Nursing Care: Acute Pancreatitis - Essay Example

Nursing Care: Acute Pancreatitis Acute pancreatitis is a challenging condition not only for surgeons but also for nurses taking care of them (Granger and Remick 2005). It is a life threatening condition and warrants continuous monitoring. It causes severe distress to the patient and also to the family members because of the pain and other symptoms associated with it. Nurses play an important role in any health care system. They play a major role in the assessment and treatment of patients. They promote the emotional well being of a patient because of their sense of empathy and caring feeling (Peate and Dutton, 2012). They work with people suffering from various types of illnesses in diversity of roles and actions demanding expert skills and professional knowledge. The situations are many a times complex requiring an understanding of the complexity of the situation. Every nurse-patient encounter is unique and there are no fixed solutions to many nursing problems. Due to these demands and requirements, some professional standards and skills are expected from the nurses. Competence for nurses is important for the kind of profession it is and the expectations that the profession arouses. Nursing profession involves complex combinations of performance, knowledge, attitudes and skills (David 2005). In this essay, nursing care of a patient with pancreatitis will be discussed to enhance reflective thinking and appraise nursing competence during case management. The case discussion is about a 58 year old patient by name James (name changed to maintain privacy). James was brought to the emergency room on a Friday evening after a weekend party with severe abdominal pain. He was accompanied by his wife and friend. In the past, James had few episodes of abdominal pain and he responded well to antigastritis treatments. However, since the intensity of pain was more and he also had severe vomiting, his wife forced him to see a doctor in the emergency room. In the emergency room, James appeared dehydrated and was in distress. On enquiry, it was found that he did not pass much urine in the past 6 hours and had vomited several number of times. He had severe abdominal pain in the centre of the abdomen which radiated towards his back. He did not have loos stools and was passing flatus normal. The emergency doctor suspected acute pancreatitis. He performed serum amylase levels and they were 3000IU/l. CT scan which was done immediately confirmed the same. The patient was then transferred to surgical intensive care unit for further management. I was put incharge of the patient and asked to pick up the patient from the emergency room. James was anxious and so was his wife. They bombarded me with questions pertaining to the nature of the disease, the course of stay in the hospital, anticipated complications and prognosis. Inflammation of pancreas is known as pancreatitis (Whitcomb 2006). Pancreas is an organ that has both exocrine and endocrine functions. It is located behind the stomach in the abdomen. Acute inflammation of the organ is actually uncommon and mostly mild. In 30 percent cases however, it is severe and the patient can become critically ill (Whitcomb 2006). Acute pancreatitis mainly presents as severe abdominal pain mainly in the epigastric region. The pain can radiate towards the back and is frequently associated with nausea and vomiting like in case of James. There are several causes of pancreas, the most common of which are gall stones and alcohol intake. James was a chronic alcoholic. He frequently binged on large quantities of alcohol. Diagnosis of pancreatitis is made by serum amylase assessment. Levels more than 1000 IU/L are diagnostic of pancreatitis, like in case of James (Whitcomb 2006; Granger and Remick 2005). Two important aspects of nursing care I would like to stress upon while taking care of James were improving comfort of the patient and providing psychological support. I offered regular analgesia to James to promote comfort. James complained of severe pain in the abdominal region, especially in the epigastric region. Since he was kept Nil Orally, he was mainly given medicines through intravenous route. Tramadol PRN orders were there. So I gave the patient IV tramadol 50 mg whenever he complained of pain. Acute pancreatitis mainly presents as severe abdominal pain mainly in the epigastric region. Several treatments are available for treatment of pain. The "step ladder" approach designated by the WHO is an useful tool to manage pain in terminally ill patients. The WHO (2009) established a 3-step analgesic ladder for management of pain in cancer and acute pain patients. Stepping up the ladder is guided by pain score. Mild pain with scores between 1-4 must be treated with nonsteroidal antiinflammatory agents or NSAID. Pain scores of 5-6 suggestive of moderate pain must be treated with weak opioids. Severe pain scores between 7-10 must be managed with strong opioids like hydromorphone, morphine and fentanyl (WHO, 2009). In patients with acute pancreatitis, tramadol and pethidine are preferred opioid analgesics because, morphine causes spasm of sphincter of Oddi (Whitcomb 2006). The pain can radiate towards the back and is frequently associated with nausea and vomiting (Whitcomb 2006). On the first day of admission, James had repeated episodes of vomiting which were controlled with round the clock ondensetron. James received 4 mg of ondensetron 8th hourly through intravenous route. He often complained of nausea which would subside after giving ondensetron. James was in severe dehydration at the time of admission. His lips were dry and eyes sunken. His blood pressure was 110/70 mm Hg. His heart rate was 120 per minute. Initial ABG showed mild metabolic acidosis. His urine output also was reduced. All these point to shock status of the patient at the time of admission. I informed the emergency medical officer about the condition of the patient and based on his advice, I gave the patient normal saline bolus. I monitored the vitals of the patient hourly and updated the information on the charts. Some patients with acute pancreatitis can deteriorate very fast and constant vigilance is necessary to prevent untoward complications. After the initial normal saline bolus, IV fluids were adjusted and provided based on hydration status of the patient and electrolytes