NURSING
PROCESS:THE PATIENT WITH ACUTE PANCREATITIS
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.
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
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
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.
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.
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.
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.
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.
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.
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.
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.
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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