Pancreatitis
Chapter 44
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Acute Pancreatitis
• An acute inflammatory process of
the pancreas
• Varies from mild edema to severe
necrosis
• Most common in middle-aged
persons and African Americans
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Case Study
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• A.J. is a 48-year-old woman who
comes to the ED.
• She has nausea, vomiting, and
epigastric and left upper quadrant
pain.
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Case Study
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• She describes the pain as severe,
sharp, and radiating through to her
midback.
• She states the pain started 24 hours
ago.
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Case Study
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• A.J. admits to smoking a half-pack
of cigarettes/day but denies drinking
alcohol or using any illegal drugs.
• Her past medical history is positive
for gallstones and hypothyroidism.
• She is 5 feet 4 inches tall and weighs
160 lb.
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Case Study
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• A.J.’s vital signs:
• Blood pressure 100/70
• Heart rate 97
• Respiratory rate 30
• Temperature 100.2°F
• Health care provider suspects acute
pancreatitis and admits A.J. to the
medical-surgical unit.
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Case Study
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• What are the possible causes of
A.J.’s pancreatitis?
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Acute Pancreatitis
Etiology
• Gallbladder disease (women)
• Chronic alcohol intake (men)
• Smoking
• Hypertriglyceridemia
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Acute Pancreatitis
Etiology
• Less common causes
• Drugs
• Metabolic disorders
• Vascular diseases
• Surgery and endoscopic procedures
• Idiopathic causes
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Acute Pancreatitis
Etiology
• Less common causes
• Trauma (postsurgical, abdominal)
• Viral infections
• Penetrating duodenal ulcer
• Cysts
• Abscesses
• Cystic fibrosis
• Kaposi sarcoma
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Case Study
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• A.J. asks you what pancreatitis is.
• How would you explain the
pathophysiology of this disease
process to her?
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Acute Pancreatitis
Pathophysiology
• Caused by autodigestion of pancreas
• Injury to pancreatic cells
• Activation of pancreatic enzymes
• Activation of trypsinogen to trypsin
within the pancreas leads to
bleeding
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Acute Pancreatitis
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Acute Pancreatitis
Pathophysiology
• Mild pancreatitis
• Edematous or interstitial
• Severe pancreatitis
• Necrotizing
• Endocrine and exocrine dysfunction
• Necrosis, organ failure, sepsis
• Rate of mortality: 25%
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Acute Pancreatitis
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Acute Pancreatitis
Clinical Manifestations
• Abdominal pain predominant
• Left upper quadrant or midepigastrium
• Radiates to the back
• Sudden onset
• Deep, piercing, continuous or steady
• Aggravated by eating
• Starts when recumbent
• Not relieved with vomiting
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Case Study
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• As you admit A.J. to the medical-
surgical unit, for what other clinical
manifestations of pancreatitis would
you assess her?
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Acute Pancreatitis
Clinical Manifestations
• Flushing
• Cyanosis
• Dyspnea
• Nausea/vomiting
• Low-grade fever
• Leukocytosis
• Hypotension, tachycardia
• Jaundice
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Acute Pancreatitis
Clinical Manifestations
• Abdominal tenderness with guarding
• Decreased or absent bowel sounds
• Crackles
• Abdominal skin discoloration
• Grey Turner’s spots or sign
• Cullen’s sign
• Shock
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Case Study
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• For what potential complications of
acute pancreatitis will you monitor
A.J.?
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Acute Pancreatitis
Complications
• Pseudocyst
• Fluid, enzyme, debris, and exudates
surrounded by wall
• Abdominal pain, palpable mass,
nausea/vomiting, anorexia
• Detected with imaging
• Resolves spontaneously or may
perforate and cause peritonitis
• Surgical or endoscopic drainage
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Acute Pancreatitis
Complications
• Pancreatic abscess
• Collection of pus
• Results from extensive necrosis
• May perforate
• Upper abdominal pain, mass, high
fever, leukocytosis
• Surgical drainage
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Acute Pancreatitis
Complications
• Systemic complications
• Pleural effusion
• Atelectasis
• Pneumonia
• ARDS
• Hypotension
• Hypocalcemia: tetany
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Case Study
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• What diagnostic studies would you
expect the health care provider to
order for A.J.?
