NUR 111 (Nursing Care of Clients with Life –

Threatening Conditions, Acutely Ill/Multi-organ

Problems, High Acuity and Emergency
STUDENT ACTIVITY SHEET Situation)
BS NURSING / FOURTH YEAR
Session # 12

LESSON TITLE: Liver Failure and Acute Pancreatitis Materials: MS notebook, paper, pen, index card,
and bond paper (short & long size)
LEARNING TARGETS:
At the end of the lesson, the student nurses will be to: References:
1. Describe hepatic failure and acute pancreatitis; Smeltzer S.C., & Bare B.G. (2010) Brunner and
2. Discuss assessment findings upon physical Suddarth’s Textbook of Medical- Surgical Nursing.
examination; Lippincott William & Wilkins
3. Identify possible causes of hepatic failure and acute
pancreatitis; and, Sommer S., Johnson J. (2013) RN Adult Medical
4. Explain nursing management during acute stage of Surgical Nursing. Assessment Technology
hepatic failure and acute pancreatitis. Institute, LLC.
https://www.nurseslab.com

LESSON PREVIEW/REVIEW (10 minutes)

Instruction: List down the signs and symptoms of upper gastrointestinal bleeding and explain each symptom.
1. ________________________________________________________________________________
2. ________________________________________________________________________________
3. ________________________________________________________________________________

Instruction: Differentiate intra-abdominal hypertension from abdominal compartment syndrome.

Intra-abdominal hypertension is _______________________________________________________________
__________________________________________________________________________________________
While, abdominal compartment syndrome is _____________________________________________________
__________________________________________________________________________________________.

MAIN LESSON (60 minutes)

LIVER FAILURE
Hepatic failure can result from acute liver injury, causing acute liver failure (ALF) or fulminant hepatic failure (FHF), or
progressive chronic liver disease such as cirrhosis.
An alteration in hepatocyte functioning affects the liver metabolism, detoxification process, protein synthesis, manufacture
of clotting factors, and preservation of immunocompetence.
FHF occurs when severe hepatic injury results in encephalopathy and severe coagulopathy within 28 days of the onset of
symptoms in patients without a history of chronic liver disease.
Liver transplant is the only viable treatment option for patient with FHF.

Causes
The most commonly identified cause of FHF is drug induced, with acetaminophen the most common culprit, followed by
viral hepatitis.
Other causes include infection (cytomegalovirus [CMV], adenovirus), metabolic disorders and severe ischemic insult or
shock.

Signs and Symptoms

 Manifestation depends on the complications associated with the liver dysfunction.
 Patient behavior may range from agitation to frank coma.
 Evidence of GI bleeding, renal failure, or respiratory distress may also be present.
 The initial manifestation in FHF is commonly bleeding from coagulopathy.

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Physical Examination
Vital signs
 BP: < 90 mm Hg (with shock)
 HR: > 120 beats/min (with shock)
 Temperature may be mildly elevated
 RR: tachypnea initially progressing to respiratory depression associated with encephalopathy.
Neurologic
 Mildly confused to coma
 Personality changes
 Asterixis
Pulmonary
 Crackles
 Labored respirations
Gastrointestinal
 Hematemesis and melena
 Ascites
 Hepatomegaly may be present
 Splenomegaly may be present
 Factor hepaticus
 Diarrhea
Skin
 Jaundice
 Ecchymosis and petechiae
 Pruritus
 Edema

Acute Care Patient Management

Nursing Diagnosis: Deficient fluid volume related to ascites secondary to hypoalbuminemia, bleeding secondary to
decreased clotting factors or variceal hemorrhage, and diuretic therapy.

Outcome Criteria
 BP 90 TO 120 mm Hg
 Central venous pressure 2 to 6 mm Hg
 Serum albumin 3.5 to 5 mg/dl
 Platelet count >50,000/mm3
 Urine output 30 ml/hr
 Serum sodium 135 to 145 mEq/L
 Serum potassium 3.5 to 5 mEq/L
 Intake approximates output

Patient Monitoring
 Obtain pulmonary artery pressure, central venous pressure, and blood pressure until the patient’s condition is
stable, then hourly.
 Continuously monitor ECG for lethal dysrhythmias that may result from electrolyte and acid-base imbalances.
 Monitor fluid volume status. Measure intake and output hourly.

