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1

What are S/S of Acute Pancreatitis?

-Severe abdominal pain and tenderness and back pain
-Typically the pain occurs in the midepigastric region
-Pain is acute in onset, occurring 24-48 hours after a heavy meal or alcohol ingestion, and it may be diffuse and difficult to localize
-more severe after meals and is unrelieved by antacids
-abdomen distention/decreased peristalsis
-nausea and vomiting that fails to relieve pain or nausea
-Abdominal guarding
-A rigid or board-like abdomen is an ominous sign
-Ecchymosis in the flank or around the umbilicus
-fever, jaundice, confusion, and agitation
-HTN
- tachycardia, cyanosis, cold, clammy skin, acute renal failure, respiratory distress and hypoxia, dyspnea, tachypnea, and abnormal ABGs
-Myocardial depression, hypocalcemia, hyperglycemia, and disseminated intravascular coagulation (DIC) may occur
-Stools are often bulky, pale, and foul-smelling

2

what are Nursing interventions for Acute Pancreatitis?

-Relieve pain with parenteral opioids, preferably morphine or hydromorphone
-Oral feedings are withheld to decrease the formation and secretion of secretin
-parenteral fluids
-N/G suction may be used to relieve N&V or treat abdominal distention and paralytic ileus
-Oral hygiene
- maintained on bed rest to decrease the metabolic rate and reduce secretion of pancreatic and gastric enzymes
-watch for hemorrhage of pancreas
-placing patient in semi-Fowler’s position
-monitor of pulse ox
-Turn, cough, and deep breath
-take daily wt

3

Once Acute Pancreatitis subsides what kind of diet will the client need to be on?

gradually reintroduce oral feedings of high carb and low fat and protein. The patient should avoid heavy meals and alcohol

4

Is a patient with acute pancreatitis at risk for impaired skin integrity?

yes they are at risk for breakdown b/c of poor nutritional status, enforced bed rest, and restlessness. Patient may have drains or surgical incision. Assess wounds, drainage sites, and skin for infection, inflammation, and breakdown. Perform wound care, skin care, or consult with enterostomal therapist. Turn patient q2h.

5

what potential complications should the nurse monitor for when having a patient with acute pancreatitis?

-fluid and electrolyte disturbances are common b/c of N&V
- movement of fluid from vascular to peritoneal cavity, diaphoresis, fever, and use of N/G suction.
-Assess patient’s fluid and electrolyte status by noting skin turgor and moistness of mucous membranes.
-Daily wt, measure I&O, assess for ascites by measure abdominal girth. Fluids are IV.
-Keep emergency meds available b/c of risk of circulatory collapse and shock. The nurse promptly reports decreased blood pressure and reduced urine output (hypovolemia) monitor for neurologic, cardiovascular, renal, and respiratory dysfunction.
-Shock and multiple organ failure may occur with acute pancreatitis.

6

What lab values would the nurse want to monitor with a patient with acute pancreatitis?

In 90% of cases, serum amylase and lipase levels rise in excess of 3 times their normal upper limit within 24 hrs. Serum amylase usually returns to normal within 48-72 hrs, but serum lipase levels may remain elevated for 5-7 days. Urinary amylase levels also become elevated and remain longer than serum. The WBC count is usually elevated; hypocalcemia is present and correlates well with the severity of pancreatitis. Transient hyperglycemia and glucosuria and elevated bilirubin levels occur in some patients with acute pancreatitis. H&H are used to monitor the patient for bleeding. Peritoneal fluid, obtained thru paracentesis or peritoneal lavage, may contain increased levels of pancreatic enzymes. The fat content of stools is 50-90% (normal is 20%) Low serum magnesium, low serum calcium. Acid-base imbalance.

7

What is Criteria for Predicting Severity of Pancreatitis?

CRITERIA ON ADMISSION TO HOSPITAL:
Age >55
WBC >16,000 mm
Serum glucose >200 mg/dl
Serum LDH > 350 IU
AST >250U/ml
CRITERIA WITHIN 48 HRS OF HOSPITAL ADMISSION
Fall in HCT >10%
BUN increase > 5mg/dl
Serum Calcium 4 mEq/L
Fluid retention or sequestration >6 L
PO2

8

How do you treat acute pancreatitis?

