When caring for a client with acute pancreatitis The nurse should use which comfort measures?

Inhaltsverzeichnis Show

Treatment of Acute Pancreatitis
Nutritional Support
Pain Control
Treatment of Underlying Issues
Endoscopic Retrograde Cholangiopancreatography (ERCP)
Antioxidant therapies
Treatment Considerations for Severe Acute Pancreatitis
Nursing Care Plans
Recommended Resources

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In most cases, acute pancreatitis resolves with therapy, but approximately 15% of patients develop severe disease.3 Severe acute pancreatitis can lead to life-threatening failure of multiple organs and to infection. Therefore, it is extremely important to seek medical attention if experiencing signs or symptoms of acute pancreatitis. Several clinical risk-scoring systems are available to help physicians predict who is most likely to develop severe acute pancreatitis. These scores rely on several pieces of clinical data collected at admission and during the first 48 hours of hospitalization. Commonly used scoring systems include:

The Bedside Index of Severity in Acute Pancreatitis (BISAP)
The Ranson criteria
The APACHE II score

Treatment of Acute Pancreatitis

Fluids

One of the primary therapies for acute pancreatitis is adequate early fluid resuscitation, especially within the first 24 hours of onset. Pancreatitis is associated with a lot of swelling and inflammation. Giving fluids intravenously prevents dehydration and ensures that the rest of the organs of the body get adequate blood flow to support the healing process.

Nutritional Support

Initially, no nutrition is given to rest the pancreas and bowels during the first 24 to 48 hours. After 48 hours, a plan to provide nutrition should be implemented because acute pancreatitis is a highly active state of inflammation and injury that requires a lot of calories to support the healing process. In most cases, patients can start to take in food on their own by 48 hours. If this is not possible, then a feeding tube that is passed through the nose into the intestines can be used to provide nutrition. This method is safer than providing nutrition intravenously. There is no benefit to using probiotics for acute pancreatitis.

Pain Control

Intravenous medications, typically potent narcotic pain medications, are effective in controlling pain associated with acute pancreatitis. Nausea is a common symptom and can be due to pancreatic inflammation as well as slowing of the bowels. Effective intravenous medications are available for nausea. Pain and nausea will decrease as the inflammation resolves.

Treatment of Underlying Issues

In addition to providing supportive care, underlying causes need to be promptly evaluated. If the acute pancreatitis is thought to be due to gallstones, medication, high triglycerides, or high calcium levels within the patient’s body (or other external causes), directed therapy can be implemented.

Endoscopic Retrograde Cholangiopancreatography (ERCP)

ERCP is a procedure in which a physician with specialized training passes a flexible, thin tube with a camera attached to the end through the patient’s mouth and into the first part of the small intestine, where the bile duct and pancreatic duct exit. With this device, a small catheter can be passed into the bile duct to remove gallstones that might have gotten stuck and are the cause of pancreatitis. In certain situations, a special catheter can also be passed into the pancreatic duct to help the pancreas heal. For more information on ERCP, please click here.

The Following Procedures can be Performed With ERCP:

Using a small wire on the endoscope, a physician finds the muscle that surrounds the pancreatic duct or bile duct and makes a tiny cut to enlarge the duct opening. When a pseudocyst is present, the duct is drained.
The endoscope is used to remove pancreatic or bile duct stones with a tiny basket. Gallstone removal is sometimes performed along with a sphincterotomy.
Using the endoscope, a physician places a tiny piece of plastic or metal that looks like a straw into a narrowed pancreatic or bile duct to keep it open.
Some endoscopes have a small balloon that a physician uses to dilate, or stretch, a narrowed pancreatic or bile duct. A temporary stent can be placed for a few months to keep the duct open.

It is well documented that one of the main side effects of ERCP is pancreatitis; however, there are several clearly defined situations when urgent ERCP is indicated for acute pancreatitis.

Antioxidant therapies

Basic and clinical evidence suggests that the development of both acute pancreatitis (AP) and chronic pancreatitis (CP) can be associated with oxidative stress. Findings show that free radical activity and oxidative stress indices are higher in the blood and duodenal juice of patients with pancreatitis.

Based on these findings, the idea of using antioxidant regimens in the management of both AP and CP as a supplement and complementary in combination with its traditional therapy is reasonable. In practice, however, the overall effectiveness of antioxidants is not known, and the best mixture of agents and dosages is not clear. Currently, a trial of a mixture of antioxidants containing vitamin C, vitamin E, selenium, and methionine is reasonable as one component of overall medical management.

In summation, there is no definite consensus on the dosage, length of therapy, and ultimately, the benefits of antioxidant therapy in the management of AP or CP. Further well-designed clinical studies are needed to determine the appropriate combination of agents, time of initiation, and duration of therapy.

