Pancreatitis Concept Map PDF

Preview

Summary

Pancreatitis concept map from lippincott the point...

Description

CONCEPT MAP Nursing Diagnosis

Nursing Diagnosis

Acute pain related to CT scan of an enlarged diameter of the pancreas as evidence by reports of pain

Imbalanced nutrition less than body requirements related to NPO as evidence by vomiting Subjective Data: Vomiting that fails to relieve pain

Subjective Data: Patient rates her pain 10/10

Objective Data: increased amylase/lipase/glucose levels

Objective Data: Patient is crying and clutching abdomen

Reason for Seeking Health Care (Admitting Diagnosis) Acute pancreatitis

Nursing Diagnosis

Nursing Diagnosis

Deficient knowledge related to lack of exposure as evidence by new condition

Risk for infection related to immunosuppression

Subjective Data: New disease process is introduced to the patient

Subjective Data: Severe abdominal pain

Objective Data: The nurse educates the patient on an increased serum lipase level

Objective Data: High WBC of 16,500

PLAN OF CARE PRIORITY #1 Nursing Diagnosis: Acute pain related to CT scan of an enlarged diameter of the pancreas as evidence by reports of pain Intervention (s) The nurse will

Administer analgesics in timely manner (smaller, more frequent doses). Administer medication as indicated

Investigate verbal reports of pain, noting specific location and intensity (0–10 scale). Note factors that aggravate and relieve pain.

Withhold food and fluid as indicated.

Rationale

Severe and prolonged pain can aggravate shock and is more difficult to relieve, requiring larger doses of medication, which can mask underlying problems and complications and may contribute to respiratory depression. Morphine is effective in relieving pain Pain is often diffuse, severe, and unrelenting in acute or hemorrhagic pancreatitis. Severe pain is often the major symptom in patients with chronic pancreatitis. Isolated pain in the RUQ reflects involvement of the head of the pancreas. Pain in the left upper quadrant (LUQ) suggests involvement of the pancreatic tail. Localized pain may indicate development of pseudocysts or abscesses. Limits and reduces release of pancreatic enzymes and resultant pain.

Expected Outcome: The patient will Report pain is relieved/controlled. PRIORITY #2 Nursing Diagnosis: Imbalanced nutrition less than body requirements related to NPO as evidence by vomiting Intervention (s) The nurse will

Maintain NPO status and gastric suctioning in acute phase. Assess abdomen, noting presence and character of bowel sounds, abdominal distension, and reports of nausea.

Rationale

Prevents stimulation and release of pancreatic enzymes (secretin), released when chyme and HCl enter the duodenum. Gastric distention and intestinal atony are frequently present, resulting in reduced and absent bowel sounds. Return of bowel sounds and relief of symptoms signal readiness for discontinuation of gastric aspiration

Provide frequent oral care.

Assist patient in selecting food and fluids that meet nutritional needs and restrictions when diet is resumed.

(NG tube). Decreases vomiting stimulus and inflammation and irritation of dry mucous membranes associated with dehydration and mouth breathing when NG is in place. Previous dietary habits may be unsatisfactory in meeting current needs for tissue regeneration and healing. Use of gastric stimulants (caffeine, alcohol, cigarettes, gasproducing foods), or ingestion of large meals may result in excessive stimulation of the pancreas and recurrence of symptoms.

Expected Outcome: The patient will Experience no signs of malnutrition. PRIORITY #3 Nursing Diagnosis: Deficient knowledge related to lack of exposure as evidence by new condition Intervention (s) The nurse will

Rationale

Discuss other causative and associated factors such as excessive alcohol intake, gallbladder disease, duodenal ulcer. Stress the importance of follow-up care, and review symptoms that need to be reported immediately to physician (recurrence of pain, persistent fever, nausea and vomiting, abdominal distension, frothy and foul-smelling stools, general intolerance of food).

Avoidance may help limit damage and prevent development of a chronic condition. Prolonged recovery period requires close monitoring to prevent recurrence and complications (infection, pancreatic pseudocysts).

Recommend cessation of smoking.

Nicotine stimulates gastric secretions and unnecessary pancreatic activity.

Review importance of initially continuing bland, low-fat diet with frequent small feedings and restricted caffeine, with gradual resumption of a normal diet within individual tolerance.

Understanding the purpose of the diet in maximizing the use of available enzymes while avoiding overstimulation of the pancreas may enhance patient involvement in self-monitoring of dietary needs and responses to foods.

Expected Outcome: The patient will Verbalize understanding of condition/disease process and potential complications.

PRIORITY #4 Nursing Diagnosis: Risk for infection related to immunosuppression Intervention (s) The nurse will

Use strict aseptic technique when changing surgical dressings or working with IV lines, indwelling catheters and tubes, drains. Change soiled dressings promptly. Stress importance of good handwashing. Observe rate and characteristics of respirations, breath sounds. Note occurrence of cough and sputum production. Observe for signs of infection like fever and respiratory distress in conjunction with jaundice;

Rationale

Limits sources of infection, which can lead to sepsis in a compromised patient. Reduces risk of cross-contamination. Fluid accumulation and limited mobility predispose to respiratory infections and atelectasis. Accumulation of ascites fluid may cause elevated diaphragm and shallow abdominal breathing. Cholestatic jaundice and decreased pulmonary function may be first sign of sepsis involving Gram-negative organisms.

Expected Outcome: The patient will Achieve timely healing, be free of signs of infection.

Narrative Nurse’s Note Date/Tim e

Nurse’s Note

10-4-2020

MONICA DONALDSON PRESENTS TO THE EMERGENCY DEPARTMENT WITH COMPLAINTS

1200

OF SEVERE ABDOMINAL PAIN AND VOMITING. SHE RATES HER PAIN 10 ON A SCALE OF 1 TO 10. SHE IS CRYING AND CLUTCHING HER ABDOMEN.

10-4-2020

VITAL SIGNS ARE TAKEN

1230 10-4-2020

PAIN MEDICATION WAS ADMINISTERED AS ORDERED BY PHYSICIAN

1300 10-4-2020

CT, CBC, AND CMP WERE ORDERED TO FURTHER EVALUATE MS. DONALDSON’S CONDITION

1330 10-4-2020

PAIN WAS REEVALUATED AN HOUR AFTER PAIN MEDICATION WAS GIVEN

1400 10-4-2020

MISS DONALDSON IS GOING TO BE ADMITTED TO THE INPATIENT UNIT WITH A DIAGNOSIS

1500 10-4-2020 1600

PATIENT DISCHARGE INSTRUCTIONS WERE GIVEN

Signature

Narrative Nurse’s Note Date/Tim e

Nurse’s Note

Signature...