Pancreatitis

Risk Factors for Cholecystitis: Recognizing Cues​ A nurse is caring for a client during a routine, physical examination. Identify which finding, documented in the medical record, would alert the nurse of the client's increased risk for cholecystitis?​ Male client over the age of 40 years old Female client taking norgestimate-ethinyl estradiol daily Decreased serum triglyceride level after following a low-fat diet for 6 months​ Rapid weight gain over the past 3 months​

Norgestimate-ethinyl estradiol is a birth control pill containing estrogen, which places the client at increased risk for cholecystitis. ​Rapid weight loss, increased triglyceride levels, and female clients over the age of 40 years are at increased risk. ​ Using clinical judgment, you have recognized cues (i.e., risk factors) that increase the client's risk for cholecystitis. Understanding relevant client data is necessary to make appropriate clinical decisions

Nursing Care of the Client With Pancreatitis​ A nurse is caring for a client with acute pancreatitis. Which actions should be included in the plan of care? Included Not Included administering intravenous (IV) morphine​ monitoring Chvostek's sign providing a diet low in carbohydrates and high in fat​ monitoring blood glucose for hyperglycemia auscultating lung fields for crackles Showing question as presented to the student.

Pain relieve is a priority in the acute phase of pancreatitis. Hypocalcemia can occur, so observing for tetany and assessing Chvostek's sign or Trousseau's sign is important. Pancreatitis can damage the beta cells impairing insulin production. Blood glucose should be closely monitored. Abdominal guarding causes the client to take shallow breaths. This problem as well as retroperitoneal fluid accumulation can lead to respiratory infection. ​ The client with acute pancreatitis should take nothing by mouth (NPO) until pain resolves then resume a low-fat, high-carbohydrate diet.

Administering Pancrelipase​ A nurse is teaching a client about taking pancrelipase to manage chronic pancreatitis. Which statement by the client indicates an understanding of the medication? ​ "I will sprinkle the contents of medication capsule on peanut butter."​ "I will chew the medication thoroughly before swallowing."​ "I will drink a full glass of water after taking this medication." "I will take the medication one hour before meals."​

Pancrelipase is taken to aid with digestion of fat and proteins and should be taken with a full glass of water. The medication is slow-release and should not be chewed. ​ Pancrealipase should be taken with every meal or snack. Contents of the capsule can be sprinkled on an acidic, non-protein food, such as applesauce, banana, or pear. Teach the client to wipe the lips and rinse the mouth after taking to prevent skin irritation. ​

Question 6 / 8 The nurse caring for Patrick begins to implement prescriptions for care. Which prescription should be matched to the associated rationale? Each option can only be used once. PrescriptionRationaleMinimizes pancreas stimulation and enzyme secretion.Restores fluid and electrolyte balance.Reduces nausea and vomiting.Reduces the incidence of sepsis.Reduces gastric acid secretion. Nothing by mouth (NPO) Lactated Ringer's 150 mL/hour Ondansetron intravenous (IV) as needed Imipenem intravenous (IV) every 6 hours Omeprazole by mouth (PO) daily

PrescriptionRationale Nothing by mouth (NPO) Minimizes pancreas stimulation and enzyme secretion. Lactated Ringer's 150 mL/hour Restores fluid and electrolyte balance. Ondansetron intravenous (IV) as needed Reduces nausea and vomiting. Imipenem intravenous (IV) every 6 hours Reduces the incidence of sepsis. Omeprazole by mouth (PO) daily Reduces gastric acid secretion.

Unfolding a Case Study Patient Information Patrick Patrick is 40 years old. He presents to the emergency department (ED) describing severe pain on the left side of the abdomen that started after going to bed last night. Patrick has a history of hypertension. Current medications are furosemide and lisinopril. He has smoked for 18 years and drinks alcoholic beverages most days of the week. Patrick reports that the pain got worse after eating breakfast this morning. ​ Question 3 / 8 Within a few hours, Patrick is admitted to an inpatient hospital bed on the medical/surgical unit. After receiving report from the emergency department and performing an assessment, what should the nurse include in the plan of care as priority outcomes for Patrick? Select all that apply. Preventing complications, such as hypovolemic shock Restoring fluid and electrolyte balance​ Smoking cessation​ Reducing pancreatic secretions Ongoing pain management Showing question as presented to the student.

Priority outcomes for a client with acute pancreatitis who is hospitalized include pain relief, preventing complications, reducing pancreatic secretions, correcting fluid and electrolyte imbalance, and preventing infections. ​ A discussion about smoking cessation should occur before discharge; however, smoking cessation is not the immediate priority. Stopping tobacco and alcohol use will prevent future attacks but will not resolve the current situation. ​ Using clinical judgment, you have generated solutions. Using prioritization, you planned specific actions that align with the client's needs to achieve the desired outcome.

