Nursing assessment and Management clients with Pancreatic disorders

Nursing assessment and Management
clients with Pancreatic disorders
Mr. ANILKUMAR BR M.Sc. N
Assist Professor
Medical –Surgical Nursing Department

THE PANCREAS
•The pancreas, located in the upper abdomen, has
endocrine as well as exocrine functions .
•The secretion of pancreatic enzymes into the
gastrointestinal tract through the pancreatic duct
represents its exocrine function.
•The secretion of insulin, glucagon, and somatostatin
directly into the bloodstream represents its endocrine
function.

Exocrine Pancreas
• The secretions of the exocrine pancreas are digestive
enzymes high in protein content and an electrolyte-rich
fluid.
• The secretions are very alkaline because of their high
concentration of sodium bicarbonate and are capable of
neutralizing the highly acid gastric juice that enters the
duodenum.
• The enzyme secretions include amylase, which aids in the
digestion of carbohydrates; trypsin, which aids in the
digestion of proteins; and lipase, which aids in the digestion
of fats.

Endocrine Pancreas
• The islets of Langerhans, the endocrine part of the
pancreas, are collections of cells embedded in the
pancreatic tissue.
• They are composed of alpha, beta, and delta cells.
• The hormone produced by the beta cells is called
insulin; the alpha cells secrete glucagon and the
delta cells secrete somatostatin.

PANCREATIC DISORDERS
•Pancreatitis (inflammation of the pancreas) is a serious
disorder. The most basic classification system used to
describe or categorize the various stages and forms of
pancreatitis divides the disorder into acute or chronic forms.
•Acute pancreatitis can be a medical emergency associated
with a high risk for life-threatening complications and
mortality, whereas chronic pancreatitis often goes
undetected until 80% to 90% of the exocrine and endocrine
tissue is destroyed.
•Acute pancreatitis does not usually lead to chronic
pancreatitis unless complications develop.

PANCREATIC DISORDERS
Although the mechanisms causing pancreatic
inflammation are unknown, pancreatitis is
commonly described as auto digestion of the
pancreas.
Generally, it is believed that the pancreatic duct
becomes obstructed, accompanied by hyper
secretion of the exocrine enzymes of the pancreas.

ACUTE PANCREATITIS
• Acute pancreatitis is an inflammation of the
pancreas, ranging from mild edema to extensive
hemorrhage, resulting from various insults to the
pancreas. (Mild acute pancreatitis is characterized by
edema and in-flammation confined to the pancreas)
• It is defined by a discrete episode of abdominal pain
and serum enzymes elevations. The structure and
function of the pancreas usually return to normal
after an acute attack.

Pathophysiology and Etiology
1. Excessive alcohol consumption is the most common cause
in the United States.
2. Also commonly caused by biliary tract disease, such as
cholelithiasis, acute and chronic cholecystitis.
3. Less common causes are bacterial or viral infection, blunt
abdominal trauma, peptic ulcer disease, ischemic vascular
disease, hyperlipidemia, hypercalcemia; the use of
corticosteroids, thiazide diuretics, and oral contraceptives;
surgery on or near the pancreas or after instrumentation of
the pancreatic duct by ERCP; tumors of the pancreas or
ampulla; and a low incidence of hereditary pancreatitis.

4. Mortality is high (10%) because of shock, anoxia,
hypotension, or multiple organ dysfunction.
5. Attacks may resolve in complete recovery, may recur
without permanent damage, or may progress to chronic
pancreatitis.
6. Auto digestion of all or part of the pancreas is involved,
but the exact mechanism is not completely understood.

Clinical Manifestations
(Depends on severity of pancreatic damage)
1. Severe abdominal pain is the major symptom of
pancreatitis. Pain is frequently acute in onset,
occurring 24 to 48 hours after a very heavy meal or
alcohol ingestion ( Abdominal pain and tenderness
and back pain result from irritation and edema of
the inflamed pancreas that stimulate the nerve
endings).
2. Nausea and vomiting.
3. Fever.

