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SIRS/pancreatitis
| Question | Answer |
|---|---|
| Pathophysiology of SIRS Systemic inflammatory response system | First is general inflammation…… then the inflammation damages the vital organs…. patient goes into a hyper metabolic state …..there is nutrition impairment ….and MODS |
| Risk factors for SIRS | If the patient is experiencing shock, has had multiple transfusions, has had massive tissue injury or burns, or has pancreatitis |
| Why is a patient at risk for SIRS with multiple transfusions | Because it creates an antibody overload |
| Why is a patient at risk for SIRS with massive tissue injury or burns | Trauma evokes systemic immune response |
| Complications of SIRS | Clotting problems, MODS, brain shuts down, kidney/liver/heart failure, Pancreas/G.I./respiratory failure |
| Diagnosis of SIRS | Must have two or more of the following symptoms. Temp less than 97 or more than one 100.4, heart rate less than 90, respirations greater than 20, white blood count less than four or more than 12, |
| What are two white blood cell levels that we look for in lab work for SIRS | ESR, CRP |
| Signs and symptoms of SIRS | Low BP, HR increased, RR increased, temperature can be increased or decreased, pain is increased, flushed or pale, crackles in the lungs, distended abdomen, little to no bowel sounds and decreased elimination |
| Nursing interventions for us IRS | Bladder scan and straight Cath patient, risk for infection, hand hygiene, neutropenic precautions, vent, falls risk, Foley care, I’s & O’s, TPN, antimicrobials, Colace, blood glucose level/insulin, impaired nutrition, dialysis, analgesics, opioids |
| Inflammation of the pancreas. It may be acute or chronic. It is most often associated with alcoholism or obstruction of the pancreatic duct by a gallstone | Pancreatitis |
| What are causes of pancreatitis | Alcoholism, obstruction by gallstone, viral infections, peptic ulcer disease, cyst, metabolic disorders such as renal failure or hyperparathyroidism, trauma from external injury, surgery, or endoscopic procedures, high fat diet, & cigarette smoking |
| Digestive enzymes that digest pancreatic tissue, fat, elastic tissue in the blood vessels | Trypsin, elastase, phospholipase |
| Autodigestion | Digestive enzymes are activated by an unknown mechanism and begin to digest pancreatic tissue, fat, and elastic tissue and blood vessels. |
| Signs and symptoms of pancreatitis | Abdominal pain, Severe vomiting, flushing, cyanosis, dyspnea, low-grade fever, tachypena, tachycardia, and hypotension. Tender distended abdomen, absent bowel sounds |
| Early signs and symptoms of shock | Restlessness and tachycardia |
| Late signs and symptoms of shock | Hypotension |
| Signs and symptoms of chronic pancreatitis | Similar to the acute pancreatitis but usually appears as periodic attacks are become more and more frequent |
| With what type of pancreatitis may diabetes mellitus develop | Chronic pancreatitis |
| Complications of pancreatitis | Pseudocysts, abscess, hypocalcemia, pulmonary/cardiac/renal complications |
| A fluid filled pouch attached to the pancreas | Pseudocyst |
| Symptoms of pseudo cyst | Abdominal pain, nausea, vomiting, and anorexia |
| Diagnostic lab findings in acute pancreatitis | Elevated levels of serum amylase, serum lipase, and urinary amylase. Elevated WBC count, elevated serum lipid and glucose levels and decreased serum calcium levels. |
| Diagnostic tools for pancreatitis | Ultrasonography , ERCP which may reveal presence of gallstones, cyst, or abscesses that could help rule out other disorders that might be causing the patient symptoms |
| Medical treatment for the patient with acute pancreatitis | NPO, IV fluids, blood or plasma expanders to increase blood volume. Urinary output is monitored, nasogastric tube, TPN peritoneal Lavidge or laparoscopic to remove toxic fluid from peritoneum |
| Drug therapy for a patient with acute pancreatitis | Analgesics, anti-spasmodic agents anticholinergic agents, gastric acid inhibitor‘s, opioids, insulin, oral hypoglycemic drugs, histamine blocker‘s, bile salts |
| Surgical interventions for pancreatitis | Endoscopic sphincterotomy cholecystectomy, debridement, and endoscopic or percutaneous debridement |
| Focused assessment patient with acute pancreatitis | Report signs of hypovolemic shock such as restlessness, tachycardia, tachynepa, hypotension, and decrease urinary output. Inspect abdomen/flanks for discoloration. Abdomen distention tenderness and diminished bowel sounds.. Assess patient’s mental status. |
| Nursing care for a patient with pancreatitis experiencing pain related to inflammation by Larry obstruction or auto digestion | Analgesics, anti-spasmodic drugs, use distraction, imagery, relaxation techniques. If I was physician if pain is unrelieved |
| Nursing care for a pancreatitis patient with fluid volume deficit related to vomiting, bleeding, fluid shift from bloodstream to abdominal cavity | NG tube, IV fluids, monitor vitals and inputs and outputs and weight. Look at electrolyte studies. Report any signs of fluid volume deficit such a tachycardia hypertension dry skin and concentrated urine to the physician |
| Nursing care for pancreatitis patient with potential for infection | Monitor vitals, look at lab values for blood cell counts, administer antimicrobials and use standard precautions for invasive procedures |
| Nursing care for pancreatitis patients with potential for an adequate oxygenation related to pain and pulmonary complications | Assess respirations and breath sounds. Help patient to change positions cough and deep breathe at least every two hours and plays patient in semi Fowler‘s position to promote lung expansion |
| Nursing care for pancreatitis patients with an adequate nutrition related to anorexia, vomiting, digestive disturbances | Administer TPN monitor for hyperglycemia and administer insulin as needed take daily weights monitor patients tolerance for oral intake and discourage spicy foods caffeine and alcohol |
| Nursing care for pancreatitis patient with anxiety related to acute symptoms | Respond patient’s needs ask what questions she has and provide prompt explanations and check on patient often |
| Patient teaching for pancreatitisaA | A Bland high carbohydrate low fat diet will avoid stimulating the pancreas and promote healing. You may be able to tolerate small frequent meals better at first and then move on to larger meals. Abstain from alcohol and tobacco because it decreases your r |
Created by:
Michelle McCourt
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