Concordia College College of Nursing
Case Study On Acute Pancreatitis Prepared by: De Castro, Richelle Sandriel C. BSN III-D
Submitted to: Mrs. Cedie Loo RN, MSN I. INT INTRODU ODUCTIO CTION N
Acute pancreatitis is an acute inflammatory process with variable involvement of adjacent and remote organs. Although pancreatic function and structure eventually return to normal, the risk of recurrent attacks is nearly 50% unless the precipitating cause is removed. Initial manifestations and exacerbations of chronic pancreatitis may be indistinguishable from attacks of acute pancreatitis. And they should be treated as such. The inflammation inflammation begins in the perilobular and peripancreatic fatty tissue, manifested by edema and spotty fat necrosis. The disease may progress to the peripheral acinar cells, pancreatic ducts, blood vessels, and bordering organs. organs. In severe cases; patchy areas of the pancreatic parenchyma parenchyma become necrotic.
II. OB OBJE JECT CTIV IVES ES General: After this case study, I will be able to know what Acute Pancreatitis is, causes of Acute Pancreatitis, how it is acquired and prevented, its treatments and prevention its occurrence.
Specific:
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After the completion of this study, I will be able to: Define what is Acute Pancreatitis Trace the pathophysiology of Acute Pancreatitis Enumerate the different sign and symptoms of Acute Pancreatitis Identify and understand different types of medical treatment necessary for the treatment of Acute Pancreatitis
III. PATIENT’S PROFILE Name: E.S Address: San Juan City Age: 65 years old Sex: Female Nationality: Filipino Religion: Roman Catholic Date & Time of Admission: Admission: April 16, 2010 (09:34 pm) Mode of Arrival: wheelchair Chief Complaint: Severe Abdominal Pain Source of Information: Information: Patient, Chart, Chart, SO Final Diagnosis: Acute Pancreatitis, Pancreatitis, Acalculous Cholecystitis, Multiple Hepatic Cysts
IV.NURSING HISTORY
PAST MEDICAL HISTORY Accor ccordi ding ng to the pati patien ent’ t’s s SO, she had had compl omplet eted ed his his child hildho hoo od immunization. immunization. He had no allergy to foods or medications. medications. She has hypertension and takes Amiodipine and Metropolol to manage her illness. On June 2006, the patient was admitted at a government hospital due to Polycystitis. HISTORY OF PRESENT ILLNESS Acco Ac cord rdin ing g to the the pati patien ent’ t’s s SO, SO, 3 days days prio priorr to admi admiss ssio ion n the the pati patien entt expe experi rien ence ced d su sudd dden en onse onsett of abdo abdomi mina nall pain pain,, diff diffus use. e. No meds meds take taken n or consultation made. 2 days PTA the patient still have the same abdominal pain, this time was more severe and they monitored it. The patient is negative to bladder change. Few hours PTA, the patient could not any more tolerate the pain; she was brought to OLLH hence admitted.
FAMILY HEALTH HISTORY According to the patient’s SO, both his maternal and paternal have a history Hypertension and Kidney Problem: Polycystic Kidney.
PERSONAL / SOCIAL HISTORY The patient is the 4th among 6 siblings. She is living with 7 other family member members. s. His spous spouse e is unemp unemploy loyed ed and so was she. They They are are only only finan financia cially lly supported with their children who are working.
V. Labora Laborator tory y Work Works s TEST 1. Serum amylase
PURPOSE
NURSING CONSIDERATIONS
NORMAL VALUES
ABNORMAL RESULTS
Levels of The patient need 26 to 102 A marked increase amylase in a not fast before units/L (more than three blood sample test but must (SI, o.4 to 1.74) times the upper Most abstain alcohol. limit of normal) in commonly If severe the level strongly used test to abdominal pain suggests acute diagnosis of occur, obtain pancreatitis. acute sample before After the onset of pancreatitis. therapeutic acute pancreatitis, To evaluate intervention. levels of amylase in possible Handle sample the blood rise pancreatic gently to prevent within six to 12 injury caused hemolysis. hours, peak within by abdominal 12 to 48 hours and trauma. remain elevated for three to five days in uncomplicated attacks.
2. Serum lipase
Determines Instruct levels of lipase patient to fast in a blood overnight sample before test. Elevated Handle serum lipase sample gently levels help to to prevent confirm the hemolysis. pancreatic origin of elevated serum amylase levels.
3. To aid in the Ultrasonograp diagnosis of hy (Pancreas) pancreatitis, pseudocysts, and pancreatic carcinoma. for initial evaluation when biliary causes are suspected. The sensitivity of this study in detecting pancreatitis is 62 to 95 percent.
less than 160 units/L (SI,<2.72 µkat/L)
Increased levels suggest acute pancreatitis or pancreatic duct obstruction. After an acute attack, levels remain elevated for up to 14 days. Increased levels may occur in other pancreatic injuries such as perforated peptic ulcer with chemical pancreatitis caused by gastric juices.
