What is the most appropriate nursing diagnosis for the client with acute pancreatitis?

A client is admitted to the health care facility with abdominal pain, a low-grade fever,abdominal distention, and weight loss. The physician diagnoses acute pancreatitis.What is the primary goal of nursing care for this client?Relieving abdominal painR: The predominant clinical feature of acute pancreatitis is abdominal pain, whichusually reaches peak intensity several hours after onset of the illness. Therefore,relieving abdominal pain is the nurse's primary goal. Because acute pancreatitis causesnausea and vomiting, the nurse should try to prevent fluid volume deficit, not overload.The nurse can't help the client achieve adequate nutrition or understand the diseaseand its treatment until the client is comfortable and no longer in pain.A client is evaluated for severe pain in the right upper abdominal quadrant, which isaccompanied by nausea and vomiting. The physician diagnoses acute cholecystitis andcholelithiasis. For this client, which nursing diagnosis takes top priority?A. Acute pain related to biliary spasmsB. Deficient knowledge related to prevention of disease recurrenceC. Anxiety related to unknown outcome of hospitalization D. Imbalanced nutrition: Lessthan body requirements related to biliary inflammationAR:The chief symptom of cholecystitis is abdominal pain or biliary colic. Typically, thepain is so severe that the client is restless and changes positions frequently to findrelief. Therefore, the nursing diagnosis of Acute pain related to biliary spasms takeshighest priority. Until the acute pain is relieved, the client can't learn about prevention,may continue to experience anxiety, and can't address nutritional concerns.The digestion of carbohydrates is aided byAmylaseR:Amylase is secreted by the exocrine pancreas. Lipase aids in the digestion of fats.Trypsin aids in the digestion of proteins. Secretin is the major stimulus for increasedbicarbonate secretion from the pancreas.Upon receiving the dinner tray for a client admitted with acute gallbladder inflammation,the nurse will question which of the following foods on the tray?A. Hot roast beef sandwich with gravyB. White riceC. Vanilla puddingD. Mashed potatoesAR: The diet immediately after an episode of acute cholecystitis is initially limited to low-fat liquids. Cooked fruits, rice or tapioca, lean meats, mashed potatoes, bread, andcoffee or tea may be added as tolerated. The client should avoid fried foods such asfried chicken, because fatty foods may bring on an episode of cholecystitis.

In this article, we’ll talk about pancreatitis nursing interventions and assessment…two skills you’ll use regularly as a bedside RN. Pancreatitis is an inflammatory condition involving the pancreas. It can be acute or chronic, and is associated with a lot of other disorders such as alcoholism, disorders of the biliary tract, and use of certain medications like glucocorticoids. It can also be considered “idiopathic” which simply means it occurs because it occurs and we don’t really know why. Even though it’s pretty common does not mean it cannot be very serious. Acute pancreatitis has a 10% mortality rate and can lead to serious respiratory complications ranging from hypoxia to ARDS. Chronic pancreatitis, on the other hand, can cause permanent damage to the pancreas. 

Because it’s a pretty common condition, chances are you’ll see in your Med/Surg clinicals and definitely on your GI exam. So, let’s go through it using the Straight A Nursing LATTE method. If you’re not sure what the LATTE method is, check out this post.

L: How does the patient LOOK?

The patient with pancreatitis will be complaining of severe upper or epigastric abdominal pain that may radiate to the back. This pain could be worse after eating high-fat foods, or drinking alcohol. In many cases the patient will have nausea with or without vomiting. Many times these patients are thin due to either chronic weight loss secondary to the condition or chronic alcohol use (many patients who are dependent on alcohol drink their calories instead of eating real meals, so many times these patients are significantly malnourished).

A: How will you ASSESS this patient? 

• Do a thorough pain assessment. A good routine to follow is the PQRST model which explores what propagates the pain (or relieves it), the quality of the pain, whether the pain radiates anywhere, the severity of the pain, and if it improves or worsens over time. 
• Assess the patient’s blood pressure. In many cases it will be reduced due to volume losses. However, severe pain can elevate blood pressure which could (for a little while at least) mask a hypovolemic state. 
• Assess heart rate, which is likely to be elevated due to pain and as a compensatory mechanism for the hypotension.
• Take the patient’s temperature. A fever could indicate respiratory compromise such as pleural effusion and even ARDS. The causes for these complications are multifactoral, but one reason is that pancreatic enzymes can leak into the pleural cavity causing pleural effusion. 
• Check for Chvostek’s sign which indicates hypocalcemia. You do this by stimulating the facial nerve and watching for twitching, which is a sign of low calcium levels. The exact mechanism of hypocalcemia and pancreatitis is not known. However, we do know that it occurs for different reasons based on the early or late stages of the disease. In the early stages, hypocalcemia is believed to be secondary to hypoparathyroidism, low magnesium levels and even the autodigestion of mesenteric fat by pancreatic enzymes. In the later stages, hypocalcemia is often present in conjunction with sepsis.
• Weigh your patient daily to monitor fluid balance.

