all right guys we're getting into the last few disorders of this section um so this uh particular video is going to be over acute pancreatitis but we have for billiard disorders we have acute pancreatitis chronic pancreatitis and then we have the gallbladder disorders or um Coley problems as I call as I call them so um these are kind of an extension of like lower GI or other GI issues but they kind of are in their own category which is why I have them in their own PowerPoint so let's talk about acute pancreatitis um this is something you'll definitely want to be familiar with there's a lot of patients that come into the hospital with this and there's also a lot of like nclex-like questions there's a lot of stuff that can go wrong with acute pancreatitis so it's definitely a topic that you want to be familiar with any topic where it's like a disease where like things can go wrong the nurse needs to take action you just want to focus on those I'm not saying it's the only one sometimes NCLEX is random and does some other you know stuff that's not very common but we try to stick with things we're going to see often and this is definitely something that if you work in any sort of medical unit even if you do things like work in an ICU or work on any sort of cardiac unit you might see a patient that have this as a problem um so acute pancreatitis is as the name suggests it is a acute inflammation of the pancreas and what happens with acute pancreatitis is is that you have to go back to what are the functions of the pancreas um now most people the first thing they say is like oh insulin and yes that's true um the pancreas does help us to secrete insulin but the other thing that it does is it helps to give enzymes it deposits enzymes um into the digestive tract in order to help break down food and so what happens during acute pancreatitis is that the pancreas gets pissed off inflamed and it just starts spilling out all those enzymes that are meant to digest now in the digestive tract those that excuse me those enzymes are very helpful and needed but what happens in acute pancreatitis is they start to spill out other places and actually they start to Auto digest or eat the pancreas itself so in other words it's starting to like literally like self-digest itself so it starts gnawing at the pancreas itself it can also spread to nearby tissues and cause lots of issues to places like the lungs so it can lead to a lot of problems because I always think of them like little Pac-Man that are going around and chomping on everything um now there's a variety of causes for them but in the United States per your textbook the most common cause of acute pancreatitis and Men is going to be chronic alcohol use or long-term alcohol use and the most common cause in women is going to be gallbladder disease now there's of course lots of other reasons that it can happen so don't necessarily you see acute pancreatitis patient you shouldn't say like hey they must be a drinker we don't know but just kind of keep in mind that those are some common reasons why people get them other causes would be you know drug reactions high triglycerides can lead to it or pancreatic cancer so the paint this patient is going one of the main symptoms and one of the main priorities for this patient is going to be pain management um so this person is going to feel pain that is in the left upper quadrant or mid abigastric area and that's going to because of of course where the pancreas is located but their pain is going to be a lot worse when they're eating because you have to think about like okay if I have a pancreas problem where my pancreas is spilling too many digestive enzymes what tells it to make more enzymes it's when we eat so um I usually just tell the story about the guy that one of my patients had that was having really bad pancreas or really bad pain and so we decided to drink and he's like man it was just so strange she's like I drank like a fifth of whiskey and I was like man it's not getting well maybe I think he started with beer I want to say he drank some beer and he was like oh man it's not getting better and he's like and that's when I realized I needed to be drinking whiskey and um so then he tried whiskey and of course it just made things worse and um and you know he went in and he's like I don't know why they're calling me an alcoholic I was just trying to get rid of the pain and um that's the thing is sometimes this pain is so bad and you keep thinking if you put something in that it's going to make it better but it just makes it infinitely worse um the pain is going to also be sudden it can radiate to the back and usually they describe it as like a severe deep or piercing pain they also commonly have nausea vomiting as a symptom um their bowel sounds can be decreased or absent because the inflammatory process they can have a low-grade fever and we also want to look for respiratory symptoms like shortness of breath or dyspnea and then um any sort of abnormal lung sounds like Crackle some priority assessments we want to do this patient can have a lot of instability like chemodynamic instability so I want to check their heart rate and their blood pressure I'm going to be looking for shock and remember with shock your heart rate goes up blood pressure goes down um we're going to be assessing for those GI symptoms like nausea vomiting and seeing what makes it better or worse