This paper summarizes the publishing’s of Doenges, Moorhouse, and Murr (2010) and Christenson and Kockrow (2011) which describes the disease process pancreatitis. Christenson et al. (2011) discusses common signs and symptoms patients experience with pancreas disorders. Doenges et al. (2010) discusses the most common diagnostic techniques and the most popular medical and nursing management procedures that are practiced today. Christenson et al. (2010) defines the abbreviation AST as Aspartate aminotransferase and ALT as alanine aminotransferase.
Both of these publishing’s have the same definitions of pancreatitis and both suggest that lifestyle changes, medications, and surgical intervention may be necessary to decrease the chance of more acute episodes. On Wednesday September 28 CS 51-year-old man, with recent laparoscopic cholecystectomy, presented to the emergency department with complaints of severe abdominal pain. The episode started around 1100 and was initially mild. He was able to eat normally, but around 1400, the pain became much worse to the point that he had difficulty breathing. He took an oxycodone, which provided little relief.
CS found that flexing his hips and staying still helped relieve the pain. He described the pain as cramping and wrapping around to his back, worse on the right side. He has nausea, but has not experienced vomiting. In the emergency department he was given diluadid, which relieved the pain. He has had four episodes similar to this since June and has not seen improvement since the cholecystectomy in August. Christenson et al. (2011), states that the pancreas is a gland located in the upper posterior abdomen which is responsible for both endocrine and exocrine functions.
The endocrine function refers to the Islets of Langerhans, which produce and secrete insulin into the bloodstream where they travel to distant organs. The exocrine function includes glands that produce and secrete enzymes which accumulate in the intralobular ducts, and empty into the main pancreatic duct, which then drains into the duodenum when needed for digestion. Doenges et al. (2010) states that amylase breaks down carbohydrates into sugars which are more easily absorbed by the body. This enzyme can also be found in saliva.
Another pancreatic enzyme lipase works with bile from the gallbladder to break down fat. Protease breaks down proteins and helps keep the intestine free of bacteria, yeast and protozoa. Doenges et al. (2010) describes pancreatitis as an inflammation of pancreas. The most common cause of pancreatitis is obstruction by gallstones which accounts for forty percent of cases. Doenges et al. (2010), states that alcohol abuse is another major cause which contributes to thirty-five percent. Certain procedures, viral or bacterial infections, and certain pharmaceutical drugs can cause pancreatitis also.
This inflammation can cause activation of pancreatic enzymes resulting in localized damage to the pancreas, autodigestion, and fibrosis of the pancreas. Christenson et al. (2011) states that if left untreated pancreatitis can lead to widespread range of consequences and life-threatening complications, including hypovolemia, shock, acute renal failure, diabetes, acute respiratory distress syndrome, and multi organ failure. It is estimated by Doenges et al. (2010) that eighty-seven thousand people are diagnosed with chronic pancreatitis each year in the United States.
Twenty-two thousand were said to be hospitalized for acute pancreatitis in 2007. The mortality rate is less than one percent for mild acute pancreatitis, but can approach ten percent to thirty percent for severe acute pancreatitis. It is also estimated by Doenges et al. (2010) that more than two billion dollars are spent each year in the United States on treatment and diagnosis of pancreatitis. Doenges et al. (2010) separates pancreatitis into two categories, acute or chronic. Acute is when a sudden inflammation occurs over a short period of time. Chronic pancreatitis is associated with chronic alcoholism sixty percent of the time.
Patients can present with a range of signs and symptoms. Christenson et al. (2011) states that some general signs and symptoms include fatigue, restlessness, apprehension, hypertension, hypotension, ascites, pale or yellow skin, Positive Cullen’s sign, diarrhea, hypoactive bowl sounds, abdominal distension and tenderness, dark and decreased urine, steatorrhea, loss of appetite, weight loss, severe deep abdominal pain, usually in the epigastric region and may radiate to the back, patient may curl up on left side with both arms over abdomen and knees and hips flexed, tachypnea with or without dyspnea, and decreased depth of respiration.
There are several diagnostic procedures physicians can order to diagnose pancreatitis. Doenges et al. (2010) describes serum amylase as a common marker for pancreatitis. Increased levels can indicate pancreatitis because of obstruction of the normal flow of pancreatic enzymes. This value may be up to five or more times the normal level in acute pancreatitis. Levels are typically elevated in chronic pancreatitis, but not seen as high as in acute phase. Serum lipase is more specific to the pancreas than amylase. Doenges et al. (2010) also states that amylase and Lipase commonly rise together, but lipase typically stays elevated longer.
Magnetic resonance cholangiopancreatography or MRCP is an imaging tool that uses magnetic resonance to visualize the biliary tree. This test can discover suspected pancreatic duct obstruction which could be the cause for pancreatitis. Doenges et al. (2010) states that endoscopic retrograde cholangiopancreatography or ERCP is a diagnostic study that uses endoscopy along with x-rays to provide what is considered the most accurate view of the pancreatic and bile ducts. It is typically used to diagnose fistulas, obstructive biliary disease, and pancreatic ductal system abnormalities, such as strictures or stones.
In chronic pancreatitis with loss of pancreatic functions, Doenges et al. (2010) stated that replacement enzymes, such as pancreatin (Dizymes) and pancrelipase (Protilase and Cotazym) can be prescribed to correct shortages to promote digestion and absorption of nutrients. On Wednesday September 28 CS, 51-year-old man, with recent laparoscopic cholecystectomy, presented to the emergency department with complaints of severe abdominal pain. The episode started around 1100 and was initially mild. He was able to eat normally, but around 1400, the pain became much worse to the point that he had difficulty breathing.
