Nursing Care Plan for acute pancreatitis PDF
Pancreatitis is an inflammatory condition affecting the pancreas. The pancreas is an organ that is tucked behind the stomach. It releases enzymes that aid in digestion and regulates the body’s glucose levels through the function of the hormone insulin. Pancreatitis is usually acute, but it can also develop into a chronic disease. Treatment options will vary depending on the severity and type of pancreatitis. Show
Types of PancreatitisPancreatitis is generally divided into two stages: Acute and Chronic. However, there is another type called necrotizing pancreatitis, but this condition usually manifests as a result of acute pancreatitis.
There are three classifications of acute pancreatitis:
2. Interstitial edematous pancreatitis. This type can be classified as AP and is characterized by pancreatic enlargement or localized swelling resulting from inflammatory edema. This usually resolves during the first week of disease onset.
3. Chronic pancreatitis (CP). This type usually persists for more extended periods and then reappears. It is defined by persistent inflammation that does not subside or improve, resulting in irreversible damage (e.g., scar tissue formation, fibrosis, and calcification). If the pancreatic cells are damaged, the insulin-producing cells (Beta cells) are also harmed, resulting in diabetes in the worst-case scenario. Numerous physiological factors can contribute to this, but alcoholism is the most prevalent. It works by altering the composition of pancreatic proteins produced, leading to the development of protein plugs. Signs and Symptoms of PancreatitisThe following are symptoms of acute pancreatitis:
Patients with CP may also experience abdominal pain, vomiting, and nausea. The following signs and symptoms may also be present:
Causes of PancreatitisAlcohol and gallstones are the two most common causes of pancreatitis. About two-thirds of those who suffer from this illness are in this cohort.
Risk Factors to Pancreatitis
Complications of Pancreatitis
Diagnosis of PancreatitisThe handling physician may order multiple diagnostic tests to ascertain and corroborate the presence of pancreatitis. Primary tests include:
Both of which are elevated in patients suffering from this condition. On the other hand, the physician may order more baseline investigations; these include:
Acute pancreatitis can be diagnosed by its presentation; thus, radiologic examinations are beneficial for visualizing the pancreas’ anatomic features. Moreover, it confirms and detects inflammatory processes and obtains information about the biliary and pancreatic ducts. Traditional modalities include visualization of the abdomen.
Some additional tests include:
Treatment of Pancreatitis
While AP is usually self-limiting, changing the patient’s dietary intake can help alleviate its signs and symptoms. The following are alternative treatments and home remedies to manage AP:
Prevention of PancreatitisPancreatitis may or may not be preventable, depending on the underlying cause. However, there are a few things to minimize the risk of acquiring or developing pancreatitis:
Nursing Diagnosis for PancreatitisNursing Care Plan for Pancreatitis 1Imbalanced Nutrition: Less Than the Body Requirements Nursing Diagnosis: Imbalanced Nutrition: Less Than the Body Requirements related to poor oral intake, secondary to pancreatitis, as evidenced by stable weight loss, lack of interest in food, impaired muscle tone, inadequate food consumption, intolerance to food, and reported changes in taste sensations. Desired Outcomes:
Nursing Care Plan for Pancreatitis 2Nausea Nursing Diagnosis: Nausea related to blockage of pancreatic ducts, secondary to pancreatitis, as evidenced by gagging sensation, vomiting, abdominal pain, bad or sour taste on the mouth, and increased swallowing Desired Outcomes:
Nursing Care Plan for Pancreatitis 3Hyperthermia secondary to infective process of pancreatitis as evidenced by temperature of 38.5 degrees Celsius, rapid breathing, profuse sweating, and chills Desired Outcome: Within 4 hours of nursing interventions, the patient will have a stabilized temperature within the normal range. Pancreatitis Nursing InterventionsRationalesAssess the patient’s vital signs at least every 4 hours.To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment, particularly the antibiotics and fever-reducing drugs (e.g. Tylenol) administered.Remove excessive clothing, blankets and linens. Adjust the room temperature.To regulate the temperature of the environment and make it more comfortable for the patient.Administer the prescribed antibiotic and anti-pyretic medications.Use the antibiotic to treat bacterial infection (pancreatitis), which is the underlying cause of the patient’s hyperthermia. Use the fever-reducing medication to stimulate the hypothalamus and normalize the body temperature.Offer a tepid sponge bath.To facilitate the body in cooling down and to provide comfort.Elevate the head of the bed.Head elevation helps improve the expansion of the lungs, enabling the patient to breathe more effectively. Nursing Care Plan for Pancreatitis 4Nursing Diagnosis: Acute Pain related to obstruction of pancreatic ducts secondary to acute pancreatitis as evidenced by pain score of 10 out of 10, verbalization of sharp abdominal pain, guarding sign on the abdomen, and restlessness Desired Outcome: The patient will demonstrate relief of pain as evidenced by a pain score of 0 out of 10, stable vital signs, and absence of restlessness. Pancreatitis Nursing InterventionsRationaleAdminister prescribed pain medications.To alleviate the symptoms of acute abdominal pain. Pain on the right upper quadrant of the abdomen suggests the involvement of the head of the pancreas, while left upper quadrant pain refers to the tail of the pancreas. Narcotic analgesics such as meperidine should be preferred over morphine, as the latter has a side effect of biliary pancreatic spasms. Antacids may be used in combination with analgesics in order to neutralize gastric acidity and reducing the production of pancreatic enzymes.Assess the patient’s vital signs and characteristics of pain at least 30 minutes after administration of medication. To monitor effectiveness of medical treatment for the relief of abdominal pain. The time of monitoring of vital signs may depend on the peak time of the drug administered. Elevate the head of the bed if the patient is short of breath.To increase the oxygen level