hey everyone it's sarah with registernursern.com and in this video i'm going to be doing an nclex review over pancreatitis this video is part of an nclex review series over the gi system so be sure to check out the other videos in this series and as always in the youtube description below or at the end of this youtube video you can access the free review quiz that will test you on pancreatitis so let's get started first let's start out talking about what is pancreatitis just as the name says it is inflammation of the pancreas and what has happened here is our pancreas it has for some reason became really inflamed and swollen and you have cells inside your pancreas that secrete hormones and enzymes and whenever inflammation sets in these cells get really irritated and they can start malfunctioning in a sense and what can happen is that this can lead to digestion of the pancreas by its own digestive enzymes and if the patient has chronic pancreatitis it can cause irreversible structural changes to the organ so it just really over time will quit working now there are two types of pancreatitis that we're going to cover in this lecture we'll cover acute and chronic pancreatitis but before we get into that let's talk about the function of the pancreas because in order for you to understand those signs and symptoms complications nursing interventions you really have to understand how this organ works normally and all of it else will just click together okay so let's talk about the pancreas where is the pancreas found it is found in the up upper abdomen next to the duodenum which is that first part of the small intestine so we have our pancreas we have our duodenum and then right here inside the pancreas we have our pancreatic duct then right next to it we have our common bile duct which is connected to our gallbladder and this gallbladder will secrete bile down through here and the pancreatic duct will secrete its digestive enzymes and they will meet together and at called the impula of vader and the bio and the digestive enzymes will come out through the major duodenal papilla and be secreted into the duodenum now surrounding that major duodenal papilla is called the sphincter of od and what the sphincter of od does is it's a muscular valve that controls the flow of that bile and those enzymes into the duodenum and also it prevents reflux of that duodenal contents back into the pancreas now let's talk about our cells that make up our pancreas okay your pancreas performs really two functions an exocrine function which is by the astanar cells and an endocrine function which is by the eyelids of langerhans so let's look at these and pay close attention to this part of the lecture because if you can understand what these cells do pancreatitis makes so much sense okay let's talk about the exocrine function these purple i mean these light purple areas that you see which is connected to the pancreatic duct are called the acinar cells and the asanar cells secrete inactive digestive digestive enzymes into those pancreatic ducts which flow down and hit the duodenum these enzymes do not become active until they hit the duodenum and what enzymes do they does the acinar cells secrete it secretes amylase which breaks down carbs to glucose it secretes protease which breaks down proteins and it secretes lipase which breaks down fats now if you have some inflammation of this pancreas going on these asana cells um don't want to work properly what they'll do is they'll activate inside of the pancreas which will start to digest it because we don't want to activate it inside we want it in the duodenum in addition to you have surrounding your pancreatic duct cells called epithelial cells and these epithelial cells secrete bicarb which we've learned in peptic ulcer disease that bicarb helps neutralize that stomach acid so keep the bicarb in mind because when we talk about one of the causes of chronic pancreatitis we're going to talk about cystic fibrosis and that is really where things are messing up and why this patient's getting pancreatitis so that's the role of those epithelial cells along with secreting fluid then we have our endocrine cells and our endocrine cells are these dark purple areas and they're specifically known as the eyelids of langerhans and we really talked a lot about these in diabetes mellitus because these cells secrete several things like insulin glucagon somatostatin and pancreatic polypeptide into the bloodstream because surrounding your pancreas is a bloodstream so that's where those hormones go and the digestive enzymes go into the pancreatic duct now and this will play a role in your patients blood sugars and what you're going to see with a pancreatitis if they have it really severe enough you're going to see some wacky blood sugars and they're going to present with signs and symptoms of diabetes mellitus because these cells are inflamed they're damaged they're not able to secrete the right amount of insulin that that person needs so they're going to be having issues with that now just to recap these enzymes that are secreted in the pancreas are not active activated while they're inside there they don't become activated until they hit that duodenum where a biochemical change with the assistance of stomach acid happens and then they're ready to do their job because connected here is your stomach so the person's ate their food the food's going to travel down to the small intestine it's going to come in contact with those digestive enzymes that have just and bile that's got secreted through that major duodenal papilla and then all our digestion is going to happen now what can pancreat pancreatitis lead to what can