Severe abdominal pain is the major
symptoms of acute pancreatitis

(Depends on severity of pancreatic damage)
1. Hypotension is typical and reflects hypovolemia and shock caused by the
loss of large amounts of protein-rich fluid into the tissues and peritoneal
cavity.
2. Respiratory distress and hypoxia are common, and the patient may
develop diffuse pulmonary infiltrates, dyspnea, tachypnea, and
abnormal blood gas values ( ABGs).
3. Myocardial depression, hypocalcaemia, hyperglycemia, and
disseminated intravascular coagulopathy (DIC) may also occur with
acute pancreatitis.

Purplish discoloration of the flanks (Turner's sign) or of the
periumbilical area (Cullen's sign) occurs in extensive
hemorrhagic necrosis of the pancreas.

Assessment and Diagnostic Findings
1. The diagnosis of acute pancreatitis is based on a
history of abdominal pain, the presence of known risk
factors, physical examination findings, and diagnostic
findings.
2. Serum amylase and lipase levels are used in making
the diagnosis of acute pancreatitis. In 90% of the
cases, serum amylase and lipase levels usually rise in
excess of three times their normal upper limit within
24 hours.

•Abdominal X-ray to detect an ileus or isolated loop of small
bowel overlying pancreas.
•CT scan is the most definitive study for determining
pancreatic changes.
•Chest X-ray for detection of pulmonary complications.
Pleural effusions are common, especially on the left, but
may be bilateral.

Medical Management client with acute pancreatitis
• Management of the patient with acute pancreatitis is directed toward
relieving symptoms and preventing or treating complications.
• All oral intake (NPO) is withheld to inhibit pancreatic stimulation and
secretion of pancreatic enzymes.
• Parenteral nutrition is usually an important part of therapy, particularly in
debilitated patients, because of the extreme metabolic stress associated with
acute pancreatitis.
• Nasogastric suction may be used to relieve nausea and vomiting.
• Restoration of circulating blood volume with I.V. crystalloid or colloid
solutions or blood products.
• Maintenance of adequate oxygenation reduced by pain, anxiety, acidosis,
abdominal pressure, or pleural effusions.

POSTACUTE MANAGEMENT
•Antacids may be used when acute pancreatitis begins to
resolve. Oral feedings low in fat and protein are initiated
gradually.
•Caffeine and alcohol are eliminated from the diet. If the
episode of pancreatitis occurred during treatment with
thiazide diuretics, corticosteroids, or oral contraceptives,
these medications are discontinued.
•Follow-up of the patient may include ultrasound, x-ray
studies, or ERCP to determine whether the pancreatitis is
resolving and to assess for abscesses and pseudocysts.

PAIN MANAGEMENT
•Adequate pain medication is essential during the course of
acute pancreatitis to provide sufficient pain relief and
minimize restlessness, which may stimulate pancreatic
secretion further.
•Antiemetic agents may be prescribed to prevent vomiting.
•Electrolyte replacements as needed.
•Regular insulin to treat hyperglycemia.
•Antibiotic therapy for documented infection or sepsis.

COMPLICATIONS
1. Fluid and electrolyte disturbances
2. Necrosis of the pancreas
3. Shock and multiple organ dysfunction
4. Hemorrhage with hypovolemic shock.
5. Acute renal failure
6. Pancreatic ascites, abscess, or pseudocyst.

NURSING PROCESS: THE PATIENT WITH ACUTE
PANCREATITIS
• Assessment
1. Obtain history of gallbladder disease, alcohol use, or
precipitating factors.
2. Assess GI distress, including nausea and vomiting, diarrhea,
and passage of stools containing fat.
3. Assess characteristics of abdominal pain.
4. It also is important to assess the patient’s nutritional and fluid
status and history of gallbladder attacks and alcohol use.
5. Assess respiratory rate and pattern and breath sounds.

NURSING PROCESS: THE PATIENT WITH ACUTE
PANCREATITIS
• Assessment
5. The nurse assesses the emotional and psychological status of
the patient and family and their coping, because they are often
anxious about the severity of the symptoms and the acuity of
illness.

