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NUR 201 Week 10 > Pancreatitis > Flashcards

Pancreatitis Flashcards

- Acute and chronic.

1
Q

?

Is an acute inflammation of the pancreas

> ° of inflammation varies from mild edema to severe hemorrhagic necrosis
Most common in middle-aged men & women; affects genders equally
Rate in African Americans is 3x higher than in white persons

A

Acute pancreatitis (AP)

> Involves a spillage of pancreatic enzymes into surrounding pancreatic tissue causing autodigestion & severe pain

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2
Q

Etiology

  • In the US, the most common cause is __ __ (more common in women)
  • 2nd most common cause is chronic alcohol intake (more common in men)
  • Smoking is an independent risk factor for AP
A

gallbladder disease (gallstones)

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3
Q
  • Biliary sludge or microlithiasis, a mixture of cholesterol crystals & calcium salts, is found in 20-40% of pts w/AP
    > Formation of biliary sludge is seen in pts w/bile stasis
  • AP attacks are also assoc w/___ (serum levels >1000 mg/dL)
A

hypertriglyceridemia

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4
Q
  • Less common causes
    > Trauma [postop, post-procedure following ERCP]
    > Viral infections [mumps, coxsackievirus B, HIV]
    > Penetrating duodenal ulcers
    > Cysts
    > Abscesses
A

> Cystic fibrosis
Kaposi sarcoma
Certain drugs [corticosteroids, thiazide diuretics, oral contraceptives, sulfonamides, NSAIDs)
Metabolic disorders [hyperparathyroidism, renal failure]
Vascular diseases
Idiopathic [unknown] causes

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5
Q

Pathophysiology

  • Caused by autodigestion of pancreas
    > Injury to pancreatic cells
    > Activation of pancreatic enzymes
A
  • Activation of trypsinogen to trypsin within pancreas leads to bleeding
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6
Q
  • May be d/t reflux of bile acids into the pancreatic ducts through an open or distended sphincter of Oddi
A
  • Reflux may be d/t blockage created by gallstones; obstruction of pancreatic ducts results in pancreatic ischemia
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7
Q

?

This is an inactive proteolytic enzyme produced by the pancreas
> It’s released into the SI via the pancreatic duct

A

Trypsinogen

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8
Q

> In the SI, it’s activated to trypsin by enterokinase

> Normally, trypsin inhibitors in the pancreas & plasma bind & inactivate any trypsin that’s inadvertently produced

A

> In pancreatitis, activated trypsin is present in the pancreas

> This enzyme can digest the pancreas & produce bleeding

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9
Q

Pathogenic Process of AP

A
  • Alcohol consumption is another common cause
    > Exact mechanism unknown
    > Alcohol may increase production of pancreatic enzymes
    > 5-10% of alcohol abusers develop pancreatitis
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10
Q

___ pancreatitis

  • Necrotizing
  • Endocrine & exocrine dysfunction
  • Necrosis, organ failure, sepsis
  • Rate of mortality: 25%
A

Severe [pancreatitis] (also called necrotizing pancreatitis)

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11
Q

___ pancreatitis

  • Edematous or interstitial
A

Mild [pancreatitis] (also known as edematous or interstitial pancreatitis)

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12
Q

Clinical Manifestations

! Abdominal pain predominant
> LUQ or mid-epigastrium [d/t distention of the pancreas, peritoneal irritation, & obstruction of the biliary tract]
> Radiates to back [b/c of the retroperitoneal location of the pancreas]
> Sudden onset
> Deep, piercing, continuous or steady

A

> Aggravated by eating
Starts when recumbent
Not relieved w/vomiting

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13
Q
  • Flushing
  • Cyanosis
  • Dyspnea
  • N/V
A
  • Low-grade fever
  • Leukocytosis
  • Hypotension, tachycardia
  • Jaundice
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14
Q
  • Abd tenderness w/muscle guarding is common
  • Decreased or absent bowel sounds [paralytic ileus can occur & causes marked distention]
  • Crackles in lungs
A
  • Abdominal skin discoloration [d/t intravascular damage from circulating trypsin]
    > Grey Turner’s spots or sign [a bluish flank discoloration]
    > Cullen’s sign [a bluish, periumbilical discoloration]

These result from seepage of blood-stained exudate from the pancreas & may occur in severe cases

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15
Q

Shock

  • D/t hemorrhage into the pancreas
  • Toxemia from activated pancreatic enzymes
  • Hypovolemia as a result of fluid shift into retroperitoneal space (massive fluid shifts)
A
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16
Q

What are 2 significant local complications of AP?