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Acute Pancreatitis
Diagnostic Studies
• Laboratory tests
• Serum amylase level
• Serum lipase level
• Liver enzyme levels
• Triglyceride levels
• Glucose level
• Bilirubin level
• Serum calcium level
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Acute Pancreatitis
Diagnostic Studies
• Abdominal ultrasonography
• X-ray
• Contrast-enhanced CT scan
• Endoscopic retrograde
cholangiopancreatography (ERCP)
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Acute Pancreatitis
Diagnostic Studies
• Endoscopic ultrasonography (EUS)
• Magnetic resonance
cholangiopancreatography (MRCP)
• Angiography
• Chest x-ray
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Acute Pancreatitis
Collaborative Care
• Objectives include
• Relief of pain
• Prevention or alleviation of shock
• ↓ Pancreatic secretions
• Correction of fluid/electrolyte
imbalance
• Prevention/treatment of infection
• Removal of the precipitating cause
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Acute Pancreatitis
Collaborative Care
• Conservative therapy
• Supportive care
• Aggressive hydration
• Pain management
• IV morphine, antispasmodic agent
• Management of metabolic complications
• Oxygen, glucose levels
• Minimizing pancreatic stimulation
• NPO status, NG suction, decreased acid
secretion, enteral nutrition if needed
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Acute Pancreatitis
Collaborative Care
• Conservative therapy
• Shock
• Plasma or plasma volume expanders
(dextran or albumin)
• Fluid/electrolyte imbalance
• Lactated Ringer’s solution
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Acute Pancreatitis
Collaborative Care
• Conservative therapy
• Ongoing hypotension
• Vasoactive drugs: dopamine (Intropin)
• Prevent infection
• Enteral nutrition
• Antibiotics
• Endoscopically or CT-guided
percutaneous aspiration
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Acute Pancreatitis
Collaborative Care
• Surgical therapy
• For gallstones
• ERCP
• Cholecystectomy
• Uncertain diagnosis
• Not responding to conservative therapy
• Drainage of necrotic fluid collections
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Acute Pancreatitis
Collaborative Care
• Drug therapy
• IV morphine
• Antispasmodics
• Carbonic anhydrase inhibitors
• Antacids
• Proton pump inhibitors
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Acute Pancreatitis
Collaborative Care
• Nutritional therapy
• NPO status initially
• Enteral versus parenteral nutrition
• Monitor triglycerides if IV lipids given
• Small, frequent feedings when able
• High-carbohydrate
• No alcohol
• Supplemental fat-soluble vitamins
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Acute Pancreatitis
Nursing Assessment
• Subjective data
• Health history
• Biliary tract disease
• Alcohol use
• Abdominal trauma
• Duodenal ulcers
• Infection
• Metabolic disorders
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Acute Pancreatitis
Nursing Assessment
• Subjective data
• Medications
• Thiazides
• NSAIDs
• Surgery or other treatments
• Pancreas, stomach, duodenum, biliary
tract
• ERCP
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Acute Pancreatitis
Nursing Assessment
• Subjective data: functional health
patterns
• Alcohol abuse
• Fatigue
• Nausea, vomiting, anorexia
• Dyspnea
• Pain
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Acute Pancreatitis
Nursing Assessment
• Objective data
• Restlessness, anxiety, low-grade fever
• Flushing, diaphoresis
• Discoloration of abdomen/flank
• Cyanosis
• Jaundice
• Decreased skin turgor
• Dry mucous membranes
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Acute Pancreatitis
Nursing Assessment
• Objective data
• Tachypnea
• Basilar crackles
• Tachycardia
• Hypotension
• Abdominal distention/tenderness
• Diminished bowel sounds
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Acute Pancreatitis
Nursing Assessment
• Abnormal laboratory findings
• ↑ Serum amylase/lipase levels
• Leukocytosis
• Hyperglycemia
• Hypocalcemia
• Abnormal findings on
ultrasonography/CT scans
• Abnormal findings on ERCP
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Case Study
Fuse/Thinkstock
• A.J.’s laboratory results
demonstrate
• Elevated serum amylase and lipase
levels
• Mild leukocytosis
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Case Study
Fuse/Thinkstock
• She undergoes an ERCP, which
revealed the presence of gallstones
blocking the common bile duct.
• She is currently on NPO status and
receiving IV morphine for pain
control.
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Case Study
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• When you plan care for A.J., what
priority nursing diagnoses would
you identify for her?
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Acute Pancreatitis
Nursing Diagnoses
• Acute pain
• Deficient fluid volume
• Imbalanced nutrition: less than body
requirements
• Ineffective self-health management
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Acute Pancreatitis
Planning
• Patient will have
• Relief of pain
• Normal fluid and electrolyte balance
• Minimal to no complications
• No recurrent attacks
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Acute Pancreatitis
Nursing Implementation
• Health promotion
• Assessment and early treatment of
predisposing/etiologic factors
• Early diagnosis/treatment of biliary
tract disease
• Elimination of alcohol intake
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Acute Pancreatitis
Nursing Implementation
• Acute intervention
• Monitoring vital signs
• Assess respiratory function
• Monitor IV fluids
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Case Study
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• For what electrolyte imbalances
would you monitor A.J.?
• Explain the rationale for your
answer.
