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pancreatic-pseudocyst Powered By Docstoc
					   NURSING DX                                                                                                                     NURSING DX
   Ineffective Breathing Pattern r/t inability to expand lungs fully, presence of fluid in pleural                                Ineffective Health Maintenance r/t lack of knowledge regarding diagnoses, demonstrated lack of
   cavity, inflammatory response (asthma and COPD), and pain from thoracentesis and JP drain                                      adaptive health promoting behaviors, language barrier AEB refusal of medications, pt reaching into
   exchange AEB requesting to be put back on the nasal cannulas, shallow, rapid breathing,                                        his attends and then putting his hand out to grab an item, inability to focus when nurse is
   tachycardia, anxiousness, abnormal rate, inability to use the Incentive Spirometer appropriately.                              instructing or looking away when nurse is attempting to discuss.

OUTCOMES: Breath sounds will be present in all lung fields within 48 hours.                                                       OUTCOMES: Patient will verbalize importance of adhering to highest priority medications prior to

   INTERVENTIONS                                                                                         DX                          INTERVENTIONS
   *Nurse will (check 02 sat) and provide oxygen via cannula if client appears to be                     Pancreatitis                *Nurse will offer the highest priority medications earlier in the day with explanations done in
   having difficulty breathing, checking on him q 30 minutes, or will ask him to always                  with                        Spanish stating their importance if client refuses. Rationale is that some cirrhosis patients can get a
   call for the nurse if he wants to be put on the oxygen. Rationale is that the patient                 developing                  little out of control or “unreasonable” towards the later evening and night. So, by offering the
   understands that he has breathing difficulties and he also just had a thoracentesis and               pseudocyst                  teaching and highest priority meds earlier in the day, this favors compliance.
   JP drain exchange and so won’t want to inhale or exhale forcefully because of the                                                 *Nurse will educate the family about patient’s current medications. Rationale is that they are very
   pain.                                                                                                                             involved with the patient’s care and thus it is important that they understand the different
   *Nurse will position patient in high or semi-fowler’s position at least every 2 hours.                                            medications purposes so that they can encourage the patient to comply with the therapeutic
   Rationale is to facilitate normal lung expansion which can improve respiratory status.                                            regiment after discharge.
   *Nurse will encourage the client to use the incentive spirometer q2h or ad lib.                     SECONDARY DX                  *Nurse will discuss behaviors that the client wishes to remain unchanged by current diagnosis.
   Rationale is that patient is immobile and quite weak, thus needs to intentionally                     Cirrhosis                   Rationale is that the client has personally meaningful or valuable behaviors that need to be
   practice deep breathing to prevent atelectasis or stasis of secretions within the lungs               COPD                        addressed, understood, and preserved. In this way, the nurse will know what behaviors the patient
   because this can cause diminished lung function.                                                      Pleural effusion            is willing to change to improve health status and what medications will be most beneficial to
                                                                                                                                     compensate for those behaviors left unchanged.