NURSING DIAGNOSIS
1. Acute pain related to inflammation, edema, distention of the
pancreas, and peritoneal irritation.
2. Ineffective breathing pattern related to severe pain,
pulmonary infiltrates, pleural effusion, atelectasis, and
elevated diaphragm.
3. Imbalanced nutrition, less than body requirements, related
to reduced food intake and increased metabolic demands.
4. Impaired skin integrity related to poor nutritional status, bed
rest, and multiple drains and surgical wound.

Nursing Interventions
1. RELIEVING PAIN AND DISCOMFORT
2. RESTORING ADEQUATE FLUID BALANCE
3. IMPROVING BREATHING PATTERN
4. IMPROVING NUTRITIONAL STATUS
5. IMPROVING SKIN INTEGRITY
6. MONITORING AND MANAGING POTENTIAL
COMPLICATIONS

Pancreatitis
Nursing Interventions
P- Pain: Morphine or Dilaudid
A- Antispasmodic drugs- motility
N- NPO/NGT suction- pancreas to rest, TPN
C- Calcium, hypocalcemia, replace Ca
R- Replace F/E- NG losses and fluid shift
E- Endocrine & Enzymes
A- Antibiotics- with fever
S- Steroids- corticosteroids during acute attacks
28

Patient Education and Health Maintenance
1. Instruct patient to gradually resume a low-fat diet.
2. Instruct patient to increase activity gradually, providing for
daily rest periods.
3. Reinforce information about disease process and precipitating
factors. Stress that subsequent bouts of acute pancreatitis may
destroy the pancreas, cause additional complications, and lead to
chronic pancreatitis.
4. If pancreatitis is a result of alcohol abuse, the patient needs to
be reminded of the importance of eliminating all alcohol; advise
about Alcoholics Anonymous or other substance abuse
counseling.

CHRONIC PANCREATITIS
• Chronic pancreatitis is defined as the persistence of
pancreatic cellular damage after acute inflammation
and decreased pancreatic endocrine and exocrine
function. Or
• Chronic pancreatitis is an inflammatory disorder
characterized by progressive anatomic and
functional destruction of the pancreas.

1. Alcohol consumption in Western societies and malnutrition worldwide are
the major causes of chronic pancreatitis. Excessive and prolonged
consumption of alcohol accounts for approximately 70% of the cases.
2. The incidence of pancreatitis is 50 times greater in alcoholics than in the
nondrinking population.
3. Long-term alcohol consumption causes hypersecretion of protein in
pancreatic secretions, resulting in protein plugs and calculi within the
pancreatic ducts.
4. Alcohol also has a direct toxic effect on the cells of the pancreas. Damage
to these cells is more likely to occur and to be more severe in patients
whose diets are poor in protein content and either very high or very low in
fat.

1. Chronic pancreatitis is characterized by recurring
attacks of severe upper abdominal and back pain,
accompanied by vomiting. (Some patients experience
continuous severe pain; others have a dull, nagging
constant pain).
2. Weight loss is a major problem in chronic
pancreatitis: more than 75% of patients experience
significant weight loss, usually caused by decreased
dietary intake secondary to anorexia or fear that eating
will precipitate another attack.

1. The stools become frequent, frothy, and foul-
smelling because of impaired fat digestion, which
results in stools with a high fat content. This is
referred to as “steatorrhea”
2. Diabetes mellitus

1. ERCP (Endoscopic Retrograde Cholangio-Pancreatography) is the
most useful study in the diagnosis of chronic pancreatitis. It provides
detail about the anatomy of the pancreas and the pancreatic and
biliary ducts.

ERCP (Endoscopic Retrograde Cholangio-Pancreatography)

ERCP (Endoscopic Retrograde Cholangio-
Pancreatography)
• It is also helpful in obtaining tissue for analysis and
differentiating pancreatitis from other conditions,
such as carcinoma.

