RUNNING HEAD: Case 51 1

Case 51

Epidemiology

In the US there are approximately 40 cases per year per 100,000 adults. This number has

risen in the last several decades most likely due to the increased intake of fat and alcohol in our

diets. Worldwide the US has the highest rates of pancreatitis and is followed next by Finland;

incidence of the disease outside North America, Europe, and Australia is less well known. The

onset of the disease can be caused in many different ways, the most common being alcohol-

related, biliary tract-related, and ERCP-related and the age group most commonly affected are

35-75 year olds. Males are more often affected and it is usually alcohol related, while with

females it is more likely to be caused by biliary tract disease. African Americans hospitalization

rates are three times higher than whites when it comes to pancreatitis.

Pathophysiology

The pancreas is located in the left upper quadrant of the abdomen and has both endocrine

and exocrine functions. The endocrine functions include secreting glucagon and insulin, while

the exocrine function is to produce digestive enzymes and alkaline fluid. With pancreatitis the

main problem is when the exocrine function begins to fail at working effectively. The digestive

enzymes that the pancreas produces are amylase, trypsin, and lipase; they break down

carbohydrates, proteins and fats respectively. The inflammation of the pancreas is caused by a

premature activation of these enzymes. Necrosis, hemorrhage, and autodigestion occurs when the

enzymes are activated before leaving the organ. There are several mechanisms that exist to

prevent premature activation of the enzymes. A disruption in these protective measures may

occur which leads to acute pancreatitis. Some examples of things that typically cause the

mechanisms to fail are alcohol use, gallstones, and certain drugs.

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Scenario

B.K is a 63-year-old woman who is admitted to the medical-surgical unit from the

emergency department (ED) with nausea and vomiting (N/V) and epigastric and left upper

quadrant (LUQ) pain that is severe, sharp, and boring and radiates through to her mid-back. The

pain started 24 hours ago and awoke her in the middle of the night. B.K. is a divorced, retired

sales manager who smokes a half-pack of cigarettes daily. The ED nurse reports that B.K. is

anxious and demanding. B.K. denies using alcohol. Her vital signs (VS) are as follows: 100/70,

97, 30, 100.2F (37.9C) (Tympanic), SpO2 88% on room air and 92% on 2L of oxygen by nasal

cannula (NC). She is in normal sinus rhythm. She will be admitted to the hospitalist service. She

has no primary care provider (PCP) and hasn’t seen a physician “in years”.

The ED nurse giving you the report states that the admitting diagnosis is acute

pancreatitis of unknown etiology. A computed tomography (CT) scan has been ordered, but,

unfortunately, the CT scanner is down and won’t be fixed until morning. However, an ultrasound

of the abdomen was performed, and “no cholelithiasis, gallbladder wall thickening, or

choledocholithiasis was seen. The pancreas was not well visualized due to overlying bowel gas.”

Admission labs have been drawn; a clean-catch urine specimen was sent to the lab, and the urine

was dark in color.

Case Study Prompts

1. What are the possible causes of pancreatitis? Some of the common causes are

chronic alcohol use, biliary tract malfunctions, and cholelithiasis (Gallbladder

stones).

2. If a CT scan is planned for the morning, what orders would you expect? The

patient would be ordered NPO several hours prior to the examination. This is

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required to help visualize the organ’s size and in this case to give the pancreas a

rest. Food and fluids are only going to exacerbate B.K.’s symptoms and cause

potential harm.

3. What other information do you need from the ED nurse before you assume

responsibility for the patient? When her last intake was and what it was, what she

has been using to manage her pain, and when the last time she voided/had a bowel

movement was.

4. Which specific laboratory results point to a diagnosis of pancreatitis? Elevated

lipase, amylase, and WBC all indicate pancreatitis.

5. Which labs are the most important to monitor in acute pancreatitis? Why are they

significant? Lipase and amylase are the enzymes that are produced by the

pancreas and when they are prematurely activated in the pancreas they cause

autodigestion. Increased WBC is a sign that the body is trying to fight off an

infection, which is being caused by the pancreatitis.

6. What do the BUN and creatinine tell you about her renal function and volume

status? The level of creatinine is an indicator of how well the renal system is able

to filter the blood. When the kidneys are not functioning properly creatinine will

build up in the blood supply instead of being filtered out and excreted in the urine.

BUN is the measurement of nitrogen in the blood; a waste product of urea. When

the kidneys are not able to remove the nitrogen from the blood the BUN levels

rise and it is an indicator of how well they are working. The elevated state of

B.K.’s BUN and creatinine means that her renal function is down and that she is

dehydrated.

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7. Why are the WBC’s elevated? The autodigestion of the pancreatic tissue is

providing bacteria the opportunity to attack weakened tissue. The body is

responding to this attack by increasing the amount of WBCs to combat these

pathogens.

