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Focus on Pancreatitis(Relates to Chapter 44, (Relates to Chapter 44,
“Nursing Management: Liver, Pancreas, “Nursing Management: Liver, Pancreas, and Biliary Tract Problems” and Biliary Tract Problems”
in the textbook) in the textbook)
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Acute Pancreatitis
•An acute inflammatory process of the pancreas
•Degree of inflammation varies from mild edema to severe necrosis
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Acute PancreatitisEtiology and Pathophysiology
•Most common in middle-aged men and women
•Severity of the disease varies according to the extent of pancreatic destruction
•Can be life-threatening•African American rate three
times higher than for whites
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Acute PancreatitisEtiology and Pathophysiology (Cont’d)
•Primary etiologic factors are •Biliary tract disease
•Most common: Gallbladder disease
•Alcoholism
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Acute PancreatitisEtiology and Pathophysiology (Cont’d)
•Less common causes•Trauma (postsurgical,
abdominal)•Viral infections (mumps,
coxsackievirus HIV)•Penetrating duodenal ulcer•Cysts • Idiopathic
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Acute PancreatitisEtiology and Pathophysiology
•Less common causes (cont’d)•Abscesses •Cystic fibrosis •Kaposi’s sarcoma •Metabolic disorders•Vascular diseases•Postop GI surgery
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Acute PancreatitisEtiology and Pathophysiology
•Less common causes (cont’d)•Drugs
•Corticosteroids•Thiazide diuretics •Oral contraceptives•Sulfonamides •NSAIDs
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Acute PancreatitisEtiology and Pathophysiology
•Caused by autodigestion of pancreas
•Etiologic factors• Injury to pancreatic cells•Activate pancreatic enzymes
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Acute Pancreatitis
Fig. 44-14Fig. 44-14
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Acute PancreatitisEtiology and Pathophysiology
•Trypsinogen•Activated to trypsin by
enterokinase• Inhibitors usually inactivate
trypsin•Enzyme can digest the
pancreas and can activate other proteolytic enzymes
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PancreatitisEtiology and Pathophysiology
•Elastase•Activated by trypsin
•Plays a major role in autodigestion
•Causes hemorrhage by producing dissolution of the elastic fibers of blood vessels
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Acute PancreatitisEtiology and Pathophysiology
•Phospholipase A•Plays a major role in
autodigestion•Activated by trypsin and bile
acids•Causes fat necrosis
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Acute PancreatitisEtiology and Pathophysiology (Cont’d)
Trypsin Edema, necrosis, hemorrhage
Elastase Hemorrhage
Phospholipase A Fat necrosis
Kallikrein Edema, vascular permeability, smooth muscle contraction, shock
Lipase Fat necrosis
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Acute PancreatitisEtiology and Pathophysiology (Cont’d)
•Alcohol•May stimulate production of
digestive enzymes• Increases sensitivity to
hormone cholecystokinin•Stimulates production of pancreatic enzymes
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Acute PancreatitisEtiology and Pathophysiology (Cont’d)
•Edematous pancreatitis•Mild and self-limiting
•Necrotizing pancreatitis•Degree of necrosis correlates
with severity of manifestations
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Acute PancreatitisClinical Manifestations
•Abdominal pain is predominant symptom•Pain located in the left upper
quadrant•Pain may be in the
midepigastrium•Commonly radiates to the
back
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Acute PancreatitisClinical Manifestations
•Abdominal pain (cont’d)•Sudden onset•Severe, deep, piercing,
steady•Aggravated by eating•Not relieved by vomiting
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Acute PancreatitisClinical Manifestations
•Flushing•Cyanosis•Dyspnea•Edema•Nausea/vomiting•Bowel sounds decreased or
absent
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Acute PancreatitisClinical Manifestations (Cont’d)
•Low-grade fever•Leukocytosis•Hypotension•Tachycardia• Jaundice •Abdominal tenderness
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Acute PancreatitisClinical Manifestations (Cont’d)
•Abdominal distention•Abnormal lung sounds•Crackles
•Discoloration of abdominal wall
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Acute PancreatitisComplications
