CARING FOR THE PATIENT WITH ACUTE PANCREATITIS

A Case Study
Presented To
The Clinical Instructors
Central Philippines Adventist College
Alegria, Murcia, Negros Occidental

In Partial Fulfillment of the Requirement in

NCM:118b
Presented by: Group B
Jorolan, Darah Marie G.
Panton, Bob Aeroll P.
Ortilano, Dexter Niel N.
Ordanel Glynn Donn.
Labordo, Mae Denn F.
Mahilum, Kimberly P.
Mondreal, Christine Joy R.
Lequin, Regine
Reyes, Dremsy Love G.
Payos, Christine

Date Submitted:
October 6, 2022

ACKNOWLEDGEMENT

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We thank God for all the knowledge and the strength that He bestowed upon us and we
are bringing back the glory and praises to Him who is the source of our wisdom in
making this case study. We extend also our heartfelt thanks to our clinical instructor who
guided us to increase our knowledge, improve our skills and to be a more competent
student nurses. To our ever supportive parents and sponsors for the financial and
emotional support to us in times that we felt worn-out, we express our thanks you. And
lastly, to our classmate and friends we thank you for being there for us and for helping us
in times of need.

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 DEDICATION

We would like to dedicate this fruit of our work to our Loving God, Beloved Parents, and
Clinical Instructors and to all the people who served as our inspiration and strength in
pursuing and striving for the best in finishing this requirement.

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TABLE OF CONTENTS
Acknowledgement………………………………………………………………………i
Dedication ……………………………………………………………………………ii

CHAPTER I INTRODUCTION AND DATABASE

Objectives of the Study (KSA format) ………………………………………………....

Demographic Data (Provide confidentiality) …………………………………………...
Introduction (Preferably about your experience during your patient care…………...….
Nursing History………………………………………………………………………...
Health History – Past and Present…………………………………….……......
Functional Health Patterns (Gordon’s – past and present) ………….……. ...….
. Family Genogram……………………………………………………………....

CHAPTER II THE DISEASE ENTITY

The Medical Diagnosis with chief complaints (Brief description) …………………….

Theoretical Background ………………………………………………………………..
Paradigm and Pathophysiology of the Disease …………………………………………

CHAPTER III THE MANAGEMENT

Physical Assessment ……………………………………………………………………

Diagnostic Test results & significance ………………………………………………
Drug Study ……………………………………………….…………………………….
Nursing Care Plan ………………………………………………………………………
Discharge Plan ……………………………………………………………………......

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CHAPTER IV GENERAL EVALUATION OF THE STUDY
Conclusion ……………………………………………………………………….….
Implication of the Study to: …………………………………………………………
Nursing Education……………………………………………………
Nursing Practice……………………………………………………...
Nursing Research……………………………………………….........

Personal Reaction (SKA)……………………………………………………

BIBLIOGRAPHY…………………………………………………………… …….

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 OBJECTIVES

After one-hour presentation, the audience will be able to:

Knowledge
1. Identify the modifiable and non-modifiable factors of Acute Pancreatitis.

2. Determine the different changes in the body in the course of the disease.

3. Familiarize the interventions of medical health group in treating the disease.

4. Distinguish a specific pharmacological and non-interventions pharmacological of

acute pancreatitis.

5. Enhance learning potential by taking essential notes to increase learning.

Skills
1. Apply the knowledge, strategies and techniques that was discussed in our study in

the continuum of nursing care.

2. Express own opinions and level of understanding that can contribute to the study.

3. Compose a critical thinking questions that can help evaluate the study.

Attitude
1. Display professionalism by listening attentively to the presenter’s topic.

2. Create a learning atmosphere by showing interest in the given topic.

3. Engage in courtesy and respect while the presenters are discussing the topic.

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 Demographic Data
Name: Barasan, Julita C.
Age: 72 years’ old
Sex: Female
Civil Status: Widow
Address: Blk. 4, Lot 15, Terranova Subd., Alijis
Birthday: July 9, 1951
Birthplace: Sagay
Educational Attainment: None
Occupation: None
Religion: Catholic
Nationality: Filipino
Date of Admission: September 24, 2022
Date of Discharge: September 29, 2022
Hospital #: 341376
Case #: 1132999
Room#: 2EO4
Attending Physician: Dr. Jed Josef De Leon
Medical Diagnosis: Acute Pancreatitis

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 CHAPTER 1
INTRODUCTION AND DATABASE
Pancreatitis is inflammation of the pancreas. The pancreas is a long, flat gland that sits
tucked behind the stomach in the upper abdomen. The pancreas produces enzymes that
help digestion and hormones that help regulate the way your body processes sugar
(glucose). The pancreas is a gland that sits just behind the stomach. It has two roles: To
secrete digestive juices into the small bowel to digest food and neutralize gastric acid
secretion and to release insulin to regulate the glucose levels in the blood.
There are three types of pancreatic cells:
Acinar cells- which produce pancreatic digestive enzymes. It is a highly specialized
structure developed for synthesis, storage, and secretion of digestive enzymes. The acinar
cell arises from the same pancreatic progenitor as duct and islet cells and is tightly
polarized.
Ductal cells- lining pancreatic ducts, which secrete a watery fluid to carry the digestive
enzymes into the intestine. In addition, these cells secrete bicarbonate that neutralizes
stomach acidity.
Endocrine cells- which secrete insulin and other hormones.
Because acinar and ductal cells secrete into a duct this portion is called the exocrine
pancreas. Pancreatic digestive enzymes are made as inactive precursors and carried to the
small bowel where there are additional enzymatic processes that convert the inactive
digestive enzymes to actives ones that digest our food. When pancreatic enzymes are
prematurely activated in the pancreas, they attack the pancreas itself instead of digesting
food and cause pancreatitis.
Also, Pancreatitis can occur as acute pancreatitis, meaning it appears suddenly and lasts
for days. Some people develop chronic pancreatitis, which is pancreatitis that occurs over
many years. Mild cases of pancreatitis improve with treatment, but severe cases can
cause life-threatening complications.
Our study focuses on acute pancreatitis, it is a condition where the pancreas becomes
inflamed (swollen) over a short period of time. Acute pancreatitis is most often linked to,
gallstones and drinking too much alcohol but sometimes the cause is not known. And it’s
treatment aims to help control the condition and manage any symptoms.
Caring for a patient with acute pancreatitis can be challenging but fulfilling, enriched,
with a lot of knowledge and joy to serve a client with this disease.
So, with this in mind the researchers put out a study to increase understanding when
caring for a patient with acute pancreatitis.

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 NURSING HISTORY

Health History

I. Chief Complaint: Loss of Appetite and Vomiting

II. History of Present Illness: a week prior to PTA, onset of loss appetite associated with

1 episode of vomiting of previously ingested food, non-bilious, non-projected. ODA,

persistence of symptoms prompted admission. Patient appeared drowsy, arousal course in

the ward. Pt history taken, physical exam, laboratory done, and the result is acute

pancreatitis.

III. Past Medical History

1. Medical Illness:

a. Childhood illness-flu, cough

b. Adult Illness-hypertensive (2022) atherosclerosis (2022)

2. Psychiatric Illness: None

3. Surgical Procedures: None

4. Accidents/Trauma/Injuries: None

5. Other Hospitalizations: None

6. Immunizations: Complete Vaccination

7. Allergies-None

8. Medication- None

9
9. Exposure to Environmental Hazards- None

10. Blood Transfusion- None

11. Foreign History/Military/Pat Residence- None

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 GORDON’S FUNCTIONAL PATTERNS

HEALTH PERCEPTION:

Prior to admission, patients had done check-ups and seek medical assistance. It uses

herbal medicines such as oregano and ginger. The patient doesn’t have any accident

experiences. Her illness was caused by having gallstones that causes inflammation to her

pancreas.

