Lewis Pancreatitis PP

Pancreatitis
Chapter 44
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Acute Pancreatitis
• An acute inflammatory process of

the pancreas
• Varies from mild edema to severe
necrosis
• Most common in middle-aged
persons and African Americans

Case Study
Fuse/Thinkstock
• A.J. is a 48-year-old woman who

comes to the ED.
• She has nausea, vomiting, and
epigastric and left upper quadrant
pain.

Case Study
Fuse/Thinkstock
• She describes the pain as severe,

sharp, and radiating through to her
midback.
• She states the pain started 24 hours
ago.

Case Study
Fuse/Thinkstock
• A.J. admits to smoking a half-pack

of cigarettes/day but denies drinking
alcohol or using any illegal drugs.
• Her past medical history is positive
for gallstones and hypothyroidism.
• She is 5 feet 4 inches tall and weighs
160 lb.

Case Study
Fuse/Thinkstock
• A.J.’s vital signs:

• Blood pressure 100/70
• Heart rate 97
• Respiratory rate 30
• Temperature 100.2°F
• Health care provider suspects acute
pancreatitis and admits A.J. to the
medical-surgical unit.
Case Study
Fuse/Thinkstock
• What are the possible causes of

A.J.’s pancreatitis?

Acute Pancreatitis
Etiology
• Gallbladder disease (women)
• Chronic alcohol intake (men)
• Smoking
• Hypertriglyceridemia

Acute Pancreatitis
Etiology
• Less common causes
• Drugs
• Metabolic disorders
• Vascular diseases
• Surgery and endoscopic procedures
• Idiopathic causes

Acute Pancreatitis
Etiology
• Less common causes
• Trauma (postsurgical, abdominal)
• Viral infections
• Penetrating duodenal ulcer
• Cysts
• Abscesses
• Cystic fibrosis
• Kaposi sarcoma
Case Study
Fuse/Thinkstock
• A.J. asks you what pancreatitis is.

• How would you explain the
pathophysiology of this disease
process to her?

Acute Pancreatitis
Pathophysiology
• Caused by autodigestion of pancreas
• Injury to pancreatic cells
• Activation of pancreatic enzymes
• Activation of trypsinogen to trypsin
within the pancreas leads to
bleeding

Acute Pancreatitis

Acute Pancreatitis
Pathophysiology
• Mild pancreatitis
• Edematous or interstitial
• Severe pancreatitis
• Necrotizing
• Endocrine and exocrine dysfunction
• Necrosis, organ failure, sepsis
• Rate of mortality: 25%

Acute Pancreatitis

Acute Pancreatitis
Clinical Manifestations
• Abdominal pain predominant
• Left upper quadrant or midepigastrium
• Radiates to the back
• Sudden onset
• Deep, piercing, continuous or steady
• Aggravated by eating
• Starts when recumbent
• Not relieved with vomiting
Case Study
Fuse/Thinkstock
• As you admit A.J. to the medical-

surgical unit, for what other clinical
manifestations of pancreatitis would
you assess her?

Acute Pancreatitis
• Flushing
• Cyanosis
• Dyspnea
• Nausea/vomiting
• Low-grade fever
• Leukocytosis
• Hypotension, tachycardia
• Jaundice
Acute Pancreatitis
• Abdominal tenderness with guarding
• Decreased or absent bowel sounds
• Crackles
• Abdominal skin discoloration
• Grey Turner’s spots or sign
• Cullen’s sign
• Shock

Case Study
Fuse/Thinkstock
• For what potential complications of

acute pancreatitis will you monitor
A.J.?

Acute Pancreatitis
Complications
• Pseudocyst
• Fluid, enzyme, debris, and exudates
surrounded by wall
• Abdominal pain, palpable mass,
nausea/vomiting, anorexia
• Detected with imaging
• Resolves spontaneously or may
perforate and cause peritonitis
• Surgical or endoscopic drainage
Acute Pancreatitis
Complications
• Pancreatic abscess
• Collection of pus
• Results from extensive necrosis
• May perforate
• Upper abdominal pain, mass, high
fever, leukocytosis
• Surgical drainage

Acute Pancreatitis
Complications
• Systemic complications
• Pleural effusion
• Atelectasis
• Pneumonia
• ARDS
• Hypotension
• Hypocalcemia: tetany

Case Study
Fuse/Thinkstock
• What diagnostic studies would you

expect the health care provider to
order for A.J.?

