing pain.

Collaborative: Administer medication as needed: Narcotics, Analgesics e.g. Meperidine

Meperidine is usually effective in relieving pain and may be preferred over morphine, which may have side effect of biliary pancreatic spasms.

Reference: Nursing Care Plan by Doenges

Problem: Loss of Appetite Nursing Diagnosis: Nutrition: Altered, les than body requirements r/t anorexia secondary to acute pancreatitis Taxonomy: Nutritional / Metabolic Cause Analysis: Diminished senses of food and smell often result in the loss of appeal of food. Loss of appetite occurs because of the decreased metabolic rate and increased of catabolism. (Fundamentals of Nursing, 7th ed., by Kozier) Cues Subjective: The patient may verbalize loss of appetite. STO: Within 3 hours of giving effective nursing intervention, patient will be able to gain back his appetite slowly as evidenced by consumed 2 full tablespoon of rice every meal and gradual increase of body weight. Objectives Intervention Independent: Weigh daily Encourage bed rest or limited activity during acute phase of illness. Recommended rest before meals Provide oral hygiene. Serve foods in wellventilated, pleasant surroundings, with unhurried atmosphere, congenial company. Rationale STO: Provide information about dietary needs/effectiveness of therapy. Decreasing metabolic needs aids in preventing caloric depletion and conserves energy. Quiets peristalsis and increases available energy for eating. A clean mouth can enhance the taste of food. Pleasant environment aids in reducing stress and is more. After 3 hours of giving effective nursing intervention, patient will be able to gain back his appetite slowly as evidenced by consumed 2 full tablespoon of rice every meal and gradual increase of body weight. Evaluation

Objective: Weight loss Vomiting Decreased subcutaneous fat/muscle mass Poor muscle tone Pale conjunctiva and mucous membranes Aversion to eating

LTO: Within 3 days of implementing nursing intervention, the patient will be able to gain back his appetite as evidenced by consumed meal served and eating of biscuits between meals.

LTO: After 3 days of implementing nursing intervention, the patient will be able to gain back his appetite as evidenced by consumed meal served and eating of biscuits between meals.

Collaborative: Administer medications as indicated: Belladonna alkaloids Anticholinergics given 1530min before eating provide relief from

(Donnatal), Butabarbital Sodium with belladonna (Butibel) propantheline. Bromide (Pro-Banthyne)

cramping pain and diarrhea, decreasing gastric motility and enhancing time for absorption of nutrients.

Reference: Medical-Surgical by Smeltzer & Bare, Vol. 1, pp 1012: Nursing Care Plan, 6th ed., by Doenges, pp 322

Problem: Difficulty of Breathing Nursing Diagnosis: Ineffective breathing pattern r/t pleural effusion secondary to acute pancreatitis Cause Analysis: Left pleural effusion frequently develop in the client with acute pancreatitis. Amylase effusions probably occur when exudates containing pancreatic enzymes passes from the peritoneal cavity into the transdiaphragmatic lymph channels. (Med-Surg, 5th ed. by Ignatavicus p. 1404) Accumulation of such exudates may occur in the pleural cavity, fluid-filled space that surrounds the lungs. Excessive amounts of such fluids can impair breathing by limiting the expansion of the lungs during inhalation. (www.Wikepedia.com) Cues Subjective: The patient may report difficulty of breathing. STO: Within 8 hours of nursing intervention, the patient will be able to demonstrate cooperative behavior such as deep breathing exercise and maintaining a proper position. LTO: Objectives Intervention Independent: Assess respiratory rate and depth by ausculating og breath sounds at least every shift. Assess the muscle use in breathing Maintain the patient in semi-fowlers position. Change every 2 hours. Rationale STO: Respiratory rate and rhythm changes are early warning signs of impending respiratory difficulties. Using accessory muscle is an indication of difficulty breathing Decreases pressure in the diaphragm and allows greatear lung expansion. Changing position frequently assist aeration nad drainage of all lobes. Cyanosis of nail beds may represent vasoconstriction to the affected vessels. Taking deep breaths will clear the airways and reduce incidence of etelectasis. After 8 hours of nursing intervention, the patient will be able to demonstrate cooperative behavior such as deep breathing exercise and maintaining a proper position. LTO: After 3 days of nursing intervention, the patient will be able to maintain effective breathing pattern with respiratory rate and depth that is normal for client and free of dyspnea. Evaluation

Objective: Dyspnea Tachypnea Cyanosis Nasal Flaring

Within 3 days of nursing intervention, the patient will be able to maintain effective breathing pattern with respiratory rate and depth that is normal for client and free of dyspnea.

Observe for color of the skin, mucous membrane and nail beds, noting presence of peripheral cyanosis Instruct the patient in techniques of deep breathing every 2 hours.

Provide relaxation training as appropriate like biofeedback and imagery.

Prevents over exhaustion and reduces oxygen consumption. To promote comfort to the client.

Collaborative: Monitor ABGs, pulse oximetry, review chest Xray results. Decreasing partial pressure oxygen and increasing partial pressure carbon dioxide and changes in the x-rays developin complications requiring further evaluation/treatment. Increases available oxygen for optimal oxygenation.

Administer supplemental oxygen as needed.

