NUR 397 Pancreatitis/Pancreatic Disorders

A patient has been diagnosed with stage IV metastatic pancreatic cancer. Which management strategy is typical for this type of cancer?

palliative

Which symptom of chronic pancreatitis also occurs with acute pancreatitis?

abdominal pain Rationale Abdominal pain occurs with both types of pancreatitis, though pain intensity does vary between the two. Ascites, loss of exocrine function, and protein malabsorption occur only with chronic pancreatitis.

Which possible complication of chronic pancreatitis presents as a painful, palpable mass in the left upper quadrant?

abscess or pseudocyst

The nurse is caring for a patient who has been admitted multiple times for pancreatitis. The patient has inflammation and fibrosis of the tissue and diminished pancreatic function. Which assessment finding is priority for this patient?

alcohol consumption Rationale The patient who undergoes a microdiskectomy typically can return home the same day. The patient who undergoes a traditional open laminectomy typically can return home 48 hours after the procedure, will have a drain in place after the procedure, and will need to wear special stockings after the procedure

Which condition is the primary risk factor for chronic calcifying pancreatitis?

alcoholism Rationale Alcoholism is the primary risk factor for chronic calcifying pancreatitis. Cholecystitis is a risk factor for chronic obstructive pancreatitis. Metabolic disturbances and viral infection are risk factors for acute pancreatitis, not chronic calcifying pancreatitis.

Which dietary suggestion is indicated for a patient who is in the healing phase after acute pancreatitis? (select all that apply)

bland foods low-fat foods small, frequent meals

Which factor increases the risk for developing pancreatic cancer? (select all that apply)

cirrhosis smoking chronic pancreatitis Rationale Pancreatic cancer is an abnormal growth in the pancreas. Cirrhosis, cigarette smoking, and chronic pancreatitis cause chronic irritation of the pancreatic tissue, increasing the risk for pancreatic cancer. Aging and vitamin deficiencies are not risk factors associated with pancreatic cancer.

Which scan will provide the most reliable diagnosis of acute pancreatitis?

contrast enhanced CT Rationale Contrast-enhanced CT provides more reliable images and diagnosis of acute pancreatitis. A chest x-ray will show elevation but is not diagnostic. An abdominal ultrasound is not helpful to view the whole pancreas. An ERCP is better for diagnosing pancreatic stones, not acute pancreatitis.

The nurse suspects that a patient may have acute pancreatitis as evidence by which group of laboratory results?

elevated lipase elevated WBC count elevated glucose

A patient with chronic pancreatitis has developed a pseudocyst that has not resolved after 8 weeks, and the health care provider plans a percutaneous drainage procedure. The patient asks the nurse why this is necessary as it does not seem to be causing problems. Which complication does the nurse explain the procedure will prevent?

hemorrhage Rationale Pseudocysts may resolve spontaneously or may rupture and cause hemorrhage. Those that have not resolved after 6 to 8 weeks should be drained. The patient would have symptoms of infection, such as fever and malaise, if abscess or infection were present. Steatorrhea (fatty stool) is not a complication of pseudocyst.

Which diet does the health care provider prescribe for a patient during the healing phase of acute pancreatitis? (select all that apply)

high protein low fat meal high carbohydrates

The patient presents to the ED with severe abdominal pain. The nurse is reviewing the patient's laboratory results. Which laboratory finding would prompt the nurse to suspect a diagnosis of acute pancreatitis? (select all that apply)

increased serum amylase decreased serum calcium increased alanine aminotransferase

A patient is in the healing stage of pancreatitis. The patient asks the nurse how to go about planning daily menus based around some favorite foods. Which meal is most appropriate for this patient?

A scoop of mildly seasoned chicken salad served with crackers. Rationale When the patient in the healing phase of pancreatitis begins tolerating food, the most appropriate meals are small and frequent, moderate to high in carbohydrates, high in protein, and low in fat. Meals should be bland, and little spice should be used. As such, the most appropriate meal for this patient is a scoop of mildly seasoned chicken salad and crackers, as this is a high-protein and high-carbohydrate meal that is prepared with little spice. The two slices of ham and toast may be appropriate, but black tea contains caffeine and is therefore a GI stimulant and should be avoided. The fish is appropriate, but the macaroni and cheese is high in fat. The skinless poached chicken and rice are appropriate, but this patient should not season the food with pepper.

