Name : Muhammad Alvin Fuzail Iyaz

SID : P1337420621035
Class : 2A3 RKI

ACUTE PANCREATITIS
WOC ACUTE PENCREATITIS
 Nursing diagnoses
Anxiety related to the changes in health
status
Goals and Outcome Criteria Intervention
After carrying out nursing care for ….. 1. Use a calming approach
perfusion adequate peripheral tissue with 2. State clearly the expectations of the patient
outcome criteria:
perpetrator
1. Clients are able to identify and express 3. Explain all procedures and how you feel
symptoms of anxiety.
during the procedure
2. Identify, disclose and demonstrate
techniques to control anxiety. 4. Understand the patient's perspective on
3. Vital signs within normal limits stressful situations
4. Posture, facial expressions, body
5. Accompany the patient to provide safety
language and activity levels showed
reduced anxiety. and reduce fear
6. Encourage the family to accompany the
child
7. Do back/neck rub
8. Listen attentively
9. Identify anxiety levels
10. Help the patient identify situations that
cause anxiety
11. Encourage patient to express feelings, fears,
perceptions
12. Instruct the patient to use relaxation
techniques
13. Give medicine to reduce anxiety
Acute pain related to the agent of injury
(biology)
After carrying out nursing care for …..
perfusion adequate peripheral tissue with
outcome criteria:
Goal: The client will be free from acute pain
during treatment
Objective : The client will not experience injury
agents (biology) during treatment.
Outcomes: during treatment, clients:
1. Reporting pain is gone/controlled
2. show a relaxed posture
3. show normal vital signs.
1. Provide a quiet environment, the room is
slightly dark as indicated R / Decreases
reaction to external stimulation or
sensitivity to light and increases rest /
relaxation.
2. Provide appropriate active/passive range of
motion exercises and neck/shoulder muscle
massage. R / Can help relax muscle tension
which increases the reduction of pain or
discomfort.
3. Increase bed rest, assist essential self-care
needs. R / Reducing movement that can
increase pain.
4. Give analgesics, such as acetaminophen,
codeine. R / May be needed to relieve
severe pain.
Changes in nutrition less than body
requirements related to nausea, vomiting
After carrying out nursing care for …..
perfusion adequate peripheral tissue with
outcome criteria:
Goal: the client will increase nutritional intake
adequately during treatment
2. Give medication as indicated: (vitamins A, D,
Objective: the client will be free from nausea,
vomiting during treatment
Outcomes: during client care:
1. Says there is no disturbance of
3. Assess the abdomen, note the character of
sensation in the sense of taste
2. Says can enter food adequately
3. Spend a portion of food
4. Shows weight gain
5. Shows good muscle tone
4. Observation of color/consistency/number of
1. Give oral care R / Reduce vomiting and
inflammation / irritation of dry mucous
membranes associated with dehydration
and breathe through the mouth when the
NGT is inserted
E, K) R / replacement needs such as
impaired fat metabolism, decreased
absorption or deviation of fat-soluble
vitamins
bowel sounds, abdominal distension and
complaints of nausea R / abdominal
distension and intestinal atony often occur,
resulting in decreased / absent bowel
sounds. Return of bowel sounds and
disappearance of symptoms indicates
readiness to stop gastric aspiration (NG
tube)
feces. Note the consistency; mushy or foul
smell R / steatorrhea occurs due to
incomplete fat digestion
Fluid volume deficit related to active fluid
loss.
After carrying out nursing care for …..
perfusion adequate peripheral tissue with
outcome criteria:
Goal: The client will increase the volume of
adequate fluids during treatment.
Objective: The client will not experience active
fluid loss during treatment.
Outcomes: during treatment, the client shows:
1. Urine output within normal limits
2. Urine concentration within normal
limits
3. Normal weight
4. Normal skin turgor
5. Normal BP
6. Moist skin/mucous membranes
7. Absence of signs and symptoms of
dehydration
1. Explain the reason for fluid loss and teach
the patient how to monitor fluid volume.