Other diagnostic investigations
• Various imaging procedures, including:
1. Magnetic resonance imaging ( MRI)
2. Computed tomography ( CT-SCAN) and ultrasound, have been
useful in the diagnostic evaluation of patients with suspected
pancreatic disorders.
3. A glucose tolerance test ( GTT) evaluates pancreatic islet cell
function, information necessary for making decisions about
surgical resection of the pancreas.
4. An abnormal glucose tolerance test indicative of diabetes may
be present

Medical Management
The management of chronic pancreatitis depends on
its probable cause in each patient.
Treatment is directed toward preventing and
managing acute attacks, relieving pain and
discomfort, and managing exocrine and endocrine
insufficiency of pancreatitis.

Medical Management
1. Pain management.
2. Correction of nutritional deficiencies.
3. Pancreatic enzyme replacement.
4. Treatment of diabetes mellitus.
5. Endoscopic placement of pancreatic stent allowing free
flow of pancreatic juices through distorted and
irregular/narrowed pancreatic duct.
6. Diabetes mellitus resulting from dysfunction of the
pancreatic islet cells is treated with diet, insulin, or oral
antidiabetic agents.

Surgical Management
Surgery is generally carried out to relieve abdominal pain and
discomfort, restore drainage of pancreatic secretions, and
reduce the frequency of acute attacks of pancreatitis.
The surgery performed depends on the anatomic and
functional abnormalities of the pancreas, including the
location of disease within the pancreas, diabetes, exocrine
insufficiency, biliary stenosis, and pseudocysts of the pancreas.
The Care is similar to the patient undergoing abdominal
surgery.

Pancreaticojejunostomy
• Pancreaticojejunostomy (also referred to as Roux-en-Y) with a side-to-
side anastomosis or joining of the pancreatic duct to the jejunum
allows drainage of the pancreatic secretions into the jejunum.

•Autotransplantation or implantation of the
patient’s pancreatic islet cells has been
attempted to preserve the endocrine function of
the pancreas in patients who have undergone
total pancreatectomy.
• Resection of part of pancreas (Whipple procedure,
distal pancreatectomy) or removal of entire pancreas
(total pancreatectomy).

Complications
1. Pancreatic pseudocyst.
2. Pancreatic ascites and pleural effusions.
3. GI hemorrhage.
4. Biliary tract obstruction.
5. Pancreatic fistula.

Pancreatic pseudocyst
• A pancreatic pseudocyst is a circumscribed collection of fluid rich
in pancreatic enzymes, blood, and necrotic tissue, typically located
in the lesser sac of the abdomen.

Nursing Assessment
• Assess level of abdominal pain.
• Assess nutritional status.
• Assess for steatorrhea and malabsorption.
• Assess for signs and symptoms of diabetes mellitus.
• Assess current level of alcohol intake and motivation
and resources available to abstain from drinking such
as Alcoholics Anonymous.
• Provide pre and post operative nursing care

• Cancer of the pancreas may arise in the head (70%) or body and tail
(30%) of the pancreas. Adenocarcinoma of the cells that line the
ducts of the pancreas is the most common (80%) type.
• Pancreatic cancer is the fourth-leading cause of cancer deaths in the
United States because 90% of tumors are not resectable at the time
of diagnosis.
• Usually occurs between ages 60 and 80, but can be found in younger
patients.

•Cigarette smoking, exposure to industrial chemicals or
toxins in the environment, and a diet high in fat, meat, or
both are associated with pancreatic cancer, although their
role is not completely clear.
• The risk for pancreatic cancer increases as the extent of
cigarette smoking increases. Diabetes mellitus, chronic
pancreatitis, and hereditary pancreatitis are also
associated with pancreatic cancer.
•The pancreas can also be the site of metastasis from other
primary tumors.

• Cancer may arise in any portion of the pancreas (in
the head, the body, or the tail); clinical manifestations
vary depending on the location of the lesion and
whether functioning, insulin secreting pancreatic islet
cells are involved.
• Approximately 75% of pancreatic cancers originate in
the head of the pancreas and give rise to a distinctive
clinical picture.

