ASKEP PANKREATITIS

Pancreatitis

Konsep Medis Dan

Asuhan Keperawatan

Suatu proses peradangan akut pada pankreas. Derajat peradangan bervariasi dari sedang-

edema-nekrosis.

Acute PancreatitisDefinition

Kebanyakan terjadi pada usia pertengahan. Derajat keperahan penyakit tergantung pada

seberapa besar kerusakan pankreas. Bisa Mengancam Nyawa.

Acute PancreatitisEtiology and

Pathophysiology

Primary etiologic factors are

Biliary tract disease Most common: Gallbladder disease

Alcoholism

Pathophysiology

Less common causes

Trauma (postsurgical, abdominal) Viral infections (mumps, coxsackievirus HIV) Penetrating duodenal ulcer Cysts Idiopathic

Pathophysiology

Less common causes (cont’d)

Abscesses Cystic fibrosis Kaposi’s sarcoma Metabolic disorders Vascular diseases Postop GI surgery

Pathophysiology

Less common causes (cont’d)

Drugs Corticosteroids Thiazide diuretics Oral contraceptives Sulfonamides NSAIDs

Pathophysiology

Caused by autodigestion of pancreas Etiologic factors

Injury to pancreatic cells Activate pancreatic enzymes

Pathophysiology

Acute Pancreatitis

Fig. 44-14

Trypsinogen

Activated to trypsin by enterokinase Inhibitors usually inactivate trypsin Enzyme can digest the pancreas and can

activate other proteolytic enzymes

Pathophysiology

Elastase

Activated by trypsin Plays a major role in autodigestion Causes hemorrhage by producing dissolution of

the elastic fibers of blood vessels

PancreatitisEtiology and

Pathophysiology

Phospholipase A

Plays a major role in autodigestion Activated by trypsin and bile acids Causes fat necrosis

Pathophysiology

PathophysiologyTrypsin Edema, necrosis,

hemorrhageElastase Hemorrhage

Phospholipase A Fat necrosis

Kallikrein Edema, vascular permeability, smooth muscle contraction, shock

Lipase Fat necrosis

Alcohol

May stimulate production of digestive enzymes Increases sensitivity to hormone

cholecystokinin Stimulates production of pancreatic enzymes

Acute Pancreatitis Etiology and

Pathophysiology

Edematous pancreatitis

Mild and self-limiting Necrotizing pancreatitis

Degree of necrosis correlates with severity of manifestations

Pathophysiology

Abdominal pain is predominant symptom

Pain located in the left upper quadrant Pain may be in the midepigastrium Commonly radiates to the back

Acute PancreatitisClinical Manifestations

Abdominal pain (cont’d)

Sudden onset Severe, deep, piercing, steady Aggravated by eating Not relieved by vomiting

Flushing Cyanosis Dyspnea Edema Nausea/vomiting Bowel sounds decreased or absent

Low-grade fever Leukocytosis Hypotension Tachycardia Jaundice Abdominal tenderness

Abdominal distention Abnormal lung sounds

Crackles Discoloration of abdominal wall

Acute PancreatitisClinical

Manifestations

Two significant local complications

Pseudocyst Abscess

Acute PancreatitisComplications

Pseudocyst

Cavity surrounding outside of pancreas filled with necrotic products and liquid secretions

Abdominal pain Palpable epigastric mass

Pseudocyst (cont’d)

Nausea, vomiting, and anorexia Elevated serum amylase May resolve spontaneously within a few weeks

or may perforate, causing peritonitis Treatment: Internal drainage procedure

Pancreatic abscess

A large fluid-containing cavity within pancreas Results from extensive necrosis in the pancreas Upper abdominal pain Abdominal mass

Acute Pancreatitis Complications

Pancreatic abscess (cont’d)

High fever Leukocytosis Requires surgical drainage

Acute Pancreatitis Complications

Main systemic complications

Pulmonary Pleural effusion Atelectasis Pneumonia

Systemic complications (cont’d)

Cardiovascular Hypotension

Tetany (caused by hypocalcemia)

History and physical examination Laboratory tests

Serum amylase Serum lipase 2-hour urinary amylase and renal amylase

clearance

Acute PancreatitisDiagnostic Studies

Laboratory tests (cont’d) Blood glucose Serum calcium Triglycerides

Flat plate of abdomen Abdominal/endoscopic ultrasound Endoscopic retrograde

cholangiopancreatography (ERCP) Chest x-ray

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are needed to see this picture.

