INTRODUCTIONPancreatitis is an inflammation of the pancreas. It may be either acute or chronic. The two forms of pancreatitis have different courses and are considered two different disorders.

Anatomy - Pancreas is a leaf-shaped organ situated in the upper part of one’s abdomen. It is about 6 inches or 15 cms long (about 5 inches long) (the first portion of the small intestine leading out of the stomach) and a tapered tail that rests on the front of the left kidney

Physiology or Function- Pancreas is one of the organs in the body that has both exocrine and endocrinal functions. It has three major functions: to secrete fluid containing digestive enzymes into the duodenum; to secrete the hormones insulin and glucagon, which help regulate sugar levels in the blood stream; and to secrete into the duodenum the large quantities of sodium bicarbonate( the chemical in baking soda) needed to neutralize the acid coming from the stomach.

Exocrine Function - It secretes an alkaline juice with enzymes such as - amylase and lipase, which help digest the fat, protein as well as carbohydrates from the food that we eat. The alkaline juice and helps to neutralize the acid secretions of the stomach. It secretes about 1.5 liters of these juices in a day.

The enzymes are conveyed to the upper part of the small intestine called duodenum via a tube called the pancreatic duct.

Endocrine Function - It also secretes two important hormones namely - Insulin and Glucagon which are essential for regulation of glucose in the blood.

Inflammation of the pancreas can be caused by gallstones, alcohol, various drugs, some viral infections, and digestive enzymes. Pancreatitis usually develops quickly and subsides quickly (acute pancreatitis). In some cases, however, inflammation persists and gradually destroys pancreatic functions (chronic pancreatitis).

Acute PancreatitisEtiologyPancreatitis is most commonly associated with excessive alcohol consumption. Alcohol appears to act directly on the acinar cells of the pancreas and the pancreatic duct to irritate and inflame the structures. Biliary disease such as cholelithiasis (gallstones) or cholangitis (inflammation of the bile ducts) may also trigger pancreatitis. Gallstones may plug the pancreatic duct and cause inflammation from excessive fluid pressure on sensitive ducts. The irritant effect of bile itself may cause inflammation. Blunt trauma to the abdomen or infection may trigger the process by causing ischemia, inflammation, and activation of the pancreatic enzymes. Drugs such as thiazide diuretics (hydrodiuril), estrogen, opioids, corticosteroids, and excessive serum calcium from hyperparathyroidism are less common causes of pancreatitis.

Elderly patients and patients with a first diagnosis of pancreatitis have a higher mortality rate. In addition, patients who have pancreatitis associated with biliary disease have a higher mortality rate that patients with alcohol related pancreatitis.

PreventionCaution patients who drink alcohol to stop. Patients with Biliary disease ln need to seek medical treatment for these conditions so that pancreatitis does not develop. Monitor patient, especially the elderly for any abdominal complaints when they are placed on medications that are associated with pancreatitis.

PrevalencePancreatic disease is more common among Mexican American and Chinese Americans risk factors including working in occupations such as mining, factories using chemicals and farming using pesticide. The high use of alcohol and cigarette smoking add to the risk of pancreatic disease.

Signs and SymptomsPatients with acute pancreatitis are very ill, with dull abdominal pain, guarding, a rigid abdomen, hypotension or shock and respiratory distress from accumululation of fluid in the retroperitoneal space. The abdominal pain is generally located in the midline just below the sternum, with radiation to the spine, back, and flunk. Location and degree of pain indicate the area of the pancreas involved and to some extent the amount of involvement. Respirations are likely to be shallow as the patient attempts to splint painful areas. Eating makes the pain worse.The patient may have a low-grade fever, dry mucous mambranes and tachycardia. If the primary cause is billary, tha patient may complain a nausea and vomiting, and jaundice may evident. The islets of langerhans in a terminal one-third of the pancreas are usually impaired.

ComplicationsIt may be useful to think of pancreatitis as a chemical burn to the organ. As with other severe burns, that is likely to occur from secondary causes. From the onset of symptoms, cardiovascular, pulmonary(including acute respiratory distress syndrome), and renal failure are the most likely causes of death. Hemorrhage, peripheral vascular collapse, and infection are also major concerns for patients with pancreatitis. A purplish discoloration of the flanks (turner’s sign) or a purplish discoloration around the umbilicus( cullen’s sign) may occur with extensive hemorrhagic destruction of the pancreas.

Diagnostic TestsSerum amylase(normal: 80-180 U/dL) and serum lipase (normal: 0-160 U/L) may be elevated 5 to 40 times normal. The levels usually begin to drop within 72 hours. Urine amylase elevates and stays

elevated for a longer period of time. Glucose, bilirubin, alkaline phosphatase, lactic dehydrogenase, ALT, AST, cholesterol and potassium are all elevated. Decreases are measured in serum albumin, calcium, sodium, and magnesiumX-ray examination may show pleural effusion from local inflammatory reaction to pancreatic enzymes, pulmonary infiltrates, or a change in a size of the pancreas. Computed tomography and Ultrasonography can provide more complete information about the pancreas and surrounding tissues.

