Acute Pancreatitis

G2
Patient Presentation:
Mrs. T is an 88 year old woman presented with complaints of nausea, vomiting, and abdominal
pain. Her vital signs on admission are temperature 99.6F (37.6C), blood pressure 113/82, Pulse
84, and respiratory rate 20. Her laboratory tests reveal white blood cell count (WBC)
13,000/mm3, potassium (K+) 3.2 mEq/L, lipase 449 units/L, amylase 306 units/L, total bilirubin
3.4mg/dL, direct 2.2 mg/dL, aspartate aminotransferase (AST) 142 U/L, and alanine
aminotransferase (ALT) 390 U/L. Physical examination reveals a distended abdomen that is very
tender on palpation. Bowel sounds are present in all quadrants, but hypoactive.
Patient Presentation (cont.):
Mrs. T is admitted with a diagnosis of acute pancreatitis She will be kept nothing by
mouth (NPO). Intravenous (IV) fluid of D51/2 NS with 40 mEq of potassium chloride
(KCL) per liter at 100 mL per hour is prescribed. The health care provider prescribes
continued administration of her preadmission medications, that is pantoprazole sodium
and levothyroxine sodium (in IV form because the client is NPO) and spironolactone
(available in oral form), and adds the prescription of IV metoclopramide and morphine
sulphate. A nasogastric (NG) tube is inserted and attached to low wall suction. Case
study Mrs. Miller’s NG tube is draining yellow-brown drainage. Her pain is being
managed effectively with IV morphine 4 mg every four hours. Mrs. T is anxious and
has many questions for the nurse: “What is the test I am having done today? What is
pancreatitis? Will I need to have surgery? Why did they put this tube in my nose?
When will I be able to eat real food?”
I. Objectives
At the end of this case presentation, the students will be able to:

1. Define Acute Pancreatitis

2. Explain the disease process including:

a.) the risk factors;

b.) etiology of the disease;

c.) its anatomy and Pathophysiology;

d.) clinical Manifestation;

e.) and the theoretical framework that best applies.

3. Identify nursing functions relating to:

a.) Preoperative Care

b.) Postoperative Care

c.) Discharge Instructions

 II. Definition
Acute pancreatitis is sudden inflammation that lasts a short time.
It can range from mild discomfort to a severe, life-threatening illness.
Most people with acute pancreatitis recover completely after getting
the right treatment. In severe cases, acute pancreatitis can cause
bleeding, serious tissue damage, infection, and cysts. Severe
pancreatitis can also harm other vital organs such as the heart, lungs,
and kidneys.
III. Etiology
Gallstones (including microlithiasis) are the most common
cause of acute pancreatitis accounting for 40 to 70 percent of
cases. However, only 3 to 7 percent of patients with gallstones
develop pancreatitis the mechanism by which the passage of
gallstones induces pancreatitis is unknown. Two factors have
been suggested as the possible initiating event in gallstone
pancreatitis: reflux of bile into the pancreatic duct due to
transient obstruction of the ampulla during passage of
gallstones; or obstruction at the ampulla secondary to stone(s)
or edema resulting from the passage of a stone.
Cholecystectomy and clearing the common bile duct of stones
prevents recurrence, confirming the cause-and-effect
relationship
Other Etiologic Factors
● Alcohol (acute and chronic alcoholism)
● Hypertriglyceridemia
● Endoscopic retrograde cholangiopancreatography (ERCP), especially
after biliary manometry

● Trauma (especially blunt abdominal trauma)

● Postoperative (abdominal and non-abdominal operations)
● Drugs(azathioprine, 6-mercaptopurine, sulfonamides,
estrogens,
tetracycline, valproic acid, anti-HIV medications)

● Sphincter of Oddi dysfunction

 IV. Anatomy of
the Pancreas
The pancreas is an elongated,
tapered organ located across the
back of the belly, behind the
stomach. The right side of the
organ—called the head—is the
widest part of the organ and lies
in the curve of the duodenum,
the first division of the small
intestine.
IV. Physiology of
the Pancreas
It plays an essential role in
converting the food we eat into fuel
for the body's cells. The pancreas
has two main functions: an exocrine
function that helps in digestion and
an endocrine function that regulates
blood sugar.
IV. Pathophysiology
The pathophysiology of acute pancreatitis
is characterized by a loss of intracellular
and extracellular compartmentation, by an
obstruction of pancreatic secretory
transport and by an activation of
pancreatic enzymes.
 IV. Pathophysiology
The digestive chemicals (enzymes) that
are made in the pancreas become activated
and start to 'digest' parts of the pancreas.
They are normally only activated after they
reach the part of the gut just after the
stomach (the duodenum). This leads to a
range of chemical reactions that cause
inflammation in the pancreas. How the above
causes actually trigger this sequence of
events is not clear.
V. Clinical Manifestations

