Question

FC is a 54-year-old man with a history of chronic heavy alcohol use. Last year, he had gastrointestinal bleeding for which he was hospitalized. Recently, he was hit by a car and was hospitalized for a broken leg which was treated with open reduction and internal fixation. On post op day 2, he complains of a steady pain in the epigastrium that radiates to his back. He refuses breakfast and states, “I feel like throwing up.” The nurse notes decreased bowel tones. Vital signs are as follow:

BP 110/65

HR 100

Temp 100 F

RR 20

02 Saturation 96% on RA

Labs:

Amylase 350 units/L

Lipase 420 units/L

ALT: 60 units/L

AST: 120 units/L

Alk phos 100 units/L

Bilirubin (total) 0.15

1. What diagnosis should the nurse suspect? Why?

2. What are Frank’s risk factors for this diagnosis?

3. What orders might the nurse expect?

Answer 1

What diagnosis should the nurse suspect? Why?

answer:

The nurse should suspect the diagnosis of acute pancreatitis because of the following reasons.

1.Steady pain in the epigastrium radiating to the back :patient symptomatology

Patient complaints of pain radiating to the back with feeling of nausea or throwing up. Since pancreas is a retroperitoneal organ,the irritation of the pancreatic nerves due to inflammation causes the pain referred to the back. The patient's symptomatology of the steady epigastric pain radiating to the back provides the clue to suspect the diagnosis of pancreatitis.

2.The presence of risk factors for pancreatitis which include chronic alcoholism and blunt abdominal trauma should make nurse suspect pancreatitis.

2a]The patient is a chronic alcoholic. Alcohol damages the pancreas by causing episodes of inflammation of the pancreas predisposing the patient to acute pancreatitis.

Alcohol causes inflammation of the pancreatic parenchyma which causes the release of enzymes trypsinogen[active form trypsin]into the pancreatic parenchyma and initiates the cascade of pancreatic inflammation and destruction causing acute pancreatitis changes.

2b]. The patient has history of blunt trauma. Frank was hit by a car recently and operated for fracture two day's back.Blunt trauma upper abdomen and lower chest is a risk factor for pancreatitis as the pancreas is retroperitoneal organ abutting the spinal column.Blunt abdominal injuries which creates crushing pressure by pressing the pancreas on to the vertebral bodies can cause pancreatic damage and traumatic pancreatitis

3.The labs show elevation in the levels of Amylase,Lipase which are Amylase350 units/L and Lipase 420 units/L respectively.

The normal blood levels of serum amylase are around 25 to 85 units per litre and normal lipase levels are 0 to 140 units per liter depending upon the lab references. High level of lipase  is an indicator of pancreatitis and this is specific for diagnosis of pancreatitisThe levels of serum amylase and lipase are elevated for the patient ,hence acute pancreatitis .Serum lipase levels are specific for the diagnosis of acute pancreatitis.

Since the patient has elevated serum lipase levels ,the nurse must suspect the diagnosis of acute pancreatitis for Frank.

What are Frank’s risk factors for this diagnosis?

answer:

Frank’s risk factors for this diagnosis are

a] chronic alcoholism:

Frank has a history of chronic heavy alcohol use. Chronic alcoholism is one of the major risk factors for pancreatic parenchymal injury. Ethanol sensitizes the pancreas and causes inflammation .There is release of  the inactive pancreatic enzymes trypsinogen[active form trypsin]into the pancreatic parenchyma causing pancreatic inflammation and destruction. Chronic alcoholism is a major risk factor for acute and chronic  pancreatitis.

b] trauma

Blunt trauma abdomen and lower chest is a risk factor for pancreatitis as the pancreas is retroperitoneal organ abutting the spinal column.Blunt abdominal injuries/crush injuries which creates crushing pressure by pressing the pancreas on to the vertebral bodies can cause pancreatic damage and traumatic pancreatitis

Frank was hit by a car recently and operated for fracture 2 days  back, there is a possibility of trauma to the upper abdomen and injury to  pancreas and post traumatic pancreatitis.(delayed manifestation]

The other risk factors for pancreatitis included gallstones, steroids intake, drugs like nonsteroidal anti-inflammatory drugs , diuretics, azathioprine ,autoimmune diseases like systemic lupus erythematosus, post ERCP , hypercalcemic states and so on.The concomitant presence of these all also need to be investigated /ruled out for Frank.