A

pseudocyst & abscess

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17
Q

?

This is an accumulation of fluid, pancreatic enzymes, tissue debris, & inflammatory exudates surrounded by a wall adjacent to the pancreas

> Manifestations include abd pain, palpable epigastric mass, N/V, anorexia

A

Pseudocyst

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18
Q
  • Serum amylase lvl freq remains elevated
  • CT, MRI, & EUS may be used to detect a pseudocyst
A
  • Cysts usually resolve spontaneously within a few wks but may perforate, causing peritonitis, or rupture into the stomach or duodenum
  • Treatment = surgical drainage procedure; percutaneous catheter placement & drainage; endoscopic drainage
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19
Q

When a pseudocyst gets infected, a __ __ results from necrosis in the pancreas

It may rupture or perforate into adjacent organs
Manifestations include upper abdominal pain, abd mass, high fever, & leukocytosis

A

Pancreatic abscess

! These necessitate prompt surgical drainage to prevent sepsis

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20
Q

Systemic complications

  • Pleural effusion
  • Atelectasis
  • Pneumonia
  • ARDS
A
  • Hypotension
  • Thrombi, pulmonary embolism, DIC
  • Hypocalcemia = tetany [sign of severe dz]
    > D/t combining of calcium & fatty acids during fat necrosis
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21
Q
  • Pulmonary complications are probably d/t the passage of exudate containing pancreatic enzymes from the peritoneal cavity through transdiaphragmatic lymph channels
A
  • Enzyme-induced inflammation of the diaphragm occurs w/the result being atelectasis caused by reduced diaphragm movement
  • Trypsin can activate prothrombin & plasminogen, inc the risk for intravascular thrombi, pulmonary emboli, & DIC
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22
Q

Laboratory tests

  • Serum amylase level
  • Serum lipase level
  • Liver enzyme levels
  • Triglyceride levels
A
  • Glucose level
  • Bilirubin level
  • Serum calcium level [decrease]
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23
Q

?

This lab result is usually elevated early & remains elevated for 24-72 hrs

A

serum amylase

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24
Q

?

This lab result is also elevated in AP & is an important test b/c other disorders like mumps, cerebral trauma, & renal transplantation can also inc these lvls

A

serum lipase

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25
Q

Diagnostic Studies

  • Abdominal US
  • X-ray
  • Contrast-enhanced CT scan
    ! Is the best imaging test for pancreatitis & related comp’s like pseudocysts & abscesses
  • Endoscopic retrograde cholangiopancreatography (ERCP)
    > Can cause AP in some cases
A
  • Endoscopic ultrasonography (EUS)
  • Magnetic resonance cholangiopancreatography (MRCP)
  • Angiography
  • Chest x-ray [to show pulm changes like atelectasis & pleural effusions]
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26
Q

Interprofessional Care Objectives

  • Relief of pain
  • Prevention or alleviation of shock
  • ↓ pancreatic secretions
A
  • Correction of fluid/electrolyte imbalances
  • Prevention/treatment of infections
  • Removal of precipitating cause(s), if possible
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27
Q

Conservative Therapy

  • Supportive care
    > Aggressive hydration
    > Pain management
  • IV morphine, antispasmodic agent

> Management of metabolic complications
- Oxygen, glucose lvls
* Supplemental oxygen is used to maintain O2 sat >95%
* In pts w/severe pancreatitis, serum glucose lvls are closely monitored

A

> Minimizing pancreatic stimulation
- NPO status, NG suction, decreased acid secretion, enteral nutrition if needed [for severe AP d/t lack of oral intake]