During admission, the patient takes medication as prescribed and abides by any medical

treatment offered. Patient showed interest in listening to health teachings. 

NUTRITIONAL METABOLIC:

Prior to admission, patient’s diet has always consisted of high cholesterol. She eats her

meals for 3 time a day. Patient is gaining weight every week as she stated.

During admission, she eats her meals three times a day and has was advised to have soft

diet and a small slice of fruit each meal.  

ACTIVITY AND EXERCISE:

Prior to admission, the patient likes to always do house chores; she does walks 10–15

minutes a day within their backyard.

During admission, the patient has decreased speed of movement and is unable to perform

activities that require strength because of her current health condition.

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SLEEP REST PATTERN:

Prior to admission, the patient usually sleeps depending on how tired she is as what she

verbalized. She sleeps around 9pm and wakes up at 5:30am

During admission, she sleeps from 8 p.m. until 6 a.m. She can’t sleep continuously and

wakes up from time to time to urinate.

ELIMINATION PATTERN:

Prior to admission, patient regularly urinates. Patients defecate one a day every morning,

stool is usually brown and formed. 4-5 times a day urinate.

During admission, the urine color is light yellow. There is no burning sensation or pain

during urination. Patient moves her bowels once a day, brown in color and sometimes

dark brown, and formed stools.

SELF PERCEPTION:

Prior to admission, the see herself not seeking medical attention due to not knowing

about her condition in the first place. See sees herself as an active person and loves to just

work by doing house chores that could make her body actively moves. The patient feels

good about herself whn she’s active and busy.

During admission, the patient felt self-pity because of her current physical health. The

patient became fearful and anxious.

ROLE RELATIONSHIP:

The patient is widowed and she lives together with her Son and the family. She has a

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good relationship with her family and close to her grand son and daughter. She is

depending on her son and doesn’t have difficulty in living with his son’s family.

COPING STRESS:

Prior to admission, patient was able to cope up with her stress through cleaning their

house and cooking for her family. And also going out their house and walking around

mini garden. She goes to church every Sundays that helped her relax and cope with

stress.

During admission, the patient copes with stress and problems by meditating and talking

to her son. 

RECREATIONAL:

Prior to admission, patient does gardening and household chores every day and this

serves as her recreational activity.

During admission, patient does not have any recreational activities due to current

condition that limits her movements.

VALUES AND BELIEFS:

The patient is a is Catholic and goes to church near their place to attend their church

service.

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FAMILY GENOGRAM

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 CHAPTER II
THE DISEASE ENTITY
This chapter includes the theoretical background of the disease process, the anatomy and
physiology of the system or organs involved and the concept map. This chapter deals
with explaining on how the disease occurs.

Chief Complaint: Vomiting and Loss of appetite

Medical Diagnosis: Acute Pancreatitis

Theoretical Background of Acute Pancreatitis:

Pancreatitis is an inflammation (swelling) of the pancreas. When the pancreas is

inflamed, the powerful digestive enzymes it makes can damage its tissue. The inflamed
pancreas can cause release of inflammatory cells and toxins that may harm your lungs,
kidneys and heart. On the other hand, Acute pancreatitis is usually a sudden and severe
illness caused when the pancreas rapidly becomes inflamed. Pancreas enzymes and
various poisons (toxins) may enter the blood stream in an acute attack, and injure other
organs such as the heart, lungs and kidneys. The signs and symptoms of acute pancreatitis
upper abdominal pain, abdominal pain that radiates to your back, tenderness when
touching the abdomen, fever, rapid pulse, nausea and vomiting. Typically, a person has a
sudden onset of pain in the center of their upper abdomen, below the breastbone, or
sternum. The pain may intensify and become severe, and it may spread into the back.
Leaning forward may ease it, but lying down or walking can make it worse. Anyone with
unrelenting pain should receive medical attention. Moreover, gallstones and alcohol
misuse are the most common causes of acute pancreatitis. Other possible causes of acute
pancreatitis include: infections, some autoimmune conditions, such as lupus and
Sjögren’s disease. Specific genetic mutations, trauma or injury to the pancreas, high
triglyceride levels in the blood, high calcium levels in the blood and certain medications.

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Severe cases often involve some tissue death, or necrosis. This increases the risk of
sepsis, a severe bacterial infection that can affect the whole body. Sepsis can lead to
multiorgan damage or failure. Severe acute pancreatitis can also cause hypovolemic
shock. This involves severe blood and fluid loss leaving the heart unable to pump enough
blood to the body. If this happens, parts of the body can rapidly become deprived of
oxygen. This is a life threatening situation.

Treatment for mild acute pancreatitis

The aim is to maintain bodily functions and ease the symptoms while the pancreas heals
itself. The treatment may include:

Painkillers: Mild acute pancreatitis can be moderately or severely painful.

Nasogastric tubes: These can remove excess liquid and air to relieve nausea and
vomiting.

Bowel rest: The gastrointestinal tract needs to rest for a few days, so the person will not
have any food or drink by mouth until their condition improves.

Preventing dehydration: Dehydration often accompanies pancreatitis, and it can worsen

the symptoms and complications. Healthcare professionals usually provide fluid
intravenously for the first 24–48 hours. A person can usually return from the hospital
after about 5–7 days.

Treatment for severe acute of pancreatitis includes:

Treatment in the intensive care unit (ICU): There, injected antibiotics can help prevent
an infection from developing in the dead tissue.

Intravenous fluids: These help maintain hydration and prevent hypovolemic shock.

Feeding tubes: These provide nutrition, and taking this course early may improve the
outcome.

Surgery: In some cases, the medical team may recommend surgical removal of the dead
tissue.

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Furthermore, pancreatitis can lead to potentially fatal complications. These can
include ,the obstruction of a bile or pancreatic duct, leakage from a pancreatic
duct,pseudocysts, with a risk of rupture, hemorrhage, or infection, damage to the
pancreas, a buildup of fluid around the lungs, a blockage in a vessel that drains blood
from the spleen,sepsis,hypovolemic shock. Heart, lung, and kidney failure may also
occur. Without treatment, these can lead to death.

Anatomy of Pancreas

The pancreas is an accessory organ and exocrine gland of the digestive system, as well as
a hormone producing endocrine gland. It is a retroperitoneal organ consisting of five parts
and an internal system of ducts. The pancreas is supplied by pancreatic arteries stemming
from surrounding vessels and is innervated by the vagus nerve (CN X), celiac plexus, and
superior mesenteric plexus.

Location:

The pancreas is an elongated organ (approximately 15 cm) which lies obliquely across
the posterior abdominal wall, at the level of the L1 and L2 vertebral bodies. To put it in a
clinical context, its oblique position makes it impossible to see the entire pancreas in a
single transverse section. The pancreas comes in contact with several neighboring
structures as it traverses the epigastric, left hypochondriac, and a small portion of the
umbilical regions of the abdomen. With the exception of the tail, the pancreas is situated
in the retroperitoneal space of the abdominal cavity, in other words, behind the
peritoneum.

The head is the expanded medial part of the pancreas. It lies directly against the
descending and horizontal parts of the C-shaped duodenum which wraps around the
pancreatic head. Projecting inferiorly from the head is the uncinate process, which
extends posteriorly towards the superior mesenteric artery. Continuing laterally from the
head is the neck, a short structure of approximately 2 cm that connects the head with the
body. Posterior to the neck are the superior mesenteric artery and vein and the origin of

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the hepatic portal vein – formed by the union of the superior mesenteric and splenic
veins.