Which intervention is necessary in a patient with acute pancreatitis who is at risk for a paralytic ileus? (select all that apply)

Ask if the patient has passed flatus. Maintain a patent NG tube. Rationale It is important to determine if the patient has passed gas or stool. It is also important to make sure the NG tube is functioning. Enteral feedings are not indicated in patients at risk for paralytic ileus. A saline enema would not be administered. Pain medication cannot be decreased by the nurse.

A patient who has had acute mid-epigastric pain for 3 days has elevated glucose, bilirubin, serum lipase, and a threefold increase in alanine aminotransferase. The serum amylase is normal. Which possible cause for this patient's pain does the nurse suspect?

It may be caused by acute biliary pancreatitis.

Which assessment finding would the nurse monitor to evaluate the effectiveness of pancreatic enzyme therapy?

Consistency and number of stools. Rationale If the pancreatic enzymes are effective, the patient should have less frequent, less fatty stools. Blood glucose monitoring is performed when patients receive total parenteral nutrition. Urine output does not indicate effectiveness of pancreatic enzyme therapy. Monitoring weight is necessary for patients who have fat and protein malabsorption.

A patient who has just undergone a Whipple procedure for pancreatic cancer has frank blood and an increased output from the biliary drainage tubes. Which action by the nurse is priority?

Contact the surgeon. Rationale The surgeon should be contacted because frank blood with increasing output may indicate a disruption or leakage of the anastomosis site. Documenting the output should not be done until after the surgeon is contacted. Clamping the NG tube is not indicated. Assessing the vital signs should be done after the surgeon is contacted.

The nurse is reviewing the laboratory results for a patient with acute pancreatitis. Which finding does the nurse expect to find in the report? (select all that apply)

Decrease in albumin level. Increase in serum glucose level. Increase in BUN. Rationale Acute pancreatitis occurs because of a premature activation of excessive pancreatic enzymes, which destroy ductal tissue and pancreatic cells. It results in autodigestion and fibrosis of the pancreas. In acute pancreatitis, the albumin level is decreased because fluid shifts into the peritoneal cavity. This occurs as a result of the inflammatory process in the pancreas. The serum glucose level is elevated because of the pancreatic injury. The BUN is increased because of dehydration. The platelet count is decreased because of inflammation of the biliary tract, including the spleen. Triglycerides are increased because of changes in fat metabolism.

When performing an abdominal assessment on a patient diagnosed with pancreatitis, the nurse notes gray-blue discoloration around the periumbilical area, a dull sound on percussion, and normal bowel sounds. Which action by the nurse is priority?

Document the findings. Rationale A blue discoloration around the periumbilical area is a normal finding in a patient with acute pancreatitis. A dull sound on percussion may be caused from pancreatic ascites. The findings should be documented. The patient does not need to go to the operating room. The health care provider does not need to be contacted immediately. Checking the hemoglobin and hematocrit level is not indicated.

A patient is admitted to the hospital for treatment for acute pancreatitis. The patient's spouse asks the nurse when the patient will be allowed to eat. The nurse bases her response upon which understanding of care of a patient with acute pancreatitis?

Food is withheld during the acute phase to reduce enzyme secretion. Rationale Patients with acute pancreatitis are NPO during the acute phase to allow the pancreas to rest and to reduce the secretion of pancreatic enzymes, which would be stimulated in the presence of food. Long-term TPN is not indicated. The patient is NPO only during the acute phase and if food increases symptoms.

The nurse is providing discharge teaching to a patient who is being discharge home after hospitalization for acute pancreatitis. Which statement by the patient indicates a need for further teaching?

I may have caffeine and chocolate in moderation. Rationale Patients recovering from pancreatitis should avoid caffeine, chocolate, and other GI stimulants. Fat-soluble vitamins may be prescribed. Patients should avoid alcohol, which could trigger a return of symptoms. The diet should be high in carbohydrates and protein and low in fats.

The nurse is teaching a patient with chronic pancreatitis about pancreatic enzyme replacement therapy. Which statement by the patient indicates a correct understanding of the teaching?

