Case Scenario: Pancreatitis

A2 SUBGROUP A LVA R E Z , D A P H N E K AY E S . ARIM AS , RACHEL A. DAL ANGIN , JELLIE S. BENEDICTO, NORIEL L. G E L I , D AV E M I C H A E L C .

Case Scenario: Pancreatitis

A 40-year old man had severe abdominal pain 24 hours after alcohol ingestion. The pain is accompanied by nausea and vomiting. He is agitated and confused when you arrived at the ER. Pain in the midepigastrum is accompanied by abdominal distention and decrease peristalsis. Pain medication is ordered too. The client has long term history of alcohol abuse.

How does long-term alcohol consumption causes pancreatitis?

According to Friedrich 1878 and Jeremy S. Wilson 2004 Alcohol Abuse / Long tern Alcohol intake : Triggers

Pancreatic enzyme

secretion Give Increase Amylase level in the Blood. ( 3x more than normal values) Predisposing factor for Cholelithiasis (Gallstone

Explain the medical management mentioned above? What is the rationale of these managements?
Nasogastric suction, the rationale is that it is used to relieve nausea and vomiting to decrease painful abdominal distention and paralytic ileus. This is also to remove gastric secretions in an effort to limit pancreatic secretion. Cimetidine is a histamine-2 antagonist it is used to decrease pancreatic activity by inhibiting secretion of gastric acid.

The diagnosis of acute pancreatitis is based on what laboratory/diagnostic tests? Explain your answer.
Obstruction of the bile duct Reflux of enzyme (amylase, lipase, trypsin) Activation of enzymes Vasodilation Increase permeability Osmotic pressure Shifting of enzymes Specially amylase and lipase Increase enzymes in the blood stream Diagnostic Procedure: serum amylase and lipase level test Result: Elevated serum amylase and lipase level Serum amylase return within 48-72hours Serum lipase level may remain elevated for a long period of time

Upon palpation, the abdomen is rigid or boardlike. Also there is ecchymosis in the flank. What conditions these two signs may indicate?

Turners sign- flank pain Cullens sign- umbilical area discoloration, this signs may indicate severe pancreatitis Abdominal rigid or board-like, usually indicates peritonitis

What are the major complications of pancreatitis? Explain how these happen. Hemorrhage, Hypovolemic Shock, and Respiratory Distress
Trypsin activates pancreatatic enzymes, phospholipase A, elastase, and kallikrein. Trypsin may cause edema, necrosis, and hemorrhage in the pancreas. Elastase may attack the walls of smaller blood vessels and facilitate hemorrhage. Phospholipase A allows damage to the acinar cell mambrane to occur, and may alter coagulation. Severe hemorrhage leads to hypovolemic shock.

Acute pancreatitis produces retroperitoneal edema, elevation of the diaphragm, pleural effusion, and inadequate lung ventilation. Intra-abdominal infection and labored breathing increase the bodys metabolic demands, which further increases pulmonary reserve and leads to respiratory failure.

List down three priority nursing diagnosis and nursing interventions to manage the client.

1. Acute pain related to alcohol consumption

as evidenced by pain in the midepigastrum 2. Deficient fluid volume related to nasogastirc drainage as evidenced by nasogastric suctioning 3. Imbalanced nutrition: less than body requirements related to inadequate dietary intake as evidenced by alcohol ingestion

Nursing Care Plans

BSN2A2 SUBGROUP

Acute pain related to alcohol consumption as evidenced by pain the midepigastrum

Assessment Subjective Cues: Pain in the midepigastrum

Objective Cues: -Abdominal distention -Decrease peristalsis -Rigid boardlike abdomen

Scientific Explanation
Alcohol ingestion Digestive enzymes release sooner than normal Formation of protein plug Vasodilation Increase permeability small ducts within the pancreas Hypersecretion of enzymes Self protective mechanism breakdown Irritation of the pancreas Abdominal pain

Planning
Discharge outcome: After 2 days of nursing intervention, the client will be able to report pain is relieved. Short-term outcome: After 8 hours of nursing intervention, the client will be able to obtain relief of pain from medications administered.

Implementation and Rationale

Implementation Rationale

Independent: Assess patient for pain level.

Use relaxation

Helps to establish plan of

care and shows concern for the patient.

Alternative nonmedicinal

techniques, biofeedback, guided imagery, and other alternatives to ease pain

therapeutics may be significantly helpful in reducing anxiety and discomfort

Implementation and Rationale

Implementation Rationale

Independent: Instruct patient/family regarding medication administration , and be able to answer all questions

Patient and/or family

may believe that patient will become addicted to medication and try to refuse pain relief. False misconceptions should be illuminated. Knowledge will foster compliance

Implementation and Rationale

Implementation Rationale

Independent: Instruct patient to notify nurse of pain when it first begins.

Allows for timely

intervention to preclude pain from becoming exquisite and requiring extensive analgesic administration

Implementation and Rationale

Implementation Rationale

Collaborative: Administer medications (usually meperidine [Demerol] IV as ordered.

Demerol is the drug of

choice for pancreatitis. Morphine should not be given because most opiatetype narcotics cause spasms of the sphincter of Oddi, increasing patients pain. Large dosages may be required for patients relief of pain, and may even be ineffective at relieving discomfort.