● Fever ● Pain in the upper part of

● Higher heart rate your belly that goes into
● Nausea and vomiting your back. Eating may
● Swollen and tender belly make it worse, especially
foods high in fat.
VI. Risk Factors

● Autoimmune diseases ● Metabolic disorders

● Drinking lots of alcohol ● Surgery
● Infections ● Trauma
● Gallstones ● In up to 15% of people
● Medications with acute pancreatitis, the
cause is unknown.
VII. Theoretical Framework
Dorothea Orem: Self-Care Deficit Theory
Orem's self-care deficit theory suggests patients are better able to recover when they maintain some
independence over their own self-care.

Self-Care Deficits

A self-care deficit is an inability to perform certain daily functions related to health and well-being,
such as dressing or bathing. Self-care deficits can arise from physical or mental impairments, such as
surgery recovery, depression, or age-related mobility issues. Nurses play an important role when it
comes to addressing self-care deficits through assessment and intervention. For assessment, nurses
must be aware of the patient’s strengths, weaknesses, environment, and situational needs.
Intervention can include, but is not limited to, helping patients create short-term goals, spurring
motivation, creating opportunities for independence, and offering help with daily activities.
Self-Care Deficit Nursing Diagnosis

According to Nurseslabs, signs and symptoms associated with self-care deficits

include:

● Inability to maintain proper hygiene

● Inability to dress oneself

● Inability to feed oneself

● Mobility issues

● Frustration/depression

● Problems with using the toilet

 Orem’s Self-Care Deficit Theory
Orem’s self-care deficit theory focuses on the specific scenarios needing the attention of
nurses, and it lists five ways to help:

1. Acting for and doing for others

2. Guiding others

3. Supporting another

4.Providing an environment promoting personal development in relation to meeting future

demands

5. Teaching another

How do nurses determine whether a patient is facing a self-care deficit? Orem’s theory
includes three steps. First, a nurse gathers information about the patient. This includes the
patient’s health, needs, goals, and capacity, from the perspective of both the patient and the
attending physician. Next, the nurse strategizes ways to help the patient with his or her
self-care deficit. Next, the nurse works directly with the patient to meet these needs.
Methods to Follow Accordance to Situation
Hygiene — Nurses can help patients maintain their own personal hygiene by providing reminders
and motivation for self-care. This could include daily prompting for activities like bathing and washing
up.

Dressing/grooming — Nurses can help their patients by recommending clothing that is easy to put
on and remove, giving them privacy, and providing frequent motivation.

Feeding — Nurses can help enable patients to feed themselves as soon as possible. By creating a
conducive environment to eating (positioning the patient, ensuring they have access to their dentures,
etc.), patients can stay independent throughout their meals.

Toileting — Nurses should work to simplify toileting for patients. This can include using bedpans,
suppositories, stool softeners, or commodes. Nurses should also be nearby in case of any accidents
or falls.

Speech deficit — Nurses should work closely with speech pathologists to ensure that any type of
speech deficit will not interfere with communication about care.
CHOLECYSTECTOMY
Pre-operative
A. Assessment

Nursing assessment of a patient with acute pancreatitis involves:

● Assessment of current nutritional status and increased metabolic requirements.

● Assessment of respiratory status.
● Assessment of fluid and electrolyte status.
● Assessment of sources of fluid and electrolyte loss.
● Assessment of abdomen for ascites.
B. Preoperative Teaching Plan
B. Preoperative Teaching Plan
B. Preoperative Teaching Plan
C. Preoperative Medication
Generic Classificatio Dosage and Mechanism Indication Adverse Nsg
Name n Frequency of Action Reaction Management

Ampicillin Penicillin 1-2 g a day Interference Bacterial Wheezing, severe Position leaning
diarrhea, stomach forward w/ arms
with cell wall Infection and chest resting
cramps, fever
(varies) synthesis on table for
breathing,
hydration, and
comfort

Pancreatin Digestive 600 mg Replace digestive Pancreatitis Allergic reaction: Position leaning
enzymes when the hives; difficult forward w/ arms
Enzyme body does not have breathing; swelling and chest resting
enough of its own. of your face, lips, on table for
tongue, or throat. breathing, and
apply cold
compress for
swelling.