Therapeutic InterventionsTreatment of acute pancreatitis depends on the intensity of the symptoms. Treatment is concerned with the maintenance of life support until the inflammation resolves, along with preventing or treating complications. Intravenous fluids are administred, such as crystalloid, electrolytes, or colloids(such as albumin) solutions, if the patient experiences hypovolemic shock. Blood or blood products may also be ordered if the patient has significant blood loss from hemorrhage. The patient may be given anti-anxiety agents to decrease oxygen demands. The patient may require supplemental oxygen if abdominal pressur, pleural effusion, or acidosis cause an impaired gas exchange or ineffective breathing pattern.The physician usually orders mepiridine hydrochloride(Demerol) for pain because some experts believe morphin can cause spasm of the sphincter of oddi an increase pain. Pain and anxiety increase pancreatic secretion by stimulating the autonomic nervous system. Phenergan may be ordered to potentiate the Demerol; it may also help reduced nausea.The patient is usually ordered to have nothing by mouth (NPO) to rest the gastrointestinal tract, although recent research indicates that patients may experience ferwer complications if enteral feeding is maintained. The patient have a nasogastic tube inserted into the stomach and attached to low suction to empty gastric contents and gas. IV odansetron(Zofran) for nausea and a histamine(H2) antagonist such famotidine (pepcid) may help decrease acid stimulation of pancreatic secretion. A foley catheter may be inserted to provide accurate output measurements and to assess need for fluid replacement. Strict intake and output must be documented. Additional typical drug orders include sodium bicarbonate to reverse the acidosis caused by shock, electrolytes such as calcium and magnesium to replace losses, short acting insulin to combat hyperglycemia, and antibiotic to treat sepsis.

PATIENT PROFILE

Name: Pabia Lilit Age: 58 years old Sex: Female Status: MarriedAddress: Brgy. Labangon, Cebu CityOccupation: Manicurist Nationality: Filipino Religion: Roman CatholicDate and Time of Admission: June 14, 2014 at 3:55AM Ward and Bed no: CCMC Medical Ward #2Admitting Diagnosis: Acute Pancreatitis No. of Admission: 1st timeChief Complaint: Epigastric Pain noted 2 weeks PTAAdmitted Under: Dr. Bibera of the Department of Internal MedicineCase Number: 683713

HISTORYPresent Illness:

2 weeks PTA, patient had complaints of pain around the epigastric area, with a pain score of 10 out of 10, aggravated mostly by walking and alleviated by resting. No nausea, vomiting, and fever were noted. No consultation was done and symptoms were tolerated.

2hrs PTA, patient experienced difficulty of breathing which prompted her to seek consultation to the ER where she was advised to be admitted for her to be under close monitoring and undergo different diagnostic test.

During admission patient is having epigastric pain, yellowish sclera, tenderness upon palpation of the abdomen, her skin is jaundice and has poor skin turgor.

Past History:Patient is non-asthmatic, non-hypertensive, non-diabetic, non-smoker and non-alcoholic

beverage drinker. She has no known previous hospitalization and surgery.Family History:

Patient claims to have had no childhood illness or injuries. She has no known family history of hypertension, asthma, diabetes milletus, food and drug allergies.

DEVELOPMENTAL Theories Robert Havighurst’s Developmental TheoryMiddle Age(30-60)

In the middle years, from about thirty to about fifty-five, men and women reach the peak of their influence upon society, and at the same time the society makes its maximum demands upon them for social and civic responsibility. It is the period of life to which they have looked forward during their adolescence and early adulthood. And the time passes so quickly during these full and active middle years that most people arrive at the end of middle age and the beginning of later maturity with surprise and a sense of having finished the journey while they were still preparing to commence it.

The biological changes of ageing, which commence unseen and unfelt during the twenties, make themselves known during the middle years. Especially for the woman, the latter years of middle age are full of profound physiologically-based psychological change.

The developmental tasks of the middle years arise from changes within the organism, from environmental pressure, and above all from demands or obligations laid upon the individual by his own values and aspirations.

Since most middle-aged people are members of families, with teen-age children,it is useful to look at the tasks of wife, as people live and grow in relation to one another.

The Woman of the Family

a woman

a wife

a mother

a homemaker and

family manager

Achieving adult civic and social responsibility2) Establishing and maintaining an economic standard of living3) Assisting teen-age children to become responsible and happy adults4) Developing adult leisure-time activities5) Relating onself to one's spouse as a person6) Accepting and adjusting to the physiological changes of middle age7) Adjusting to ageing parents

Erikson’s Eight Stages of Development (Psychosocial Development)

STAGE PSYCHOSOCIAL CRISIS Actual findingsAge: 58 years

Generativity versus stagnation

-creativity,productivity, concern for others.

-As older adults can often look back on their lives with happiness and are content, feeling fulfilled with a deep sense that life has meaning and they’ve made a contribution to life

-Our strength comes from a wisdom that the world is very large and we now have a detached concern for the whole of life, accepting death as the completion of life.

The patient has established stable familial and social relationships. Although she has had a few mistakes and regrets in life, it has made her what she is today and she was able to move on with her life despite challenges and trials. She was a responsible partner and mother that raised their children properly and with values. Now they have all grown up and alone in each other’s company.

