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Pancreatitis: inflammatory disease of the pancreas that may result in autodigestion of the pancreas by its own enzymes.
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Pathophysiology: proteolytic enzymes within the pancreas are activated by endotoxins, exotoxins, ischemia, anoxia, or trauma. Pancreatic enzymes begin process of autodigestion of pancreas and surrounding tissues; also activate other enzymes that digest cellular membranes. Autodigestion leads to edema, hemorrhage, vascular damage, coagulation necrosis, and fat necrosis.
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Risk factors:
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Obesity.
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Alcoholism, alcohol consumption.
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Biliary tract disease.
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Abdominal trauma.
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Surgery.
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Drugs.
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Metabolic disease.
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Intestinal disease.
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Obstruction of the pancreatic ducts.
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Infections.
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Carcinoma.
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Adenoma.
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Hypercalcemia.
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Assessment:
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Subjective data:
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Pain:
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Sudden onset; severe, widespread, constant, and incapacitating.
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Location-epigastrium, right upper quadrant (RUQ) and left upper quadrant (LUQ) of abdomen; radiates to back, flanks, and substernal area.
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Nausea.
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History of risk factors.
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Dyspnea.
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Objective data:
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Elevated: temperature, pulse, respirations, BP (unless in shock).
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Decreased breath sounds related to atelectasis/pleural effusion.
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Increased crackles, cyanosis.
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Hemorrhage, shock.
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Vomiting.
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Fluid and electrolyte imbalances, dehydration.
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Decreased bowel sounds; abdominal tenderness with guarding.
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Stools: bulky, pale, foul smelling, steatorrhea (excessive fat in stools).
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Skin: pale, moist, cold; may be jaundiced.
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Muscle rigidity.
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Supine position leads to increased pain.
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Fluid accumulation in the abdomen.
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Lab data:
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Elevated:
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Amylase, serum, and urine.
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Serum lipase, AST (SGOT).
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Alkaline phosphatase.
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Bilirubin, glucose; serum and urine.
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Urine protein, WBC.
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Leukocytes.
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BUN.
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LDH (liver function, lactate dehydrogenase).
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Decreased:
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Serum calcium.
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Protein.
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Ultrasound for gallstones, CAT scan.
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Analysis/nursing diagnosis:
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Altered nutrition, less than body requirements, related to nausea and vomiting.
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Pain related to inflammatory and autodigestive processes of pancreas.
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Fluid volume deficit related to inflammation, decreased intake, and vomiting.
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Ineffective breathing pattern related to pain and pleural effusion.
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Knowledge deficit related to risk factors and disease management.
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Nursing care plan/implementation:
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Goal: control pain.
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Medications: analgesics-meperidine (not morphine or codeine due to spasmodic effect).
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Position: sitting with knees flexed.
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Goal: rest injured pancreas.
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NPO.
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NG tube to low suction.
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Medications:
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Antiulcers.
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Antibiotics.
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Antiemetics.
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Antispasmodics.
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Anticholinergics.
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Histamine-2 receptors.
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Goal: prevent fluid and electrolyte imbalance.
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Monitor: vitals, CVP.
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IVs, fluids, blood, albumin, plasma.
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Goal: prevent respiratory and metabolic complications.
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Cough, deep breathe, change position.
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Monitor: blood sugar as ordered.
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Monitor calcium levels: Chvostek's and Trousseaus sign positive when calcium deficit exists.
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Goal: provide adequate nutrition.
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Low-fat diet.
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Bland, small, frequent meals.
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Vitamin supplements.
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Avoid alcohol.
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Goal: prevent complications.
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Monitor for signs of:
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Peritonitis.
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Perforation.
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Respiratory complications.
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Hypotension, shock.
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DIC.
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Hemorrhage from ulcers, varices.
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Anemia.
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Encephalopathy.
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Goal: health teaching.
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Food selections for low-fat, bland diet.
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Necessity of vitamin therapy.
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Importance of avoiding alcohol.
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Signs and symptoms of recurrence.
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Importance of rest, to prevent relapse.
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Desired effects and side effects of prescribed medications:
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Narcotics for pain.
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Antiemetics for nausea and vomiting.
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Pancreatic hormone and enzymes to replace enzymes not reaching duodenum.
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Evaluation/outcome criteria:
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Pain is relieved.
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No complications, peritonitis, respiratory.
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States dietary allowances and restrictions.
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Takes medications as ordered; states purposes, side effects.