Jesse Mosier
Nursing 217
Nursing Diagnosis: Acute Pain R/T inflamed pancreas, GB distension, Bililary Obstruction, AEB Pain 7/10
Goal: Patient pain level will decrease to pt’s comfort level of 2-3/10.
OUTCOME
CRITERIA:
1. Pt’s pain level
will trend to 2-3/10
q hr as assessed
PRN.
INTERVENTIONS:
SCIENTIFIC RATIONALE:
EVALUATION:
1. Assess pain
characteristics q hr and
PRN.
(Independent/Collaborative)
1. Establishing a patient’s pain comfort level will provide a
basis to determine effectiveness of pain management
interventions. Single dimension pain ratings are valid and
reliable as measures of pain intensity level. Self report is
considered the single most reliable indicator of pain
presence and intensity. My patient states he has a sharp,
constant pain in his midepigastic area which radiates to his
back that is unrelieved by changing position. This is a
cardinal finding in cases of acute pancreatitis. Because this
pain is not static but dynamic, it is necessary to monitor
pain levels on a regular basis. Failure of clinicians to assess a
client's pain, accept the findings, and treat the report of
pain is a common cause of unrelieved pain and suffering. As
my patient has reported a pain level of 7/10 it is important
to know the location, duration, characteristics of his pain to
property treat and relieve it, and identify any changes in
underlying physiologic status. Using OLDCARTS analysis is a
valid way to obtain information on pt’s pain and assess for
interventions/treatments that were effective in the past.
Effective pain relief is critical for decreasing risk factors for
complications with this patient including respiratory
dysfunction, tachycardia, Hypertension, Hyperglycemia,
increased muscular contraction and spasm, muscular
weakness, fatigue, nausea, and decreased immune
1. P- Patient states pain 7/10
located in midepigatric area
(UL and UR abdomen
quadrants) sharp, constant,
unrelieved by repositioning,
vomiting. With administration
of Demerol and Morphine
level decreased to 6/10 then
5/10. Alternative pain
techniques (massage,
distraction) although
reported to be relaxing by the
patient did not further
decrease pain level. Will
continue to monitor pain
level, characteristics, and
apply interventions.
response, weakness, fatigue, and catabolism.
2. Pt’s pulse will
2. Assess Pt’s VS q 4 hr, PRN
trend to below 100 (Independent)
bpm, Systolic BP will
trend to below
120mm/Hg, Dystolic
BP will remain
below 80mm/Hg,
Temp. will trend to
below 100*F ,
Respirations will
remain 12-20per
min, O2 sat will
remain >93% on RA
as assessed q 4hrs,
PRN.
2. As pain impulses ascend the spinal cord toward the brain
stem and thalamus, the autonomic nervous system
becomes stimulated as part of the stress response. Pain
elicits the fight-or-flight reaction of the general adaptation
syndrome. Stimulation of the sympathetic branch of the
autonomic nervous system results in physiological
responses including dilation of bronchial tubes and
increased respiratory rate, increased heart rate, peripheral
vasoconstriction (pallor, elevation in blood pressure),
increased blood glucose level, diaphoresis, increased muscle
tension, dilation of pupils, and decreased gastrointestinal
motility. By identifying vital sign trends the pt’s physiological
response to pain can be identified and interventions can be
taken. An example regarding this effect is illustrated with
the pt’s increased temperature. This increased temp trend
suggests infection and inflammatory response. (WBC at
11.3, and Neut % at 82 to support) Further Inflammation
will exacerbate and increase patient’s pain level as the
enlargement of the pancreas and stretching of the
peritoneum will increase peritoneal/abdominal pressure
and pain. By identifying this change a medical intervention
can be applied, in this case Tylenol which will reduce the
pt’s temperature and associated discomfort, and would
aide in reducing pt’s pain in conjunction with opioid
analgesics.
2. P-HR trending down (117
1/6, 76 on end of shift 1/7).
Systolic BP trending down
from admission (152/92 on
1/6, 117/76 on end of shift
1/7) Respiration trend
remained 12-20 bpm, easy,
regular, O2 Sat. remained
>93% stable, Temp. trending
up(99.4/100.1/101.7/101.4/1
01.3) but decreased with
Tylenol PRN order
administration (99.3 (1/6)
100.0 (1/7) Will continue to
monitor. Offered cold
compress, encouraged ice
chip consumption.