Instruct Pancreas Alterations in the patient to fast demonstrates size, contour and for 8 to 12 a coarse, parenchymal hours before uniform echo texture of the the test to pattern pancreas suggest reduce bowel (reflecting possible pancreatic gas. tissue density) disease. Instruct to and is usually An enlarged abstain from more pancreas with smoking echogenic than decreased before the the adjacent echogenicity and test to liver. distinct borders eliminate the suggests risk of pancreatitis. swallowing air An ill-defined mass while inhaling, with scattered which internal echoes, or a interferes with mass in the head of test results. the pancreas (obstructing the common bile duct) and a large noncontracting gallbladder suggest pancreatic carcinoma.
4. Ultrasonograp hy (Gallbladder & Biliary system)
Particularly Provide a fatuseful for free meal in identifying the evening gallstones in before the the gallbladder test. or in the ducts Tell patient that drain the that he must gallbladder as fast for 8 to the cause of 12 hours acute before the pancreatitis procedure. However, this During the test cannot scan, instruct identify the to exhale more serious deeply and abnormalities hold his associated breath, when with moderate requested. and severe pancreatitis
5. Abdominal X-ray
Reveal a normal appearance of the digestive tract or abnormalities (paralysis of regions of the small intestine and spasm of part of the colon).
Gallbladder is Mobile, echogenic sonolucent and areas, usually linked pear-shaped; to an acoustic its outer walls shadow, suggest normally apper gallstones within sharp and gallbladder lumen smooth. or the biliary The common system. bile duct has a May not be visible linear when the apperance but gallbladder is is sometimes shrunken or filled obscured by with gallstones. overlying A fine layer of bowel gas. echoes that slowly gravitates to the dependent portion of the gallbladder as the patient changes position, suggests biliary sludge within the gallbladder lumen.
The bowel gas The size, shape, or location pattern (stomach, of the bladder or kidneys small and large may be abnormal. Kidney bowel) and soft stones may be seen in the tissue densities kidney, ureters, bladder, or (liver, spleen, urethra. kidneys, and Abnormal growths, such as bladder) are large tumors, or ascites normal in size, may be seen shape, and In some cases, gallstones location. can be seen on an abdominal X-ray. X-ray. The walls of the intestines may look abnormal or thick A collection of air inside the belly cavity but outside the intestines (caused by a hole in the stomach or intestines) may be seen.
6. Chest X-ray To evaluate any abnormalities on the chest.
7. Compute d tomograp hy scan (pancreas )
The diaphragm Elevation of diaphragm, diaphragm, looks normal in collection of fluid in the shape and chest cavity collapse of the location base of the lungs and No abnormal inflammation of the lungs. collection of fluid or air is seen, and no foreign objects are seen. The lungs look normal in size and shape, and the lung tissue looks normal. No growths or other masses can be seen within the lungs.
For Instruct patient The diagnosing to fast after pancreatic acute administration parenchyma pancreatitis of oral contrast displays a for medium. uniform determining Check density, the extent of patient’s especially pancreatitis. history for when an I.V. enlargement recent barium contrast or abnormal studies and for medium is contours of hypersensitivit used. the pancreas, y to iodine, The gland inflammation seafood, or thickens from of the tissues contrast tail and has a surrounding media. smooth the pancreas, Describe surface. collection of possible fluid around adverse the pancreas, reactions to and collection the medium of gas in the (nausea, pancreas or flushinf, in the tissues dizziness, behind the sweating) and pancreas. tell to report these symptoms.
Changes in the pancreatic size and shape suggests carcinoma and pseudocysts. Acute pancreatitis, either edematous (interstitial) or necrotizing (hemorrhagic), produces diffuse enlargement enlargement of the pancreas. In acute edematous pancreatitis, parenchyma density is uniformly decreased. In acute necrotizing pancreatitis, pancreatitis, the density is non-uniform because of the presence of necrosis and hemorrhage. In acute pancreatitis, inflammation inflammation typically spreads into the peripancreatic fat. Pseudocysts, Pseudocysts, may be unilocal, multi-local, appear as sharply circumscribed, lowdensity areas that may contain debris.
VI.PATHOPHYSIOOGY
VII.
ANATOMY AND PHYSIOLOGY
Pancreas
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Pancreas is an organ located behind the stomach and next to the liver and the gall bladder. Pancreatic juices contain Enzymes, which help digest or break down food proteins. Normally the juices leave the pancreas via a duct like channel and join the common bile duct, which carries the secretions from the gallbladder, and pour the mixture into the duodenal portion of the stomach.
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VIII. DISCHARGE PLANNING MEDICATIONS: - Metoclopromide (Plasil) - Omeprazole ( Omepron) 40mg - Metronidazole 500mg - Amikacin ( Konmalin) 500mg - Calcibloc 5mg ECONOMIC STATUS: E.S. a housewife, supported financially by her children who are working, can afford for to pay for her medications, and other necessities by using the money sent to her. TREATMENT: The client should be encouraged to learn and use of relaxation techniques including guided imagery and music therapy are used to shift the focus of the brain away from the pain, decrease muscle tension, and reduce stress. Tension and stress can also be reduced through biofeedback. Being massaged or applying backrub is very relaxing and helps reduce stress.