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28
Q
  • Atropine & other anticholinergic drugs should be avoided when paralytic ileus is present b/c they can decrease GI mobility, thus exacerbating the problem
A
  • Other rx’s that relax smooth muscles (spasmolytics) like nitroglycerin or papaverine, may be used
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29
Q
  • Shock
    > Plasma or plasma volume expanders (dextran or albumin)
A
  • Fluid/electrolyte imbalance
    > Lactated Ringer’s solution
  • Central venous pressure readings may be used to assist in determining fluid replacement req’s
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30
Q
  • Ongoing hypotension
    > Vasoactive drugs: ___ (?)
A

dopamine

Increases systemic vascular resistance in pts w/ongoing hypotension

31
Q
  • Prevent infection
    > Enteral nutrition
    > Antibiotics
    > Endoscopically or CT-guided percutaneous aspiration (w/Gram stain & culture)
A
32
Q

Surgical Therapy

  • For gallstones
    > ERCP
    > Cholecystectomy
  • Uncertain diagnosis
  • Not responding to conservative therapy
  • [Percutaneous] Drainage of necrotic fluid collections (w/a drainage tube left in place)
A
  • When AP is r/t the presence of gallstones, an urgent ERCP plus endoscopic sphincterotomy (severing of the muscle layers of the sphincter of Oddi) may be done
    > May be followed by laparoscopic cholecystectomy to reduce potential for recurrence
33
Q

Drug Therapy

  • IV morphine
  • Antispasmodics
  • Carbonic anhydrase inhibitors
  • Antacids
  • Proton pump inhibitors
A
  • Morphine - for pain relief
34
Q

?

acetazolamide [Diamox]

↓ volume & bicarbonate conc of pancreatic secretion

A

Carbonic anhydrase inhibitor(s)

35
Q

?

Neutralization of gastric HCI acid secretion
↓ production & secretion of pancreatic enzymes & bicarbonate

A

Antacids

36
Q

?

dicyclomine [Bentyl]

↓ vagal stimulation, motility, pancreatic outflow
↓ volume & conc of bicarbonate & enzyme secretion

! contraindicated in paralytic ileus

A

antispasmodics

37
Q

?

omeprazole [Prilosec]

↓ HCI acid secretion (HCI acid stimulates pancreatic activity)

A

Proton pump inhibitors

38
Q

Nutritional Therapy

  • NPO status initially
  • Enteral (via nasojejunal tube) vs parenteral nutrition
  • Monitor blood triglycerides if IV lipids given
A
  • Small, freq feedings when able
    > High-carbohydrates (b/c that is least stimulating to exocrine portion of pancreas)
  • No alcohol
  • Supplemental fat-soluble vitamins
39
Q

Nursing Assessment - Subjective Data

  • Past health history
    > Biliary tract dz
    > Alcohol use
    > Abdominal trauma
    > Duodenal ulcers
    > Infection
    > Metabolic disorders
A
  • Medications
    > Thiazides, NSAIDs
  • Surgery or other treatments
    > Pancreas, stomach, duodenum, biliary tract
    > ERCP
40
Q

Subjective Data: Functional Health

  • Alcohol abuse; fatigue [health perception - health management]
  • N/V, anorexia [nutritional-metabolic]
  • Dyspnea [activity-exercise]
A
  • Pain [cognitive-perceptual]
    > severe mid-epigastric or LUQ pain that may radiate to the back, aggravated by food & alcohol intake & unrelieved by vomiting
41
Q

Objective Data

  • Restlessness, anxiety, low-grade fever [general]
A
  • Flushing, diaphoresis [integumentary]
  • Discoloration of abdomen/flank
  • Cyanosis
  • Jaundice
  • Decreased skin turgor
  • Dry mucous membranes
42
Q
  • Tachypnea, basilar crackles [respiratory]
  • Tachycardia, hypotension [cardiovascular]
A
  • Abd distention/tenderness [gastrointestinal]
  • Muscle guarding
  • Diminished bowel sounds
43
Q

Possible diagnostic findings

↓ or ↑ serum amylase/serum lipase lvls (?)
- Leukocytosis
- Hyperglycemia
Hypo or hypercalcemia (?)
- Abn findings on US/CT scans, ERCP