by allowing optimal lung expansion.Place the patient in complete bed rest during severe episodes of pain. Perform relaxation techniques such as deep breathing exercises, guided imagery, and provision of distractions such as TV or radio.To reduce gastrointestinal stimulations thereby decreasing pancreatic activity.Nursing Care Plan for Pancreatitis 5Nursing Diagnosis: Deficient Knowledge related to new diagnosis of chronic pancreatitis as evidenced by patient’s verbalization of “I want to know more about my new diagnosis and care” Desired Outcome: At the end of the health teaching session, the patient will be able to demonstrate sufficient knowledge of chronic pancreatitis and its management. Pancreatitis Nursing InterventionsRationalesAssess the patient’s readiness to learn, misconceptions, and blocks to learning (e.g. denial of diagnosis or poor lifestyle habits)To address the patient’s cognition and mental status towards the new diagnosis of chronic pancreatitis and to help the patient overcome blocks to learning.Explain what pancreatitis is, its types (specifically chronic pancreatitis). Avoid using medical jargons and explain in layman’s terms.To provide information on pancreatitis and its pathophysiology in the simplest way possible.Educate the patient about lifestyle changes that can help manage chronic pancreatitis. Create a plan for Activities of Daily Living (ADLs) with the patient that involve alcohol avoidance, smoking cessation, dietary changes, and physical activity.To help the patient avoid alcohol intake that may lead to preventing further damage to the pancreas. To encourage the patient to stop smoking, as nicotine is a stimulant for unnecessary gastric secretions and pancreatic activity.Inform the patient the details about the prescribed medications (e.g. drug class, use, benefits, side effects, and risks) to manage chronic pancreatitis. Ask the patient to repeat or demonstrate the self-administration details to you.To inform the patient of each prescribed drug and to ensure that the patient fully understands the purpose, possible side effects, adverse events, and self-administration details.Encourage the patient to continue following a low fat, bland diet with caffeine restrictions. Refer the patient to a dietitian as required.To avoid overstimulation of the pancreas. To enable to patient to receive more information in managing diet through a dietitian.Nursing Care Plan for Pancreatitis 6Nursing Diagnosis: Risk for Fluid Volume Deficit Desired Outcome: The patient will demonstrate adequate hydration and balanced fluid volume Nursing Stat Facts Please enable JavaScript Nursing Stat FactsPancreatitis Nursing InterventionsRationalesAssess vital signs, particularly blood pressure level.Pancreatic ischemia may lead to third space fluid shifting, which may lower blood pressure levels and put the patient at risk for hypotensive episodes.Commence a fluid balance chart, monitoring the input and output of the patient. Include episodes of vomiting, gastric suctioning, and other gastric losses in the I/O charting.To monitor patient’s fluid volume accurately.Start intravenous therapy as prescribed. Electrolytes may need to be replaced intravenously. Encourage oral fluid intake of at least 2000 mL per day if not contraindicated.To replenish the fluids and electrolytes lost from vomiting or other gastric losses, and to promote better blood circulation around the body.Educate the patient (or guardian) on how to fill out a fluid balance chart at bedside.To help the patient or the guardian take ownership of the patient’s care, encouraging them to drink more fluids as needed, or report any changes to the nursing team. Prepare the patient to undergo peritoneal lavage, if indicated.To provide a rapid treatment of metabolic abnormalities by removing pancreatic enzymes and toxic chemicals in acute pancreatitis.Nursing Care Plan for Pancreatitis 7Nursing Diagnosis: Risk for Infection Desired Outcome: The patient will be able to avoid the development of an infection. Pancreatitis Nursing InterventionsRationalesAssess vital signs and observe for any signs of infection as well as for any signs of respiratory distress and cholestatic jaundice.Sepsis or infection of the blood may be evidenced by fever accompanied by cholestatic jaundice and respiratory distress.Perform a focused assessment on the abdominal region, particularly checking for abdominal pain, abdominal rigidity, diminishes or absent bowel sounds, and rebound tenderness.Peritonitis is a serious complication of pancreatitis. It is evidenced by abdominal pain, abdominal rigidity, diminishes or absent bowel sounds, and rebound tenderness.Obtain a sample for culture, such as pancreatic enzyme, blood, urine, or sputum.To identify the presence of an infection and its causative agent.Teach the patient how to perform proper hand hygiene.To maintain patient safety and reduce the risk for cross contamination.Nursing ReferencesAckley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon Disclaimer:Please follow your facilities guidelines, policies, and procedures. The medical information on this site is provided as an information resource only and is not to be used or relied on for any diagnostic or treatment purposes. This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment. What is the nursing diagnosis for pancreatitis?Based on the assessment data, the nursing diagnoses for a patient with pancreatitis include: Acute pain related to edema, distention of the pancreas, and peritoneal irritation.
What is the most important nursing intervention for acute pancreatitis?Acute Pain Interventions
Administering pain medications frequently, as ordered, is important in managing pain. Smaller, more frequent doses of pain medications are preferred over larger doses. Larger doses of pain medications can cause complications for a patient with pancreatitis, including respiratory depression.
What are the priority goals of care for a patient with acute pancreatitis?Maintain bedrest during acute attack. Provide quiet, restful environment. Decreases metabolic rate and GI stimulation and secretions, thereby reducing pancreatic activity. Promote position of comfort on one side with knees flexed, sitting up and leaning forward.
What are five nursing care plans?There are five main components to a nursing care plan including; assessment, diagnosis, expected outcomes, interventions, and rationale/evaluation.
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