Caring for the Patient with Acute Pancreatitis

Cholecystitis: Collaborative Interventions

- Manage pain - NPO w/ NG tube, later progressing to low-fat diet - Anti-emetics - Anticholinergics (antispasmodics)- help decrease the spasms

Acute Pancreatitis:Clinical Manifestations part 2

1. Decreased/absent bowel sounds ("ileus") 2. Intravascular damage (2º to circulatingtrypsyn) & retroperitoneal bleeding: - Cyanosis, greenish-yellow discoloration of abdominal wall - (Grey) Turner's Sign - Cullen's Sign 3.Hypotension/tachycardia 4. Shock 5. Acute: damage is potentially reversible

Acute Pancreatitis: What common causes of it?

1. Gallbladder disease (women) 2. Alcohol (men)

what are complications of Acute pancreatitis

1. Pseudocyst 2. Abscess

Prevention of Exacerbations of Chronic Pancreatitis

1.Avoid things that make your symptoms worse, such as drinking caffeinated beverages. 2.Avoid alcohol ingestion; refer to self-help group for assistance. 3.Avoid nicotine. 4.Eat bland, low-fat, high-protein, high-carbohydrate meals; avoid gastric stimulants, such as spices. 5.Eat small meals and snacks high in calories. 6.Take the pancreatic enzymes that have been prescribed for you with meals. 7.Rest frequently; restrict your activity to one floor until you regain your strength.

Which symptom would the nurse most likely observe in a patient with cholecystitis from cholelithiasis?

Nausea after ingestion of high-fat foods

Acute pancreatitis patient/family teaching

When no longer NPO) Diet teaching - CHO encouraged (less stimulating to pancreas); fat restriction

A patient with cholecystitis has a gallstone lodged in the common bile duct. When assessing this patient, the nurse expects to note:

Yellow sclerae

Bile bag

a collection bag that drains the bile from the common bile duct and It is emptied regularly and will be greenish in color. Patients may go home with them and if they are there would be related teaching

Acute pancreatitis interventions to monitor for hyperglycemia

because endocrine function of the pancreas is insulin function and can impact the other half of pancreas function. They may need to go on insulin

Chronic PancreatitisEnzyme Replacement/PERT considerations

•Take pancreatic enzymes before or with meals and snacks. (up to date: take with first bite of meals) •Sometimes ordered to administer with antacid or H2 blockers; (because a decreased pH inactivates drug). •Tell the patient to swallow the tablets without chewing to minimize oral irritation. •Avoid lip/skin contact with enzymes. (Wipe lips prn after ingesting.) •Mix the powder form in applesauce or fruit juice at patient's request. •Do not mix enzyme preparations in protein-containing foods.- it deactivates it •Do not crush enteric-coated preparations. •Follow up on all scheduled laboratory testing. (Pancrelipase can cause an increase in uric acid levels.)

etiology of obstructive jaundice

No bile flow into duodenum, bilirubin accumulates in blood

Etiology of Intolerance to fatty foods (nausea, sensation of fullness, anorexia)

No bile in small intestine for fat digestion

Etiology of Clay-colored stools

No bilirubin reaching small intestine to be converted to urobilinogen

Etiology of No urobilinogenin urine

No bilirubin reaching small intestine to be converted to urobilinogen

Why does a patient experience ↑ serum amylase & lipase with Acute Pancreatitis?

Pancreatic cell injury

Why does a patient experience Cullen's & Turner's Signs with Acute Pancreatitis?

Pancreatic enzyme leakage into cutaneous tissue (in severe cases; poor prognosis)

what is the purpose of the T-tube?

Purpose is to maintain Patency of the common Bile duct

Why does a patient experience paralytic ileus with Acute Pancreatitis?

Related peritoneal irritation causes intestinal motility to slow down/stop

•Hepatobiliary scan (HIDA scan):

•Nuclear medicine test •Visualizes the gallbladder & patency of biliary system

Acute Pancreatitis definition

•Premature activation of excessive pancreatic enzymes that destroy pancreatic cells, resulting in autodigestion & fibrosis of pancreas.

Chronic Pancreatitis

•Progressive, destructive - w/ remissions & flares; caused by inflammation & fibrosis of tissue

Acute Pancreatitis

•Ranges from mild edema to severe hemorrhagic necrosis. •Gallstones & ETOH two most common causes. •CT scan is best imaging for pancreatitis & its complications. •Shows pancreatic diameter, calcifications, pancreatic cysts or pseudocysts

•Pancreatic-enzyme replacement therapy (PERT):

•Standard of care to prevent malnutrition, malabsorption, & excessive weight loss. •Very often given "pancrelipase": - Contains varying amounts of amylase, lipase, & protease. •Record number & consistency of stools per day to monitor effectiveness of enzyme therapy. How will you know if it is effective?... •Given orally

Pseudocyst

- cavity (filled w/ necrotic products) surrounding outside of pancreas (resolves spontaneously or perforates into peritoneum) - Forms on the Outside