8. Identify three actions you could initiate to help correct this situation: Since B.K.

has a pleural effusion in her left lower lobe her ability to ventilate and perfuse

oxygen has been decreased. To increase her SpO2 and decrease the rate of her

respirations the rate of her oxygen could be increased to 4L O2/NC. If this proved

to be ineffective then moving to a simple face mask and titrating the O2 rate until

therapeutic would be necessary. Sitting B.K. up in bed would allow her to fully

expand her lungs to maximize her ability to ventilate and decrease the effort

required to breathe. Encourage her to cough and deep breath to keep the fluid

moving in her lungs to decrease the chances of pneumonia and teach her how to

use the incentive spirometer.

9. B.K. turns on her call light. She complains of thirst and demands something to

drink. Her orders indicate “NPO, except sips and chips.” What is your response

to her request? What nursing action would help her complaints? “Sips and chips”

indicates that the physician has approved the consumption of small sips of water

and to suck on ice chips. This may be contraindicated to her pancreatitis because

the mechanical stimulation of objects in the mouth and swallowing triggers the

pancreas to secrete digestive enzymes which will further complicate her

condition. To maintain her fluid status IV fluids should be given and allow her to

only have a small amount of water and ice.

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10. What will you do next? Since her pulse oximetry is 87% the biggest concern is

oxygen not being perfused to vital tissues. To correct this the head of the bed

should be elevated to aid in lung expansion, coughing and deep breathing to help

clear mucous from the lungs, and titrating the rate of the oxygen being delivered

until she is able to maintain a saturation of 92% or higher.

11. Your assessment findings are as follows: lung sounds absent in the LLL and very

diminished in the right lower lobe (RLL). You percuss a dull thud over the left

middle lobe (LML) and LLL up to the scapula tip. On percussion, you hear

resonance over the entire right lung and left upper lobe (LUL). What is

significance of your findings? The absent lungs sounds in the LLL indicates that

they have been either collapsed or that there is so much fluid pushing up against

the lobe that they are not able to fill with air. The diminished sounds over the

RLL is a sign that the fluid has now begun to move to the right lung and cause

problems there as well. The dull thud on percussion shows that fluid is starting to

build up in the left lung and resonance indicates that those parts of the lungs are

still clear of fluid and able to expand properly. These findings are all indicative of

a significant pleural effusion that needs to be addressed.

12. What actions should you take next? Report these worsening conditions to the

attending physician and continue to monitor pulse oximetry, perform pulmonary

toileting, and position the client so that the lungs are able to expand.

13. Based on the evolving pleural effusion with evidence of decompensation (hypoxia)

by the patient, what treatment would the physician likely pursue, and what

preparations would you be responsible for? Since there is an increasing amount

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of fluid filling the pleural space a thoracentesis should be performed. This

procedure involves the removal of fluid using a long needle inserted into the

chest. It is typically performed at the bedside by a physician and is very effective

at decreasing the amount of pressure applied to the lungs. The responsibilities of

the nurse for this procedure include having the patient sit up in bed and lean

forward placing the elbows on the bedside table, inform the patient that they may

feel some discomfort and while the needle is removed to take a deep breath and

hum to prevent the chance of a pneumothorax. Once the procedure is complete a

sterile occlusive dressing will be placed over the insertion site and needs to be

monitored by the nurse.

14. How would you know whether B.K. was not able to tolerate the advancement in

diet? A full liquid diet consists of foods that are normally in liquid form at room

temperature. If B.K. began to experience nausea, vomiting, pain one to two hours

after eating, or difficulty swallowing then it may indicate the need to change her

diet order.

15. If B.K. does not tolerate the advancement in diet, what physiologic need should be

addressed at 72 hours? After 72 hours of being NPO the body will begin to

metabolize fats for energy and demands for nutrition will increase. Mental status

changes including lethargy and grogginess occur and blood pressure decreases.

The body is starving and if the digestive system cannot handle food then TPN

should be considered to ensure that the patient is receiving the required nutrients

to preserve life.

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16. What is B.K. most likely experiencing and what actions will you take? B.K. is

most likely experiencing alcohol withdrawal. Her pancreatitis was most likely

caused by chronic alcohol abuse and she is exhibiting all of the tell-tale signs and

symptoms of withdrawal. The CIWA scale identifies how intense the withdrawal

is and is a tool that informs nurses how much lorazapam (Ativan) to administer to

the patient. Ativan is an antiaxiety agent and helps decrease the symptoms of

ETOH withdrawal by depressing the central nervous system (CNS). Along with

drug administration it is important to frequently reorient the patient to their

surrounds, reduce stimuli, and ensure patient safety by initiating seizure

precautions.

17. What will you include in your discharge teaching with B.K.? To help B.K.’s

pancreas heal a diet of low fat, cholesterol, and caffeine diet, cessation of smoking

and drinking alcohol, small frequent meals, and the importance of regular

physician visits to identify possible problems before they occur. Since she is

estranged from her family social service consult should help her reconnect with

her loved ones.