(for example by recording daily weight and
managing intake and output). R / This action
encourages patient involvement in personal
care.
2. Cover the patient only with a thin cloth.
Avoid overheating. R / to prevent
vasodilation and reduced circulating blood
volume.
3. Check urine specific gravity every 8 hours. R
/ increased specific gravity of urine can
indicate dehydration.
4. Assess skin turgor and oral mucous
membranes every 8 hours. R / check for
dehydration. Provide careful oral care every
4 hours. Avoid dehydration of mucous
membranes is a good indicator of fluid
status.
5. Monitor and record vital signs every 2 hours
or as often as needed until stable. Then
monitor and record vital signs every 4 hours.
R / tachycardia, dyspnea, or hypotension
may indicate fluid volume deficiency or
electrolyte imbalance.
Ineffective breathing pattern related to
pain
After carrying out nursing care for …..
perfusion adequate peripheral tissue with
outcome criteria:
Goal: The client demonstrates an effective
breathing pattern
Objective: The client does not experience pain
Outcomes: during treatment, clients:
1. Do not complain of shortness of breath
2. Normal respiratory rate
3. Pulse back to normal
1. Teach the patient effective deep breathing
exercises. R / helps reduce pain
2. Assist to be in a comfortable position that
allows maximum chest expansion. R / to
facilitate breathing.
3. Give pain medication when instructed. R / to
allow maximum chest expansion.
4. Observe and record respiratory status every
4 hours. R / detects early signs of
disturbance
5. Observe for pain every 3 hours. R / pain can
reduce the effort of breathing and
ventilation.
Sleep Rest Disorders related to pain After carrying out nursing care for …..
perfusion adequate peripheral tissue with
outcome criteria:
1. The number of hours of sleep within
normal limits is 6-8 hours/day
2. Sleep patterns, quality within normal
limits
3. Feeling refreshed after sleeping or
resting
4. Able to identify things that improve
sleep
1. Determination of the effects of medication
on sleep patterns
2. Explain the importance of adequate sleep
3. Facility to maintain activity before bed
(reading)
4. · Create a comfortable environment
5. · Collaborate on giving sleeping pills
6. · Discuss with patients and families about
the patient's sleep techniques
7. Instruct to monitor the patient's sleep
8. · Monitor eating and drinking time with
bedtime
9. Monitor / record the patient's sleep needs
every day and (Riyadi)
Activity intolerance related to general
weakness
After carrying out nursing care for ….. 1. Instruct patient to stop activity if
perfusion adequate peripheral tissue with palpitations, chest pain, shortness of
outcome criteria:
breath, weakness or dizziness occur. R /
Goal : Client will increase activity tolerance strain / excessive cardiopulmonary stress /
during treatment
stress can cause decompensation / failure.
Objective: The client will be free from 2. Provide a quiet environment. Maintain bed
weakness during treatment
rest when indicated. Limit visitors, calls, and
Outcomes: during treatment, clients: repeated interruptions of unplanned
10. Demonstrate tolerance for activity actions. R / increase rest to reduce the
11. say not weak and tired body's oxygen demand and reduce heart
12. absence of palpitations and
and lung strain.
tachycardia,
13. blood pressure and breathing and 3. Assess the patient's ability to perform
tissue work back to normal normal activities. Record reports of
weakness, fatigue, and difficulty completing
tasks. R / influences the choice of
intervention or assistance.
Bibliography
Riyadi, S. S. (n.d.). In Askep pada Pasien dengan Gangguan Eksokrin dan Endokrin pada Pankreas (p. 2008). Jogjakarta: Graha Ilmu.
Tim Promkes RSST - RSUP dr. Soeradji Tirtonegoro Klaten. (2022, Juli 22). Mengenal Pankreatitis. Retrieved sept 27, 2022, from
Kementerian Kesehatan Direktorat Jendral Pelayanan Kesehatan:
https://yankes.kemkes.go.id/view_artikel/397/mengenal-pankreatitis