A

↑

Hypocalcemia

44
Q

Nursing Diagnoses

  • Acute pain
  • Deficient fluid volume
A
  • Imbalanced nutrition: less than body requirements
  • Ineffective health management
45
Q

Patient will have

  1. Relief of pain
  2. Normal fluid & electrolyte imbalance
  3. Minimal to no complications
  4. No recurrent attacks

> These aren’t SMART goals

A
46
Q

Health Promotion

  • 1. Assessment of pt for predisposing & etiologic factors
  • 2. Encouragement of early treatment of these factors (to prevent occurrence of AP)
A
  • Early diagnosis & treatment of biliary tract dz, such as cholelithiasis
  • Elimination of alcohol intake
47
Q

Acute Care

  • Monitoring VS (what’s going on in the acute phase?)
    > Hemodynamic stability may be compromised by hypotension, fever, & tachypnea
  • Monitor response to IV fluids
  • Closely monitor F&E balance
    > Freq vomiting along w/gastric suction, may result in dec Cl, Na, & K lvls
A
  • Assess resp function (lung sounds, O2 sat)
    > Resp failure can develop in pt w/severe AP
    > If ARDS develops, pt may req intubation & mechanical ventilation support
48
Q

Acute Care: Monitor F&E balance

> Cl, Na, & K
Hypocalcemia
- Tetany [jerking, irritability, & muscular twitching]
! Numbness or tingling around the lips & in the fingers is an early indicator of hypocalcemia
- Calcium gluconate to treat

> Hypomagnesemia

A
49
Q

?

Is a carpal spasm induced by inflating a BP cuff above the systolic pressure for a few min

A

Trousseau’s sign

50
Q

?

Is contraction of facial muscles in response to a light tap over the facial nerve in front of the ear

A

Chvostek’s sign

51
Q
  • Pain assessment & management

> Morphine
Position of comfort w/freq position changes
- Flex trunk & draw knees to abdomen
- Side-lying w/HOB elevated 45°

A
  • Freq oral/nasal care
    > Oral care essential to prevent parotitis
    > If pt is taking anticholinergics to dec GI secretions, there will be addl dryness of the mouth
  • Proper admin of antacids [to neutralize gastric acid secretion]
    > Sip slowly or insert in NG tube
52
Q
  • Observation for signs of infection (fever; resp infections [shallow, guarded breaths])
  • TCDB, semi-Fowler’s position
  • Wound care (for an anastomotic leak or a fistula)
A
  • Observation for paralytic ileus, renal failure, mental changes
  • Monitor serum glucose (to assess damage to β-cells of islets of Langerhans)
  • Post-op wound care
    > Prevent skin irritation
    > Pouching, drains; sterile pouching systems; WOCN consult
53
Q

Ambulatory Care

> Physical therapy
Assessment of opioid addiction (more common in chronic than acute)
Counseling regarding abstinence from alcohol & smoking

A
  • Dietary teaching
    > Low-fat, high carbohydrate
    > No crash diets or bingeing as they can precipitate attacks
  • Pt/family teaching
    > Signs of infection, DM, steatorrhea (foul-smelling, fatty stools)
    > Rx’s/diet
54
Q

Restrict fats b/c they stimulate the secretion of ___, which then simulates the pancreas

A

cholecystokinin

55
Q

Nursing Implementation - AP Expected Outcomes

  • Have adequate pain control
  • Maintain adequate fluid volume
A
  • Be knowledgeable about treatment regimen
  • Get help for alcohol dependence & smoking cessation (if appropriate)
56
Q

?

This is a continuous, prolonged, inflammatory, & fibrosing process of the pancreas

> Pancreas becomes progressively destroyed as it’s replaced w/fibrotic tissue
Strictures & calcifications may occur in pancreas

A

Chronic pancreatitis (CP)

57
Q

Etiology - CP

  • Alcohol abuse
  • Gallstones
  • Tumor; pseudocysts
  • Trauma
  • Systemic diseases (SLE)
  • Autoimmune pancreatitis, CF
  • Idiopathic
A

Chronic pancreatitis may follow acute pancreatitis, but may also occur in the absence of an acute condition

