Disorders of the Pancreas

Terminal Learning Objective

At the completion of this lesson you (the student) will relate planning and provision of safe and effective nursing care of a client with a disorder of the pancreas

ENABLING LEARNING OBJECTIVES

A: Describe the structure and function of the pancreas

B: Explain the etiology/pathophysiology, clinical manifestations assessment, diagnosis, and medical management of a patient with acute pancretitis.

C: Describe the etiology/pathophysiology, clinical manifestations, diagnoses, medical and nursing management of chronic pancreatitis.

ENABLING LEARNING OBJECTIVES

D: Identify nursing diagnosis and interventions for the client with pancreatitis

E: Identify the etiology/pathophysiology, assessment and medical management of pancreatic cancer.

Structure and Function of the Pancreas

The pancreas lies behind the stomach in the concavity produced by the C-shape of the duodenum

It is both an exocrine and endocrine gland

Structure and Function of the Pancreas

Exocrine functionPancreatic juice

Endocrine functionHormones

Etiology/Pathophysiology of Pancreatitis

Inflammation of the pancreas Reflux of bile and duodenal contents leads to

autodigestion Swelling results in impaired release of pancreatic

contents Obstruction leads to further autodigestion

Etiology/Pathophysiology of Pancreatitis

Structural/vascular abnormalities Trauma or disruption of the pancreatic fluids Infectious disease Metabolic disorders Inflammatory bowel disease Heredity Excessive alcohol intake and certain drugs Refeeding after prolonged fasting or anorexia

Clinical Manifestations

Necrosis, caused by autodigestion hyperglycemia, hypocalcemia

Hemorrhage of the gland with hypovolemic shock

Peritonitis, pancreatic abscess, pseudocyst

Clinical Manifestations

Severe fluid and electrolyte imbalance, acute renal failure

Sepsis Pleural effusion, ARDS Blood coagulopathies

Assessment

The most common- Severe mid upper abdominal pain, which may radiate to both sides and straight up the back

Nausea, vomiting and flatulence Stools may be frothy and foul smelling Jaundice may be noted if common bile duct is

obstructed

Assessment

Bowel sounds may be diminished, with abdominal distention and tenderness

Hypotension and hypovolemia May also have Cullen’s and Turner’s signs Fever, tachycardia Chvostek’s sign Trousseau’s sign

Cullen’s Sign

Chvostek’s Sign

Trousseau’s Sign

Diagnosis Elevated serum and urine amylase, lipase and

AST/ALT levels Billirubin level may be elevated with obstructed

common bile duct Elevated WBC level indicated by CBC Hyperglycemia, hypocalcemia, hypokalemia,

hypomagnesemia CT scan (pancreatic edama and necrosis)

Diagnosis

Endoscopic and Ultrasound exams to determine pancreatic cysts, abscesses and pseudocysts (fibrous capsules filled with fluid, blood, enzymes, pus and tissue debris)

Medical Management

Measures to relieve pain and spasms Restore fluid and electrolyte loss Prevent or treat systemic complications Clear liquid diet with progression to low fat diet Avoid digestive stimulants

Etiology/Pathopysiology of Chronic Pancreatitis

Chronic pancreatitis is defined as prolonged,progressive inflammation of the pancreas

The gland undergoes fibrotic scarring recurrent inflammation

The pancreas hardens and exocrine and endocrine functions are partly or completely lost as pancreatic tissue is destroyed

Etiology/Pathopysiology of Chronic Pancreatitis

The most common cause is chronic alcoholism Hyperparathyroidism Trauma to the pancreas Heredity pancreatitis Hypertriglyceridemia

Etiology/Pathopysiology of Chronic Pancreatitis

Autoimmune pancreatitis Repeatedly formed gallstones Most causes are similar to acute pancreatitis Some causes are unknown

Complications

Simliar to those of acute pancreatitis Biliary tract obstruction Partial to complete loss of gland function

Assessment

Persistent pain in epigastrium or LUQ radiating to the back

Weight loss Flatulence, vomiting, and diarrhea Firm mass may be felt in upper left quadrant Light colored and foul smelling stools,

steatorrhea

Assessment

If pseudocysts are present, they contribute to the severity of symptoms

If secondary diabetes occurs, patient may have increased appetite, thirst and urination

Peripheral edema and ascites

Diagnostic procedures

Abnormal labs, as with acute pancreatitis CT, MRI and Ultrasound ERCP (Endoscopic Retrograde

Cholangiopancretography) Glucose tolerance test

Medical Management

Depends on the cause and weather pancreatic duct is obstructed

If no obstruction Abstinence from alcohol Clear liquid, advance to fat free diet Correction of biliary tract disease and/or

hyperparathyriodism may give good results

Medical Management Demerol is ordered cautiously Insulin and pancreatic enzyme replacement

Pancreatin (Creon, Bioglan, Panazyme, Creon 10 and Creon 20, Protilase, Ultrase, Viokase, Zymase, Pancreacarb)

Partcial or total pancreatectomy Reconstitution of the duct with scarring, stricture

and stenosis Pancreatic autotransplantation

Nursing Diagnoses Associated with Pancreatitis

Pain R/T stimulation of nerve endings caused by enlargement of the pancreatic capsule, obstruction, or chemical irritation from enzymes

Ineffective breathing R/T pain, ascites High risk for fluid volume deficit R/T vomiting,

diarrhea, gastric decompression, fluid shifts, decrease oral intake, hemorrhage

Nursing Diagnoses Associated with Pancreatitis

High risk for altered nutrition R/T malabsorption, N/V, pain

High risk for ineffective management of therapeutic regimen R/T to insufficient knowledge or self care, diet therapy

Etiology/Pathophysiology of Pancreatic Cancer

Pancreatic cancer is the fourth leading cause of cancer death in men and sixth in women

High death rate attributed to the difficulty in diagnosing the cancer at a curable stage

Occurs after middle age with peak incidence around age 60

Found in cigarette smokers, those exposed to chemical carcinogens and people with diabetes mellitus

Etiology/Pathophysiology of Pancreatic Cancer

Linked to diet high in meat, fat and coffee consumption

May be primary or metastasis from lung, stomach, duodenum or common bile

Tumor grows rapidly and quickly invades surrounding organs and tissue

Many patients only live 4 to 8 months after diagnoses

Assessment of Pancreatic Cancer

Vague symptoms, which accounts for the delay in diagnosis

Pain present in 85% of cases Anorexia, nausea, flatulence, change in stools Fatigue

Assessment of Pancreatic Cancer

Steady, dull and aching pain in the epigastrium or referred to the back; usually worse at night

Weight loss Jaundice, pruritis Recent onset of diabetes mellitus

Medical Management Definitive diagnosis before surgery is difficult However, tumors are usually inoperable by the time

a diagnoses is made Whipple produce often performed Total pancreatectomy with resection of parts of the

GI tract Subtotal pancretectomy has complication of

postoperative pancreatic fistulas and is not recommended

Medical Management

Medical Management Adjuvant therapy (surgical resection, radiation

and chemotherapy) is believed by some to be the most effective treatment of the almost always fatal pancreatic cancer

Immediate post-operative care is usually done in the intensive care setting

Review of Main Points

Structure and function of the pancreas Acute pancreatitis Chronic pancreatitis Pancreatic cancer

QUESTIONS??