assessing for bowel sounds looking for those systemic signs of infection assessing pain there's also two signs that are really commonly connected with acute pancreatitis they can be caused by other things but they're most commonly associated especially nclex-wise with acute pancreatitis and one's called the gray Turner side and one call one is called the colon sign and both of these are like a bruising or a bluish color and um the gray Turner sign is a flank discolor discoloration and what you want to remember With Your Flank Your Flank is your back like where your kidneys are and so um you want to be looking uh wake up you want to be looking there for that discoloration and I always remember great Turners because you have to turn to their back to see it and then Cullen's sign I think of like a c because I always think of this picture I think of it almost looks like a c around the um I was gonna say umbilical cord um under the around the umbilicus um and so it's kind of a see or Cirque or you could think C for circle around the umbilicus or the belly button uh we also want to look for signs of complications like peritonitis they can get systemic inflammation infection we're going to talk a lot there's a lot of complications with this and then the other complication there at risk was what's known as and I'll talk more about this on the next slide but we want to assess the respiratory status um or and do really thorough respiratory assessment because they're really high risk for what's known as ards or acute respiratory distress syndrome syndrome I can talk um so acute pancreatitis is better if their pain and symptoms are improving if there's signs that they're getting adequate nutritional intake or tolerating their parenteral feeding because we want to make sure you know sometimes this can stick around for a while so we end up having to do Alternatives we'll talk about those when we get to treatments we want them to have decreased or absence of fever or any signs of inflammation and of course no complications um if their pain and symptoms are increasing if they're signs of poor or inadequate nutrition increasing worsening fever signs of inflammation we're going to be concerned about them having um you know getting complications or having long-term complications of course systemic complications too the other uh or I should say the specific signs or complications we usually talk about we talk about infectious kind of complications where they can have systemic infection like sirs or sepsis they can get what's called a pseudosis which we'll talk about more on the next slide but like a pocket of nastiness pretty much can form on the outside it can burst so yes it can definitely cause problems these patients for it's really not well understood why but they can kind of sequester or hold on to calcium within the pancreas and it leads you to have in your blood less calcium which can lead to tetany just rhythmias things like that which will always be concerning and then um they can also go into what's called ards and I'm going to stay talk about ards for a little bit this is what we call a Whited out checks chest x-ray like normally the lungs should be black because there's air moving but there's all this junk and what happens is is that because of where the pancreas is located and the enzymes and stuff can spill into the lymphatic system that's connected to the lungs the lungs are very permeable where they let stuff in sometimes that maybe shouldn't get in they're very prone to inflammation or fluid shifts remember how I always talk about how if you're going to get fluid shift somewhere usually the first place is going to be the lungs um so um it's really common to get what's called ards which is an inflammation of the lungs where to the point where it gets so full of junk that oxygen can't get in so no matter how much oxygen we give these patients their oxygen levels can't come up and so we end up having to do all these crazy strategies you'll learn about it and um and I'm going to say crazy is not that crazy but intense strategies to get them oxygen did and saved their life it's very high mortality rate so let's talk about these other complications so they can collect excess pancreatic enzymes in these little cysts if they become infected they can get an abscess they can end up with systemic infection this can burst um I talked about how they can spread into the bloodstream or the rest of the body ards we worry about sepsis and things like that which is a bloodstream infection again that can also travel to the lungs through the lymphatic system and then calcium gets deposited in the pancreas they can have that low calcium which can lead again dysrhythmias and a lot of issues but yeah the pancreas can definitely with inflammation everything goes Haywire um some labs and Diagnostics that we want to look at will want to check their pancreatic enzymes normal is going to for amylase is going to be less than 120 and for a lipase it's going to be less than 160. so both these pancreatic enzymes can be looked at but lipase is definitely more specific to pancreatitis whereas amylase can be elevated for a lot of other reasons so normally we're going to be looking more at that life Pace versus that amylase also liver function testing checking in AST alt normal again is less than 36 ish you know they're a little different in their numbers but around then there's