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Focus on Pancreatitis (Relates to Chapter 44, Nursing Management: Liver, Pancreas, and Biliary Tract Problems in the textbook) Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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2 Acute Pancreatitis An acute inflammatory process of the pancreas Degree of inflammation varies from mild edema to severe necrosis. Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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3 Acute Pancreatitis Etiology and Pathophysiology Most common in middle-aged men and women Severity of the disease varies according to the extent of pancreatic destruction. African American rate 3 times higher than that of whites Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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4 Acute Pancreatitis Etiology and Pathophysiology Primary etiologic factors are Biliary tract disease Most common in women Alcoholism Most common in men Hypertriglyceridemia Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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5 Acute Pancreatitis Etiology and Pathophysiology Less common causes Trauma (postsurgical, abdominal) Viral infection Penetrating duodenal ulcer Cysts Idiopathic causes Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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6 Acute Pancreatitis Etiology and Pathophysiology Less common causes (contd) Abscesses Cystic fibrosis Kaposi sarcoma Metabolic disorders Vascular diseases Postop GI surgery Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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7 Acute Pancreatitis Etiology and Pathophysiology Less common causes (contd) Drugs Corticosteroids Thiazide diuretics Oral contraceptives Sulfonamides NSAIDs Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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8 Acute Pancreatitis Etiology and Pathophysiology Caused by autodigestion of pancreas Etiologic factors Injury to pancreatic cells Activation of pancreatic enzymes Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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9 Acute Pancreatitis Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Fig. 44-13. Pathogenic process of acute pancreatitis. GI, Gastrointestinal.

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10 Acute Pancreatitis Etiology and Pathophysiology Trypsinogen Activated to trypsin by enterokinase Inhibitors usually inactivate trypsin. Enzyme can digest the pancreas and can activate other proteolytic enzymes. Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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11 Pancreatitis Etiology and Pathophysiology Elastase Activated by trypsin Plays a major role in autodigestion Causes hemorrhage by producing dissolution of the elastic fibers of blood vessels Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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12 Acute Pancreatitis Etiology and Pathophysiology Phospholipase A Plays a major role in autodigestion Activated by trypsin and bile acids Causes fat necrosis Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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13 Acute Pancreatitis Etiology and Pathophysiology Trypsin Edema, necrosis, hemorrhage ElastaseHemorrhage Phospholipase A Fat necrosis Kallikrein Edema, vascular permeability, smooth muscle contraction, shock Lipase Fat necrosis Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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14 Acute Pancreatitis Etiology and Pathophysiology Alcohol May stimulate production of digestive enzymes Increases sensitivity to hormone cholecystokinin Stimulates production of pancreatic enzymes Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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15 Acute Pancreatitis Etiology and Pathophysiology Edematous pancreatitis Mild and self-limiting Necrotizing pancreatitis Degree of necrosis correlates with severity of manifestations. Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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16 Acute Pancreatitis Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Fig. 44-14. In acute pancreatitis, the pancreas appears edematous and is commonly hemorrhagic (H).

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17 Acute Pancreatitis Clinical Manifestations Abdominal pain is predominant symptom. Pain located in the left upper quadrant Pain may be in the midepigastrium. Commonly radiates to the back Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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18 Acute Pancreatitis Clinical Manifestations Abdominal pain (contd) Sudden onset Severe, deep, piercing, steady Aggravated by eating Onset when recumbent Not relieved by vomiting Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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19 Acute Pancreatitis Clinical Manifestations Flushing Cyanosis Dyspnea Edema Nausea/vomiting Bowel sounds decreased or absent Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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20 Acute Pancreatitis Clinical Manifestations Low-grade fever Leukocytosis Hypotension Tachycardia Jaundice Abdominal tenderness Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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21 Acute Pancreatitis Clinical Manifestations Abnormal lung sounds Crackles Discoloration of abdominal wall Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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22 Acute Pancreatitis Complications Two significant local complications Pseudocyst Abscess Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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23 Acute Pancreatitis Complications Pseudocyst Cavity surrounding outside of pancreas filled with necrotic products and liquid secretions Abdominal pain Palpable epigastric mass Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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24 Acute Pancreatitis Complications Pseudocyst (contd) Nausea, vomiting, and anorexia Elevated serum amylase May resolve spontaneously within a few weeks, or may perforate, causing peritonitis Treatment: Internal drainage procedure Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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25 Acute Pancreatitis Complications Pancreatic abscess A large fluid-containing cavity within the pancreas Results from extensive necrosis in the pancreas Upper abdominal pain Abdominal mass Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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26 Acute Pancreatitis Complications Pancreatic abscess (contd) High fever Leukocytosis Requires surgical drainage Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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27 Acute Pancreatitis Complications Main systemic complications