report. Accurate fluid management is crucial in the treatment of patients with acute pancreatitis, because they can land up in electrolyte disturbances easily. An input-output chart was maintained and hourly urine measurement was done. Acute pancreatitis is usually self-limiting. In some cases, it can lead to necrosis of the organ due to microcirculatory stasis and infarction within and around the gland. Patients with acute pancreatitis can be in shock (Whitcomb 2006). On examination, there can be abdominal tenderness, gaurding, or even rigidity. In some patients, there can be brusing in the loin or periumbilical region. The former is known as Grey Turners sign and the latter Cullens sign (Whitcomb 2006). Some patients can have paralytic ileus (Whitcomb 2006). Since James was nil-by-mouth for 3 days, he needed appropriate oral care. His dry lips were soaked with wet gauze frequently to make him feel comfortable. he was also monitored for paralytic ileus which is a common complication in patients with acute pancreatitis. Its is very important to keep the patient nil by mouth. This is is to reduce stimulation of secretion of pancreatic enzymes. An NG tube was placed for regular nasogastric aspiration and James did not like it. He often complained to me and other nurses to remove it. I gave him psychological support and told him the importance of having that in place. I promised to give him a gift if he allowed us to keep for three days without removing in between. Pancreas produces enzymes like lipase, trypsin and protease that aid in the digestion of food we eat. These are normally activated in the duodenal part of the intestine. In acute pancreatitis, the enzymes get activated in the pancreas itself, leading to swelling of the organ, bleeding, necrosis and abscess formation. Even cysts can be formed around the pancreas (Whitcomb 2006). Activation of certain enzymes like chymotrypsinogen, trypsinogen, catalase and elastase cause increase in capillary permeability and leaking of fluid into surrounding tissues and peritoneal space (Whitcomb 2006). James was very scared about the nature of illness. He was an educated man and he knew what pancreatitis was. Also, the disease made him so uncomfortable that his anxiety even worsened. Repeated vomiting, constant nausea, frequent bouts of pain, frequent sampling and procedures like nasogastric tube placement cause distress in the patient. I spoke to the psychologist and involved him in counseling the patient. I invited the patients friends to cheer him up. I showed his chart everyday to escalate his progress in treatment. James improved dramatically and was shifted to the ward in 4 days. According to the NMC, (cited in Somerville, and Keeling 2004), nurses have a duty bested upon them to provide care that is to the best of their ability to the patients. In order to impart this duty, they need to have good knowledge, possess good skills and display appropriate behavior during their interaction with patients and their colleagues. They are obliged to act as per the expectations of their profession. These expectations are the core of competence. Critical thinking and analysis refers to research for practice which is possible through thorough professional development and value for evidence (ANMCI, 2005). One important aspect of this domain is reflective practice which helps in individual and professional development. Clinical experience is an essential component of nursing education and one of the methods of development of clinical experience is to place the nurses in different quality clinical placements (Burton and Ormrod, 2011). The rotation through these venues helps the nurses assimilate competence and grow into a confident professional (Levett-Jones 2006). The most important aspect of expert clinical practice is clinical decision making which is a complex phenomenon and the thinking process varies from one nurse to the other (Higuchi and Donald 2002). Through this experience I learnt that critical analysis and thinking and provision and coordination of care are important domains of standards of competence for nursing profession. It is through critical analysis and thinking that I could manage the case efficiently. Due to provision and coordination of care I could initiate immediate laboratory investigations and treatment. I have realized that scientific knowledge is the core for clinical competence without which one cannot excel in provision of care. Whatever action we take as nurses must be moral and ethical. I believe that while managing this patient, my actions were ethically and morally right. I was also aware of myself as a professional because of which I could act promptly and efficiently. Clinical practice is an art and our own experiences help us to do better the next time a similar situation is encountered. The domain of collaborative and therapeutic practice is concerned with standards for establishment, sustainance and conclusion of professional relationships with various individuals and groups. The domain also covers those competence aspects which are related to interdisciplinary health matters (ANMCI, 2005). Knowledge is very important for critical analysis and thinking and this can be gained by reading, discussing and reflecting. In this exercise, I have reflected upon 2 domains of nursing competence, namely critical analysis and thinking and provision and coordination of care which I personally believe are important in managing any clinical situation. Coordination is very important in nursing profession because, for providing proper care, it is essential for nurses to coordinate between their colleagues, mentors, superiors and other health professionals like physicians and laboratory personnel. References Australian Nursery and Midwifery Council or ANMC. (2005). 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(2004) A practical approach to promote reflective practice within nursing. Nursingtimes.net, 100(12), p.42 [online] 24th November, 2012. Available from: http://www.nursingtimes.net/nursing-practice-clinical-research/a-practical-approach-to-promote-reflective-practice-within-nursing/204502.article WHITCOMB, D.C. (2006) Clinical practice: Acute pancreatitis. N Engl J Med. 354(20). p. 2142-50. WHO. (2009) WHO Definition of Palliative Care. [online] 24th November, 2012. Available from: from http://www.who.int/cancer/palliative/definition/en/ Read More