Assessment for Pancreatitis:

•Obtain vital signs immediately (shock is an outstanding symptom of pancreatitis).
•May have high blood pressure due to hypovolemia from release of protein rich fluids into the peritoneal space.
•Severe mid to upper abdominal pain, radiating to both sides and straight to the back.
•Nausea vomiting and flatulence are usually present.
•Complaints of steatorrhea (foul smelling or frothy stool)
•Symptoms are relieved when the client sits up and leans forward or curls into a fetal position.
•Upon physical examination may notice jaundice, abdomen is tender on palpations.
•As abdominal distention worsens bowel sounds may diminish.
•Cullen’s sign (bluish-gray discoloration to the skin about the umbilicus).
•Turner’s sign (bluish-gray discoloration to the skin about the umbilicus).
•Both Cullen’s sign and Turner’s sign indicate bleeding into abdominal area.
•Fever, tachycardia, and shallow breathing.
•Facial twitching (Chvostek’s sign)
•Spasms of fingers when taking blood pressure (Trousseau’s sign)
•Obtain complete medical history
•Inquire the frequency and amount of alcohol ingestion and determine when they had their last drink (may experience alcohol withdrawal).

Diagnostics for Pancreatitis:

•Serum lipase (may be elevated)
•Serum amylase (may be elevated)
•Serum trypsinogen (may be low)
•Fecal fat test show fatty stools
•Abdominal CT scan (may show pancreatic edema and necrosis)
•Abdominal ultrasound (may determine presence of pancreatic cysts, abscesses, and pseudocysts).
•ERCP-Endoscopic retrograde cholangiopancreatography (used to identify stones, tumors, and possible stenosis of bile ducts).

Assessement for Carcinoma of Pancreas:

•Most common symptom is left upper abdominal pain
•Abdominal pain may refer to back.
•Jaundice
•Anorexia and weight loss
•Light color stools and dark urine (symptoms associated with obstructive jaundice).
•Palpable mass in left upper quadrant (possible tumor or enlarged gallbladder).
•Ascites in the later stages of disease.

Diagnostics for Carcinoma of Pancreas:

•Abdominal CT scan or ultrasonography (may show pancreatic enlargement).
•Biopsy provides evidence of malignant cells. (ERCP or needle aspiration).
•Serum amylase, alkaline phosphatase, and bilirubin levels (supporting evidence of diseased pancreas).

Med-Surg Management for Carcinoma of Pancreas:

•Radical pancreatoduodenectomy (Whipple procedure), removes head of the pancrease, resects the duodenum and stomach, and redirects the flow of secretions from the stomach, gallbladder, and pancreas into the jejunum.
•Splenectomy may be preformed due to common metastasis to spleen.
•Deposit of radioactive seeds may be implanted during surgery.
•May perform total pancreatectomy.
•Radiation therapy or chemotherapy (5-fluorouracil or mitomycin).
•Poor prognosis is given to clients with Carcinoma of the pancreas, most clients die months after onset of symptoms, despite medical, or surgical treatment.

Outpatient Care for Cholecystitis:

Pre-op:
•Teach about: pre-surgical procedure, laboratory testing, consent form.
•Complete skin preparation, insert IV lines, administer sedation.

Post-op:
•Provide intensive intructions about self care to client, and caregiver.
•Perform follow up measures such as telephoning the client day after surgery.

If patient is having a cholecystectomy nurse should discuss:
•Location of pain or discomfort
•Ask weather specific foods cause pain or discomfort
•Discuss other problems like N/V or abdominal cramping
•Inspects the skin and sclera for jaundice and palpates the abdoment for tenderness

Routine assessments pre-surgical and post-surgical are necessary after surgery.

If T-Tube is in place after cholecystectomy:
•Monitor and record drainage
•Maintain tube patency by keeping collector below incision (prevents backflow of bile).
•Measure bile drainage every 8 hours.
•If 500 ml of bile drains notify physician.

Patient and Family teaching:
•Have client meet with dietician to see what foods to avoid
•Teach client to read labels to determine fat content.
•Discuss potential side effects of Medication.
•Inform client not to stop medication until physician verifies it.
•Discuss importance of reporting to physician severe pain, jaundice, fever, or if the color of stool or urine changes.

References:

Introductory Medical-Surgical Nursing
Lippincott Williams & Wilkins a Wolters Kluwer business

Diagnostic tests for Cholelithiasis and Cholecystitis
-cholecytography x-ray procedure used to examine gallbladder when gallstones are suspected
-CT scan shows infecton and any rupture
-Radionuclide Biliary Scan to see if common bile duct is blocked
-ERCP (Endoscopic Retrograde Cholangiopancreatography) to locate stone that have been collected in the common bile duct

Signs and Symptoms
The initial s/s -belching
-nausea
-RUQ discomfort with pain or cramps after high fat meals
Acute Cholecystitis
-fever
-vomiting
-tenderness over liver
-severe pain (biliary colic) pain radiates to back and shoulders
Gallbladder becomes swollen
Slight jaundice, urine dark brown, stool light in color

Jaundice (Icterus)
-Greenish yellow discoloration of tissue. It is a result from an abnormally high concentration of the pigment bilirubin in the blood. It is visable in the skin, oral mucous membranes and sclera.

Obstructive Jaundice
Gallstones, inflammation or tumors obstruct the bile duct, causing reabsorption of bile into the blood. Elevated conjugated bilirubin levels.

Nursing management for terminal malignant disorder
Evaluate general physical condition
Obtain history of all symptoms present before admissions

• Ask client about symptoms, weight loss, bleeding tendencies, and type of pain

Physical exam includes
• Inspect for jaundice
• Visual exam of stool & urine
• Palpate abdomen for tenderness or distention
• Labs include blood and urine analysis, detection for glucose
• Record vitals and weight and nutritional status

See chapter 20 of Timby for post operative

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