Pancreatitis

Definition and Etiology

An acute inflammation process of the pancreas
with associated escape of the pancreatic
enzyme into surrounding tissue.
The primary etiologic factors are alcoholism &
biliary tract disease.
May be a complication of viral or bacterial
disease, peptic ulcer, trauma.
 Pancreatitis
Incidence & Risk Factors
Major- Biliary stones, Alcohol use/abuse
Minor- Age: 55 to 65 yrs. for biliary pancreatitis
45- 55 yrs. For alcohol-related
Female for biliary tract pancreatitis; Male-for
alcohol-related pancreatitis.
Trauma, Infectious disease, drug toxicities,
chronic diseases( inflammatory diseases).
 Pancreatitis
Assessment
Pain: Steady & severe in nature; located in
the epigastric or umbilical region; may radiate
to the back. Worsened by lying supine; may be
lessened by flexed knee, curved-back position.
Vomiting Varies in severity, but is usually
protracted, worsened by ingestion of food or
fluid. Does not relieve the pain. Usually
accompanied by nausea.
 Pancreatitis
Assessment cont
Fever: Rarely exceeds 39 C.
Abdominal Finding: Rigidity, tenderness, guarding,
distended, decreased or absent peristalsis and paralytic
ileus.Fatty stools-(steatorrhea)
Laboratory Finding: Elevation of white count- 20,000-
50,000. Elevated serum lipase and amylase(5 to 40 times);
glucose, bilirubin, alkaline phosphatase. Urine amylase
elevated.Abnormal low serum CA, Na & Mg.-due to
dehydration. Binding of Ca in areas of fat necrosis.
 Pancreatitis
Ransons criteria
Admission criteria Criteria during initial 48
hours
Age: 55 yrs. Or older Hct: decrease or more than
10%
WBC: 16,000/mm3 or BUN:increase greater than 5
higher mg/dl.
LDH: 350 IU/L or higher CA: falls to less than 8
Glucose > 200 mg/dl. mg/dl.
PaO2 < 60 mm Hg
AST: 250 U/L or higher Fluid sequestration; greater
than 6 liter.
 Pancreatitis
Nursing Interventions
Alleviate pain & anxiety. Anxiety increases pancreatic
secretions. Demerol-then morphine.
Reduce pancreatic stimulus- NPO, NGT to remove gastric
secretions. Drugs to reduce pancreatic secretions-
anticholinergics-suppress vagal stimulation, NaHco-reverse
metabolic acidosis.Regular insulin to treat hyperglycemia.
Prevent or treat infection-with abx.
Aggressive respiratory care- monitor ABG.
Reduce body metabolism- bedrest, cool quiet environment.
Provide client and family instruction-avoid alcohol,
coffee,heavy meals and spicy food.
 Pancreatitis
Major complications
Cardiovascular- hypotension/shock from hypovolemia.
Hematologic-Anemia from blood loss, DIC,
leukocytosis from gen.inflammation or secondary
infections.
Respiratory-atelectasis, pneumonia, pleural effusion,
ARDS
GI- bleeding
Renal- oliguria, acute tubular necrosis
Metabolic-hyperglycemia, hypocalcemia.
 CA of the Pancreas
Etiology
Etiology-unknown. Malignant disease of the
exocrine pancreas & more than 85% of the cases
are ductal adenocarcinomas. 2/3 develop in the
head; remainder occur in the body or tail of the
gland. It occurs more commonly in male.
The tumor is usually deeply encased in normal
tissue & poorly demarcated. The common duct is
often obstructed and distended by the presence of
the tumor. Metastasis has almost always occurred
before the tumor produces the first symptoms.
 CA of the Pancreas
Signs and Symptoms
Jaundice (lesions of pancreatic head only)
Clay-colored stool
Dark urine
Abdominal pain: usually vague, dull, non-specific
Weight loss
Anorexia
Nausea and vomiting
Glucose intolerance
GI bleeding
Spleenomegaly
ascites
 CA of the Pancreas
Interventions
Non-surgical- High doses of opioid analgesics.
Chemotherapy, radiation therapy-intensive external
beam radiation therapy by shrinking the tumor
cells.
Surgical management: Whipple procedures: the
procedure entails the removal of the head of the
pancreas, duodenum, a portion of the jejunum, the
stomach and the gallbladder, with the anastomosis of
the pancreatic duct, the common bile duct, and the
stomach to the jejunum.
 CA of the Pancreas
Postoperative Care
Monitor vital parameters. Check vital signs, ABG, intake
and output. Be alert to signs of bleeding or shock. Maintain
urine output at 30 to 50 ml/hr.
Initiate pulmonary hygiene.
Establish effective pain management.
Monitor dressing and drainage tubes.
Maintain nutritional support with enteral and parenteral
support. Monitor BS and insulin. Administer pancreatic
enzyme replacement. Assess for signs of dumping
syndrome ( rapid shift of fluid from vascular into the
intestinal lumen with a resultant decrease in blood
volume).
 Cholelithiasis
Definition, Incidence, Predisposing Factors