Hydrocodone Opiate 2.5 - 10 mg Binds to and Pain Nausea, vomiting, Promote rest,
activates the constipation, advice clear or ice
lightheadedness, cold beverages,
mu-opioid dizziness, or fiber, and adequate
receptor drowsiness fluids.
D. Preoperative Preparation
Bowel preparation (or bowel prep) empties and cleans out your large intestine (colon). Bowel prep
is done before tests that look inside your colon, such as a colonoscopy. These tests look for small
growths (called polyps), cancer, or other problems like bleeding.

Follow the instructions exactly about when to stop eating and drinking. If you don't, your surgery
may be cancelled. If your doctor told you to take your medicines on the day of surgery, take them
with only a sip of water.

Take a bath or shower before you come in for your surgery. Do not apply lotions, perfumes,
deodorants, or nail polish.

Do not shave the surgical site yourself.

Take off all jewellery and piercings. And take out contact lenses, if you wear them.
Post Operative
A. Monitor
● Vital signs
- Temperature
- Respiratory Rate
- Blood Pressure
- Temperature
- Pulse Oximetry
● Hemorrhage
● Shock
● Hemodynamic Stability
● Blood Glucose Level,
● Abdominal Compartment Pressure,
B. Risk Factors
Cholecystectomy

● Indigestion
● Infection
● Bleeding
● Bile Leakage
● Injury to bile duct
● Deep vein thrombosis
● Risks from general anesthesia
C. Nursing Diagnosis
● Pain and discomfort related to recent surgical incision
● Imbalanced nutrition: less than body requirements related to inadequacy in
dietary intake, impaired absorption, reduced food intake, and increased metabolic
demands.

● Activity intolerance related to fatigue

● Ineffective breathing pattern related to severe pain and pulmonary infiltrates
● Impaired skin integrity resulting from poor nutritional status, bed rest, and surgical
wound

● Fear in relation to recovery process

● Ineffective coping related to limitations in mobility and impaired skin integrity
● Risk for Deficient Fluid Volume
● Risk for Aspiration
● Risk for Infection
D. Diet Progression
● After surgery the patient is placed under Nothing Per Orem (NPO).
● Start with clear liquids to prevent nausea, vomiting and constipation, (soup, Jell-O, juices,
popsicles, and carbonated beverages) then advance to soft to regular low fat diet.
● Eat smaller meals more often instead of fewer larger meals.
● You can eat a normal diet, but avoid eating fatty food for about one (1) month. Fatty foods include
hamburgers, whole milk, cheese and many snack foods. If your stomach is upset, try bland, low-fat
foods like plain rice, broiled chicken, toast and yogurt.
● rink plenty of fluids (unless your doctor tells you not to).
● If you have diarrhea, try avoiding spicy foods, dairy products, fatty foods and alcohol. If the
diarrhea continues for more than 2 weeks, talk to your doctor.
● Eat lots of whole grains, fruits, green leafy vegetables. Avoid foods that cause constipation such
as red meat, processed foods such as pizza, frozen dinners, pasta, and sugar products such as
cakes, pies, pastries, doughnuts and drinks containing caffeine.
Increase in cortisol level after the surgery leads to the protein and muscle depletion therefore
early nutrition plays very important role in the recovery of patients after surgery.

● Lean-meat proteins ● Whole grains

● White fish or canned fish ● Low-fat dairy
● Vegetables ● Fresh herbs and spices
● Fruits ● Tomato-based sauces
● Beans and lentils
 E. Drug Study
Generic Classificatio Dosage and Mechanism Indication Adverse Nsg
Name n Frequency of Action Reaction Management

Codeine Opiate 15/30/60 mg Binds to Pain Drowsiness, The patient to lie

mu-opioid lightheadedness, down and not to
dizziness, move so as not to
receptors sedation, accumulate injuries
shortness of or pain.Give
breath, nausea, medicines as
vomiting, sweating, ordered to stop the
and constipation vertigo.