Patient Assessment
 Assess hydration status. Note skin turgor on inner thigh or forehead, condition of buccal membranes, and
development of edema and crackles.
 Assess for signs and symptoms of bleeding.
 Measure abdominal girth once each shift to determine progression of ascites.
 Assess respiratory status.

Diagnostic Assessment
 Review serial serum ammonia, albumin, bilirubin, platelet count, PT, PTT and ALT to evaluate hepatic function.
 Review serial serum electrolytes.
 Review urine electrolyte, BUN, and creatinine to evaluate renal function.

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Patient Management
 Administer intravenous crystalloids as ordered
 Administer potassium as ordered. Validate adequate urine output before potassium administration.
 Sodium restriction of 0.5 g/day and fluid restriction to 1000 ml/day may be ordered.
 Vitamin K or fresh frozen plasma (FFP) may be required to promote the clotting process.
 Institute bleeding precautions. Avoid razor blades and use soft-bristled toothbrushes.
 Paracentesis may be performed if abdominal distention is severe.
 Prepare the patient and family for liver transplant, as indicated.

Acute Pancreatitis

Pancreatitis, which is the inflammation of the pancreas, can be acute or chronic in nature. It may be caused by edema,
necrosis or hemorrhage. In men, this disease is commonly associated to alcoholism, peptic ulcer or trauma; in women, it’s
associated to biliary tract disease. Prognosis is usually good when pancreatitis follows biliary tract disease, but poor when
the factor is alcoholism. Mortality rate may go as high as 60% when the disease is associated from necrosis and
hemorrhage. (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.

Classification
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.
Pathophysiology
Self-digestion of the pancreas caused by its own proteolytic enzymes, particularly trypsin, causes acute pancreatitis.
 Entrapment. Gallstones enter the common bile duct and lodge at the ampulla of Vater.
 Obstruction. The gallstones obstruct the flow of the pancreatic juice or causing a reflux of bile from the common
bile duct into the pancreatic duct.
 Activation. The powerful enzymes within the pancreas are activated.
 Inactivity. Normally, these enzymes remain in an inactive form until the pancreatic secretions reach the lumen of
the duodenum.
 Enzyme activities. Activation of enzymes can lead to vasodilation, increased vascular permeability, necrosis,
erosion, and hemorrhage.
 Reflux. These enzymes enter the bile duct, where they are activated and together with bile, back up into the
pancreatic duct, causing pancreatitis.

Causes
Mechanisms causing pancreatitis are usually unknown but it is commonly associated with autodigestion of the pancreas.
 Alcohol abuse. Eighty percent of the patients with pancreatitis have biliary tract disease or a history of long-term
alcohol abuse.
 Bacterial or viral infection. Pancreatitis occasionally develops as a complication of mumps virus.
 Duodenitis. Spasm and edema of the ampulla of Vater can probably cause pancreatitis.

Medications
 The use of corticosteroids, thiazide diuretics, oral contraceptives, and other medications have been associated
with increased incidences of pancreatitis.

Clinical Manifestations

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The signs and symptoms of pancreatitis include:
 Severe abdominal pain. Abdominal pain is the major symptom of pancreatitis that causes the patient to seek
medical care and this result from irritation and edema of the inflamed pancreas.
 Board like 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.

Complications
Complications that arise in pancreatitis include the following:
 Fluid and electrolyte disturbances. These are common complications because of nausea, vomiting, movement of
fluid from the vascular compartment to the peritoneal cavity, diaphoresis, fever, and use of gastric suction.
 Pancreatic necrosis. This is a major cause of morbidity and mortality in patients with pancreatitis because of
resulting hemorrhage, septic shock, and multiple organ failure.
 Septic shock. Septic shock may occur with bacterial infection of the pancreas.

