Afro acute_and_chronic_pancreatitis

Copyright © 2010, 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

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)


Acute Pancreatitis

•An acute inflammatory process of the pancreas

•Degree of inflammation varies from mild edema to severe necrosis


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


Acute PancreatitisEtiology and Pathophysiology (Cont’d)

•Primary etiologic factors are •Biliary tract disease

•Most common: Gallbladder disease

•Alcoholism



•Less common causes•Trauma (postsurgical,

abdominal)•Viral infections (mumps,

coxsackievirus HIV)•Penetrating duodenal ulcer•Cysts • Idiopathic



•Less common causes (cont’d)•Abscesses •Cystic fibrosis •Kaposi’s sarcoma •Metabolic disorders•Vascular diseases•Postop GI surgery



•Less common causes (cont’d)•Drugs

•Corticosteroids•Thiazide diuretics •Oral contraceptives•Sulfonamides •NSAIDs



•Caused by autodigestion of pancreas

•Etiologic factors• Injury to pancreatic cells•Activate pancreatic enzymes


Acute Pancreatitis

Fig. 44-14Fig. 44-14



•Trypsinogen•Activated to trypsin by

enterokinase• Inhibitors usually inactivate

trypsin•Enzyme can digest the

pancreas and can activate other proteolytic enzymes


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



•Phospholipase A•Plays a major role in

autodigestion•Activated by trypsin and bile

acids•Causes fat necrosis



Trypsin Edema, necrosis, hemorrhage

Elastase Hemorrhage

Phospholipase A Fat necrosis

Kallikrein Edema, vascular permeability, smooth muscle contraction, shock

Lipase Fat necrosis



•Alcohol•May stimulate production of

digestive enzymes• Increases sensitivity to

hormone cholecystokinin•Stimulates production of pancreatic enzymes



•Edematous pancreatitis•Mild and self-limiting

•Necrotizing pancreatitis•Degree of necrosis correlates

with severity of manifestations


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



•Abdominal pain (cont’d)•Sudden onset•Severe, deep, piercing,

steady•Aggravated by eating•Not relieved by vomiting



•Flushing•Cyanosis•Dyspnea•Edema•Nausea/vomiting•Bowel sounds decreased or

absent


Acute PancreatitisClinical Manifestations (Cont’d)

•Low-grade fever•Leukocytosis•Hypotension•Tachycardia• Jaundice •Abdominal tenderness


Acute PancreatitisClinical Manifestations (Cont’d)

•Abdominal distention•Abnormal lung sounds•Crackles

•Discoloration of abdominal wall


Acute PancreatitisComplications

•Two significant local complications•Pseudocyst•Abscess


Acute PancreatitisComplications (Cont’d)

•Pseudocyst •Cavity surrounding outside of

pancreas filled with necrotic products and liquid secretions

•Abdominal pain•Palpable epigastric mass



•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



•Pancreatic abscess•A large fluid-containing

cavity within pancreas•Results from extensive

necrosis in the pancreas•Upper abdominal pain•Abdominal mass



•Pancreatic abscess (cont’d)•High fever•Leukocytosis•Requires surgical drainage



•Main systemic complications•Pulmonary

•Pleural effusion•Atelectasis•Pneumonia



•Systemic complications (cont’d)•Cardiovascular

•Hypotension•Tetany (caused by

hypocalcemia)


Acute PancreatitisDiagnostic Studies

•History and physical examination

•Laboratory tests•Serum amylase•Serum lipase•2-hour urinary amylase and

renal amylase clearance



•Laboratory tests (cont’d)•Blood glucose•Serum calcium•Triglycerides



•Flat plate of abdomen•Abdominal/endoscopic

ultrasound•Endoscopic retrograde

cholangiopancreatography (ERCP)

•Chest x-ray



Acute PancreatitisDiagnostic Studies (Cont’d)

•CT of pancreas•Magnetic resonance

cholangiopancreatography (MRCP)


Acute PancreatitisCollaborative Care

•Objectives include•Relief of pain•Prevention or alleviation of

shock•↓ of pancreatic secretions•Fluid/electrolyte balance•Removal of the precipitating

cause


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



•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



•Conservative therapy (cont’d)•Suppression of pancreatic

enzymes•NPO•NG suction

•Prevent infections•Peritoneal lavage or dialysis

•Remove kinin and phospholipase A exudate



•Surgical therapy indicated if •Presence of gallstones•Uncertain diagnosis•Unresponsive to conservative

therapy•Abscess, pseudocyst, or

severe peritonitis



•Surgical therapy (cont’d)•ERCP•Endoscopic sphincterotomy•Laparoscopic

cholecystectomy



•Drug therapy• IV morphine•Nitroglycerin or papaverine•Antispasmodics •Carbonic anhydrase inhibitor•Antacids•Histamine (H2) receptor