Evidence/Researched based support for nursing interventions

A search of several online databases for research articles related to pancreatitis was

performed to further enrich the understanding of this disease. Enzyme replacement therapy is an

intervention performed for those who had their pancreas removed. Since the pancreas is

responsible for the production of amylase, lipase, and trypsin, all important enzymes involving

the digestion of food, its absence would cause serious problems for a patient who wished to

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continue to advance their diet. Artificial enzymes are created and given to the patient to

supplement the lack of natural catalysts. “Patients who have, or are considered likely to

have,steatorrhea (the pathological excretion of more than 15 grams of fat per day in the stool)

should receive pancreatin supplementation, as should those with an abnormal pancreatic function

test combined with clinical evidence of malabsorption… Even if the excretion of fat in the stool

is in the low abnormal range (7–15 g/d), pancreatin should be given if there is evidence of

malassimilation, e.g., weight loss, or if the patient has abdominal manifestations attributable to

maldigestion and malabsorption.” (Mayerle 2013) Without these pancreatic enzymes the patient

is not able to absorb fat and many other nutrients. In case 51 B.K. developed a pleural effusion,

which may make people wonder “Why a pleural effusion? The pancreas deals with digestion, not

the lungs!” The answer boils down to anatomy. “Pulmonary complications occur when fluid

leaking from the pancreas increases fluid in the pleural space, causing pleural effusion.”

(Holcomb 2007) Since the pancreas rests below the diaphragm it is likely that inflammation can

be transferred to the lungs easily. The most common causes of pancreatitis are alcohol abuse,

smoking, and biliary tract malfunctions, another rare but important cause is certain drugs; ACE

inhibitors for example. “Numerous ACE inhibitors have been associated with

Acute pancreatitis of generally mild intensity has been drug-induced

pancreatitis, including enalapril (table II), captopril, lisinopril, quinapril,

ramipril and perindopril.In a case-control study,[6] ACE inhibitors were

associated with an odds ratio of 1.5 for drug-induced pancreatitis, with the

risk increasing with increasing drug dose and being highest during the first 6

months of treatment.” (Drugs & Therapy 2009) Although it is rare for these

drugs to cause pancreatitis it is important to know all the possibilities when

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identifying the cause of a disease. One demographic of people who are at

risk for developing pancreatitis is those who have cystic fibrosis. “Defects in

the CFTR protein cause abnormal chloride transport across the apical

membranes of epithelial cells in the airways, pancreas, intestine, and vas

deferens, leading to progressive lung disease, pancreatic dysfunction,

elevated sweat electrolyte levels, and male infertility, respectively.” (De

Boeck) Pancreatitis is a well-documented and understood disease; years of

research have been done to fully comprehend every angle of the disease.

Pancreatic cancer remains one of the most deadly forms of cancer and the

ability to screen for it is severely underdeveloped. It is recommended that

more time is placed in developing a new tactic to identifying this tragic form

of cancer before it is too late.

Conclusion

Pancreatitis is a disease that affects many adults of all nationalities. It is

caused mostly by factors that can be altered such as diet, exercise, smoking,

and alcohol consumption. The pathophysiology of pancreatitis is well

understood and intervention plans are well developed for each possible

cause. Case study 51 provided a scenario that could easily be seen in a real-

life clinical setting and posed questions that directly applied to how a nurse

would act in realistic situations. Through completing the case a great amount

of knowledge and understanding was attained. The vast amount of research

and evidence supporting interventions suggests that many decades of hard

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work and testing have been fruitful; medicine has a firm grip on pancreatitis.

The next step in preventing this disease is in education; reaching out to

those who are at risk and helping them obtain the resources necessary to aid

them in steering clear of pancreatitis.

Case 51 11

References

Acute Pancreatitis . (n.d.). Acute Pancreatitis. Retrieved February 24, 2014, from

http://emedicine.medscape.com/article/181364-overview#a0156

De Boeck, K., Weren, M., Proesmans, M., & Kerem, E. (2005). Pancreatitis among patients with cystic

fibrosis: correlation with pancreatic status and genotype. Pediatrics, 115(4 Part 1), e463-9.

Holcomb, S. (2007). Stopping the destruction of acute pancreatitis. Nursing, 37(6), 42-48.

Hopkins, J. (2012, November 12). Basics of Pancreatic Cancer. Johns Hopkins Medicine.

Retrieved February 26, 2014, from http://pathology.jhu.edu/pc/basicintro.php?area=ba

Mayerle, J., Hoffmeister, A., Werner, J., Witt, H., Lerch, M. M., & Mössner, J. (2013). Chronic

Pancreatitis--Definition, Etiology, Investigation and Treatment. Deutsches Aerzteblatt

International, 110(22), 387-393. doi:10.3238/arztebl.2013.0387

Prevent and manage drug-induced pancreatitis by identifying the offending agent and

understanding the underlying mechanisms. (2009). Drugs & Therapy Perspectives, 25(8),

19-22