3. Pt will
3. Instruct patient to utilize
demonstrate/verbal noninvasive methods q
ize three effective
shift, PRN. (Independent)
methods of
noninvasive pain
management after
one on one teaching
session.
3. Distraction directs a client's attention to something other
than pain and thus reduces the awareness of pain.
Distraction works best for short, intense pain lasting a few
minutes, such as during an invasive procedure or while
waiting for an analgesic to work. Use activities enjoyed by
the client that will act as distractions. My patient really
enjoys talking about his work and his family. Relaxation
techniques include meditation, yoga, Zen, guided imagery,
and progressive relaxation exercises. Relaxation is mental
and physical freedom from tension or stress that provides
individuals a sense of self-control. You are able to use
relaxation techniques at any phase of health or illness.
Physiological and behavioral changes associated with
relaxation include the following: decreased pulse, blood
pressure, and respirations; heightened global awareness;
decreased oxygen consumption; a sense of peace; and
decreased muscle tension and metabolic rate. Massage is
effective for producing physical and mental relaxation,
reducing pain, and enhancing the effectiveness of pain
medication. Massaging the back, shoulders, hands, and/or
feet for 3 to 5 minutes relaxes muscles and promotes sleep
and comfort. Stimulation of the skin helps relieve pain. The
proper use of cutaneous stimulation helps reduce muscle
tension that increases pain. When using cutaneous
stimulation, eliminate sources of environmental noise, help
the client to assume a comfortable position, and explain the
purpose of the therapy. Other noninvasive medthods
3. P- Pt. identified one
noninvasive pain control
method. Will continue to
reinforce teaching.
Additional pharmacological
interventions are needed to
further decrease pt’s pain
level.
include music, guided imagery, and biofeedback
4. Pt will return
demonstrate proper
Abdominal splinting
after one on one
teaching session.
4. Demonstrate proper
Abdominal Splinting
technique to patient.
(Independent)
4. Abdominal splinting can done either seated upright or
lying down. Instruct the patient to hold a pillow or rolled
blanket over the abdomen, and to wrap both arms or hands
as fully as possible across the pillow and press firmly.
Instruct pt to then take a slow, deep breath and then cough
at the end of the deep breath pressing firmly over
abdomen. Splinting with a pillow or a rolled blanket
provides support to the abdominal area thereby decreasing
pain from movement. It also aids in decreasing pain when
coughing and assists in expectoration of secretions and
keeping lung fields clear.
4. P-after first teaching
session pt was not able to
successfully demonstrate
technique. Further instruction
was given and pt successfully
demonstrated and stated
decreased pain when
technique utilized.
5. Pt Lipase level will 5. Assess Lipase/ Amylase
trend to 0-60
lab values when available,
units/L, Amylase
PRN (Dependent)
will trend to 30-110
units/L when
available.
5. Serum amylase levels in patients with pancreatitis vary
depending on the severity of the disease. On average,
during uncomplicated cases, the serum amylase level starts
increasing from two to 12 hours after the onset of
symptoms and peaks at 12 to 72 hours. It usually returns to
normal within one week with treatment. Although it lacks
sensitivity, measurement of the serum amylase level is the
most widely used method of diagnosing pancreatitis and the
degree of its severity. Lipase levels increase within four to
eight hours of the onset of clinical symptoms and peak at
about 24 hours. Levels decrease within eight to 14 days. The
specificity of lipase measurements are better than those of
amylase measurements, particularly in detecting alcoholic
pancreatitis. The specificity of lipase measurement, as well
as amylase measurement, may be improved by raising the
threshold to at least three times the upper limit of the
normal reference values. Decreases in these lab values
would indicate effective treatment as they correlate to a
decrease in inflammation and permeability of the pancreas.
This decrease in inflammation will result in decreasing
pressure in the peritoneum and abdomen and a decrease in
pain level for the pt.
5. M- Lipase/Amylase levels
on 1/6 were 5504 units/L and
278 units/L, 1/7 Lipase 1218
units/L and Amylase 110
units/L.
6. Pt’s pancreatic,
bililary duct, and
Gall Bladder
inflammation/disten
tion will trend to
reduce, EF will trend
towards 35-75% to
as assessed.
6. Assess Ultra Sound to
Upper Abdomen Area on
admission, PRN.