Discharge Teaching A nurse is caring for a client following a laparoscopic cholecystectomy. What should the nurse include in the discharge teaching? Report any purulent drainage from the incisions. Report the need to take pain medication for shoulder pain. Keep the small abdominal incisions clean and dry for one week. Postoperative nausea and vomiting should be expected for 3 to 4 days.

Purulent drainage from the incisions would be a sign of infection and should be reported to the provider.​ The client may shower the day after the procedure and remove any abdominal dressings. Referred shoulder pain is common after the laparoscopic procedures when carbon dioxide is used to inflate the abdominal cavity that is not readily absorbed by the body. Nausea and vomiting are not expected postoperatively and should be reported to the provider.

Discharge Teaching A nurse is caring for a client following a laparoscopic cholecystectomy. What should the nurse include in the discharge teaching? Report any purulent drainage from the incisions. Report the need to take pain medication for shoulder pain. Keep the small abdominal incisions clean and dry for one week. Postoperative nausea and vomiting should be expected for 3 to 4 days.

Purulent drainage from the incisions would be a sign of infection and should be reported to the provider.​ The client may shower the day after the procedure and remove any abdominal dressings. Referred shoulder pain is common after the laparoscopic procedures when carbon dioxide is used to inflate the abdominal cavity that is not readily absorbed by the body. Nausea and vomiting are not expected postoperatively and should be reported to the provider. ​

Unfolding a Case Study Patient Information Patrick Patrick is 40 years old. He presents to the emergency department (ED) describing severe pain on the left side of the abdomen that started after going to bed last night. Patrick has a history of hypertension. Current medications are furosemide and lisinopril. He has smoked for 18 years and drinks alcoholic beverages most days of the week. Patrick reports that the pain got worse after eating breakfast this morning. ​ Question 2 / 8 Patrick is placed into an exam room in the emergency department. Nursing assessment reveals:​ Vital Signs​ Physical Assessment​ Laboratory Values​ WBC: 14,000​ amylase: 205 U/L​ lipase: 400 U/L​ calcium: 7.9 mg/dL​ The nurse is provided numerous prescriptions to care for Patrick. Select the three priority nursing actions that need immediate nurse intervention. ​ Position the client side-lying with the head of the bed elevated. Start oxygen via nasal cannula at 4 L/min. Notify the house supervisor of the need for an inpatient bed​. Establish intravenous (IV) access and administer morphine. Perform medication reconciliation​.

Resolving the client's oxygenation and pain issues are the priority. Intravenous (IV) morphine and a side-lying position with the head of bed elevated will lower the pain level.​ Oxygen administration will elevate the client's oxygen saturation to an acceptable level (>95%). ​ Medication reconciliation and preparing for inpatient admission are important but are not the priority actions. ​ Using clinical judgment, you have taken action to are for this client. You identified and implemented appropriate actions understanding the rationale for each.

Laboratory Findings With Acute Pancreatitis​ A nurse is caring for a client recently admitted with acute pancreatitis. When reviewing the medical record, which laboratory finding would the nurse expect? Decreased serum lipase level​ Increased serum calcium level​ Decreased serum amylase level Increased blood glucose level

Serum lipase and amylase are elevated in acute pancreatitis. Serum calcium is often decreased. ​Blood glucose is elevated in acute pancreatitis due to decreased insulin production in the pancreas.

Assessment Findings in Pancreatitis Bowel sounds will be decreased or absent as peristalsis slows. Paralytic ileus may occur, which causes abdominal distention. ​ Crackles may be present in the lung fields. Intravascular damage may cause cyanosis or a yellow-brown discoloration of the abdominal wall. ​ Ecchymoses of the flanks (Grey Turner sign) and the periumbilical area (Cullen's sign) are common. This is caused by seepage of bloodstained exudate from the pancreas. ​ In severe cases, shock may result from:​ hemorrhage into the pancreas​ toxemia from the activated pancreatic enzymes ​ hypovolemia due to fluid shifts into the retroperitoneal space

Systemic Complications of Pancreatitis​ Pancreatitis can cause cardiovascular and pulmonary problems such as pleural effusion, atelectasis, pneumonia, and acute respiratory distress syndrome. Pulmonary complications are due to exudate containing pancreatic enzymes traveling from the peritoneal cavity through transdiaphragmatic lymph channels, causing inflammation of the diaphragm. Atelectasis further reduces diaphragm movement. ​ Trypsin can activate prothrombin increasing the client's risk thromboembolism development, which could lead to pulmonary embolism or disseminated intravascular coagulation (DIC). Hypertension occurs from fluid shifts and sepsis. ​ Hypocalcemia may cause tetany, which is a sign of severe disease. Calcium combines with fatty acids during fat necrosis causing hypocalcemia. Clients are also at risk for abdominal compartment syndrome from intraabdominal hypertension and edema.

