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Chapter: Medical Surgical Nursing: Assessment and Management of Patients With Biliary Disorders

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Nursing Process: The Patient With Acute Pancreatitis

The health history focuses on the presence and character of the abdominal pain and discomfort.

NURSING PROCESS:THE PATIENT WITH ACUTE PANCREATITIS

 

Assessment

 

The health history focuses on the presence and character of the abdominal pain and discomfort. The nurse assesses the presence of pain, its location, its relationship to eating and to alcohol con-sumption, and the effectiveness of pain relief measures. It also is important to assess the patient’s nutritional and fluid status and history of gallbladder attacks and alcohol use. A history of gastro-intestinal problems, including nausea, vomiting, diarrhea, and passage of fatty stools, is elicited. The nurse assesses the abdomen for pain, tenderness, guarding, and bowel sounds, noting the presence of a board-like or soft abdomen. It also is important to assess respiratory status, respiratory rate and pattern, and breath sounds. Normal and adventitious breath sounds and abnormal findings on chest percussion, including dullness at the bases of the lungs and abnormal tactile fremitus, are documented. The nurse assesses the emotional and psychological status of the pa-tient and family and their coping, because they are often anxious about the severity of the symptoms and the acuity of illness.

 

Diagnosis

 

NURSING DIAGNOSES

 

Based on all the assessment data, the major nursing diagnoses of the patient with acute pancreatitis include the following:

 

        Acute pain related to inflammation, edema, distention of the pancreas, and peritoneal irritation

 

        Ineffective breathing pattern related to severe pain, pul-monary infiltrates, pleural effusion, atelectasis, and elevated diaphragm

 

        Imbalanced nutrition, less than body requirements, related to reduced food intake and increased metabolic demands

        Impaired skin integrity related to poor nutritional status, bed rest, and multiple drains and surgical wound

 

COLLABORATIVE PROBLEMS/POTENTIAL COMPLICATIONS

Based on assessment data, potential complications that may occur include the following:

 

        Fluid and electrolyte disturbances

 

        Necrosis of the pancreas

 

        Shock and multiple organ dysfunction

 

Planning and Goals

 

The major goals for the patient include relief of pain and discom-fort, improved respiratory function, improved nutritional status, maintenance of skin integrity, and absence of complications.

Nursing Interventions

 

RELIEVING PAIN AND DISCOMFORT

 

Because the pathologic process responsible for pain is autodiges-tion of the pancreas, the objectives of therapy are to relieve pain and decrease secretion of the enzymes of the pancreas. The pain of acute pancreatitis is often very severe, necessitating the liberal use of analgesic agents. Meperidine (Demerol) is the medication of choice; morphine sulfate is avoided because it causes spasm of the sphincter of Oddi (Porth, 2002). Oral feedings are withheld to decrease the formation and secretion of secretin. The patient is maintained on parenteral fluids and electrolytes to restore and maintain fluid balance. Nasogastric suction is used to remove gas-tric secretions and to relieve abdominal distention. The nurse provides frequent oral hygiene and care to decrease discomfort from the nasogastric tube and relieve dryness of the mouth.

 

The acutely ill patient is maintained on bed rest to decrease the metabolic rate and reduce the secretion of pancreatic and gas-tric enzymes. If the patient experiences increasing severity of pain, the nurse reports this to the physician because the patient may be experiencing hemorrhage of the pancreas, or the dose of analgesic may be inadequate.

 

The patient with acute pancreatitis often has a clouded senso-rium because of severe pain, fluid and electrolyte disturbances, and hypoxia. Therefore, the nurse provides frequent and repeated but simple explanations about the need for withholding fluid in-take and about maintenance of gastric suction and bed rest.

 

IMPROVING BREATHING PATTERN

 

The nurse maintains the patient in a semi-Fowler’s position to decrease pressure on the diaphragm by a distended abdomen and to increase respiratory expansion. Frequent changes of po-sition are necessary to prevent atelectasis and pooling of res-piratory secretions. Pulmonary assessment and monitoring of pulse oximetry or arterial blood gases are essential to detect changes in respiratory status so that early treatment can be ini-tiated. The nurse instructs the patient in techniques of cough-ing and deep breathing to improve respiratory function and encourages and assists the patient to cough and deep breathe every 2 hours.

 

IMPROVING NUTRITIONAL STATUS

 

The patient with acute pancreatitis is not permitted food and oral fluid intake; however, it is important to assess the patient’s nu-tritional status and to note factors that alter the patient’s nutri-tional requirements (eg, temperature elevation, surgery, drainage). Laboratory test results and daily weights are useful in monitoring the nutritional status.

 

Parenteral nutrition may be prescribed. In addition to ad-ministering parenteral nutrition, the nurse monitors serum glu-cose levels every 4 to 6 hours. As the acute symptoms subside, the nurse gradually reintroduces oral feedings. Between acute attacks, the patient receives a diet high in carbohydrates and low in fat and proteins. The patient should avoid heavy meals and alcoholic beverages.

 

IMPROVING SKIN INTEGRITY

 

The patient is at risk for skin breakdown because of poor nutri-tional status, enforced bed rest, and restlessness, which may result in pressure ulcers and breaks in tissue integrity. In addition, the patient who has undergone surgery, has had multiple drains in-serted, or has an open surgical incision is at risk for skin break-down and infection. The nurse carefully assesses the wound,drainage sites, and skin for signs of infection, inflammation, and breakdown. The nurse carries out wound care as prescribed and takes precautions to protect intact skin from contact with drainage. Consultation with an enterostomal therapist is often helpful in identifying appropriate skin care devices and protocols. It is im-portant to turn the patient every 2 hours; use of specialty beds may be indicated to prevent skin breakdown.