What orders might the nurse expect?

Answer:

The orders the nurse expects for Frank along with their rationale are detailed below

1. TPR charting, input-output charting,NPO, IV Fluids hydration, electrolytes monitoring and administration may be advised.

Pancreatitis is an inflammatory process and is accompanied with fluid and electrolyte imbalances. The patient is unable to eat anything .So maintaining the patient hydration by IV Fluids administration  and strict input output monitoring is required .There is a risk of hypotension in severe pancreatitis and hence the IV fluids must be carefully titrated as per the patients hydration and urine output status

NPO on nil per oral status is advised in acute pancreatitis to limit the release of pancreatic enzymes secretion and the pancreatic pain.

.2. Injectable/oral antacids

The gastric acidity stimulates the release of the pancreatic enzymes and aggravates the symptoms of pancreatitis. Neutralizing the acidity of the stomach by administering antacids will help to relieve the symptoms of pancreatitis and also help to relieve the symptoms of nausea.

In view of previous history of upper gastrointestinal bleeding that the patient has,the use of antacid will also prevent bleeding episodes from alcoholic gastritis.

3.pain relief medications.

The nurse expects this prescription order because the patients of pancreatitis have severe pain and needs relief from pain. Meperidine is the drug of choice for pain relief along with the Fentanyl and pentazocine. Morphine is avoided on account of its action on the pancreatic sphincter leading to sphincter spasm and worsening of the pancreatitis is symptoms.

4.Ryle tube insertion and aspiration:

Decompressing the stomach and decreasing the gastric acidity help to relieve the symptoms of acute pancreatitis by decreasing the the pancreatic secretion and inflammation and hence this order is anticipated.

5.Intravenous broad-spectrum antibiotics.

There is a risk of infection in acute pancreatitis with risk of development of infected pancreatic fluid collections or pancreatic abscess due to the infection of the pancreatic parenchyma. Hence prophylactic antibiotics are advised in acute pancreatitis.

6.Antiemetics.

The patient is having nausea and throwing up.The antiemetics drugs may are advised for symptomatic relief as also to provide gastrointestinal rest and decrease the intestinal secretions and resolve pancreatitis.

7.Random blood sugar levels, monitoring the blood glucose levels, insulin drip in cases of high blood sugars recording

This physician order is expected because pancreatitis is often associated with alterations in the blood glucose levels due to beta cell dysfunction and systemic insulin resistance.

Since the secretion of insulin from the pancreas is affected in patients of acute pancreatitis, there is a possibility of alterations of the blood sugar level. The stimulation of the sympathetic nervous system causes release of glucagon which elevates the blood sugar and pancreatic inflammation decreases the release of insulin which causes increase in the blood sugar by preventing its utilization and internalization into the body cells.

8.CBC, pancreatic function tests ,liver function tests, the renal function tests,electrolytes tests to be performed

This physician order is expected to ask for complete labs  diagnostic profile of the patient. Elevations of the serum levels of lipase confirms the diagnosis of acute pancreatitis and its trend indicates the resolution of the disease.

9.CT Scan prescription

The order for CT abdomen may be expected from the physician.CT Scan in acute pancreatitis reveals extent of damage that has occurred to the pancreas including the presence or absence of fluid collections or pancreatic necrosis

10.. injection octreotide

Somatostatin or octreotide[Long acting somatostatin analogues] is the hormone that inhibits the release of the pancreatic enzymes and thereby offers anti inflammatory control of the pancreatitis process.The somatostatin /octreotide injection prescription may be added to the patient's orders by the physician as per the practice of the place.