Prioritization of Care​ In the medical/surgical unit, a nurse is caring for four clients diagnosed with cholecystitis. Which assessment finding should be immediately reported to the provider? ​ The client is having increased pain after eating​. The client's stools are tan colored​. The client reports they are having chronic heartburn. The client's urine is bright yellow​.

Tan or gray stools indicate biliary obstruction, which needs rapid intervention. Chronic heartburn, yellow urine, and pain after eating are all expected findings with cholecystitis. ​

Evaluate Outcomes​ of Client Teaching A nurse is preparing a client for an endoscopic retrograde cholangiopancreatography (ERCP) to remove gallstones. After teaching, which statement made by the client indicates a need for further information?​ "I know I must sign a consent form before the procedure." "I'm glad some medication will be pushed in my intravenous (IV) to help me relax before the procedure." "I hope the throat spray keeps me from gagging." "I'm so glad I don't have to lie supine for very long for this procedure."​

The client must lie supine and very still for about one hour to perform the procedure of endoscopic retrograde cholangiopancreatography (ERCP). ​ The client must sign an informed consent. Intravenous (IV) sedation is administered to relax the client and an anesthetic throat spray is used to suppress the gag reflex as the endoscope is passed. ​ Using clinical judgment, you have evaluated outcomes of your actions and recognized what the client needed for further clarification in your teaching. Great job!​

Treatment of Acute Cholecystitis​ A client is admitted into the hospital with suspected acute cholecystitis. Which prescriptions should the nurse anticipate being prescribed for the client? Select all that apply​. Indwelling urinary catheter to monitor output​ Blood draw for liver function tests​ Antiemetics as needed for nausea and vomiting​ A low-sodium diet​ Lactated Ringer's intravenous (IV)​

The client should have a low-fat diet with small, frequent meals. Sodium is not restricted. ​ Lactated Ringer's solution restores fluid and electrolyte balance. Antiemetics (ondansetron) will control nausea and vomiting. ​ Gallstones is the most common cause of cholecystitis and could involve the liver if an obstruction is present. Therefore, liver function tests should be monitored. ​ An indwelling urinary catheter is not necessary. ​

Nursing Assessment: Analyzing Cues​ A nurse is admitting a client with acute pancreatitis. When completing the assessment, which finding should the nurse expect? Pain in the right upper quadrant of the abdomen that radiates to the right shoulder Epigastric pain radiating to the back Report of worsening pain when sitting up​ Pain relieved by defecation

The pain of acute pancreatitis is primarily characterized by its acute, sudden onset pain in the left upper quadrant of the abdomen or the epigastric region; the pain radiates to the back because of the location of the pancreas (retroperitoneal). While assessing the client, the nurse needs to analyze what cues they should expect, so that they can link the cues to the clinical situation (i.e., acute pancreatitis). ​ Pain can be worse when lying supine. Side-lying with knees pulled to chest and the head of the bed elevated 45 degrees is often a comfortable position for the client

nfolding a Case Study Patient Information Patrick Patrick is 40 years old. He presents to the emergency department (ED) describing severe pain on the left side of the abdomen that started after going to bed last night. Patrick has a history of hypertension. Current medications are furosemide and lisinopril. He has smoked for 18 years and drinks alcoholic beverages most days of the week. Patrick reports that the pain got worse after eating breakfast this morning. ​ Question 5 / 8 Hypocalcemia can cause tetany as well as numbness and tingling around the lips and in the fingers. The nurse prepares to assess Trousseau's sign. Which nursing action is correct?​ Tap the skin over the facial nerve 2 cm lateral to the ear.​ Have the client wrinkle the forehead, close the eyes, smile, pucker the lips, show the teeth, and puff out the cheeks. Place a blood pressure cuff on the client's arm and inflate 20 mm Hg above systolic blood pressure for 3-5 minutes. Ask the client to look toward each ear then follow the nurse's fingers through the six cardinal fields of gaze. Showing student answer. Correct!