•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



•Nutritional therapy (cont’d)•Supplemental fat-soluble

vitamins•Supplemental commercial

liquid preparations•Parenteral nutrition•No caffeine or alcohol


Acute PancreatitisNursing Assessment

•Health history•Biliary tract disease•Alcohol use•Abdominal trauma•Duodenal ulcers• Infection •Metabolic disorders


Acute PancreatitisNursing Assessment (Cont’d)

•Medication usage•Thiazides, estrogens,

corticosteroids, NSAIDs•Surgical procedures•Nausea/vomiting•Dyspnea•Severe pain



•Physical examination findings•Fever• Jaundice•Discoloration of abdomen/flank•Tachycardia•Hypotension•Abdominal distention/tenderness



•Abnormal laboratory findings•↑ Serum amylase/lipase•Leukocytosis•Hyperglycemia•Hyperlipidemia•Hypocalcemia•Abnormal ultrasound/ CT/ ERCP


Acute PancreatitisNursing Diagnoses

•Acute pain•Deficient fluid volume• Imbalanced nutrition: Less

than body requirements• Ineffective therapeutic

regimen management


Acute PancreatitisPlanning

•Overall goals•Relief of pain •Normal fluid and electrolyte

balance•Minimal to no complications•No recurrent attacks


Acute PancreatitisNursing Implementation

•Health Promotion•Assessment of predisposing

factors•Early diagnosis/treatment of

cholelithiasis•Eliminate alcohol intake


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



•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



•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



•Ambulatory and Home Care•Physical therapy•Counseling regarding

abstinence from alcohol, caffeine, and smoking

•Assessment of narcotic addiction



•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



•Expected outcomes•Maintains adequate fluid

volume•Maintains weight appropriate

for height•Food and fluid intake

adequate to meet nutritional needs



•Expected outcomes (cont’d)•Describes therapeutic

regimen•Expresses commitment to

lifestyle changes


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


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


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


Chronic PancreatitisEtiology and Pathophysiology (Cont’d)

•Chronic calcifying pancreatitis• Inflammation•Sclerosis

•Mainly in the head of the pancreas and around the pancreatic duct



•Chronic calcifying pancreatitis (cont’d)•Most common form of chronic

pancreatitis•May be referred to as

alcohol-induced pancreatitis



•Chronic calcifying pancreatitis (cont’d)•Ducts are obstructed with

protein precipitates•Precipitates block the

pancreatic duct and eventually calcify



•Chronic calcifying pancreatitis (cont’d)•Calcification is followed by

fibrosis and glandular atrophy

•Pseudocysts and abscesses commonly develop


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


Chronic PancreatitisClinical Manifestations (Cont’d)

•Constipation•Mild jaundice with dark

urine•Steatorrhea•Frothy urine/stool•Diabetes mellitus


Chronic PancreatitisClinical Manifestations (Cont’d)

•Complications•Pseudocyst formation•Bile duct or duodenal

obstruction•Pancreatic ascites•Pleural effusion


Chronic PancreatitisClinical Manifestations

•Complications (cont’d)•Splenic vein thrombosis•Pseudoaneurysms•Pancreatic cancer


Chronic PancreatitisDiagnostic Studies

•Confirming diagnosis can be challenging

•Based on signs/symptoms, laboratory studies, and imaging


Chronic PancreatitisDiagnostic Studies (Cont’d)

•Laboratory tests•Serum amylase/lipase

•May be ↑ slightly or not at all•↑ Serum bilirubin•↑ Alkaline phosphatase



•Laboratory tests (cont’d)•Mild leukocytosis•Elevated sedimentation rate

•ERCP•Visualize pancreatic/common

bile duct



•CT•MRI•MRCP•Transabdominal ultrasound


Chronic PancreatitisDiagnostic Studies (Cont’d)

•Endoscopic ultrasound•Secretin stimulation test•Assess degree of pancreatic

function•Not useful in diagnosis


Chronic PancreatitisCollaborative Care

•Prevention of attacks•During acute attack, follow

acute therapy•Relief of pain•Control of pancreatic

exocrine and endocrine insufficiency


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



•Pancreatic enzyme replacement

•Acid-neutralizing and acid-inhibiting drugs



•Surgery• Indicated when biliary

disease is present or if obstruction or pseudocyst develops

•Divert bile flow or relieve ductal obstruction


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


Case Study


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


Case Study (Cont’d)•Pain began 24 hours ago

•She is divorced, retired, and smokes a half-pack of cigarettes a day


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


Discussion Questions1.What are the possible causes

of pancreatitis?

2.What is her priority of care?


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?

Education

Afro acute_and_chronic_pancreatitis