happen is that these digestive enzymes are not going to be able to be delivered to the duodenum so you're going to be seeing malabsorption along with those hormones aren't going to be going into the bloodstream normally so you're going to be seeing blood sugar issues and the pancreas will swell and leak those digestive enzymes into the surrounding tissues and organs so really this can affect the whole body if it gets really bad and the patient doesn't get treatment so some things you can see again you can see those blood sugar issues you can see ascites which is swelling in the abdomen you can see malabsorption from where these digestive enzymes are not making it to the gut so their stools will be oily looking they're not digesting those fats you're going to see weight loss with the gi system you're going to they're going to have extreme pain because it's going to hurt so bad these digestive enzymes leaking into the tissues um diarrhea again it'll be oily shock systemic shock multi-organ failure respiratory distress which is going to lead to death if this patient doesn't get it treated internal bleeding um where and this is where you're going to be seeing the colon sign and the gray turner sign from a retroperitoneal bleeding also um you can see fibrosis if this gets really bad like in chronic pancreatitis the tissue can become necrotic and change you'll have fibrosis of pancreas which these cells will not work at all and cyst formation out of that tissue which can have pulling of infection it can abscess and rupture now let's look at the key points between acute pancreatitis and chronic pancreatitis because they have a little bit of variations okay now with acute pancreatitis there is sudden inflammation due to something that has triggered those digestive enzymes to activate inside of the pancreas and the two major causes of acute pancreatitis are gallstones and alcohol abuse in high amounts drinking a high amount of alcohol can cause this and whenever patients who are experiencing acute pancreatitis it will come on just suddenly and quickly their pancreas is working so those endocrine and exocrine cells will be able to work compared to someone who has chronic so they tend to have when you check their blood work they will have extremely high amylase and lipase and again those were those digestive enzymes that the asinar cells secreted now with chronic pancreatitis this is caused from chronic recurring inflammation to that pancreas that just isn't getting better and it can be caused by repeated episodes of acute pancreatitis and the most common cause of chronic pancreatitis is alcohol abuse years and years of alcohol abuse so acute pancreatitis the cause is gallstones and high ingestion of alcohol the cause of chronic pancreatitis is years of alcohol abuse that's one of the main causes there's other causes which we'll talk a little bit about later now with chronic pancreatitis and the damage to the pancreas is irreversible so what's done is done and um they tend depending on their amylase and live case how they have the function of those asanar cells they tend not to function as well as whenever someone who just has this acute episode that came on so their amylase and lipase can be normal or a little slightly elevated now um structure changes that you're going to see with chronic because it's damaged you're going to see that loss of function to those endocrine and exocrine cells and you're going to see damage to those pancreatic ducts the pancreas itself the tissue that make up the pancreas it's become necrotic it's dyed you're going to see fibrosis of it with cysts and calcification now with acute what can happen is that those digestive enzymes are going to cause the pancreas to start digesting itself patients going to have a lot of pain swelling it's going to be inflamed and if it's not treated quickly improperly the tissue will die and they can experience the fibrosis and the cysts and the abscess now due to the location of the pancreas and how it surrounds those other organs that inflammation and those free digestive enzymes can flow to those other organs and vessels that are surrounding the pancreas which is why when this comes on suddenly the patient it can lead to death because it can be fatal because it can affect the lungs causing acute respiratory distress syndrome and it can affect major vessels and lead to bleeding and hemorrhaging now acute pancreatitis is reversible if treated properly and there's limit usually limited structural change to the pancreas and like i said it can lead to chronic pancreatitis now let's look at a more in-depth look at the causes of acute pancreatitis and chronic pancreatitis okay we said that a cause of acute pancreatitis was gallstones okay why do gallstones cause acute pancreatitis first of all what in the world are gallstones okay gall stones are hardened deposits of undissolved cholesterol salt or bilirubin and this is coming from that gallbladder and maybe what's happened is that gallbladder's function um is not functioning properly it's just keeping that bio and stuff stagnant in there so that stuff can harden and what can happen is that one of these stones can come down and block that common bile duct and remember and as that bile flows down through that common bile duct the pancreatic duct is coming from the pancreas and they come together at the ampulla of vader and a little stone can get in there and block that pancreatic duct and what's going to happen is that you're going to get a backup of those pancreatic digestive enzymes they have nowhere to go except to set in that pancreas and pressure is going to build over time then you get this activation of enzymes