Pancreatitis is inflammation of the pancreas. It occurs when enzymes in the pancreas start digesting their own tissue, known as autodigestion. Symptoms can range from mild to severe, with pancreatitis being acute or chronic. Acute pancreatitis will cause severe abdominal pain and tenderness, along with abdominal distention, nausea, vomiting, and fever. Chronic pancreatitis may also present with the same symptoms, or it may be asymptomatic.
In this article:
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Deficient Knowledge
- Imbalanced Nutrition: Less Than Body Requirements
- Ineffective Tissue Perfusion
Nursing Process
Nurses can expect to care for patients with pancreatitis in inpatient settings. The pain associated with inflammation and the need for IV fluids requires some patients with pancreatitis to be hospitalized. The nurse can also expect to provide education regarding lifestyle changes such as avoiding alcohol and smoking and making diet changes.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to pancreatitis.
Review of Health History
1. Identify the patient’s general symptoms.
Acute pancreatitis occurs as the pancreas tries to recover from an injury. It may cause the following symptoms:
- Nausea and vomiting
- Rapid heartbeat
- Sudden, severe epigastric abdominal pain
- Diarrhea
2. Assess for signs of the deteriorating pancreas.
Chronic pancreatitis shows signs of deterioration over time, such as:
- Bloating and discomfort after eating
- Unintentional weight loss
- Loss of appetite
3. Investigate the abdominal pain further.
Abdominal pain is the main symptom of pancreatitis. Pancreatitis can cause moderate to severe dull abdominal pain that develops suddenly. It can radiate to the back or below the left shoulder blade. Acute pancreatitis is more severe and penetrating in nature. When palpated, the abdomen may feel tender. The degree of pain can change for chronic pancreatitis. It may be intermittent, but it usually does not disappear entirely. Abdominal pain is common after eating with chronic pancreatitis.
4. Determine the patient’s risk factors.
The following modifiable factors raise the risk of pancreatitis:
- Obesity: Raises the risk of pancreatitis due to increased insulin levels and the unregulated breakdown of fats.
- Diet: Processed and red meats and saturated fats raise triglyceride levels and increase the likelihood of acute pancreatitis.
- Smoking: Increases the risk of developing chronic pancreatitis due to damage and changes in the function of the pancreas.
- Alcohol consumption: Excessive and chronic alcohol consumption is the most common cause of pancreatitis.
5. Collect the patient’s family history.
Inquire if the patient has family members with chronic pancreatitis. This increases the risk, especially when combined with other risk factors.
6. Review the patient’s medical history.
Look for the following conditions that can cause pancreatitis:
- Gallstones
- Viral infections
- Autoimmune diseases
- Inherited gene mutations
- Cystic fibrosis
- High blood triglyceride levels (hypertriglyceridemia)
- High blood calcium levels (hypercalcemia)
- Restricted blood supply (Ischemia)
- Cancer
- Traumatic injury to the pancreas
- Surgical procedures that damage the pancreas
- Conditions that affect the blood flow to the pancreas (such as ischemia or vasculitis – inflamed blood vessels)
- Medications affecting the pancreas
Physical Assessment
1. Conduct a thorough physical examination.
Assess the following symptoms of acute or chronic pancreatitis:
- General: fever, restlessness
- CNS: decreased mentation
- HEENT: yellowish eyes
- Respiratory: tachypnea, basilar rales upon auscultation
- Cardiovascular: tachycardia, hypotension
- Gastrointestinal: abdominal tenderness, abdominal guarding, distention, vomiting blood (hematemesis), black tarry stool (melena), clay-colored stool, greasy stool (steatorrhea), epigastric abdominal pain, or abdominal pain that radiates to the back
- Genitourinary: dark urine
- Integumentary: yellowing skin (jaundice), itchy skin (pruritus), pale skin, diaphoresis
2. Auscultate the bowel sounds.
Diminished or absent bowel sounds are expected if an ileus is present during auscultation for acute pancreatitis.
3. Check for pancreatic necrosis or hemorrhaging.
- Cullen sign-bleeding in the peritoneum causes bluish discoloration around the umbilicus.
- Grey-Turner sign-bleeding at the back of the peritoneum results in ecchymosis along the flanks. Commonly seen along with Cullen’s sign.
- Fox’s sign-retroperitoneal bleeding causes bruising over the inguinal ligament.
Diagnostic Procedures
1. Collect blood samples for testing.
White blood cells, kidney function, liver enzymes, and pancreatic enzyme levels will be monitored.
