AFAMS Master Lesson Plan (MLP)
Nursing Program
Disorders of the Pancreas
Instructor
Serial/Semester
Location
Start/Finish Time
Date
LESSON OBJECTIVE
Performance: To gain an understanding of disorders of the pancreas.
Conditions:
The student will be presented a powerpoint presentation by the instructor and will have
all necessary references made available to him/her.
Standard:
1.
Click here to insert a statement of the required level of proficiency.
TEACHING POINTS
1. Describe the structure and function of the
pancreas
2. Explain the etiology/pathophysiology, clinical
manifestations assessment, diagnosis, and
medical management of a patient with acute
pancreatitis.
3. Describe the etiology/pathophysiology,
clinical manifestations, diagnosis, medical
and nursing management of chronic
pancreatitis.
4. Identify nursing diagnosis and interventions
for the patient with pancreatitis
5. Identify the etiology/pathophysiology,
assessment and medical management of
pancreatic cancer.
6.
7.
8
9.
10.
INSTRUCTIONAL STRATEGY
Interactive Lecture
Method:
Instructor
Media:
Classroom
Environment:
OTHER LESSON SPECIFICATIONS
Knowledge Lesson
Type of Lesson:
1/50
Ratio:
Resources:
.
LESSON PLAN APPROVAL
End of Lesson Test: None
Minutes
Instructional Time: 138
Reference(s):
ISBN 0-323-01728-2
Adult Health Nursing, 4th Edition
01 Jan 2003
ISBN 0-7817-3553-X
Introductory Medical-Surgical Nursing, 8th Edition
01 Jan 2002
AFAMS Master Lesson Plan (MLP)
Nursing Program
Disorders of the Pancreas
Signature of Standards Officer
1
Date
AFAMS Master Lesson Plan (MLP)
Nursing Program
Disorders of the Pancreas
INTRODUCTION
Allocated Time:
Review:
5 Minutes
You have had previous anatomy and physiology lectures in your combat medic
training, this lecture will build upon prior instruction.
Objective:
To discuss/describe topics related to the nursing process.
Importance:
Nurses work in various health care settings so it is important to gain an
understanding of this subject as it will apply to your clinical practice.
Fit:
Given the five elements of the nursing care process and a scenario of a patient
in a clinical setting with a disorder of the pancreas by correctly responding to
written, oral, and experiential assessment measures
Approach:
You will be presented the subject in lecture format and will be tested using a
written exam at a later date.
Control Statement:
If you have any questions during the lesson please feel free to ask.
BODY
1. Teaching Point: Describe the structure and function of the pancreas
Minutes
Allocated Time:
Introduction:
Learner Participation:
Knowledge Lesson Please follow along with your hand outs and take notes.
Skill Lesson
Powerpoint presentation with associated handouts.
Learning Support:
a. Structure and function(s) of the pancreas
(1) The pancreas lies behind the stomach in the concavity produced by the C-shape of the duodenum
(2) It is both an exocrine and endocrine gland
(a) Exocrine gland secretes pancreatic juice via the pancreatic duct to the common bile duct and to
the duodenum via the papilla of Vater
1) Pancreatic juice is the most important digestive juice. It contains enzymes (protease, lipase and
amylase) that digest all three major kinds of foods: fats, protein, and carbohydrates
2) It also contains sodium bicarbonate, an alkaline substance that neutralizes the hydrochloric acid
in the gastric juice that enters the intestines
(b) Endocrine gland that secretes hormones in the blood
1) Beta cells of Islets of Langerhans secrete insulin to decrease blood sugar
2) Alpha cells secrete glucagon to increase blood sugar
2
AFAMS Master Lesson Plan (MLP)
Nursing Program
Disorders of the Pancreas
Knowledge Lesson:
Question:
Answer:
Check on Learning
In a knowledge lesson, pose questions to the class.
What is the most important digestive juice?
Pancreatic juice
Skill Lesson:
In a skill lesson, provide practice and watch students perform a skill.
2. Teaching Point: Explain the etiology/pathophysiology, clinical manifestations assessment, diagnosis,
and medical management of a patient with acute pancreatitis.
