MED SURG 2: EXAM 1

4 main pancreatic enzymes

amylase

trypsin

lipase

elastase

what does amylase break down

carbs

what does trypsin and elastase break down

protein

what does lipase break down

fats

where are pancreatic enzymes activated

small intestine

where are the enzymes activated during pancreatitis

in the pancreas

why are pancreatic enzymes activated early

the pancreatic duct is blocked and they leak into the pancreas

lipolysis role in pancreatitis

breaks down fats which pull calcium out of bloodstream to cause hypocalcemia

proteolysis role in pancreatitis

\-trypsin is activated which breaks down the protein

\-that is auto digested by pancreas

\-pancreas becomes inflammed

role of blood vessel necrosis in pancreatitis

\-broken down proteins obstruct BV

\-leads to thrombosis and gangrene in the pancreas

\-results in necrotizing pancreatitis

role of hemorrhage in pancreatitis

damaged pancreatic blood vessels d/t activated elastase

role of diffuse inflammation in pancreatitis

severe pancreatitis causes activation of cytokines that trigger inflammation all over

most common causes of pancreatitis

gallstones and alcohol abuse

how do gallstones cause pancreatitis

stones block common bile duct which causes everything to back up and activates the enzymes

how does alcohol cause pancreatitis

byproducts are toxic and cause leaking of enzymes into the pancreas

drugs that can damage the pancreas

corticosteroids (presidone)

thiazide diuretics(HCTZ)

birth control

other causes of pancreatitis

unkown/idiopathic

trauma to pancreas

drugs

mumps

hypercalcemia

high triglyceride levels

normal triglyceride levels

150

where does pancreatitis pain present

mid-epigastric area and radiates to left to the back

which position should be avoided with pancreatitis

supine, they will usually curl up into fetal postion to avoid stretching out the pancreas

what can nausea and vomiting lead to

dehydration and weight loss

why does vomiting with pancreatitis occur

back up of contents into the stomach

s/sx of pancreatitis

pain

n/v

jaundice

brusing

peritonitis

Cullens sign vs Grey Turners sign

Cullens: blue/grey discoloration of abdomen/umbilical area

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Grey Turners: flank and retroperitoneal bleeding

what is Cullens sign/Grey Turners sign an indication of

internal bleeding

type of bowel sounds with pancreatitis

hyperactive or absent

sign that pancreatitis has caused peritonitis

rigid/board like abdomen

labs uses to diagnose pancreatitis

serum amylase

serum lipase

LFTs

albumin

serum calcium/magnesium

hyperglycemia

triglycerides

WBC

which lab is most definitive for pancreatitis

serum lipase

effects of pancreatitis on amylase and lipase

elevates it

effects of pancreatitis on LFT

AST, ALT elevate if there is liver damage

effects of pancreatitis on albumin

decreases it due to protein breakdown

effects of pancreatitis on Ca and Mg

decreases if severe

effects of pancreatitis on glucose

body is in overdrive and glucagon is excessively released

effects of pancreatitis on triglycerides

indicates cause of pancreatitis if levels are above 1000

effects of pancreatitis on WBC

activates WBC breakdown d/t inflammation

imaging used for pancreatitis diagnosis

ultrasound and CT scan

when is ERCP used for diagnosing pancreatitis

want to know if stones are still present

purpose of ERCP for pancreatitis

find and extract stones

why should ERCP be avoided for acute pancreatitis

can further release enzymes

2 main types of pancreatitis

interstitial edematous and necrotizing

which type of pancreatitis can cause shock

necrotizing

what should be our primary concern with any acute/chronic condition

what could kill them

2 primary concerns with pancreatitis

hypovolemia (circulation)

severe uncontrolled pain

complications of severe acute pancreatitis

peritonitis

bowel obstruction

acute renal failure

hyperglycemia

pleural effusion

penumona

what would indicate renal failure in acute severe pancreatitis

increase creatine and BUN

decreased GFR

most severe complications of severe acute pancreatitis

hypovolemic shock

DIC (small clots everywhere)

organ failure

how can pleural effusion occur due to pancreatitis

enzymes enter the pleural space because of inflammation response

sign that the patient has DIC

petichiae on upper body and increased PT time

which of the ABC’s are of most concern with pancreatitis

breathing and circulation

how should breathing concerns be addressed with pancreatitis

used incentive spirometer hourly and place in semi fowlers

how should circulation concerns be managed with pancreatitis

use large bore IV to deliver normal saline

how is pain managed with pancreatitis

opioids (morphine or dilaudid)

which minerals do we want to replace with pancreatitis

Ca and Mg

signs of hypocalcemia (TWITCH)

