ATI Med-Surg: Chapter 54: Pancreatitis – Flashcards

The islets of Langerhans in the pancreas secrete insulin and glucagon. The pancreatic tissues secrete digestive enzymes that break down carbohydrates, proteins, and fats.

Autodigestion of the pancreas by pancreatic digestive enzymes that activate prematurely before reaching the intestines. The mechanism of action is unknown. Pancreatitis can result in inflammation, necrosis, and hemorrhage.

Includes severe, constant, knifelike pain (left upper quadrant, mid-epigastric, and/or radiating to the back) that is unrelieved by nausea and vomiting.

Inflammatory process due to activated pancreatic enzymes autodigesting the pancreas. Severity varies, but overall mortality is 10% to 20%.

Progressive, destructive disease with the development of calcification and necrosis, possibly resulting in hemorrhagic pancreatitis. Mortality can be as high as 50%.

● Avoid excessive alcohol consumption. ● Eat a diet low-fat diet.

◯ Biliary tract disease (gallstones can cause a blockage where the common bile duct and pancreatic duct meet ◯ Alcohol use ■ The primary cause of chronic pancreatitis is alcohol use disorder. This may occur more often in older adults as age-related changes reduce the ability to physiologically handle alcohol. ◯ Endoscopic retrograde cholangiopancreatography (ERCP) (postprocedure complication) ◯ Gastrointestinal surgery ◯ Metabolic disturbances (hyperlipidemia, hyperparathyroidism, hypercalcemia) ◯ Kidney failure or transplant ◯ Genetic predisposition ◯ Trauma ◯ Penetrating ulcer (gastric or duodenal) ◯ Medication/drug toxicity

◯ Sudden onset of severe, boring pain ■ Epigastric, radiating to back, left flank, or left shoulder ■ Worse when lying down or while eating ■ Worse after consumption of alcohol or high-fat foods ■ Not relieved with vomiting ◯ Pain relieved somewhat by fetal position ◯ Nausea and vomiting ◯ Weight loss

■ Seepage of blood-stained exudates into tissue as a result of pancreatic enzyme actions ☐ Ecchymoses on the flanks (Turner's sign) ☐ Bluish-grey periumbilical discoloration (Cullen's sign) ■ Generalized jaundice ■ Absent or decreased bowel sounds (possible paralytic ileus) ■ Warm, moist skin; fruity breath (evidence of hyperglycemia) ■ Ascites ■ Tetany ☐ Trousseau's sign (hand spasm when blood pressure cuff is inflated) ☐ Chvostek's sign (facial twitching when facial nerve is tapped)

■ Serum amylase (increases within 12 hr, remains increased for 4 days) and serum lipase (increases slowly but remains increased for up to 2 weeks) ☐ Urine amylase remains increased for up to 2 weeks. ☐ Increases in enzymes indicate pancreatic cell injury. ☐ Memory aid: In pancreatitis, the "ases" (aces) are high. ☐ For amylase and lipase to be considered positive, the enzyme increases must be significant (two to three times greater than the expected value for amylase, and three to five times greater than the expected value for lipase). The degree of enzyme elevation does not directly correlate with the severity of the disease. ■ WBC count: increased due to infection and inflammation ■ Platelets: decreased ■ Serum calcium and magnesium: decreased due to fat necrosis with pancreatitis ■ Serum liver enzymes and bilirubin: increased with associated biliary dysfunction ■ Serum glucose: increased due to a decrease in insulin production by the pancreas

Computed tomography (CT) scan with contrast is reliably diagnostic of acute pancreatitis.

◯ Rest the pancreas. ■ NPO - no food until pain-free ■ Total parenteral nutrition (TPN) or jejunal feedings (less risk of hyperglycemia) ■ When diet is resumed: bland, low-fat diet with no stimulants (caffeine); small, frequent meals ■ Administer antiemetic as needed, as prescribed ■ Nasogastric tube - gastric decompression ■ No alcohol consumption ■ No smoking ■ Limit stress ■ Pain management ◯ Position the client for comfort (fetal, side-lying, the head of the bed elevated, sitting up or leaning forward). ◯ Administer analgesics and other medications as prescribed. ◯ Monitor blood glucose and provide insulin as needed (potential for hyperglycemia). ◯ Monitor hydration status (orthostatic blood pressure, intake and output, laboratory values). ◯ Administer IV fluids and electrolyte replacement as prescribed.

■ Nursing Considerations ☐ Large doses of IV opioids often are needed for pain management. ☐ Meperidine (Demerol) is discouraged in older adult clients due to the risk of seizures.

■ Antibiotics may be used, but are generally indicated for clients who have acute necrotizing pancreatitis. ■ Nursing Considerations ☐ Monitor for evidence of infection. ☐ Monitor for seizures.

Decrease intestinal motility and the flow of pancreatic enzymes. ■ Nursing Considerations - Use with caution in clients who have cardiac problems or ulcerative colitis.

Relax smooth muscle. ■ Nursing Considerations ☐ Monitor for jaundice. ☐ May cause orthostatic hypotension.

Decrease gastric acid secretion.

Aid with digestion of fats and proteins when taken with meals and snacks. ■ Nursing Considerations ☐ Client may sprinkle contents of capsules on nonprotein foods. ☐ Client should drink a full glass of water following pancrelipase. ☐ Clients should wipe lips and rinse mouth after taking (to prevent skin breakdown or irritation).

ERCP to create an opening in the sphincter of Oddi if pancreatitis is caused by gallstones

◯ Cholecystectomy if pancreatitis is a result of cholecystitis and gallstones ◯ Pancreaticojejunostomy (Roux-en-Y) reroutes drainage of pancreatic secretions into jejunum ● Care After Discharge ◯ Home health services may be indicated for clients regarding nutritional needs, possible wound care, and assistance with ADLs. ◯ Alcoholics Anonymous (AA) may be indicated for the client or family member who has an alcohol use disorder.

Up to 6 L of fluid can be third-spaced; caused by retroperitoneal loss of protein-rich fluid from proteolytic digestion. The client can develop hypovolemic shock. ◯ Nursing Actions - Monitor vital signs, electrolytes, and provide IV fluid and electrolyte replacement.

◯ Client Education - Encourage the client to avoid alcohol intake and caffeinated beverages, and to participate in support groups for individuals who have alcohol use disorder.

◯ Cause - leakage of fluid out of damaged pancreatic duct ◯ Nursing Actions ■ Monitor for rupture and hemorrhage. ■ Maintain sump tube if placed for drainage of cyst. ■ Monitor skin around tube for breakdown secondary to corrosive enzymes.

◯ Cause - lack or absence of insulin (due to destruction of pancreatic beta cells) ◯ Nursing Actions ■ Monitor blood glucose. ■ Administer insulin as prescribed. ◯ Client Education - Inform the client about long-term diabetes management.

More common complication in older adults and may precipitate pneumonia ◯ Causes ■ Splinting of chest due to pain upon coughing and deep breathing ■ Pancreatic ascites ◯ Nursing Actions - Monitor for hypoxia and provide ventilatory support.

◯ Causes - release of thromboplastic endotoxins secondary to necrotizing hemorrhagic pancreatitis (NHP) ◯ Nursing Actions - Monitor bleeding times.

◯ Cause - necrotizing hemorrhagic pancreatitis ◯ Nursing Actions ■ Administer treatments as prescribed. ■ Monitor for evidence of organ failure (respiratory distress, jaundice, oliguria). ■ Report unexpected findings to provider.