Acute Pancreatitis
Diagnostic Studies
• Laboratory tests
• Serum amylase level
• Serum lipase level
• Liver enzyme levels
• Triglyceride levels
• Glucose level
• Bilirubin level
• Serum calcium level
Acute Pancreatitis
Diagnostic Studies
• Abdominal ultrasonography
• X-ray
• Contrast-enhanced CT scan
• Endoscopic retrograde
cholangiopancreatography (ERCP)

Acute Pancreatitis
Diagnostic Studies
• Endoscopic ultrasonography (EUS)
• Magnetic resonance
cholangiopancreatography (MRCP)
• Angiography
• Chest x-ray

Acute Pancreatitis
Collaborative Care
• Objectives include
• Relief of pain
• Prevention or alleviation of shock
• ↓ Pancreatic secretions
• Correction of fluid/electrolyte
imbalance
• Prevention/treatment of infection
• Removal of the precipitating cause
Acute Pancreatitis
Collaborative Care
• Conservative therapy
• Supportive care
• Aggressive hydration
• Pain management
• IV morphine, antispasmodic agent
• Management of metabolic complications
• Oxygen, glucose levels
• Minimizing pancreatic stimulation
• NPO status, NG suction, decreased acid
secretion, enteral nutrition if needed
Acute Pancreatitis
Collaborative Care
• Shock
• Plasma or plasma volume expanders
(dextran or albumin)
• Fluid/electrolyte imbalance
• Lactated Ringer’s solution

Acute Pancreatitis
Collaborative Care
• Ongoing hypotension
• Vasoactive drugs: dopamine (Intropin)
• Prevent infection
• Enteral nutrition
• Antibiotics
• Endoscopically or CT-guided
percutaneous aspiration

Acute Pancreatitis
Collaborative Care
• Surgical therapy
• For gallstones
• ERCP
• Cholecystectomy
• Uncertain diagnosis
• Not responding to conservative therapy
• Drainage of necrotic fluid collections

Acute Pancreatitis
Collaborative Care
• Drug therapy
• IV morphine
• Antispasmodics
• Carbonic anhydrase inhibitors
• Antacids
• Proton pump inhibitors

Acute Pancreatitis
Collaborative Care
• Nutritional therapy
• NPO status initially
• Enteral versus parenteral nutrition
• Monitor triglycerides if IV lipids given
• Small, frequent feedings when able
• High-carbohydrate
• No alcohol
• Supplemental fat-soluble vitamins

Acute Pancreatitis
Nursing Assessment
• Subjective data
• Health history
• Biliary tract disease
• Alcohol use
• Abdominal trauma
• Duodenal ulcers
• Infection
• Metabolic disorders

Acute Pancreatitis
Nursing Assessment
• Subjective data
• Medications
• Thiazides
• NSAIDs
• Surgery or other treatments
• Pancreas, stomach, duodenum, biliary
tract
• ERCP

Acute Pancreatitis
Nursing Assessment
• Subjective data: functional health
patterns
• Alcohol abuse
• Fatigue
• Nausea, vomiting, anorexia
• Dyspnea
• Pain

Acute Pancreatitis
Nursing Assessment
• Objective data
• Restlessness, anxiety, low-grade fever
• Flushing, diaphoresis
• Discoloration of abdomen/flank
• Cyanosis
• Jaundice
• Decreased skin turgor
• Dry mucous membranes
Acute Pancreatitis
Nursing Assessment
• Objective data
• Tachypnea
• Basilar crackles
• Tachycardia
• Hypotension
• Abdominal distention/tenderness
• Diminished bowel sounds

Acute Pancreatitis
Nursing Assessment
• Abnormal laboratory findings
• ↑ Serum amylase/lipase levels
• Leukocytosis
• Hyperglycemia
• Hypocalcemia
• Abnormal findings on
ultrasonography/CT scans
• Abnormal findings on ERCP
Case Study
Fuse/Thinkstock
• A.J.’s laboratory results

demonstrate
• Elevated serum amylase and lipase
levels
• Mild leukocytosis

Case Study
Fuse/Thinkstock
• She undergoes an ERCP, which

revealed the presence of gallstones
blocking the common bile duct.
• She is currently on NPO status and
receiving IV morphine for pain
control.

Case Study
Fuse/Thinkstock
• When you plan care for A.J., what

priority nursing diagnoses would
you identify for her?

Acute Pancreatitis
Nursing Diagnoses
• Acute pain
• Deficient fluid volume
• Imbalanced nutrition: less than body
requirements
• Ineffective self-health management

Acute Pancreatitis
Planning
• Patient will have
• Relief of pain
• Normal fluid and electrolyte balance
• Minimal to no complications
• No recurrent attacks

Acute Pancreatitis
Nursing Implementation
• Health promotion
• Assessment and early treatment of
predisposing/etiologic factors
• Early diagnosis/treatment of biliary
tract disease
• Elimination of alcohol intake

Acute Pancreatitis
• Acute intervention
• Monitoring vital signs
• Assess respiratory function
• Monitor IV fluids

Case Study
Fuse/Thinkstock
• For what electrolyte imbalances

would you monitor A.J.?
• Explain the rationale for your
answer.