Trousseau’s sign

arrhythmias

increase in bowel sounds/diarrhea

tetany

Chvostek’s sign

hypotension

very 1st sign of hypocalcemia

numbness/tingling around the mouth

1st reason a NG tube is being used

gastric decompression

why is an NG tube used for pancreatitis

take away gastric juices to allow for less stimulation

why would an H2 receptor blocker be given for management of pancreatitis

reduces gastric acid secretions to allow for less stimulation

where is bile made

liver

which enzyme stimulates the gallbladder to release bile

cholecystokinin

what is cholecystitis

gallbladder inflammation

what makes up gallstones

cholesterol

2 types of cholecystitis

calculous and acalculous

what is a calculous cholecystitis

inflammation caused by gallstones

5 risk factors to cholecystitis (5 f’s)

female

forty or more

fat

fertile

fair (white)

where is cholecystitis pain located

RUQ and can radiate to right shoulder

trigger for cholecystitis pain

high fat meal

other assessments that indicate cholecystitis

rebound tenderness and positive murphy’s sign

what does a positive murphy’s sign mean

hook hand under the rib and have patient take a breath, if there is pain then it is positive

additional s/sx of cholecystitis

n/v

indigestion

belching

gas

abdominal fullness

fever

tachycardia from dehydration

which is the 1st test done to diagnose cholecystitis

ultrasound- to find stones

why is a HIDA scan done for cholecystitis

helps find stones in the bile duct using gamma rays

why is ERCP done for cholecystitis

visualizes stones in the ampula of Vater

which kind of surgery is preferred for cholecystitis

laparoscopic

when is a laparotomy preferred for cholecystitis

patients with very inflamed gallbladders, obstructions, or perforations

drawbacks with laparotomies

longer recovery and increased pain management

preparations prior to gallbladder removals

pain relief

antibiotics

NPO

NG tube if vomiting

labs

what is important with a basic metabolic panel for cholecystitis

check electrolytes, if K+ is low then patient can undergo cardiac arrest

what is important with taking CBCs for cholecystitis

check for low hemoglobin, this can lead to hypovolemic shock

post op assessment for cholecystitis

ABCs (airway)

vitals

check incisions for bleeding

physical assessment

pain relief methods post op for cholecystitis

oral or IV opioids (Norco)

what other meds are given post op for cholecystitis

Zofran

post op education for cholecystitis

use incentive spirometer

liquids and low fat solids to start

ambulation

no heavy lifting or strenuous activity

what is appendicitis

inflammation of the appendix

who is most at risk for developing appendicitis

young adults

2 causes of appendicitis

fecaliths

infection

what are fecaliths

fecal stones that block the appendix

patho of appendicitis

the lumen of the appendix is blocked which causes increased pressure and inflammation

complications with appendicitis

abscesses

gangrene

perforation that leads to peritonitis

type of pain associated with appendicitis

dull and steady ache

location of appendicitis pain

periumbilical area and moves toward RLQ

s/sx of appendicitis

pain

n/v

fever

anorexia

diarrhea or constipation

what are we concerned about with sudden pain relief with appendicitis

the appendix has perforated

physical tests done for appendicitis

rebound tenderness

rovsing’s sign

obturator test

iliopsoas test

what is rovsing’s sign

pressure is applied over LLQ and pain is felt in the RLQ

diagnostic factors for appendicitis

elevated WBC

ultrasound

CT

what does a WBC level of 20,000/mm3 indicate with appendicitis

appendix has perforated

surgeries for appendicitis

laparoscopic or open appendectomy

when would an open appendectomy be used over a laparoscopic one

perforated appendix or patient has peritonitis