Careplan Acute Pancreatitis 734l56

Student Nurses’ Community NURSING CARE PLAN – Acute Pancreatitis ASSESSMENT SUBJECTIVE: “Masakit ang tiyan ko” (I'm having severe abdominal pain)

as verbalized by the patient.

OBJECTIVE: • • • •

Abdominal guarding behavior Inability to concentrate. Irritability V/S taken as follows T: 37.0˚C P: 67 R: 18 BP: 110/ 80

DIAGNOSIS

INFERENCE

PLANNING

Acute pain. May be related to obstruction of pancreatic, biliary ducts, chemical contamination of peritoneal surfaces by pancreatic exudate, autodigestion of pancreas, and extension of inflammation to the retroperitoneal nerve plexus.

Acute pancreatitis is a serious and at times lifethreatening inflammatory process of the pacreas. This process is caused by a premature activation of pancreatic enzymes that destroy ductal tissue and pancreatic cells, resulting in autodigestion and fibrosis of the pancreas. The pathologic changes occur in variable degrees. The severity ofpancretitis depends on the extent of inflammation and tissue destruction.

After 4 hours of nursing interventions, the Patient will report pain is relieved; follow prescribed therapeutic regimen; and demonstrate use of methods that provide relief.

INTERVENTION Independent • Investigate verbal reports of pain, noting specific location and intensity.

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Maintain bed rest during acute attack and provide quiet, restful environment.

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Promote position of comfort.

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Keep environment free of food odors.

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Maintain meticulous skin care, especially in draining abdominal wall fistulas.

RATIONALE • Pain is often diffuse, and unrelenting in acute or hemorrhagic pacreatitis. Severe pain is often the major symptom in a patient with chronic pancreatitis. • Decrease stimulation of pancreatic secretions, thereby reducing pain. • Reducing abdominal pressure and tension. • Sensory stimulation can activate pancreatic enzymes. • Pancreatic enzymes can digest the skin and tissues of the abdominal wall, creating abscesses and ulceration.

EVALUATION After 4 hours of nursing interventions, the Patient was able to report pain is relieved; follow prescribed therapeutic regimen; and demonstrate use of methods that provide relief.

Student Nurses’ Community Collaborative • ister intravenous analgesics as prescribed.

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Withhold food and fluid, as indicated.

• Severe or prolonged pain can aggravate shock and is more difficult to relieve, requiring larger doses of medication, which can mask underlying problems and complications. • Patient should be kept noting by mouth status until pain and nausea subside to limit or reduce release of pancreatic enzymes and resultant pain.