Ibuprofen NSAIDs 200 - 400 mg Synthesis of Pain Hemorrhage, Avoid bumping into
prostaglandins via vomiting, anemia, solid objects,
the arachidonic decreased patient should rest,
acid pathway hemoglobin, and manage
eosinophilia, and stress.
hypertension.

Rocephin Carbapenem 1-2 g / 50 ml Inhibition of Bacterial Swelling, redness, Cold compress for
bacterial cell pain, or soreness swelling.
antibiotics Infection at the injection site
wall synthesis
 F. Postoperative Management
Diet
● Start with clear liquids today to prevent nausea, vomiting and constipation, (soup, Jell-O, juices, popsicles, and
carbonated beverages.) then advance to a regular low fat diet.

● Eat smaller meals more often instead of fewer larger meals.

● You can eat a normal diet, but avoid eating fatty food for about one (1) month. Fatty foods include hamburgers, whole
milk, cheese and many snack foods. If your stomach is upset, try bland, low-fat foods like plain rice, broiled chicken,
toast and yogurt.

● Drink plenty of fluids (unless your doctor tells you not to).
● If you have diarrhea, try avoiding spicy foods, dairy products, fatty foods and alcohol. If the diarrhea continues for more
than 2 weeks, talk to your doctor.
● Eat lots of whole grains, fruits, green leafy vegetables. Avoid foods that cause constipation such as dairy products,
red meat, processed foods such as pizza, frozen dinners, pasta, and sugar products such as cakes, pies, pastries,
doughnuts and drinks containing caffeine.
 Medication Activity

● Take pain medications as prescribed

● Rest for the next 24 hours.
by your doctor.
● No strenuous activity for two weeks.
● Take your pain medication with
● No heavy lifting for two (2) weeks.
crackers or toast.
● Take antibiotics as ordered
if prescribed by your doctor
 G. Prevention

1.Limit alcohol consumption. By drinking less (or not at all), you can help protect your
pancreas from the toxic effects of alcohol and reduce your risk for pancreatitis.

2.Eat a low-fat diet. Gallstones, a leading cause of acute pancreatitis, can develop
when too much cholesterol accumulates in your bile, a fluid that helps break down
fats. To reduce your risk for gallstones, eat a low-fat diet that includes whole grains
and a variety of fresh fruits and vegetables. To help prevent pancreatitis, avoid fatty or
fried foods and full-fat dairy products.
3.Exercise regularly and lose excess weight. People who are overweight are more
likely to develop gallstones, which leads to a greater risk for acute pancreatitis. Losing
extra pounds gradually and maintaining a healthy weight by eating a balanced diet and
engaging in regular physical activity can help prevent gallstones from forming.

4.Skip crash diets. The caveat to losing weight is to do it gradually. When you go into
crash-diet mode, prompting quick weight loss, your liver ramps up cholesterol
production in response, which increases your risk for gallstones.

5.Don’t smoke. A review of existing studies published in the September 2019 issue of
the journal Pancreatology found that adults who smoked were 1.5 times more likely to
develop acute or chronic pancreatitis than nonsmokers.
H. Discharge Instructions (METHODS)

Medication
Home medication are not yet given to the
patient unless prescribed by physician but
medications that are currently being taken
are as show in the drug study. Upon
prescription, patient is take appropriate
dose, time, and interval. If in doubt, the
patient may contact her physician.
Exercise Treatment

● Walking short distances for ● Instruct client and relatives in

exercise is acceptable. prescribed medication regimen.

● Do not drive for at least 5-7 days
after surgery or within 24 hours of
taking any prescription pain
medication.
● After 2 weeks, you may jog, ride a
stationary bike, flat surface bike, or
low resistance elliptical
trainer.Exercise
● Encourage routine and reminders
to facilitate adherence. Teach the
patient and relatives at the right
time to take her medications as
well as other measures that will be
advised by her physician.
● The family members must provide
the patient with adequate support,
care, and pray for the patient.
Health Teaching Outpatient Referral

● Instruct he relatives of importance of ● Instruct the client’s relative to attend

aseptic technique in wound cleaning and follow up check-ups referred by the
food preparation. physician.
● Instruct the relatives to serve variety of
fruits and vegetables. These foods help in ● Instruct family members to seek
the healing process. immediate medical care if the patient
● Instruct client to comply with prescribed experiences difficult breathing.
medications as well as treatments and
modifications in activity and diet.
● Stress the significance of maintaining a
good personal hygiene to promote sense
of well-being and to prevent bacteria from
harboring around and towards the incision
site.
● Providing a calm environment should also
be instructed to the client’s significant
others for him to take enough rest
periods.
Diet Spirituality

