ACUTE PANCREATITIS

Marcia DuncombeShawntay Fernandez

Syreeta GarriquesJennifer Pacheco

Pathophysiology

Unknown Alcohol / Drugs Pancreatic duct obstruction

Assessment Findings

Sudden / Severe abdominal pain N / V Dyspnea / Tachypnea Fever Decreased / absent bowel sounds Distended / tender abdomen Referred shoulder pain Hypovolemia

Edematous (Mild) Pancreatitis

Edema in surrounding tissues Minimal necrotizing of fat tissues

Necrotizing (Severe) Pancreatitis

Necrosis of pancreatic tissue Bleeding into surrounding tissues High mortality rate

Diagnostic StudiesAmylase 

 ↑↑ Rises three times the limit in 24 hours, may remain elevated for 3 to 5 days

Lipase ↑↑ Rises three times the limit in 24 hours, may remain elevated for 5 to 7 days

WBC ↑ Secondary to inflammation process

Glucose ↑ Elevated if islets of Langerhans cells have been effected

LDH ↑ Associated with  acute pancreatitis

Albumin ↓ Associated with acute inflammation and infections, protein deficiency

AST ↑ AST is found in the pancreas, elevated levels occur after injury or cell death

Na+, K+. Mg+ ↓ Decreased due to vomiting

Ca++ ↓ Decreased due to vomiting, also associated with a decrease in albumin levels.

Low levels lead to a prolonged QT level.

Hct ↑ Related to hemoconcentration due to dehydration

Hgb ↓ Decreased due to bleeding

ABGs Abnormal Pt. may develop metabolic acidosis associated with damage to islets of Langerhans cells. 

Without insulin, fatty acids are released into circulation.

Acute pancreatitis reduces bicarb levels.

Diagnostic Imaging Test

Abdominal scan Abdominal CT scan Endoscopic Retrograde

Cholangiopancreatography (ERCP) Magnetic Resonance

Cholangiopancreatography (MRCP)

Priscilla’s Labs Indicate:

↑ Amylase, Lipase, WBC, Glucose, LDH, Hct ↓ Electrolytes Abnormal ABGs indicate Metabolic Acidosis

with respiratory compensation.  ECG indicates prolonged QT interval

associated with ↓ in Calcium. Priscilla’s doctor did not perform

diagnostic imaging tests. 

Nursing Actions for Pain Meds

Assess Pt. Request order for pain medication Administer medication Reassess patient’s pain level Pain can lead to increased secretion of

pancreatic enzymes.

Medication Administration

Gentamicin - Prophylactic antibiotics limited to patients with pancreatic necrosis.

Antibiotics given until cultures are negative. Famotidine - Decrease HCl acid secretion

(HCl acid stimulates pancreatic activity)

Dietary Management NPO status (Initially)

Reduces pancreatic secretions / enzymes to de-crease stimulation of pancreas

Allows pancreas to rest Until pain, N/V have resolved Diagnostic markers (e.g. serum lipase level 10-140 U/L) normalize.

NG suction Reduces vomiting, gastric distention, prevents gastric acidic contents

from entering duodenum Enteral feedings / Parenteral Nutrition

Moderate to severe pancreatitis High Carb. – less stimulating to exocrine portion of pancreas.

PO status re-initiated Gradually initiated Diet is low fat, low protein, high carbohydrates Eliminate Alcohol / Caffeine Avoid heavy meals

Nursing Diagnoses, Outcomes and Interventions

Ineffective Breathing Pattern R/T severe pain, pulmonary infiltrates, pleural effusion, atelectasis, and elevated diaphragm.

Interventions• Assess respiratory status (rate, pattern, breath sounds), pulse oximetry,

ABGs.• Maintain semi-fowlers position• Turn and reposition every 2 hours• Cough and deep breathe every hour• Administer 02 as ordered / PRN• Administer antibiotics as prescribed to reduce metabolic demand

Outcomes• Patient will have normal respiratory rate and pattern and absence of

adventitious breath sounds. • Pt will have normal ABGs and pulse oximetry readings• No signs and symptoms of respiratory infection / impairment• Pt will remain alert and responsive

Nursing Diagnoses, Outcomes and Interventions

Imbalanced Nutrition Less than body requirements R/T reduced food intake and increased metabolic demands.