what we're looking at because again you can see here with the pancreas it's connected to the gallbladder and if the gallbladder the liver aren't working stones are building up it can lead to issues we're going to check for complications too we'll look at a calcium level normals nine to ten and a half we would expect it to be low because um the pancreas can sequester that calcium we'll also check a glucose usually during acute pancreatitis it's going to be elevated because of um irritation inflammation and stress in the body increases your blood glucose um patients with acute pancreatitis are not high risk for being diabetes necessarily or getting diabetes we talk about that more with chronic but we do want to keep an eye on their glucose because if the body's fighting inflammation um you know we want to make sure that the best way that inflammation infection other stuff can heal is if those glucose levels are under control um and then an ABG and then we have to think about what complication would this help with and if you said ards you are correct we wanted to keep a close eye on the AVG to see um what's going on when it comes to their uh we could um we cut a respiratory status oxygenation because what we look at you don't have to know this in depth like for this exam but definitely we'll want to note per complex is is that we have what's called refractory hypoxemia and what that means is again is like no matter how much oxygen I give this patient their O2 levels are still going to be low so they could be on a hundred percent tons of flow and still have like barely any auction sets like some of these patients um with Ard ards patients I've seen them have a low like a sat in the 70s and that's good for them like that's the best we can do for them um so we're going to check that and look for any sort of respiratory acidosis that kind of stuff and then we want to find the problem of course visualize it visualize the gallbladder to see if they're Stones because again depending on the cause of the pancreatitis we need to get to the bottom of it if there's an obstruction we need to relieve that obstruction all right so let's do a practice question it says for each of the following prescriptions indicate whether indicate whether it is indicated contraindicated or unnecessary um so the first one and I should say this should say four acute pancreatitis um the first one says diet prescription NPO so this is a patient we talked about that anytime I stimulate or put food into them drinks and them whatever it might be that they secrete more pancreatic enzymes which makes things worse so it seems to make sense to me that we would want them so it's good to have them in po the next one is chest x-ray daily so I know we talked about having respiratory complications I just don't know if they necessarily we have to check an x-ray every day versus if a problem came up or if they started having the abnormal lung sounds or changes to the respiratory stress we might want to check one so I'm going to say unnecessary it's not going to hurt them to get one but I don't know that it's necessary that we check one daily uh D5 half an s 150 milliliters per hour continuous this is like IV fluids so this patient is going to be high risk for being dehydrated because they can't probably take anything orally they may have been nauseous and vomiting um so this seems like something that would be appropriate and if you're wondering about that D5 because you might be saying like oh didn't you say like their blood sugar can get increased um D5 happiness is not a lot a ton of sugar um and this is considered uh what do you call this is a fluid that we use pretty regularly for patients so if you're looking deep into it or you're like oh 150 that's a little fast like I'm not try I'm just really trying to more so get here for helping you understand that IV fluids are appropriate for a patient with acute pancreatitis um the next one ibuprofen 800 milligrams po PRN for pain so they're going to have pain um but the thing with the patients with acute pancreatitis is they have such severe pain that Ibuprofen is not going to do it you know and on top of that this is Po so it's going to put them at increased risk for um you know having issues with more pancreas pancreatic enzymes spilling so this is going to be contraindicated um tpn 75 milliliters per hour continuous so um this patient like I mentioned has some nutritional deficits and because they can't take anything by mouth it is possible and I would think it would be appropriate for them to have some sort of parenteral nutrition so I'm going to say yes indicate it ondansetron four milligrams IV pushed for nausea it's a good way to practice to see if you know your meds that we've talked about so ondansetron is also known as zofran and so um which is a antiemetic so we have to think one are they going to be nauseous and two is this an appropriate route for the medicine Etc so it's IV push so yay we like IV push and then yeah that like we talked about before this patient can be nauseous and vomiting um have vomiting so this is a appropriate order all right CBC and BMP daily so a CBC you know lets us know what their white blood cell count is it lets us know what their hemoglobin is their platelets and then a BMP tells us about electrolytes in kidney function so all of these can be affected with pancreatitis I would think it's indicated um O2 