Pancreatitis

Question 1

Pancreas Physiology: exocrine functions (3)

Answer 1

• highly alkaline secretions: neutralize gastric juices in duodenum
• amylase, lipase, and proteases: digestion
• secretin secreted in duodenum at contact with gastric juices leads to secretions of pancreatic juices

Question 2

Pancreas Physiology: endocrine functions

Answer 2

insulin, glucagon and somatostatin production

Question 3

In acute pancreatitis what does the nurse need to assess for in the patient’s history?

Answer 3

assess hx of gallstones and alcohol abuse

Question 4

S/s mild pancreatitis

Answer 4

confined edema and inflammation, minimal organ dysfunction

Question 5

s/s severe pancreatitis (6)

Answer 5

widespread enzyme digestion, necrosis, peritonitis, pulmonary insufficiency, GI Bleeding, shock

Question 6

reflux of bile acids with activation and black flow of pancreatic juices –>

Answer 6

autodigestion with blood vessel damage and loss of blood: increased serum lipase, amylase

Question 7

Clinical manifestations of acute pancreatitis (6)

Answer 7

• abdominal pain (sudden), back pain, N/V
• low-grade fever, leukocytosis
• hypotension, tachycardia, tachypnea
• muscle guarding, rigid-board like abdomen (peritonitis)
• abdominal distention, decreased bowel sounds
• crackles, pulmonary infiltrates

Question 8

Why do crackles manifest in acute pancreatitis?

Answer 8

they result from exudate with enzymes collected by the lymphatic system

Question 9

2 signs and lab results for acute pancreatitis

Answer 9

• grey turner’s sign
• cullen’s sign
• If Cullens and grey turners –> possible peritonitis
• elevated serum amylase and lipase

Question 10

Clinical manifestations of acute pancreatitis (what can happen in the lungs)

Answer 10

-pleural effusion, atelectasis, PNA

Question 11

Acute pancreatitis complications: Fat necrosis, hypocalcemia

Answer 11

-lipase released from pancreatic cells start digesting fatty acids, attracting calcium in the process –> fatty acids combine with calcium to produce chalky-white areas called fat saponification

Question 12

Clinical manifestations of hypocalcemia (3)

Answer 12

• Trousseau sign (carpal spasm)
• Chvostek sign (face twitching)
• lip, finger, extremity numbness

Question 13

Criteria for predicting severity of pancreatitis: criteria on admission to the hospital (5)

Answer 13

• age > 55
• serum WBC > 16,000 mm
• serum glucose > 200 mg/dL
• serum lactose dehydrogenase > 350 IU/ L
• AST > 250 IU/ L

Question 14

Criteria for predicting severity of pancreatitis: signs and mortality (4)

Answer 14

two or fewer signs: 1% mortality
3 or four signs: 15% mortality
5 or 6 signs: 40% mortality
6 or more signs: 100% mortality

Question 15

Acute pancreatitis: diagnostic studies (4)

Answer 15

• Labs: serum amylase and lipase, calcium (decrease), WBC (increase)
• abdominal US, X-ray, CT, MRI
• H/H
• ERCP (if suspicion of gallstone pancreatitis)

Question 16

Acute pancreatitis goals for collaborative care: decrease inflammation (5)

Answer 16

• effective respiratory function (priority)
• prevention or tx of shock
• relief of pain
• FE balance (monitor calcium –> lip/finger numbness, trousseau, chvostek and magnesium) glucose
• prevent infection (PNA/ peritonitis)/treat cause

Question 17

acute pancreatitis: conservative treatment (9)

Answer 17

• respiratory care priority: semi-fowlers, pulmonary assessment, oxygen, pulse oximeter, C&DM, IS
• prevention and treatment of hypovolemic/septic shock
• early antimicrobials, prevention of infection (PNA/peritonitis)
• pain management: opioids
• maintenance of fluid balance: IV hydration and albumin
• NPO, preferred enteral feedings, when not possible TPN, PPN
• monitor nutritional status
• NG tube: relief of nausea, vomiting, digestion
• biliary drainage

Question 18

Acute pancreatitis: conservative treatment (medications) (2)

Answer 18

• H2 receptor blockers (famotidine, ranitidine): decrease pancreatic activity by decrease secretion of gastric acid
• PPIs (pantoprazole-protonix): first line treatment for decrease of acidity from gastric juice and secretion volume; max 8 weeks

Question 19

adverse effects of protonix (3)

Answer 19

higher risk for PNA, depression in older adults, and kidney failure

Question 20

Acute pancreatitis: surgical tx (4) and risks (1)

Answer 20

• ERCP plus sphincterotomy if obstruction is present
• possible cholecystectomy
• excision of pseudocysts and abscesses
• partial pancreatectomy, pancreatojejuostomy

-RISK FOR BLEEDING AND PERFORATION

Question 21

Parenteral nutrition

Answer 21

Central PN (TPN): D20-D50
peripheral PN (PPN): D10-D20

Question 22

Goal for parenteral nutrition

Answer 22

meet nutritional needs, healing

Question 23

Parenteral nutrition: intravenous fat emulsions (3)

Answer 23

• concurrent with TPN, slow rate (around 8ml/h)
• rate per order
• new tubing for each infusion

Question 24

Parenteral nutrition: 2012 research and priority assessment

Answer 24

2012: non critically ill hospitalized patients with average blood glucose levels above 180 mg/dl in response to tpn had a 5.6 fold increase in risk of mortality compared with those whose blood glucose levels remained below 140 mg/dl
- priority assessment: BLOOD GLUCOSE

Question 25

Parenteral nutrition: assess which labs, which may be elevated?, what may indicate intolerance and increase mortality?

Answer 25

• VS, weight, electrolytes, BUN, CBC, liver, pre-albumin, IV site, wound healing
• BUN may be elevated
• acute hyperglycemia may indicate client intolerance and increase mortality risk

Question 26

Parenteral nutrition: line, if administering lipids with PN what to do, what to do if the bag is empty

Answer 26

• preferably dedicated line
• If administering lipids with PN, run pump on concurrent mode
• If bag is empty: run D10-D20 for TPN; D5 for PPN