   MEDICATIONS                                            PATHOPHYSIOLOGY                                                                                                                    PT HEALTH HISTORY
   Bacitracin-neomycin-polymyxin (triple                  --Pancreatitis: (acute inflammatory process of the pancreas, with many possible etiologies. For my patient’s history of            60s, hispanic, Spanish-speaking, married male with
   antibiotic) 3.5-400-500 ointment: for                  drinking, cirrhosis, having gallstones removed at one time, it seems that alcoholism and biliary tract disease. The                long history of alcohol use (quit about 3 years ago),
   insertion site of JP drain.                            damage occurs after the pancreatic enzymes are activated. The pancreas produces trypsinogen, an inactive proteolytic               tobacco 40 years (quit), cirrhosis of the liver,
   Cholestryramine(questran) packet 4 grams:              enzyme that usually gets released into the small intestine through the pancreatic duct, and then activated into trypsin by         asthma, COPD, and HTN. Pt also has hx of CAD
   to promote clearance of cholesterol (pt has            enterokinase. The pancreas also has trypsin inhibitors (also present in plasma) that would inactivate any trypsin that is          with prior infarction by echocardiogram, benign
   hyperlipidemia and HTN)                                inadvertently produced. In pancreatitis, either through blockage of the duct, perhaps by gallstones, there is activated            prostatic hypertrophy with urinary retention, and
   Digoxin (Lanoxin) tablet 0.125mg PO daily              trypsin, which begin to digest the pancreatic tissues and then activate other proteolytic enzymes like elastase and                degenerative joint disease which is illustrated by
   to increase contractility of heart muscle (pt          phospholipase A. These two enzymes autodigest the pancreas and actually cause hemorrhage (elastase destroys the                    his musculoskeletal impairment. Iron study during
   had prior MI)                                          elastic fibers of blood vessels) and fat necrosis (phsopholipase A). It is not known how exactly the mechanism works               a prior admit, when the pt was admited with ETOH
   Fat Emulsion (Liposyn, intralipid) 20% inj             with chronic alcoholism but alcohol does cause digestive enzymes to be release sooner than normal within the                       withdrawal, showed elevated ferritin (1205) which
   250 mL: to provide nutrition because pt is on          pancreas and it also created permeability of the smaller ducts that move enzymes around in the pancreas, which allows              would occur with cirrhosis and iron is 32 with iron
   clear liquid diet and has chronic malnutrition         the leakage of juices into healthy tissues, which then become damaged. Also, excessive alcohol consumption can                     binding capacity of 184 and percent sat of 17.
   from cirrhosis, pancreatitis, and poor diet.           cause protein plugs( precursor to small stones) that can block part of the pancreatic duct. Also, in pancreatitis, due to          Upon exam, light touch and pinprick sensations are
   Fluticasone-salmetrol (Advair Diskus) 250-             its inflammatory nature and autodigestion of pancreatic tissues, the endocrine cells called Islets of Langerhans become            diminished below the knees. Patient is
   50mcg/dose BID: for management of asthma               damaged, therefore, the production and secretion of insulin, glucagons, and somatostatin is inhibited. This will                   malnourished upon appearance (prealbumin was 8).
   symptoms                                               interfere with the ability to maintain normal blood sugar levels, which is why this patient needs insulin and is on the
   Lorazepam (Ativan) 2mg/mL inj 1 mg q6h                 sliding scale.
   PRN: for anxiety and agitation (mostly                 --Pseudocyst: This is a cavity that can be surrounding the pancreas or continuous with the pancreas. It is filled with
   when he was going through detox)                       necrotized tissues and liquid secretions (plasma, pancreatic enzymes, and inflammatory exudates). As fluid escapes                 PRESENTATION
   Metoprolol (Lopressor) tablet 25mg BID:                from it, the serosal surface of the pancreas becomes inflamed and then granulation tissue forms and encapsulates the               Pt presented (about 2 weeks before I gave
   Management of HTN                                      exudate. These can rupture and then the treatment is an anastomosis between the pancreatic duct and the jejunum to                 care)with fever, nausea, vomiting, abdominal pain
   Oxycodone (Roxicodone) 1mg/ml solution                 drain it.                                                                                                                          that would not go away for two days. Dx was
   5-10mg: for pain from thoracentesis and JP             --Pleural Effusion: It is reasonable to assume the cause of this was because the pancreatic pseudocyst was spreading to            pancreatitis with biliary origin and progressive
   drain exchange                                         neighboring tissues and eventually managed to being damaging the left lung, which is why it was nearly collapsed.                  symptoms of sepsis. Underwent ERCP with
   TPN solution 1000mL Q24 hour IV: for                   When the infectious fluid seeped into the pleural space, the immune response is of course to send WBCs to fight the                removal of stones, complicated by aspiration and
   nutrition                                              invading cells. This did not really work for this patient because his JP drain was not functioning and so the                      ongoing sepsis. Patient also pulled his Dobhoff
   Insulin regular human (Novolin) SQ sliding             anymes/exudates/secretions were not draining, but they were accumulating in the abdominal cavity.                                  tube so currently has no NG tube and is drinking
   scale (high dose) 100units/ml Q6h:                     --Cirrhosis: This is probably what began the pancreatitis in my patient. Stemming from chronic alcohol use in this                 fluids but needs help because has a shaky hold. CT
   management of blood sugar because patient              case, the damaging effects cause a replacement of healthy liver tissue with fibrotic scar tissue and also nodules, which           showed Left lobe pleural effusion, so underwent
   has diabetes mellitus type II                          progresses ultimately to liver failure. Ascites is a common complication and has a poor prognosis. Some other issues               thoracentesis (this was the day that I provided care)
                                                          are hepatic encephalopathy due to high ammonia and other nitrogenous substances that can’t be cleared by the liver                 and also had his JP drain exchanged for a bigger
                                                          anymore and are carried to the brain, affecting cerebral functioning, causing unresponsiveness, forgetfulness, or                  sized drain (16 French pigtail drain) because the
                                                          difficulty concentrating. Cirrhosis can also cause dysfunction with the immune system, which can lead to infection.                CT showed that the catheter was transversing the
                                                          --COPD: With the long history of smoking and also having asthma, this patient had a lot of fibrotic tissue built up in             stomach and was twisted This was why it was not
                                                          his lungs, so even in a semi-healthy state his lungs do not function up to standards. So, with an infectious process               draining and probably caused the pleural effusion
                                                          involved his alveoli simply become congested and suffocated from the exudate.                                                      and sepsis.