2. Check the blood glucose.
Blood glucose test results reveal the capability of the pancreas to produce insulin adequately. With pancreatitis, glucose levels will be elevated.
3. Send stool samples to be examined.
The stool elastase test checks the adequacy of digestive enzymes, while fecal fat analysis reveals fat malabsorption manifested by excess fat in the stool (steatorrhea).
4. Review the imaging scan findings.
- Computed tomography (CT scan) of the abdomen visualizes the presence of gallstones and the extent of pancreatitis. It is indicated for severe acute pancreatitis.
- Ultrasound of the abdomen is the recommended initial test for inflammation of the pancreas and gallstones.
- Endoscopic ultrasound is used primarily to detect pancreatic or bile duct inflammation and obstructions.
- Magnetic resonance imaging (MRI) scan shows gallbladder, pancreas, and duct abnormalities.
- Endoscopic retrograde cholangiopancreatography (ERCP) is not the first-line diagnostic test for pancreatitis. Caution is used due to the high risk of infection and organ perforation.
- Magnetic resonance cholangiopancreatography (MRCP) is noninvasive and safer than ERCP to visualize biliary and pancreatic ducts.
5. Determine prognosis and the level of care.
The severity of acute pancreatitis can range from mild to severe. Persistent SIRS (systemic inflammatory response syndrome), Glasgow coma scale >3, APACHE score >8, or a Ranson score >3 require admission to an intensive care unit.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you’ll learn more about possible nursing interventions for a patient with pancreatitis.
Initiate Supportive Care
1. Resuscitate with fluids.
Within the first 24 hours, patients require rapid intravenous (IV) hydration. Aggressive fluid resuscitation is crucial, especially in the early stages of pancreatitis. Patients should be kept NPO if nausea, vomiting, or abdominal pain is present.
2. Follow the guidelines in fluid resuscitation.
The American College of Gastroenterology guidelines recommends IV of Ringer’s lactate. LR is the preferred crystalloid and has been shown to reduce systemic inflammation in acute pancreatitis.
3. Do not overhydrate.
Overhydration can result in higher rates of sepsis and mortality. Insert a urinary catheter to monitor intake and output closely.
4. Use antibiotics cautiously.
Non-infected pancreatitis does not benefit from antibiotics.
5. Consider enteral feeding.
Enteral feedings may begin once abdominal pain subsides. This is accomplished through a nasogastric (NG) tube.
6. Anticipate the possibility of TPN use.
Total parenteral nutrition (TPN) may be advised for patients who cannot tolerate NG feedings. The TPN solution contains enough fat emulsions to prevent essential fatty acid insufficiency.
7. Manage the pain.
Intense pain is associated with pancreatitis. Opioids and patient-controlled analgesia (PCA) are necessary for pain control.
Manage Pancreatitis
1. Treat the underlying condition.
Assess and treat the underlying cause of pancreatitis once it has been controlled. Necrotizing pancreatitis, gallstone pancreatitis, alcohol-induced pancreatitis, and more will require different interventions.
2. Prepare for surgical or invasive procedures.
Minimally invasive or traditional surgical procedures can be done to remove the cause of pancreatitis.
- Endoscopic retrograde cholangiopancreatography (ERCP) removes blockages (like gallstones). It also helps in diagnosing issues with the pancreatic and bile ducts. Urgent ERCP must be done within 24 hours for acute pancreatitis and cholangitis.
- Cholecystectomy is the removal of the gallbladder due to gallstone formation causing pancreatitis.
- Pancreaticojejunostomy relieves blockages in the pancreatic ducts to reduce pain.
- Stenting can open narrowed pancreatic ducts to allow secretions to flow through the pancreatic ducts.
Partial or complete removal of the pancreas may be required for chronic pancreatitis. Complete removal (total pancreatectomy) is avoided when possible as the pancreas is crucial to making insulin and digestive enzymes.
3. Encourage the patient to cease alcohol consumption.
Pancreatitis can develop after years of daily heavy drinking. Advise the patient to enroll in an alcohol addiction treatment program if this is the cause of pancreatitis. If alcohol consumption continues, pancreatitis will worsen and could become life-threatening.
4. Discontinue the medication causing pancreatitis.
Discontinue any medication irritating the pancreas. Collaborate with the provider and the patient to discover alternative options.
