Concordia CollegeCollege of Nursing

CaseStudy

OnAcute

Pancreatitis

Prepared by:De Castro, Richelle Sandriel C.

BSN III-D

Submitted to:Mrs. Cedie Loo RN, MSN

I. INTRODUCTION

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 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. In severe cases; patchy areas of the pancreatic parenchyma become necrotic.

II. OBJECTIVES

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:

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.SAddress: San Juan CityAge: 65 years oldSex: FemaleNationality: FilipinoReligion: Roman CatholicDate & Time of Admission: April 16, 2010 (09:34 pm)Mode of Arrival: wheelchairChief Complaint: Severe Abdominal PainSource of Information: Patient, Chart, SOFinal Diagnosis: Acute Pancreatitis, Acalculous Cholecystitis, Multiple Hepatic Cysts

IV. NURSING HISTORY

PAST MEDICAL HISTORYAccording to the patient’s SO, she had completed his childhood immunization. He had no allergy

to foods or 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

According to the patient’s SO, 3 days prior to admission the patient experienced sudden onset of abdominal pain, diffuse. No meds taken 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 members. His spouse is unemployed and so was she. They are only financially supported with their children who are working.

V. Laboratory Works

TEST PURPOSE NURSING CONSIDERATIONS

NORMAL VALUES

ABNORMAL RESULTS

1. Serum amylase

Levels of amylase in a blood sample Most commonly used test to diagnosis of acute pancreatitis. To evaluate possible pancreatic injury caused by abdominal trauma.

The patient need not fast before test but must abstain alcohol. If severe abdominal pain occur, obtain sample before therapeutic intervention. Handle sample gently to prevent hemolysis.

26 to 102 units/L (SI, o.4 to 1.74)

A marked increase (more than three times the upper limit of normal) in the level strongly suggests acute pancreatitis. After the onset of acute pancreatitis, levels of amylase in the blood rise within six to 12 hours, peak within 12 to 48 hours and remain elevated for three to five days in uncomplicated attacks.

2. Serum lipase Determines levels of lipase in a blood sample Elevated serum lipase levels help to confirm the pancreatic origin of elevated serum amylase levels.

Instruct patient to fast overnight before test. Handle sample gently to prevent hemolysis.

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.

3. Ultrasonography

(Pancreas)

To aid in the diagnosis of 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.

Instruct patient to fast for 8 to 12 hours before the test to reduce bowel gas. Instruct to abstain from smoking before the test to eliminate the risk of swallowing air while inhaling, which interferes with

test results.

Pancreas demonstrates a coarse, uniform echo pattern (reflecting tissue density) and is usually more echogenic than the adjacent

liver.

Alterations in the size, contour and parenchymal texture of the pancreas suggest possible pancreatic disease. An enlarged pancreas with decreased echogenicity and distinct borders suggests pancreatitis. An ill-defined mass with scattered internal echoes, or a mass in the head of the pancreas (obstructing the common bile duct) and a large noncontracting gallbladder suggest pancreatic carcinoma.

4. Ultrasonography (Gallbladder & Biliary system)

Particularly useful for identifying gallstones in the gallbladder or in the ducts that drain the gallbladder as the cause of acute pancreatitisHowever, this test cannot identify the more serious abnormalities associated with moderate and severe pancreatitis

Provide a fat-free meal in the evening before the test.Tell patient that he must fast for 8 to 12 hours before the procedure.During the scan, instruct to exhale deeply and hold his breath, when requested.

Gallbladder is sonolucent and pear-shaped; its outer walls normally apper sharp and smooth.The common bile duct has a linear apperance but is sometimes obscured by overlying bowel gas.

Mobile, echogenic areas, usually linked to an acoustic shadow, suggest gallstones within gallbladder lumen or the biliary system.May not be visible when the gallbladder is shrunken or filled with gallstones.A fine layer of echoes that slowly gravitates to the dependent portion of the gallbladder as the patient changes position, suggests biliary sludge within the gallbladder lumen.

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).

The bowel gas pattern (stomach, small and large bowel) and soft tissue densities (liver, spleen, kidneys, and bladder) are normal in size, shape, and location.

The size, shape, or location of the bladder or kidneys may be abnormal. Kidney stones may be seen in the kidney, ureters, bladder, or urethra.Abnormal growths, such as large tumors, or ascites may be seenIn some cases, gallstones can be seen on an abdominal X-ray.The walls of the intestines may look abnormal or thickA 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.

The diaphragm looks normal in shape and locationNo abnormal 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.

Elevation of diaphragm, collection of fluid in the chest cavity collapse of the base of the lungs and inflammation of

the lungs.

7. Computed tomography scan (pancreas)

For diagnosing acute pancreatitis for determining the extent of pancreatitis.enlargement or abnormal contours of the pancreas, inflammation of the tissues surrounding the pancreas,collection of fluid around the pancreas, and collection of gas in the pancreas or in the tissues behind the pancreas.

Instruct patient to fast after administration of oral contrast medium.Check patient’s history for recent barium studies and for hypersensitivity to iodine, seafood, or contrast media.Describe possible adverse reactions to the medium (nausea, flushinf, dizziness, sweating) and tell to report these symptoms.

The pancreatic parenchyma displays a uniform density, especially when an I.V. contrast medium is used.The gland thickens from tail and has a smooth surface.

Changes in the pancreatic size and shape suggests carcinoma and pseudocysts.Acute pancreatitis, either edematous (interstitial) or necrotizing (hemorrhagic), produces diffuse enlargement of the pancreas.In acute edematous pancreatitis, parenchyma density is uniformly decreased.In acute necrotizing pancreatitis, the density is non-uniform because of the presence of necrosis and hemorrhage.In acute pancreatitis, inflammation typically spreads into the peripancreatic fat.Pseudocysts, may be unilocal, multi-local, appear as sharply circumscribed, low-density areas that may contain debris.

VI. PATHOPHYSIOOGY

VII. ANATOMY AND PHYSIOLOGY

Pancreas

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.

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 caffeine- containing 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 T-tube. 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-DJournal

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 understanding diseases like pancreatitis or in targeted drug delivery.

A common result of scorpion stings, pancreatitis is an inflammation of the pancreas. ECU microbiologist Dr. Paul Fletcher believed that scorpion venom might be used as a way to discover how pancreatitis 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 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 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 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

i http://timesofindia.indiatimes.com/life/health-fitness/health/Scorpion-venom-may-help-treat-pancreatitis/articleshow/5742047.cms