Acute Pancreatitis
• Monitor fluid and electrolyte balance
• Chloride, sodium, and potassium

• Hypocalcemia
• Tetany
• Calcium gluconate to treat
• Hypomagnesemia

Monitoring for Tetany

Acute Pancreatitis
• Pain assessment and management
• Morphine
• Position of comfort with frequent position
changes
• Flex trunk and draw knees to abdomen
• Side-lying with head of bed elevated 45
degrees
• Frequent oral/nasal care
• Proper administration of antacids
Acute Pancreatitis
• Observation for signs of infection
• TCDB, semi-Fowler’s position
• Wound care
• Observation for paralytic ileus, renal
failure, mental changes
• Monitor serum glucose
• Post-op wound care
Audience Response Question
The nurse explains to a patient with an episode of

acute pancreatitis that the most effective means
of relieving pain by suppressing pancreatic
secretions is the use of:
a. Antibiotics.
b. NPO status.
c. Antispasmodics.
d. Proton pump inhibitors.

Case Study
Fuse/Thinkstock
• A.J. is recuperating from her acute

pancreatitis without difficulty.
• Her health care provider writes an
order for her to be discharged home.
• What would be your priority
teaching to be completed prior to
her leaving?

Acute Pancreatitis
• Ambulatory and home care
• Physical therapy
• Assessment of narcotic addiction
• Counseling regarding abstinence from
alcohol and smoking

Acute Pancreatitis
• Ambulatory and home care
• Dietary teaching
• Low-fat, high-carbohydrate
• No crash diets
• Patient/family teaching
• Signs of infection, diabetes mellitus,
steatorrhea
• Medications/diet

Acute Pancreatitis
• Expected outcomes
• Have adequate pain control
• Maintain adequate fluid volume
• Be knowledgeable about treatment
regimen
• Get help for alcohol dependence ( if
appropriate)

Chronic Pancreatitis
• Continuous, prolonged inflammatory,

and fibrosing process of the pancreas
• Etiology
• Alcohol, gallstones, tumor,
pseudocysts, trauma, systemic disease
• Acute pancreatitis
• Idiopathic

Pathophysiology
• Two major types
• Chronic obstructive pancreatitis
• Gallstones cause inflammation of
sphincter of Oddi
• Chronic nonobstructive pancreatitis
• Inflammation and sclerosis in head of
pancreas and around duct

• Abdominal pain
• Located in the same areas as in acute
pancreatitis
• Heavy, gnawing feeling; burning and
cramplike
• Malabsorption with weight loss
• Constipation, jaundice, icteric urine,
steatorrhea, diabetes mellitus
• Complications include
• Pseudocyst formation
• Bile duct or duodenal obstruction
• Pancreatic ascites
• Pleural effusion
• Splenic vein thrombosis
• Pseudoaneurysm
• Pancreatic cancer
Diagnostic Studies
• Confirming diagnosis can be
challenging
• Based on signs/symptoms,
laboratory studies, and imaging

Diagnostic Studies
• Laboratory tests
• Serum amylase/lipase levels
• May be ↑ slightly or not at all
• ↑ Serum bilirubin level
• ↑ Alkaline phosphatase level
• Mild leukocytosis
• ↑ Sedimentation rate

Diagnostic Studies
• ERCP
• CT, MRI, MRCP, abdominal and/or
endoscopic ultrasonography
• Stool samples for fat content
• ↓ Fat-soluble vitamin and cobalamin
levels
• Glucose intolerance/diabetes
• Secretin stimulation test
Collaborative Care
• Analgesics for pain relief (morphine
or fentanyl transdermal patch
[Duragesic])
• Diet
• Bland, low-fat
• Small, frequent meals
• No smoking
• No alcohol or caffeine
Collaborative Care
• Pancreatic enzyme replacement
• Bile salts
• Insulin or oral hypoglycemic agents
• Acid-neutralizing and acid-inhibiting
drugs
• Antidepressants

Collaborative Care
• Surgery
• Indicated when biliary disease is
present or if obstruction or pseudocyst
develops
• Diverts bile flow or relieves ductal
obstruction
• Choledochojejunostomy
• Roux-en-Y pancreatojejunostomy
Collaborative Care
• Pancreatic drainage
• ERCP with spincterotomy and/or
stent placement

Nursing Management
• Focus is on chronic care and health
promotion
• Patient and family teaching
• Dietary control
• Pancreatic enzyme with meals/snack
• Observe for steatorrhea
• Monitor glucose levels
• Antacids after meals and at bedtime
• No alcohol

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Pancreatitis

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

• An acute inflammatory process of

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

• A.J. is a 48-year-old woman who

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

• She describes the pain as severe,

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

• A.J. admits to smoking a half-pack

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

• A.J.’s vital signs:

• What are the possible causes of

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

• A.J. asks you what pancreatitis is.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

• As you admit A.J. to the medical-

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

• For what potential complications of

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

• What diagnostic studies would you

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

• A.J.’s laboratory results

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

• She undergoes an ERCP, which

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

• When you plan care for A.J., what

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

• For what electrolyte imbalances

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

• Chloride, sodium, and potassium

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

The nurse explains to a patient with an episode of

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

• A.J. is recuperating from her acute

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

• Continuous, prolonged inflammatory,