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Pancreas

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olanjones's version from 2017-04-20 16:38

Acute Pancreatitis

Question Answer
Most common inMiddle-aged men & women; in African Americans 3x ↑ than in white persons
Inflammatory processcan vary from mild edema to severe hemorrhagic necrosis
Common causesGallstones (↑common in women), Chronic ETOH (↑common in men), Smoking, Hypertriglyceridemia > 1000mg/dL (Biliary sludge, a mixture of cholesterol crystals & calcium salts, is found in 20-40% of pts w/ acute pancreatitis
Other causesDrug induced (corticosteroids, NSAIDs, thiazides, sulfa, BCP), Metabolic disorders, Vascular disease, Surgical/endo procedures, Trauma, Viral infection, Ulcers, Cystic fibrosis, Kaposi sarcoma, Idiopathic
PathoAutodigestion of pancreas; injury to pancreatic cells activate enzymes (trypsinogen→trypsin) in pancreas instead of intestine →digestion & bleeding; May be d/t reflux of bile acids into pancreas through sphincter of Oddi
Effects of pancreatic enzymes-Trypsin: edema, necrosis, hemorrhage
-Elastase: hemorrhage
-Phospholipase A & lipase: fat necrosis
-Kallikrein: edema, vascular permeability, smooth muscle contraction, shock
Mild pancreatitisedematous or interstitial pancreatitis
Severe pancreatitisnecrotizing pancreatitis; permanent ↓in endocrine & exocrine function; Pts w/ severe pancreatitis also have ↑risk for developing pancreatic necrosis, organ failure, &septic complications, (25% mortality rate)
Manis- painSudden onset (often when recumbent) of severe, deep, piercing, continuous/steady LUQ or midepigastric pain that commonly radiates to the back, aggravated by eating, not relieved by vomiting
Other S/SFlushing, cyanosis, dyspnea, N&V, low-grade fever, leukocytosis, hypotension, tachycardia, jaundice
On exam may findAbd tenderness w/ guarding; ↓or absent bowel sounds; abd distention (d/t paralytic ileus); Crackles in lungs, Abdominal skin discoloration (Grey Turner’s spots, Cullen’s sign)
Causes of shock in these ptsHemorrhage into pancreas, toxemia from activated pancreatic enzymes, or hypovolemia as a result of fluid shift into retroperitoneal space (massive fluid shifts)
*Chronic pancreatitisIn the United States, chronic pancreatitis is found almost exclusively in individuals who abuse alcohol; serum amylase & lipase may be slightly↑ or not at all; Serum bilirubin & alkaline phosphatase may be ↑. There is usually mild leukocytosis & ↑sed rate
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Complications

Question Answer
PseudocystAccumulation of fluid, pancreatic enzymes, tissue debris, & inflammatory exudates surrounded by a wall
S/S: abdominal pain, palpable epigastric mass, nausea, vomiting, anorexia
Dx pseudocyst*endoscopic u/s*, ↑serum amylase, CT, MRI
Tx pseudocystUsu resolve spontaneously w/in a few weeks but may perforate, causing peritonitis, or rupture into the stomach/duodenum; May use surgical drainage; percutaneous catheter placement & drainage; endoscopic drainage
AbscessCollection of pus from extensive necrosis, may become infected or perforate into adjacent organs
S/S: upper abdominal pain, abdominal mass, high fever, leukocytosis
Tx abscessPrompt surgical drainage to prevent sepsis
Systemic complications-Pleural effusion, atelectasis, pneumonia, ARDS (prob from exudate through transdiaphragmatic lymph channels)
-Hypotension from calcium & fatty acids during fat necrosis; -Tetany (d/t hypocalcemia)
-Trypsin can activate prothrombin & plasminogen which ↑pt's risk of intravascular thrombi, PE, & DIC
Dx LabsSerum amylase (↑ early for 24-72 hrs) & ↑lipase (helps to confirm since other disorders may ↑amylase); ↑liver enzymes, triglycerides, glucose, bilirubin; ↓calcium
Dx ImagingAbd u/s, x-ray, CT w/ contrast (best option), MRI, Angiography; Endoscopic retrograde cholangiopancreatography (is used but can cause acute pancreatitis)
Goals of CCRelief of pain; Prevention/alleviation of shock; Reduction of pancreatic secretions; Correction of F&E imbalances; Prevention/treatment of infections; Removal of the precipitating cause, if possible
CC surgeryMay be indicated when dx is uncertain or in pts who do not respond to conservative therapy; if r/t gallstone may have ERCP +endoscopic sphincterotomy (sever muscle layers of sphincter of Oddi) & lap cholecystectomy
Tx painVery important! IV morphine, Pain meds combined w/ antispasmodics (dicyclomine); Avoid anticholinergic drugs when paralytic ileus is present
Tx generalMostly supportive care: aggressive hydration, pain management, management of metabolic complications (O2, glucose), minimize pancreatic stimulation (NPO; suctioning; ↓acid secretion using PPIs, antacids, carbonic anhydrase inhibitors; enteral nutrition if needed)
Tx shockBlood volume replacements (dextran, albumin), F&E imbalance correction (LRs); may need CVP monitoring; Vasoactive drugs (dopamine) to ↑SVR
Tx infection controlMany organisms come from the intestine, enteral feeding reduces the risk of necrotizing pancreatitis; Monitor pt closely so abx tx can be instituted early if necrosis/infection occur; Endoscopically or CT-guided percutaneous aspiration w/ Gram stain & culture may be done
Tx nutritionBecause of infection risk, parenteral nutrition is reserved for pts who cannot tolerate enteral nutrition
-If on IV lipids, monitor blood triglyceride levels
-If enteral, small frequent feeding (↑carbs b/c they are ↓stimulating)
-Must abstain ETOH; fat-soluable vit may be given
Signs of food intoleranceReports pain, ↑abd girth, or ↑serum amylase & lipase levels
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Pancreatitis Nursing