The way to access Chvostek's sign: Tapping the skin over the facial nerve 2 cm lateral to the ear.​ Trousseau's sign: Placing a blood pressure (BP) cuff on the client's arm and inflating 20 mm Hg above systolic BP for 3-5 minutes. cranial nerve 7: Having the client wrinkle the forehead, close the eyes, smile, pucker the lips, show the teeth, and puff out the cheeks. ​cranial nerve 6: Asking the client to look toward each ear then follow the nurse's fingers through the six cardinal fields of gaze

Question 7 / 8 The nurse understands that Patrick is at risk for respiratory complications due to fluid accumulation preventing the diaphragm from functioning properly and abdominal guarding with shallow breaths. In addition to providing supplemental oxygen, what action can the nurse take to minimize the risks? Select all that apply​. Have the client lie supine to facilitate complete lung expansion. ​ Encourage the client to turn, cough, and deep breath hourly.​ Instruct the client on using an incentive spirometer.​ Keep the head of the bed elevated at least 45 degrees. Ambulate the client every 2 hours. ​

Use of an incentive spirometer and turning, coughing, and deep breathing hourly will encourage lung expansion. ​ Elevating the head of the bed also facilitates chest expansion and provides pain relief. ​ Side-lying provides pain relief. Lying supine increases discomfort for a client with acute pancreatitis causing shallow breathing. The client needs to rest in a side-lying position with the head of the bed elevated until pain is resolved. Antiemetic stockings should be used during bed rest. ​ Using clinical judgment, you have taken action to care for this client. By understanding the rationale, you identified and implemented appropriate actions.

Teaching About Medications: Take Action ​ The nurse is teaching a client with a new prescription for chenodeoxycholic acid to treat cholelithiasis. What information should the nurse include in the teaching?​ This medication is used to control the pain caused by biliary obstruction. This medication requires renal function monitoring every 6 months. This medication will dissolve the gallstones gradually over time. This medication cannot be taken by clients diagnosed with hypertension.​

Using clinical judgment, you have taken action in the care of this client. Teaching about new prescriptions is essential for client compliance. ​ Bile acids (ursodeoxycholic acid or chenodeoxycholic acid) can be used to dissolve stones. However, this treatment does not prevent recurrence.​ Clients taking chenodeoxycholic acid should have a gallbladder ultrasound every 6 months. Caution should be used in clients who have liver dysfunction, not hypertension. Opioid analgesics are used for pain control.

Clinical Manifestations of Acute Pancreatitis Main Symptom Other Symptoms Other symptoms include: nausea and vomiting low-grade fever hypotension tachycardia jaundice​ The graphic below illustrates symptoms of acute pancreatitis.

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Introduction to Nursing Care: Pancreatitis The pancreas is positioned behind the stomach, close to the duodenum, and is highly associated with digestive functions. Its main functions are to produce insulin and make digestive juices. Problems of the pancreas lead to altered nutrient absorption, causing malnutrition and impaired elimination. ​ Pancreatitis, inflammation of the pancreas, can present as an acute or chronic problem. As pancreatic enzymes leak into surrounding tissues, autodigestion occurs along with severe pain. Inflammation can be mild edema to severe hemorrhagic necrosis.​ Acute pancreatitis is increasingly common for unknown reasons. In the United States, an average of 275,000 hospitalizations occur annually as a result of acute pancreatitis (NIH, 2017). Chronic pancreatitis results in about 86,000 hospitalizations annually (NIH, 2017). ​

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What is Pancreatitis? ​ The pancreas produces digestive enzymes that mix with food in the small intestine to assist with digestion. Pancreatitis occurs when the enzymes leak into the tissues surrounding the organ and damage the pancreas, causing inflammation. African Americans have a higher risk of developing pancreatitis, and the disorder is more common in men than women (NIH, 2017). ​ Acute pancreatitis occurs suddenly and only lasts several days with proper treatment. Chronic pancreatitis occurs when the pancreas does not heal or recover from an acute episode and gets worse over time. This condition leads to chronic damage to the pancreas. Whether acute or chronic, pancreatitis is a serious condition that can lead to major complications. ​

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Discharge Teaching for the Client With Pancreatitis​ Due to the loss of physical and muscle strength, physical therapy may be needed for clients with pancreatitis. Diet recommendations must be followed, including fat restriction and increased carbohydrate consumption. Teach the client that crash and binge dieting can precipitate an acute attack. ​ All medications must be taken as prescribed. Continued care to prevent infection and detect complications is important. ​The client must be able to recognize the signs of infection, diabetes, and steatorrhea because these problems indicate ongoing destruction of pancreatic tissue and insufficiency. Counseling about cessation of smoking and alcohol use prevents future attacks and the development of chronic pancreatitis. ​

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Managing a Jackson-Pratt Drain A nurse is providing care to a client with a pancreatic abscess that was recently drained. A Jackson-Pratt drain was left in place for continuous drainage. Which action took by the nurse will ensure proper function of the drain?​ Coil the tubing of drain​. Empty the bulb every day. Place the drain to wall suction. Keep the bulb compressed​.