Sigmund Freud’s Psychosexual Theory(Psychosexual Development)

Stage Consequences of Psychological fixation Actual Findings

Genital stage

Age: puberty to death

Erogenous zone: sexual interests mature

-its purpose is the psychological detachment and independence from the parents.

- affords the person the ability to confront and resolve his or her remaining psychosexual childhood conflicts.

The patient married at a young age. She has had a satisfying relationship with her husband and was blessed with 2 children.

Jean Piaget’s Cognitive Theory(Cognitive and Language Development)

Formal operational  (11 years and up) 

Can think logically about abstract propositions and test hypotheses systemtically 

Becomes concerned with the hypothetical, the future, and ideological problems 

James Fowler’s Stages (Faith Development)

Stage Basic Actual Findings

Stage 6 – "Universalizing" faith, or what some might call "enlightenment"

The individual would treat any person with compassion as he or she views people as from a universal community, and should be treated with universal principles of love and justice.

The family has come to a realization that everything was meant to happen because she believes that her life is a part of a greater plan – God’s plan.

Gordon’s Functional Health PatternI. Health Perception and Health Management Pattern

Patient describes health as wealth, and further adds “Dogay man sad ni akong sakit wala lng mi kwarta para sa tambal sa hospital.” She rates health as 7/10 (with 10 as the highest and 1 as the lowest) since she can’t do the activities, that she usually does, such as doing household chores, because of her illness as claimed. When asked of how she manages health, she cites that she drinks a lot of water, eating fish and vegetables instead of pork or salty, oily and sweet foods, exercising everyday such as doing household chores and walking. In her current health condition, she cites to manage it by taking the prescribed medications with good compliance; have all the diagnostic test done; follow the prescribed diet and by taking a lot of rest.

II. Nutritional Metabolic Pattern

About three months ago, patient weighed 45 kg Currently, she weighs 40 kg with a BMI of 17.93 (interpretation: under weight) with a height of 4’9’’. Before the onset of the signs and symptoms of her condition, patient describes her appetite as good. She eats at least 3 times a day with light snacks in between. Patient’s food preferences include fish, vegetables, sea foods and lechon. When asked if she had specific dietary practices in accordance to her condition, she answered, “Yes, din-a kaayo ko tig kaun ug tam-is, mga parat, mantikaun na pagkaun sukad nagkasakit ko , pero mukaun jud ko ug lechon panagsa, mga espisyal na okasyon.” Patient has not encountered any difficulty in eating, neither swallowing. She’s the one who shops, prepares and cooks the family’s meals. The patient had been wearing dentures since she was 30 years old. She cleans it every night before going to bed. The patient visits the dentist only when needed such as tooth extraction and denture adjustment. In terms of water consumption, she drinks around 8 to 10 glasses of water a day. Patient drinks 1 cup of coffee with 1 tsp. sugar every morning. She also consumes carbonated drinks, approximately 2-3 glasses a week. During hospitalization, patient’s appetite decreased because she feels weak and tired as claimed. She has a low salt low fat diet. Patient did not have any difficulty in eating, neither swallowing. In terms of water consumption, she drinks around 6-7 glasses of water a day. Patient did not consume any caffeinated or carbonated drink. No other alterations in patient’s eating pattern had been noted.

Usual Meal 24 – hour recallBreak-fast 5:00 AM

1 cup coffee and 1-2 pcs. Of medium sized pandesal bread

6:00 AM1 cup milk and 3 pcs. Slice bread

Snacks 9:00 AM 3-4 pcs. Plain crackers, 1 pc. apple, 1 glass water

9:00 AM4 pcs. medium sized cup cake and 1 glass apple juice

Lunch 12:00 NN1 cup of rice, utan bisaya, 1 pc. medium sized fried fish and 1 glass water

11:30 AM1/2 cup rice, 1 pc. small sized sweet and sour fish, vegetables and 1 glass water

Snacks 3:00 PM1-2 pcs. sandwiches with regular sandwich spread and 1 glass of water

3:00 PM1 cup milk and 3 pcs. Slice bread

Dinner 7:30 PM1 cup of rice, chopsuey fish tinola, 1 glass of water

6:30 PM1/2 cup rice, chopsuey, beef, and 1 glass water

III. Elimination Pattern

Before the onset of the signs and symptoms of her illness, patient usually eliminates bowel twice a day, usually in the morning, without use of laxatives and but with necessary straining. Stools were described to be brown in color, and well formed. Patient does not usually experience diarrhea as claimed. Patient voids with ease about 5-8 times a day with strong flow of amber/ dark yellow urine. Patient reports no difficulty in urinating or any associated problems aside from mobilizing to and from the comfort room.

Patient still urinates several times a day amounting to approximately 1 cup or 180 mL per episode of yellow, dark, and aromatic urine in full, continuous flow. No retention, pain, urgency or incontinence has been noted. There was a problem in ambulation so she was given bed pan.

IV. Activity- Exercise Pattern

Patient usually wakes up at 5AM, feeling well rested and refreshed.