Question Answer
Subjective- Past HHbiliary tract disease, alcohol use, abdominal trauma, duodenal ulcers, infection, metabolic disorders; surgical procedures on the pancreas, stomach, duodenum, or biliary tract; endoscopic retrograde cholangiopancreatography
Subjective- Medsuse of thiazides, NSAIDs
Subjective- Health patternsETOH abuse; fatigue; N&V, anorexia; dyspnea, pain aggravated by food & unrelieved by vomiting
Objective-Restlessness, anxiety, low-grade fever; cyanosis, jaundice; decreased skin turgor, dry mucous membranes; adb distention, tenderness, guarding, ↓bowel sounds
-S/S that separate these pt's from those w/ liver failure: *flushing, diaphoresis, discoloration of abdomen and flanks; tachypnea, basilar crackles; tachycardia, hypotension*
Diagnostic findings↑ Serum amylase & lipase levels, leukocytosis, hyperglycemia, hypocalcemia, abnormal findings on u/s & CT scans of pancreas, abnormal findings on ERCP
NI health promoAssessment for predisposing & etiologic factors; Encouragement of early treatment of these factors to prevent occurrence of acute pancreatitis; Early tx of biliary tract disease; Eliminate ETOH (esp if previous attacks)
Acute NIMonitor: VS, Respiratory function (lung sounds, SpO2) – if ARDS develops may need intubation/mechanical ventilation
Frequent oral/nasal care (if on anticholinergics mouth may be dry)
If on antacids, should be sipped slowly or inserted in NG tube
NI F&E balance-Frequent vomiting & gastric suction, may ↓chloride, sodium, & potassium levels
-Hypocalcemia (observe for tetany, tingling, Chvostek’s, Trousseau’s); tx w/ calcium gluconate as ordered
-Hypomagnesemia- monitor serum levels
NI painPain & restlessness ↑ metabolic rate & subsequent stimulation of pancreatic enzymes, can contribute to hemodynamic instability
*Meds, Positioning: flex trunk draw knees up, side-lying w/ head ↑45 degrees (anything that ↓tension on abd)
NI infectionObserve for fever, signs of paralytic ileus, renal failure, mental changes; Monitor glucose
Use TCDB to prevent respiratory infection
Use skin barriers, pouching, drains to protect skin (consult w/ specialist or enterostomal nurse if available)
NI ambulatory & home carePT for loss of strength; Assess for narcotic addiction d/t frequent opioid use during acute stage; Counseling for ETOH, smoking abstinence; Dietary teaching, S/S of infection, DM, steatorrhea, Medications
NI expected outcomesPt will: Have adequate pain control; Maintain adequate fluid balance; Be knowledgeable about tx regimen; Get help for ETOH dependence (if appropriate)
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