I may spread the capsule contents over applesauce, mashed fruit, or rice cereal. Rationale Patients who cannot swallow pancreatic enzyme capsules may break them open and spread the contents over applesauce, mashed fruit, or rice cereal. They should be taught to drink a large amount of water to make sure the enzymes do not remain in the mouth. Mixing the enzymes with high-protein foods results in the enzymes breaking the protein down into a watery substance. Contents should not be chewed or crushed because this will destroy the delayed-release coating.

The nurse is providing teaching about pancreatic enzyme replacement to a patient diagnosed with chronic pancreatitis. Which statement by the patient indicates the need for further teaching?

I will take the pancreatic enzyme half an hour before meals.

A patient hospitalized with pancreatitis is being discharged with home health services. The patient is severely weakened after this illness. Which nursing intervention is the highest priority in conserving the patient's strength?

Limiting the patient's activities to one floor of the home. Rationale Limiting the patient's activities to one floor of the home will prevent tiring the patient with stair-climbing. Taking a PRN sleeping medication may not necessarily increase the patient's strength level or conserve strength; also, the patient may not be experiencing difficulty sleeping. Arranging for a nutritional consult or placing the patient on PRN nasal oxygen will not necessarily result in an increase in the patient's strength level or conserve strength; no information suggests that the patient has any history of breathing difficulties.

Which nursing assessment is priority for a patient with severe acute pancreatitis?

Perfusion and other signs of shock.

The nurse is assessing a patient's alcohol intake to determine whether it is the underlying cause of the patient's attacks of panceratitis. Which question does the nurse ask to elicit this information?

Tell me more about your alcohol intake. v

A patient admitted with a diagnosis of pancreatitis is questioning the NPO order. Which statement by the nurse is most appropriate?

This reduces pancreatic enzyme secretion. Rationale The patient is kept NPO to reduce pancreatic enzyme secretion and rest the pancreas. The patient should have pain relief; however, this is not the reason for the patient's NPO status. The patient is not NPO to rest the stomach or decrease vomiting. The patient is not NPO to give IV replacement with calcium.

As part of the pathophysiologic process during acute pancreatitis proteolysis results in which effect?

Thrombosis and gangrene of the pancreas.

A patient who has acute pancreatitis is prescribed famotidine. The nurse explains that this drug is given for which purpose?

To decrease gastric acid secretion that often occurs with pancreatitis.

The nurse is caring for a patient recently diagnosed with type 1 diabetes mellitus who has had an episode of acute pancreatitis. The patient asks the nurse how he developed diabetes when the disease does not run in the family. Which response by the nurse is best?

Type 1 diabetes can occur when the pancreas is destroyed by disease.

The nurse is preparing to instruct a patient with chronic pancreatitis who is to begin taking pancrelipase. Which instruction does the nurse include when teaching the patient about this medication?

Wipe your lips after taking pancrelipase. Rationale Pancrelipase is a pancreatic enzyme used for enzyme replacement for patients with chronic pancreatitis. To avoid skin irritation and breakdown from residual enzymes, the lips should be wiped. Pancrelipase should be administered after antacids or H 2 histamine blockers are taken. The drug should not be chewed to minimize oral irritation but allowed to be released more slowly. It should be taken with meals and snacks and followed with a glass of water.

A patient has just been diagnosed with pancreatic cancer. The patient's upset spouse tells the nurse that they have recently moved to the area, have no close relatives, and are not yet affiliated with a church. Which response by the nurse is best?

Would you like me to contact the hospital chaplain for you? Rationale It is appropriate for the nurse to suggest contacting the hospital chaplain as a counseling option for the patient and family. Suggesting that the patient find a support group does not assist the patient and the family with the problem. It is inappropriate for the nurse to suggest that the patient and the family need a therapist. The spouse has already told the nurse that they have recently moved to the area, so it is unlikely that they have already made close friends.

After receiving a change of shift report, which patient does the nurse plan to assess first?

Young adult patient with acute pancreatitis who is dypneic and has a RR of 34 to 38 breaths/min. Rationale Acute respiratory distress syndrome is a possible complication of acute pancreatitis. The patient with dyspnea is at greatest risk for rapid deterioration and requires immediate assessment and intervention. The patient with cholecystitis and the patient with an elevated temperature will require further assessment and intervention, but these are not medical emergencies requiring the nurse's immediate attention. The older-adult patient's glucose level will require intervention, but again, this is not a medical emergency.