● Eat smaller meals more often instead of ● Encourage family members to pray
fewer large meals. constantly and surrender all their
● Encourage fiber-rich and low-fat meals. worries to God especially their present
● Drink plenty of fluids (unless discouraged condition to lessen anxiety and to
by physician). promote presence of mind.
● If diarrhea is experienced, avoid spicy
and fatty foods, dairy products and
alcohol. If diarrhea persists for 2 weeks,
consult physician.
● Try going on bland diet low-fat diet when
stomach is upset. This includes rice,
broiled chicken, toast, and yogurt.
I. Nursing Care Plan
Assessment Diagnosis Planning Implementation Rationale Evaluation

S: Ineffective breathing Short term goals: At the 1. Elevate bed 1. Facilitates lung Goal met, client can
pt states air is hard to pattern related to end of the shift the head and expansion identify interventions
grasp increase abdominal client will be able to maintain that reduce breathing
distention and pressure identify interventions semi-fowler’s 2. Regulates discomfort and exhibits
O: that reduce breathing position breathing normal RR. Client no
pt exhibits shallow discomfort and the pattern and longer struggles
heavy fast-paced client’s RR will 2. Assist patient in intensity gasping for air and has
breathing with the RR normalize proper eliminated every sign of
of 28 breaths/ minute breathing respiratory distress.
Long term goals: The exercises by
client will have constant providing well
pt uses
regular breathing placed counting
accessory
pattern with the for each
muscle in
absence of any sign of interval
breathing
respiratory distress
Nasal flaring
is evident

pt is breathing through
the mouth, practicing
pursed lip breathing
Assessment Diagnosis Planning Implementation Rationale Evaluation

S: Dehydration as Short Term Goal: 1. Increase fluid 1. Replacing the Goal met, the pt was
Patient complains of manifested by poor Signs of dehydration is intake lost fluids and alleviated of fatigue and
fatigue, thirst, and skin condition, thirst, expected to be relieved electrolytes thirst with I & O balance
discomfort. and imbalanced I & O. from the patient. 2. Instruct best resolves Restored.
significant dehydration. Signs of dehydration
Long Term Goal: others to such as poor skin
O: The pt will have normal provide fruits 2. Fruits and elasticity and lack of
Unequal ratio of I & O. I & O, maintain good and vegetables vegetables moisture were
skin elasticity and in the pt’s diet such as eliminated.
Skin on lips and moisture, and be free seed-free
throughout the body is from any signs of 3. Monitor pt for watermelon,
dry. dehydration. signs of papaya,
dehydration lettuce, and
Skin turgor is slightly cucumber are
deviated from normal. water rich,
good for
hydration.

3. Identifying the
risk at the
earliest
possible time
will prevent the
occurence of
dehydration.
Assessment Diagnosis Planning Implementation Rationale Evaluation

S: Infection related to Short Term Goal: 1. Note the color 1. GT tube Goal met, pt expresses
Pt voices concern on incision on the At the end of the shift, and condition of drainage may and demonstrates
possible wound abdominal area for GT the existing signs and surrounding initially contain understanding of
infection tube insertion symptoms of sepsis tissue. blood and then aseptic technique,
will be relieved and 2. Observe the changes to including proper self
Pt reports tingling the pt will express character and greenish brown cleaning and
burning sensation on feeling of comfort and color of color due to bile. maintenance of incision
GT tube incision site understanding of drainage 2. Noted risk site and dressing.
aseptic technique and 3. Note the factors provides Wound healed in a
O: proper self wound care. risk information and timely manner with the
Skin surrounding the factors. frontline defense absence of any sign of
incision is reddish and Long Term Goal: 4. Stress proper against sepsis.
moderately swollen. Within hospitalization, hand hygiene to healthcare
the client will achieve all caregivers infection
Temperature of timely wound healing between 3. Keeps the skin
surrounding tissue is in the absence of signs procedures and clean and
slightly elevated. of sepsis. client. provides a
5. Change the barrier from
dressing as microbial
often as infection.
necessary.
6. Clean skin with
appropriate
soap and
water.
7. Disinfect
incision area w/
betadine
solution.