Minutes
Allocated Time:
Introduction:
Learner Participation:
Knowledge Lesson Please follow along with your hand outs and take notes.
Skill Lesson
Powerpoint presentation with associated handouts.
Learning Support:
a. Etiology/pathophysiology
(1) Inflammation of the pancreas, ranging from mild edema and inflammation to enzymatic digestion
of the pancreas, extensive hemorrhage and necrosis
(2) The function of the pancreas usually returns to normal within 6 months after an acute attack
(3) Pancreas becomes inflamed when there is reflux of bile and duodenal contents into the pancreatic
duct, causing swelling and obstruction
a) Pancreas begins to digest itself (autodigestion) with its own enzymes (especially Trypsin)
(4) Swelling of the opening of the pancreatic duct impairs or obstructs the release of
a) Bicarbonate, which is released to neutralize the GI contents
b) Trypsin, which digests proteins
c) Amylase, which digests carbohydrates
d) Lipase, which digests fats
(5) Trapped enzymes begin to act on pancreas itself
(6) Causes
a) Structural/vascular abnormalities
b) Trauma or disruption of the pancreatic ducts
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AFAMS Master Lesson Plan (MLP)
Nursing Program
Disorders of the Pancreas
c) Infectious disease
d) Metabolic disorders (hyperlipidemia, hypercalcemia)
e) Inflammatory bowel disease
f) Heredity
g) Excessive alcohol intake and certain drugs
h) Re-feeding after prolonged fasting or anorexia
i) Many people who have no other illnesses may develop acute pancreatitis
b. Clinical manifestations
(1) Necrosis (caused by auto-digestion)
(2) Hyperglycemia, hypocalcemia
(3) Hemorrhage of the gland with hypovolemic shock
(4) Peritonitis, pancreatic abscess, pseudocyst
(5) Severe fluid and electrolyte imbalance, acute renal failure
(6) Sepsis
(7) Pleural effusion, ARDS
(8) Blood coagulopathies
c. Assessment
(1) Most common - severe mid-upper abdominal pain, which may radiate to both sides and straight
through the back
(2) Nausea, vomiting and flatulence
(3) Stools may be frothy and foul smelling
(4) Jaundice may be noted if common bile duct is obstructed
(5) Bowel sounds may be diminished, with abdominal distention and tenderness
(6) Hypotension and hypovolemia from third spaced fluid and protein (due to systemic inflammatory
process)
(7) May also have Cullen's (bluish discoloration around the umbilicus) and Turner's (discoloration on
the flanks - both indications of pancreatic bleeding) signs
4
AFAMS Master Lesson Plan (MLP)
Nursing Program
Disorders of the Pancreas
(8) Fever, tachycardia
(9) Chvostek's and Trousseau's signs
d. Diagnosis
(1) Elevated serum and urine amylase, lipase and AST/ALT
(2) Bilirubin may be elevated with obstructed common bile duct
(3) CBC - elevated WBC
(4) Hyperglycemia, hypocalcemia, hypokalemia, hypomagnesemia
(5) CT scan (pancreatic edema and necrosis)
(6) Endoscopic and Ultrasound exams to determine pancreatic cysts, abscesses and pseudocysts
(fibrous capsules filled with fluid, blood, enzymes, pus and tissue debris)
e. Medical management
(1) Measures taken to relieve pain and spasms (cause an increase in pancreatic secretions)
(a) Demerol is usually the medication of choice
(b) Usually NPO, with NG tube to low continuous suction to relieve distention, N/V, and reduce
stimulation of pancreas to release juices
(c) Atropine, or anticholinergics, to reduce activity of vagus nerve (Vagus nerve controls stomach
activity)
(d) Cholecystectomy for gallstone pancreatitis
NOTE: Morphine may cause spasms of the Sphincter of Oddi and should be avoided
(2) Restore fluid and electrolyte losses
(a) IV fluids
(b) Albumin may be given IV to pull fluid trapped in peritoneum back into circulation
(3) Prevent or treat systemic complications, i.e., respiratory distress syndrome, bleeding abnormalities
(a) Antibiotics (IV) to prevent localized abscesses and/or systemic sepsis
(b) Percutaneous needle aspiration to treat pseudocysts
(c) Patient may require debridement of necrotic tissue every 2 to 3 days
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AFAMS Master Lesson Plan (MLP)
Nursing Program
Disorders of the Pancreas
1) Multiple drains may be placed in the abdomen to drain fluid and debris
2) Continuous irrigation may be performed
(4) With improvement, clear liquid diet with progression to low-fat diet
(5) Alcohol, caffeine and pepper, which are digestive stimulants, are to be avoided
Knowledge Lesson:
Question:
Answer:
Check on Learning
In a knowledge lesson, pose questions to the class.