Which symptom presents in a patient with acute pancreatitis and indicates complications? (select all that apply)

jaundice darkened urine clay colored stools Rationale Acute pancreatitis occurs because of an inflammation of the pancreas. The enzymes released by the pancreas cause autolysis of the pancreatic tissue. Jaundice, darkened urine, and clay-colored stools indicate complications of acute pancreatitis. Jaundice occurs because of an obstruction in the biliary tract, where bile cannot be absorbed into the GI tract. Bile salts accumulate in the skin, causing a yellowish discoloration. An increase in serum bilirubin because of the biliary obstruction causes darkened urine. Stools become clay-colored because of an obstruction in the biliary tract. Vertigo and depression are not symptoms of acute pancreatitis.

The nurse is assessing a patient a patient the ED. Which assessment finding would prompt the nurse to suspect a pancreatic pseudocyst? (select all that apply)

jaundice palpable epigastric mass epigastric pain radiating to the back Rationale Patients with a pancreatic pseudocyst often have jaundice, a palpable epigastric mass, and epigastric pain that radiates to the back. Steatorrhea and odynophagia are not common findings of a pancreatic pseudocyst.

The patient recently diagnosed with acute pancreatitis reports severe pain despite IV narcotic pain medication. Into which position would the nurse assist the patient to help decrease pain?

side lying Rationale The side-lying position may decrease the abdominal pain of pancreatitis. Prone, supine, and high-Fowler positions are not indicated to decrease pain in pancreatitis.

Which enzyme is involved in enzymatic fat necrosis of the endocrine and exocrine cells of the pancreas?

lipase Rationale The lipase enzyme is involved in enzymatic fat necrosis of both the endocrine and exocrine cells of the pancreas. Trypsin activates elastase, which dissolves the elastic fibers of the blood vessels and ducts. Kallikrein releases vasoactive peptides, bradykinin, and a plasma kinin known as kallidin.

In the health record of a patient newly diagnosed with pancreatic cancer, which clue would the nurse consider a risk factor?

smoking Rationale Cigarette smoking is a major risk factor for the development of pancreatic cancer. Hepatitis can cause liver cancer. Malnutrition can weaken the immune system. A sedentary lifestyle increases the risk for heart disease.

A patient is experiencing an attack of acute pancreatitis. Which nursing intervention is the highest priority for this patient?

Administer opioid analgesic medication. Rationale For the patient with acute pancreatitis, pain relief is the highest priority. Although measuring intake and output, NPO status, and positioning for comfort are all important, they are not the highest priority.

When the nurse is caring for a patient with pancreatic cancer who is having severe pain, which intervention is the priority?

Administration of high dose opioid analgesics when the patient reports pain. Rationale High doses of opioid analgesics are given for pancreatic cancer pain without regard for drug dependency because of the poor prognosis. Reassurance, supplementation, and adjunctive pain management should all be used, but they are not the top priority.

A patient has been discharged to home after being hospitalized with an acute episode of pancreatitis. The patient, who is an alcoholic, is unwilling to participate in AA, and the patient's spouse expresses frustration to the home health nurse regarding the patient's refusal. Which response by the nurse is best?

I'll get you some information on the support group Al-Anon. Rationale Putting the patient's spouse in contact with an Al-Anon support group assists with the spouse's frustration. Telling the spouse that the patient will sign up for AA meetings when the patient is ready and telling the spouse to keep mentioning AA do not address the spouse's frustration with the patient's refusal to participate in AA. Encouraging the spouse to say more about his or her frustration may allow the spouse to vent frustration, but it does not offer any options or solutions.

A patient has undergone a Whipple procedure for pancreatic cancer. Which intervention does the nurse implement to prevent complications? (select all that apply)

Monitor mental status. Measure blood glucose levels. Assess bowel sounds and stools. Rationale Postoperative changes in mental status or level of consciousness could be indicative of hemorrhage, so they should be monitored for frequently. After removal of the pancreas, blood glucose should be measured routinely to monitor for postoperative diabetes mellitus. Bowel sounds and stools should be assessed to monitor for postoperative ileus or bowel obstruction. Biliary drainage should be dark green-black and oily, not clear or bloody. Absence of bile-colored drainage can indicate disruption or leakage at a site of surgical anastomosis. The patient should be placed in a semi-Fowler position, not supine, to reduce tension on the suture line and the anastomosis site and to optimize lung expansion.

