Unit 3: Acute Pancreatitis

Question 1

Pancreatitis

Answer 1

• inflammation of the pancreas
• acute or chronic
• hospitalization in ICU
• mild to severe
• w/ severe acute pancreatitis may develop SIRS and end-organ dysfunction

Question 2

Chronic Pancreatitis

Answer 2

persistent inflammation that causes scarring and damage to the pancreas and surrounding tissue

Question 3

Causes of Acute Pancreatitis

Answer 3

• Alcohol
• Gallstones
• Trauma
• Medication reactions
• Hypertriglyceridemia
• Bile Duct abnormalities or obstruction (tumor)
• Surgery
• Infectious organisms
• Parasites
• Spider bites
• Scorpion stings
• Idiopathic (unidentified cause)
• Pancreas divisum (congenital anomaly where pancreatic duct is divided into 2 parts)

Question 4

Most Prevalent Causes of Acute Pancreatitis

Answer 4

• Gallstones

- Alcohol

Question 5

Gallstone Pancreatitis

Answer 5

• due to presence of gallstones obstructing the bile duct or located near the area where the bile duct and pancreatic duct empty into the duodenum
• causes alteration in the flow of bile and pancreatic enzymes leading to inflammation of the pancreas

Question 6

Pathophysiology of Acute Pancreatitis

Answer 6

• reversible process involving inflammation of the pancreas secondary to the release of pancreatic enzymes that “autodigest” the pancreas, peripancreatic tissue, and adjacent areas
• may occur as an isolated event, or may be recurrent

Question 7

Autodigestion

Answer 7

occurs when the pancreatic enzymes digest the pancreas and surrounding tissue

Question 8

Clinical Manifestations

Answer 8

• sudden onset of epigastric pain that is felt in the LUQ or mid-abdomen; can radiate to back or shoulder blades
• pain is deep and very sharp
• pain becomes more intense within minutes of eating foods high in fat
• pain constant and severe
• pain lasts several days
• complain of severe pain when lying flat or bending forward
• pain associated w/ nausea, vomiting, and anorexia

Question 9

General Clinical Presentation of Pancreatitis

Answer 9

• abdominal fullness from gas or bloating
• hiccups
• indigestion
• fever
• tachycardia
• hypotension

Question 10

What does the Physical Exam Reveal?

Answer 10

-tender abdomen with localized guarding and rebound tenderness

Question 11

Cullen’s Sign

Answer 11

periumbilical bruising

Question 12

Grey Turner’s Sign

Answer 12

flank bruising

Question 13

What Indicates Retroperitoneal Hemorrhage?

Answer 13

• Cullen’s Sign and Grey Turner’s sign
• take 24 to 48 hours to develop
• can be a predictor of acute pancreatitis w/ pancreatic necrosis and retroperitoneal or intra-abdominal bleeding

Question 14

Laboratory Tests Used in Diagnosis of Pancreatitis

Answer 14

• Metabolic Panel
• Hematology Studies
• Serum amylase
• Serum Lipase

Question 15

Amylase

Answer 15

enzyme that aids in digestion of carbohydrates

Question 16

Lipase

Answer 16

enzyme that aids in the digestion of fats

Question 17

What is the most specific test for pancreatitis?

Answer 17

• Serum Lipase (elevated)

- lipase only produced by the pancreas

Question 18

Diagnostic Imaging Tests For Pancreatitis

Answer 18

-Abdominal CT scan
-Abdominal MRI
-Abdominal Ultrasound
>these evaluate for inflamed pancreas, gallstones, and bile duct obstruction or distention

Question 19

Connection Check: The most specific laboratory result in in the patient with acute pancreatitis is an elevation in which laboratory value?
A. Serum bilirubin
B. Serum Lipase
C. Serum trypsin
D. Serum lactase

Answer 19

B. Serum Lipase

Question 20

Four Scoring Systems of Pancreatitis

Answer 20

• Ranson’s Criteria
• APACHE II score (Acute Physiology and Chronic Health Evaluation)
• Balthazar CT severity index
• Bedside Index Severity of Acute Pancreatitis (BISAP)

