What is pancreatitis
Pancreatitis is a serious medical condition that has life threatening complication. Background knowledge of the pathophysiology, clinical presentation, and investigations needed is essential for an ICU nurse to proceed with the nursing process. This work aim to provide a brief, yet a comprehensive, review on pancreatitis and the role of ICU nurse can play in this client care.
Pancreatitis occurs in an acute or a chronic form, acute pancreatitis occurs on the background of a normal pancreas, which may return to normal after resolution. In chronic pancreatitis, however, there is continuing inflammation with irreversible structural changes. In practice the differentiation between acute and chronic pancreatitis may be extremely difficult. Any of the causes of acute pancreatitis if untreated may result in recurrent episodes classified as acute relapsing pancreatitis. In other cases the recurrent episodes of recurrent pancreatitis may represent exacerbations of an underlying chronic process (Kumar and Clark 2008).
Pathophysiology of Pancreatitis
Pancreatitis is inflammation of the pancreas which acts as an exocrine gland secreting digestive enzymes acting with to digest food. Normally these enzymes are not active until they reach the duodenum; however, when the pancreas is inflamed, they act against cells that produced them inside the pancreas (Greenberger and Toskes 2008). Mechanisms by which pancreatic necrosis occurs remain speculative. However, there is some evidence that the final common pathway is a marked elevation of intracellular calcium which in turn leads to activation of intracellular proteases. It is these activated enzymes which are responsible for cellular necrosis. Acute pancreatitis may be obstructive (gallstone-related pancreatitis) or more commonly idiopathic. There is also evidence that alcohol interferes with calcium homeostasis in pancreatic acinar cells (Kumar and Clark 2008).
Diagnosis of pancreatitis
Patients present with one or more of the following symptoms; first, is pain, which ranges from mild to severe, of sudden onset and persistent in nature, located in the upper abdomen radiating to the back, relived on sitting up or bending, and exacerbated by food intake and alcohol consumption. Second, is fever that is low grade (below 101 F) if more it points to a complication or infection. Pancreatitis patients are mostly hypovolemic and dehydrated as fluid accumulates in the abdomen. Jaundice is not a common presentation unless there is obstruction of the common bile duct although there may be an increase in the total bilirubin not amounting to jaundice. Pleural effusion (of the left side) causing dyspnea is a significant finding, which shows the value of routine chest radiographs (Sedlack et al 2008). Plain x-ray abdomen may show the sentinel loop sign (a dilated loop of bowel over the pancreatic area) and-or colon cutoff sign (abrupt cutoff of gas in the transverse colon) (Sedlack et al 2008).
Determining the serum level of amylase is the most useful test for acute pancreatitis. The level of amylase increases two or three hours after an attack and remains increased for three or four days. The magnitude of the increase does not correlate with the clinical severity of the attack. Serum amylase levels may be normal in some (<10%) patients because of alcohol or hyper-triglyceridemia, and a persistent increase suggests a complication. Since serum amylase is cleared by the kidney. The urine amylase level remains elevated after the serum amylase level returns to normal. Isoenzyme identification may aid in distinguishing between salivary (non-pancreatic) and pancreatic sources. Serum lipase may help distinguish between pancreatic hyper-amylasemia and an ectopic source (lung, ovarian, or esophageal carcinoma). Lipase levels are also increased for a longer time than amylase levels after acute pancreatitis (Whitcomb 2006).
Prognosis and complications
A mass of inflamed pancreatic tissue (phlegmon) when formed results in local complications, like pseudocysts, which may resolve within 6 weeks without intervention. A pancreatic abscess may develop2 to 4 weeks after the acute episode which has to be drained surgically. Jaundice secondary to obstruction of the common bile duct may develop, in addition pancreatic ascites results from disruption of the pancreatic duct or a leaking pseudocyst. A local complication of pancreatitis should be suspected if fever, persistent pain, or persistent hyperamylasemia occurs. A systemic complication is respiratory distress syndrome, where circulating lecithinase probably splits fatty acids off lecithin, producing a faulty surfactant. Pleural effusions occur in approximately 20% of patients with acute pancreatitis; further, fat necrosis may be due to increased levels of serum lipase (Sedlack et al 2008).
Nursing Assessment, diagnosis and care
The ICU nurse is the member of the multidisciplinary team would you expect to engage in the care of this client because of serious threatening complications like respiratory distress because of pleural effusion or increased levels of serum lipase (Manjuck et al 2005). Second is because of threatening increased intra-abdominal pressure, secondary to fistula or ascites (De Waele et al 2005). Stratan (2006. P. 111) suggested in 15-20% of patients severe pancreatic damage may threaten life and the rate of complications like necrosis, dehydration, and infection and abscess formation are high in this group of patients. In addition, these patients need parentral nutrition at least during the early phase of the disease, being an acute abdomen case.
It is the first step in the whole nursing process and includes collecting objective and subjective information that contribute to nursing diagnosis, planning and then intervention (Workman and Cooper 2004). Based on the above discussion, the main subjective data needed for assessment are pain and dyspnea, objectively, fever, jaundice, total and differential leucocytic count (as indicators of infection and necrosis), serum amylase, serum lipase and chest x-ray are important data for a nursing diagnosis. Further, the patient's general condition (vital signs) and signs of dehydration may point to the need of parentral nutrition (Stratan 2006).
Nursing diagnosis and clinical implications
For nursing diagnosis, the problem should be targeted, assessed, aiming to determine the goals and objectives within a time frame and put an intervention plan (Doegene et al 2008). In acute pancreatitis, pain is because of pancreatic inflammation, plural effusion or peritoneal irritation may be contributing factors because either of the pathophysiological process or because of a complication Doegene et al 2008). Next is setting the nursing time-framed objective, which is pain relief, by administering analgesics, knowing that morphine is contraindicated in acute pancreatitis (Peiro et al 2008). The second nursing diagnosis is hypovolemia or the need to nutritional support, recent evidence (Siow 2008 and Doley et al 2009) suggests that enteral and parentral are comparable in terms of hospital stay, infection, need for surgical intervention and mortality. Thus, nasogastric tube is not used unless informed by the attending physician.
Nutritional support can be in the form of parentral fluid therapy where large fluids shifts can rapidly cause edema (including ascites and pulmonary edema) and hypovolemia; aggressive fluid resuscitation, mainly with colloids, may prevent organ failure. Arterial blood pressure and fluid balance charts give little indication of intravascular volume. Fluid shifts/loss can cause various electrolyte imbalances. Biochemistry should be monitored and major imbalances rectified (Woodrow 2006). The main objective of enteral feeding in pancreatitis patients is to put the pancreas at rest and reduce its exocrine activity; therefore, diet should be low in fat, high in carbohydrates and proteins unless blood glucose level is elevated because of defective insulin secretion. The second aim is to avoid relapse; therefore meals should be small and frequent with special care to avoid alcohol, and smoking (nicotine being a pancreatic stimulator (Kumar and Clark 2008).
Medication education efforts
On discharge the pancreatitis patient should be acknowledged there are medications, which may predispose to recurrence, some of them are of common use. Antibiotics like tetracycline, rifampin, sulfasalazine and sulpha combination (trimethoprim-sulfamexazole) are toxic to the pancreas. Further, analgesics like acetaminophine-caffeine-dihdrocodeine bitrate, and tramadol cause dysfunction of the sphincter of Oddi (a smooth muscle complex surrounding the common bile and pancreatic ducts) the same way morphine does (Wells et al 2009).