and remember this isn't supposed to happen in the pancreas so whenever this happens that vicious cycle of pancreatitis starts to happen until they can get that gallstone removed so those juices can flow out down into the duodenum and get it treated now another cause of acute pancreatitis is alcohol and sometimes patients go on have been on a drinking binge and they've consumed like a crazy amount of alcohol alcohol your pancreatic cells particularly really don't like alcohol specifically those asana cells it damages them and your pancreatic duct cells don't like it as well because it messes with bicarb that remember those epithelial cells produce and the fluids so you're not going to get the bicarbonate and the fluid production the juices in the fluid in the pancreatic duct is going to become viscous and thick and it can cause occlusion of that pancreatic duct then you get the activation of those digestive enzymes and again that ugly cycle happens all over other causes are infections tumors medications and trauma now let's look at chronic pancreatitis the cause okay so we said that long-term alcohol abuse causes it it's the same concept remember your pancreas really just doesn't like alcohol and it damages it so this person just keeps consuming alcohol over years and years and they have that recurrent inflammation over and over on that pancreas and that those structures of the pancreas start to become deformed they start malfunctioning it doesn't work properly those cells quit doing what they're supposed to do and so they get chronic pancreatitis irreversible changes just from continually drinking alcohol now i wanted to touch on another cause of chronic pancreatitis which is cystic fibrosis this will help you as well on nclex okay we know with cystic fibrosis they have a lot of the respiratory issues but cystic fibrosis also affects the pancreas and the reason why is because these patients lack the cftr protein and what does this protein do it's very important it plays a role in the movement of chloride ions to help balance salt and water and we're really talking about the salt and water and those epithelial cells that line those pancreatic ducts because remember they secrete bicarb and fluids to help keep that fluid thin which will mix with those digestive enzymes that secreted by the astana cells and allow it to easily flow through um the pancreatic dug down through the ampulla of vader and then out into the duodenum well what happens is that your bicarb production goes down in cystic fibrosis that mucus it becomes thick mucous that is inhabiting that pancreas and you get blockage of those ducts and digestive enzymes start to activate and and this is just a chronic um inflammation the pancreas in the pancreas starts to just die and the tissue will become necrotic fibrosis hence cystic fibrosis the pancreatic tissue tissue will become fibrose and the end result is that that patient will no longer produce those pancreatic digestive enzymes by those astronaut cells and and that is why with these patients you will have to administer with their meals those pancreatic enzymes to help them digest those fats and carbs and other causes of chronic pancreatitis is increased calcium and high cholesterol levels now let's look at how pancreatitis is diagnosed as a nurse you want to be familiar with what the physician may order so you can be looking for certain test results and know what a patient may be going for and why they're going for this okay and typical blood tests you will see ordered are like an amylase level or a lipase level and again and really in acute pancreatis these will be elevated and you can see the electrolytes will be all out of whack usually elevated and also another thing they'll order is called a ct scan or an ultrasound which will take imaging of the pancreas so they can assess it look at the structure of it and another thing they will order is a test called an ercp and this is where a scope is used to assess that pancreas the bile ducts and the gallbladder and they can actually diagnose pancreatitis with this but they can also treats some of the causes for instance they can go in if a gallstone's in there they can go in and remove it or if these pancreatic ducts are blocked they can go in put in a little stent or a balloon and open up the duct or if there's a cyst in there they can drain it so a lot of times patients will be getting an ercp now let's look at the signs and symptoms that you may see in a patient with acute pancreatitis versus chronic pancreatitis because the signs and symptoms are a little bit different and the reason why is be is because in acute pancreatitis your patient still has majority of the function of the pancreas so those aston are cells and isolates of langerhorn cells are working so um your patient's gonna be having a lot more pain increase amylase and lipase levels however compared to the patient with chronic pancreatitis this has been going on for a while now so chances are they've really lost majority of the function of their pancreas and you're going to start seeing those long-term effects more in the patient with chronic so let's look at acute first okay with acute these patients are all of a sudden going to complain of very intense painful mid epigastric pain and sometimes it can be in the left upper quadrant as well and that's just because where the pancreas is located and it can radiate to the back now a lot of times patients will say it hurts when i'm lying flat so um you don't want to put them in the supine position typically the pain they won't have any pain and then all of a sudden they'll say the pain came on after you know i was binge drinking drink a lot of