A typical day of the patient

Time Usual Activity5:00 AM

6:00 AM7:00 AM7:30 AM9:00 AM10:00AM

12:00 NN1:00 PM4:30 PM6:00 PM7:30 PM8:30 PM9:00 PM10:00 PM

-Wakes-up-Prepares and cooks breakfast-Breakfast-Takes a bath-Do household chores-Snacks-Selling fruits/ Doing manicure-Lunch -Selling fruits/ Doing manicure-SnacksPrepares dinner -Dinner-Cleans the dishes-relaxing, watching TV-Sleep

She claims that she really has a balanced lifestyle by doing physical activities by being productive at the same time such as doing household chores and having a regular walk around their neighborhood and by relaxing and by watching TV after. She claimed that she has no problem in maintaining and managing their home.

Upon the onset of the signs and symptoms of her illness, she can’t do her usual activities spontaneously, because of the pain in her epigastric area, but she accomplishes it by the help of an assistant.

During hospitalization, she claims that her activities had been quite limited inside the hospital room, since she is in complete bed rest without toilet privileges. Thus, she is able to take lots of bed rest.

V. Cognitive- Perceptual Pattern

Patient is a high school under-grad from a municipal school in Mindanao. She claims to easily comprehend, and speak in vernacular, Tagalog and English. She rates her intelligence as fair, stating that “Dili sad bright kaayo pero kamao pod.” She is able to make own decisions. Patient has experienced no difficulty in hearing, feeling, tasting, and smelling.

During hospitalization, patient is oriented to the place (hospital), time (afternoon) and people around her (student nurses). Patient can converse well with student nurses and could recall both long- term and short term memories as evidenced by her ability to restate past events such as her birth date, their current living quarters, address, and the last meal taken as confirmed by her SO. Patient can make rational decisions which were proven when asked of what she would do if ever the hospital was on fire. She verbalized, “Mu dagan ug dali-dali pagawas sa hospital.” Patient is able to express her feelings freely through verbalizations.

VI. Sleep- Rest Pattern

Before hospitalization, patient usually wakes up at around 5 am, feeling well rested and refreshed and sleeps at around 11pm, having an average sleep of 6 hours. She doesn’t take any afternoon naps. Patient claims not to have any difficulty sleeping, and doesn’t and has not tried the use of any medications to facilitate sleep. She uses 1 blanket and 1 pillow in sleeping and she turns off the lights before going to bed.

During hospitalization, patient usually wakes up at around 7 am, feeling and sleeps at around 10 pm, having an average sleep of 9 hours. Patient complains that she cannot sleep properly because she is not comfortable with her position and when pain occurs. There were no sleep medications prescribed and taken.

VII. Self-perception- Self-concept PatternBefore hospitalization, Patient is concerned about her financial matters because her salary is

good only for their food. She cites that her greatest accomplishments in life include having built the family she has at present and being able to raise her children.

During hospitalization, Her goal is to get well soon and to go back to her business work for them to have an income. She too is proud that she has maintained the optimism and fulfillment in her life despite condition.

VIII. Role- Relationship Pattern

Patient is the 4th child in the family, and has 6 siblings. She has been married to her husband for 33 years then got separated after. She is a mother of 2 children (1 boy and 1 girl). She claims to have maintained a good and open relationship with the people around her. She feels all the support her family members are giving her, especially now that she is sick. She turns help directly to her new live-in partner. That’s why problems are easily solved because all of them get themselves involved in every issue that arises. Patient states that she finds no difficulty or hesitation communicating with her family, her friends, as well as the health care team.

IX. Sexuality- Reproductive Pattern She believes to have fully achieved the essence of being a woman: becoming a daughter, a wife and a mother. Patient had onset of puberty at 13 years old. She noticed the enlargement of her breast and onset of menarche. Back then, her menstruation occurs regularly, lasting up to 5 days, consuming 2-3 napkins a day. Patient claims she had not experienced problems with her menstruation. She has been sexually active by the age of 25 years old with her husband. They haven’t used any contraceptive. She had no experience of symptoms or signs of STDs and wasn’t ever diagnosed to have one. Obstetrical score at present is G2P2002. All of her children were delivered via NSVD. There were no complications during the pregnancy, labor and delivery of her 2 children. Patient is now in the menopausal stage. It started when she was aging 42. She practices BSE regularly.

X. Coping- Stress Tolerance PatternPatient defines stress as problems in life, "Kanang mga problema na maabot nato". Her short-

term problems include minor arguments and misunderstandings among family members every now and then. When asked of her long-term problems, patient simply states, “Wala man kaayo koy problema. Kung naa man gani, dili nako hunahunaon.” Although when confronted with problems, she confides with her live-in partner. She finds this very effective, as she is able to express her emotions as well as seek the advices of those she trusts.. The patient’s outlook is positive despite her current condition. For the past years, the major change that had occurred in her life was her having her own live-in partner. She claimed to have no suicidal ideation.

XI. Value- Belief PatternPatient is a Roman Catholic. She regularly participates in the holy mass every Sunday. She

believes in God and views Him as the giver of everything. She considers self as God- fearing and believes that God is all knowing. The patient views herself as a prayerful person and seeks for divine intercession especially in times of need and crisis, just as when confronted with health issues. The most important values the patient considers are love and respect. Believing that love encompasses all the other values and that such is never made without respect. She gathers strength and hope from the love of her family.

During hospitalization, no alterations in client’s belief and values had been noted.