Treatment Considerations for Severe Acute Pancreatitis

Necrotizing pancreatitis:

The definition of severe acute pancreatitis includes cases in which a portion of pancreatic tissue is no longer viable because of injury—this is called necrosis. Over time, the body will resorb this dead tissue. In some cases, this dead tissue can become a source of infection. When infection is suspected, diagnosis can be made by needle biopsy, and if confirmed, medical treatment with antibiotics is required along with consideration of drainage.

Pancreatitis is a disease in which the pancreas (the large gland behind the stomach and next to the small intestine) becomes inflamed. It is the painful inflammatory condition in which the enzymes of the pancreas are prematurely activated resulting in autodigestion of the pancreas. The common cause of pancreatitis are biliary tract disease and alcoholism, but can also result from such things as abnormal organ structure, blunt trauma, penetrating peptic ulcers, and drugs such as sulfonamides and glucocorticoids.

Pancreatitis may be acute or chronic, with symptoms mild to severe.

Acute pancreatitis is a sudden inflammation that lasts for a short time. It may range from mild discomfort to a severe, life-threatening illness.
Chronic pancreatitis is long-lasting inflammation of the pancreas. It most often happens after an episode of acute pancreatitis.

Nursing Care Plans

Nursing care management of patients with pancreatitis includes relief of pain and discomfort caused by pancreatitis, improvement of nutritional status, improving respiratory function, and improvement of fluid and electrolyte status.

Here are eight (8) nursing care plans (NCP) and nursing diagnosis for patients with pancreatitis:

Nursing Diagnosis

May be related to

Obstruction of pancreatic, biliary ducts
Chemical contamination of peritoneal surfaces by pancreatic exudate/autodigestion of pancreas
Extension of inflammation to the retroperitoneal nerve plexus

Possibly evidenced by

Reports of pain
Self-focusing, grimacing, distraction/guarding behaviors
Autonomic responses, alteration in muscle tone

Desired Outcomes

Report pain is relieved/controlled.
Follow prescribed therapeutic regimen.
Demonstrate use of methods that provide relief.

Nursing Interventions	Rationale
Investigate verbal reports of pain, noting specific location and intensity (0–10 scale). Note factors that aggravate and relieve pain.	Pain is often diffuse, severe, and unrelenting in acute or hemorrhagic pancreatitis. Severe pain is often the major symptom in patients with chronic pancreatitis. Isolated pain in the RUQ reflects involvement of the head of the pancreas. Pain in the left upper quadrant (LUQ) suggests involvement of the pancreatic tail. Localized pain may indicate development of pseudocysts or abscesses.
Maintain bedrest during acute attack. Provide quiet, restful environment.	Decreases metabolic rate and GI stimulation and secretions, thereby reducing pancreatic activity.
Promote position of comfort on one side with knees flexed, sitting up and leaning forward.	Reduces abdominal pressure and tension, providing some measure of comfort and pain relief. Note: Supine position often increases pain.
Provide alternative comfort measures (back rub), encourage relaxation techniques (guided imagery, visualization), quiet diversional activities (TV, radio).	Promotes relaxation and enables patient to refocus attention; may enhance coping.
Keep environment free of food odors.	Sensory stimulation can activate pancreatic enzymes, increasing pain.
Administer analgesics in timely manner (smaller, more frequent doses).	Severe and prolonged pain can aggravate shock and is more difficult to relieve, requiring larger doses of medication, which can mask underlying problems and complications and may contribute to respiratory depression.
Maintain meticulous skin care, especially in presence of draining abdominal wall fistulas.	Pancreatic enzymes can digest the skin and tissues of the abdominal wall, creating a chemical burn.
Administer medication as indicated:
Narcotic analgesics: meperidine (Demerol), fentanyl (Sublimaze), pentazocine (Talwin);	Meperidine is usually effective in relieving pain and may be preferred over morphine, which can have a side effect of biliary-pancreatic spasms. Paravertebral block has been used to achieve prolonged pain control. Note:Pain in patients whohave recurrent or chronic pancreatitis episodes may be difficult to manage because they may become dependent on the narcotics given for pain control.
Sedatives: diazepam (Valium); antispasmodics: atropine;	Potentiates action of narcotic to promote rest and to reduce muscular and ductal spasm, thereby reducing metabolic needs, enzyme secretions.
Antacids: Mylanta, Maalox, Amphojel, Riopan;	Neutralizes gastric acid to reduce production of pancreatic enzymes and to reduce incidence of upper GI bleeding.
Cimetidine (Tagamet), ranitidine (Zantac), famotidine (Pepcid)	Decreasing secretion of HCl reduces stimulation of the pancreas and associated pain.
Withhold food and fluid as indicated.	Limits and reduces release of pancreatic enzymes and resultant pain.
Maintain gastric suction when used.	Prevents accumulation of gastric secretions, which can stimulate pancreatic enzyme activity.
Prepare for surgical intervention if indicated.	Surgical exploration may be required in presence of intractable pain and complications involving the biliary tract, such as pancreatic abscess or pseudocyst.

Recommended Resources

Recommended nursing diagnosis and nursing care plan books and resources.

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Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
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NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
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