alcohol the other night or um it was after i ate a fatty greasy meal so they'll report that they can also have as it gets worse with acute they can have fever from the inflammation increased heart rate decreased blood pressure and usually that's representing they're going into shock it's affecting all those other organs throughout nausea and vomiting extremely nauseous and vomiting which makes the pain worse as they are dry heaving and throwing up and they can have increased glucose levels again because those eyes lit of langerhans are not working properly so you want to really monitor those blood sugars increase amylase and lipase levels and you'll want to remember these any time in nursing school you see funny looking names or someone's name that's called a sign like colon sign or gray turner sign remember that very very common to be on an exam okay so let's talk about colon sign colon sign and whenever a patient has severe pancreatitis this is when you're going to see is in severe cases you will see this bluish discoloration around the umbilicus around the belly button now um what are why are you seeing colons in gray turner well what's happened is that in severe pancreatitis those digestive enzymes have become free and they're just going to the surrounding tissues which is damaging vessels tissues whatever and it's causing bleeding and that bleeding is uh seeping down and collecting around the belly button and the flanks of the sides and you will see this blueish discoloration is just blood underneath from a retroperitoneal hemorrhage now and you also have gray turners which is where you'll see the blue bluish discoloration on the flanks the side of the abdomen so how do you tell these two from each other how i remember is this colon starts with c the word circle i remember the word circle because a belly button makes a circle so we have bluish discoloration around there um gray turner um i remember the word turner like turn her over and you turn her over on her side and right there you will see the bluish so that's how i remember it so hopefully that will help you okay with chronic pancreatitis here's signs and symptoms you may see and they're going to have just this chronic it's always there mid epigastric pain it may be in episodes as well but they have a pretty much all the time sometimes though if they're if this is really bad and they've had extensive damage to that pancreas they may have no pain at all why because those asana cells aren't even working and so they're not releasing those digestive enzymes which is causing a lot of that pain because that's where a lot of your pain is coming from so um they may not have pain and if they do have pain they'll notice that it's always there but it increases after drinking alcohol or eating like a fatty greasy meal they may have swelling in their abdomen or like a mass just from where that pancreas is really enlarged there's fibrosis may have some pseudocyst so you may see that or can palpate that you will see steriteria and this is diarrhea that looks like an oily greasy stool it'll really float to the top have like this residue of just like grease in water and we know the oil and water don't mix and you will see that and that is because of the decreased pancreatic enzymes which is why as nurses will be administering pancreatic enzymes to these patients which we'll talk a little bit about in nursing interventions and they don't have the ability to break down those fats and so it's really just coming out and whenever they use the bathroom that's because those aston ourselves are damaged they will have weight loss because they can't digest food properly like those carbs and fats and they also in really late cases may have jaundice where they have the yellowing of the skin the whites of the eyes will be yellow and this is because of damage to that bile duct that helps remove bile from the liver so here's your gallbladder and right connected to this part of this bile duct would be the liver and it drains down bile well you have damage to this from all this damage that's going on from this inflammation because remember these digestive juices have just migrated outwards and just damaged everything around it so it's not going to remove the bile from the liver which is going to back up and the patient's going to have those signs and symptoms of that they can also have the dark urine as well and this is because again that excessive bile in the body and it's leaking into the kidneys and the urine looks really dark they can also have diabetes mellitus and again that's because of damage to those eyelids of langerhan cells and so they'll have to have insulin beyond that to cover their blood sugars now let's look at the nursing interventions that you're going to be doing for a patient with pancreatitis okay our goal as a nurse is to allow the patient's pancreas to rest we do not want it to be stimulated so it won't release those digestive enzymes and we want to control their pain they're going to have a lot of pain with this condition we want to monitor them for complications administer medications per physician's order which will include pancreatic enzymes antibiotics sometimes um in stomach acid blockers and we're going to provide them diet education okay so practically all the time the patient is going to be nothing by mouth initially and we want to let that pancrea the pancreas rest and we don't want to give it any stimulation to produce enzymes and um as they get better their signs and symptoms start to slowly go away we will carefully introduce um liquids typically no liquids with fats because that and will stimulate and require a lot of digestive enzymes to break