Pancreatitis

Question 1

pancreatitis

Answer 1

• Islets of Langerhans: secrete insulin and glucagon
• Pancreatic tissues secrete digestive enzymes that break down carbs, proteins, and fats
• Pancreatitis: autodigestion of the pancreas by pancreatic digestive enzymes that activate prematurely before reaching the intestines
  
  • MOA: unclear
  • Inflammation of the pancreatic tissue causes duct obstruction, which can lead to increased pressure and duct rupture, causing the release of pancreatic enzymes into the pancreatic tissue
  • Can result in pancreatic inflammation, necrosis, hemorrhage

Question 2

acute vs. chronic pancreatitis

Answer 2

• Acute pancreatitis: inflammatory process due to activated pancreatic enzymes autodigesting the pancreas ranging from mild to necrotizing hemorrhagic pancreatitis (widespread bleeding and necrosis)
  
  • Classic presentation of acute attack: severe, constant, knifelike pain (LUQ, midepigastric, and/or radiating to the back)
• Chronic pancreatitis: progressive, destructive dz of inflammation and fibrosis of pancreas

Question 3

how can chronic pancreatitis be classified?

Answer 3

• Chronic calcifying pancreatitis: assoc with alcohol use disorder
• Chronic obstructive pancreatitis: assoc with cholelithiasis
• Autoimmune pancreatitis
• Idiopathic and hereditary pancreatitis

Question 4

pancreatitis: health promotion and dz prevention

Answer 4

• Avoid excess alcohol consumption
• Eat a low fat diet

Question 5

pancreatitis: risk factors

Answer 5

• Biliary tract dz: gallstones can cause a blockage where the common bile duct and pancreatic duct meet
• Alcohol use: primary cause of chronic pancreatitis is alcohol use disorder
  
  • Times of inc alcohol consumption, like vacations or holidays, are assoc with acute pancreatitis
• Inc age: more common in older adults
• Endoscopic retrograde cholangiopancreaticography (ERCP): post procedure complication
• GI surgery
• Metabolic disturbances: hyperlipidemia, hyperparathyroidism, hypercalcemia
• Kidney failure or transplant
• Genetic predisposition
• Trauma
• Penetrating ulcer: gastric or duodenal
• Medication toxicity
• Viral infections: coxsackievirus B and HIV
• Cigarette smoking

Question 6

pancreatitis: expected findings

Answer 6

• Sudden onset of severe, boring pain (goes thru body)
  
  • Epigastric, radiating to back, left flank, or left shoulder
  • Worse when lying down
• Pain relieved somewhat by fetal position or sitting upright, bending forward
• n/v
• Weight loss
• Seepage of blood stained exudates into tissue as a result of pancreatic enzyme actions
  
  • Ecchymoses on the flanks: Turner’s sign
  • Bluish gray periumbilical discoloration: Cullen’s sign
• Generalized jaundice
• Absent or dec bowel sounds (possible paralytic ileus)
• Warm, moist skin and fruity breath: evidence of hyperglycemia
• Ascites
• Tetany due to hypocalcemia
  
  • Trousseau’s sign: hand spasm when BP cuff is inflated
  • Chvostek’s sign: facial twitching when facial nerve is tapped

Question 7

pancreatitis: lab findings

Answer 7

• Serum amylase: inc w/in 12 to 24 hr and remains inc for 2-3 days
  
  • Continued elevation can indicate pancreatic abscess or pseudocyst
• Serum lipase: inc slowly but remains inc for up to 2 weeks
  
  • Urine amylase remains inc for up to 2 weeks
  • Inc in enzymes indicate pancreatic cell injury
• WBC count: inc due to infection and inflammation
• Platelets: dec
• Serum calcium and magnesium: dec due to fat necrosis w/ pancreatitis
• Serum liver enzymes and bilirubin: inc with assoc biliary dysfunction
• Serum glucose: inc due to a dec in insulin production by the pancreas
• ESR: elevated

Question 8

pancreatitis: diagnostic procedures

Answer 8

CT scan w/ contrast: reliably diagnostic for acute pancreatitis

Question 9

pancreatitis: nursing care

Answer 9

• Rest pancreas:
  
  • NPO: no food until pain free
  • For severe pancreatitis: TPN or jejunal feedings
    
    • Contraindicated if paralytic ileus develops, less risk of hyperglycemia
  • When diet is resumed: bland, high protein, low fat diet with no stimulants (caffeine)
    
    • small, frequent meals
  • Administer antiemetic as needed, as prescribed
  • NG tube: gastric decompression
    
