Nursing Management of Patients WithBiliary, Exocrine & Hepatic Disorders (Day #1): Acute Alcohol WithdrawalPancreatitis Flashcards
Wernicke-Korsakoff Syndrome
Complication of chronic alcohol abuse; Inflammation & hemorrhagic, degeneration of the brain
Caused by thiamine deficiency
ETOH induced suppression of thiamine absorption
Poor diet
May lead to Korsakoffs Psychosis; Irreversible form of amnesia, Loss of ST memory, inability to learn
Thiamine should be given before or with glucose
Administration of IV glucose to those with severe malnutrition can exhaust thiamine & precipitate W-K syndrome
Treatment for life-threatening hypoglycemia should not be withheld for thiamine administration
Withdrawal or “Banana Bag”
Daily liter of D5 ½ NS with
MVI
Folate
Thiamine
Magnesium
Example CIWA-Ar / Alcohol Withdrawal “Protocol” Orders
Vital signs & CIWA-Ar Score every 2-hours. Decrease to every 4-hours when CIWA-Ar score is less than 10 two times in a row.
Medicate with Lorazepam every 2 - 4 hours PRN symptoms of withdrawal, based on frequency of CIWA scores using the following dosage scale:
CIWA-Ar Score = 0 – 5 None
CIWA-Ar Score = 6 – 9 1 mg Lorazepam IV or PO
CIWA-Ar Score = 10 – 14 2 mg Lorazepam IV or PO
CIWA-Ar Score = 15 – 19 2.5 mg Lorazepam IV or PO
CIWA-Ar Score = Greater than 20 3.0 mg Lorazepam IV or PO
Pathophysiology of Pancreatitis
Inflammatory process associated with
Edema
Auto-digestion of pancreas
Fat necrosis
Hemorrhage (Activation of Trypsinogen to Trypsin within pancreas leads to bleeding)
Mild pancreatitis
Edematous
Interstitial
Severe pancreatitis
Necrotizing
Endocrine & exocrine dysfunction
Necrosis, organ failure, sepsis
5% fatality rate
Pancreatitis: Risk Factors
Alcohol abuse (1st)
Gallstones (2nd)
Edema / Obstruction
Reflux of bile or direct injury
Trauma
Blunt or penetrating
Intra-operative
Distention r/t ERCP (Endoscopic Retrograde Cholangiopancreatography)
Viral (Mumps)
Drugs
Azathioprine (Direct)
Estrogens (Direct)
Antibiotics
Anticonvulsants
Thiazide diuretics
Sulfonamides
Valproic acid
Metabolic
Pancreatitis: Clinical Manifestations
Abdominal pain
Epigastric / umbilical
Radiates to back, chest, flank, lower abdomen
12-48 hours after ETOH binge
Aggravated by eating
Nausea, vomiting
Abdominal distention
Fever
Edema of pancreatic capsule
Local peritonitis
Ductal spasm
Auto-digestion
Increased enzyme production with eating
Acute Pancreatitis: Clinical Manifestations
Abdominal pain predominant
Left upper quadrant or mid-epigastric
Radiates to back, chest, flank, lower abdomen
Sudden onset
Deep, piercing, continuous, or steady
Eating worsens pain
Starts when recumbent
Not relieved with vomiting
Flushing
Cyanosis
Dyspnea
Nausea/vomiting
Low-grade fever
Leukocytosis
Hypotension, tachycardia
Jaundice
Abdominal tenderness with muscle guarding
Decreased or absent bowel sounds
Crackles in lungs
Abdominal skin discoloration
Shock
Pancreatitis: Uncommon (But interesting) Findings
Grey Turner’s Sign
Bluish discoloration of the flank
d/t tissue catabolism
Cullen’s Sign
Bluish discoloration of peri-umbilical area
d/t blood stained peritoneal fluid
Jaundice (Gallstone induced)
Obstruction of common bile duct
Pancreatitis: Circulatory Complications
Hypotension
Hypovolemia; Loss of blood & proteins into retro-peritoneum
Pallor; Cool, clammy skin (Hypoperfusion)
Decreased level of consciousness
Shock
Pancreatitis: Other Complications
Pancreatic pseudo-cyst / abscess
Fluid, pancreatic enzymes, debris, & exudates surrounded by wall
Abdominal pain, palpable mass, N/V, anorexia
Detected with imaging
Resolves spontaneously or may perforate & cause peritonitis
Surgical, percutaneous, or endoscopic drainage
Respiratory:
Atelectasis
Pleural effusion
Pneumonia, ARDS
Risk of Thrombi, PE, & DIC
Cerebral abnormalities: Belligerence, confusion, psychosis, coma
Hypocalcemia; Tetany
Abdominal compartment syndrome
Development of DM
Pancreatitis: Labs/Diagnostics
Most sensitive indicators
Serum / urine amylase
Serum lipase
Serum Ca+
Glucose
Bilirubin
Alkaline phosphatase
Blood Urea Nitrogen (BUN)
Liver function tests
MRI
CT Scan
Chest x-ray
Abdominal x-ray
Acute Pancreatitis: Interprofessional Goals
Relief of pain
Prevention or alleviation of shock
Decreased pancreatic secretions
Correction of fluid/electrolyte imbalances
Prevention/treatment of infections
Removal of precipitating cause
Pancreatitis: Collaborative Management