PHYSICAL EXAMINATION (2 Days)DAY 1 DAY 2Date of Assessment: June 20, 2014 Place of Assessment: Medical Ward, CCMCTime of Assessment: 8:00 AMGeneral Assessment: >Examined lying on bed, awake, afebrile, coherent, responsive, with IVF of 4 PNSS iL @ 10gtss/min infusing well @ left arm, with oxygen inhalation via nasal canula of 2-4 Lpm and with the following vital signs: BP= 130/80mmHg; HR: 74bpm; RR: 22cpm; Temp: 36.8° C/ axilla; O2 saturation of 98%

Height: 4’9’’Weight: 40 kgBMI: 17.93

Date of Assessment: June 21, 2014 Place of Assessment: Medical Ward, CCMCTime of Assessment: 9:30 AMGeneral Assessment: >Examined lying on bed, awake, afebrile, coherent, responsive, with IVF of 5 PNSS iL @ 10gtss/min infusing well @ left arm, with oxygen inhalation via nasal canula of 2-4 Lpm and with the following vital signs: BP= 110/80mmHg; HR: 69bpm; RR: 21cpm; Temp: 37° C/ axilla; O2 saturation of 99%

Height: 4’9’’Weight: 40 kgBMI: 17.93

SKIN brown, no swelling, no masses , no lesions, hair evenly distributed on skin, warm to touch, dry and rough in texture, with poor skin turgor, and with IVF of 4 PNSS iL @ 10gtss/min infusing well @ left arm,

5 PNSS

NAILS Long intact but unkempt, convex curvature, smooth texture, (-) swelling or any deformities, (-) nail clubbing, no ingrown toenails, CRT >2 sec

Well trimmed nails

HAIR AND HEAD Normocephalic, symmetric, still and upright, no swelling, no areas of tenderness; hair is short, dark brown, dry and thick, with no lice infestation, no dandruff, and evenly distributed; face is symmetrical with no abnormal facial movements noted, mouth opens and closes fully

EYES symmetrically aligned in sockets, upper and lower lids completely approximated when closed, skin intact and free of erythema, edema, discharge and lesions, evenly distributed lashes with an outward curve, Pupils Equally Rounded and Reactive to Light Accommodation, icteric sclerae, pale palpebral conjunctivae,

EARS ears are equal in size and similar in appearance, color is same to that of face, pinnae are in line with the outer canthus of eyes and within 10 degree angle of vertical position, with piercing on both ears, no discharges and no tenderness upon palpation

NOSE AND SINUSES In midline, color consistent with the rest of the face, smooth and symmetrical, mucosa is moist, no swelling, no discharges, (+) nasal flaring

ORAL CAVITY not cracked, pale lips and dry mucous membrane, no ulcerations, no halitosis. Tongue is in midline and does not deviate to other side.

NECK AND LYMPH NODES

neck is symmetrical, coordinated with no difficulty, uniform in color; nodules are nonpalpable, no tenderness upon palpation; neck muscles equal in size and head centered

THORAX AND equal chest expansion, no lesions, no

LUNGS tenderness, no swelling, no use of accessory muscles

CARDIAC AND PERIPHERAL CIRCULATION

distinct s1 and s2 heart sounds upon auscultation, no murmur , no chest pain, heart rate at 74 bpm with regular rhythm , +3 palpable peripheral pulses on both upper and lower extremities Pulse Strength0- ABSENT+1- weak, thready, difficult to palpate, obliterated with pressure+2, diminished pulse, can’t be obliterated+3- easy to palpate, full pulse, can’t be obliterated+4 strong bounding pulse

ABDOMEN Swollen, (+) tenderness, audible bowel sounds 5 clicks per minute, complaints of pain at the epigastric region

RECTUM intact, no rashes, no hemorrhoids, no abnormal discharges, no itchiness (verbal assessment)

NEUROMUSCULOSKELETAL

+3 peripheral pulses, unable to stand spontaneously without assistance, with weak ROM in both upper and lower extremities, equal muscle strength (both upper extremities and both of lower extremities), no edema, no swelling, no lesion, no scar, no tenderness, no deformities, convex nails, intact without inflammation, can feel sensations at both lower and upper extremities (can feel pinch and tip of pen

Muscle strengthR L4/5 4/5

3/5 3/ 5

GRADING SCALE:5- full ROM against gravity, full resistance4- full ROM against gravity, some resistance3- full ROM with gravity2- full ROM with gravity eliminated, passive motion1- slight reaction0- no reaction

NEUROLOGIC ASSESSMENT

Mental Assessmentawake, coherent, oriented to time, place, person, but unable to follow instructions properly and must be spoken clearly and explain it in understandable way, good eye contact, speaks in moderate tone short term memory intact (able to recall onset of symptoms), long term memory intact (able to recall name, address, and birthdate), with a GCS of 15

Cerebellar Assessment(+) finger to finger test(+) finger to nose testInvoluntary movements not noted

Sensory Assessment(+) stereognosis (keys identified

while eyes are closed)(+) graphesthesia (able to identify

letter O at the back)(+) 2-point discrimination (able to

identify sharp from dull)(+) kinesthesia (able to identify the

direction to which the finger was pointing)