A Jackson-Pratt (JP) drain prevents accumulation of fluid after abscess drainage, by creating suction in the tube. The bulb is squeezed flat (compressed) and connected to the tube that protrudes from the body. The bulb expands as it fills with fluid. The bulb should be emptied every 8 to 12 hours. ​ The tubing should not be coiled to ensure proper drainage. Wall suction is not used.

Preoperative Teaching: Evaluate Outcomes The nurse is caring for a client who is to undergo a laparoscopic cholecystectomy. Which statement made by the client indicates a need for further preoperative teaching?​ "I will have a drain coming out of my abdomen after the procedure, which will need to be emptied daily." "I may have pain in my right shoulder after the procedure."​ "I can return to work one week after the procedure."​ "I will have four small incisions covered with bandages on my abdomen after surgery."​

A T-tube or a Jackson-Pratt (JP) drain may be placed during an incisional cholecystectomy, not during a laparoscopic cholecystectomy. ​All other statements indicate a correct understanding of the preoperative teaching. ​ Using the clinical judgment, you have evaluated outcomes of your actions and recognized that the client needed further clarification. Great job!​

Preoperative Teaching​ The nurse is caring for a client who will undergo a laparoscopic removal of the gallbladder. Which information should be included in the preoperative teaching?​ "You will have four small abdominal incisions that will need to be monitored for signs of infection."​ "You will be in the hospital for 3 to 5 days after the procedure."​ "You may return to work in 2 to 3 days after the procedure."​ "A t-tube device will be placed in the common bile duct to promote bile drainage and prevent further problems."

A laparoscopic cholecystectomy is performed through one to four small abdominal incisions used to visualize and remove the gallbladder.​ An incisional cholecystectomy requires the client to remain in the hospital for 3-5 days after the procedure. Clients with a laparoscopic procedure will usually go home the same day. ​ A t-tube is placed in the common bile duct during an incisional cholecystectomy.

Diet After Cholecystectomy​ The nurse is preparing to discharge a client following a laparoscopic cholecystectomy. The client asks, "Will I need to continue a low-fat diet when I get home?" Which is the best response made by the nurse? "A low-fat diet is recommended for several weeks after the surgery, which allows your body to adjust not having a gallbladder."​ "Now that your gallbladder is gone, you can eat anything you would like."​ "You will not be able to digest fats without a gallbladder, so you must eat a low-fat diet."​ "A low-fat diet will prevent gallstones from forming again and should be continued."​

After the removal of the gallbladder, bile drains directly from the liver into the duodenum. A low-fat diet is recommended until the adjustment to this change occurs. ​ Following the gallbladder removal, most clients tolerate a regular diet with moderate fat intake but should always avoid excessive fat intake

Discharge Teaching After Laparoscopic Cholecystectomy The nurse is planning to discharge a client following a laparoscopic cholecystectomy. Which statement made by the client indicates an understanding of the teaching?​ "I will report any pus or drainage from my incisions to the provider immediately." "I will empty and measure the contents of the bile bag from the T-tube every day."​ "I will keep the bandages on my abdomen for 72 hours and avoid showering."​ "I will use an over-the-counter antacid if nausea or vomiting occurs once I am home."​

Bandages should be removed the day after surgery, and the client should shower. Pus, drainage, fever, chills, nausea, or vomiting are concerning symptoms, and the provider should be notified immediately. ​ A T-tube is not paced during a laparoscopic cholecystectomy. A T-tube is inserted during an incisional cholecystectomy to maintain patency of the common bile duct until the edema from the trauma of exploring the duct has resolved. Excess bile will drain into the tube.​

Teaching About Medications: Evaluate Outcomes​ A client diagnosed with cholelithiasis has been prescribed cholestyramine. After teaching, which statement made by the client indicates a need for clarification? "I will continue taking a fat-soluble vitamin supplement."​ "A high-fiber diet is important while taking this medication." ​ "This medication can only be taken with water." "This medication will lower my cholesterol."​

Cholestyramine is a bile acid sequestrant used to lower the cholesterol levels and prevent pruritus caused by partial bile obstruction. Client compliance is a problem because of the medications taste. It is recommended to take with fruit juice or milk to improve the taste. ​ Side effects of cholestyramine include: (a) constipation, so a high-fiber diet is recommended, and (b) decreased vitamin absorption, so a supplement is recommended. ​ Using clinical judgment, you have evaluated outcomes of your actions and recognized what the client needed further clarification in your teaching. Great job!​

