A PRESENTATI ON BY

HENRY R. CHOUI NARD

Case Study 51
Pancreatitis
Epidemiology
40 cases per year per 100,000 adults
US has the highest rates of pancreatitis
African Americans 3 times more likely
Common causes
Alcohol use
Biliary tract malfunctions
Cholelithiasis (Gallbladder stones)
Pathophysiology
Endocrine and Exocrine functions
Digestive enzymes
Amylase
Tripsin
Lipase


Premature Activation Autodigestion

Assessment
Abdominal pain that radiates to the back
Tenderness and Guarding
Pain worsens after eating
Diagnostics
Blood tests
Stool tests
CT Scan
Ultrasound
Interventions
Fasting slowly advancing diet
Pain Management
IV fluids
Surgery
http://daveproject.org/transgastric-endoscopic-
necrosectomy-for-walled-off-pancreatic-
necrosis/2009-10-28/
Enzyme replacement therapy
Case Study
B.K. is a 63-year-old woman who is admitted to the
medical-surgical unit from the ED with nausea and
vomiting and epigastric and LUQ abdominal pain
that is sever, sharp, and boring and radiates through
her mid-back. The pain started 24hrs ago and awoke
her in the middle of the night. B.K. is retired and
smokes half-pack of cigarettes daily. She is anxious
and demanding when she arrives on the unit. B.K.
denies using alcohol. VS are 100/70, 97bpm, 30,
100.2F, 88% Room Air, 92% 2L NC. Hasnt been to
a physician in years.
Case Study Continued
ED nurse giving you the report states the admitting
diagnosis is acute pancreatitis of unknown etiology.

What do you think might be the cause?
Case Update
CT scanner is down but an ultrasound was
performed.
no cholelithiasis, gallbladder wall thickening, or
choledocholithiasis was seen. Pancreas was not well
visualized due to overlying bowel gas.
Urine was dark in color

How does this information change your thoughts
about the cause?
Case Study Progress
B.K. is restless, lying on her right side, diaphoretic
with poor skin turgor, tachycardic, tachypnea, absent
breath sounds LLL, N/V with dry heaves, hypoactive
bowel sounds, distended/firm abdomen that is
tender with guarding noted.

Of these assessment findings, what do you think
points towards the diagnosis of acute pancreatitis?
Laboratory Test Results
BUN 24mg/dL
WBC 17,500/mm
3
Total bilirubin 2.0 mg/dL
Creatinine 1.4 mg/dL
Amylase 2,000 u/L
Lipase 3,000 u/L
Albumin 3.0 g/dL

Which values are important with this case?
Chest X-ray Report
The admission Chest X-ray reports reads, small
pleural effusion in the LLL

What are some ways that you as a nurse could
improve her condition?
NPO Woes
B.K. complains of thirst and demands something to
drink, her orders indicate NPO, except sips and
chips

How do you handle her request?
Why is she NPO?

Silent Night But Wait!
B.K. eventually falls asleep peacefully. Suddenly
several hours later her pulse oximeter alarm goes off.
It reads 87% and she is moaning softly.

What will you do!?

Respiratory Assessment
Lungs sounds absent in the LLL and very diminished
in the RLL. You percuss a dull thud over the LML
and LLL up to the scapula tip. You also hear
resonance over the entire right lung and LUL.

What do these finding suggest?
What will most likely be ordered to verify your
findings?

Another Chest X-ray
A STAT CXR shows significant pleural effusion
developing in the LLL with extension into the RLL.

As a nurse, what are you responsible for with a
thoracentesis?
What caused this effusion to happen in the first
place?
Things Begin to Look Better
The physician removed 200ml of slightly cloudy serous
fluid and the antibiotics were adjusted. B.K. is on 3L NC
with unlabored and regular respirations; 96%
CT scanner is working and it shows a moderately severe
pancreatitis, but no local fluid collection or pseudocysts.
No ileus or evidence of neoplasia was noted
Her laboratory values are decreasing towards normal
levels. Physician writes an order to advance B.K. diet to
full liquids.

If she cannot tolerate this diet, what physiologic need
should be addressed at 72hrs?
And on the Third Day
B.K. becomes agitated with tremors, some
disorientation, and auditory hallucinations. Her
pulse and BP are elevated, although her pain has not
increased. She has had no visitors since her
admission.

What is B.K. most likely experiencing?
What actions will you take?
The Real Truth Revealed
The physician orders scheduled Librium and a social
services consult to evaluate and treat possible alcohol
abuse.
3 days later she is lucid, tolerating clear liquids, and her
pain is controlled w/ PO pain medications. She
eventually admits to drinking 3-4 scotch-on-the-rocks
daily and is estranged from her family due to her
drinking. Her discharge is ordered for this evening if she
tolerates a low-fat/low-cholesterol diet, which she
does.

Why a low-fat/low-cholesterol diet?
What will you include in her discharge teaching?
Research Opportunities
Pancreatitis is very well known and documented
disease.
Mortality rates are high, how do we improve?
There is no reliable screening test for the early
detection of pancreatic cancer.
We need to invest in the development of an effective
screening test.
Sources Cited
Acute Pancreatitis . (n.d.). Acute Pancreatitis. Retrieved February 24, 2014,
from http://emedicine.medscape.com/article/181364-overview#a0156
Clinic, M. (n.d.). Pancreatitis. Diagnosis at Mayo Clinic. Retrieved
February 26, 2014, from http://www.mayoclinic.org/diseases-
conditions/pancreatitis/basics/tests-diagnosis/con-20028421
Harding, M., & Snyder, J. S. (2013). Case Study 51. Winningham's critical
thinking cases in nursing: medical-surgical, pediatric, maternity, and
psychiatric (5th ed., pp. 229 - 233). St. Louis, Mo.: Elsevier/Mosby.
Hopkins, J. (2012, November 12). Basics of Pancreatic Cancer. Johns
Hopkins Medicine. Retrieved February 26, 2014, from
http://pathology.jhu.edu/pc/basicintro.php?area=ba
Transgastric Endoscopic Necrosectomy for Walled-Off Pancreatic Necrosis.
(n.d.). DAVE Project Gastroenterology RSS. Retrieved March 4, 2014,
from http://daveproject.org/transgastric-endoscopic-necrosectomy-for-
walled-off-pancreatic-necrosis/2009-10-28/