Assessment and Diagnostic Findings

The diagnosis of pancreatitis is based on a history of abdominal pain, the presence of known risk factors, physical
examination findings, and diagnostic findings.
 Serum amylase and lipase levels. These are used in making diagnosis, although their elevation can be attributed
to many causes, and serum lipase remain 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 extent of edema and necrosis.
 Ultrasound of abdomen: May be used to identify 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 (procedure is contraindicated in acute phase).
 CT–guided needle aspiration: Done to determine whether infection is present.
 Abdominal x-rays: May demonstrate dilated loop of small bowel adjacent to pancreas or other 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 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.

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  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 pancreatojejunostomy (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 pancreatojejunostomy (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 Management
The patient who is admitted to the hospital with a diagnosis of pancreatitis is acutely ill and needs expert nursing care.

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.

Nursing Interventions
Performing nursing interventions for a patient with pancreatitis needs expertise and efficiency.
 Relieve pain and discomfort. The current recommendation for pain management in this population is parenteral
opioids including morphine, hydromorphone, or fentanyl via patient-controlled analgesia or bolus.
 Improve breathing pattern. The nurse maintains the patient in a semi-Fowler’s position and encourages frequent
position changes.
 Improve nutritional status. The patient receives a diet high in carbohydrates and low in fats and proteins between
acute attacks.
 Maintain skin integrity. The nurse carries out wound care as prescribed and takes precautions to protect intact
skin from contact with drainage.

Discharge and Home Care Guidelines

A prolonged period is needed to regain the strength of a patient who has experienced pancreatitis and to return to the
previous level of activity.
 Teaching. Teaching needs to be repeated and reinforced because the patient may have difficulty in recalling
many of the explanations and instructions given.

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  Prevention. The nurse instructs the patient about the factors implicated in the onset of pancreatitis and about the
need to avoid high-fat foods, heavy meals, and alcohol.
 Identification of complications. The nurse should give verbal and written instructions about the signs and
symptoms of pancreatitis and possible complications that should be reported promptly to the physician.
 Home care. The nurse would be able to assess the patient’s physical and psychological status and adherence to
the therapeutic regimen.

CHECK FOR UNDERSTANDING (25 minutes)

You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed.
You are given 25 minutes for this activity:

Multiple Choice

1. A male client with a history of cirrhosis and alcoholism is admitted with severe dyspnea resulted to ascites. The
nurse should be aware that the ascites is most likely the result of increased.
A. Pressure in the portal vein
B. Production of serum albumin
C. Secretion of bile salt
D. Interstitial osmotic pressure
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

2. Which diagnostic test is best to evaluate liver enlargement and ascites?

A. Ultrasound
B. X-ray
C. CT Scan
D. Nuclear medicine
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

3. Mr. Gonzales was admitted to the hospital with ascites and jaundice. To rule out cirrhosis of the liver: Which laboratory
test indicates liver cirrhosis?
A. Decreased red blood cell count
B. Decreased serum acid phosphatase
C. Elevated white blood cell count
D. Elevated serum aminotransferase
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

4. A patient with chronic alcohol abuse is admitted with liver failure. You closely monitor the patient’s blood pressure
because of which change that is associated with the liver failure?
A. Hypoalbuminemia
B. Increased capillary permeability
C. Abnormal peripheral vasodilation
D. Excess renin release of the kidney
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

5. You’re caring for Lewis, a 67 y.o. patient with liver cirrhosis who developed ascites and requires paracentesis. Relief of
which symptom indicated that the paracentesis was effective?