Unfolding a Case Study Patient Information Patrick Patrick is 40 years old. He presents to the emergency department (ED) describing severe pain on the left side of the abdomen that started after going to bed last night. Patrick has a history of hypertension. Current medications are furosemide and lisinopril. He has smoked for 18 years and drinks alcoholic beverages most days of the week. Patrick reports that the pain got worse after eating breakfast this morning. ​ Question 1 / 8 Based on Patrick's history, what is the likely cause of this medical condition?​ Medication-induced​ diseases Chronic alcohol consumption Cholelithiasis Cholecystitis​

Chronic alcohol consumption is likely the cause for this episode of acute pancreatitis. Smoking is also a risk factor for developing acute pancreatitis. ​ Gall bladder inflammation (cholecystitis) and gallstones (cholelithiasis) are the most common causes of acute pancreatitis in women and neither were included in this client's history. ​ Furosemide and lisinopril should not cause pancreatitis. ​ Using clinical judgment, you have recognized and analyzed cues (i.e., assessment findings); making the connection between cues and acute pancreatitis. Well done!

Nutrition to Prevent Acute Pancreatic Attacks​ A nurse is teaching about ways of preventing an acute attack to a client with chronic pancreatitis. Which of the following statements made by the client indicates an understanding of the teaching? Select all that apply. "I will limit alcohol intake to two drinks per day."​ "I will use skim milk when cooking."​ "I will plan to eat small, frequent meals."​ "I will eat easy-to-digest foods with limited spice."​ "I will drink regular soda to maintain my blood glucose."​

Clients with chronic pancreatitis should avoid caffeine and alcohol intake. Both will stimulate the pancreas. ​ Pancreatic enzymes break down carbohydrates, fats, and proteins for digestion. Eating a low fat (skim milk) diet is important to preventing attacks. Supplemental fat-soluble vitamins may be needed. The diet should be high in carbohydrates because these foods stimulate the pancreas the least. ​ Small meals with easy-to-digest foods are the best daily approach to nutrition

Diagnosis of Pancreatitis Laboratory Tests Diagnostic Tests Serum amylase and lipase are the primary laboratory test for pancreatitis. Amylase elevates immediately and stay high for 24 to 72 hours. Prolonged elevation is indicative of an abscess. Lipase levels will also be elevated.​ Other laboratory tests include liver enzymes, triglycerides, glucose, bilirubin, and serum calcium. ​ Laboratory TestExpected in PancreatitisSerum amylaseElevatedSerum lipaseElevatedBlood glucoseElevatedSerum calciumLowSerum triglyceridesElevated

Diagnostic Tests Computed tomography (CT) scan is the best imaging for pancreatitis and related complications. A chest x-ray may show atelectasis and pleural effusion

Expected Findings With Cholelithiasis: Analyzing Cues A nurse is caring for a client diagnosed with obstructive cholelithiasis. When reviewing the medical record, which laboratory result is expected?​ Expected Not Expected serum amylase 75 U/L white blood cell (WBC) count 9,000 direct bilirubin 2.5 mg/dL alkaline phosphatase 48 U/L​

Direct bilirubin level should be less than 0.3 mg/dL. It can be elevated in a client with cholelithiasis if obstruction is present. ​ White blood cell (WBC) count is within the expected range (4,500-11,000); it would be elevated with cholecystitis.​ Serum amylase is within the expected range (30-110 U/L); it would be elevated with obstruction affecting the pancreas. ​ Alkaline phosphatase is within the expected range (44-147 U/L); it Would be elevated with obstruction affecting the liver. ​

Clinical Manifestations of Acute Cholecystitis: Analyzing Cues​ The nurse is admitting a client with suspected acute cholecystitis. When reviewing the medical record, which clinical manifestations would be expected to be documented to support this diagnosis? Select all that apply​. Aching pain in the left lower quadrant of the abdomen​ Positive Cullen's sign Feelings of indigestion​ Pain in the right upper quadrant of the abdomen after eating a fatty meal​ Palpable mass in the left upper quadrant of the abdomen​ Fever

During acute cholecystitis, the client may describe severe pain in the right upper abdominal quadrant following a high-fat meal. The pain usually radiates to the right shoulder. Fever and dehydration are expected findings as well as indigestion, belching, flatulence, nausea, and vomiting. ​No mass or pain would be experienced in the left upper quadrant of the abdomen. Cullen's sign is associated with pancreatitis. ​ Using clinical judgment, you have recognized and analyzed cues (i.e., assessment findings); making the connection between cues and cholecystitis. Well done!​

Assessment of Acute Pancreatitis​ A nurse is performing an assessment on a client diagnosed with acute pancreatitis. Which of the following clinical manifestations would the nurse anticipate as a sign of pancreatitis?​ Central cyanosis​ Hyperactive bowel sounds Wheezing in the lower lung fields​ Gray-blue discoloration of the skin around the umbilicus

Ecchymoses of the umbilical area (Cullen's sign) appears as a bluish periumbilical discoloration. Ecchymoses of the flanks (Grey Turner's sign) is also present.​ Bowel sounds will be decreased or absent. The respiratory system is not affected.