down in the body we don't want to do that and of course that will be by however the physician orders it um we will be maintaining iv hydration because remember this patient's not going to be eating or drinking they have to stay hydrated if they get become dehydrated it's going to cause this condition become worse and if it's taking them a long time to heal i've had patients where it's taking a long time for the pancreatitis to start getting better you will have to start them on tpn which is a nutrition through a central line that will give them the require their daily requirements of lipids and carbs and things like that another thing is that and probably will have to insert and maintain a nasogastric tube and ng tube which will um be present down through the nose it'll go in through the nostril and down through and it'll set into the stomach and it will remove gastric contents and gas which will help decrease vomiting and again we just don't want that pancreas to be stimulated and then it'll be removed once the patient gets better and you're going to monitor those blood sugars because again they will probably be high because those cells aren't working and you'll have to provide insulin coverage per physician's order you'll want to monitor their stools for that oily greasy look to them because if they are taking pancreatic enzymes the physician orders that you want to look at those stools to make sure that they're getting um the proper amount of those pancreatic enzymes because they're taking them and the stools are still greasy then something's wrong the physician needs to look back at that again and you'll want to report that another thing is you're going to be monitoring that urinary output you're going to see how much they're putting out how much they're taking in and specifically the color we're looking for that dark brown color which is showing us that hey something worse is going on that bile is just collecting and leaking into the kidneys and and you'll be administering pain medications typically at first it's the intravenous route because it works fast and they're having really bad pain typically morphine is usually avoided because it can cause spasms at that sphincter of od and some patients have actually reported you know you're giving them morphine but they're still having crazy intense pain and it's not helping it actually seems to be making it worse and that's because that sphincter of oddi remember that's around surrounds the major duodenal papilla and it controls the flow of the digestive juices that go into the duodenum so that can spasm non-pharmacological techniques uh positioning remember laying in that supine flat position causes their pain to be worse so we want to make sure that they're leaning forward or they're sitting up just so that perineum is not stretching and compressing that inflamed pancreas and um we'll be administering drugs per physician's order to possibly decrease the acid secretions and these drugs will include like your ppis proton pump inhibitors we talked a lot about those in the peptic ulcer disease video h2 blockers and antacids and these will prevent those digestive if we decrease the acid it will prevent those digestive enzymes from becoming activated because that's how that whole biochemical process happens is that those digestive enzymes which are inactivated come through the pancreas down to the duodenum where contact comes in contact with stomach acid and then they become activated and if we decrease acid it'll decrease our activation another thing really ordered a lot with chronic pancreatitis and your patients who have the cystic fibrosis are the pancreatic enzymes such as creon or also called pancreatin and how these work is that they help break down the fats the carbs and the proteins where your asana cells aren't able to do the job so um to know that they're working right we have that decrease in that steroia and that oily greasy stool and you'll want to administer that right before the meals which makes sense because we want those to be present in there and by the time they eat they can do their job and work and break down that food a lot of times they come in capsules and you swallow them whole but sometimes patients have swallowing difficulties especially if this is in children and you can open up the capsule and mix it but you have to be careful with what you mix it in because you want to mix your pancreatic enzymes in like an acidic food why because these enzymes love acidic conditions and they work better like applesauce so mix it in applesauce avoid alkaline foods that are basic because this actually destroys the enzyme and won't allow it to work properly and this is like milk pudding ice cream so make sure you're not mixing it in that now some diet education okay patients with pancreatitis they need to avoid alcohol especially your patients with chronic pancreatitis that's usually the biggest cause so no alcohol or avoid those greasy fatty foods as well they want to consume a low fat diet that's bland small meals rather than huge large ones a high protein they'll want to limit their sugars and refine refined carbs really a lot of times patients do have issues with diabetes so they'll want to watch that and your refined carbs are like high fructose corn syrup white breads things like that and they'll want to consume more complex carbs like your fruits your vegetables and your grains because this uses less insulin so the body those isolate langerhan cells won't have to produce as much insulin okay so that wraps up this review on pancreatitis thank you so much for watching don't forget to take the free quiz and to subscribe to our channel for more videos