HEALTH TEACHINGS: - Encourage to take a well - balanced diet. - Encourage a healthy lifestyle. - Educate patient in pain management. OPD VISITS: Teach patient that if acute abdominal pain or biliary tract disease (as evidenced by jaundice, clay- colored stools, and darkened urine) occurs, she should notify it to the physician. She may report to the physician after 7 to 10 days to know the indictor of disease or response progression. DIET: The client should be instructed to avoid alcohol, spicy foods, any caffeinecontaining foods, heavy meals, high fatty foods. Small, frequent feeding of bland diet. SPIRITUAL CARE: Encourage client to pray in accordance with their beliefs. Ask for help to God for complete recovery. DAILY DIARY
29 April 2010 (Thursday)
I woke up at 4:30am and did my everyday routine. Took a bath, dressed up and ate. Then went to school to fetch Cess then headed to Our Lady of Lourdes Hospital in Mandaluyong. We stayed in the waiting are only to find out that Mrs. Loo was our C.I. I got ecstatic and excited at the same time because I admit that she’s one of my favorite C.I’s (no joke to ma’am ah).
Then Mrs. Loo took the endorsement form and jot down important
things that we need to know with our oatients then she assigned it to us one by one. I got a patient in room 415A. Me and April were assigned there. It’s my first time to handle a patient that has NGT tube, Jackson Pratt, and Ttube. I was so excited to drain all of those.
We did the taking of Vital Signs
then we recorded it. Then off to morning care. I sponged bathed my patient with the help of my duty mate, Lyka. Then we also did perineal care. After that we went to the station to plot the vital signs. Then we were assigned to have the first break. After which, we went to our room and told us to do a Nursing Care Plan of our patient. Mrs. Loo then told us the requirements. We did the NCP then have it checked. Glad I got 8/10.
Then by 12nn, we did
the VS again, recorded it then plot it. Then before we left, I drained the NGT, JP and T-Tube of my patient. I was so glad of that day’s duty.
REFLECTION This is the second time that I am handled by Mrs. Loo. And yet again, she never failed us to give insights and new learnings about the things in the ward. This is our first time to have a duty in St. Anthony Unit in Our Lady of Lourdes Hospital. Yet, the things to do are the same with the ones in the St. Vincent Unit. This time, the patients are less and our ratio is 1:1. I have a patient with NGT, T-Tube and JP. I’m tasked to drain those at the end of our shift. I felt really excited because it is my first time to handle a patient with those tubings. I’m glad that our c.i, Mrs. Loo was very patient to teach me the things I need to do with my patient. I felt great that day because we’re not that kind of busy and at the same time we had a lot of time to talk about things under the sun. De Castro, Richelle Sandriel C. BSN III-D Journal
Scorpion venom may help treat pancreatitis Researchers at North Carolina State University and East Carolina University have gained insight into scorpion venom’s effects on the ability of certain cells to release critical components - a finding that may prove useful in understandin understanding g diseases like pancreatitis or in targeted drug delivery. A common result of scorpion stings, pancreatitis is an inflammation of the pancreas. ECU microbiologist microbiologist Dr. Paul Fletcher believed that scorpion venom might be used as a way to discover how pancreatitis occurs occurs - to see which cellular processes are affected at the onset of the disease. Fletcher pinpointed a protein production system found in the pancreas that seemed to be targeted by the venom of the Brazilian scorpion Tityus serrulatus serrulatus and then contacted NC State physicist Dr. Keith Weninger, who had studied that particular protein system. "This particular protein system has special emphasis at two places in the body - the pancreas and the nervous system," Weninger says. "In the pancreas, it is involved in the release of proteins through the membrane of a cell." The pancreas specializes in releasing two kinds of proteins using separate cells: digestive enzymes that go into the small intestine and insulin and its relatives that
go into the bloodstream, yet this same release mechanism is important important in all of our cells for many processes. Cells move components in and out through a process called vesicle fusion. The vesicle is a tiny, bubble-like chamber inside the cell that contains the substance to be moved, stored and released - in this case, proteins like enzymes or hormones. The vesicle is moved through the cell and attaches to the exterior membrane, where the vesicle acts like an airlock in a spaceship, allowing allowing the cell membrane to open and release the proteins without disturbing the rest of the cell’s contents. The proteins that aid in this process are known as Vesicle Associated Membrane Proteins, or VAMPs. Weninger provided Fletcher with two different VAMP proteins found in the pancreas, VAMP2 and VAMP8. They were engineered to remove the membrane attachments so they could be more easily used for experiments outside cells and tissues. Fletcher’s team demonstrated that the scorpion venom attacked the VAMP proteins, cutting them in one place and eliminating the vesicle’s ability to transport its protein cargo out of the cell. i
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http://timesofindia.indiatimes. http://timesofindia.indiatimes.com/life/health-fitn com/life/health-fitness/health/S ess/health/Scorpion-venom-may corpion-venom-may-help-treat-help-treatpancreatitis/articleshow/5742047.cms