T: What TESTS will be ordered? 

• Chemistry panel to monitor electrolytes, especially calcium
• WBC to monitor for infection and inflammation
• Bilirubin may be elevated
• Blood sugar can be elevated…recall that its the beta cells of the pancreas that secrete insulin
• Serum alk phosphatase will be elevated 
• Serum amylase will likely also be elevated
• CT scan could show an enlarged organ, any cysts that are present
• ERCP (Endoscopic retrograde cholangiopancreatography) is a test that shows the anatomy of the pancreas including the ducts which are often blocked or malfunctioning in acute pancreatitis
• Chest x-ray would reveal pleural effusion (a serious complication of pancreatitis) 
• An abdominal x-ray may be ordered to rule out other GI disorders

T: What TREATMENTS will be provided?

• The three mainstays of pancreatitis treatment are NPO, NGT and pain management. 
  • The patient will be NPO to give the pancreas a rest since eating stimulates the pancreas to release enzymes
  • Pancreatitis often comes with pretty significant nausea/vomiting. The NGT will decrease gastric distention and remove gastric juices. Though patients typically HATE the insertion aspect of the NGT, it typically often relieves their unrelenting nausea pretty effectively and quickly. 
  • Pain medication can include meperidine and/or opiates. Many resources will state that meperedine is the medication of choice due to the fact that it causes less spasming of the sphinctor of Vater than opiates do. However, meperedine has a dangerous byproduct called MPTP that is neuro toxic. So, for this reason, many healthcare practitioners skip the meperedine and just go with morphine or some other opioid.
• Fluids to replace volume losses
• Medications to reduce gastric acids include H2 receptor blockers, PPIs and antacids
• Anticholinergic medications may be used to decrease secretion of pancreatic enzymes and slow gastric motility
• Antibiotics as needed
• Insulin may be needed in cases of hyperglycemia
• Patients with impaired pancreatic enzyme secretion may need to take exogenous pancreatic enzymes long-term
• Surgery may be needed if there are cysts, biliary obstructions or abscesses present 
• If the cause is a malfunctioning pancreatic sphinctor, surgery can be done to enlarge it

E: How will you EDUCATE the patient? 

• ETOH cessation if needed (ETOH is medical abbreviation for “alcohol”)
• Patient will need to be careful with their diet, typically starting with low-fat and low-protein foods, then progressing slowly
• If DM is present, the patient will need a lot of education surrounding the management of this disease and the necessary dietary modifications
• The patient will need to avoid caffeine as it can exacerbate the condition
• Teach the patient which foods trigger attacks, so they can avoid them (typically this includes fatty red meats, fried foods, butter or margarine, sugary foods and full-fat dairy)
• If the patient is discharged with pancreatic enzymes, they need to understand to take them WITH meals
• The patient should be instructed to report abdominal distention, abdominal cramping or pain, and foul-smelling or frothy stools (which can indicate an ongoing problem)

I hope this quick overview helps you take excellent care of your patients with pancreatitis whether they be real patients in the hospital or hypothetical ones on your exams!

Get this on audio on the Straight A Nursing Podcast – Episode 66

References

Ahmed, A., Azim, A., Gurjar, M., & Baronia, A. K. (2016). Hypocalcemia in acute pancreatitis revisited. Indian Journal of Critical Care Medicine : Peer-Reviewed, Official Publication of Indian Society of Critical Care Medicine,20(3), 173–177. https://doi.org/10.4103/0972-5229.178182

Browne, G. W., & Pitchumoni, C. (2006). Pathophysiology of pulmonary complications of acute pancreatitis. World Journal of Gastroenterology : WJG, 12(44), 7087–7096. https://doi.org/10.3748/wjg.v12.i44.7087

Cleveland Clinic. (2017, November 29). Best and Worst Foods for Pancreatitis Pain. Retrieved from Health Essentials from Cleveland Clinic website: https://health.clevelandclinic.org/best-and-worst-foods-for-pancreatitis-pain/

Dreiling, D. A., & Janowitz, H. D. (1960). Inhibitory effect of new anticholinergics on the basal and secretin-stimulated pancreatic secretion in patients with and without pancreatic disease. The American Journal of Digestive Diseases, 5(7), 639–654. https://doi.org/10.1007/BF02290198

Ingelfinger, F. J. (1963, June). Anticholinergic Therapy of Gastrointestinal Disorders | NEJM. Retrieved from The New England Journal of Medicine website: https://www.nejm.org/doi/pdf/10.1056/NEJM196306272682608

National Headache Foundation. (2007, October 25). Demerol®. Retrieved from National Headache Foundation website: https://headaches.org/2007/10/25/demerol/

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