Prevent Recurrent Pancreatitis
1. Promote lifestyle changes.
Patients must stop smoking and drinking alcohol if chronic pancreatitis has developed. These factors have a significant impact on the pancreas. It will also hasten the development of complications if not avoided.
2. Avoid fat intake.
Advise the patient to maintain a low-fat diet rich in fruits and vegetables. Emphasize the need to drink plenty of water daily. It will help lessen the pancreas’s workload and prevent pancreatitis from worsening.
3. Take nutritional supplements.
Exocrine pancreatic insufficiency (EPI) can occur in patients with chronic pancreatitis over time. Supplements (including pancreatic enzymes, vitamins, and minerals) aid patients in digestion and receiving adequate calories and micronutrients.
4. Prevent the development of diabetes.
Developing diabetes mellitus is common following acute pancreatitis. Preventing severe pancreatitis will decrease this risk. The exact cause is not fully understood and is likely related to multiple factors.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for pancreatitis, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for pancreatitis.
Acute Pain
Pain associated with pancreatitis can be caused by inflammation of the pancreas and obstruction of the biliary ducts.
Nursing Diagnosis: Acute Pain
Related to:
- Gallstones
- Inflammation
- Obstructed and damaged biliary ducts
- Autodigestion of the pancreas causing toxins to be released
As evidenced by:
- Verbalization of abdominal pain
- Body language/guarding behavior
- Facial grimacing
- Agitation/restlessness
- Changes in vital signs
Expected outcomes:
- Patient will verbalize reduced pain or relief by pharmacologic pain interventions.
- Patient will follow the prescribed treatment plan to maintain pain relief.
Assessment:
1. Assess for pain.
Pancreatitis can cause pain that is often severe and persistent. The nurse can assess pain by asking the patient their pain level on a 0-10 scale, or by using a non-verbal pain scale if the patient is unable to verbalize.
2 . Assess for abdominal tenderness.
Patients with pancreatitis generally present with abdominal pain. Palpating the abdomen is important to know exactly where the pain is, especially if the patient can’t verbalize the exact location. It’s also important to note any guarding with palpation.
3. Observe changes in vitals and nonverbal cues.
Assess the patient for nonverbal signs of pain including sweating, restlessness, grimacing, and changes in vital signs. Use these observations along with the patient’s verbal reports of pain (if they’re able to verbalize their pain) to assess if interventions are effective.
Interventions:
1. Administer pain medications routinely.
Administering pain medications frequently, as ordered, is important in managing pain. Smaller, more frequent doses of pain medications are preferred over larger doses. Larger doses of pain medications can cause complications for a patient with pancreatitis, including respiratory depression.
2. Maintain NPO status and suctioning.
Eating will likely worsen abdominal pain and any nausea or vomiting. Patients will likely be placed on NPO status and a nasogastric tube may be inserted to allow the pancreas to rest. IV fluids will be given for hydration.
3. Provide alternative pain management.
The patient may experience pain relief by participating in distraction activities (TV, games, music) or activities that promote relaxation such as massage, guided imagery, and hot/cold therapy.
4. Promote a position of comfort.
The supine position often increases a patient’s pain. Encourage patients to lay on their side with knees slightly flexed to decrease abdominal pressure. This aids in pain relief and comfort.
Deficient Knowledge
Patients with pancreatitis may not know what triggered the onset and what they can do, or what they can avoid, to help symptoms from recurring.
Nursing Diagnosis: Deficient Knowledge
Related to:
- Lack of exposure
- Lack of recall
- Cognitive limitation
- Lack of interest
- Poor access to resources
As evidenced by:
- Inability to remember instructions
- Verbalizes a lack of understanding
- Denies a need to learn/uninterested
- Worsening of pancreatitis
Expected outcomes:
- Patient will verbalize an understanding of pancreatitis and potential complications.
- Patient will demonstrate adherence to prescribed medications and diet.
- Patient will verbalize an understanding of required testing and follow-up.
Assessment:
1. Assess willingness to learn.
Assess whether the patient is willing to learn. A patient seeking information and education is open to learning. This will set a foundation for where to start with educating the patient.
2. Assess learning styles.
Evaluate how the patient prefers to learn and what’s most effective. Verbalization can be supported by written materials. Ensure material is suited to the patient’s education and health literacy level.
3. Assess the patient’s knowledge.
Assess what the patient already knows about their treatment plan and pancreatitis. Do not assume the patient understands. Have the patient teach-back information previously provided.