Why should morphine be avoided in a patient with pancreatitis?
Morphine may cause spasms of the Sphincter of Oddi
Skill Lesson:
In a skill lesson, provide practice and watch students perform a skill.
3. Teaching Point: Describe the etiology/pathophysiology, clinical manifestations, diagnosis, medical
and nursing management of chronic pancreatitis.
Minutes
Allocated Time:
Introduction:
Learner Participation:
Knowledge Lesson Please follow along with your hand outs and take notes.
Skill Lesson
Powerpoint presentation with associated handouts.
Learning Support:
a. Etiology/pathophysiology
(1) Prolonged, progressive inflammation of the pancreas
(2) With chronicity, the gland undergoes fibrotic scarring from recurrent inflammation
(3) The pancreas hardens and exocrine and endocrine functions are partly or completely lost as
pancreatic tissue is destroyed
(4) Causes
(a) Chronic alcohol abuse is the most common (leads to edema of the duodenum and decreases the
tone of the sphincter of Oddi with movement of duodenal contents into the pancreatic duct)
(b) Hyperparathyroidism
(c) Trauma to the pancreas
(d) Hereditary pancreatitis
(e) Hypertriglyceridemia
(f) Autoimmune pancreatitis
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AFAMS Master Lesson Plan (MLP)
Nursing Program
Disorders of the Pancreas
(g) Repeatedly formed gallstones
(h) Most causes of chronic pancreatitis are similar to those of acute
(i) For some, the cause is unknown
NOTE: With chronicity, the gland undergoes fibrotic scarring due to the recurring inflammation. The
pancreas becomes hard, which then results in the partial to complete loss of gland function as pancreatic
tissue is gradually destroyed
(5) Complications
(a) Similar to those of acute pancreatitis
(b) Biliary tract obstruction
(c) Partial to complete loss of gland function
b. Assessment
(1) Persistent pain in epigastrium or LUQ radiating to the back
NOTE: Pain is sometimes relieved by assuming a forward position, taking the stomach weight off the
pancreas
(2) Weight loss
(3) Flatulence, vomiting and diarrhea
(4) Firm mass may be felt in upper left quadrant
(5) Dark urine
(6) Light colored and foul smelling stools, steatorrhea
(7) If pseudocysts are present, they contribute to severity of symptoms
(8) If secondary diabetes occurs, patient may have increased appetite, thirst and urination
(9) Peripheral edema and ascites (from loss of protein and fluid into third space)
c. Diagnosis
(1) Abnormal labs, as with acute pancreatitis
(2) CT, MRI and ultrasonography
(3) ERCP (Endoscopic Retrograde Cholangiopancreatography)
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AFAMS Master Lesson Plan (MLP)
Nursing Program
Disorders of the Pancreas
(4) Glucose tolerance test - shows impaired ability to metabolize carbohydrates due to endocrine
dysfunction
d. Medical management
(1) Depends on cause and whether pancreatic duct is obstructed
(2) If no obstruction
(a) Abstinence from alcohol
(b) Clear liquid, advance to fat free diet
(c) Correction of biliary tract disease and/or hyperparathyroidism may give good results
(3) Demerol is ordered cautiously, but focus is on non-opioid pain management
(4) Insulin and pancreatic enzyme replacement
(a) Pancreatin (Creon, Bioglan, Panazyme, Donnazyme, Entozyme)
(b) Pancrelipase (Pancrease, Cotazyme, Creon 10 and Creon 20, Protilase, Ultrase, Viokase, Zymase,
Pancreacarb)
(5) Partial or total pancreatectomy
(6) Reconstitution of the duct with scarring, stricture and stenosis
(7) Pancreatojejunostomy
(8) Pancreatic autotransplantation
(a) Excision and relocation of the pancreas
(b) Innervation is cut, relieving pain symptoms
(c) Exocrine function is lost, but endocrine function is retained
(d) Will require lifelong supplements
Knowledge Lesson:
Question:
Answer:
Check on Learning
In a knowledge lesson, pose questions to the class.