Question 21

Ranson’s Criteria

Answer 21

measures severity of illness and the likelihood of mortality in patients w/ pancreatitis

• evaluated upon admission, and then again within the first 48 hours according to the scoring criteria
• if at 48 hours the patient has a score of greater than or equal to 3, severe pancreatitis is likely

Question 22

Mortality Associated with Ranson’s Score

Answer 22

• 0 to 2: 2% mortality
• 3 to 4: 15 % mortality
• 5 to 6: 40% mortality
• 7 to 8: 100% mortality

Question 23

Treatment

Answer 23

• NPO status to prevent release of pancreatic enzymes responsible for autodigestion of the pancreas
• IV hydration and pain medications
• if has severe acute pancreatitis, managed in ICU
• aggressive supportive therapy
• if has necrotic pancreatitis, antibiotics are given
• if pancreatitis caused by gallstones, undergo a cholecystectomy

Question 24

Approved Agents for Acute Pancreatitis

Answer 24

• Opioid Narcotics: Morphine Sulfate (for pain)
• Anticholinergic agents
• Spasmolytic
• H2 (histamine) antagonist or proton pump inhibitor
• Pancreatic enzymes
• Antibiotics
• Octreotide

Question 25

Anticholinergic Agents

Answer 25

decreases intestinal motility and decrease pancreatic enzyme release

Question 26

Spasmolytics

Answer 26

relaxes smooth muscle and relax sphincter of Oddi

Question 27

H2 (Histamine) antagonist or proton pump inhibitor

Answer 27

decreases gastric acid secretions

Question 28

Pancreatic enzymes

Answer 28

aids in digestion of fats and proteins; take w/ meals

Question 29

Antibiotics

Answer 29

treats acute necrotizing pancreatitis

Question 30

Octreotide

Answer 30

decreases secretion of enzymes

Question 31

Diet for Acute Pancreatitis

Answer 31

- IV fluids and parenteral nutrition, avoiding use of enteral nutrition in an effort to "rest" the inflamed pancreas and prevent the release of pancreatic enzymes - new guidelines: initiation of early enteral feeding

Question 32

Complications of Acute Pancreatitis

Answer 32

- Necrotizing Pancreatitis - Pancreatic Hemorrhage - Pancreatic Pseudocysts - Pleural Effusions

Question 33

Necrotizing Pancreatitis

Answer 33

- may present 1 or more weeks after initial onset of acute pancreatitis - diagnosed by CT scan; shows presence of air and gas surrounding the pancreas - caused by activation of pancreatic enzymes that basically "eat through" the tissue of the pancreas and enter the peritoneal cavity and surrounding tissue, causing extensive peripancreatic tissue breakdown, inflammation, and hemorrhage from the rupture of surrounding blood vessels - can develop sepsis, shock, and multiple-organ failure

Question 34

Two Types of Pancreatic Necrosis

Answer 34

-Sterile -Infected >type is determined through a needle biopsy and culture

Question 35

Sterile Necrosis

Answer 35

areas of necrosis that are free from bacteria

Question 36

Infected pancreatic necrosis

Answer 36

necrosis that is caused by bacteria

Question 37

How is Necrotizing Pancreatitis Treated?

Answer 37

- medically in the basis of clinical presentation - drainage or surgical intervention that involves debridement of the necrotic tissue and infected debris via the step-up approach - if culture is positive; antibiotics

Question 38

Surgical Management for Necrotizing Pancreatitis

Answer 38

-pancreatic resection, open abdominal resection w/ open packing and serial debridement every 2 to 3 days, or necrosectomy (resection of necrotic tissue) with lavage or drainage

Question 39

Complication: Pancreatic Hemorrhage

Answer 39

- hemorrhage as a result of pancreatic enzymes causing micro-rupture of the vascular system surrounding the pancreatic bed - experience increased pain, decreased BP, and elevated HR - abdominal exam may reveal Grey Turner's sign or Cullen's sign - if an active bleed is diagnosed, patients undergo embolization to stop the hemorrhage