After the neck, the pancreas continues with the body, which consists of two surfaces
(anterior and posterior) and two borders (superior and inferior). It is located anterior to
the L2 vertebra, and also forms the floor of the omental bursa (lesser sac). The aorta,
superior mesenteric artery, left renal vessels, left kidney, and left suprarenal gland are
situated posterior to the pancreatic body. Finally, the intraperitoneal tail is the last part of
the pancreas. It is closely related to the hilum of the spleen and runs with the splenic
vessels in the splenorenal ligament.

Physiology

The pancreas is a unique organ because it fulfills both exocrine and endocrine roles. Its
exocrine function includes the synthesis and release of digestive enzymes into the
duodenum of the small intestine. Its endocrine function involves the release of insulin and
glucagon into the bloodstream, two important hormones responsible for regulating
glucose, lipid, and protein metabolism.

The main players responsible for pancreatic function are endocrine and exocrine glands.
The latter synthesize inactive pancreatic digestive enzymes (zymogens), which are
released into the glandular and pancreatic ductal systems. Upon reaching the duodenum,
the zymogens are activated by proteolytic enzymes, becoming active peptidases,
amylases, lipases and nucleases which act to further digest food entering the small
intestine from the stomach.

The endocrine function of the pancreas is carried out by the pancreatic islets of
Langerhans. These endocrine glands secrete hormones directly into the bloodstream and
consist of three main cell types (alpha, beta, and delta) which. In a nutshell, beta cells
secrete insulin, alpha cells release glucagon, and delta cells produce somatostatin. These
hormones are crucial in regulating glucose metabolism and gastrointestinal functions.

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 Paradigm and Pathophysiology of the Disease

The disease of the patient is caused by gallstones. With age, is 70 years old, ,hypertension
and high intake of cholesterol, the risk factors are identified. Thus begins the formation
of gallstones that causes a blockage in the sphincter of odi and leads to build up of
pancreatic secretions which leads to an increased lipase level and insuffiecient release of
pancreatic enzymes which also results in dyspepsia which is treated by bearse a
digestives medication and increased gastric acid level which treated by pantropazole
proton pump inhibitor medication.

Continuing on due to increased pressure within the pancreas and compression of the
blood vessels it resulted to tissue ischemia and leads to necrosis of pancreatic cells. After
that the body’s immune system triggered an inflammatory response which results into a
decreases albumin level, increased level of increased level of neutrophils, monocyte and
decreased level of lymphocyte which was revealed by serum blood test and CBC. Since
the pancreas is already inflamed it leads to an irritation of the adjacent intestine which
causes the patient to manifest nausea and vomiting which is then managed by potassium
chloride.

Thus it is important to monitor the vital signs of the patient, improving nutritional status
by encouraging the patient to have a diet high in carbohydrates and low fats and
protein ,improving respiratory function by maintaining semi-Fowler’s position and

19
encourages frequent position changes and improving fluid and electrolyte status by
increasing fluid intake and eating a balanced diet that contain electrolytes.

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21
 CHAPTER III
THE MANAGEMENT

This chapter deals about presenting the medical and nursing interventions applied. It
includes the complete physical assessment of the patient, diagnostic test results and its
significance, drug study and the discharge summary.

Physical Assessment

General Appearance 
Patient is conscious, coherent, and cooperative and able to perform some ADLS, Patient's
vital signs are: Temp: 36.8; PR:97bpm; RR 17; O2 sat 98%; Bp 120/90 mmHg
Neurological
Pupils Black in color with equal side and is round. Pupils constrict when focused on an
object close to the eye. 
Upper extremities
Upper extremities have normal tendon reflexes. Eye respond spontaneously, oriented and
obeys command. 
Skin
Brown in color, presence of dark spots in some of His skin, presence of light and dark
brown moles in the skin, and has good skin turgor.
Nails
No clubbing, trimmed on both hands and feet, capillary refill is less than 2 seconds,
convey curved shaped nails on the hand. Nails are intact with the epidermis 
HEENT
Hand is smooth hard and symmetrical, round, erect and in midline, brownish hair color
with white hairs. Eyes are moist and able to close and open without any difficulties,
smooth eye movement throughout the 6 cardinals of eye movement. ears are equal in size
bilateraly, no tenderness and no lesions.
Neck
No nodules, symmetric with head on center
Face
face appears dry and not totally uniform due to aging, with no presence of nodules or
masses.
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Lower Extremities
Absence of tremors, nails are brittle, both legs has no presence of deformities or
tenderness and swelling.
Abdomen
(+)Vomiting and (+) Dyspepsia

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 DIAGNOSTIC TEST
Date/Name of Test Specimen Rationale Normal Values Test Result Significance
CBC:

 RBC Blood To monitor the current 3.6-8.69 10^g/L 4.13 Normal

level of blood components
 HGB and useful to obtain 108-142 g/L 143 Normal
prognostic information.
 Lymphocyte 18-40% 11 Normal
s
1-8% 13 Indicates a slight
 Monocytes susceptibility for
35-60 74 infection.
 Neutrophil Indicate a possible
infection
6.9-10.6 6.5 Normal
 MPV

Blood for diagnosing acute

Sept 24,2022 pancreatitis, as it is the Likely that you have
most sensitive and specific 23.00-300.00 U/L 660 acute pancreatitis
 Lipase marker for pancreatic cell
damage.

Blood
Risk for malnutrition.
3.50-5.00 g/dl 2.93
 Albumin

24
Sept 29, 2022
Normal potassium levels
Blood in the blood must be
 Potassium maintained to prevent 3.5-5.10 meq/L 8.5 Risk for hyperkalemia.
dysfunction of nerves and
muscles.

Urinalysis Urine Urine tests such as urinary

trypsinogen-2 and urinary Color  Pale straw Normal
amylase, can be used to  Yellow (light/pale
determine other potential to dark)
causes of the patient
condition. Tansparency
 Clear to cloudy  Hazy Risk for urinary tract
infection.

Volume
 30 ml  40cc/hr Normal

Ph reaction
 5.0 Normal
 4.6-8.0

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 RBC  4.73 Normal
 0 - 5 /hpf

Date: September 28, 2022

Name of Test: Chest PA X-ray

Specimen: Lungs

Rationale: To assess Lung condition

Test Result:

Significance:

Heart size could not be properly assessed due to poor inspiratory effort.

Aortic knob is calcified

Aortic knob is calcified

Osteophytes at the lateral aspects, bodies of thoracic spines

Both lungs are clear

Trachea is at midline

26
Both hemidiaphragm are shot

Remarks: Atherosclerotic Aorta, Thoracic Osteophytes XA

Drug Study

27
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29
30
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33
 NURSING CARE PLAN

Cues Actual/ Expected Nursing Orders Rationale Evaluation

Potential Outcome
Nursing
Diagnosis
Subjective Data: Risk for Short Term Monitor intake Provides Short Term
“Grabe gid akon Deficient After 2 hours and output information After 2 hours
nga pagsuka” Fluid Volume of nursing about of nursing
intervention, replacement intervention,
the patient will needs and the patient
Objective Data: participate in organ will
Vomiting activities that function participate in
Dehydration reduce the Monitor for activities that
Dry pale lips occurrence of signs of Prolonged reduce the
Decreased fluid vomiting. increased or vomiting, occurrence of
intake continued gastric vomiting.
Long Term nausea/vomiting, aspiration
After 8 hours abdominal and restricted Long Term
of nursing cramps oral intake After 8 hours
interventions, weakness, can lead to of nursing
the patient will twitching, deficits in interventions,
be able to seizures, sodium, the patient
display irregular heart potassium will be able
adequate fluid rate, and chloride to display
balance as paranesthesia, adequate
evidenced by hypoactive of fluid balance
stable vital absent bowel as evidenced
signs, moist sounds, by stable
mucous depressed vital signs,
membranes, respirations moist
good skin Reduces mucous
turgor/ Eliminate membranes,
noxious stimulation
capillary refill of vomiting good skin
and adequate sights/smells turgor/
from center
urine output. capillary
environment refill and
Indicators of adequate
Monitor vital
adequacy of urine output.
signs, assess
mucous circulating
membranes, skin volume
turgor, perfusion
peripheral pulses
and capillary
refill