(Dependent/Collaborative)
6. Abdominal ultrasound is used to examine organs in the
abdomen including the liver, gallbladder, spleen, pancreas,
and kidneys. As my pt presented with sharp epigastric
abdominal pain an ultrasound was performed on 1/6. An
Abdominal ultrasound can be very useful in detecting acute
pancreatitis. In many cases ultrasound can differentiate
which type of acute pancreatitis is presenting; mild or
edematous and severe or necrotizing. Mild acute
pancreatitis sometimes presents with just focal involvement
of the gland, especially the head. In addition if associated
complications develop such as pseudocysts or vascular
abnormalities such as pseudoaneurysms, ultrasound can
detect them. By using the data provided by the ultrasound
a diagnosis of acute pancreatitis can be made (along with
any common complications) and interventions can be put in
place to reduce pt’s pain level.
6. U-UltraSound on 1/6 shows
pericolic fluid with GB
distention, Fatty Liver, and
trace acities to GB. Further
ultrasound(s) should be
completed to monitor for
improved EF>13%changes in
physiology and function. Will
continue to apply nonpharmacological and
pharmacological (Demerol,
Morphine) interventions to
reduce pain related to
inflammation and distention.
7. Pt will remain
free of S/S of FVD,
hypovolemia as
assessed q sift
7. Lactating Ringers @150
ml/hr Per MD order
(Dependent)
7. This patient was diagnose with acute pancreatitis.
Treatment of acute pancreatitis necessitates aggressive fluid
replacement as retrooperitoneal fluid losses and
dehydration can cause rapid development of hypovolemia.
Development of hypovolemia can result increased mortality
and morbidity tachycardia, hypotension, scant urine output,
and prerenal azotemia. Reduced volume can also result in
organ failure, which is responsible for many of the early
deaths attributed to acute pancreatitis. Aggressive fluid
resuscitation can also be used to minimize ischemia and
reperfusion injury, thereby preventing organ failure. These
fluid losses have been shown to respond to IV fluid therapy.
Hemoconcentration based on a serum hematocrit level at
admission has been consistently demonstrated to be linked
to the development of pancreatic necrosis. Pancreatic
necrosis may lead to the development of pancreatic
pseudocysts or tissue abscess serious complications that we
want to avoid. Pancreatic circulation depends on sufficient
circulating volume to avoid necrosis. By providing the LR
additional fluid input is provided and the risk of pancreatic
necrosis decreases. EBP has also shown the Lactating
Ringers are more effective at decreasing inflammation than
Normal Saline in pt’s with acute pancreatitis. In addition the
administration of IV fluid assists in maintaining fluid balance
as this patient reports being nauseous and vomiting for
some time prior to admission putting him at risk for
dehydration and FVD.
7. P- IV patent, running at
150ml/hr. Pt MM, lips moist,
skin non-tenting, provided Ice
Chips, Cap refill <3 sec, no
changes in mental status. Skin
dry, moisturized. Output low.
Will continue to monitor
output. Maintain strict I&O
and assess for other S/S of
FVD. Hematocrit at 38.9%.
8. Pt’s pain level will
trend to 2-3/10 q as
assessed q hr, PRN
9. Serum Calcium
8.Maintain NPO with Ice
Chips and Meds Per MD
order(Dependent)
8. The pancreas produces enzymes important to digestion.
When food enters the stomach, these pancreatic enzymes
are released into a system of ducts that culminate in the
main pancreatic duct. The pancreatic duct joins the
common bile duct and the juices then make their way to the
duodenum. The common bile duct originates in the liver and
the gallbladder. The pancreatic juices and bile are then
released into the duodenum, helping the body to digest
fats, carbohydrates, and proteins. It is believed that
Pancreatic stimulation caused by eating increases
pancreatic inflammation. Minimizing this
inflammation/inflammatory process will assist in decreasing
pt’s pain level.
8. U- Patient states pain 7/10
located in midepigatric area
(UL and UR abdomen
quadrants) sharp, constant,
unrelieved by repositioning,
vomiting. With administration
of Demerol and Morphine
level decreased to 6/10 then
5/10. Alternative pain
techniques (massage,
distraction) although
reported to be relaxing by the
patient did not further
decrease pain level. Will
continue to monitor pain
level, characteristics, and
apply interventions.
Ultrasound sounds shows GB
distension and inflammation.
levels will trend to
8.2-9.6 mg/dl q day
as assessed.
