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Nursing Care and Pathophysiology for Pancreatitis

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Pathophysiology: Inflammation of the pancreas from a variety of causes.

Overview

  1. Inflammation of the pancreas
  2. Autodigestion of pancreas results from long-term damage

Nursing Points

General

  1. Causes
    1. Alcohol abuse
    2. Gallbladder disease
    3. Obstruction of the ducts
    4. Hyperlipidemia
    5. PUD
  2. Types
    1. Acute – occurs suddenly with most patients recovering fully
    2. Chronic – usually due to long standing alcohol abuse with loss of pancreatic function

Assessment

  1. Abdominal pain
    1. Sudden onset
    2. Mid epigastric
    3. LUQ
  2. N/V
  3. Weight loss (malabsorption)
  4. Abdominal tenderness
  5. Abnormal Labs
    1. ↑ WBC, bilirubin, ALP, amylase, lipase
  6. Cullen’s sign
    1. Bruising and edema around the umbilicus
  7. Turner’s sign
    1. Flank bruising
    2. Indicative of pancreatic autodigestion or retroperitoneal hemorrhage
  8. Steatorrhea – fatty, foul-smelling stools

Therapeutic Management

  1. Suppress Pancreatic secretions
    1. NPO
    2. NG tube insertion to decompress stomach
  2. IV hydration
  3. TPN for prolonged exacerbations
    1. To provide adequate nutrition
  4. ERCP to remove gallstones
    1. Endoscopic Retrograde Cholangiopancreatography
    2. Camera inserted to visualize common bile duct
  5. Surgery
    1. Whipple – remove a portion of pancreas (for mass or tumor)
    2. Pancreatectomy – remove pancreas
      1. Will require Insulin, Glucagon, and pancreatic enzyme supplementation
    3. Cholecystectomy – if the source is gallbladder disease
  6. Medications
    1. Analgesics
    2. H2 blockers
    3. Proton pump inhibitors
    4. Insulin
    5. Anticholinergics

Nursing Concepts

  1. Comfort
    1. Administer analgesics as ordered
    2. Sit upright during meals
  2. Nutrition
    1. Smaller, frequent meals
    2. Low fat diet

Patient Education

  1. Educate on avoidance of alcohol
  2. Notify provider of exacerbations

Reference Links

Study Tools

Video Transcript

In this lesson, we’re going to talk about Pancreatitis.

But, before we do, let’s review the basic functions of the pancreas. Like we always say, once we understand how something works, we can better understand what happens when it isn’t working. So the pancreas is both an endocrine and exocrine gland. Endocrine means it secretes hormones directly into the bloodstream – those are insulin, which decreases blood glucose, and glucagon which increases blood glucose. Exocrine means it secretes these chemicals out into the GI tract. The pancreas secretes these digestive enzymes amylase, lipase, trypsin, and nuclease. Amylase helps break down carbs, lipase helps break down fats, trypsin breaks down proteins, and nuclease helps to break down nucleic acid. So the pancreas plays a huge role in the digestion and absorption of our food and nutrients.

So Pancreatitis is inflammation (that’s the -itis) of the pancreas. The unique thing here is that when this happens, the pancreas will actually start to eat itself. It’s called autodigestion. Remember it has all these digestive enzymes in it, so if they can’t get where they need to be they begin the digestion process from inside the pancreas. Ultimately this can lead to loss of function of the pancreas. The two most common causes are chronic alcoholism and gallbladder disease, especially if the ducts get obstructed. You can see here that the exocrine duct of the pancreas joins with the common bile duct just before it enters the duodenum. So if there are gallstones or if there’s inflammation here in the bile ducts, it can obstruct the pancreatic duct as well. Then also hyperlipidemia, peptic ulcer disease, and of course pancreatic cancer can all cause pancreatitis.

The #1 symptom of pancreatitis is severe, severe abdominal pain. This is extremely painful. It’s usually midepigastric or Left Upper Quadrant pain. They’ll also have nausea/vomiting and weight loss – think about how they aren’t digesting and absorbing the nutrients like they should. They’ll have an elevated white blood cell count, bilirubin, and ALP, as well as elevated levels of Amylase and Lipase because they aren’t being used. We’ll also see Cullen’s sign which is this bruising around the umbilicus like you see here, and Grey Turner’s Sign which is bruising on the flank. And finally they will have steatorrhea, which is fatty, foul-smelling stools.

So our #1 goal with medical management is to suppress or decrease the amount of enzymes that the pancreas secretes to try to limit that autodigestion. We’ll make them NPO and sometimes place an NG tube to decompress the stomach – less gastric acid secretion means less pancreatic secretions. So when they are NPO, it’s important that we make sure they are getting hydration and we’ll do TPN which is nutrition through the IV as well. As far as medications, we’ll give analgesics for the pain and acid reducers like H2 blockers and PPI’s. The one thing that is different about Pancreatitis is the we WILL actually give them Anticholinergics. That’s because these meds will actually decrease gastric secretions and gastric motility. The less gastric activity, the less pancreatic stimulation. That’s actually what we want. And then of course keep in mind that the pancreas controls insulin and glucagon, so we need to monitor their blood sugars closely and give those meds to them as needed.

As far as procedures we can do, one of the most common things you’ll see is an ERCP, which stands for Endoscopic Retrograde CholangioPancreatography. Any time you see Chole or Cholangio, thing gallbladder. Basically they insert a scope down into the duodenum and then have this probe that looks backwards up through the common bile duct (that’s the “retrograde” part). They do this to look for any gallbladder issues and to remove gallstones or any other duct obstructions. We may also see the patient get their gallbladder removed in a cholecystectomy to reduce any problems that causes or we could see them remove the pancreas altogether. Keep in mind, these patients will instantly become a diabetic and will need insulin and glucagon for the rest of their lives, as well as having to take supplemental pancreatic enzymes. Finally there’s a procedure called a whipple, which could be done for pancreatic cancer or some other kind of lesion on the pancreas. They will remove the first part of the pancreas and the duodenum. They’ll reattach the stomach and the tail of the pancreas lower down on the small intestine to the jejunum. If there was some sort of injury or lesion causing the pancreatitis, that should fix the problem.

Priority nursing concepts for a patient with Pancreatitis would be comfort, because this is quite painful, nutrition, because they lose their ability to digest and absorb nutrients and may need to be on TPN, and patient education because their entire lifestyle may have to change, especially if they have their pancreas removed. Also, it’s incredibly important that we educate these patients to stop drinking alcohol. It’s extremely hard on the GI system, including the pancreas. Make sure you check out the care plan attached to this lesson for more detailed nursing interventions and rationales.

So let’s recap – Pancreatitis is inflammation of the pancreas that leads to autodigestion and loss of function of the pancreas. It could be acute, which usually resolves completely, or chronic which leads to progressive loss of function. Common causes are chronic alcoholism and gallbladder disease. Patients will present with severe abdominal pain, nausea, vomiting, and weight loss, plus bruising around the umbilicus or the flank. It’s possible to remove the pancreas to alleviate the problem, but it will leave patients on medications and supplements for a lifetime. Our priority in addition to managing their pain is going to be making sure that we manage their nutritional needs because they will likely need to be NPO and be on TPN for a while.

Okay guys, that’s it for Pancreatitis. Make sure you check out the rest of the resources attached to this lesson to learn more! Now, go out and be your best selves today. And, as always, happy nursing!

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