Interventions:
1. Use multiple learning techniques.
Offer a variety of learning techniques after assessing which way the patient learns best. Evaluate which techniques work best for the patient by asking them questions to assess how much they have retained.
2. Ensure a comfortable learning environment.
Ensure the environment is calm and conducive to learning. Also, ensure the patient’s pain is controlled. Someone that is distracted by pain, loud noises, and staff interruptions will not be able to focus on learning.
3. Provide supportive treatment resources.
Alcohol abuse is the most common cause of chronic pancreatitis. Collaboration with a social worker or case manager may be necessary to ensure the patient has resources available to seek treatment. Educate the patient on the effects alcohol and smoking has on their health and how pancreatitis can develop again.
4. Stress the importance of follow-up.
Educate the patient on the importance of following up to ensure they are healing properly. Inform them of symptoms to look for and when to notify their doctor. Doctor’s appointments, lab work, substance abuse resources, and dietician guidelines are important for the patient to adhere to.
Imbalanced Nutrition: Less Than Body Requirements
Patients with pancreatitis can experience an imbalance in nutrition due to their lack of appetite and impaired digestion from inflammation in the pancreas.
Nursing Diagnosis: Imbalanced Nutrition
Related to:
- Vomiting
- Impaired digestion
- Lack or loss of appetite
- NPO status or dietary restrictions
As evidenced by:
- Reports of insufficient food intake
- Weight loss
- Aversion to food
- Poor energy
- Decreased muscle tone
- Nutritional deficits identified through lab work
Expected outcomes:
- Patient will maintain their weight or will not lose more than 5 pounds while inpatient.
- Patient will verbalize dietary recommendations upon discharge.
- Patient will maintain lab values within normal range.
Assessment:
1. Assess current nutrition.
Perform an in-depth assessment of the patient’s current nutritional habits. This information can then be used to decide if the patient’s nutrition is adequate or if there is something in their diet that could have brought on pancreatitis.
2. Assess for hyperglycemia.
Patients with chronic pancreatitis are at a high risk of hyperglycemia due to damaged cells in the pancreas and the inability to regulate glucose. The nurse should monitor the patient’s glucose levels.
3. Monitor labs.
Lab values may be abnormal when a patient has imbalanced nutrition. Lab values also give an idea of inflammation in the body and how the patient’s pancreas is healing over time. Amylase and lipase monitor digestive enzyme levels and will be elevated with pancreatitis.
Interventions:
1. Provide nutritional support.
The patient’s nutritional habits may not be supportive of healing. They will most likely need education on what to eat and drink, and what to avoid. Usual recommendations include high protein and nutrients found in fruits, vegetables, and whole grains. Patients should avoid alcohol and greasy or fried foods.
2. Provide optimal oral hygiene.
Increasing the patient’s appetite is important. Providing good oral hygiene can stimulate their appetite by creating a more pleasant sensation after vomiting and from dry mucous membranes.
3. Administer antiemetics when needed.
Vomiting not only causes an imbalance in electrolytes but creates an aversion to eating. Administering an antiemetic before mealtime can help.
4. Provide nutritional supplements.
Chronic pancreatitis causes altered metabolism and absorption. Regular lab work will monitor nutritional deficits. Patients may need vitamin supplements such as multivitamins, calcium, iron, folate, and vitamins A, D, E, and B12.
Ineffective Breathing Pattern
Acute pancreatitis can cause physical symptoms like abdominal pain and distension and chemical changes in the body, which can ultimately affect lung function, causing ineffective breathing patterns and decreased oxygen levels in the blood.
Nursing Diagnosis: Ineffective Breathing Pattern
Related to:
- Abdominal distension
- Abdominal discomfort
- Increased intra-abdominal pressure
- Acid-base imbalance
- Fatigue
- Pain
- Anxiety
As evidenced by:
- Altered chest excursion
- Tachypnea
- Cyanosis
- Hypoxemia
- Hypoxia
- Hyperventilation
- Hypoventilation
- Decreased Spo2
- Altered ABGs
Expected outcomes:
- Patient will exhibit a normal breathing rate and pattern without signs of respiratory distress.
- Patient will report the ability to breathe comfortably.
Assessment:
1. Assess the patient’s respiratory status.
Note the patient’s respiratory rate, rhythm, depth, and ease of respiration. Tachypnea may occur with pancreatitis, which may lead to hypoxia and respiratory acidosis.
2. Assess the patient’s pattern of respiration in relation to symptoms.
When the pancreas becomes inflamed, it can cause abdominal pain, tenderness, and distension, resulting in shortness of breath. The pain and dyspnea (shortness of breath) can worsen after meals.