-relieving s/s and preventing or treating complications. -All oral intake is withheld, to inhibit stimulation of the pancreas and its secretion of enzymes.
- Parenteral nutrition is usually an important part of therapy; particularly in debilitate patients b/c of the extreme metabolic stress associated with acute pancreatitis.
- Patient who do not tolerate enteral feeding require parenteral nutrition.
-NG suction may be used to relieve N&V, abdominal distention and paralytic ileus.
- H2 (tagamet or Zantac) may be prescribed to decrease pancreatic activity by inhibiting secretion of hydrogen chloride.
-PPI may be used for patients who do not tolerate H2 antagonists.

9

What is a Cullen’s sign?

It is black-blue bruising around the umbilicus. This sign takes 24-48 hours to appear and predicts a severe attack of acute pancreatitis, with mortality rising from 8-10% to 40%. It may be accompanied by Grey-Turner's sign (bruising of the flank).

10

Why is resting the pancreas important?

The pancreas enzymes are digesting it, you must rest the pancreas to stop the production and enzymes to allow it to heal.

11

How does smoking adversely impact the pancreas?

Smoking stimulates the pancreas to release pancreatic enzymes. The risk for pancreatic cancer increases as the extent of cigarette smoking increases.

12

How does alcohol impact the pancreas?

-Instruct patient to eliminate alcohol and refer to AA. -Alcohol intake produces further damage to pancreas and precipitates attacks of acute pancreatitis.
-Long-term use of alcohol is commonly associated with acute episodes of pancreatitis, but the patient usually has had undiagnosed chronic pancreatitis before the 1st episode of acute pancreatitis occurs.
-Alcohol consumption in Western societies and malnutrition worldwide are the major causes of chronic pancreatitis.
-Excessive and prolonged consumption of alcohol accounts for 70-80% of all cases of chronic pancreatitis. -The incidence of pancreatitis is 50 X’s greater in people with alcoholism than those without.
-Long term alcohol use causes hypersecretion of protein in pancreatic secretion, resulting in protein plugs and calculi within the pancreatic ducts. Alcohol also has a direct toxic effect on the cells of the pancreas.

13

What is a whipple procedure?

it is the pancreaticoduodenectomy. The end result of resection of carcinoma of the head of the pancreas or ampulla of Vater. The common duct is sutured to the end of the jejunum, and the remaining portion of the pancreas and the end of the stomach are sutured to the side of the jejunum. (removal of the head of the pancreas, the entire duodenum, a portion of the jejunum, the distal third of the stomach, and the lower half of the CBD, with the reestablishment of continuity of the biliary, pancreatic, and GI tract systems)

14

What are complications of a whipple procedure?

- Hemorrhage,
- vascular collapse,
- hepatorenal failure

15

what are the Nursing interventions post op?

-nursing care is directed toward promoting comfort, preventing complications
- assisting the patient to return to and maintain as normal and comfortable a life as possible.
-Monitor IV and arterial line, patient will be on ventilator post op.
-Monitor and report changes in v/s, ABGs and pressures, pulse ox, lab values, and urine output.
-Assess for bleeding.
-Malabsorption and diabetes mellitus.
-Patient should have N/G tube and parenteral nutrition to allow the GI tract to rest while promoting adequate nutrition.
-Monitor glucose, b/c with removal of part of pancreas, diabetes will occur.

16

what is important teaching for patient with chronic pancreatitis?

it is important to instruct the patient and family about continuing need for pancreatic enzyme replacement, a low-fat diet, and vitamin supplements.

17

what are the medication used for chronic pancreatitis?

- Meds are: Pancrease and Pancrelipase
- Purpose of meds: to produce enzymes to aid in the digesting of food.
- Timing of administration of meds in relationship to meals: you must give before meals.
- How do you know if meds are effective? If steatorrhea( fat in the fecal matter) persists then they are not working.

18

what are S/S of DIABETES MELLITUS?

3P's
- Poluria (increased urination)
- Polydipsia (increased thirst) occurs as a result of the excess loss of fluid associated with osmotic diuresis.
- Polyphagia (increased appetite) resulting from the catabolic state induced by insulin deficiency and the breakdown of proteins and fats.

-Other symptoms include fatigue and weakness, sudden vision changes, tingling or numbness in hands or feet, dry skin, skin lesions or wounds that are slow healing, and recurrent infections. The onset of type 1 diabetes may also be associated with sudden wt loss or nausea, vomiting, or abdominal pains if DKA has developed.

19

How do stress, infection and steroid impact blood glucose?