Pulmonary Pleural effusion Atelectasis Pneumonia Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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28 Acute Pancreatitis Complications Systemic complications (contd) Cardiovascular Hypotension Tetany (caused by hypocalcemia) Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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29 Acute Pancreatitis Diagnostic Studies Laboratory tests Serum amylase Serum lipase Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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30 Acute Pancreatitis Diagnostic Studies Laboratory tests (contd) Liver enzymes Blood glucose Triglycerides Bilirubin Serum calcium Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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31 Acute Pancreatitis Diagnostic Studies Abdominal/endoscopic ultrasound X-ray Contrast-enhanced CT scan Endoscopic retrograde cholangiopancreatography (ERCP) Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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33 Acute Pancreatitis Diagnostic Studies Endoscopic ultrasound Magnetic resonance cholangiopancreatography (MRCP) Chest x-ray Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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34 Acute Pancreatitis Collaborative Care Objectives include Relief of pain Prevention or alleviation of shock of pancreatic secretions Fluid/electrolyte balance Prevention/treatment of infection Removal of the precipitating cause Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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35 Acute Pancreatitis Collaborative Care Conservative therapy Supportive care Aggressive hydration Pain management IV morphine Combined with antispasmodic agent Management of metabolic complications Minimizing stimulation Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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36 Acute Pancreatitis Collaborative Care Conservative therapy (contd) Shock Plasma or plasma volume expanders (dextran or albumin) Fluid/electrolyte imbalance Lactated Ringers solution Ongoing hypotension Vasoactive drugs: dopamine (Intropin) Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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37 Acute Pancreatitis Collaborative Care Conservative therapy (contd) Suppression of pancreatic enzymes NPO NG suction Prevent infections Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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38 Acute Pancreatitis Collaborative Care Surgical therapy indicated if Presence of gallstones Uncertain diagnosis Unresponsive to conservative therapy Abscess, pseudocyst, or severe peritonitis Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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39 Acute Pancreatitis Collaborative Care Surgical therapy ERCP Endoscopic sphincterotomy Laparoscopic cholecystectomy Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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40 Acute Pancreatitis Collaborative Care Drug therapy IV morphine Nitroglycerin or papaverine Antispasmodics Carbonic anhydrase inhibitors Antacids Histamine (H 2 ) receptor blockers Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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41 Acute Pancreatitis Collaborative Care Nutritional therapy NPO status initially to reduce pancreatic secretion IV lipids Monitor triglycerides. Small, frequent feedings High-carbohydrate, low-fat, high-protein diet Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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42 Acute Pancreatitis Collaborative Care Nutritional therapy (contd) Supplemental fat-soluble vitamins No alcohol Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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43 Acute Pancreatitis Nursing Assessment Health history Biliary tract disease Alcohol use Abdominal trauma Duodenal ulcers Infection Metabolic disorders Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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44 Acute Pancreatitis Nursing Assessment Medication usage Thiazides, estrogens, corticosteroids, NSAIDs Surgical procedures Nausea/vomiting Dyspnea Severe pain Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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45 Acute Pancreatitis Nursing Assessment Physical examination findings Fever Jaundice Discoloration of abdomen/flank Tachycardia Hypotension Abdominal distention/tenderness Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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46 Acute Pancreatitis Nursing Assessment Abnormal laboratory findings serum amylase/lipase Leukocytosis Hyperglycemia Hyperlipidemia Hypocalcemia Abnormal ultrasound/CT/ERCP Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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47 Acute Pancreatitis Nursing Diagnoses Acute pain Deficient fluid volume Imbalanced nutrition: Less than body requirements Ineffective self-health management Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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48 Acute Pancreatitis Planning Overall goals Relief of pain Normal fluid and electrolyte balance Minimal to no complications No recurrent attacks Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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49 Acute Pancreatitis Nursing Implementation Health promotion Assessment of predisposing factors Early diagnosis/treatment of cholelithiasis Elimination of alcohol intake Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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50 Acute Pancreatitis Nursing Implementation Acute intervention Monitoring vital signs IV fluids Observation of side effects of medications Assessment of respiratory function Pain assessment and management Frequent position changes Side-lying with HOB elevated 45 degrees Knees up to abdomen Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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51 Acute Pancreatitis Nursing Implementation Acute intervention (contd) Fluid/electrolyte balance Blood glucose monitoring Monitoring for signs of hypocalcemia Tetany (jerking, irritability, twitching) Numbness around lips/fingers Positive Chvosteks or Trousseaus sign Monitoring for hypomagnesemia Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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52 Acute Pancreatitis Nursing Implementation Acute intervention (contd) NG tube care Frequent oral/nasal care Observation for signs of infection Wound care Observation for paralytic ileus, renal failure, mental changes Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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53 Acute Pancreatitis Nursing Implementation Ambulatory and home care Physical therapy Counseling regarding abstinence from alcohol, caffeine, and smoking Assessment of narcotic addiction Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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54 Acute Pancreatitis Nursing Implementation Ambulatory and home care (contd) Dietary teaching High-carbohydrate, low-fat diet Patient/family teaching Signs of infection, high blood glucose, steatorrhea Medications/diet Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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55 Acute Pancreatitis Nursing Implementation Expected outcomes Have adequate pain control Maintain adequate fluid volume Be knowledgeable about treatment regimen Get help for alcohol dependence, if appropriate Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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56 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. Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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57 Chronic Pancreatitis Etiology and Pathophysiology May follow acute pancreatitis May occur in the absence of any history of an acute condition Two major types Chronic obstructive pancreatitis Chronic nonobstructive pancreatitis Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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58 Chronic Pancreatitis Etiology and Pathophysiology Chronic obstructive pancreatitis Associated with biliary disease Most common cause of this type Inflammation of the sphincter of Oddi associated with cholelithiasis Other causes include Cancer of ampulla of Vater, duodenum, or pancreas Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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59 Chronic Pancreatitis Etiology and Pathophysiology Chronic nonobstructive pancreatitis Inflammation Sclerosis Mainly in the head of the pancreas and around the pancreatic duct Most common form of chronic pancreatitis Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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60 Chronic Pancreatitis Clinical Manifestations Abdominal pain Located in the same areas as in acute pancreatitis Heavy, gnawing feeling; burning and cramplike Abdominal tenderness Malabsorption with weight loss Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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61 Chronic Pancreatitis Clinical Manifestations Constipation Mild jaundice with dark urine Steatorrhea Frothy urine/stool Diabetes mellitus Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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62 Chronic Pancreatitis Clinical Manifestations Complications include Pseudocyst formation Bile duct or duodenal obstruction Pancreatic ascites Pleural effusion Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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63 Chronic Pancreatitis Clinical Manifestations Complications (contd) Splenic vein thrombosis Pseudoaneurysm Pancreatic cancer Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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64 Chronic Pancreatitis Diagnostic Studies Confirming diagnosis can be challenging. Based on signs/symptoms, laboratory studies, and imaging Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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65 Chronic Pancreatitis Diagnostic Studies Laboratory tests Serum amylase/lipase May be slightly or not at all serum bilirubin alkaline phosphatase Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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66 Chronic Pancreatitis Diagnostic Studies Laboratory tests (contd) Mild leukocytosis Elevated sedimentation rate ERCP Visualization of pancreatic/common bile duct Stool samples Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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67 Chronic Pancreatitis Diagnostic Studies CT MRI MRCP Transabdominal ultrasound EUS Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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68 Chronic Pancreatitis Diagnostic Studies Secretin stimulation test Assessment of degree of pancreatic function Not useful in diagnosis Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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69 Chronic Pancreatitis Collaborative Care Prevention of attacks During acute attack, follow acute therapy. Relief of pain Control of pancreatic exocrine and endocrine insufficiency Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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70 Chronic Pancreatitis Collaborative Care Bland low-fat, high-carbohydrate diet Bile salts Help absorption of fat-soluble vitamins Prevent further fat loss Control of diabetes No alcohol Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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71 Chronic Pancreatitis Collaborative Care Pancreatic enzyme replacement Acid-neutralizing and acid-inhibiting drugs Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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72 Chronic Pancreatitis Collaborative Care Surgery Indicated when biliary disease is present, or if obstruction or pseudocyst develops Diverts bile flow or relieves ductal obstruction Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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73 Chronic Pancreatitis Nursing Management Focus is on chronic care and health promotion. Dietary control No alcohol Control of diabetes Taking pancreatic enzymes Patient and family teaching Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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74 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: 1. Antibiotics. 2. NPO status. 3. Antispasmodics. 4. H 2 R blockers or proton pump inhibitors. Audience Response Question Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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Case Study Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 75

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76 Case Study 63-year-old woman 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. Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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77 Case Study Pain began 24 hours ago. She is divorced and retired, and smokes a half-pack of cigarettes a day. Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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78 Case Study Vital signs Blood pressure 100/70 Heart rate 97 Respiratory rate 30 Temperature 100.2F She is diagnosed with acute pancreatitis and is admitted to the medical-surgical unit. Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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79 Discussion Questions 1.What are the possible causes of pancreatitis? 2.What is her priority of care? Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

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80 Discussion Questions 3.What laboratory tests are the most important to monitor in acute pancreatitis? 4.What patient teaching should you do with her? Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.