CT of pancreas Magnetic resonance

cholangiopancreatography (MRCP)

Objectives include

Relief of pain Prevention or alleviation of shock ↓ of pancreatic secretions Fluid/electrolyte balance Removal of the precipitating cause

Acute PancreatitisCollaborative Care

Conservative therapy

Supportive care Aggressive hydration Pain management

IV morphine Combined with antispasmodic agent

Management of metabolic complications Minimizing stimulation

Conservative therapy (cont’d)

Shock Plasma or plasma volume expanders

(dextran or albumin) Fluid/electrolyte imbalance

Lactated Ringer’s solution Ongoing hypotension

Vasoactive drugs: Dopamine (Intropin) ↑ Systemic vascular resistance

Acute Pancreatitis Collaborative Care

Conservative therapy (cont’d)

Suppression of pancreatic enzymes NPO NG suction

Prevent infections Peritoneal lavage or dialysis

Remove kinin and phospholipase A exudate

Surgical therapy indicated if

Presence of gallstones Uncertain diagnosis Unresponsive to conservative therapy Abscess, pseudocyst, or severe peritonitis

Surgical therapy

ERCP Endoscopic sphincterotomy Laparoscopic cholecystectomy

Drug therapy

IV morphine Nitroglycerin or papaverine Antispasmodics Carbonic anhydrase inhibitor Antacids Histamine (H2) receptor

Nutritional therapy NPO status initially to reduce pancreatic secretion IV lipids

Monitor triglycerides Small, frequent feedings High-carbohydrate, low-fat,

high-protein diet Bland diet

Nutritional therapy (cont’d)

Supplemental fat-soluble vitamins Supplemental commercial liquid preparations Parenteral nutrition No caffeine or alcohol

Health history

Biliary tract disease Alcohol use Abdominal trauma Duodenal ulcers Infection Metabolic disorders

Acute PancreatitisNursing Assessment

Medication usage

Thiazides, estrogens, corticosteroids, NSAIDs

Surgical procedures Nausea/vomiting Dyspnea Severe pain

Physical examination findings

Fever Jaundice Discoloration of abdomen/flank Tachycardia Hypotension Abdominal distention/tenderness

Abnormal laboratory findings

↑ Serum amylase/lipase Leukocytosis Hyperglycemia Hyperlipidemia Hypocalcemia Abnormal ultrasound/ CT/ ERCP

Acute pain Deficient fluid volume Imbalanced nutrition: Less than body

requirements Ineffective therapeutic regimen management

Acute PancreatitisNursing Diagnoses

Overall goals

Relief of pain Normal fluid and electrolyte balance Minimal to no complications No recurrent attacks

Acute PancreatitisPlanning

Health promotion

Assessment of predisposing factors Early diagnosis/treatment of cholelithiasis Eliminate alcohol intake

Acute PancreatitisNursing

Implementation

Acute intervention Monitor vital signs IV fluids Observe for side effects of medications Assess respiratory function Pain assessment and management

Frequent position changes Side-lying with HOB elevated 45 degrees Knees up to abdomen

Implementation

Acute intervention (cont’d) Fluid/electrolyte balance

Blood glucose monitoring Monitor for signs of hypocalcemia

Tetany (jerking, irritability, twitching) Numbness around lips/fingers Positive Chvostek or Trousseau sign

Monitor for hypomagnesemia

Implementation

Acute intervention (cont’d)

