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Care of Patient with Pancreatic Problems:

Terms in this set (30)

Incidences:
- Death occurs in a small percentage of patients with acute pancreatitis, but with early diagnosis and treatment, mortality can be reduced.

- It occurs at a higher rate in older adults and in patients with postoperative pancreatitis. The prognosis for recovery is usually good for pancreatitis associated with biliary tract disease and poor if pancreatitis accompanies alcoholism.

Assess:
- Severe abdominal pain, mid-epigastric area or left upper quadrant.

- Assess intensity and quality of pain. Usually sudden onset and radiates to back, left flank, or left shoulder.

- The pain is described as intense, boring (feeling that it is going through the body), continuous/worsened by lying in the supine position, often finds relief by assuming the fetal position (with the knees drawn up to the chest and the spine flexed) or by sitting upright and bending forward.

- Assess weight loss resulting from nausea and vomiting and weight.

- Gray-blue discoloration of the abdomen and periumbilical area; gray-blue discoloration of the flanks, caused by pancreatic enzyme leakage to cutaneous tissue from the peritoneal cavity;
absent or decreased bowel sounds usually indicate paralytic (adynamic) ileus.

- On light palpation, note abdominal tenderness, rigidity, and guarding as a result of peritonitis.

- A palpable mass may be found if a pancreatic pseudocyst is present. Pancreatic ascites creates a dull sound on percussion.

Vital signs: elevated temperature, tachycardia, and decreased blood pressure

Auscultate the lung fields for adventitious sounds or diminished breath sounds, and observe for dyspnea or orthopnea.
- Pancreatic infection> septic shock

- Hemorrhage>NHP

- Acute kidney failure

- Paralytic ileus

- Hypovolemic shock

- Pleural effusion, acute respiratory distress syndrome, pneumonia, atelectasis

- Multi-organ system failure

- Disseminated intravascular coagulation (DIC)

- Type 2 Diabetes mellitus

- Parotitis (inflammation of salivary galnd)

Critical Rescue:
- A patient with acute pancreatitis, monitor for significant changes in vital signs that may indicate the life-threatening complication of shock.

- Hypotension and tachycardia may result from pancreatic hemorrhage, excessive fluid volume shifting, or the toxic effects of abdominal sepsis from enzyme damage.

- Observe the patient for changes in behavior and level of consciousness (LOC) that may be related to alcohol withdrawal, hypoxia, or impending sepsis with shock.

Action Alert:
Paralytic (adynamic) ileus: is a common complication of acute pancreatitis and prolonged nasogastric intubation may be necessary.

- Assess frequently for the return of peristalsis by asking the patient if he or she has passed flatus or had a stool.

- The return of bowel sounds is not reliable as an indicator of peristalsis return; passage of flatus or a bowel movement is the most reliable indicator. See the discussion of intestinal obstructions in Chapter 57 on p. 1157.

Monitor respiratory complications:
- Observe respiratory status every 4 to 8 hours or more often as needed, provide oxygen to promote comfort in breathing.

- Pleural effusions increase patient discomfort.

- Assess fluid overload - weight gain, lung crackles, dyspnea and other signs of respiratory failure.

Observe for hypocalcemia by assessing for Chvostek's and Trousseau's signs.

- These tests cause muscle spasms after stimulating the associated nerves. (Chapter 11)
• Intense abdominal pain (major clinical manifestation) that is continuous and burning or gnawing

• Abdominal tenderness

• Ascites

• Possible left upper quadrant mass (if pseudocyst or abscess is present)

• Respiratory compromise manifested by adventitious or diminished breath sounds, dyspnea, or orthopnea

• Steatorrhea; clay-colored stools

• Weight loss

• Jaundice

• Dark urine

• Polyuria, polydipsia, polyphagia (diabetes mellitus)

- Abdominal pain is typically described as a continuous burning or gnawing dullness with periods of acute exacerbation (flare-ups). The pain is very intense and relentless. The frequency of acute exacerbations may increase as the pancreatic fibrosis develops.

- Pancreatic insufficiency in chronic pancreatitis causes loss of exocrine function.
Loss of pancreatic endocrine function is responsible for the development of diabetes mellitus

Manifestations:
- Abdominal pain is described as continuous burning or gnawing dullness with periods of acute exacerbation (flare-ups).

- The pain is very intense and relentless.

- The frequency of acute exacerbations may increase as the pancreatic fibrosis develops.

- Decreased pancreatic secretions and bicarbonate, reduction in pancreatic enzyme secretion to produce steatorrhea (stools are pale, bulky, and frothy and have an offensive odor) resulting from severe malabsorption of fats.

- The action of colonic bacteria on unabsorbed lipids and proteins is responsible for the extremely foul odor.

- Fat content is visible in the stools.

- Stool fat output may be more than 40 g/day.