    • For severe vomiting or paralytic ileus
  • No alcohol consumption
  • Smoking
  • Limit stress
  • Pain mgmt
• Position client for comfort: fetal, side lying, HOB elevated, sitting up or leaning forward
• Administer analgesics
• Monitor blood glucose, and provide insulin as needed: potential for hyperglycemia
• Monitor hydration status: orthostatic BP, I&O, lab values
• Administer IV fluids and electrolyte replacements

Question 10

pancreatitis: classes of medications

Answer 10

• opioid analgesics
• abx
• histamine receptor antagonists
• PPIs
• pancreatic enzymes

Question 11

pancreatitis: opioid analgesics

Answer 11

• morphine or hydromorphone
• For acute pain
• Nursing considerations: meperidine is discouraged due to risk of seizures, esp in older adult clients

Question 12

pancreatitis: abx

Answer 12

• imipenem
• Can be used but are generally indicated for clients who have acute necrotizing pancreatitis
• Nursing Considerations:
  
  • monitor for evidence of infection
  • Monitor for seizures

Question 13

pancreatitis: histamine 2 receptorantagonists

Answer 13

• ranitidine
• Dec gastric acid secretion
• Client edu:
  
  • Take 1 hr before or 1 hr after antacid

Question 14

pancreatitis: PPI

Answer 14

• omeprazole
• Dec gastric acid secretion
• Nursing considerations:
  
  • Monitor for hypomagnesemia

Question 15

pancreatitis: pancreatic enzymes

Answer 15

• pancrelipase
• Aid w/ digestion of fats and proteins when taken with meals and snacks
• Nursing considerations:
  
  • Client can sprinkle contents of capsule 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)
  • Take after antacid or histamine receptor antagonists
  • Teach client to take pancrelipase with every meal and snack

Question 16

pancreatitis: therapeutic procedures

Answer 16

• ERCP to create an opening in the sphincter of Oddi if pancreatitis is caused by gallstones
• Cholecystectomy if pancreatitis is the result of cholecystitis and gallstones
• Sphincterotomy to enlarge the pancreatic duct sphincter
• Endoscopic pancreatic necrosectomy and natural orifice transluminal endoscopic surgery to remove necrotic tissue
• Pancreaticojejunostomy (Roux-en-Y): reroutes drainage of pancreatic secretions into jejunum

Question 17

chronic pancreatitis due to alcohol use: client edu

Answer 17

• encourage the client to avoid alcohol intake and caffeinated beverages and to participate in support groups for individuals who have alcohol use disorder

Question 18

pancreatitis: possible complications

Answer 18

• hypovolemia
• pancreatic infection
• type 1 DM
• left lung effusion and atelectasis
• coagulation defects
• multi system organ failure

Question 19

pancreatitis: complication of hypovolemia

Answer 19

• up to 6 L of fluid can be 3rd spaced, caused by retroperitoneal loss of protein rich fluid from proteolytic digestion
  
  • Client can develop hypovolemic shock
• Nursing actions:
  
  • Monitor for V/S, electrolytes, and for hypoTN and tachycardia
  • Provide IV fluid and electrolyte replacement

Question 20

pancreatitis: complication of pancreatic infection

Answer 20

• Pseudocyst: outside pancreas
• Abscess: inside pancreas
  
  • Cause: leakage of fluid out of damaged pancreatic duct
  • Manifestations: fever, epigastric mass, n/v, jaundice
• 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

Question 21

pancreatitis: complication of Type 1 DM

Answer 21

• Cause: lack or absence of insulin due to destruction of pancreatic beta cells
• Nursing actions:
  
  • Monitor blood glucose
  • Administer insulin as prescribed
• Client edu:
  
  • Inform the client about long term diabetes mgmt

Question 22

pancreatitis: complication of left lung effusion and atelectasis

Answer 22

• More common complication in older adults
• Can precipitate pneumonia
• Causes:
  
  • Splinting of chest due to pain upon coughing and deep breathing
  • Pancreatic ascites
• Nursing action:
  
  • Monitor for hypoxia
  • Provide ventilatory support

Question 23

pancreatitis: complication of coagulation defects

Answer 23

• DIC
  
  • Causes: release of thromboplastic endotoxins secondary to necrotizing hemorrhagic pancreatitis
• Nursing actions: monitor coagulation studies and for bleeding

Question 24

pancreatitis: complication of multi system organ failure

Answer 24

• Inflammation of pancreas is believed to trigger systemic inflammation
• Cause: necrotizing hemorrhagic pancreatitis
• Nursing actions:
  
  • Administer tx as prescribed
  • Monitor for evidence of organ failure: resp distress, jaundice, oliguria