Question 40

Complication: Pancreatic Pseudocyst

Answer 40

- encapsulated areas of fluid that contain pancreatic enzymes and pancreatic tissue - usually form within 4 to 6 weeks after an episode of acute pancreatitis - vary in size and number - resolve spontaneously over several weeks - if pseudocyst becomes infected, it is known as a pancreatic abscess, and patient requires either percutaneous drainage or necrosectomy (excision of necrotic tissue) to drain or debride the infected fluid collection and surrounding tissue - with infected pseudocyst: chills, fever, N/V, and abdominal pain - monitor for rupture and impending shock

Question 41

Complications: Pleural Effusions

Answer 41

- abnormal accumulation of fluid between the layers of the pleura in the lung - can occur in pancreatitis b/c of impaired capillary permeability or inflammation - typically located in left lung b/c of the proximity of the pancreas to the left hemidiaphragm but can be bilateral - may complain of SOB, hiccups, or pleuritic chest pain - pleural effusions are filled with exudates (high protein and blood) and have high amylase levels (> 30 times normal)

Question 42

Nursing Management: Assessment and Analysis

Answer 42

``` >classic presentation of acute pancreatitis is sudden onset of acute unbearable abdominal pain >other manifestations: -elevated HR and respiratory rate -low BP -pain -elevated serum lipase, amylase, and glucose values -hypocalcemia -steatorrhea, clay-colored stools -hypovolemia -hypoxia -pleural effusions -manifestations of adult respiratory distress syndrome (ARDS) -multiple organ dysfunction ```

Question 43

Nursing Diagnoses

Answer 43

- acute pain r/t inflammation, edema, and distention of the pancreas and surrounding tissue - ineffective breathing patterns r/t pain, pulmonary infiltrates, pleural effusions, and atelectasis - imbalanced nutrition, less than body requirements r/t decreased food intake and increased metabolic demands

Question 44

Nursing Assessments for Acute Pancreatits

Answer 44

- Vital Signs - Oxygen Status - Pain location, intensity, duration - Abdominal assessment - Grey Turner's and/or Cullen's sign - Serum lipase and amylase - Serum glucose - Serum calcium, Trousseau sign or Chvostek sign - Stool color - Nutritional intake - Daily weight, monitoring of fluid intake and output

Question 45

Assessments: Vital Signs

Answer 45

- fever and tachycardia may = inflammation - elevated respiratory rate may occur b/c of anxiety and pain - rate may be shallow and rapid as a result of pain - blood pressure may be low d/t dehydration and fluid shifts secondary to the inflammatory response

Question 46

Assessments: Oxygen status

Answer 46

-PaO2 may be decreased b/c of alveoli collapse and pleural effusion

Question 47

Assessment: Pain location, intensity, and duration

Answer 47

- pain located in RUQ (head of pancreas) or LUQ (tail of pancreas) is r/t autodigestion of the pancreas d/t leaking of pancreatic enzymes into tissue surrounding the pancreas, leading to edema, distention of the pancreas, and peritoneal irritation - localized pain may = pseudocyst or abscess formation

Question 48

Assessment: Abdominal assessment

Answer 48

palpation may reveal rebound tenderness, muscle guarding, or rigid abdominal muscles

Question 49

Assessment: Grey Turner's and/or Cullen's sign

Answer 49

-Grey Turner's sign is bruising noted on the flank d/t leaking of exudate stained with blood into the flank area -Cullen's sign is bruising around the umbilicus >bruising in these areas indicates hemorrhage, severe inflammation, and tissue damage

Question 50

Assessment: Serum Lipase and Amylase

Answer 50

- Elevated lipase and amylase are d/t inflammation of the pancreas, which interrupts its normal structure and function - Serum lipase is a useful biomarker b/c levels can remain elevated for up to 2 weeks - Elevated amylase levels that are three times normal are indicative of acute pancreatitis; elevated within 12 hours of the onset of inflammation, and can last 4 days