What is the most common cause of chronic pancreatitis?
Chronic alcohol abuse.
Skill Lesson:
In a skill lesson, provide practice and watch students perform a skill.
8
AFAMS Master Lesson Plan (MLP)
Nursing Program
Disorders of the Pancreas
4. Teaching Point: Identify nursing diagnosis and interventions for the patient with pancreatitis
Minutes
Allocated Time:
Introduction:
Learner Participation:
Knowledge Lesson Please follow along with your hand outs and take notes.
Skill Lesson
Powerpoint presentation with associated handouts.
Learning Support:
9
Nursing Diagnosis
Pain R/T stimulation of nerve
endings caused by
enlargement of pancreatic
capsule, obstruction, or
chemical irritation from
enzymes
Outcome
Patient will verbalize
reasonable control of pain
Ineffective breathing R/T
pain, ascites
Patient will maintain effective
breathing pattern
High risk for fluid volume
deficit R/T vomiting,
diarrhea, gastric
decompression, fluid shifts,
decreased oral intake,
hemorrhage
Patient will maintain normal
fluid volume
Nursing Interventions
1) Assess pain location,
character, frequency and
duration
2) Administer narcotic
analgesics as ordered
3) Assist client to sit upright or
assume side-lying position with
knees flexed
4) Inform physician of sudden
increase of pain with rigid
abdomen, which are symptoms
of ruptured pancreas
5) Administer antihistamines
and anticholinergics as needed
6) Restrict fat as necessary to
prevent aggravation of pain
7) Use alternative comfort
measures: repositioning,
positive imagery, and providing
time for listening
1) Asses respiratory status, i.e.,
rate, rhythm, oxygenation
2) Administer O2 as needed
3) Control pain with
appropriate measures
4) Keep HOB elevated
5) Instruct client on T/C/DB
(Turn, Cough, and Deep
Breath)
1) Assess for S/S of fluid
volume deficit: decreased level
of consciousness, poor skin
turgor, cool, dry, or clammy
skin, weak peripheral pulses,
edema formation
2) Monitor I&O
3) Encourage fluids within
dietary limitations
4) Monitor VS, shock is often
an outstanding symptom of
AFAMS Master Lesson Plan (MLP)
Nursing Program
Disorders of the Pancreas
High risk for altered nutrition
R/T malabsorption, N/V, pain
Patient will maintain
adequate nutrition
High risk for ineffective
management of therapeutic
regimen R/T to insufficient
knowledge for self care, diet
therapy
Patient will maintain
therapeutic regimen
acute pancreatitis
1) Maintain caloric intake
during NPO status with
prescribed glucose solution
2) Provide small, frequent
meals
3) Monitor blood glucose
levels closely
4) Administer tube feedings as
ordered, monitor tolerance
5) Administer antacids and H2
receptor antagonists as ordered
6) Administer prescribed
pancreatic enzyme
replacements as ordered
1) Bland, low-fat, caloriecontrolled diet
2) Eat four or more small
meals a day
3) Take prescribed meds as
directed
4) Increase activity gradually
5) Strongly encourage the
client to avoid alcoholic
beverages
6) Instruct on proper
techniques on monitoring
glucose and administering
insulin
Knowledge Lesson:
Question:
Answer:
Check on Learning
In a knowledge lesson, pose questions to the class.
Click here to enter the question.
Click here to enter the answer.
Skill Lesson:
In a skill lesson, provide practice and watch students perform a skill.
5. Teaching Point: Identify the etiology/pathophysiology, assessment and medical management of
pancreatic cancer.