Pancrelipase

- contains the enzymes (including lipases, proteases, and amylases) needed for the digestion of proteins, starches, and fats. - DO not chew

Abscess

- large fluid-containing cavity within pancreas (results in extensive necrosis of pancreas); need prompt surgical drainage - Forms on the inside

Acute Pancreatitis: Clinical Manifestations

1. Abdominal pain - predominant symptom - LUQ, mid-epigastric, or retroperitoneal - Sudden onset - Aggravated by eating, recumbency(lying down), alcohol - Unrelieved with vomiting - the pain is unrelieved 2. N/V 3. Low-grade fever 4. Leukocytosis 5. Jaundice within 24 hrs- due to a backup of bilirubin

The nurse is caring for a patient following a laparoscopic cholecystectomy. Which nursing action is priority?

Assess puncture sites for bleeding - they will have minimal pain and no abdominal dressing

Why does a patient experience N/V with Acute Pancreatitis?

Associated with any pain originating in viscera

Cholelithiasis:Non-surgical Approaches

- Mechanical lithotripsy - Biliary stent placement - ERCP w/ sphincterotomy LOOK UP

Cholelithiasis/Cholecystitis:Who is at risk?

- Middle-age females - Fair skin - Overweight - High-fat diet - Oral contraceptives

Acute pancreatitis interventions to maintain F&E balance

- Monitor VS frequently - Monitor for fluid imbalances & electrolyte imbalances - Aggressive hydration (done through IV)

Acute pancreatitis interventions to allow pancreas to rest/suppress pancreatic enzyme stimulation?

- NPO; meticulous oral care - NG (salemsump)→ LWS

Etiology of Fever, chills, cholangitis

Bacterial reflux from biliary tract to system circulation

Turner's Sign

Bluish flank discoloration

A patient who has a history of alcohol abuse now has recurrent exacerbations of chronic pancreatitis. The nurse asks the patient to obtain a stool specimen. When assessing the patient's stool, what would the nurse expect to observe? Select all that apply.

- Oily in consistency - Float in the toilet - Excessively foul-smelling the body cannot digest the fat and so these manifestations present

Acute pancreatitis

- acute inflammation of the pancreas - 2° release of enzymes into - pancreatic tissue itself

How do you know that PERT is really working?

the stool becomes less frequent and less fatty - Pay attention to their alertness

Cholecystitis non-surgical collaborative care?

•Avoid fatty foods (NPO if major flare) •With biliary pain, opioids are indicated •Anti-emetics & antispasmodics •Rarely - extracorporeal shock wave lithotripsy (ESWL) or ERCP w/ sphincterotomy

Cholelithiasis & Cholecystitis clinical manifestations

•Episodic/vague upper abdominal pain - radiates to right shoulder •Pain triggered by high-fat or high-volume meal •N/V/dyspepsia/eructation/flatulence •Fever- low grade •Jaundice, clay-colored stools, dark urine, steatorrhea (most common with chronic cholecystitis)

Chronic pancreatitis Clinical manifestations

•Intense abdominal pain (tenderness less than when acute) •Mass? - suspect pseudocyst or abscess •Ascites •Respiratory compromise •Steatorrhea •Dark urine

Cholecystitis surgical

•Laparoscopic cholecystectomy •Open cholecystectomy w/ T-tube

How is acute pancreatitis like pac man?

The enzymes are supposed to leave the pancreas but they are just staying and eating it up

Which goal is most important for a patient with acute pancreatitis?

The patient reports minimal abdominal pain.

Etiology of Steatorrhea

Undigested fatty componentsof food are eliminated in stool. Occurs because no bile in small intestine, thus preventing emulsion, digestion & absorption of fat

chronic Pancreatitis and weight loss

Weight loss can be significant: •Sometimes a candidate for TPN •If taking PO, may need up to 4000 to 6000 calories/day to maintain weight. - protein and fat malabsorption result in significant weight loss and decreased muscle mass in the patient with chronic pancreatitis. Therefore the nutritional interventions for acute pancreatitis are also used for chronic pancreatitis. The patient often limits food intake to avoid increased pain. For this reason, nutrition maintenance is often difficult to achieve. Patients receive either total parenteral nutrition (TPN) or total enteral nutrition (TEN), including vitamin and mineral replacement

Endoscopic retrograde cholangiopancreatography (ERCP)

When cause of cholecystitis is not known, or the patient has manifestations of biliary obstruction.

Cholelithiasis

gallbladder stones

Cholecystitis - Diagnostic Assessment May Include

•Ultrasound of the RUQ is the best initial diagnostic test: - Safe, accurate, and painless

pain control for chronic pancreatitis

•Yes - opioids used; however, to be used cautiously.