Question 51

Assessments: Serum Glucose

Answer 51

glucose elevations d/t the digestion of the pancreas, which leads to decreased production and availability of insulin

Question 52

Assessments: Serum Calcium, Trousseau sign, or Chvostek sign

Answer 52

>Hypocalcemia -assess for neuromuscular irritability when calcium levels are low b/c of the accumulation of fatty acids, which chelate calcium salts, causing soapy deposits in the abdomen >Trousseau sign -hand spasms with inflation of the blood pressure cuff 20 mm Hg above the patients systolic BP for 3 to 5 minutes; under these ischemic conditions, the nerves become irritable, and spams results >Chvostek's sign -facia twitching; tapping the skin over the facial nerve anterior to the external auditory meatus; in a patient w/ acute hypocalcemia, ipsilateral contraction of the facial muscles occurs

Question 53

Assessment: Stool color

Answer 53

steatorrhea, clay-colored stools due to obstruction of bile flow

Question 54

Assessment: Nutritional intake

Answer 54

patients exhibit loss of appetite b/c of pain; in alcoholic pancreatitis, patients may be malnourished at baseline

Question 55

Assessment: Daily weight, monitoring of fluid intake and output

Answer 55

- monitor fluid status and prevent dehydration - hypovolemia occurs b/c of third-space losses in the retroperitoneum from autodigestion of the pancreas and capillary leak; these fluid shifts can impact weight, and with significant ascites formation, the weight increases as the fluid retention increases

Question 56

Nursing Actions for Acute Pancreatitis

Answer 56

- Maintain NPO - NGT to low suction, as ordered - Administer analgesics, antiemetics, histamine blockers, sedatives, and antianxiety meds - Promote bedrest in semi-fowlers position or fetal position - Encourage coughing and deep breathing

Question 57

Actions: Maintain NPO status

Answer 57

decreases the secretion of digestive enzymes and prevents the contraction of the gallbladder and release of cholecystokinin

Question 58

Actions: NGT to low suction as ordered

Answer 58

decompresses stomach, prevents abdominal distention

Question 59

Actions: Administer analgesics

Answer 59

decreases symptoms of pain

Question 60

Actions: Administer antiemetics

Answer 60

decrease symptoms of N/V, which may occur for a prolonged time

Question 61

Actions: Administer histamine blockers

Answer 61

to decrease acid secretion and inhibit pancreatic enzyme activity

Question 62

Actions: Administer sedatives and anti-anxiety meds

Answer 62

help decrease spasms and subsequent enzyme secretions

Question 63

Actions: Promote bedrest in semi-Fowler's position or fetal position

Answer 63

- bedrest decreases the stimulation of pancreatic secretions and resulting pain - semi-Fowlers position relieves abdominal pressure and tension - fetal position is most comfortable

Question 64

Actions: Encourage coughing and deep breathing

Answer 64

- prevents atelectasis and improve oxygenation | - patients commonly have pleural effusions

Question 65

Nursing Teaching

Answer 65

- Appropriate diet and intake of small, frequent meals and vitamin supplements; carbohydrate-containing foods; avoid fat and protein-rich foods - Abstain from alcohol - Abstain from smoking - Disease symptoms, progression, diagnostic procedures, and interventions

Question 66

Evaluating Care Outcomes

Answer 66

- acute pancreatitis is a serious, life-threatening disorder - b/c of the potential for sepsis and hypovolemia, monitoring of fluid and electrolytes, and CBC, is a priority for evaluating effectiveness of treatment plan - pain management and nutritional status are indicators of how the disease process is progressing - positive outcomes: stable vital signs, stable weight, serum electrolytes WNL, decreased pain, and decreased liver enzymes - may be hospitalized for weeks and require transitional care that focuses on reestablishing their weight and muscles mass, as well as understanding the disease process and lifestyle changes