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Pathophysiology
Self-digestion of the pancreas by its own proteolytic enzymes (trypsin) causes acute inflammation of the pancreas. Enzymes within the pancreas may be prematurely activated by obstruction of gallstones in the bile duct. The enzymes then reflux back into the pancreatic duct causing inflammation, erosion and necrosis. There is an elevated risk of mortality due to hypovolemic shock, hypotension or multiple organ dysfunction. Acute pancreatitis is a sudden inflammation that only lasts a short time. Chronic pancreatitis is long-lasting and usually occurs after an acute episode.
Etiology
Acute: In the US, 80%-90% of acute pancreatitis cases are the result of gallstones followed by alcohol intake. Other etiology includes infections, hypercalcemia, hypertriglyceridemia, trauma, pancreatic cancer, autoimmune disease and certain medications.
Chronic: Long-term alcohol use is the major contributor to chronic pancreatitis, in addition to gallstones, hereditary disorders, cystic fibrosis and hypertriglyceridemia
Desired Outcome
The desired outcome of pancreatitis is the absence of obstruction, inflammation or infection of the pancreas and bile duct. Patient will be free from pain and vomiting.
Pancreatitis Nursing Care Plan
Subjective Data:
- Abdominal pain – mid-epigastric pain that radiates to the back
- Anorexia
- Nausea / vomiting
Objective Data:
- Vomiting
- Fever
- Dry mucous membranes
- Rigid abdomen
- Tachycardia
- Hypotension
- Bruising in the flank and around the umbilicus
- Elevated serum lipase/amylase levels
Nursing Interventions and Rationales
- Assess and monitor vitals
- Temperature – fever is a sign of infection and stress response
- Hypotension (decreased blood pressure) with tachycardia (elevated heart rate): a sign of hypovolemia and can lead to shock
- Assess and manage pain
- Administer medications as ordered: opioid or non-opioid medications for pain
- Positioning: place in semi-Fowler’s to decrease pressure on abdomen and diaphragm
- Monitor labs
- Serum lipase – may stay elevated for up to 12 days
- Serum amylase – usually returns to normal within a few days of treatment
- CRP – 24-48 hours after presentation – higher levels may indicate possible organ failure
- WBC – >12,000/uL (leukocytosis) may = inflammation or infection
- Hematocrit – >47% may indicate more severe disease
- Serum glucose – monitor for hyperglycemia due to lack of insulin secretion
- Administer Medications as ordered
- Cimetidine (Tagamet) – often given to decrease secretion of hydrochloric acid
- Antibiotics – as necessary for primary infection
- Insulin – as necessary for significant hyperglycemia
- Nutrition Monitoring and Education
- Maintain NPO status during acute phase of illness
- Provide clear liquid diet for a few days once inflammation is under control
- Parnteral nutrition – in severe cases may be given to inhibit stimulation of pancreatic enzymes and to decrease metabolic stress
- Assess fluid/electrolyte balance
Monitor
- Skin turgor- tenting is a sign of moderate to severe dehydration
- Mucous membranes- lips and mouth should be moist and shiny
- I & O monitor for retention or excess output of fluid
Administer
- Aggressive IV hydration is recommended within the first 12-24 hours of onset, unless contraindicated (cardiac or renal comorbidities)
- Encourage lifestyle changes
Counsel patient on healthy lifestyle choices to include:
- Stop smoking
- Cessation of drinking alcohol
- Healthy diet and exercise to maintain appropriate weight.
- Lower fat intake to improve hypertriglyceridemia
- Optimal hydration – pancreatitis can cause dehydration, encourage patient to drink more water throughout the day
References
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