Cranial nerves:Olfactory (sensory): can distinguish the

scent of alcohol from the coffeeOptic (sensory): able to read student’s

nameplate at a distance of 2 feetOculomotor (motor): equal eye movement, Trochlear (motor): (+) PERRLATrigeminal (sensory): (+) blink reflex, can

open and close mouth, can feel touch on face

Abducens (motor): (+)PERRLAFacial (sensory): can feel light touch on face

(motor): able to smile and frownAcoustic (sensory): able to hear whispered

words at 2 feet distanceGlossopharyngeal (motor): can swallow

(sensory): (+) gag reflex Vagus (sensory): (+) gag reflex

(motor): can swallowSpinal Accessory (motor): able to turn head

to sideHypoglossal (motor): can move tongue

from side to side

Deep Tendon Reflexes:

GRADING:

Brachioradialis +2

Biceps +2

Triceps +2

Patellar +2

Achilles +2

SCALE: 0 - No reflex +1 - Minimal Activity+2 - activity normal responses+3 - More active than normal+4 - Maximal activity (hyperactive)

LABORATORY STUDYCOAGULATION RESULT REFERENCES INTERPRETATIONSProthrombin time

Activity

INR

31.50 sec

21.50%

2.58

10-14 sec

>to 70%

<to 1.20 %

Impaired in deficiency of factors

prolonged in deficiency of fibrinogen, factors and in heparin therapy

prolonged by deficiency of factors, fat malabsorption, severe liver disease.

Chemistry: Amylase 374 u/l 30.0-130.0 u/l

A marked increase in the level strongly suggests acute pancreatitis.

Lipase 1221 u/l 70.0-290.0 u/l Increased levels suggests acute pancreatitis or pancreatic duct obstruction

Hematology:RDWPlatelet

0.185147 10^ g/l

0.115-0.150170-400 10^g/l

Thalassemia, iron ,B12 deficiency Decreased in thrombocytopenic purpura, acute leukemia

Differential countSegmenters

Lymphocytes

Eosinophils

0.82%

0.13%

0.00

0.55- 0.65%

0.25-0.35%

0.02-0.04%

Increased acute infection, trauma or surgery

Decreased with aplastic anemia, immunodeficiency including AIDS

Decreased with stress, use of some medications. (ACTH)

Alkaline phosphate

Direct bilirubin

Total bilirubin

73.0 u/l

14.14 mg/dl

19.9 mg/dl

42.0-98.0 u/l

0.0-0.20 mg/dl

0.30-1.2mg/dl

Condition reflecting increased osteoblastic activity of the bone

Biliary obstruction and disease

Hemolytic anemia

Lipid profile:CholesterolHDL cholesterol

BUN

CREATINE

93.0mg/dl4.6mg/dl

36.6mg/dl

1.50mg/dl

120.0-200.0> 35

6.1- 20.1

0.6- 1.1

Pernicious anemiaLower in patient with increased risk for coronary heart disease

Obstructive uropathy

; Conic Renal diseaseIII. SUMMARY OF SIGNIFICANT FINDINGS:

Gordon’s Functional Health Pattern

Health Assessment or Physical Examination

Laboratory and Diagnostic Studies

Therapeutic Management

Key Nursing Problem

“Dogay man sad ni akong sakit wala lng mi kwarta para sa tambal sa hospital.”, “Yes, din-a kaayo ko tig kaun ug tam-is, mga parat, mantikaun na pagkaun sukad nagkasakit ko , pero mukaun jud ko ug lechon panagsa, mga espisyal na okasyon.”Upon the onset of the signs and symptoms of her illness, she can’t do her usual activities spontaneously, because of the pain in her epigastric area,activities had been quite limited inside the hospital roomPatient complains that she cannot sleep properly because she is not comfortable with her position and when pain occurs"Kanang mga problema na maabot nato"., “Wala man kaayo koy problema. Kung naa man gani, dili nako hunahunaon.”

, dry and rough in texture, with poor skin turgor, and with IVF of 4 PNSS iL @ 10gtss/min infusing well @ left arm,CRT >2 secicteric sclerae, pale palpebral conjunctivae, (+) nasal flaringpale lips and dry mucous membrane,Swollen, (+) tenderness, complaints of pain at the epigastric regionunable to stand spontaneously without assistance, with weak ROM in both upper and lower extremities,but unable to follow instructions properly and must be spoken clearly and explain it in understandable way,

A marked increase more than three times the upper limit of normal in the level strongly suggests acute pancreatitis.After the onset of acute pancreatitis, level of amylase in the blood rise within six to 12 hours, peak within 12 to 48 hours and remain elevated for three to five days in uncomplicated attacks.Increased levels suggest acute pancreatitis or pancreatic duct obstruction. After an acute attack, levels remain elevated for up to 14 days. Increased levels may occur in other pancreatic injuries such as perforated peptic ulcer with chemical pancreatitis caused by gastric juices.