34
 Prothrombin
Observe for is reduced
signs of bleeding and
coagulation
time
prolonged
when bile
flow is
obstructed,
increasing
risk of
bleeding or
hematoma
formation

Use small gauge Avoids

needles for trauma and
injections, apply bleeding of
firm pressure for gums,
longer than usual alcohol can
after be drying
venipuncture and cause
irritation

Cues Actual/ Potential Expected Nursing Orders Rationale Evaluation

Nursing Outcome
Diagnosis
Subjective Data: Imbalanced After 2 Assess for These After 2

35
 Nutrition: Less weeks of dysphagia, indicators of a weeks of
Objective Data: Than Body nursing polydipsia, and hyperglycemic nursing
-loss of appetite Requirements intervention polyuria. state reflect the interventio
related to the patient need for health n the
-poor muscle tone anorexia, dietary attains care provider patient
restrictions, and baseline evaluation and attains
-loss weight digestive body weight intervention to baseline
dysfunction and exhibits ensure proper body
V/S taken as a positive or metabolism of weight and
follows balanced carbohydrates exhibits a
nitrogen (N) if endocrine positive or
T - 35.9 state on N function is balanced
studies by Monitor capillary impaired. nitrogen
PR- 74 bpm the 24-hr blood sugar levels Hyperglycemia (N) state
RR-20 period for the presence of occurs because on N
BP- 110/80 before hyperglycemia. of interference studies by
O2sat-97% hospital Adjust insulin with beta cell the 24-hr
discharge. amounts according function. It is period
b to capillary blood transient with before
Short Term glucose levels, as acute hospital
Objective: prescribed. pancreatitis but discharge.
After 4hrs common with
of nursing chronic
intervention pancreatitis, Short
the patient during which Term
will DM is likely to Objective:
verbalized develop. After 4hrs
and of nursing
demonstrate Laboratory interventio
selection of values of n the
food or fasting blood patient
meals that sugar and will
achieve a bedside verbalized
cessation of monitoring of and
weight loss blood glucose demonstra
and may reveal te
abdominal abnormalities selection
distention in blood of food or
glucose levels meals that
and direct the achieve a
appropriate cessation
insulin of weight
therapy. loss and
Weigh the patient abdominal
daily to assess gain distention
or loss. Progressive
weight loss

36
 may signal the
need to change
the diet or
provide
enzyme
replacement
therapy

Provide oral
hygiene at frequent
This measure
intervals.
enhances
appetite and
minimizes
Administered nausea
enteral or
parenteral nutrition Enteral
as prescribed feedings are
being used
with increasing
frequency but
should be
infused past
the ligament of
Treats to avoid
pancreatic
stimulation.
Parenteral
nutrition likely
is instituted if
distal enteral
feedings are
unobtainable
or unsuccessful
within 5-7
days.

Cues Actual/ Expected Nursing Orders Rationale Evaluation

Potential Outcome
Nursing
Diagnosis
Subjective Data: Dysfunctional Short 1. Assess for These findings Short
Gastrointesti Term the absence may be present Term
Objective Data: nal Motility After 2 of with bowel After 2
dysfunction,

37
nausea and related to hours of flatus/bowel which can occur hours of
vomiting bowel nursing sounds or with an nursing
dysfunction interventi change in electrolyte interventio
Abdominal occurring on the bowel imbalance n the
cramping with patient sounds and resulting directly patient will
electrolyte will the from severe participate
Regurgitation disturbance participat presence of pancreatitis. in activities
e in abdominal Bowel that reduce
dysfunction may
activities cramping or the
occur at any
that pain. occurrence
point along the
reduce 2. Assess for of
GI tract.
the bowel Diminished or vomiting.
occurrenc sounds in all absent bowel
e of four sounds suggest Long
vomiting. abdominal the presence of Term
quadrants ileus and After 8hrs
Long 3. In the therefore must of nursing
Term absence of be auscultated in interventi
After bowel all four on the
8hrs of sounds, quadrants before patient GI
nursing keep the NPO can be
motility
patient rescinded.
interventi normalizes
NPO. Hypoactive
on the as
4. Following sounds (3-5/min)
patient GI indicate
evidenced
recommenc by the
motility decreased
ement of presence
normalize motility;
fluids and of bowel
s as hyperactive
food, sounds and
evidenced sounds (more
monitor for flatus and
by the than 34/min) can
bowel absence of
presence be caused by
movements nausea,
of bowel anxiety,
and emesis. infectious vomiting,
sounds
and flatus diarrhea,
and irritation of
absence intestinal
of nausea, mucosa from
vomiting, blood, or
gastroenteritis.
High-pitched
tinkling sounds
(hyperperistalsis)
occur during
intestinal
obstruction,
usually
accompanied by
cramping pain.
Fluids and food

38
 are not tolerated
until the bowel
returns to
normal function,
as evidenced by
bowel sounds.
Absence of
emesis and the
presence of
bowel
movements
indicate return
of normal GI
function

Cues Actual/ Expected Nursing Orders Rationale Evaluation

Potential Outcome
Nursing
Diagnosis
Subjective Impaired Gas After 8 1. Assess and 1. Irregul After 8
Data: Exchange hours of document RR ar hours of
related to nursing q2-4h as pattern nursing
Objective ventilation- interventi indicated by the ,

39
Data: perfusion on, the patient’s decrea interventio
mismatching patient condition. Note sed n, the
-labored occurring has pattern, degree chest patient has
with adequate of excursion, excursi
breathing adequate
and whether
atelectasis or gas on, and gas
the patient uses
-nasal accumulating exchange accessory use of exchange
flaring pulmonary as muscles of accesso as
fluid evidenced respiration. ry evidenced
-cyanosis by RR 12- Report muscle by RR 12-
20 significant s of 20
-V/S taken breaths/m deviations from respira breaths/mi
as follows: in with baseline to the tion
health care
n with
normal occur normal
provider.
T - 35.9 depth and with depth and
2. Auscultate both
pattern impend pattern
lung fields q4-
PR- 74 bpm (eupnea); ing
RR-20
8h (eupnea);
oxygen 3. Assess sputum respira
BP- 110/80 oxygen
saturation production, and tory
O2sat- saturation
greater promptly report compr
97% greater
than 92%; to the health omise
care provider than 92%;
no (can
an increase or no
significant occur
changes in color change with
significant
mental (from clear to
ARDS changes in
status;
white to yellow
and mental
to green) in status;
orientatio respiratory respira
n to tory orientation
secretions.
person, 4. Assess for failure) to person,
place, and changes in and place, and
time; and mental status, may be time; and
breath restlessness, a sign breath
sounds agitation, and of sounds that
that are alterations in inadeq are clear
mentation. and
clear and uate
Monitor pulse
audible pain audible
oximetry q8h or as
throughou indicated (report control throughout
t the lung oxygen saturation 92% or the lung
fields or less). Monitor worsen fields
Shortterm ing Short-term
Objective pancre Objectives
s atitis. After 2hrs
After 2hrs Presence of of nursing
of nursing abnormal interventio
interventi (crackles, rhonchi, n the
on the wheezes) or patient will
patient diminished breath able to use
will able sounds can occur and
to use and with fluid overload