 

MONITORING AND MANAGING POTENTIAL COMPLICATIONS

 

Fluid and electrolyte disturbances are common complications be-cause of nausea, vomiting, movement of fluid from the vascular compartment to the peritoneal cavity, diaphoresis, fever, and the use of gastric suction. The nurse assesses the patient’s fluid and electrolyte status by noting skin turgor and moistness of mucous membranes. The nurse weighs the patient daily and carefully measures fluid intake and output, including urine output, naso-gastric secretions, and diarrhea. In addition, it is important to assess the patient for other factors that may affect fluid and elec-trolyte status, including increased body temperature and wound drainage. The nurse assesses the patient for ascites and measures abdominal girth daily if ascites is suspected.

 

Intravenous fluids are administered and may be accompanied by infusion of blood, blood products, and albumin to maintain the blood volume and to prevent or treat hypovolemic shock. It is important to keep emergency medications readily available be-cause of the risk of circulatory collapse and shock. The nurse promptly reports decreased blood pressure and reduced urine output because they may indicate hypovolemia and shock or renal failure. Low serum calcium and magnesium levels may occur and require prompt treatment.

 

Pancreatic necrosis is a major cause of morbidity and mortal-ity in patients with acute pancreatitis. The patient who develops necrosis is at risk for hemorrhage, septic shock, and multiple organ failure. The patient may undergo diagnostic procedures to confirm pancreatic necrosis; surgical débridement or insertion of multiple drains may be performed. The patient with pancreatic necrosis is usually critically ill and requires expert medical and nursing management, including hemodynamic monitoring in the intensive care unit.

 

In addition to carefully monitoring vital signs and other signs and symptoms, the nurse is responsible for administering pre-scribed fluids, medications, and blood products; assisting with supportive management, such as use of a ventilator; preventing additional complications; and attending to the patient’s physical and psychological care.

 

Shock and multiple organ failure may occur with acute pan-creatitis. Hypovolemic shock may occur as a result of hypo-volemia and sequestering of fluid in the peritoneal cavity. Hemorrhagic shock may occur with hemorrhagic pancreatitis. Septic shock may occur with bacterial infection of the pancreas. Cardiac dysfunction may occur as a result of fluid and electrolyte disturbances, acid–base imbalances, and release of toxic sub-stances into the circulation.

 

The nurse closely monitors the patient for early signs of neu-rologic, cardiovascular, renal, and respiratory dysfunction. The nurse must be prepared to respond quickly to rapid changes in the patient’s status, treatments, and therapies. In addition, it is important to inform the family about the status and progress of the patient and allow them to spend time with the patient.

 

PROMOTING HOME AND COMMUNITY-BASED CARE

Teaching Patients Self-Care

The patient who has survived an episode of acute pancreatitis has been acutely ill. A prolonged period is needed to regain strength and return to previous level of activity. The patient is often still weak and debilitated weeks or months after an acute episode of pancreatitis. Because of the severity of the acute illness, the pa-tient may not recall many of the explanations and instructions given during the acute phase, so these often need to be repeated and reinforced. The nurse instructs the patient about the factors implicated in the onset of acute pancreatitis and about the need to avoid high-fat foods, heavy meals, and alcohol. It is important to give the patient and family verbal and written instructions about signs and symptoms of acute pancreatitis and possible com-plications that should be reported promptly to the physician.

 

If acute pancreatitis is a result of biliary tract disease, such as gallstones and gallbladder disease, additional explanations are needed about required dietary modifications. If the pancreatitis is a result of alcohol abuse, the nurse reminds the patient of the importance of eliminating all alcohol.

 

Continuing Care

 

A referral for home care often is indicated; this enables the nurse to assess the patient’s physical and psychological status and ad-herence to the therapeutic regimen. The nurse also assesses the home situation and reinforces instructions about fluid and nutri-tion intake and avoidance of alcohol.

 

When the acute attack has subsided, some patients may be inclined to return to their previous drinking habits. The nurse provides specific information about resources and support groups that may be of assistance in avoiding alcohol in the future. Re-ferral to Alcoholics Anonymous or other appropriate support groups is essential. A summary of nursing management of the patient with acute pancreatitis is provided in the Plan of Nursing Care.

 

Evaluation

 

EXPECTED PATIENT OUTCOMES

 

Expected patient outcomes may include:

 

         Reports relief of pain and discomfort

a)     Uses analgesics and anticholinergics as prescribed, with-out overuse

b)    Maintains bed rest as prescribed

c)     Avoids alcohol to decrease abdominal pain

         Experiences improved respiratory function

a)     Changes position in bed frequently

b)    Coughs and takes deep breaths at least every hour

c)     Demonstrates normal respiratory rate and pattern, full lung expansion, normal breath sounds

d)    Demonstrates normal body temperature and absence of respiratory infection

         Achieves nutritional and fluid and electrolyte balance

a)     Reports decrease in number of episodes of diarrhea

b)    Identifies and consumes high-carbohydrate, low-protein foods

c)     Explains rationale for eliminating alcohol intake

d)    Maintains adequate fluid intake within prescribed guidelines

e)      Exhibits adequate urine output

         Exhibits intact skin

a)     Skin is without breakdown or infection

b)    Drainage is contained adequately

         Absence of complications

a)     Demonstrates normal skin turgor, moist mucous mem-branes, normal serum electrolyte levels

b)    Exhibits stabilization of weight, with no increase in ab-dominal girth

c)     Exhibits normal neurologic, cardiovascular, renal, and respiratory function

 

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