Nursing Management of Patients WithBiliary, Exocrine & Hepatic Disorders (Day #1): Acute Alcohol WithdrawalPancreatitis Flashcards

1
Q

Wernicke-Korsakoff Syndrome

A

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

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2
Q

Withdrawal or “Banana Bag”

A

Daily liter of D5 ½ NS with

MVI
Folate
Thiamine

Magnesium

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3
Q

Example CIWA-Ar / Alcohol Withdrawal “Protocol” Orders

A

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

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4
Q

Pathophysiology of Pancreatitis

A

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

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5
Q

Pancreatitis: Risk Factors

A

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

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6
Q

Pancreatitis: Clinical Manifestations

A

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

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7
Q

Acute Pancreatitis: Clinical Manifestations

A

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

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8
Q

Pancreatitis: Uncommon (But interesting) Findings

A

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

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9
Q

Pancreatitis: Circulatory Complications

A

Hypotension
Hypovolemia; Loss of blood & proteins into retro-peritoneum
Pallor; Cool, clammy skin (Hypoperfusion)
Decreased level of consciousness
Shock

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10
Q

Pancreatitis: Other Complications

A

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

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11
Q

Pancreatitis: Labs/Diagnostics

A

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

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12
Q

Acute Pancreatitis: Interprofessional Goals

A

Relief of pain
Prevention or alleviation of shock
Decreased pancreatic secretions
Correction of fluid/electrolyte imbalances
Prevention/treatment of infections
Removal of precipitating cause

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13
Q

Pancreatitis: Collaborative Management

A

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

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14
Q

Interventions: Preventing Infection & Managing Metabolic Complications

A

Prevent infection
Enteral nutrition
Antibiotics
Endoscopic or CT-guided percutaneous aspiration

Manage metabolic complications
Oxygen
FBS, serum glucose levels
Sliding scale insulin coverage

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15
Q

Interventions: Promoting Pancreatic Rest & Nutrition

A

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

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16
Q

Interventions: Promoting Nutritional Balance

A

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

17
Q

Interventions: Maintaining Fluid & Electrolyte Balance

A

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

18
Q

Interventions: Promoting Patient Comfort

A

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

19
Q

Pancreatitis: Indications for Surgery

A

Uncertainty of diagnosis; relief of pain

Treat secondary infection
Necrosis
Abscess

Correction of biliary tract disease

Progressive deterioration despite supportive care

20
Q

Diagnostic & Therapeutic Procedures

A

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

21
Q

Chronic Pancreatitis

A

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

22
Q

Chronic Pancreatitis: Clinical Manifestations

A

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

23
Q

Chronic Pancreatitis: Interprofessional Care

A

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

24
Q

Surgery for Chronic Pancreatitis

A

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