Pancreatitis Nursing Diagnosis Care Plans
Pancreatitis is a disease characterized by the inflammation of the pancreas, an elongated gland in the abdomen that produces enzymes.
These pancreatic enzymes are necessary for digestion, as well as for the regulation of glucose balance. Excellent nursing care can be delivered to a patient with acute or chronic pancreatitis with the use of the following nursing care plans.
- Hyperthermia secondary to infective process of pancreatitis as evidenced by temperature of 38.5 degrees Celsius, rapid breathing, profuse sweating, and chills
Desired Outcome: Within 4 hours of nursing interventions, the patient will have a stabilized temperature within the normal range.
|Assess the patient’s vital signs at least every 4 hours.||To assist in creating an accurate diagnosis and monitor effectiveness of medical treatment, particularly the antibiotics and fever-reducing drugs (e.g. Paracetamol) administered.|
|Remove excessive clothing, blankets and linens. Adjust the room temperature.||To regulate the temperature of the environment and make it more comfortable for the patient.|
|Administer the prescribed antibiotic and anti-pyretic medications.||Use the antibiotic to treat bacterial infection (pancreatitis), which is the underlying cause of the patient’s hyperthermia. Use the fever-reducing medication to stimulate the hypothalamus and normalize the body temperature.|
|Offer a tepid sponge bath.||To facilitate the body in cooling down and to provide comfort.|
|Elevate the head of the bed.||Head elevation helps improve the expansion of the lungs, enabling the patient to breathe more effectively.|
2. Nursing Diagnosis: Acute Pain related to obstruction of pancreatic ducts secondary to acute pancreatitis as evidenced by pain score of 10 out of 10, verbalization of sharp abdominal pain, guarding sign on the abdomen, and restlessness
Desired Outcome: The patient will demonstrate relief of pain as evidenced by a pain score of 0 out of 10, stable vital signs, and absence of restlessness.
|Administer prescribed pain medications.||To alleviate the symptoms of acute abdominal pain. Pain on the right upper quadrant of the abdomen suggests the involvement of the head of the pancreas, while left upper quadrant pain refers to the tail of the pancreas. Narcotic analgesics such as meperidine should be preferred over morphine, as the latter has a side effect of biliary pancreatic spasms. Antacids may be used in combination with analgesics in order to neutralize gastric acidity and reducing the production of pancreatic enzymes.|
|Assess the patient’s vital signs and characteristics of pain at least 30 minutes after administration of medication.||To monitor effectiveness of medical treatment for the relief of abdominal pain. The time of monitoring of vital signs may depend on the peak time of the drug administered.|
|Elevate the head of the bed if the patient is short of breath.||To increase the oxygen level by allowing optimal lung expansion.|
|Place the patient in complete bed rest during severe episodes of pain. Perform relaxation techniques such as deep breathing exercises, guided imagery, and provision of distractions such as TV or radio.||To reduce gastrointestinal stimulations thereby decreasing pancreatic activity.|
3. Nursing Diagnosis: Deficient Knowledge related to new diagnosis of chronic pancreatitis as evidenced by patient’s verbalization of “I want to know more about my new diagnosis and care”
- Desired Outcome: At the end of the health teaching session, the patient will be able to demonstrate sufficient knowledge of chronic pancreatitis and its management.
|Assess the patient’s readiness to learn, misconceptions, and blocks to learning (e.g. denial of diagnosis or poor lifestyle habits)||To address the patient’s cognition and mental status towards the new diagnosis of chronic pancreatitis and to help the patient overcome blocks to learning.|
|Explain what pancreatitis is, its types (specifically chronic pancreatitis). Avoid using medical jargons and explain in layman’s terms.||To provide information on pancreatitis and its pathophysiology in the simplest way possible.|
|Educate the patient about lifestyle changes that can help manage chronic pancreatitis. Create a plan for Activities of Daily Living (ADLs) with the patient that involve alcohol avoidance, smoking cessation, dietary changes, and physical activity.||To help the patient avoid alcohol intake that may lead to preventing further damage to the pancreas. To encourage the patient to stop smoking, as nicotine is a stimulant for unnecessary gastric secretions and pancreatic activity.|
|Inform the patient the details about the prescribed medications (e.g. drug class, use, benefits, side effects, and risks) to manage chronic pancreatitis. Ask the patient to repeat or demonstrate the self-administration details to you.||To inform the patient of each prescribed drug and to ensure that the patient fully understands the purpose, possible side effects, adverse events, and self-administration details.|
|Encourage the patient to continue following a low fat, bland diet with caffeine restrictions. Refer the patient to a dietitian as required.||To avoid overstimulation of the pancreas. To enable to patient to receive more information in managing diet through a dietitian.|
4. Nursing Diagnosis: Risk for Fluid Volume Deficit
Desired Outcome: The patient will demonstrate adequate hydration and balanced fluid volume
|Assess vital signs, particularly blood pressure level.||Pancreatic ischemia may lead to third space fluid shifting, which may lower blood pressure levels and put the patient at risk for hypotensive episodes.|
|Commence a fluid balance chart, monitoring the input and output of the patient. Include episodes of vomiting, gastric suctioning, and other gastric losses in the I/O charting.||To monitor patient’s fluid volume accurately.|
|Start intravenous therapy as prescribed. Electrolytes may need to be replaced intravenously. Encourage oral fluid intake of at least 2000 mL per day if not contraindicated.||To replenish the fluids and electrolytes lost from vomiting or other gastric losses, and to promote better blood circulation around the body.|
|Educate the patient (or guardian) on how to fill out a fluid balance chart at bedside.||To help the patient or the guardian take ownership of the patient’s care, encouraging them to drink more fluids as needed, or report any changes to the nursing team.|
|Prepare the patient to undergo peritoneal lavage, if indicated.||To provide a rapid treatment of metabolic abnormalities by removing pancreatic enzymes and toxic chemicals in acute pancreatitis.|
5. Nursing Diagnosis: Risk for Infection
Desired Outcome: The patient will be able to avoid the development of an infection.
|InterventionsRationalesAssess vital signs and observe for any signs of infection as well as for any signs of respiratory distress and cholestatic jaundice.||Sepsis or infection of the blood may be evidenced by fever accompanied by cholestatic jaundice and respiratory distress.|
|Perform a focused assessment on the abdominal region, particularly checking for abdominal pain, abdominal rigidity, diminishes or absent bowel sounds, and rebound tenderness.||Peritonitis is a serious complication of pancreatitis. It is evidenced by abdominal pain, abdominal rigidity, diminishes or absent bowel sounds, and rebound tenderness.|
|Obtain a sample for culture, such as pancreatic enzyme, blood, urine, or sputum.||To identify the presence of an infection and its causative agent.|
|Teach the patient how to perform proper hand hygiene.||To maintain patient safety and reduce the risk for cross contamination.|