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Education (Department of Nursing) 6 of 11
 A. Pruritus
B. Dyspnea
C. Jaundice
D. Peripheral neuropathy
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

6. You’re caring for Betty with liver cirrhosis. Which of the following assessment findings leads you to suspect hepatic
encephalopathy in her?
A. Asterixis
B. Chvostek sign
C. Trousseau’s sign
D. Hepatojugular reflex
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

7. Develop a teaching care plan for Angie who is about to undergo a liver biopsy. Which of the following points do you
include?
A. “You’ll need to lie on your stomach during the test”
B. “you’ll need to lie on your right side after the test.”
C. “During the biopsy you’ll be asked to exhale deeply and hold it.”
D. “The biopsy is performed under general anesthesia.”
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

8. The student nurse is teaching the family of a patient with liver failure. You instruct them to limit which foods in the
patient’s diet?
A. Meats and beans
B. Butter and gravies
C. Potatoes and pasta
D. Cakes and pastries
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

9. When teaching a client about pancreatic function, the nurse understands that pancreatic lipase performs which
function?
A. Transport fatty acids into the brush border
B. Breaks down fat into fatty acids and glycerol
C. Triggers cholecystokinin to contract the gallbladder
D. Breaks down protein into dipeptides and amino acid
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

10. For Rico who has chronic pancreatitis, which nursing intervention would be most helpful?
A. Allowing liberalized fluid intake
B. Counseling to stop alcohol consumption
C. Encouraging daily exercise
D. Modifying dietary protein
ANSWER: ________

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RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

11. A clinical manifestation of acute pancreatitis is epigastric pain. Your nursing intervention to facilitate relief of pain
would place the patient in a:
A. Knee chest position
B. Semi-Fowler’s position
C. Recumbent position
D. Low -Fowlers position
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

12. What assessment finding of a patient with acute pancreatitis would indicate a bluish discoloration around the
umbilicus?
A. Grey-Turner’s sign
B. Homan’s sign
C. Rovsing’s sign
D. Cullen’s sign
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

13. Pancreatitis is commonly characterized by:

A. Edema and inflammation
B. Pleural effusion
C. Sepsis
D. Disseminated intravascular coagulation
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

14. A major symptom of pancreatitis that brings the patient to medical care is:
A. Severe abdominal pain
B. Fever
C. Jaundice
D. Mental agitation
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

15. The nurse should assess for an important early indicator of acute pancreatitis, which is a prolonged and elevated
level of:
A. Serum calcium
B. Serum lipase
C. Serum bilirubin
D. Serum amylase
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

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RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.

1. ANSWER: ________
RATIO:_______________________________________________________________________________________
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2. ANSWER: ________
RATIO:_______________________________________________________________________________________
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3. ANSWER: ________
RATIO:_______________________________________________________________________________________
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4. ANSWER: ________
RATIO:_______________________________________________________________________________________
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_____________________________________________________________________

5. ANSWER: ________
RATIO:_______________________________________________________________________________________
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6. ANSWER: ________
RATIO:_______________________________________________________________________________________
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7. ANSWER: ________
RATIO:_______________________________________________________________________________________
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8. ANSWER: ________
RATIO:_______________________________________________________________________________________
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9. ANSWER: ________
RATIO:_______________________________________________________________________________________
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10. ANSWER: ________

RATIO:_______________________________________________________________________________________
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11. ANSWER: ________

RATIO:_______________________________________________________________________________________
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12. ANSWER: ________
RATIO:_______________________________________________________________________________________
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13. ANSWER: ________

RATIO:_______________________________________________________________________________________
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14. ANSWER: ________

RATIO:_______________________________________________________________________________________
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15. ANSWER: ________

RATIO:_______________________________________________________________________________________
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LESSON WRAP-UP (25 minutes)

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.

AL Strategy: Number Heads Together

Instruction: You will be placed in teams of four. You will be given a designated number in each team. The teacher will
pose a question and you will be given time to discuss your answers as a team, after, the teacher will call out a number.
The student with that number stand. The student standing will be the team’s speaker. You will be given 2-3 mins to
discuss your answer.

Al Strategy: Buzz Group

Instruction: You will form into groups (compose of 4-6 students) in order to discuss answer to question prompt by the
instructor. You will be given 3 minutes to discuss among yourselves prior to sharing it with the class.

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(For Related Learning Experience, please refer to your clinical instructor.)

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