•Two significant local complications•Pseudocyst•Abscess
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Acute PancreatitisComplications (Cont’d)
•Pseudocyst •Cavity surrounding outside of
pancreas filled with necrotic products and liquid secretions
•Abdominal pain•Palpable epigastric mass
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Acute PancreatitisComplications
•Pseudocyst (cont’d)•Nausea, vomiting, and anorexia•Elevated serum amylase•May resolve spontaneously
within a few weeks or may perforate, causing peritonitis
•Treatment: Internal drainage procedure
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Acute PancreatitisComplications
•Pancreatic abscess•A large fluid-containing
cavity within pancreas•Results from extensive
necrosis in the pancreas•Upper abdominal pain•Abdominal mass
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Acute PancreatitisComplications
•Pancreatic abscess (cont’d)•High fever•Leukocytosis•Requires surgical drainage
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Acute PancreatitisComplications
•Main systemic complications•Pulmonary
•Pleural effusion•Atelectasis•Pneumonia
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Acute PancreatitisComplications
•Systemic complications (cont’d)•Cardiovascular
•Hypotension•Tetany (caused by
hypocalcemia)
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Acute PancreatitisDiagnostic Studies
•History and physical examination
•Laboratory tests•Serum amylase•Serum lipase•2-hour urinary amylase and
renal amylase clearance
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Acute PancreatitisDiagnostic Studies
•Laboratory tests (cont’d)•Blood glucose•Serum calcium•Triglycerides
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Acute PancreatitisDiagnostic Studies
•Flat plate of abdomen•Abdominal/endoscopic
ultrasound•Endoscopic retrograde
cholangiopancreatography (ERCP)
•Chest x-ray
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Page 32
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Acute PancreatitisDiagnostic Studies (Cont’d)
•CT of pancreas•Magnetic resonance
cholangiopancreatography (MRCP)
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Acute PancreatitisCollaborative Care
•Objectives include•Relief of pain•Prevention or alleviation of
shock•↓ of pancreatic secretions•Fluid/electrolyte balance•Removal of the precipitating
cause
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Acute PancreatitisCollaborative Care (Cont’d)
•Conservative therapy •Supportive care
•Aggressive hydration•Pain management
• IV morphine•Combined with antispasmodic agent
•Management of metabolic complications
•Minimizing stimulation
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Acute PancreatitisCollaborative Care
•Conservative therapy (cont’d)•Shock
•Plasma or plasma volume expanders (dextran or albumin)
•Fluid/electrolyte imbalance•Lactated Ringer’s solution
•Ongoing hypotension•Vasoactive drugs: Dopamine (Intropin)•↑ Systemic vascular resistance
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Acute PancreatitisCollaborative Care
•Conservative therapy (cont’d)•Suppression of pancreatic
enzymes•NPO•NG suction
•Prevent infections•Peritoneal lavage or dialysis
•Remove kinin and phospholipase A exudate
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Acute PancreatitisCollaborative Care
•Surgical therapy indicated if •Presence of gallstones•Uncertain diagnosis•Unresponsive to conservative
therapy•Abscess, pseudocyst, or
severe peritonitis
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Acute PancreatitisCollaborative Care
•Surgical therapy (cont’d)•ERCP•Endoscopic sphincterotomy•Laparoscopic
cholecystectomy
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Acute PancreatitisCollaborative Care (Cont’d)
•Drug therapy• IV morphine•Nitroglycerin or papaverine•Antispasmodics •Carbonic anhydrase inhibitor•Antacids•Histamine (H2) receptor
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Acute PancreatitisCollaborative Care (Cont’d)
•Nutritional therapy•NPO status initially to reduce
pancreatic secretion• IV lipids
•Monitor triglycerides•Small, frequent feedings•High-carbohydrate, low-fat,
high-protein diet•Bland diet
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Acute PancreatitisCollaborative Care
•Nutritional therapy (cont’d)•Supplemental fat-soluble
vitamins•Supplemental commercial
liquid preparations•Parenteral nutrition•No caffeine or alcohol
Page 42
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Acute PancreatitisNursing Assessment
•Health history•Biliary tract disease•Alcohol use•Abdominal trauma•Duodenal ulcers• Infection •Metabolic disorders