40
demonstr or atelectasis. demonstrat
ate the Copious secretions e the
hyperinflati that change color hyperinflat
on arterial can indicate ion
blood gas respiratory tract
results as infection; copious
available
secretions without
(report
PaO2 less color changes can
than 80 occur with
mm Hg). pulmonary edema.
These are early
Elevate signs of hypoxia.
head of
bed 30 These decreased
degrees or values usually
higher, signal need for
depending supplementary
on the
oxygen.
patient’s
comfort This position
level. optimizes
Administer ventilation and
oxygen as oxygenation.
prescribed.
Monitor Hypoxia is an early
oxygen sign of impending
delivery respiratory failure
system at
and necessitates
regular
oxygen delivery.
intervals.
Explain to Pancreatitis results
the patient in decreased
and production of
significant surfactant, and
others that pain limits
the patient adequate
is at risk for respiratory
hypostatic excursion,
pneumonia
increasing the
.
Teach use
potential for
of a hypostatic
hyperinflati pneumonia.
on device
(e.g., Deep breathing
incentive expands alveoli
spirometer and helps mobilize
) followed secretions to the
by airways, while
coughing
coughing further
exercises.
mobilizes and

41
Explain clears secretions.
that Ten breaths/hr is
emphasis recommended to
of this maintain adequate
therapy is
alveolar inflation.
on
inhalation
to expand A cascade cough
the lungs helps keep lungs
maximally. expanded when
Ensure that abdominal pain
the patient would not
inhales otherwise enable
slowly and deep cough.
deeply 2
times
normal
tidal
volume
and holds
the breath
at least 5
sec at the
end of
inspiration.
Monitor
the
patient’s
progress
and
document
in nurses’
notes.
Teach the
cascade
cough (i.e.,
a
succession
of more
short and
forceful
exhalations
) to
patients
who
cannot
cough
effectively

42
Cues Actual/ Expected Nursing Orders Rationale Evaluation
Potential Outcome
Nursing
Diagnos
is
Subjective Risk for Short Term Observation Observation Short
Data: falls r.t After 1 1. Assess history of 1. Individuals Term
Left hour of falls. are more likely to After 1
“Wala Lower nursing 2. Assess age- fall again if they hour of
kusog and interventio related physical have sustained one nursing
akong upper n patient changes. or more falls in interventio
wala nga body will relate 3. Assess the the past six n patient
tiil kag weaknes the intent patient’s balance months. now relate
kamot” as s, to use and gait. 2. The ability the intent
verbalized balance safety 4. Assess for of people to to use
by the difficult measures disease-related protect themselves safety
patient y to prevent symptoms. from falls is measures
falls. 5. Review the affected by such to prevent
patient’s factors as age and falls.
Objective Long Term medications. development.
Data: After 2 6. Assess for unsafe Older people with Long Term
 Left hours of clothing. weak muscles are After 2
sided nursing more likely to fall hours of
weaknes interventio Management than those who nursing
s n the 1. Provide maintain muscle interventio
 Impaired patient will signs or secure strength, n the
levels of demonstrat wristband flexibility, and patient
alertness e selective identification for endurance. now

43
 Aged prevention patients at risk for 3. Older adults demonstrat
50+ measures. falls to remind who have poor e selective
years healthcare balance or prevention
and providers to difficulty walking measures.
older implement fall are more likely to
 Dizzines precaution fall.
s behaviors. 4. For patients
2. Respond to with stroke were
call light as soon more likely to fall
as possible. than other
3. Place items patients, thereby
the patient uses lengthening their
within easy reach, stay and
such as call light, increasing their
urinal, water, and medical costs
telephone. during physical
4. Place beds rehabilitation
are at the lowest 5. Risk factors
possible position. for falls also
Set the patient’s include
sleeping surface medication use
as near the floor such as
as possible if antihypertensive
needed. agents, ACE-
5. Raise side inhibitors,
rails on beds, as diuretics, tricyclic
needed. For beds antidepressants,
with split side alcohol use,
rails, leave at least antianxiety agents,
one of the rails at opiates, and
the foot of the bed hypnotics or
down. tranquilizers.
6. Have the
patient wear Management
proper footwear. 1. Signs are
7. Ask the vital for patients at
family to stay risk for falls.
with the patient. 2. Items that
are too far may
require the patient
to reach out or
ambulate
unnecessarily and
can potentially be
a hazard or
contribute to falls.

44
 3. Helps
prevent the patient
from going out of
bed without any
assistance.
4. Keeping the
beds closer to the
floor reduces the
risk of falls and
serious injury.
5. According
to research, a
disoriented or
confused patient is
less likely to fall
when one of the
four rails is left
down.
6. Advise
patient to use
nonskid socks to
prevent the feet
from sliding upon
standing.
7. Helps
prevent the patient
from accidentally
falling or pulling
out tubes.

45
Cues Actual/ Expected Nursing Orders Rationale Evaluation
Potential Outcome
Nursing
Diagnos
is
Subjective Risk for Short Term Observation Observation Short
Data: ineffecti After 45 1. Assess for 1. Particular Term
ve min. of signs of decreased clusters of signs After 45
“Gabinho Tissue nursing tissue perfusion and symptoms min. of
d akon Perfusio interventio 2. Record BP occur with nursing
wala nga n r.t n patient readings for differing causes. interventio
tiil” as Hyperte will orthostatic 2. Stable BP is n patient
verbalized nsion identify changes (drop of needed to keep will now
by the factors that 20 mm Hg sufficient tissue identify
patient improve systolic BP or 10 perfusion. factors that
circulation. mm Hg diastolic 3. Decreased improve
BP with position blood flow to circulation.
Objective Long Term changes). mesentery can
Data: After 2 3. Examine GI turn out to GI Long Term
 Left hours of function, noting dysfunction, loss After 2
sided nursing anorexia, of peristalsis, for hours of
weaknes interventio decreased or example. nursing
s n the absent bowel 4. Pulse interventio
 Dry skin patient will sounds, nausea or oximetry is a n the
BP- engage in vomiting, useful tool to patient will
150/100 behaviors abdominal detect changes in now

46
PR- 84 or actions distension, and oxygenation. engage in
RR- 16 to improve constipation. 5. Nonexistenc behaviors
O2 sat- 94 tissue 4. Use pulse e of peripheral or actions
perfusion. oximetry to pulses must be to improve
monitor oxygen reported or tissue
saturation and managed perfusion.
pulse rate. immediately.
5. Check for
pallor, cyanosis, Management
and mottling, cool 1. Sufficient
or clammy skin. fluid intake
Assess quality of maintains
every pulse. adequate filling
pressures and
Management optimizes cardiac
1. Check for output needed for
optimal fluid tissue perfusion.
balance. 2. This ensures
Administer IV adequate
fluids as ordered. perfusion of vital
2. Maintain organs.
optimal cardiac 3. This
output. promotes venous
3. If ICP is outflow from
increased, elevate brain and helps
head of bed 30 to reduce pressure.
45 degrees. 4. Gently
4. Assist with repositioning
position changes patient from a
5. Promote supine to
active/passive sitting/standing
ROM exercises. position can
6. Do not reduce the risk for
elevate legs above orthostatic BP
the level of the changes.
heart. 5. Exercise
7. Provide prevents venous
oxygen therapy as stasis and further
necessary. circulatory
compromise.
6. With arterial
insufficiency, leg
elevation
decreases arterial
blood supply to
the legs.

47
 7. This
saturates
circulating
hemoglobin and
augments the
efficiency of
blood that is
reaching the
ischemic tissues.