therapy PRN to keep spo2 above 95. so um this is a good time to ask yourself does this person have an ox potential oxygenation issue and the answer is yes remember they possibly could have those um that respiratory uh the respiratory changes because of um the movement of the pancreatic enzymes to the lungs and things like that and just the systemic inflammation that can occur as a result of pancreatitis and so this um does seem like an appropriate order insulin drip continuous IV so hmm so I did said that they could be hyperglycemic but an insulin drip is usually reserved for people that have like really severe hyperglycemia like dka stuff like this so I'm going to say this one is unnecessary I'm sorry I'm dying for some reason it's like hey you're almost done your video so here I'm gonna make you cough where you can't talk anymore so to sum that up overall what we're going to do for this patient is we give them IV fluids we might also do calcium replacement if their calcium is low replace any other electrolytes if they're in shock where they have that high heart rate low blood pressure we might give them things like albumin which helps to get fluid where it's supposed to be they're going to receive things like proton pump inhibitors antacids to help because we pretty much we want things to not be irritating especially in their GI tract and then this patient's going to either get what's called postpyloric tubing and that's that thing I talked about with the dobhof where we put that tube all the way into the duodenum where it's feeding them but it's it's going to be past the point where um the enzymes are going to be secreted so in other words we're pretty much bypassing the system like it's almost think of it like a surveillance like the pancreas has a surveillance system in the GI tract at a certain point that when it senses presence of food it secretes enzymes we're bypassing that going past that so we can still give nutrition without the pancreatic enzymes being secreted um either that or they can get tpn parental nutrition just depends doctor preference and the patient how they're doing um usually they're going to be otherwise NPO and have an NG tube um sometimes what these patients have is in one nose they'll have an NG tube that's sucking stuff out of their stomach decompressing and then the other nose they might have a post pyloric tube so don't think that just because someone has a feeding tube that we're not also they can't have a regular NG tube as well sometimes patients have both it's very it's uncomfortable but sometimes necessary um Wake On Up it just depends on how the patient is doing um and what their needs are Etc um I and I won't say that I've seen a ton of patients that have both of those but there are times that they need an NG tube and we also need to feed them so it just kind of depends um Surge and we only use like regular NG tubes for decompression it has to be a thick tube those doll Puffs are too thin so we can't use a tube to decompress and feed them um just if you're wondering surgery is sometimes needed especially if they end up with a complication the pseudosis systemic infection peritonitis that kind of stuff we talked about supporting their oxygenation as needed it's not to say that every patient with pancreatitis is going to have a lung issue we need to just watch it closely sometimes they're also hurting so bad it's hard to take deep breaths so they'll also be at risk for Respiratory complications and we give them things like anti-spasmodics you don't have to know those names or meds in depth pain management and we talked about before they're going to be in a lot of pain and pain is a huge priority for these patients but what we usually give them is IV opioids because their pain is that high and then also we don't want to do anything to stimulate their bowels that way and then anti-medics as well like ondansetron Zofran or Phenergan um as the nurse I'm going to teach them to flex their trunk draw their knees to their abdomen or sideline with the head of bed elevated because we want that head of bed elevated to help with the respiratory stuff um but sometimes that that flexion in the knees can make a big difference um uh yeah and then the sidelines sometimes with that flexion can help a lot I want to improve their comforts you know especially if they're nauseous vomiting good Oral Care monitor that respiratory status closely um they may need ECG monitoring especially with that hypocalcemia keeping a close eye on that monitor for tetany um you know the two signs of tetany is you know you um poke their cheek uh what do you call them you poke their cheek and they have kind of the spasm in their cheek that's known as shavas Tech sign and then also if you do their blood pressure and their two fingers go together it's called a carpal spasm that's what's known as the truso sign um education wise if alcohol or smoking is a behavior they regularly engage in I would encourage them to stop that or change those habits and then after resolution of their acute pancreatitis usually a low-fat diet and carbohydrates are less stimulating to the pancreas so that's usually where we start so especially like when I'm starting a back on a diet after they're getting better a higher carb diet can actually help because it's less irritating to the pancreas I think that's it I'll see you next for chronic pancreatitis if the zoom will end