Cholelithiasis/cystitis: Clinical Manifestations

1. Indigestion → excruciating pain, fever, jaundice 2. Tenderness RUQ (where gallbladder is located) 3. N/V, restlessness, diaphoresis 4. "Biliary colic" - intermittent spasms resulting from with lodged stone in duct 5. Lasts up to an hour 6. Attacks occur 3 - 6 hours after heavy meal or when patient lies down

Laparoscopic Cholecystectomy

- AKA lap chole - Since 1990 - 95% of GB surgeries - D/C within 24 hrs - the preferred method because it is quicker and faster (See Patient/Family Teaching Guide in Lewis)

Cholecystitis: Nursing Diagnoses

- Acute pain - Ineffective therapeutic regimen management r/t lack of knowledge - Teaching for diet and alcohol

Acute Pancreatitis:Nursing Diagnosis

- Acute pain - Risk for fluid volume deficit - Imbalanced nutrition: Less than body requirements - Anxiety - Ineffective therapeutic regimen management

Acute vs Chronic Pancreatitis: Nursing Implications

- Dealing with exacerbations - Diet: Bland, low-fat, high-CHO - Totally eliminate alcohol - Pancreatic enzyme replacement - Monitor for diabetes - Surgical options

The patient with severe dyspepsia has been diagnosed with cholecystitis. Which foods would the nurse teach the patient to avoid?

- Fried chicken and buttered corn - Avoid foods high in fats

Acute pancreatitis interventions to relieve pain?

- IV morphine - Assume positions that flex the trunk (less stretch on peritoneum so it causes pain relief)

During the first few weeks after a cholecystectomy, the patient should follow a diet that includes:

A limited intake of fat distributed throughout the day so there is not an excessive amount in the intestine at any one time. - Take it slow because without the gallbladder we don't have any bile - They can adjust and eat regularly at some point

A patient is diagnosed with acute pancreatitis. Which assessment would be of most concern to the nurse?

A.Bluish discoloration in periumbilical area - not an expected finding - expected finds would be Increased serum amylase, Moderate upper left quadrant pain, and Low-grade fever

what are common cause of chronic pancreatitis?

Alcoholism & Biliary Disease

Cullen's Sign

Bluish periumbilical discoloration

Why does a patient experience Hypovolemia/Tachycardia with Acute Pancreatitis?

Due to plasma volume being lost as inflammatory mediators released into circulation increase vascular permeability & dilate vessels

Acute pancreatitis health promotion

Encourage d/c alcohol intake

Etiology of Bleeding tendencies

Decreased absorption of Vit. K, resulting in decreased production of prothrombin

Etiology of pruritis

Deposition of bile salts in skin tissues

Why does a patient experience pain with Acute Pancreatitis?

Due to distention of pancreas, peritoneal irritation and related inflammation

Why does a patient experience ↑ serum triglycerides with Acute Pancreatitis?

Due to fat necrosis

Why does a patient experience ↓ serum calcium with Acute Pancreatitis?

Happens with fat necrosis (deposits in these areas)

Why does a patient experience Jaundice with Acute Pancreatitis?

Hepatobiliary obstructive process (elevated bilirubin thing)

The med-surg nurse admits a patient with slight jaundice and reports of pain on the left side and back. A diagnosis of acute pancreatitis is made. Which common response to acute pancreatitis should the nurse monitor in the patient?

Hypovolemia

Acute pancreatitis interventions to monitor stool?

Impaired protein/fat metabolism; are excreted in stool "steatorrhea" (oily & float stools )

Etiology of Dark amber urine; foams when shaken

Increase in water soluble(conjugated) bilirubin elimination in urine

A nurse is providing preoperative teaching to a patient undergoing an open cholecystectomy. Which topic should the nurse include in the teaching plan?

Increase respiratory effectiveness. - open they have an abdominal Incision

Why does a patient experience Low-grade fever/ Leukocytosis with Acute Pancreatitis?

Inflammatory process

Lap Chole Procedure

Insert the air to make the area roomier so they can interpret different areas of the anatomy so after someone has had a lap chole - it is common for them to have abdominal pain due to the fact that the air is still in the stomach and the appropriate nursing intervention is to ambulate your patient because ambulation will help absorption of the remaining air of the stomach - Incision made through right subcostal incision - T-tube ®BSD(bedside drain)

A nurse is providing dietary instructions to a patient with a history of pancreatitis. Which of the following instructions would be most appropriate?

Maintain a high-carbohydrate, low-fat diet.

Whipple Procedure(pancreatoduodenectomy)

Most common surgical intervention for pancreatic cancer

Chronic Pancreatitis

continuous prolonged, inflammatory & fibrosing process of pancreas; eventually replaced with fibrotic scar tissue

Cholecystitis

inflammation of the gallbladder

Acute Pancreatitis:Collaborative Care Includes

•Monitoring V.S. closely (can be labile) •Aggressive IV hydration- get a lot of IV fluids •Pain management: - Morphine •Keep O2 sat > 95% •Minimizing pancreatic stimulation: - NPO - NG suction - PPI's (↓ gastric acid secretion) •Preventing infections (inflamed/necrotic pancreatic tissue a good medium for bacterial growth) •Nutrition (when allowed) - small frequent meals, high in CHO