- Weight loss and muscle wasting (a decrease in muscle mass) and leads to general debilitation.

- Protein malabsorption results in a "starvation" edema of the feet, legs, and hands caused by decreased levels of circulating albumin.

Pulmonary complications:
(peuritic pain, pleural effusions, and pulmonary infiltrates) may be present and ARDS may develop. Pancreatic ascites may decrease diaphragmatic excursion and lung expansion, resulting in impaired ventilation.

In chronic pancreatitis, laboratory findings include normal or moderately elevated serum amylase and lipase levels. Obstruction of the intrahepatic bile duct can cause elevated serum bilirubin and alkaline phosphatase levels. Intermittent elevations in serum glucose levels are common and can be detected by blood glucose monitoring, both fasting and non-fasting.
Nonsurgical management (*notes on surgical management & slide 8)

- Opioid and non-opioid analgesia

- Enzyme replacement

- Pancreatic-enzyme replacement therapy (PERT), Pancrelipase

- Insulin therapy for diabetic clients (insulin or oral hypoglycemic agents)

- H2 blockers or proton pump inhibitors or neutralizing stomach acid with oral sodium bicarbonate (enhance the effectiveness of PERT)

- Refer to discharge teaching for acute pancreatitis

Nutrition therapy limit food intake to avoid increased pain.
- TPN or total enteral nutrition (TEN), with vitamin and mineral replacement may be ordered, increased number of calories, up to 4000 to 6000 calories/day, to maintain weight. Foods high in carbohydrates and protein assist in healing.

Avoid: high fat (due to
diarrhea) and alcohol.

Surgery - not a primary intervention for treatment of chronic pancreatitis.

- May be indicated for ongoing abdominal pain, incapacitating relapses of pain, or complications such as abscesses and pseudocysts.

- The underlying pathologic changes determine the procedure indicated.

- Using laparoscopy, the surgeon incises and drains an abscess or pseudocyst.

- Laparoscopic cholecystectomy or choledochotomy (incision of the common bile duct) may be indicated if biliary tract disease is an underlying cause of pancreatitis.

- If the pancreatic duct sphincter is fibrotic, the surgeon performs a sphincterotomy (incision of the sphincter) to enlarge it.

- Endoscopic sphincterotomy may be used for patients who are poor surgical candidates.
In some cases laparoscopic distal pancreatectomy may be appropriate for resection of the distal pancreas or pancreas head.

- Endoscopic pancreatic necrosectomy and natural orifice transluminal endoscopic surgery (NOTES) are becoming more common for removing necrosed pancreatic tissue.

- Both procedures are performed through the GI wall without a visible skin incision.

- The NOTES procedure is discussed in Surgical Management on p. 1217 in the Cholecystitis section.
In a few cases, pancreas transplantation may be done. However, this procedure is performed most often for patients with severe, uncontrolled diabetes
- The cancers are often metastatic and recur despite treatment. Chemotherapy shrinks tumor.

- Drugs used: 5-Fluorouracil (5-FU), with gemcitabine (Gemzar) for locally advanced, or unresectable, pancreatic cancers.

- Gemcitabine may also be given with capecitabine (Xeloda), docetaxel (Taxotere), and/or erlotinib (Tarceva), a targeted agent for unresectable or metastatic tumors.

- Some patients receive three or four drugs and have had more tumor shrinkage as a result.

- Observe for adverse drug effects, such as fatigue, rash, anorexia, and diarrhea. Chapter 22 discusses nursing implications of chemotherapy in more detail.

- Other targeted therapies being investigated include growth factor inhibitors, anti-angiogenesis factors, and kinase inhibitors (also known as tyrosine kinase inhibitors).

- Kinase inhibitors are a newer group of drugs that focus on cancer cells with little or no effect on healthy cells. Chapter 22 describes general nursing interventions associated with chemotherapy.


- To control pain, the patient takes high doses of opioid analgesics (usually morphine) as prescribed and uses other comfort measures before the pain escalates and peaks.

- Because of the poor prognosis, drug dependency is not a consideration. Chapter 3 describes in detail the care of the patient with chronic cancer pain.

- Intensive external beam radiation therapy to the pancreas may offer pain relief by shrinking tumor cells, alleviating obstruction, and improving food absorption.

- It does not improve survival rates. Implantation of radioactive iodine (125I) seeds, in combination with systemic or intra-arterial administration of floxuridine (FUDR), has also been used.

- The patient may experience discomfort during and after the radiation treatments. Chapter 22 describes radiation therapy in more detail.

- For patients experiencing biliary obstruction who are high surgical risks, biliary stents placed percutaneously (through the skin) can ensure patency to relieve pain.

- These stents are devices made of plastic materials that keep the ducts of the biliary system open. Using another approach, self-expandable stents may be inserted endoscopically to relieve obstruction.