58
Q

2 major types

> Chronic obstructive

> Chronic nonobstructive

A
59
Q

__ __ pancreatitis (?)

Inflammation & sclerosis in head of pancreas & around duct
> A genetic factor may predispose a person who drinks to the direct toxic effect of the alcohol on the pancreas

Most common cause is alcohol abuse

A

Chronic nonobstructive (pancreatitis)

Is the most common type of CP

60
Q

__ __ pancreatitis (?)

Inflammation of the sphincter of Oddi in assoc w/cholelithiasis

Cancer of the ampulla of Vater, duodenum, or pancreas

A

Chronic obstructive (pancreatitis)

61
Q
  • Abdominal pain

> Located in same areas as in AP
Heavy, gnawing feeling; burning & cramp-like

A
  • Pain is not relieved w/food or antacids
  • Attacks can become more & more frequent until they’re almost constant; or may diminish as pancreatic fibrosis develops
  • Some abd tenderness may be present
62
Q
  • Malabsorption w/wt loss
  • Constipation
  • Mild jaundice w/dark urine
A
  • Steatorrhea
  • DM
63
Q
  • Complications include

> Pseudocyst formation
Bile duct or duodenal obstruction
Pancreatic ascites or pleural effusion
Splenic vein thrombosis
Pseudoaneurysm
Pancreatic cancer

A
  • Confirming the dx of CP can be challenging
  • Based on
    > S/S
    > Lab studies
    > Imaging
64
Q

Laboratory Tests

  • Serum amylase/lipase lvls may be slightly ↑ or not at all
  • ↑ serum bilirubin, alkaline phosphatase, & ESR
  • Mild leukocytosis
A
  • ERCP [to visualize pancreatic & CBDs)
  • CT, MRI, MRCP, abd and/or endoscopic US
  • Stool samples for fecal fat content
  • ↓ fat-soluble vitamin & cobalamin lvls
  • Glucose intolerance/diabetes
  • Secretin stimulation test [to assess the ° of pancreatic dysfunction]
65
Q
  • Analgesics for pain relief (morphine or fentanyl transdermal patch [Duragesic])
  • Diet
    > Bland, low-fat
    > Small, frequent meals
A
  • No smoking
  • No alcohol or caffeine beverages
66
Q
  • Pancreatic enzyme replacement

pancrelipase (Creon, Zenpep, Pancrease)

> Contain amylase, lipase, & trypsin & are used to replace the deficient pancreatic enzymes
Are usually enteric-coated to prevent their breakdown or inactivation by gastric acid

A
  • Bile salts

> Facilitate the absorption of the fat-soluble vitamins (A, D, E, K) & prevent further fat loss

67
Q
  • If diabetes develops, it’s controlled w/insulin (more commonly) or oral hypoglycemic agents
A
  • Acid-neutralizing [antacids] & acid-inhibiting rx’s [H2-receptor blockers, PPI’s] given to decrease HCI acid secretion but have little overall effect on pt outcomes
68
Q
  • Antidepressants like nortriptyline (Aventyl) have been shown to reduce the neuropathic pain assoc w/CP
A
69
Q
  • Surgery

> Indicated when biliary dz is present or if obstruction or pseudocyst develops

> Diverts bile flow or relieves ductal obstruction

A

> Choledochojejunostomy

> Roux-en-Y pancreatojejunostomy

70
Q

?

Is a surgical diverting procedure in which the pancreatic duct is opened & an anastomosis is made w/the jejunum

A

Roux-en-Y pancreatojejunostomy

71
Q

?

Is a surgical procedure that diverts bile around the ampulla of Vater, where there may be a spasm or hypertrophy of the sphincter
> The CBD is anastomosed into the jejunum

A

Choledochojejunostomy

72
Q
  • Endoscopic procedures

> Pancreatic drainage
ERCP w/sphincterotomy and/or stent placement

A

Nursing Management

  • Focus is on chronic care & health promotion
73
Q
  • Pt & family teaching

> Dietary control

> Pancreatic enzymes taken w/ meals/snack

> Observe for steatorrhea

A

> Monitor glucose lvls

> Antacids >meals & @ bedtime (to control gastric acidity)

> No alcohol

NUR 201 Week 10 (4 decks)

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