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Acute pancreatitis.

Causes of acute pancreatitis include cholelithiasis with bile duct obstruction, alcohol abuse, abdominal trauma, viral infections, and certain medications (Holcomb, 2007). With damage of pancreatic cells or blockage of pancreatic enzyme secretion (amylase and lipase) by stones, the organ's digestive enzymes are activated within its own tissues rather than in the duodenum. The digestive enzymes elicit autodigestion of pancreatic tissue and a massive inflammatory response (Despins, Kivlahan, & Cox, 2005).

Serum amylase and lipase levels are increased markedly with acute pancreatitis. Amylase elevates almost immediately but is not specific to pancreatic disorders. Lipase elevation is diagnostic for pancreatitis; lipase peaks within 24 hours of symptom onset and remains elevated for about 2 weeks. An abdominal ultrasound or CT scan will verify the diagnosis and rule out other abdominal etiologies (Despins et al., 2005).

Case Scenario

David Gonzalez, age 57, is admitted to a medical-surgical unit with severe right upper quadrant abdominal and back pain. His abdomen is distended with diminished bowel sounds, heart rate is 90 beats per minute, respiratory rate 24 breaths per minute, oxygen saturation 95%, and blood pressure 125/64 mmHg. He complains of nausea without vomiting. The patient is ordered to receive nothing by mouth (NPO); a nasogastric tube is inserted and placed on intermittent suction. Morphine sulfate 2-4 mg is ordered IV every 2 hours as needed for pain. An IV catheter is maintained with 0.9% normal saline at 125 ml/hr and an antiemetic is administered as needed. In addition, strict intake and output, daily weights, and postural blood pressure assessments are ordered.

1. The primary rationale for maintaining NPO status and nasogastric suction for the patient with acute pancreatitis is to

a. prevent abdominal distention.

b. rest the pancreas.

c. control nausea and vomiting.

d. decrease risk for fluid overload.

2. Mr. Gonzales rates his pain as 9 on a 0-10 pain intensity scale. His serum lipase level is three times the reference range. It is most important for the nurse to assess the patient's

a. oxygen saturation.

b. capillary refill.

c. hematocrit and hemoglobin.

d. serum amylase.

3. The medical-surgical nurse is aware IV fluids are prescribed for a patient with severe pancreatitis for

a. prevention of dehydration associated with nausea.

b. prevention of hypovolemia associated with GI bleeding.

c. treatment of fluid loss from nasogastric suction.

d. replacement of vascular fluid shifted into the peritoneum.

4. The nurse will anticipate giving this patient which of the following?

a. Glucagon

b. Insulin

c. Meperidine (Demerol[R])

d. Furosemide CLasix[R])

5. Once oral intake is permitted, the person with pancreatitis would require a diet higher in

a. lipids.

b. fiber.

c. protein.

d. carbohydrate.

Answers

1. B--Eating stimulates gastrointestinal motility and digestive enzyme secretion from the pancreas which increases inflammation and pain. The pancreas requires rest in order to heal (Collins, 2009; Despins et al., 2005).

2. A--Acute, severe abdominal pain results in shallow breathing, atelectasis, and possible pneumonia, which will be reflected in a decreasing oxygen saturation and increased respiratory rate (Collins, 2009).

3. D--The inflammatory process within the pancreas results in increased capillary permeability with shift of fluid from the vascular space into peritoneal tissues, resulting in hypovolemia (Amerine, 2007; Despins et al., 2005).

4. B--Inflammation of the pancreas impairs function of its endocrine cells with a corresponding decrease in insulin production and resulting hyperglycemia (Sinni-McKeehen & Hazzard, 2007). Furosemide is not administered because most patients with pancreatitis are hypovolemic. Meperidine is less frequently utilized due to production of a metabolite that can cause CNS disorders, while glucagon administration would increase the already elevated blood glucose.

5. D--Carbohydrates are least stimulating to the pancreas and lipids are most stimulating (lipase and amylase produced by the pancreas digest fats and proteins). Fiber increases peristalsis, which stimulates pancreatic function.

Are You Certified?

Certification shows you have taken that extra step to validate your knowledge and skills. The Academy of Medical-Surgical Nurses (AMSN) and the Medical-Surgical Nursing Certification Board (MSNCB) encourage you to show your colleagues and patients your commitment to excellence in medical-surgical nursing practice. For more information, visit www.medsurgnurse.org

References

Amerine, E. (2007). Get optimum outcomes for acute pancreatitis patients. Nursing, 2(2), 54-61.

Collins, P. (2009). The gastrointestinal system. In H. Craven (Ed.), Core curriculum for medical-surgical nursing (pp. 211-212). Pitman, N J: Academy of Medical-Surgical Nurses.

Despins, L. Kivlahan, C, & Cox, K. (2005). Acute pancreatitis: Diagnosis and treatment of a potentially fatal condition. The American Journal of Nursing, 105(11), 54-57.

Holcomb, S. (2007). Stopping the destruction of acute pancreatitis. Nursing, 37(6), 42-47.

Sinni-McKeehen, B., & Hazzard, E.F. (2007). Nursing management: Integumentary problems. In S.L. Lewis, M.M., Heitkempter, S.R. Dirksen, P.G. O'Brien, & L. Bucher. (Eds.). (2007). Medical-surgical nursing: Assessment and management of clinical problems. (pp. 464-469). St. Louis: Mosby Elsevier.

Kathleen Marchiondo, MSN, RN, CMSRN, CNE, is Director, Medical-Surgical Nursing Certification Board, Pitman, NJ.
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Title Annotation:Prefaring for Certification
Author:Marchiondo, Kathleen
Publication:MedSurg Nursing
Article Type:Case study
Geographic Code:1USA
Date:Jan 1, 2010
Words:811
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