• Pain, jaundice, or both are present in more than 90%
of patients pancreatic cancer with and, along with
weight loss, are considered classic signs of pancreatic
carcinoma.
• However, they often do not appear until the disease
is far advanced esp. III or IV stage of pancreatic
cancer.

•Other signs include rapid, profound, and progressive
weight loss as well as vague upper or mid abdominal
pain or discomfort that is unrelated to any
gastrointestinal function and is often difficult to
describe.
• Anorexia, nausea, vomiting, and weakness may occur.
• Biliary obstruction produces jaundice, dark tea-colored
urine, clay-colored stools, and pruritus.
• Depression and lethargy may be present.
•Insulin deficiency: glycosuria, hyperglycemia, and
abnormal glucose tolerance.

• Magnetic resonance imaging (MRI) and Computed tomography
(CT-SCAN) are used to identify the presence of pancreatic tumors.
• ERCP is also used in the diagnosis of pancreatic carcinoma. (Cells
obtained during ERCP are sent to the laboratory for examination).
• Liver function tests (LFT) elevated; coagulation studies may be
prolonged.
• Percutaneous fine-needle aspiration or biopsy through
ultrasonography or CT scan guidance to determine malignancy.
• Percutaneous transhepatic cholangiography is another procedure
that may be performed to identify obstructions of the biliary tract
by a pancreatic tumor.

Medical Management
• If the tumor is resectable and localized (typically
tumors in the head of the pancreas), the surgical
procedure to remove it is usually extensive.
• However, definitive surgical treatment (ie, total
excision of the lesion) is often not possible because of
the extensive growth when the tumor is finally
diagnosed and because of the probable widespread
metastases (especially to the liver, lungs, and bones).

• If the patient undergoes surgery, intraoperative radiation therapy
(IORT) may be used to deliver a high dose of radiation to the tumor
with minimal injury to other tissues.

• Before extensive surgery can be performed, a fairly long period of
preparation is often necessary because the patient’s nutritional
and physical condition is often quite compromised.
• Various liver and pancreatic function studies are performed.
• A diet high in protein along with pancreatic enzymes is often
prescribed.
• Preoperative preparation includes adequate hydration, correction
of prothrombin deficiency with vitamin K, and treatment of
anemia to minimize postoperative complications.
• Parenteral nutrition and blood component therapy are frequently
required.

Pancreaticoduodenectomy. (Whipple procedure )
• Is the removal of the head of the pancreas, distal portion of the
common bile duct including the gallbladder, duodenum, and the distal
stomach with anastomosis of the remaining pancreas, stomach, and
common bile duct to the jejunum (If the gallbladder is present, it is
also removed.

Total pancreatectomy, including a splenectomy, may be
performed for diffuse tumor throughout the pancreas.

• Palliative bypass of the bile duct
(choledochojejunostomy or cholecystojejunostomy)or
stomach (gastrojejunostomy) for unresectable tumors
of the pancreas.

Other Measures
• Chemotherapy may be used in combination with radiation therapy as
neoadjuvant therapy before surgery to shrink tumors.
• Radiation therapy may be used alone.
• Endoscopic or percutaneous stent placement for relief of biliary
obstruction (usually for patients near end of life).
• Endoscopic stent for relief of duodenal obstruction (usually for
patients near end of life).

Nursing Management
1. Preoperatively and postoperatively, nursing care is directed toward
promoting patient comfort, preventing complications, and assisting the
patient to return to and maintain as normal and comfortable a life as
possible.
2. The nurse closely monitors the patient in the intensive care unit after
surgery; the patient will have multiple intravenous and arterial lines in
place for fluid and blood replacement as well as for monitoring arterial
pressures, and is on a mechanical ventilator in the immediate
postoperative period.
3. It is important to give careful attention to changes in vital signs, arterial
blood gases and pressures, pulse oximetry, laboratory values, and urine
output.
4. The nurse must also consider the patient’s compromised nutritional status
and risk for bleeding.

Nursing assessment and Management clients with Pancreatic disorders

Nursing assessment and Management clients with Pancreatic disorders

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