Evaluation
Discharge outcome met. The client was able to report pain is relieved.

Short-term outcome met. The client was able to obtain relief of pain from medications administered.

Deficient fluid volume related to nasogastirc drainage as evidenced by nasogastric suctioning

Assessment Subjective Cues: Objective Cues: -with ongoing nasogastric tube -nausea -vomiting

Scientific Explanation
Nasogastric drainage Secretion of gastric contents No formation of intestinal hormones No stimulation on the pancreas Loss of electrolytes Dehydration Deficient fluid loss

Planning
Discharge Outcome: After 2 days of nursing intervention the patient will be able to stabilize the fluid loss in the body.

Short-term Outcome: After 8 hours of nursing intervention the patient will no longer experience nausea and vomiting.

Implementation and Rationale

Implementation Rationale

Independent: Assess fluid and electrolyte status (skin turgor, mucous membrane, urine output and vital signs)

The amount and type of

fluid and electrolyte replacement are determined by the status of the BP, the laboratory evaluations of serum electrolyte and blood urea nitrogen levels, the urinary volume and the assessment of the patients condition.

Implementation and Rationale

Implementation Rationale

Independent: Assess the source of fluid and electrolyte loss (vomiting, diarrhea, nasogastric drainage, excessive diaphoresis)

Electrolyte losses

occur from nasogastric suctioning, severe diaphoresis and emesis as a result of the patients being a fasting state.

Implementation and Rationale

Implementation Rationale

Independent: Provide 24-hour fluid replacement needs and routes to be used.

Record the intake and

It prevents peaks and

valleys in fluid level.

For accurate

output and measure also other fluid losses.

determination of replacement needs.

Implementation and Rationale

Implementation Rationale

Independent: Inform the patient that there would be limit intake of alcohol and caffeinated beverages.

It tends to exert a

diuretic effect.

Implementation and Rationale

Implementation Rationale

Collaborative: Administer fluids and electrolytes. As ordered

This is for proper

Review laboratory data

(e.g. Hct; electrolytes;BUN;creati nine)

replacement of the loss fluids and electrolytes in the body. For proper diagnosis of the condition.

Evaluation
Discharge outcome met. The patient was able to stabilize the fluid loss in the body.

Short-term outcome met. The patient was no longer experiencing nausea and vomiting.

Imbalanced nutrition: less than body requirements related to inadequate dietary intake as evidenced by alcohol ingestion

Assessment Subjective Cues: Objective Cues: -Long time use of alcohol -40 years old -nausea -vomiting -with ongoing NGT -NPO

Scientific Explanation
Alcohol ingestion Digestive enzymes release sooner than normal Formation of protein plug Vasodilation Increase permeability small ducts within the pancreas Hypersecretion of enzymes Self protective mechanism breakdown Irritation of the pancreas Decrease peristalsis Decrease source of food that will enters to the stomach and be digested Inadequate nutritional supply

Planning
Discharge outcome: Upon discharge, the client will be able to maintain optimal nutrition and promote healthy living as evidenced by decrease alcohol consumption.

Planning
Short-term Outcome: After 2 hours of nursing intervention, the client will be able to:
Identify

at least 2 effects of excessive drinking alcoholic beverages to the body. Identify at least 3 benefits of decreasing intake of alcoholic beverages. Identify 2 ways to promote healthy lifestyle (healthy diet alcohol intake), no / decrease

Implementation and Rationale

Implementation Rationale

Independent: Assess the patient specially focusing on the I and O of the patient
Assess the patient for

For baseline date and

accurate monitoring of the client

To prevent patient for

being dehydrated

any signs and symptoms of dehydration and pain.

Implementation and Rationale

Implementation Rationale

Independent: Provide health teaching to the patient regarding to the proper diet . Provide health teaching to the patient about the effects of excessive intake of alcohol and the benefits if it is decrease or possibly stop.

To enhance clients

knowledge regarding the proper diet. To enhance clients knowledge regarding the effects of excessive alcohol intake and benefits if it is stop.

Implementation and Rationale

Implementation Rationale

Collaborative: Refer the patient to endocrinologist

To prevent further

development of disease that may cause peritonitis or death.

Evaluation
Discharge outcome met. The client was able to maintain optimal nutrition and promote healthy living as evidenced by decrease alcohol consumption.

Evaluation
Short-term outcome met. The client was able to: Identify at least 2 effects of excessive drinking alcoholic beverages to the body. (Liver cirrhosis and pancreatitis) Identify at least 3 benefits of decreasing intake of alcoholic beverages. (Better functioning of the liver, healthier life, free from disease) Identify 2 ways to promote healthy lifestyle

Questions
1) Acute pancreatitis caused by self digestion of the

pancreas by its own proteolytic enzymes. What is the primary enzyme that causes acute pancreatitis?
2) What are the possible complications of acute

pancreatits? And what are the signs and symptoms that indicate that the client is suffering from complications?

3) How long is the onset of pain after having a

heavy meal and alcohol ingestion?

4) What is the purpose of the naso-gastric suction

(NGT) and its nursing responsibilities?

5) Why serum amylase in the blood usually return to

normal within 48 to 72 hours? While serum lipase level may remain elevated for a longer period?