A patient with history of chronic pancreatitis presents with the left upper quadrant pain, fever, and a palpable mass. A diagnosis of pancreatic abscess is made. Which intervention is most likely to promote a positive patient outcome?

Placement of a percutaneous drain in the pancreatic abscess. Rationale Patients who have a pancreatic abscess will appear ill, have an elevated temperature, and have a high risk for fatality without aggressive treatment. Drainage via the percutaneous drainage method or laparoscopy should be performed as soon as possible to prevent sepsis. An ultrasound does not distinguish between an abscess and a pseudocyst, so it is not helpful in this scenario. Antibiotics are indicated, but antibiotic therapy alone does not resolve the abscess. Blood cultures should be obtained to identify the infectious organism, rather than serum electrolytes and a complete blood count.

Which set of assessment findings indicates to the nurse that a patient may have acute pancreatitis?

Presence of jaundice, pain worsening when lying supine. Rationale Pain that worsens when lying supine and the presence of jaundice are the only assessment findings indicative of acute pancreatitis. Pain associated with acute pancreatitis usually has an abrupt onset, is located in the mid-epigastric or upper left quadrant, lessens with sitting up, and jaundice is present.

A patient with chronic pancreatitis linked to alcoholism tells the nurse that absolute abstention from alcohol is impossible but states an intention to consume only one alcoholic beverage a day. Which response by the nurse is correct?

Recommend that the patient contact an alcoholic support group. Rationale Patients who have pancreatitis should not consume any alcohol, and if alcohol abuse is a problem, they should be referred to a support group that can assist with their addiction. Asking the family to remove alcohol from the home does not address the patient's addiction. Patients who are addicted generally cannot wean themselves off of alcohol and must not drink if they have pancreatitis. Telling the patient that this behavior will be fatal is threatening, is not therapeutic, and does not address the patient's addiction.

The nurse is attempting to position a patient having an acute attack of pancreatitis in the most comfortable position possible. Which position is appropriate for this patient?

Side lying position, with knees drawn up to the chest. Rationale The side-lying position with the knees drawn up has been found to relieve abdominal discomfort related to acute pancreatitis. No evidence suggests that supine position, sitting up in a chair, or high-Fowler position have any effect on abdominal discomfort related to acute pancreatitis.

The nurse is caring for a patient with chronic pancreatitis. Which assessment finding is related to this disease process? (select all that apply)

jaundice polydipsia polyphagia Rationale Jaundice, polydipsia, and polyphagia are manifestations observed in chronic pancreatitis. Jaundice occurs because of chronic inflammation in the biliary tract; bile cannot drain into the small intestines. Excessive thirst (polydipsia) and an increased appetite (polyphagia) occur because the patient has chronic organ dysfunction and develops diabetes mellitus (of which both symptoms are common). Diarrhea is not a symptom of chronic pancreatitis. Weight loss occurs in chronic pancreatitis.

A patient with acute pancreatitis continues to be unable to eat 48 hours after onset of the illness. The nurse notifies the health care provider to discuss which intervention to provide nutrition for this patient?

jejunal tube feedings Rationale Patients who are unable to eat after 24 to 48 hours of onset of symptoms may require jejunal tube feeding and should have early nutritional intervention to enhance immune system function. A liquid diet or gastric tube feedings will stimulate pancreatic enzyme production and make symptoms worse. Enteral feeding is preferred over TPN because it has a decreased risk for complications.

Which enzyme is responsible for the release of vasoactive peptides, bradykinin, and a plasma kinin?

kallikrein Rationale Kallikrein releases vasoactive peptides, bradykinin, and a plasma kinin known as kallidin. These substances cause vasodilation and increased vascular permeability, compounding the hemorrhagic process. Lipase enzyme is involved in enzymatic fat necrosis. Trypsin activates elastase, which dissolves elastic fibers of the blood vessels and ducts.