Patrick's condition is not improving with routine medical management. A pancreatic pseudocyst is suspected. Which procedure does the nurse anticipate to prepare the client to undergo?​ Removal of the pancreas Computed tomography (CT)-guided percutaneous drainage Cholecystectomy​ Endoscopic retrograde cholangiopancreatography (ERCP) with pancreatic sphincterotomy​

Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy is used when acute pancreatitis is caused by gallstones. The gallbladder may also need to be removed to reduce reoccurrence. ​ The correct procedure to treat a pancreatic pseudocyst is using imaging guidance to insert a catheter into the abdomen to drain the cyst. ​ The pancreas does not need to be removed.

Question 8 / 8 Patrick's condition is not improving with routine medical management. A pancreatic pseudocyst is suspected. Which procedure does the nurse anticipate to prepare the client to undergo?​ Removal of the pancreas Computed tomography (CT)-guided percutaneous drainage Cholecystectomy​ Endoscopic retrograde cholangiopancreatography (ERCP) with pancreatic sphincterotomy​

Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy is used when acute pancreatitis is caused by gallstones. The gallbladder may also need to be removed to reduce reoccurrence. ​ The correct procedure to treat a pancreatic pseudocyst is using imaging guidance to insert a catheter into the abdomen to drain the cyst. ​ The pancreas does not need to be removed.

Taking Action​ A nurse caring for clients with acute cholecystitis understands that reducing gallbladder stimulation is necessary to recovery. Which action will prevent stimulation of the gallbladder? Keeping the client nothing by mouth (NPO) and using nasogastric (NG) suctioning​ Performing a cholecystectomy Administering ondansetron​ Administering an anticholinergic medication

Foods and fluids moving through the duodenum stimulate the gallbladder. Nothing by mouth (NPO) with nasogastric (NG) suctioning will prevent stimulation.​ Removal of the gallbladder does not prevent stimulation. Antiemetics (ondansetron) prevent nausea and vomiting but do not decrease stimulation. Anticholinergics counteract the smooth muscle spasms of the bile ducts to decrease pain.

Introduction to Nursing Care: Gallbladder Disease Gallbladder disease is a common health problem in the United States with approximately 10 to 15% of the adult population having gallstones causing cholecystitis (Acalovschi & Lammert, n.d.).​ Cholelithiasis and cholecystitis are common disorders of the biliary system. Gallstones (cholelithiasis) can obstruct the neck of the gallbladder or lodge in the cystic duct. Inflammation of the gallbladder (cholecystitis) is usually associated with gallstones; although cholecystitis may be present with gallstones and can be acute or chronic. Cholecystectomy (removal of the gallbladder) is a common surgical procedure to resolve gallbladder disease.​ Nurses must be aware the risk factors and medical management of gallbladder disease to both assist clients to prevent and treat these disorders.

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Managing Pain in Acute Pancreatitis​ A nurse is caring for a newly admitted client diagnosed with acute pancreatitis. In addition to providing analgesics for pain control, what action should be included in the plan of care to relieve pain?​ Provide small, frequent meals to increase tolerance to food.​ Provide activities that focus on the pain.​ Position the client on the side with the head of bed elevated 45 degrees.​ Ambulate the client every 3 to 4 hours to increase circulation and peristalsis.

Have the client lie on the side with trunk flexed and knees drawn up to the abdomen to help relieve the pain of acute pancreatitis. Lying on the side with the head of bed elevated decreases abdominal tension.​ Activities that focus on the pain are not helpful for pain control. The client should take nothing by mouth (NPO) because food intake increases pain and inflammation. Bed rest is indicated during the acute attack because of pain. ​

Unfolding a Case Study Patient Information Patrick Patrick is 40 years old. He presents to the emergency department (ED) describing severe pain on the left side of the abdomen that started after going to bed last night. Patrick has a history of hypertension. Current medications are furosemide and lisinopril. He has smoked for 18 years and drinks alcoholic beverages most days of the week. Patrick reports that the pain got worse after eating breakfast this morning. ​ Question 4 / 8 The nurse caring for Patrick notes that his serum calcium level is low. Which statement made by the nurse indicates their understanding of the reason for hypocalcemia in acute pancreatitis?​ "The client is likely following a vegan dietary pattern."​ "Inability to tolerate oral intake has caused the calcium level to drop."​ "Calcium combines with fatty acids during fat necrosis."​ "The low calcium level is a result of an ongoing unhealthy diet and not related to the disorder."​

Hypocalcemia may cause tetany, which is a sign of severe disease. Calcium combines with fatty acids during fat necrosis causing hypocalcemia. ​ None of the other statements are correct.