Cues Actual/ Expected Nursing Orders Rationale Evaluation

Potential Outcome
Nursing
Diagnosis
Subjective impaired Short Term Observation Observation Short
Data: physical After 4 1. Assess 1. To Term
Mobility r.t hours of extent of identify After 4
“Gabinhud neuromusc nursing impairment strengths & hours of
akong wala ular intervention initially & deficiency nursing
nga kamot involvemen patient will functional ability 2. Bed interventio
kag daw t as be able to 2. Monitor rest put pt. at n patient
wala kusog” evidenced maintain/inc lower extremities risk to is now
as verbalized by rease for symptoms of develop deep able to
by the patient decreased strength of thrombophlebitis vein increase
muscular affected 3. Observe thrombosis her
 Expression strength/co body part. affected site for 3. Edemat strength of
of pain and ntrol color or edema ous tissue the
discomfort Long Term 4. Inspect heals more affected
with After 4-5 skin pressure slowly. body part.
movement days of points regularly 4. Poor

48
 nursing for pallor or circulation Long
intervention redness and may Term
Objective the patient provide gentle predispose to After 4-5
Data: will be able massage rapid skin days of
 Braden demonstrate Management breakdown. nursing
Scale-17 behaviors interventio
 Limited that enable 1. Reposition Management n the
range of resumption frequently, even patient
motion of activities. when sitting in 1. Prevent now able
 Uncoordina chair. s prolonged to resume
ted 2. Keep skin tissue with her
movements surfaces dry and pressure daily
 Poor clean and linens where activities
balance dry and wrinkle circulation is like:
 Decreased free. already - Walking
muscle 3. Place compromised - Cooking
strength pillow under , reducing - Exercise
 Inability to axilla risk of tissue
turn in bed, 4. Elevate trauma and
transfer, or lower extremities ischemia.
ambulate when sitting 2. Moist,
5. Assist contaminated
patient in areas provide
developing excellent
sitting balance media for
by raising the growth of
head of the bed. pathogenic
organisms.
3. Prevent
s abduction
of shoulders
& flexion of
elbow.
4. Enhanc
es venous
return,
reducing
venous stasis
and edema
formation.
5. Aids in
retaining
neural
pathway &
enhance
motor
response.
49
Cues Actual/ Expected Nursing Orders Rationale Evaluation
Potential Outcome
Nursing
Diagnosi
s
Subjective impaired Short Term Observation Observation Short
Data: verbal After 4 1. Investigate 1. Provides Term
Commun hours of how SO opportunity to After 4
“The ication r.t nursing communicates develop or hours of
significant Decrease intervention with the client. continue nursing
other d patient will 2. Assess client effective interventio
reported circulatio indicate an knowledge base communication n patient is
that the n to brain understandi and level of patterns that now able
patient is (e.g., ng of comprehension. have already to
having stroke, communicat Treat the client as been understand
trouble in traumatic ion an adult, avoiding established. communic
speaking, brain problems pity and 2. Knowing ation
“Nurse, injury) impatience. how much to action
mag Long Term 3. Establish expect of the problems
hambal sa After 8 therapeutic nurse- client can help
dw ga hours of client relationship to avoid Long Term
pitla sa nursing through active frustration and After 8
nga nd intervention listening, being unreasonable hours of
namon the patient available for demands for nursing
mayu ma will problem-solving. performance. interventio
intchindih establish 4. Make client 3. Aids in n the
an” method of aware of presence dealing with patient
communicat when entering the communication now able
ion. room by speaking, problems. to
Objective turning a light off 4. Getting established
Data: and on, or touching clients' method of
 Slurred client, as attention is the communic
speech appropriate. first step in ation in
 Left 5. Make eye communication verbal,
sided contact, place self . written,
weaknes at or below client’s 5. Conveys and oral.
s level, and speak interest and
 BP – face to face. promotes
160/120 6. Speak slowly contact.
 O2 sat- and distinctly, 6. Assists in

50
 95 using simple comprehension
sentences and yes and overall
or-no questions. communication
Avoid speaking .
loudly or shouting.
Supplement with Management
written 1. To test,
communication wernicke's
when possible or aphasia or
needed. Allow receptive
sufficient time for aphasia
reply; remain 2. Provide
relaxed with client. opportunity to
clarify meaning
Management 3. Test for
1. Ask patient writing
to follow simple disability
commands and 4. Help
repeat simple assess
words communication
2. Listen for needs.
errors in
conversation and
provide feedback
3. Ask p.t to
write her name
4. Refer to
speech therapist

Cues Actual/ Expected Nursing Orders Rationale Evaluatio

Potential Outcome n
Nursing
Diagnosis
Subjectiv Risk for Short Term Observation Observation Short
e Data: impaired After 2 1. Check for 1.These signs Term
Swallowin hours. of coughing or indicate After 2
“Budlay g r.t nursing choking during aspiration. hours of
an sa Neuromus interventio eating and 2.These are all nursing
mag cular n patient drinking. signs of interventi

51
tulon impairmen will 2. Observe for signs swallowing on patient
sang iya t— demonstrat associated with impairment. is now
pagkaon decreased e feeding swallowing 3.If aspirated, little able to
” as gag reflex, methods problems or no harm to the participate
verbalize facial 3. Assess ability to patient occurs. in
d by the paralysis, Long Term swallow a small 4.Pocketed food demonstra
SO perceptual After 4-5 amount of water. may be easily ting
impairmen days of 4. Check for residual aspirated at a feeding
t nursing food in mouth later time. methods.
Objective interventio after eating.
Data: n the Management Long
 (+) patient will Management 1. Timely Term
NGT maintain 1. Have suction intervention may After 4-5
 Difficul desired equipment limit amount and days of
ty of body available at untoward effect of nursing
swallo weight. bedside, aspiration. interventi
wing especially during 2. Promotes on the
 Droolin early feeding optimal muscle patient
g efforts. function and helps now able
Promote effective to limit fatigue. to
Vital swallowing using 3. Promotes maintain
signs: methods such as the relaxation and desired
BP: following: allows client to body
160/120 focus on task of weight.
PR: 94 2. Schedule eating and
RR: 14 activities and swallowing
Temp: medications to 4. Counteract
35.9C 02 provide a s hyperextension,
SAT: minimum of 30 aiding in
95% minutes of rest prevention of
before eating. aspiration and
3. Provide pleasant enhancing ability
environment free to swallow.
of distractions, 5. Uses
such as TV. gravity to
4. Assist client with facilitate
head control or swallowing and
support, and reduces risk of
position based on aspiration.
specific 6. Clients
dysfunction. with dry mouth
5. Place client in require a
upright position moisturizing
during and after agent, such as
feeding, as artificial saliva or
appropriate. alcohol-free
6. Provide oral care
52
 based on mouthwash,
individual need before and after
prior to meal. eating.
7. Serve foods at 7. Lukewarm
customary temperatures are
temperature and less likely to
water always stimulate
chilled. salivation, so
8. Stimulate lips to foods and fluids
close or manually should be served
open mouth by cold or warm as
light pressure on appropriate.
lips or under 8. Aids in
chin, if needed. sensory retraining
9. Place food of and promotes
appropriate muscular control.
consistency in 9. Provides
unaffected side of sensory
mouth. stimulation
10. Feed slowly, (including taste),
allowing 30 to 45 which may
minutes for increase salivation
meals. and trigger
11. Offer solid foods swallowing
and liquids at efforts, enhancing
different times. intake
12. Maintain upright 10. Feeling rushed
position for 45 to can increase
60 minutes after stress and level
eating. of frustration,
13. Maintain accurate may increase
record of food risk of
and fluid intake; aspiration, and
record calorie may result in
count if client’s
indicated. terminating
14. Encourage meal early.
participation in 11. Prevents client
exercise or from
activity program. swallowing
15. Administer food before it is
intravenous (IV) thoroughly
fluids, parenteral chewed. In
nutrition, or tube general, liquids
feedings. should be
offered only

53
 after client has
finished eating
solids
12. Helps client
manage oral
secretions and
reduces risk of
regurgitation.
13. If swallowing
efforts are not
sufficient to
meet fluid and
nutrition needs,
alternative
methods of
feeding must be
pursued.
14. May increase
release of
endorphins in
the brain,
promoting a
sense of general
well-being and
increasing
appetite.
15. May be
necessary for
fluid
replacement and
nutrition if
client is unable
to take anything
orally.

