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Pancreatitis Definition and Etiology

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					              Pancreatitis
          Definition and Etiology
An acute inflammation process of the pancreas
with associated escape of the pancreatic
enzyme into surrounding tissue.
The primary etiologic factors are alcoholism &
biliary tract disease.
May be a complication of viral or bacterial
disease, peptic ulcer, trauma.
                  Pancreatitis
              Incidence & Risk Factors

Major- Biliary stones, Alcohol use/abuse
Minor- Age: 55 to 65 yrs. for biliary pancreatitis
            45- 55 yrs. For alcohol-related
Female for biliary tract pancreatitis; Male-for
alcohol-related pancreatitis.
Trauma, Infectious disease, drug toxicities,
chronic diseases( inflammatory diseases).
              Pancreatitis
             Assessment
Pain:
    Steady & severe in nature; located in the
epigastric or umbilical region; may radiate to
the back. Worsened by lying supine; may be
lessened by flexed knee, curved-back position.
Vomiting
    Varies in severity, but is usually protracted,
worsened by ingestion of food or fluid. Does not
relieve the pain. Usually accompanied by
nausea.
            Pancreatitis
     Assessment con’t……
Fever:
    Rarely exceeds 39 C.
Abdominal Finding:
    Rigidity, tenderness, guarding, distended, decreased
or absent peristalsis and paralytic ileus.Fatty stools-
(steatorrhea)
Laboratory Finding:
    Elevation of white count- 20,000-50,000.
    Elevated serum lipase and amylase(5 to 40 times);
glucose, bilirubin, alkaline phosphatase. Urine amylase
elevated.Abnormal low serum CA, Na & Mg.-due to
dehydration. Binding of Ca in areas of fat necrosis.
               Pancreatitis
             Ranson’s criteria
 Admission criteria       Criteria during initial 48
                          hours
Age: 55 yrs. Or older     Hct: decrease or more than
                          10%
WBC: 16,000/mm3 or        BUN:increase greater than 5
higher                    mg/dl.
LDH: 350 IU/L or higher   CA: falls to less than 8
Glucose > 200 mg/dl.      mg/dl.
                          PaO2 < 60 mm Hg
AST: 250 U/L or higher    Fluid sequestration; greater
                          than 6 liter.
             Pancreatitis
        Nursing Interventions
Alleviate pain & anxiety. Anxiety increases pancreatic
secretions. Demerol-then morphine.
Reduce pancreatic stimulus- NPO, NGT to remove
gastric secretions. Drugs to reduce pancreatic secretions-
anticholinergics-suppress vagal stimulation, NaHco-
reverse metabolic acidosis.Regular insulin to treat
hyperglycemia.
Prevent or treat infection-with abx.
Aggressive respiratory care- monitor ABG.
Reduce body metabolism- bedrest, cool quiet environment.
Provide client and family instruction-avoid alcohol,
coffee,heavy meals and spicy food.
           Pancreatitis
        Major complications
Cardiovascular- hypotension/shock from hypovolemia.
Hematologic-Anemia from blood loss, DIC,
leukocytosis from gen.inflammation or secondary
infections.
Respiratory-atelectasis, pneumonia, pleural effusion,
ARDS
GI- bleeding
Renal- oliguria, acute tubular necrosis
Metabolic-hyperglycemia, hypocalcemia.
          CA of the Pancreas
                 Etiology
Etiology-unknown. Malignant disease of the
exocrine pancreas & more than 85% of the cases
are ductal adenocarcinomas. 2/3 develop in the
head; remainder occur in the body or tail of the
gland. It occurs more commonly in male.
The tumor is usually deeply encased in normal
tissue & poorly demarcated. The common duct is
often obstructed and distended by the presence of
the tumor. Metastasis has almost always occurred
before the tumor produces the first symptoms.
         CA of the Pancreas
       Signs and Symptoms
Jaundice (lesions of pancreatic head only)
Clay-colored stool
Dark urine
Abdominal pain: usually vague, dull, non-specific
Weight loss
Anorexia
Nausea and vomiting
Glucose intolerance
GI bleeding
Spleenomegaly
ascites
            CA of the Pancreas
             Interventions
Non-surgical- High doses of opioid analgesics.
Chemotherapy, radiation therapy-intensive external
beam radiation therapy by shrinking the tumor
cells.
Surgical management: Whipple procedures: the
procedure entails the removal of the head of the
pancreas, duodenum, a portion of the jejunum, the
stomach and the gallbladder, with the anastomosis
of the pancreatic duct, the common bile duct, and
the stomach to the jejunum.
          CA of the Pancreas
          Postoperative Care
Monitor vital parameters. Check vital signs, ABG,
intake and output. Be alert to signs of bleeding or
shock. Maintain urine output at 30 to 50 ml/hr.
Initiate pulmonary hygiene.
Establish effective pain management.
Monitor dressing and drainage tubes.
Maintain nutritional support with enteral and
parenteral support. Monitor BS and insulin.
Administer pancreatic enzyme replacement. Assess for
signs of dumping syndrome ( rapid shift of fluid from
vascular into the intestinal lumen with a resultant
decrease in blood volume).
             Cholelithiasis
    Definition, Incidence, Predisposing Factors