-IV fluids-Analgesics for pain relief-Ultrasonograms-Laboratory test-O2 inhilation provided

Acute pain Risk for

deficient fluid volume

Imbalanced nutrition

Risk for infections

Deficient knowledge

HOSTfemale58y.oprevious diagnosis of gallstones

AGENT

none

ENIVIRONMENT

lifestyle such as eating fatty foods

Pancreas secretes pancreatic fluid

Throughthe pancreatic duct to the duodenum

Damage to pancreatic cells occur due to food irritants and intake

inflammation

Edema of the pancreas and pancreatic duct

gallstones stock in the sphincter of oddi

PATHOPHYSIOLOGY

Obstruction to the flow of Pancreatic Enzymes

Activation of Pancreatic enzymes inside Pancreas

Activated enzymes accumulate in the pancreas

Overwhelming Inhibitors

Autodigestion of Pancreatic cells begin

Full Necrosis, ulceration, hemmorhage, infection

SIGNS AND SYMPTOMSEpigastric painSwollen and tender abdomenNausea and VomitingFeverIncreased heart rateJaundiceYellow scleraIncrease Amylase and Lipase

MEDICAL MANAGEMENTIV fluidsAnalgesics for pain reliefUltrasonogramsLaboratory testO2 inhalation provided

NURSING MANAGEMENTAcute Pain related to inflammation, edema, distention of the pancreas and peritoneal irritation.Imbalanced Nutrition less than body requirements related reduced food intake and increase metabolic demands.Risk for infection related to inadequate secondary defense secondary to inflammatory processKnowledge deficit related lack of information, misinterpretation, unfamiliarity with the information resources.

POSSIBLE COMPLICATIONSInfectionPsudocystBreathing ProblemsDiabetesKidney FailureMalnutrition

NURSING CARE MANAGEMENTAcute Pain related to inflammation, edema, distention of the pancreas and peritoneal irritation.

Defining Characteristics

Scientific Basis Planning

Nursing Responsibilities

Rationale Evaluation

Subjective:‘’sakit ang akong tiyan” as verbalized by the patient, with a pain score of 8 out of 10 where 1 is the lowest and 10 is the highest.

Objective:

-Abdominal guarding-inability to concentrate-irritabilty-v/s taken as follows

Temp:36.8 CPR:74bpmRR:22cpm

A highly subjective state in which a variety of unpleasant sensations and a wide range of distressing factors may be experienced by the sufferer. Pain may be acute, a symptom of injury or illness such as a myocardial infarction, or chronic, lasting longer than 6 months, the result of a long-term

After 4 hours of nursing interventions, the patient will report pain is relieved ; follow prescribed therapeutic regimen; and demonstrate use of methods that provide relief.

Investigate verbal reports of pain, noting specific location and intensity (0–10 scale). Note factors that aggravate and relieve pain.

Maintain bedrest during acute attack. Provide quiet, restful environment.

Pain is often diffuse, severe, and unrelenting in acute or hemorrhagic pancreatitis. Severe pain is often the major symptom in patients with chronic pancreatitis. Isolated pain in the RUQ reflects involvement of the head of the pancreas. Pain in the left upper quadrant (LUQ) suggests involvement of the pancreatic tail. Localized pain may indicate development of pseudocysts or abscesses.

Decreases metabolic rate and GI stimulation/secretions, thereby reducing pancreatic activity.

After 8 hours of nursing intervention the patient was able to report pain is relieved; with a given pain score of 5 out of 10 follow prescribed therapeutic regimen; and demonstrate use of methods that provide relief.

BP:130/80 illness such as arthritis. Pain may also arose from emotional, psychological, cultural, or spriritual distress. Pain can be very difficult to explain, because it is unique to the individual; pain should be accepted as described by the sufferer

Promote position of comfort, e.g., on one side with knees flexed, sitting up and leaning forward.

Provide alternative comfort measures (e.g., back rub), encourage relaxation techniques (e.g., guided imagery, visualization), quiet diversional activities (e.g., TV, radio).

Keep environment free of food odors.

Administer analgesics in timely manner (smaller, more frequent doses).

Reduces abdominal pressure/tension, providing some measure of comfort and pain relief. Note: Supine position often increases pain.

Promotes relaxation and enables patient to refocus attention; may enhance coping.

Sensory stimulation can activate pancreatic enzymes, increasing pain.

Severe/prolonged pain can aggravate shock and is more difficult to relieve, requiring larger doses of medication, which can mask underlying problems/complications and may contribute to respiratory depression

Maintain meticulous skin care, especially in presence of draining abdominal wall fistulas.

Pancreatic enzymes can digest the skin and tissues of the abdominal wall, creating a chemical burn.

Imbalanced Nutrition less than body requirements related reduced food intake and increase metabolic demands.

Defining Characteristics

Scientific Basis

Planning Nursing Responsibilities

Rationale Evaluation

Subjective:“gamai raman permi ako kaun ug mo inom ug tubig”

Objective:-low salt low fat diet-weakness of muscles required for swallowing or mastication or muscle tone

The state in which an individual’s intake of nutrients is insufficient to meet metabolic needs

After 4 hours of nursing intervention the patient will demonstrate progressive weight gain toward goal

Assess abdomen, noting presence/character of bowel sounds, abdominal distension, and reports of nausea.

Assist patient in selecting food/fluids that meet nutritional needs and restrictions when diet is resumed.

Gastric distention and intestinal atony are frequently present, resulting in reduced/absent bowel sounds. Return of bowel sounds and relief of symptoms signal readiness for discontinuation of gastric aspiration (NG tube).

