SMU-Pancreatitis+Gallbladder+disease
Pancreatitis & Gallbladder Disease
Acute Pancreatitis
Definition: Acute inflammatory process of the pancreas.
Mechanism: Spillage of pancreatic enzymes leads to autodigestion and severe pain.
Severity: Varies from mild edema to severe necrosis; commonly appears edematous and often hemorrhagic.
Clinical Manifestations
Pain:
Location: Predominantly in left upper quadrant or mid-epigastrium, may radiate to the back.
Character: Sudden onset, severe.
Other Symptoms:
Nausea/vomiting
Low-grade fever
Leukocytosis
Hypotension, tachycardia
Jaundice
Decreased or absent bowel sounds
Abdominal skin discoloration:
Grey Turner’s spots
Cullen’s sign
Diagnostic Studies
Imaging:
Abdominal ultrasonography
Abdominal X-ray
Abdominal CT scan
Endoscopic retrograde cholangiopancreatography (ERCP)
Diagnostic Findings
Laboratory Tests:
Serum amylase ↑
Serum lipase ↑
Blood glucose ↑
Urinary amylase ↑
Serum triglycerides ↑
Serum calcium ↓
Goals of Interprofessional Care
Relief of pain.
Prevention or alleviation of shock.
Reduction of pancreatic secretions.
Correction of fluid and electrolyte imbalances.
Prevention or treatment of infections.
Removal of the precipitating cause, if possible.
Interprofessional Care Management
Nutritional Support:
NPO with NG tube to suction.
Enteral or parenteral nutrition.
Small, frequent feedings when able.
Lactated Ringer's solution.
Drug Therapy:
Pain medication.
Proton pump inhibitors.
Antibiotics.
IV calcium gluconate (10%) for symptomatic hypocalcemia.
Albumin if shock present.
Nursing Management / Assessment
Subjective Data:
Pain assessment.
Health history:
Biliary tract disease.
Alcohol use.
Surgery or treatments.
Current medications.
Objective Data:
Vital signs.
Laboratory test results.
Diagnostic study findings.
Abdominal distention/tenderness.
Diminished bowel sounds.
Discoloration of abdomen/flank (e.g., jaundice).
Nursing Diagnoses
Acute pain.
Deficient fluid volume.
Acute imbalanced nutrition.
Ineffective health management.
Planning
Patient will achieve:
Relief of pain.
Normal fluid and electrolyte balance.
Minimal to no complications.
No recurrent attacks.
Nursing Interventions
Pain relief strategies.
Manage nausea and vomiting.
NG tube care, if present.
Oral care.
Monitor diet and tolerance.
Blood glucose monitoring.
Fluid and electrolyte monitoring and replacement.
Wound care and postoperative care.
Evaluation
Outcomes include:
Adequate pain control.
Maintenance of adequate fluid balance.
Understanding of treatment regimen.
Expressing desire to get help for alcohol dependence and smoking cessation, if appropriate.
Gallbladder Disease
Types of Gallbladder Disease
Cholelithiasis:
Most common disorder of biliary system; characterized by stones in the gallbladder.
Cholecystitis:
Inflammation of the gallbladder; usually associated with cholelithiasis.
Clinical Manifestations
Symptoms range from severe to none:
Pain in RUQ or epigastrium.
Tenderness, leukocytosis, fever.
Nausea/vomiting/indigestion.
Dark amber urine, clay-colored stools, pruritus.
Chronic Cholecystitis
Symptoms include:
Fat intolerance.
Clinical dyspepsia.
Heartburn, flatulence.
Complications of Cholecystitis
Severe complications include:
Gangrenous cholecystitis.
Subphrenic abscess.
Pancreatitis.
Cholangitis, biliary cirrhosis.
Fistulas, gallbladder rupture leading to peritonitis.
Choledocholithiasis.
Diagnostic Studies
Laboratory tests:
↑ WBC count, ↑ serum bilirubin level, ↑ urinary bilirubin.
↑ liver enzyme levels, ↑ serum amylase level.
Imaging studies:
Ultrasound.
ERCP and MRCP.
Percutaneous trans-hepatic cholangiography.
Interprofessional Care for Cholelithiasis
ERCP with sphincterotomy:
Visualization, dilation, stenting, stone removal.
Post-ERCP care:
Monitoring for complications, bed rest, NPO until return of gag reflex.
Medical management:
Ursodeozycholic acid and Chenodeozycholic acid.
Oral dissolution therapy for specific cases.
Additional Therapies
Extracorporeal Shock-Wave Lithotripsy (ESWL):
High-energy shock waves disintegrate stones.
Used with bile acids for improved outcomes.
Cholecystitis Management
Cholecystotomy with drainage:
For severe cases or when endoscopic drainage fails.
Postoperative care strategies:
Monitor for complications, ensure proper T-tube function, maintain patient education.
Surgical Therapy for Gallbladder Conditions
Laparoscopic cholecystectomy:
Treatment of choice; minimal postoperative pain.
Allows return to normal activities within 1 week.
Open cholecystectomy:
Traditional approach with a right subcostal incision, T-tube for drain.
Postoperative Care
Laparoscopic:
Monitor for complications, manage CO2 pain and comfort, focus on early ambulation.
Open:
Focus on ventilation, respiratory complications, and drainage maintenance.
Nursing Management / Assessment
Subjective Data: Past medical and medication history, symptom review (pain, nausea, urine/stool changes).
Objective Data: Fever, jaundice, tachycardia, abnormal diagnostic findings.
Nursing Diagnoses for Gallbladder Disease
Ineffective health management.
Impaired nutrition.
Acute pain management.
Fluid and electrolyte imbalances.
Risk for infection.
Nursing Planning and Implementation
Outcome Measures:
Patient pain level < 3, no recurrent attacks, incision site free of infection, euvolemic.
Implementation:
Manage predisposing factors, educate high-risk ethnic groups, promote early detection and low-fat diets.
Post-operative care includes thorough patient monitoring and assessment of complications.
Evaluation
Expected outcomes:
Patient appears comfortable, maintains euvolemia, free from infections, and verbalizes understanding of dietary restrictions.
NCLEX Practice Question
Effective teaching post-laparoscopic cholecystectomy when a patient states:
“I will need to maintain a low-fat diet for life because I no longer have a gallbladder.”
Group Think Scenario
A patient post-op with T-tube placement displaying signs of distress should prompt:
Notify the physician and complete further assessments.