NG tube care Frequent oral/nasal care Observe for signs of infection Wound care Observe for paralytic ileus, renal failure, mental

changes

Implementation

Ambulatory and home care

Physical therapy Counseling regarding abstinence from alcohol,

caffeine, and smoking Assessment of narcotic addiction

Implementation

Ambulatory and home care (cont’d)

Dietary teaching High-carbohydrate, low-fat diet

Patient/family teaching Signs of infection, high blood glucose, steatorrhea Medications/diet

Implementation

Expected outcomes

Maintains adequate fluid volume Maintains weight appropriate for height Food and fluid intake adequate to meet

nutritional needs

Implementation

Expected outcomes (cont’d)

Describes therapeutic regimen Expresses commitment to lifestyle changes

Implementation

Continuous, prolonged inflammatory, and

fibrosing process of the pancreas Pancreas becomes destroyed as it is replaced

by fibrotic tissue Strictures and calcifications can also occur

Chronic PancreatitisDefinition

May follow acute pancreatitis May occur in absence of any history of acute

condition Two major types

Chronic obstructive pancreatitis Chronic calcifying pancreatitis

Chronic PancreatitisEtiology and

Pathophysiology

Chronic obstructive pancreatitis Associated with biliary disease

Most common cause Inflammation of the sphincter of Oddi associated with

cholelithiasis

Other causes include Cancer of ampulla of Vater, duodenum, or pancreas

Pathophysiology

Chronic calcifying pancreatitis

Inflammation Sclerosis

Mainly in the head of the pancreas and around the pancreatic duct

Pathophysiology

Most common form of chronic pancreatitis May be referred to as alcohol-induced

pancreatitis

Pathophysiology

Ducts are obstructed with protein precipitates Precipitates block the pancreatic duct and

eventually calcify

Pathophysiology

Calcification is followed by fibrosis and glandular atrophy

Pseudocysts and abscesses commonly develop

Pathophysiology

Abdominal pain

Located in the same areas as in acute pancreatitis

Heavy, gnawing feeling; burning and cramp-like Abdominal tenderness Malabsorption with weight loss

Chronic PancreatitisClinical Manifestations

Constipation Mild jaundice with dark urine Steatorrhea Frothy urine/stool Diabetes mellitus

Chronic PancreatitisClinical Manifestations

Complications include

Pseudocyst formation Bile duct or duodenal obstruction Pancreatic ascites Pleural effusion

Chronic PancreatitisClinical

Manifestations

Complications (cont’d)

Splenic vein thrombosis Pseudoaneurysms Pancreatic cancer

Chronic PancreatitisClinical

Manifestations

Confirming diagnosis can be challenging Based on signs/symptoms, laboratory studies,

and imaging

Chronic PancreatitisDiagnostic Studies

Laboratory tests

Serum amylase/lipase May be ↑ slightly or not at all

↑ Serum bilirubin ↑ Alkaline phosphatase

Laboratory tests (cont’d)

Mild leukocytosis Elevated sedimentation rate

ERCP Visualize pancreatic/common bile duct

CT MRI MRCP Transabdominal ultrasound

Endoscopic ultrasound Secretin stimulation test

Assess degree of pancreatic function Not useful in diagnosis

Prevention of attacks

During acute attack follow acute therapy Relief of pain Control of pancreatic exocrine and endocrine

insufficiency

Chronic PancreatitisCollaborative Care

Bland low-fat, high-carbohydrate diet Bile salts

Help absorption of fat-soluble vitamins Prevent further fat loss

Control of diabetes No alcohol

Pancreatic enzyme replacement Acid-neutralizing and acid-inhibiting drugs

Surgery

Indicated when biliary disease is present or if obstruction or pseudocyst develops

Divert bile flow or relieve ductal obstruction

Focus is on chronic care and health promotion

Dietary control No alcohol

Control of diabetes Taking pancreatic enzymes Patient and family teaching

Chronic PancreatitisNursing Management

ASKEP PANKREATITIS

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