Previous dietary habits may be unsatisfactory in meeting current needs for tissue regeneration and healing. Use of gastric stimulants, e.g., caffeine, alcohol, cigarettes, gas-producing foods, or ingestion of large meals may result in excessive

After 8 hours of nursing intervention goal was not met as evidenced by the patient still low oral fluid intake and still presence of muscle tone,

Observe color/consistency/ amount of stools. Note frothy consistency/foul odor.

Note signs of increased thirst and urination or changes in mentation and visual acuity.

Maintain NPO status and gastric suctioning in acute phase.

stimulation of the pancreas/recurrence of symptoms.

Steatorrhea may develop from incomplete digestion of fats.

May warn of developing hyperglycemia associated with increased release of glucagon (damage to [beta] cells) or decreased release of insulin (damage to [beta] cells).

Prevents stimulation and release of pancreatic enzymes (secretin), released when chyme and HCl enter the duodenum.

Risk for infection related to inadequate secondary defense secondary to inflammatory process

Defining Characteristics

Scientific Basis Planning

Nursing Responsibilities Rationale Evaluation

Subjective:

Objective:-decrease differential lymphocyte and increased hematological RDW

If the client is going a lacerations impairs the body’s normal defence mechanism, there by increasing the risk of infections being invaded by pathogens organisms.

After 4 hours of nursing interventions the patient will be able to identify interventions to prevent/reduce of risk for infections

Use strict aseptic technique when changing surgical dressings or working with IV lines, indwelling catheters/tubes, drains. Change soiled dressings promptly.

Stress importance of good handwashing.

Observe rate and characteristics of respirations, breath sounds. Note occurrence of cough and sputum

Limits sources of infection, which can lead to sepsis in a compromised patient. Note: Studies indicate that infectious complications are responsible for about 80% of deaths associated with pancreatitis.

Reduces risk of cross-contamination.

Fluid accumulation and limited mobility predispose to respiratory infections and atelectasis. Accumulation of ascites fluid may cause elevated diaphragm and shallow abdominal

After 8 hours client was able to identify interventions to reduce or prevent the risk for infections

production. breathing.

Knowledge deficit related lack of information, misinterpretation, unfamiliarity with the information resources.

Defining Characteristics

Scientific Basis

Planning Nursing Responsibilities

Rationale Evaluation

Subjective:“abi nako u madala rat u ako sakit”

Objective:

-patient seeking information about her diseaserequest/demand information -irritable noted

A state in which cognitive information or psychomotor skills are lacking.

After 4 hours of nursing interventions the patient will be able to verbalized understanding condition disease process and potential complication

Review specific cause of current episode and prognosis

Discuss other causative/ associated factors, e.g., excessive alcohol intake, gallbladder disease, duodenal ulcer, hyper -lipoproteinemias, some drugs (e.g., oral contraceptives, thiazides, furosemide [Lasix], isoniazid [INH], glucocorticoids, sulfonamides).

Instruct in use of pancreatic

Provides knowledge base on which patient can make informed choices.

Avoidance may help limit damage and prevent development of a chronic condition.

If permanent damage to the pancreas has occurred,

After 8 hours of nursing interventions the patient will be able to show understanding of her condition disease process

enzyme replacements and bile salt therapy as indicated, avoiding concomitant ingestion of hot foods/fluids.

exocrine deficiencies will occur, requiring long-term replacement. Hot foods/fluids can inactivate enzymes.

DISCHARGE PLANUpon discharge, the patient will;

MEDICATION Strict adhere to medication regimen specially the prescribed home medications, to wit;Cefixime 400mg 1 tab ODTramadol 50mg 1 tab q 8hours for painOmeprazole 40 mg 1 cap BID PO 30 min before mealImidapril 10mg Essential forte tab TIDNaHCOB3 1 tab TID PO

ENVIRONMENT Encourage to have an environment conducive to health and reciperation.Encourage to maintain a clean environment at all times.Encourage to have a safety environment without any hazardous thing in the sorrounding

TREATMENT The client should be encouraged to learn and use of relaxation techniques guided imagery and music therapy are used to shift the focus of the brain away from the pain, decrease muscle tension, reduce stress. Tension and stress can also be reduced through biofeedback. Being massaged or applying backrub is very relaxing and helps reduce stress.Encourage to have a follow up check up on the given schedule and follow the physician’s order. Encourage to ask if they will have difficulties understanding what the doctors says to them.

HEALTH TEACHING Encourage to take a well balance dietEncourage a healthy lifestyleEncourage patient in pain management

OBSERVABLE SIGNS AND SYMPTOMS

Encourage patient to sought professional help if any observable signs and symptoms occur such as headache, nausea and vomiting, fever, fatigue, muscle weakness.Be able to report, with the help of her family, exacerbation of present signs and symptoms and seek prompt medical attention when deterioration of neurologic status is apparent

DIET The client should be instructed to avoid alcohol, spicy foods, any caffeine- containing foods, heavy meals, high fatty foods. Small, frequent feeding of bland diet. Encourage the patient to drink plenty of water as much of 8-12 glasses of

water daily.

SPIRITUAL Encourage client to pray in accordance with their beliefs. Ask for help to GOD for complete recovery.