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Acute Pancreatitis
Nursing Implementation
• Acute intervention
• Monitor fluid and electrolyte balance
• Chloride, sodium, and potassium
• Hypocalcemia
• Tetany
• Calcium gluconate to treat
• Hypomagnesemia
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Monitoring for Tetany
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Acute Pancreatitis
Nursing Implementation
• Acute intervention
• Pain assessment and management
• Morphine
• Position of comfort with frequent position
changes
• Flex trunk and draw knees to abdomen
• Side-lying with head of bed elevated 45
degrees
• Frequent oral/nasal care
• Proper administration of antacids
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Acute Pancreatitis
Nursing Implementation
• Acute intervention
• Observation for signs of infection
• TCDB, semi-Fowler’s position
• Wound care
• Observation for paralytic ileus, renal
failure, mental changes
• Monitor serum glucose
• Post-op wound care
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Audience Response Question
The nurse explains to a patient with an episode of
acute pancreatitis that the most effective means
of relieving pain by suppressing pancreatic
secretions is the use of:
a. Antibiotics.
b. NPO status.
c. Antispasmodics.
d. Proton pump inhibitors.
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Case Study
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• A.J. is recuperating from her acute
pancreatitis without difficulty.
• Her health care provider writes an
order for her to be discharged home.
• What would be your priority
teaching to be completed prior to
her leaving?
Copyright © 2014 by Mosby, an imprint of Elsevier Inc.
Acute Pancreatitis
Nursing Implementation
• Ambulatory and home care
• Physical therapy
• Assessment of narcotic addiction
• Counseling regarding abstinence from
alcohol and smoking
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Acute Pancreatitis
Nursing Implementation
• Ambulatory and home care
• Dietary teaching
• Low-fat, high-carbohydrate
• No crash diets
• Patient/family teaching
• Signs of infection, diabetes mellitus,
steatorrhea
• Medications/diet
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Acute Pancreatitis
Nursing Implementation
• Expected outcomes
• Have adequate pain control
• Maintain adequate fluid volume
• Be knowledgeable about treatment
regimen
• Get help for alcohol dependence ( if
appropriate)
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Chronic Pancreatitis
• Continuous, prolonged inflammatory,
and fibrosing process of the pancreas
• Etiology
• Alcohol, gallstones, tumor,
pseudocysts, trauma, systemic disease
• Acute pancreatitis
• Idiopathic
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Chronic Pancreatitis
Pathophysiology
• Two major types
• Chronic obstructive pancreatitis
• Gallstones cause inflammation of
sphincter of Oddi
• Chronic nonobstructive pancreatitis
• Inflammation and sclerosis in head of
pancreas and around duct
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Chronic Pancreatitis
Clinical Manifestations
• Abdominal pain
• Located in the same areas as in acute
pancreatitis
• Heavy, gnawing feeling; burning and
cramplike
• Malabsorption with weight loss
• Constipation, jaundice, icteric urine,
steatorrhea, diabetes mellitus
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Chronic Pancreatitis
Clinical Manifestations
• Complications include
• Pseudocyst formation
• Bile duct or duodenal obstruction
• Pancreatic ascites
• Pleural effusion
• Splenic vein thrombosis
• Pseudoaneurysm
• Pancreatic cancer
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Chronic Pancreatitis
Diagnostic Studies
• Confirming diagnosis can be
challenging
• Based on signs/symptoms,
laboratory studies, and imaging
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Chronic Pancreatitis
Diagnostic Studies
• Laboratory tests
• Serum amylase/lipase levels
• May be ↑ slightly or not at all
• ↑ Serum bilirubin level
• ↑ Alkaline phosphatase level
• Mild leukocytosis
• ↑ Sedimentation rate
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Chronic Pancreatitis
Diagnostic Studies
• ERCP
• CT, MRI, MRCP, abdominal and/or
endoscopic ultrasonography
• Stool samples for fat content
• ↓ Fat-soluble vitamin and cobalamin
levels
• Glucose intolerance/diabetes
• Secretin stimulation test
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Chronic Pancreatitis
Collaborative Care
• Analgesics for pain relief (morphine
or fentanyl transdermal patch
[Duragesic])
• Diet
• Bland, low-fat
• Small, frequent meals
• No smoking
• No alcohol or caffeine
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Chronic Pancreatitis
Collaborative Care
• Pancreatic enzyme replacement
• Bile salts
• Insulin or oral hypoglycemic agents
• Acid-neutralizing and acid-inhibiting
drugs
• Antidepressants
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Chronic Pancreatitis
Collaborative Care
• Surgery
• Indicated when biliary disease is
present or if obstruction or pseudocyst
develops
• Diverts bile flow or relieves ductal
obstruction
• Choledochojejunostomy
• Roux-en-Y pancreatojejunostomy
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Chronic Pancreatitis
Collaborative Care
• Pancreatic drainage
• ERCP with spincterotomy and/or
stent placement
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Chronic Pancreatitis
Nursing Management
• Focus is on chronic care and health
promotion
• Patient and family teaching
• Dietary control
• Pancreatic enzyme with meals/snack
• Observe for steatorrhea
• Monitor glucose levels
• Antacids after meals and at bedtime
• No alcohol
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