The nurse is preparing to administer the prescribed does of pancrelipase to a patient with chronic pancreatitis. Which pancreatic enzyme makes up this medication? (select all that apply)

lipase amylase protease Rationale Pancrelipase provides the enzymes that the body is unable to produce because of chronic pancreatitis. It is a combination of the enzymes lipase, amylase, and protease in different concentrations. It does not contain trypsin and elastase.

Which condition is indicated by an elevate serum lipase level?

pancreatic cell injury

A patient reports severe mid-epigastric pain radiating to the left flank and back. The nurse notes generalized jaundice and a gray-blue discoloration of the patient's abdomen and periumbilical area. The nurse suspects which cause of acute pain in this patient?

pancreatitis Rationale Patients with acute pancreatitis will have severe mid-epigastric pain that radiates to the left side and back and may have generalized jaundice and a gray-blue discoloration caused by pancreatic enzyme leakage into the cutaneous tissue. Biliary colic and cholecystitis will present with right-sided abdominal pain. Patients with gastroenteritis will have generalized discomfort.

The nurse is caring for a patient with acute pancreatitis. The patient is reporting shortness of breath and orthopnea. The patient's vital signs are blood pressure 140/80, pulse 110, O2 90% on room air, and temperature 99.8*F. Which complication does the nurse suspect?

pleural effusion

The nurse is caring for a patient diagnosed with acute pancreatitis who has had increased pain and guarding along with these vital signs: blood pressure 108/60 mm Hg, pulse 125 beats/min, temperature of 103.8°F (39.8°C), and an oxygen (O 2) saturation of 95% on 2 L via nasal cannula. The nurse suspects the patient has a pancreatic abscess. After contacting the health care provider, the nurse would perform which intervention first?

prepare the patient for pancreatic drainage Rationale Pancreatic drainage needs to be performed as soon as possible to prevent sepsis. Reassessing vital signs should be done after the patient is prepared for drainage. Placing the patient in a supine position is not indicated. After ensuring everything is in order for the health care provider, acetaminophen may be administered, but it is not the priority..

A patient has been placed on enzyme replacement for treatment of chronic pancreatitis. In teaching the patient about this therapy, the nurse advises the patient not to mix enzyme preparations with foods containing which element?

protein

A patient with chronic pancreatitis has edema of the feet, legs, and hands. This is a sign of which problem associated with chronic pancreatitis?

protein malabsorption

Which medication is administered to a patient with acute pancreatitis to decrease gastric acid secretion? (select all that apply)

ranitidine pantoprazole Rationale Ranitidine is a histamine receptor antagonist, and pantoprazole is a proton pump inhibitor. Both medications help decrease gastric acid secretion. Imipenem and ciprofloxacin are antibiotics. Meperidine is an opiate analgesic.

A patient is diagnosed with acute pancreatitis. Which test is a sensitive indicator of biliary obstruction in this disorder?

serum alanine aminotransferase Rationale Serum alanine aminotransferase is a sensitive indicator of biliary obstruction in acute pancreatitis. A threefold or greater rise in concentration indicates that the diagnosis of acute biliary pancreatitis is valid. Serum bilirubin, alkaline phosphatase, and serum amylase are diagnostic tests prescribed for a patient with acute pancreatitis but do not reflect biliary obstruction.

A patient who has undergone an open Whipple procedure for pancreatic cancer has a HR of 110, BP of 90/62, and urine output less than 1 mL/kg/hr. The nurse notifies the surgeon to report which postoperative complication?

shock Rationale The patient has tachycardia and hypotension, along with decreased urine output, which are indicative of shock. A fistula would cause abnormal secretions into the drain or into the peritoneum. Heart failure would manifest as crackles and respiratory distress and edema. Renal failure would cause oliguria and electrolyte imbalances.

Which complication is common for a patient with pancreatic cancer to develop?

venous emboli Rationale The patient with pancreatic cancer is at a higher risk for developing venous emboli. This occurs because necrotic products of the pancreatic tumor have thromboplastic properties which, in turn, cause a hypercoagulable state. Decreased mobility and extensive surgical manipulation are also responsible for this infection. Dyspepsia (indigestion) and eructation (belching) are not common complications associated with pancreatic cancer.