Also known as stones in the gallbladder
It is the most common disorder of the biliary
system and it has been estimated that 8-10% of
all adults in the U.S. have this condition.
Predisposing factors includes: gender, age,
estrogen RX or BCP’s, sedentary lifestyle, family
history and obesity.
Cholecystitis- inflammation of the gallbladder.
             Cholelithiasis
       Clinical Manifestations
Sudden-onset pain in the right upper quadrant (RUQ)
of the abdomen. Severe and steady in quality.
Frequently radiates to the right scapula or shoulder.
Persists for abt. 1 to 3 hours. May awaken the patient
at night. May be associated with consumption of a
large fatty meals.
Anorexia, nausea and vomiting.
Mild to moderate fever
Decreased or absent bowel sounds
Acute abdominal tenderness
Elevated WBC, slightly elevated bilirubin, and alkaline
phosphatase.
           Cholelithiasis
          Diagnostic Test
Ultrasound-best way to dx; 90-95% effective.
Serum studies- liver function test and serum
amylase
Cholangiogram
Gallbladder x-ray test.
               Cholelithiasis
               Interventions
Provide relief from vomiting. NGT-reduces distention
& eliminates gastric juices that stimulate
cholecystokinin.
Maintain fluid and electrolyte balance.
Monitor drug therapy. Administer broad spectrum
Abx. Chenodeoxycholic acid- bile acid dissolves
cholesterol calculi (60% of the stone).
NTG & papaverine to reduce spasms of duct.
Synthetic narcotics (Demerol, methadone) MSO4 may
cause spasms of Oddi and increase spasms.
         Cholelithiasis
   Interventions con’t…..
Provide low-fat diet to decrease gallbladder
stimulation; avoid alcohol and gas forming foods.
Maintain bedrest
Extracorporeal shock wave lithotripsy- shock wave
that disintegrates stones in the biliary system.
Ultrasound is used for stone localization before the
lithotriptor send waves through a water bag upon
which the patient is lying. Analgesics and sedatives to
reduce pain during procedures.
                Cholecystitis
               Assessment
Epigastric pain- after eating
Pain- localized in RUQ because of somatic sensory
nerves. Murphy’s sign- can’t take a deep inspiration
when assessor’s fingers are pressed below hepatic
margin. Pain begins 2 to 4 hours after eating fried or
fatty foods and persist more than 4 to 6 hours.
Nausea, vomiting, anorexia
Low-grade fever
Jaundice
Weight loss
           Cholecystitis
       Surgical Management
Cholecystectomy- removal of gallbladder after
ligation of the cystic duct and vessels.
Choledochostomy-opening into the common bile
duct for removal of stones. T-tube inserted into
duct and connected to drainage bottle. Purpose-
to decompress biliary tree and allow for
postoperative cholangiogram.
Endoscopic cholecystectomy-removal of
gallbladder through small puncture hole in the
abdomen. Laser dissects gallbladder.
             Cholecystitis
           Implementation
Position in low-to semi fowler’s position to facilitate
bile drainage.
Maintain skin integrity.
Prevent respiratory complications: TCDB, use of IS.
IF NGT is inserted-to relieve distention and increase
peristalsis.
If t-tube inserted-measure amt. & color. Clamp tube
before eating. As t-tube clamp-observe for abdominal
discomfort and distention. Unclamp if any N/V.
Provide low-fat high carb. and high protein.
Maintain for at least 2 to 3 months postoperatively.
        Diabetes Mellitus
    Definition and Classification
Is a chronic disorder of altered CHO, fat &
Protein metabolism caused either by:
    A relative lack of insulin (type 1).
    Or the inability to respond to insulin (type
11).
Is characterized by persistent hyperglycemia,
impaired leukocyte activity & long-term
vascular & neurological degeneration
         Diabetes Mellitus
         Risk Factors
Familial hx of DM
African-American, Hispanic, or Native
American descent.
Obesity
Morbid OB hx. Or hx of delivering infants
weighing > 9 lbs.
            Diabetes Mellitus
              Significance
Roughly 7 million people have been dx with DM.
7th leading underlying cause of death in the U.S.
Leading cause of blindness in adults 20-70 yo.
It accounts for:
     30% of new cases of ESRD
     50-60% of adult deaths from CAD
     40-50% of non traumatic amputations for
foot/ankle ulcers.