Cues Actual/ Expected Nursing Orders Rationale Evaluation

Potential Outcome
Nursing
Diagnos
is
54
Subjective Risk for Short Term Observation Observation Short
Data: falls r.t After 1 7. Assess history of 6. Individuals Term
Left hour of falls. are more likely to After 1
“Wala Lower nursing 8. Assess age- fall again if they hour of
kusog and interventio related physical have sustained one nursing
akong upper n patient changes. or more falls in interventio
wala nga body will relate 9. Assess the the past six n patient
tiil kag weaknes the intent patient’s balance months. now relate
kamot” as s, to use and gait. 7. The ability the intent
verbalized balance safety 10. Assess for of people to to use
by the difficult measures disease-related protect themselves safety
patient y to prevent symptoms. from falls is measures
falls. 11. Review the affected by such to prevent
patient’s factors as age and falls.
Objective Long Term medications. development.
Data: After 2 12. Assess for Older people with Long Term
 Left hours of unsafe clothing. weak muscles are After 2
sided nursing more likely to fall hours of
weaknes interventio Management than those who nursing
s n the 8. Provide maintain muscle interventio
 Impaired patient will signs or secure strength, n the
levels of demonstrat wristband flexibility, and patient
alertness e selective identification for endurance. now
 Aged prevention patients at risk for 8. Older adults demonstrat
50+ measures. falls to remind who have poor e selective
years healthcare balance or prevention
and providers to difficulty walking measures.
older implement fall are more likely to
 Dizzines precaution fall.
s behaviors. 9. For patients
9. Respond to with stroke were
call light as soon more likely to fall
as possible. than other
10. Place items patients, thereby
the patient uses lengthening their
within easy reach, stay and
such as call light, increasing their
urinal, water, and medical costs
telephone. during physical
11. Place beds rehabilitation
are at the lowest 10. Risk factors
possible position. for falls also
Set the patient’s include
sleeping surface medication use
as near the floor such as
as possible if antihypertensive

55
 needed. agents, ACE-
12. Raise side inhibitors,
rails on beds, as diuretics, tricyclic
needed. For beds antidepressants,
with split side alcohol use,
rails, leave at least antianxiety agents,
one of the rails at opiates, and
the foot of the bed hypnotics or
down. tranquilizers.
13. Have the
patient wear Management
proper footwear. 8. Signs are
14. Ask the vital for patients at
family to stay risk for falls.
with the patient. 9. Items that
are too far may
require the patient
to reach out or
ambulate
unnecessarily and
can potentially be
a hazard or
contribute to falls.
10. Helps
prevent the patient
from going out of
bed without any
assistance.
11. Keeping the
beds closer to the
floor reduces the
risk of falls and
serious injury.
12. According
to research, a
disoriented or
confused patient is
less likely to fall
when one of the
four rails is left
down.
13. Advise
patient to use
nonskid socks to
prevent the feet
from sliding upon

56
 standing.
14. Helps
prevent the patient
from accidentally
falling or pulling
out tubes.

Cues Actual/ Expected Nursing Orders Rationale Evaluation

Potential Outcome
Nursing
Diagnos
is
Subjective Risk for Short Term Observation Observation Short
Data: ineffecti After 45 6. Assess for 6. Particular Term
ve min. of signs of decreased clusters of signs After 45
“Gabinho Tissue nursing tissue perfusion and symptoms min. of
d akon Perfusio interventio 7. Record BP occur with nursing
wala nga n r.t n patient readings for differing causes. interventio
tiil” as Hyperte will orthostatic 7. Stable BP is n patient
verbalized nsion identify changes (drop of needed to keep will now
by the factors that 20 mm Hg sufficient tissue identify
patient improve systolic BP or 10 perfusion. factors that
circulation. mm Hg diastolic 8. Decreased improve
BP with position blood flow to circulation.
Objective Long Term changes). mesentery can
Data: After 2 8. Examine GI turn out to GI Long Term
 Left hours of function, noting dysfunction, loss After 2
sided nursing anorexia, of peristalsis, for hours of
weaknes interventio decreased or example. nursing
s n the absent bowel 9. Pulse interventio
 Dry skin patient will sounds, nausea or oximetry is a n the
BP- engage in vomiting, useful tool to patient will
150/100 behaviors abdominal detect changes in now
PR- 84 or actions distension, and oxygenation. engage in
RR- 16 to improve constipation. 10. Nonexistenc behaviors
O2 sat- 94 tissue 9. Use pulse e of peripheral or actions
perfusion. oximetry to pulses must be to improve
monitor oxygen reported or tissue
saturation and managed perfusion.
pulse rate. immediately.
10. Check for
pallor, cyanosis, Management
and mottling, cool 8. Sufficient
or clammy skin. fluid intake

57
 Assess quality of maintains
every pulse. adequate filling
pressures and
Management optimizes cardiac
8. Check for output needed for
optimal fluid tissue perfusion.
balance. 9. This ensures
Administer IV adequate
fluids as ordered. perfusion of vital
9. Maintain organs.
optimal cardiac 10. This
output. promotes venous
10. If ICP is outflow from
increased, elevate brain and helps
head of bed 30 to reduce pressure.
45 degrees. 11. Gently
11. Assist with repositioning
position changes patient from a
12. Promote supine to
active/passive sitting/standing
ROM exercises. position can
13. Do not reduce the risk for
elevate legs above orthostatic BP
the level of the changes.
heart. 12. Exercise
14. Provide prevents venous
oxygen therapy as stasis and further
necessary. circulatory
compromise.
13. With arterial
insufficiency, leg
elevation
decreases arterial
blood supply to
the legs.
14. This
saturates
circulating
hemoglobin and
augments the
efficiency of
blood that is
reaching the
ischemic tissues.

58
 Discharge Summary

Nursing Goals Nursing orders Rationale

Medication Upon discharge Instruct the client to take To ensure and

client will comply medications using the 10 minimize

with the medication rights of drug administration administration

as prescribed by the at all time. problems or wrong

physician Use acetaminophen medication and

(Tylenol) or nonsteroidal dosage and for relief

anti-inflammatory drugs, of pain and other

such as ibuprofen (Advil, complications. 

Motrin), at first to try and

control your pain as

prescribed 

Exercise  Upon discharge Depending on your physical To prompt patient to

client will plan and condition, and after the comply with exercise

execute a exercise advice of your physician, regimen.

regimen  allowed you can begin walking 5 to exercise improves

by the physician.  10 minutes twice a day, with insulin sensitivity in

a goal of increasing activity peripheral tissue

to 45 minutes at least 3 times

a week. It is important that

your exercise time be

without interruptions. This is

59
 time for yourself. If you are

unable to walk, there are

other ways to exercise (eg,

stretching, isometric

exercises).