Because illness, especially infections, cause increased blood glucose, the patient does not need to decrease the insulin dose to compensate for decreased food intake when ill and may even need to increase the insulin dose. In response to physical and emotional stressors, there is an increase in the level of ‘stress” hormones-glucagon, epinephrine, norepinephrine, cortisol, and growth hormone. These hormones promote glucose production by the liver and interfere with glucose utilization by muscle and fate tissue, counteracting the effect of insulin. If insulin levels are not increased during times of illness and infection, hyperglycemia may progress to DKA.

20

what are S/S of Hypoglycemia?

-In mild hypoglycemia, as the blood glucose level falls, the sympathetic nervous system is stimulated,
- a surge of epinephrine and norepinephrine. This causes symptoms such as:
-sweating
-tremor
-tachycardia
-palpitation
- nervousness
- hunger
- restlessness.
In moderate hypoglycemia, the fall in blood glucose level deprives the brain cell of needed fuel for functioning. Signs of impaired function of the CNS may include
-inability to concentrate,
-headache,
-lightheadedness,
-confusion,
-memory collapses,
-numbness of the lips and tongue,
-slurred speech,
-impaired coordination,
-emotional changes,
- irrational or combative behavior,
-double vision,
-drowsiness
- nightmares.
In severe hypoglycemia, CNS function is so impaired that the patient needs the assistance of another person for treatment of hypoglycemia.
- disoriented behavior
- seizures
- difficulty arousing from sleep
- loss of consciousness.

21

what are the two categories of Hypoglycemia?

adrenergic symptoms and central nervous system (CNS) symptoms

22

What causes hypoglycemia?

Hypoglycemia occurs when the blood glucose falls to less than 50-60 mg/dL. It can be caused by too much insulin or oral hypoglycemic agents, too little food, or excessive physical activity. Hypoglycemia may occur at any time of the day or night. It often occurs before meals, especially if meals are delayed or snacks are omitted. For example, midmorning hypoglycemia may occur when the morning regular insulin is peaking, whereas hypoglycemia that occurs late in the afternoon coincides with the peak of the morning NPH or Lente insulin. Middle of the night hypoglycemia may occur because of peaking evening or predinner NPH or Lente insulin, especially in patient who have not eaten a bedtime snack

23

How does exercise impact blood glucose?

exercise is extremely important in DM management b/c of its effects on lowering blood glucose and reducing cardiovascular risk factors. Exercise lowers blood glucose by increasing the uptake of glucose by body muscles and improving insulin utilization. It also improves circulation and muscle tone. Resistance (strength) training, such as wt lifting, can increase lean muscle mass, thereby increasing the resting metabolic rate. These effects are useful in diabetes in relation to losing wt, easing stress, and maintaining a feeling a well being. Exercise alters blood lipid concentration, increasing levels of high-density lipoproteins and decreasing total cholesterol and triglyceride levels.

24

what are GENERAL PRECAUTIONS FOR EXERCISE IN PEOPLE WITH DIABETES?

-Use proper footwear and, if appropriate, other protective equipment.
-Avoid exercise in extreme heat or cold.
-Inspect feet daily after exercise.
-Avoid exercise during period of poor metabolic control.

25

What are teaching to prevent and treat diabetes?

immediate treatment must be given when hypoglycemia occurs. The usual recommendation is for 15 g of a fast acting concentrated source of carbohydrate such as the following given orally:
Three or four commercially prepare glucose tablets
4-6 oz of fruit juice or regular soda
6-10 hard candies
2-3 tsp of sugar or honey
It is not necessary to add sugar to juice, even if it is labeled as unsweetened juice: The fruit sugar in juice contains enough carbohydrate to raise the blood glucose. The blood glucose level should be retested in 15 min and retreated if

26

How does glucagon impact blood glucose?

Glucagon is a hormone produced by the alpha cells of the pancreas that stimulates the liver to release glucose.

27

How do you administer glucagon?

In emergency situations, for adult patients who are unconscious and cannot swallow, an injection of glucagon 1 mg can be administered either SQ or IM

28

What are nursing interventions for client safety when administer glucagon?

After injection of glucagon, the patient may take as long as 20 minutes to regain consciousness. A concentrated source of carbohydrate followed by a snack should be given to the patient on awakening to prevent recurrence of hypoglycemia (because the duration of the action of 1 mg of glucagon is brief 8-10 minutes and its action lasts 12-27 minutes) and to replenish liver stores of glucose. Some patient experience nausea after the administration of glucagon. If this occurs, the patient should be turned to the side to prevent aspiration in case the patient vomits.