Maintain volume status
HR, B/P & urine output
Transfusion of blood or clotting factors
Conservative therapy for shock
Plasma
Plasma volume expanders (Dextran, Albumin)
Maintain electrolyte balance
LR or Saline w/ K+
Calcium gluconate
Monitor & control pain
Monitor respiratory status
Maintain nutritional status
Insulin
Treat complications (Abscess, necrosis)
Education - Procedures & rationale
Interventions: Preventing Infection & Managing Metabolic Complications
Prevent infection
Enteral nutrition
Antibiotics
Endoscopic or CT-guided percutaneous aspiration
Manage metabolic complications
Oxygen
FBS, serum glucose levels
Sliding scale insulin coverage
Interventions: Promoting Pancreatic Rest & Nutrition
NG to LIS
Severe pain, ileus, distention, N-V, suppress gastric acid secretion
Anti-spasmotic
Dicyclomine (Bentyl)
Carbonic anhydrase inhibitor diuretics
Acetazolamide (Diamox)
Antacids
Protein Pump Inhibitor (PPI)
Omeprazole (Prilosec)
Initially NPO
Enteral versus parenteral nutrition
Monitor triglycerides if IV lipids given
Small, frequent, high carb feedings when able
No alcohol
Supplement fat-soluble vitamins
Interventions: Promoting Nutritional Balance
Total Parenteral Nutrition (TPN) when enteral feeding not tolerated
25% Glucose
Fat
Protein
Electrolytes
Vitamins
Trace ingredients
24-hour infusion
Cyclic (overnight) infusion
Enteral feeding reduces risk of necrotizing pancreatitis
NG
J-Tube (Jejunal) feeding tube
When food allowed:
High carbohydrate
Fat-soluble vitamins
Interventions: Maintaining Fluid & Electrolyte Balance
Monitor vital signs
HR & B/P = Fluid volume
RR = Acid-base balance
Monitor labs & observe for:
HYPERglycemia
HYPOcalcemia
HYPOkalemia
Assess for:
Edema
Abnormal lung sounds
Altered skin turgor
Dry mucous membranes
U. O. < 30 / hour
Ongoing hypotension
Vasoactive drugs: Dopamine
Interventions: Promoting Patient Comfort
IV opioid analgesics
IV antispasmodic agents
Carbonic anhydrase inhibitor diuretic
Antacids
Proton pump inhibitors
Side-lying position w/ knees pulled up
Pillow against abdomen
Semi-fowlers position
HOB 45-degrees, trunk flexed
Oral care
Especially with NG placement
Back rubs, hand & foot massage
Relaxation techniques
Quiet environment
Pancreatitis: Indications for Surgery
Uncertainty of diagnosis; relief of pain
Treat secondary infection
Necrosis
Abscess
Correction of biliary tract disease
Progressive deterioration despite supportive care
Diagnostic & Therapeutic Procedures
Endoscopic retrograde cholangio-pancreatography (ERCP)
Interventional Radiology: Placement of percutaneous drain
Exploratory laparotomy
Cholecystectomy w/ intra-operative cholangiogram
Roux-en-Y Pancreato-jejunostomy
Sub-total Pancreatectomy; Remnant of pancreas left attached to duodenum
Pancreatico-duodenectomy (Whipple Procedure)
If disease confined to head of pancreas
Distal 1/3 of stomach
Duodenum
Common bile duct & Gallbladder
Pancreatic head
Chronic Pancreatitis
Continuous, prolonged process of inflammation & fibrosis
Etiology
Alcohol
Gallstones
Tumor
Pseudocyst(s)
Trauma
Systemic disease
Autoimmune pancreatitis
Cystic fibrosis
Chronic, obstructive, inflammation of Sphincter of Oddi
Cancer of Ampulla of Vater
Duodenal cancer
Pancreatic cancer
Chronic non-obstructive
Inflammation & sclerosis of head of pancreas & around pancreatic duct
Most common cause: Alcohol abuse
Chronic Pancreatitis: Clinical Manifestations
Abdominal pain
Same areas as acute
Heavy, gnawing feeling; burning & cramp-like
Frequent to almost constant
Malabsorption with weight loss
Constipation
Mild jaundice with dark urine
Steatorrhea
Diabetes
Complications:
Pseudocyst formation
Bile duct or duodenal obstruction
Pancreatic ascites
Pleural effusion
Splenic vein thrombosis
Pseudo-aneurysms
Pancreatic cancer
Chronic Pancreatitis: Interprofessional Care
Analgesics
Morphine
Fentanyl patch [Duragesic])
Diet
Bland, low-fat
Small, frequent meals
No smoking
No alcohol or caffeine
Pancreatic enzyme replacement
Combination of Amylase, Lipase, Trypsin
Bile salts
Insulin or oral hypoglycemic agents
Acid-neutralizing &/or acid-inhibiting drugs
Antidepressants
Surgery for Chronic Pancreatitis
Indicated when:
Biliary disease present
Obstruction
Pseudocyst
Diverts bile flow or relieves ductal obstruction
Choledochojejunostomy
Roux-en-Y pancreatojejunostomy
Endoscopic procedures
Pancreatic drainage
ERCP with sphincterotomy and/or stent placement