Page 43
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Acute PancreatitisNursing Assessment (Cont’d)
•Medication usage•Thiazides, estrogens,
corticosteroids, NSAIDs•Surgical procedures•Nausea/vomiting•Dyspnea•Severe pain
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Acute PancreatitisNursing Assessment (Cont’d)
•Physical examination findings•Fever• Jaundice•Discoloration of abdomen/flank•Tachycardia•Hypotension•Abdominal distention/tenderness
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Acute PancreatitisNursing Assessment (Cont’d)
•Abnormal laboratory findings•↑ Serum amylase/lipase•Leukocytosis•Hyperglycemia•Hyperlipidemia•Hypocalcemia•Abnormal ultrasound/ CT/ ERCP
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Acute PancreatitisNursing Diagnoses
•Acute pain•Deficient fluid volume• Imbalanced nutrition: Less
than body requirements• Ineffective therapeutic
regimen management
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Acute PancreatitisPlanning
•Overall goals•Relief of pain •Normal fluid and electrolyte
balance•Minimal to no complications•No recurrent attacks
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Acute PancreatitisNursing Implementation
•Health Promotion•Assessment of predisposing
factors•Early diagnosis/treatment of
cholelithiasis•Eliminate alcohol intake
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Acute PancreatitisNursing Implementation (Cont’d)
•Acute Intervention•Monitor vital signs• IV fluids•Observe for side effects of
medications•Assess respiratory function•Pain assessment and management
•Frequent position changes•Side-lying with HOB elevated 45 degrees•Knees up to abdomen
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Acute PancreatitisNursing Implementation
•Acute Intervention (cont’d)•Fluid/electrolyte balance
•Blood glucose monitoring•Monitor for signs of hypocalcemia
•Tetany (jerking, irritability, twitching)•Numbness around lips/fingers•Positive Chvostek or Trousseau sign
•Monitor for hypomagnesemia
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Acute PancreatitisNursing Implementation
•Acute Intervention (cont’d)•NG tube care•Frequent oral/nasal care•Observe for signs of infection•Wound care•Observe for paralytic ileus,
renal failure, mental changes
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Acute PancreatitisNursing Implementation
•Ambulatory and Home Care•Physical therapy•Counseling regarding
abstinence from alcohol, caffeine, and smoking
•Assessment of narcotic addiction
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Acute PancreatitisNursing Implementation
•Ambulatory and Home Care (cont’d)•Dietary teaching
•High-carbohydrate, low-fat diet•Patient/family teaching
•Signs of infection, high blood glucose, steatorrhea
•Medications/diet
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Acute PancreatitisNursing Implementation
•Expected outcomes•Maintains adequate fluid
volume•Maintains weight appropriate
for height•Food and fluid intake
adequate to meet nutritional needs
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Acute PancreatitisNursing Implementation
•Expected outcomes (cont’d)•Describes therapeutic
regimen•Expresses commitment to
lifestyle changes
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Chronic Pancreatitis
•Continuous, prolonged inflammatory, and fibrosing process of the pancreas•Pancreas becomes destroyed
as it is replaced by fibrotic tissue
•Strictures and calcifications can also occur
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Chronic PancreatitisEtiology and Pathophysiology
•May follow acute pancreatitis •May occur in absence of any
history of acute condition•Two major types•Chronic obstructive pancreatitis•Chronic calcifying pancreatitis
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Chronic PancreatitisEtiology and Pathophysiology (Cont’d)
•Chronic obstructive pancreatitis•Associated with biliary disease
• Most common cause• Inflammation of the sphincter of
Oddi associated with cholelithiasis
•Other causes include•Cancer of ampulla of Vater, duodenum, or pancreas
Page 59
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Chronic PancreatitisEtiology and Pathophysiology (Cont’d)
•Chronic calcifying pancreatitis• Inflammation•Sclerosis
•Mainly in the head of the pancreas and around the pancreatic duct
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Chronic PancreatitisEtiology and Pathophysiology
•Chronic calcifying pancreatitis (cont’d)•Most common form of chronic
pancreatitis•May be referred to as
alcohol-induced pancreatitis
Page 61