He took an oxycodone without relief. Flexing his hips and staying still helped relieve the pain. He describes the pain as cramping and wrapping around to his back, worse on the right side. He has associated nausea, but no emesis. In the ER he was given diluadid, which broke the pain and now feels like his normal self. He has had 4-5 episodes like this since June and has not seen improvement since the cholecystectomy. In CSs’ case he is believed to have chronic pancreatitis. CS described his severe pain as a cramping and twisting sensation, which radiates to the right side of his back.
The pain is made worst with movement, and is reduced when his knees are brought up to his chest. He states he “is experiencing nausea, but no vomiting”. CS states the pain “starts off as a mild pain for 30 minutes to an hour, and will then pop into a severe pain. ” CS has been seen four times for similar pain, which all resulted in visits to ED. He has a recent history of acute cholecystitis, which was treated with a laparoscopic cholecystectomy on August 17, 2011. A previous surgery consultation believes that the pain is a result of chronic pancreatitis. CSs’ heavy alcohol consumption is also believed to be a contributing factor.
Diagnostic procedures performed included an initial lab draw, which was notable for transaminitis. Christenson et al. (2011) states transaminitis can be defined as the generalized increased of AST and ALT levels which may occur in patients undergoing the early stages of multiorgan failure. Upon admittance the ALT was in the 329 U/L and AST was 215 U/L. Lipase was also elevated at 473 U/L. Another notable lab value was blood glucose at a level of 146 mg/dl. On the 29th the ALT level was 358 U/L, AST 215 U/L. Then on the 30th ALT level was 290 U/L and AST was 73 U/L.
An MRCP was completed; the findings were mild dilation of the common bile duct and beading of the main left intrahepatic duct. This beading, or mild bleeding, can release of enzymes and toxins into bloodstream can damage other vital organs, including the heart, lungs, and kidneys. The MRCP was however, negative for choledocholithiasis. After an inconclusive MRCP, an ERCP was performed on CS. A mild dilation of the ventral pancreatic duct was found diffusely, along with mild dilation of the entire main bile duct. Although choledocholithiasis or bleeding was not seen, the patient may have already passed a stone.
This is believed to have caused the acute episode of pancreatitis. Mild debris was collected from the pancreatic duct. A sphincterotomy on the pancreatic duct was done to prevent future episodes of pancreatitis. During his hospital stay CS was on a variety of different medications including nifedipine (Adalat CC) 60mg daily for anti-anginal and antihypertension, losartan (Cozaar) 100mg daily for stroke prevention, esomeprazole (Nexium) 40mg daily for the treatment of gastroesophageal reflux disease, and ondansteron (Zofran) 4mg/2ml every 6 hours as needed for nausea.
Nursing care plans are implemented to help prioritize care for the patient and ensure consistency throughout nursing staff. The most important plan relating to CS would be acute pain related to obstruction of pancreatic biliary ducts, as evidenced by verbal reports of 10/10 on pain scale and facial grimacing and guarding behaviors. Patient will maintain a pain level of less than 3/10 till discharge. To achieve this goal pain assessments should be conducted every hour, and instruct patient to report pain at an early level (2/10) to prevent breakthrough pain.
Position of comfort, if indicated, should be promoted. This position can be on one side with knees flexed or sitting up and leaning forward. This reduces abdominal pressure and tension, providing some measure of comfort and pain relief. Gate Control Theory can also provide alternative comfort measures including repositioning, back rub, quiet activities such as TV or radio, relaxation techniques, such as guided imagery and visualization. This blocks the stimulation of pain receptors and promotes relaxation and enables client to refocus attention and may improve coping.
Imbalanced nutrition, less than body requirements, related to loss of digestive enzymes, as evidenced by observed inadequate food intake and weight loss. Patient will consume more than half of meals and have no complaint of nausea till discharge. This goal can be achieved by assisting the patient in selecting food and fluids that meet nutritional needs and restrictions when diet is resumed. The future use of caffeine, alcohol, cigarettes, gas-producing foods, or consumption of large meals could result in excessive stimulation of the pancreas and a recurrence of symptoms.
Monitor intakes and outputs and observe the color, consistency, and amount of stools. Steatorrhea or fatty stools may develop from incomplete digestion of fats. Explain to patient that they are to resume oral intake with liquids and advance diet slowly once indicated by physician. Meals given too early may worsen symptoms. Risk for unstable blood glucose level related to pancreatic impairment. Patient will maintain glucose in normal range of 80-100 until discharge. Assess for signs of increased thirst and urination or changes in mental status and sight.
This may indicate the developing of hyperglycemia. Perform and monitor results of bedside fingerstick glucose testing and dipstick testing of urine for sugar. Early detection of inadequate glucose utilization makes it easier to manage. Monitor serum glucose levels closely, as this can indicate the need for insulin because hyperglycemia is frequently present. Discharge planning begins the moment the patient arrives on the floor. Patients’ pain should be relieved or controlled at a reasonable level such as a 3/10 on the pain scale.
They should be stable, meaning they are within normal limits concerning vital signs. The patient should understand the disease process of pancreatitis, potential complications, and therapeutic regimen understood. The patient was not discharged home with any new medications. Patient should also understand that alcohol can increase chances of re-occurrence. A referral to a support group may be needed. The patient should let his wife know that she will need to be there to take him home when he is discharged.