Risk Factors for Cholelithiasis The nurse recognizes which characteristics are most associated with the development of gallstones? Select all that apply. History of excessive alcohol intake​ Family history of gallbladder disease​ Obesity Use of estrogen replacement therapy Age over 40 years Multiparous female​

Incidence of cholelithiasis is higher in multiparous, obese women over the age of 40 years old with a family history of gallstones. Taking estrogen replacement therapy or using oral contraceptives (with estrogen) increases the risk. ​ Alcohol intake is not associated with the development of gallstones.

Diagnosing and Managing Chronic Pancreatitis Diagnosis Diagnosis is based on signs and symptoms, laboratory studies, and imaging. ​ Serum amylase and lipase may be elevated or normal depending on the degree of pancreatic fibrosis. Serum bilirubin and alkaline phosphatase levels may be increased. Mild leukocytosis and a high sedimentation rate are usually present. ​ CT scan, abdominal ultrasound, or endoscopic retrograde cholangiopancreatography (ERCP) may show calcification, ductal dilation, pseudocysts, and/or enlargement of the pancreas. ​ Stool samples reveal high fat content (steatorrhea). A secretin stimulation test can assess the degree of pancreatic dysfunction. ​

Management Nutrition therapy, pancreatic enzyme replacement (pancrelipase), and control of diabetes are necessary to control insufficiency. Prevention of acute attacks and pain management are priorities. ​ Pancrelipase is taken with every meal and snack. Insulin or oral diabetic agents may be needed to manage blood glucose. Antacids and proton pump inhibitors are used to control gastric acidity but have little overall effect on outcomes. Antidepressants may be used to reduce neuropathic pain. ​ If obstruction or pseudocysts are present, surgery may be necessary. A Roux-en-Y pancreatojejunostomy may be done to open the pancreatic duct and anastomose with the jejunum. Endoscopic retrograde cholangiopancreatography (ERCP) may be used to relieve ductal obstruction.

Chronic Pancreatitis​ Causes Manifestations Chronic pancreatitis is either obstructive caused by gallstones or nonobstructive caused by chronic alcohol use. Inflammation and sclerosis are mainly of the pancreatic head around the pancreatic duct (see the image). ​ Prolonged inflammation of the pancreas leads to progress destruction as healthy tissue is replaced with fibrotic tissue. Chronic pancreatitis may occur following an acute episode or develop in the absence of any acute attack. ​

Manifestations Pain is still the hallmark of pancreatitis, but it becomes more chronic and less severe and sudden, which is described as heavy or gnawing. Food and antacids do not relieve the pain. ​ The client will suffer from malabsorption and weight loss, constipation, mild jaundice with dark urine, steatorrhea, and diabetes. Complications include pseudocyst formation, bile duct or duodenal obstruction, pancreatic ascites or pleural effusion, splenic vein thrombosis, pseudoaneurysms, and pancreatic cancer. ​

Treatment of Pancreatitis ​ There are currently no drugs that cure pancreatitis. ​Medical management of pancreatitis includes: Minimizing Aggressive Dehydration Reducing Pain Managing Metabolic Complications​ Minimizing Pancreatic Stimulation Preventing Infections

Minimizing Pancreatic Stimulation​ Reducing or suppressing pancreatic enzymes to decrease the stimulation of the pancreas, which is essential for pancreas to rest and recovery. To accomplish this, medical management includes:​ Client is held nothing by mouth (NPO).​ Nasogastric (NG) suction may be used to prevent gastric contents from entering the duodenum and reduce distention.​ Medications are administered to suppress gastric acid secretion.​ If the condition is severe and recovery is lengthy, the client may need enteral nutrition. Note that parenteral nutrition includes an infection risk; therefore, parenteral nutrition is only used for clients who cannot tolerate enteral nutrition. ​ Once the pancreatitis resolves, the client may resume oral intake. Small, frequent, bland feedings are best tolerated. The diet should be low in fat and high in carbohydrate because that is the least stimulating nutrient. If pain returns, abdominal girth increases, or serum amylase increases, feeding should be stopped. Supplemental fat-soluble vitamins may be needed.