9. Monitor for
manifestations of
hypocalcaemia q shift, PRN
(Independent)
9. This patient was admitted with hypocalcemia a common
side effect of acute pancreatitius. Symptoms of
hypocalcemia commonly include paresthesia, muscle
spasms, cramping, grimicacing, tetany, circumoral
numbness, and seizures. Hypocalcemia can also present
with laryngospasm, neuromuscular irritability, and even
heart failure. The development of many of these
complications would further increase the pt’s pain level. By
monitoring for these complications we can apply
interventions quickly and keep the pt’s pain level from
rising.
10. Pt will
demonstrate proper
positioning for
decreased pain after
one on one teaching
session.
10. Assist patient in
assuming positions of
comfort q shift, PRN
(Independent)
10. This pt has been diagnosed with acute pancreatitis.
Acute pancreatic pain for this pt is located in midepigastic
area and radiates retroperioneally. Any enlargement of the
pancreas causes the peritoneum to stretch tightly causing
increased pain. By having the pt sit up, lean forward, or on
side with legs drawn up to chest, pain will be reduced. His
current pain level was 7/10.
9. P-Pt’s Calcium on 1/6 was
7.3mg/dl, on 1/7 decreased
to 6.6mg/dl. Albumin was
2.6g/dl. Pt did remain free of
manifestations of
hypocalcemia. Will continue
to monitor lab trends and for
any new manifestations of
hypocalcemia in pt.
10. M- Patient sitting up in
bed. HOB >45 degrees.
11. Pt’s WBC will
trend towards 4.810.8 x10^3/ul,
Neutrophils 59%
q day as assessed.
11. Assess WBC/Neut% lab
values q shift, PRN
(Dependent)
11. The body’s natural defense mechanism to infection
includes systemic inflammatory response. With acute
pancreatitis the peritoneum has increased pressure on it
related to the inflammatory process. Any additional
inflammation related to infection will increase the patients
pain level. A tend of decreasing WBC’s and % of Neutrophils
indicate this pt’s infection is resolving. The decrease
infection will correlate to a decrease in inflammation that
will decrease pt’s pain level. The presence of an active
infection may also impair or delay the pt’s ability to have a
surgical intervention. Any delay would cause the patient to
remain at a higher level of pain for a longer period of time.
11. U-WBC at 11.3x10^3/ul,
Neutrophils 82% on 1/6. No
further labs available at this
time. Will verify CBC is
ordered and will review lab
values when available. Will
monitor trend. While waiting
for results will continue to
utilize non-pharmacological
and pharmacological pain
relief relief interventions to
decrease pt’s pain level from
current 7/10 to comfort level
of 2-3/10.
12. Pt’s
temperature will
trend down toward
towards 98.6
degrees 30min-1hr
after administration
12. Administer
Acetaminophen PO 650 mg
q 4 hrs, PRN per MD order
(Dependent)
12. Acute pancreatitis causes inflammation and as part of
the inflammatory process the hypothalamus has increased
body temperature and the pt is now fibrile. Acetaminophen
is a non-opioid analgesic and antipyretics. The exact
mechanism of action of acetaminophen is not known. It is
thought to reduce the production of prostaglandins in the
brain which mitigates their effects on the CNS. It reduces
fever through its action on the hypothalmus. While
acetaminophen does not have significant anti-inflammatory
properties will provide pain relief for this pt via other
actions including acting as an adjunct analgesic to
administered opioid analgesics (e.g. Demerol) to reduce the
pt’s pain level, and also reducing discomfort related to the
pt’s fever.
12. P-Temperature initially
trending up on shift.
Exceeded MD parameters.
Notified Primary RN Jenn
Schemmerhorn who notified
MD. Temp.
(99.4/100.1/101.7/101.4/101.
3) but decreased with Tylenol
PRN order administration
(99.3 (1/6) 100.0 (1/7) Will
continue to monitor. Offered
cold compress, encouraged
ice chip consumption. Pain
5/10.
13.Pt’s WBC count
will trend towards
4.8-10.8 x10^3/ul,
Neutrophils 37-80%
as assessed q day
13.Administer Zosyn IV
3.375g q 6 hr per MD order
(Dependent)
13. Zosyn is an anti-infective and extended spectrum
penicillin. It is a combination of two drugs. Piperacillin, a
penicillin-type antibiotic that binds to bacterial cell wall
membranes causing cell death and Tazobactam a betalactamase inhibitor that assists in mitigating enzyme activity
that can destroy pennicillins. The bodies natural defense
mechanism to infection includes systemic inflammatory
response. Administering Zosyn will decrease the likelihood
for additional inflammation in relation to this pt’s infection
and will assist the body in mitigating the infection and
current inflammation the patient is experiencing. This
decrease in inflammation will decrease pt’s pain level. EBP
data suggest that the best time to introduce antibiotics is
immediately after the diagnosis of Acute Pancreatitis and
the evaluation of its severity. The presence of an active
infection may also impair or delay the pt’s ability to have a
surgical intervention. Any delay would cause the patient to
remain in pain for a longer period.