Therapy Upon discharge Discuss the importance of To prompt patient to

client will comply having a physical therapy at comply with physical

with physical home to help regain muscle therapy.

therapy regimen. tone

 Avoid or smoking.
Smoking or inhaling
secondary smoke.
Smoking increases
problems if you have
pancreatitis.
 Instruct patient to

follow and avoid

missing any therapy 

Hygiene Upon discharge the Encourage patient to To ensure safety,

client will maintain maintain proper hygiene by health and progress,

good hygiene and taking regular bath elimination of

cleanliness  infection and other

Instruct patient to always
complications that
wash hands before and after
may occur of client’s
eating 
condition.

OPD Upon discharge Discuss to the client the To ensure safety,

60
 client will seek importance of having a health and progress

further care and follow-up check-up on of client’s condition.

schedule follow-up schedule.

check-ups with the Do not drink alcohol. Tell

your doctor if you need help
physician. to quit. Counselling, support
groups, and sometimes
medicines can help you stay
sober.

Keep all follow-up

appointments with your
provider. Problems can often
show up later.

Diet Upon discharge Explain to the patient the To enhance the

client will adapt a importance of diet and healing process and

healthy diet with all maintaining her health. patient’s health as a

nutrients necessary  Drink clear liquids whole

and eat bland foods
for healing and until you feel better.
Bland foods include
development. rice, dry toast, and
crackers. They also
include bananas and
applesauce.
 Eat a low-fat diet
until your doctor says
your pancreas is
healed.

Spiritual Upon discharge Encourage client to pray To draw patient

client will seek to more frequently for healing closer to God and

draw closer to God especially in spiritual improve the quality

healing. Encourage the of her spiritual life.

patient to read the Bible and

61
ponder upon it.

CHAPTER IV

62
 GENERAL EVALUATION OF THE STUDY

Conclusion:

After taking thorough time to review the case the researchers have come up to the
following conclusions:

- Pancreatitis is inflammation of the pancreas. The pancreas is a long, flat gland that sits
tucked behind the stomach in the upper abdomen. The pancreas produces enzymes that
help digestion and hormones that help regulate the way your body processes sugar
(glucose). Usually, acute pancreatitis is caused by gallstones or by drinking a lot of alcohol
for a long time.

- Pancreatitis occurs when digestive enzymes become activated while still in the pancreas,
irritating the cells of your pancreas and causing inflammation.

- Acute pancreatitis affects men more often than women. Certain diseases, surgeries, and
habits make you more likely to develop this condition.

- Pancreatitis can occur as acute pancreatitis — meaning it appears suddenly and lasts for
days. Some people develop chronic pancreatitis, which is pancreatitis that occurs over
many years.

- Acute pancreatitis is sudden inflammation that lasts a short time. It can range from mild
discomfort to a severe, life-threatening illness. Most people with acute pancreatitis recover
completely after getting the right treatment. In severe cases, acute pancreatitis can cause
bleeding, serious tissue damage, infection, and cysts. Severe pancreatitis can also harm
other vital organs such as the heart, lungs, and kidneys.

- Treatment for acute pancreatitis depends on the severity of the condition. Sometimes the
patient needs hospitalization with administration of intravenous fluids to help restore blood
volume. Antibiotics are often prescribed if infection occurs and pain medications are often
used to provide relief. Surgery is sometimes needed when complications such as infection,
cysts, or bleeding occur.

- Patients usually recover fully from acute pancreatitis and do not experience recurrence if
the cause is removed. Thus the nursing interventions should include improving nutritional
status by encouraging the patient to have a diet high in carbohydrates and low fats and
protein ,improving respiratory function by maintaining semi-Fowler’s position and
encourages frequent position changes and improving fluid and electrolyte status by
increasing fluid intake and eating a balanced diet that contain electrolytes.

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Nursing Implication:

This study will help teachers, clinical Instructor, nursing students, and most especially,
anyone who is interested in further understanding the Acute Pancreatitis, about its disease
process, signs and symptoms that the patient manifest, the medication and the plan of care
to be implemented on the patient.

Nursing Practice:

This study hopes to enhance the students, as well as aspiring nursing students and
professional nurses alike, to become more competent and skillful in the clinical diagnosis
and treatment of Acute pancreatitis.

Nursing Research:

The study of Acute Pancreatitis will be another contribution and reference to the health
care provider. This will give further knowledge and understanding to the reader about the
uniqueness of this disease.

Personal Reaction to Learning

This case enabled us to comprehend the pathophysiology of the signs and symptoms
manifested by the patient. By studying pathophysiology, our group had a better
understanding of the disease process. The case helped us to develop critical thinking skills
relating to all the data on the status of the patient.

Skills

a. Provide efficiently appropriate and proper nursing diagnosis in line with the client’s
medical condition and skillfully formulate nursing care plans for the problem identified.

b. Present accurately a thorough general assessment of the client which includes physical
assessment and family history taking

c. Present systematically the data pertinent to the case being gathered.

Knowledge

a. Understand the pathophysiology and etiology of Acute Pancreatitis

b. Understand the role of drug therapy in managing the client related to Acute Pancreatitis

c. Recognize the contributing factors associated with the development of Acute Pancreatitis

Attitude

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a. Demonstrates awareness of own strengths and limitations as a team member

b. Initiates requests for help when appropriate to situations

c. Exhibit mastery and tact in answering relevant questions with a positive attitude towards
criticisms and suggestions.

Bibliography

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Acute Pancreatitis – National Pancreas Foundation Brochure. (n.d.). The National Pancreas
Foundation. Retrieved March 24, 2022, from
https://pancreasfoundation.org/wp-content/uploads/2017/02/AcutePancreatitis-
Brochure.pdf

Barnard, Neal D., editor. “Pancreatitis.” Nutrition Guide for Clinicians, 3rd ed., Physicians
Committee for Responsible Medicine, 2020.
https://nutritionguide.pcrm.org/nutritionguide/view/Nutrition_Guide_for_Clinicians/
1342009/all/Pancreatitis

Goulden, M. R. (n.d.). The pain of chronic pancreatitis: a persistent clinical challenge.

NCBI. Retrieved March 23, 2022, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4590150/

Lakananurak, N. (2020, May 6). Nutrition management in acute pancreatitis: Clinical

practice consideration. Baishideng Publishing Group. Retrieved March 24, 2022, from
https://www.wjgnet.com/2307-8960/full/v8/i9/1561.htm

Pancreatitis. (n.d.). Johns Hopkins Medicine. Retrieved March 23, 2022, from
https://www.hopkinsmedicine.org/health/conditions-and-diseases/pancreatitis

Pancreatitis – Causes – Treatment | familydoctor.org. (2021, January 27).

FamilyDoctor.org. Retrieved March 23, 2022, from
https://familydoctor.org/condition/pancreatitis/

Pancreatitis – Diagnosis and treatment. (2021, September 24). Mayo Clinic. Retrieved
March 24, 2022, from
https://www.mayoclinic.org/diseases-conditions/pancreatitis/diagnosis-treatment/drc-
20360233

Villa, L. (2022, January 4). Drug Use and the Pancreas | Signs & Symptoms of Drug
Abuse. DrugAbuse.com. Retrieved March 24, 2022, from
https://drugabuse.com/addiction/health-issues/pancreas/Published on March 26, 2022

Pancreas. (2022). https://pancreasfoundation.org/patient-information/acute-pancreatitis/.

Jonathan Gapp; Subhash Chandra. (2022, June 21). Acute Pancreatitis.

https://www.ncbi.nlm.nih.gov/books/NBK482468/#:~:text=The%20pathophysiology%20of
%20acute%20pancreatitis,often%20associated%20with%20acute%20pancreatitis

Adrian Rad BSc (Hons). (2022, July 20). PANCREAS.

https://www.kenhub.com/en/library/anatomy/the-pancreas

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Medical news today. (2018, February 22).
https://www.medicalnewstoday.com/articles/160427#causes.

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