3. Assess the patient’s ABG levels and oxygen saturation.
Alterations in ABG levels and oxygen saturation can be early indicators of adverse outcomes in patients with pancreatitis. If these alterations are not resolved, complications like early arterial hypoxia, atelectasis, pneumonia, and ARDS can occur.
Interventions:
1. Encourage a position of comfort.
The fetal position with knees flexed towards the abdomen can significantly reduce restlessness and pain in patients with pancreatitis, enabling the patient to breathe more comfortably.
2. Encourage controlled breathing.
Encourage the patient to breathe evenly and deeply to prevent hyperventilation.
3. Provide supplemental oxygenation.
Supplemental oxygenation provides adequate oxygenation throughout the body, promoting tissue perfusion. This will also enhance breathing comfort for patients with pancreatitis.
4. Monitor for any signs of respiratory failure.
With severe pancreatitis, inflammatory chemicals (cytokines) are released into the body, causing inflammation in various organs, including the lungs. Patients develop acute lung injury and acute respiratory distress syndrome, which can lead to the need for mechanical ventilation.
Ineffective Tissue Perfusion
Acute pancreatitis can cause complications with perfusion to the pancreas and surrounding organs.
Nursing Diagnosis: Ineffective Tissue Perfusion
Related to:
- Disease process
- Inflammatory process
- Obstruction in the pancreatic ducts or gallbladder
- Blood supply loss
- Dehydration
- Pancreatic tissue death or necrosis
As evidenced by:
- Altered LOC
- Oliguria
- Vomiting
- Fever
- Jaundice
- Pallor
- Diaphoresis
- Decrease capillary refill
- Elevated liver, kidney, and pancreatic enzymes
Expected outcomes:
- Patient will not experience worsening abdominal pain, jaundice, or elevations in liver enzymes, WBC, BUN, or creatinine.
- Patient will be free from any signs of perfusion complications, including infection, peritonitis, and pancreatic tissue necrosis.
Assessment:
1. Assess pain history and characteristics.
Patients with pancreatitis often report severe and constant abdominal pain. The pain may be localized to the epigastric area or radiate to the back. Worsening pain or pain unrelieved by medication is concerning for complications like peritonitis.
2. Assess the patient’s past medical history.
Other health conditions like peptic ulcer disease, vascular disorders, renal disease, hyperparathyroidism, hyperlipidemia, or abdominal surgical or procedural interventions like cholecystectomy or ERCP may cause pancreatitis and complicate adequate perfusion.
3. Assess laboratory test results.
In patients with pancreatitis, there is an increase in amylase levels within six hours that may remain elevated for the next 2-3 days. If the increased results persist, this can signal pancreatic perfusion problems, duct obstruction, or pancreatic duct leak. Lipase levels can increase later and remain elevated for up to two weeks.
Interventions:
1. Keep the patient on NPO and rest the bowel.
Keep the patient NPO if they exhibit abdominal pain, nausea, or vomiting as this enables the pancreas and the gastrointestinal system to rest and decreases pancreatic enzyme secretions.
2. Monitor for signs of organ failure.
SIRS (systemic inflammatory response syndrome) should be closely monitored as this predicts severe acute pancreatitis and mortality. SIRS criteria include monitoring the temperature, heart rate, respiratory rate, and WBC count.
3. Administer intravenous fluid replacement.
Pancreatitis can cause dehydration, and fluid replacement is essential to ensure adequate circulation, promote pancreatic recovery, and promote adequate tissue perfusion. Lactated Ringer’s is the recommended IV fluid.
4. Prevent electrolyte abnormalities.
Hypocalcemia and hypomagnesemia may occur from the symptoms and pathophysiology of pancreatitis. Replace electrolytes as necessary to prevent cardiac arrhythmias.
References
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- Barnard, Neal D., editor. “Pancreatitis.” Nutrition Guide for Clinicians, 3rd ed., Physicians Committee for Responsible Medicine, 2020. https://nutritionguide.pcrm.org/nutritionguide/view/Nutrition_Guide_for_Clinicians/1342009/all/Pancreatitis
- Breze, C. (2020, December 14). What is the difference between hereditary pancreatitis and familial pancreatitis? Ariel Precision Medicine. Retrieved April 2023, from https://arielmedicine.com/https-arielmedicine-com-hereditary-vs-familial-pancreatitis/
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