Also known as stones in the gallbladder

It is the most common disorder of the biliary
system and it has been estimated that 8-10% of
all adults in the U.S. have this condition.
Predisposing factors includes: gender, age,
estrogen RX or BCPs, sedentary lifestyle, family
history and obesity.
Cholecystitis- inflammation of the gallbladder.
 Cholelithiasis
Clinical Manifestations
Sudden-onset pain in the right upper quadrant (RUQ) of
the abdomen. Severe and steady in quality. Frequently
radiates to the right scapula or shoulder. Persists for abt.
1 to 3 hours. May awaken the patient at night. May be
associated with consumption of a large fatty meals.
Anorexia, nausea and vomiting.
Mild to moderate fever
Decreased or absent bowel sounds
Acute abdominal tenderness
Elevated WBC, slightly elevated bilirubin, and alkaline
phosphatase.
 Cholelithiasis
Diagnostic Test
Ultrasound-best way to dx; 90-95% effective.
Serum studies- liver function test and serum
amylase
Cholangiogram
Gallbladder x-ray test.
 Cholelithiasis
Interventions
Provide relief from vomiting. NGT-reduces distention
& eliminates gastric juices that stimulate
cholecystokinin.
Maintain fluid and electrolyte balance.
Monitor drug therapy. Administer broad spectrum
Abx. Chenodeoxycholic acid- bile acid dissolves
cholesterol calculi (60% of the stone).
NTG & papaverine to reduce spasms of duct.
Synthetic narcotics (Demerol, methadone) MSO4 may
cause spasms of Oddi and increase spasms.
 Cholelithiasis
Interventions cont..
Provide low-fat diet to decrease gallbladder
stimulation; avoid alcohol and gas forming foods.
Maintain bedrest
Extracorporeal shock wave lithotripsy- shock wave
that disintegrates stones in the biliary system.
Ultrasound is used for stone localization before the
lithotriptor send waves through a water bag upon
which the patient is lying. Analgesics and sedatives to
reduce pain during procedures.
 Cholecystitis
Assessment
Epigastric pain- after eating
Pain- localized in RUQ because of somatic sensory
nerves. Murphys sign- cant take a deep inspiration
when assessors fingers are pressed below hepatic
margin. Pain begins 2 to 4 hours after eating fried or
fatty foods and persist more than 4 to 6 hours.
Nausea, vomiting, anorexia
Low-grade fever
Jaundice
Weight loss
 Cholecystitis
Surgical Management
Cholecystectomy- removal of gallbladder after
ligation of the cystic duct and vessels.
Choledochostomy-opening into the common bile
duct for removal of stones. T-tube inserted into
duct and connected to drainage bottle. Purpose-
to decompress biliary tree and allow for
postoperative cholangiogram.
Endoscopic cholecystectomy-removal of
gallbladder through small puncture hole in the
abdomen. Laser dissects gallbladder.
 Cholecystitis
Implementation
Position in low-to semi fowlers position to facilitate
bile drainage.
Maintain skin integrity.
Prevent respiratory complications: TCDB, use of IS.
IF NGT is inserted-to relieve distention and increase
peristalsis.
If t-tube inserted-measure amt. & color. Clamp tube
before eating. As t-tube clamp-observe for abdominal
discomfort and distention. Unclamp if any N/V.
Provide low-fat high carb. and high protein. Maintain
for at least 2 to 3 months postoperatively.
 Diabetes Mellitus
Definition and Classification
Is a chronic disorder of altered CHO, fat &
Protein metabolism caused either by:
A relative lack of insulin (type 1).
Or the inability to respond to insulin (type
11).
Is characterized by persistent hyperglycemia,
impaired leukocyte activity & long-term
vascular & neurological degeneration
 Diabetes Mellitus
Risk Factors
Familial hx of DM
African-American, Hispanic, or Native
American descent.
Obesity
Morbid OB hx. Or hx of delivering infants
weighing > 9 lbs.
 Diabetes Mellitus
Significance
Roughly 7 million people have been dx with DM.
7th leading underlying cause of death in the U.S.
Leading cause of blindness in adults 20-70 yo.
It accounts for:
30% of new cases of ESRD 50-
60% of adult deaths from CAD
40-50% of non traumatic amputations for
foot/ankle ulcers.