Description of the Disease

Pancreatitis (inflammation of the pancreas) may be acute or chronic form.  It may be
caused by edema, necrosis or hemorrhage. When pancreatitis occurs after biliary tract
disease, the prognosis is usually good, but when alcoholism is a role, the prognosis is
poor. When the condition is associated with necrosis and bleeding, the mortality rate
might reach 60%. (Schilling McCann, 2009).

Pancreatitis ranges from a mild, self-limited disorder to a severe, rapidly fatal disease
that does not respond to any treatment.

 Pancreatitis is an inflammation of the pancreas and is a serious disorder.

 Pancreatitis can be a medical emergency associated with a high risk of life-
threatening complications and mortality.
 Pancreatitis is commonly described as autodigestion of the pancreas.

The most basic classification system divides the disorder into acute and chronic forms.

 Acute pancreatitis. Acute pancreatitis does not usually lead to chronic

pancreatitis unless complications develop.
 Chronic pancreatitis. Chronic pancreatitis is an inflammatory disorder
characterized by progressive destruction of the pancreas.

Signs and symptoms

 Severe abdominal pain. Abdominal pain is the major symptom of pancreatitis that
causes the patient to seek medical care and this results from irritation and edema
of the inflamed pancreas.
 Boardlike abdomen. A rigid or boardlike abdomen may develop and cause
abdominal guarding.
 Ecchymosis. Ecchymosis or bruising in the flank or around the umbilicus may
indicate severe pancreatitis.
 Nausea and vomiting. Both are also common in pancreatitis and the emesis is
usually gastric in origin but may also be bile stained.
 Hypotension. Hypotension is typical and reflects hypovolemia and shock caused
by the large amounts of protein-rich fluid into the tissues and peritoneal cavity.
Nursing Assessment

Nursing assessment of a patient with 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.

Diagnostic test
 Serum amylase and lipase levels. These are used in making a diagnosis,
although their elevation can be attributed to many causes, and serum lipase
remains elevated for a longer period than amylase.
 WBC count. The WBC count is usually elevated.
 X-ray studies. X-ray studies of the abdomen and chest may be obtained to
differentiate pancreatitis from other disorders that can cause similar symptoms.
 Ultrasound. Ultrasound is used to identify an increase in the diameter of the
pancreas.
 Blood studies. Hemoglobin and hematocrit levels are used to monitor the patient
for bleeding.
 CT scan: Shows an enlarged pancreas, pancreatic cysts and determines the
extent of edema and necrosis.
 Ultrasound of abdomen: May be used to identifying pancreatic inflammation,
abscess, pseudocysts, carcinoma, or obstruction of biliary tract
 Endoscopic retrograde cholangiopancreatography: Useful to diagnose fistulas,
obstructive biliary disease, and pancreatic duct strictures/anomalies (the
procedure is contraindicated in an acute phase).
 CT–guided needle aspiration: Done to determine whether the infection is present.
 Abdominal x-rays: May demonstrate dilated loop of small bowel adjacent to the
pancreas or another intra-abdominal precipitator of pancreatitis, presence of free
intraperitoneal air caused by perforation or abscess formation, pancreatic
calcification.
 Upper GI series: Frequently exhibits evidence of pancreatic
enlargement/inflammation.
 Serum amylase: Increased because of obstruction of normal outflow of
pancreatic enzymes (normal level does not rule out disease). May be five or
more times normal level in acute pancreatitis.
 Serum lipase: usually elevates along with amylase, but stays elevated longer.
 Serum bilirubin: Elevation is common (may be caused by alcoholic liver disease
or compression of common bile duct).
 Alkaline phosphatase: Usually elevated if pancreatitis is accompanied by biliary
disease.
  Serum albumin and protein: May be decreased (increased capillary permeability
and transudation of fluid into extracellular space).
 Serum calcium: Hypocalcemia may appear 2–3 days after onset of illness
(usually indicates fat necrosis and may accompany pancreatic necrosis).
 Potassium: Hypokalemia may occur because of gastric losses; hyperkalemia
may develop secondary to tissue necrosis, acidosis, renal insufficiency.
 Triglycerides: Levels may exceed 1700 mg/dL and may be a causative agent in
acute pancreatitis.
 LDH/AST: May be elevated up to 15 times normal because of biliary and liver
involvement.
 CBC: WBC count of 10,000–25,000 is present in 80% of patients. Hb may be
lowered because of bleeding. Hct is usually elevated (hemoconcentration
associated with vomiting or from effusion of fluid into pancreas or retroperitoneal
area).
 Serum glucose: Transient elevations of more than 200 mg/dL are common,
especially during initial/acute attacks. Sustained hyperglycemia reflects
widespread cell damage and pancreatic necrosis and is a poor prognostic sign.
 Partial thromboplastin time (PTT): Prolonged if coagulopathy develops because
of liver involvement and fat necrosis.
 Urinalysis: Glucose, myoglobin, blood, and protein may be present.
 Urine amylase: Can increase dramatically within 2–3 days after onset of attack.
 Stool: Increased fat content (steatorrhea) indicative of insufficient digestion of
fats and protein.