14. C-reactive protein is a sensitive marker of pancreatic
necrosis and it starts to increase significantly 48 hours after
13. P-Zosyn administered per
MD order. WBC at
11.3x10^3/ul, Neutrophils
82% on 1/6. No further labs
available at this time. Will
verify CBC is ordered and will
review lab values when
available to monitor trend.
14. U-C-reactive protein lab
14. Pt’s C-reactive
protein will trend to
0-0.8mg/dL q day as
assessed.
14. Monitor C-Reactive
Protein lab value when
available.
(Dependent/Collaborative)
15. Pt’s pain level
will trend to 2-3/10
following Demerol
administration as
assessed.
15. Administer Demerol IV
10mg/hr per MD order
(Dependent)
the onset of symptoms. C-reactive protein can be useful in
the identification of patients with high possibility to develop
necrosis, in particular when the value is over 150 mg/dl. By
identifying if pancreatic necrosis is occurring interventions
such as
15. This patient present with a high pain level (7/10) related
to the inflammation of his pancreas and distention of his
gall bladder. Meperidine hydrochloride(Demerol) is a
narcotic analgesic for moderate to severe pain with multiple
actions similar to those of morphine. The most prominent of
these involve the depression of the CNS ,and organs
composed of smooth muscle. The principal actions of
therapeutic value are analgesia and sedation. These are
achieved as the drug binds to opiate receptors in the CNS.
This alters the perception and response of the pt to painful
stimuli including the inflammation and distention related to
the pancreatitis. There is also some evidence that suggests
that meperidine may produce less smooth muscle spasm,
constipation, and depression of the cough reflex than equal
doses of morphine an additional benefit to this pt as
respiratory complications can occur R/T pancreatitis and its
effects on the function of the diaphragm. Administration of
this intervention will decrease pt’s pain level.
unavailable at this time. Will
follow up with MD. Once lab
data available will assess and
analyze result and apply
appropriate interventions to
reduce pain.
15.P- Pt’s Pain level trended
down from 7/10 to 5/10 but
not to comfort level of 23/10. Pt did state that it
“helped dull the pain”.
Additional PRN pain med.
(morphine) administered.
16. Pt will
verbalize/demonstr
ate understanding
of connection
between smoking
and pancreatitis
after one on one
teaching session.
16. Encourage/teach
smoking cessation q shift,
PRN(Independent/Collabora
tive)
16. This pt is a current smoker and has a 5 pack yr history.
Recent studies and an increasing amount of scientific data
have shown that smoking can be a major contributing cause
of acute and chronic pancreatitis and that the combination
of alcohol and smoking is particularly toxic. Duration of
smoking was a better predictor of increased risk than
smoking intensity. Several studies have found that smoking
cause’s pt’s to perceive pain more acutely as Tobacco use
effects the nervous system by increasing the sensations and
perceptions of pain. In addition smokers have been shown
to require more medication (both opiate and analgesics) to
ease their pain as nicotine is believed to alter the
pharmokenetics of medications. In addition to the negative
effects on pain level and sensation, smoking is a known
contributor to inflammation, decreases O2 levels increasing
workload on the heart and lungs, and interferes with the
healing process. All three of these issues will contribute to
my pt’s overall pain level. It is interesting to note however
that evidence also suggests that rapid dissipation of the
systemic effects of nicotine contributes to pain-related
symptoms during periods of relative nicotine deprivation.
This suggests that nicotine replacement (gum or patch) may
be warranted to reduce the pt’s pain level during cessation
of smoking.
16. P-Pt indicated desire to go
outside and smoke. After
teaching session he changed
his mind and decided to not
go outside and smoke for
now. Cessation resources
such as nicotine gum or
patches, 1-866-NYQUITS,
were also discussed with the
pt. as resources to assist with
cessation. Will continue to
reinforce benefits of smoking
cession in regards to pt’s pain
R/T inflammation and pt’s
perception of pain.