Reference:

Med-Surg 5t ed., by Ignatavicius p. 1404 NCP 7th ed., by Doenges, Moorhouse, Murr NCP 3rd ed., by Gulanick p. 10-11 www.Wikepedia.com

Problem: Fluid deficit Nursing Diagnosis: Fluid deficit t/t fluid and electrolyte losses secondary to acute pancreatitis Gordons Health-Illness PAttern Cause Analysis: Pancreatic juice, in healthy individuals contains enzymes and large amount of sodium bicarbonate. The average individual produces approximately 1 liter of pancreatic fluid in 24 hours. During illness or injuy, the volume of pancreatic fluid usually decreases, and the composition may change. (Luckmann, Joan and Sonensen, Kanen Creason. Medical-Surgical Nursing 3rd ed., vol. 2 W.B. SAunder Company. 1987. p. 1385) The loss of a large volume primarily within areas that are inaccessible into the retroperioneas and pancreatic spaces and abdominal cavity. Cues Subjective: The patient may report episodes of vomiting. Objectives STO: Within 1 day of nursing intervention, the patient will maintain normal pulse and respiratory rate. LTO: Within 3 days of nursing intervention, the patient may gain weight from previous weight less and may stop persistent vomiting Nursing Interventions I Independent: Assess fluid and electrolyte status (skin turgor, mucous membranes, urine output, v/s, hemodynamics parameters) Rationale STO: The amount and type of fluid and electrolyte replacement and determined by the stakes of the blood pressure, the laboratory evaluation of serum electrolyte and blood urea nitrogen levels, the urinary volume and the assessment of the patients condition. Electrolyte lossess occur from nasogastric suctioning, severe diaphoresis, emesis, and as result of patient being in a fasting state. Extensive acute pancreatitis may cause After 1 day of nursing intervention, the patient will maintain normal pulse and respiratory rate. LTO: After 3 days of nursing intervention, the patient may gain weight from previous weight less and may stop persistent vomiting Evaluation

Objective: Tachycardia Hypotension Cool and clammy skin Fever Persistent vomiting Weight loss

Assess source of fluid and electrolyte loss (vomiting, diarrhea, nasogastric drainage, excessive diaphoresis) Combat shock if present A. Adminester corticosteroids as

prescribed if patient does not respond to conventional treatment. B. Evaluate the amount of urinary output. Attempt to maintain this at 50ml/hr

peripheral vascular collapse and shock. Blood and plasma may be lost into the abdominal cavity, and therefore, there is a decreased blood and plasma volume. The toxins from the bacteria of a necrotic pancreas may cause shock.

Collaborative: Administer blood products, fluids and electrolytes (sodium, potassium, chloride) as prescribed. Administer plasena, albumin, and blood products as prescribed. Keep a supply of IV calcium gluconate readily available. Asess abdomen for aseiko formation a. measure abdominal girth daily b. weigh patient Patient with hemorrhagic pancreatitis lose large amounts of blood and plasma which decreases effective circulating blood volume. Replacement with blood, plasma or albumin assists in ensuring effective circulating blood volume. Calcium may be prescribed to prevent or treat tetany. Durin acute paancreatitis, plasma may be ost into the abdominal cavity, which diminishes the blood volume.

c. palpate abdomen for fluid volume

Reference: Med-Surg 5t ed., by Ignatavicius p. 1404 NCP 7th ed., by Doenges, Moorhouse, Murr Problem: Necrosis of pancreatic tissue Nursing Diagnosis: Risk for infection r/t compromised immune system Cause Analysis: Immunosuppression places the client at extreme risk for infection. Acute pancreatitis involves various pathologic changes, ranging from edema and inflammation to necrosis and hemorrhage. Cues Subjective: STO: Within 8 hours of nursing intervention the patient will participate I activities to reduce risk of infection. Objective: Facial grimace Irritability Fever LTO: Within 3 days of nursing intervention the patient will achieve timely healing; be free of signs of infection. Be afebrile. Objectives Intervention Independent: Use strict aseptic technique when changing surgical dressing or working with IV lines, indwelling catheters/tubes, drains. Change soiled dressings promptly. Stress importance o good hand washing. Observe rate and characteristics of respirations, breath sounds. Note occurrence of cough and sputum production. Rationale STO: Limit sources of infection, which can lead to sepsis in a compromised client. After 8 hours of nursing intervention the patient will participate I activities to reduce risk of infection. Evaluation

Reduce risk of crosscontamination. Pulmonary complications of pancreatitis include atelectasis, pleural effusion, pneumonia, and ARDS. Fluid accumulation and limited mobility predispose to respiratory infection and atelectasis.

LTO: After 3 days of nursing intervention the patient will achieve timely healing; be free of signs of infection. Be afebrile.

Accumulation o aascites fluids may cause elevated diaphragm and shallow abdominal breathing. Encourage frequently position changes, deep breathing, and coughing. Assist with ambulation as soon as stable. Observe for signs of fever and respiratory distress in conjunction with jaundice; increased abdominal pain, rigidity/rebound tenderness, recurrent fever (higher 101 F), leukocystosis, hypotension, tachychardia, and chills. Enhances ventilation of all lung segments and promotes mobilization of secretions. Cholestatic jaundice and decresed

Collaborative: Obtain culture specimen; eg., blood, wound, urine, sputum, or pancreatitic aspirate. Administer antiinfective therapies as

indicated; eg., imipenem/cilastain (Primax), metronidazole (Flagyl), levofloxan (Levoquin), cephalosporins, cefoxitin sodium (Mefoxin), plus aminoglycosides; eg., gentamicin (Garamycin), tobrmycin (Nebcin). Prepare for surgical intervention as necessary.

Reference: Medical Surgical Nursing 2nd edition., by Lippincot