Medical Management
Management of pancreatitis is directed towards relieving symptoms and preventing or
treating complications.
 Pain management. Adequate administration of analgesia (morphine, fentanyl, or
hydromorphone) is essential during the course of pancreatitis to provide sufficient
relief and to minimize restlessness, which may stimulate pancreatic secretion
further.
 Intensive care. Correction of fluid and blood loss and low albumin levels is
necessary to maintain fluid volume and prevent renal failure.
 Respiratory care. Aggressive respiratory care is indicated because of the high-
risk elevation of the diaphragm, pulmonary infiltrates and effusion, and
atelectasis.
 Biliary drainage. Placement of biliary drains (for external drainage)
and stents (indwelling tubes) in the pancreatic duct through endoscopy has been
performed to reestablish drainage of the pancreas.
Surgical Management
There are several approaches available for surgery. The major surgical procedures are
the following:

 Side-to-side pancreaticojejunostomy (ductal drainage). Indicated when dilation of

pancreatic ducts is associated with septa and calculi. This is the most successful
procedure with success rates ranging from 60% to 90%.
 Caudal pancreaticojejunostomy (ductal drainage). Indicated for uncommon
causes of proximal pancreatic ductal stenosis not involving the ampulla.
 Pancreaticoduodenal (right-sided) resection (ablative) (with preservation of the
pylorus) (Whipple procedure). Indicated when major changes are confined to the
head of the pancreas. Preservation of the pylorus avoids usual sequelae of
gastric resection.
 Pancreatic surgery. A patient who undergoes pancreatic surgery may have
multiple drains in place postoperatively, as well as a surgical incision that is left
open for irrigation and repacking every 2 to 3 days to remove necrotic debris.

Nursing Diagnosis
Based on the assessment data, the nursing diagnoses for a patient with pancreatitis
include:

 Acute pain related to edema, distention of the pancreas, and peritoneal irritation.

 Imbalanced nutrition: less than body requirements related to inadequate dietary
intake, impaired pancreatic secretions, and increased nutritional needs.
 Ineffective breathing pattern related to splinting from severe pain, pulmonary
infiltrates, pleural effusion, and atelectasis.

Planning & Goals

Planning and goals developed for a patient with pancreatitis involve:

 Relief of pain and discomfort.

 Improvement in nutritional status.
 Improvement in respiratory function.
 Improvement in fluid and electrolyte status.
Evaluation

Evaluation of a successful plan of care for a patient with pancreatitis should include:

 Relieved pain and discomfort.

 Improved nutritional status.
 Improved respiratory function.
 Improved fluid and electrolyte status.

Nursing Management
 Preoperatively and postoperatively nursing care is directed toward promoting
patient comfort, preventing complications and assisting the patient to return and
maintain as normal and comfortable a life as possible.
 The nurse closely monitors the patient in the intensive care unit after surgery; the
patient will have multiple intravenous and arterial lines in place for fluid and blood
replacement as well as for monitoring arterial pressures and is on mechanical
ventilator in the immediate postoperative period.
 It is important to give careful attention to changes in vital signs, arterial blood
gases and pressures, pulse oximetry, laboratory values and urine output.
 The nurse must also consider the patient’s compromised nutritional status and
risk for bleeding.