Minutes
Allocated Time:
Introduction:
Learner Participation:
Knowledge Lesson Please follow along with your hand outs and take notes.
Skill Lesson
Powerpoint presentation with associated handouts.
Learning Support:
10
AFAMS Master Lesson Plan (MLP)
Nursing Program
Disorders of the Pancreas
a. Etiology/pathophysiology
(1) Fourth leading cause of cancer death in men and sixth in women
(2) High death rate attributable to the difficulty in diagnosing the cancer at a curable stage
(3) Occurs after middle age with a peak incidence around age 60
(4) Found in cigarette smokers, those exposed to chemical carcinogens and people with diabetes
mellitus
(5) Linked to diet high in meat, fat and coffee consumption
(6) May be primary or metastasis from lung, stomach, duodenum or common bile duct
(7) Tumor grows rapidly and quickly invades surrounding organs and tissue
(8) Many patients live only 4 to 8 months after diagnosis
b. Assessment
(1) Vague symptoms, which accounts for the delay in diagnosis
(2) Pain present in 85% of cases
(3) Anorexia, nausea, flatulence, change in stools
(4) Fatigue
(5) Steady, dull and aching pain in the epigastrium or referred to the back; usually worse at night
(6) Weight loss
(7) Jaundice, pruritis
(8) Recent onset of diabetes mellitus
c. Medical management
(1) Definitive diagnosis before surgery is difficult
(2) However, tumors are usually inoperable by the time the diagnosis is made
(3) Whipple procedure often performed (see Christensen p. 246)
(a) Pancreatoduodenectomy
(b) Resection of the antrum of the stomach, duodenum and varying sections of the pancreas
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AFAMS Master Lesson Plan (MLP)
Nursing Program
Disorders of the Pancreas
(c) Anastomoses are constructed between the stomach, common bile duct and pancreatic ducts, and
the jejunum
(4) Total pancreatectomy with resection of parts of the GI tract
(5) Subtotal pancreatectomy has complications of postoperative pancreatic fistulas and is not
recommended
(6) Chemotherapy
(a) Combinations of drugs (5-FU and BCNU [carmustine]) produce a better response than single
agents
(b) Gemzar is a new chemotherapeutic agent for patients with metastatic adenocarcinoma that has
previously been treated with 5-FU
(7) Adjuvant therapy (surgical resection, radiation and chemotherapy) is believed by some to be the
most effective treatment of the almost always fatal pancreatic cancer
(8) Immediate post-operative care is usually done in the intensive care setting
Knowledge Lesson:
Question:
Answer:
Skill Lesson:
Check on Learning
In a knowledge lesson, pose questions to the class.
What is a surgical procedure that is performed on patients with pancreatic
cancer?
Whipple procedure.
In a skill lesson, provide practice and watch students perform a skill.
END OF LESSON TEST
Allocated Time:
Instructions:
Test Questions or
Performance
Expected:
Test Key:
0 Minutes
You will be tested on this subject at a later date.
You will be expected to review and study the material taught in this session in
order to pass the associated written test. If you have difficulty with the material
please see me so we can review together.
None.
CONCLUSION
Allocated Time:
Summary:
5 Minutes
Review and re-emphasize the difficult Teaching Points below.
1.
2.
3.
12
Describe the structure and function of the pancreas
Explain the etiology/pathophysiology, clinical manifestations
assessment, diagnosis, and medical management of a patient with
acute pancreatitis.
Describe the etiology/pathophysiology, clinical manifestations,
AFAMS Master Lesson Plan (MLP)
Nursing Program
Disorders of the Pancreas
4.
5.
diagnosis, medical and nursing management of chronic pancreatitis.
Identify nursing diagnosis and interventions for the patient with
pancreatitis
Identify the etiology/pathophysiology, assessment and medical
management of pancreatic cancer.
6.
7.
8
9.
10.
Closing Statement:
Nurses work in various health care settings so it is important to gain an
understanding of this subject as it will apply to your clinical practice.
Re-motivating
Statement:
Given the five elements of the nursing care process and a scenario of a patient
in a clinical setting with a disorder of the pancreas by correctly responding to
written, oral, and experiential assessment measures
13