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Chronic PancreatitisEtiology and Pathophysiology
•Chronic calcifying pancreatitis (cont’d)•Ducts are obstructed with
protein precipitates•Precipitates block the
pancreatic duct and eventually calcify
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Chronic PancreatitisEtiology and Pathophysiology
•Chronic calcifying pancreatitis (cont’d)•Calcification is followed by
fibrosis and glandular atrophy
•Pseudocysts and abscesses commonly develop
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Chronic PancreatitisClinical Manifestations
•Abdominal pain•Located in the same areas as
in acute pancreatitis •Heavy, gnawing feeling;
burning and cramp-like•Abdominal tenderness•Malabsorption with weight
loss
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Chronic PancreatitisClinical Manifestations (Cont’d)
•Constipation•Mild jaundice with dark
urine•Steatorrhea•Frothy urine/stool•Diabetes mellitus
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Chronic PancreatitisClinical Manifestations (Cont’d)
•Complications•Pseudocyst formation•Bile duct or duodenal
obstruction•Pancreatic ascites•Pleural effusion
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Chronic PancreatitisClinical Manifestations
•Complications (cont’d)•Splenic vein thrombosis•Pseudoaneurysms•Pancreatic cancer
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Chronic PancreatitisDiagnostic Studies
•Confirming diagnosis can be challenging
•Based on signs/symptoms, laboratory studies, and imaging
Page 68
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Chronic PancreatitisDiagnostic Studies (Cont’d)
•Laboratory tests•Serum amylase/lipase
•May be ↑ slightly or not at all•↑ Serum bilirubin•↑ Alkaline phosphatase
Page 69
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Chronic PancreatitisDiagnostic Studies
•Laboratory tests (cont’d)•Mild leukocytosis•Elevated sedimentation rate
•ERCP•Visualize pancreatic/common
bile duct
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Chronic PancreatitisDiagnostic Studies
•CT•MRI•MRCP•Transabdominal ultrasound
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Chronic PancreatitisDiagnostic Studies (Cont’d)
•Endoscopic ultrasound•Secretin stimulation test•Assess degree of pancreatic
function•Not useful in diagnosis
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Chronic PancreatitisCollaborative Care
•Prevention of attacks•During acute attack, follow
acute therapy•Relief of pain•Control of pancreatic
exocrine and endocrine insufficiency
Page 73
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Chronic PancreatitisCollaborative Care (Cont’d)
•Bland low-fat, high-carbohydrate diet
•Bile salts •Help absorption of fat-soluble
vitamins•Prevent further fat loss
•Control of diabetes•No alcohol
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Chronic PancreatitisCollaborative Care (Cont’d)
•Pancreatic enzyme replacement
•Acid-neutralizing and acid-inhibiting drugs
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Chronic PancreatitisCollaborative Care (Cont’d)
•Surgery• Indicated when biliary
disease is present or if obstruction or pseudocyst develops
•Divert bile flow or relieve ductal obstruction
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Chronic PancreatitisNursing Management
•Focus is on chronic care and health promotion•Dietary control
•No alcohol•Control of diabetes•Taking pancreatic enzymes•Patient and family teaching
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Case Study
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Case Study•63-year-old female enters the
emergency department with nausea, vomiting, epigastric pain, left upper quadrant pain
•She claims the pain is severe, sharp, and boring and radiates through to her mid-back
Page 79
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Case Study (Cont’d)•Pain began 24 hours ago
•She is divorced, retired, and smokes a half-pack of cigarettes a day
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Case Study (Cont’d)•Vital signs•Blood pressure 100/70 mm Hg•Heart rate 97 beats/min•Respiratory rate 30 breaths/min•Temperature 100.2°F
•She is diagnosed with acute pancreatitis and admitted to the medical-surgical unit
Page 81
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Discussion Questions1.What are the possible causes
of pancreatitis?
2.What is her priority of care?
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Discussion Questions (Cont’d)
3.What labs are the most important to monitor in acute pancreatitis?
4.What patient teaching should you do with her?