Interventions• Monitor serum glucose levels - administer insulin as prescribed• Administer IV fluids and electrolytes, enteral / parenteral nutrition as

prescribed• Provide high carb, low protein, low fat diet when tolerating PO nutrition• Instruct pt to eliminate alcohol consumption and refer to AA as needed• Instruct pt to avoid excessive use of caffeine and spicy foods• Monitor daily weights

Outcomes• Pt will maintain normal serum glucose levels• Pt will have decreased episodes of vomiting and diarrhea• Pt will consume foods high in carbohydrates, low in fat and protein,

eliminate alcohol and excessive amounts of caffeine from diet• Pt will maintain normal body weight

Nursing Diagnoses, Outcomes and Interventions

Risk for Infection R/T compromised host defenses secondary to acute pancreatitis, invasive lines, enteral feedings, total parenteral nutrition.

Interventions• Frequent hand washing• Monitor for signs and symptoms of infection• Administer antibiotics as ordered• Remove ET tubes and NG tubes as soon as possible

Outcomes• Pt will remain free from infection• Pt will maintain normal lab values

Complications

Prognosis

Psychosocial Aspects

CLICKER QUESTION

1.The onset of acute pancreatitis symptoms often occur

a. gradually b. in the morning, before breakfast c. after excessive alcohol use d. in association with constipation

CLICKER QUESTION

2.Where is the pain of acute pancreatitis typically located?

a. left lower quadrant b. midepigastric region c. umbilical region d. right lower quadrant 

CLICKER QUESTION

3. Acute pancreatitis may be triggered by any of the following except ?

a. hypertriglyceridemia b. pregnancy c. parenteral nutrition d. hypocalcemia

CLICKER QUESTION

4.The most common symptom of mild acute pancreatitis is

a. sharp localized pain b. abdominal distension c. diffuse lower abdominal pain d. diarrhea

CLICKER QUESTION

5.Peritoneal signs characteristic of severe acute pancreatitis include

a. hyperactive bowel sounds b. rebound tenderness c. constipation d. abdominal tenderness without rigidity

CLICKER QUESTION

6.Which blood test result will trend downward in acute pancreatitis?

a. albumin b. AST c. amylase d. lipase

CLICKER QUESTION

7.Which lab test is used for severity assessment after 72 hours?

a. isoamylase P b. amylase c. C-reactive protein d. LDH

CLICKER QUESTION

8.Ranson criteria are used in acute pancreatitis to

a. predict risk b. diagnose the disease c. determine treatment d. predict outcomes

CLICKER QUESTION

9.Which of the following meets a Ranson criterion on admission?

a. WBC count of 15,000/mm3 b. fluid retention of 4 to 5 L c. serum glucose level of 250 mg/dL d. serum calcium level of 9.5 mg/dL

CLICKER QUESTION

10.The presence of five Ranson criteria is associated with a mortality of

a. 16% b. 25% c. 40% d. 65%

CLICKER QUESTION

11.Which of the following is most likely in acute pancreatitis?

a. hypoxemia b. hypothermia c. decreased WBC count d. bradycardia

CLICKER QUESTION

12.The first goal in treating acute pancreatitis is to

a. halt enzyme elevation b. achieve hemodynamic stability c. decrease pancreatic inflammation d. remove any obstruction

CLICKER QUESTION

13.The initial dietary intervention for a patient with acute pancreatitis is

a. clear liquids b. low-fat diet c. NPO d. enteral feedings

CLICKER QUESTION

14.If tolerated, nutritional support in severe acute pancreatitis is best provided by

a. gastrostomy tube b. nasogastric tube c. PN d. jejunal tube

CLICKER QUESTION

15.Assessing for Turner sign can reveal

a. hemorrhage b. biliary obstruction c. fluid overload d. electrolyte imbalances

CLICKER QUESTION

16.Chvostek sign indicates a low level of serum

a. magnesium b. calcium c. potassium d. albumin

CLICKER QUESTION

17.Prematurely activated circulating pancreatic enzymes may result in

a. hypovolemic shock b. acute tubular necrosis c. pancreatic pseudocysts d. disseminated intravascular coagulation

CLICKER QUESTION

18. Did you enjoy our presentation?

a. Absolutely b. Positively c. Without a Doubt d. Well, of course…

REFERENCES

Parker, M. (2004). Acute pancreatitis. Emergency Nurse, 11(10), 28-35. Retrieved from CINAHL Plus with Full Text database. http://ezproxyhost.library.tmc.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=2004093202&site=nrc-live