NURSING Case Study: Pancreatitis

In this case study  we will discuss about nursing and bleow are the summaries point:- Pancreas is a gland located behind the stomach that secretes enzymes and hormones for digestion and glucose regulation. Pancreatitis is acute inflammation of the pancreas caused by activation of digestive enzymes. Pancreatitis can lead to loss of function in the pancreas and increase the risk of recurrent attacks. Symptoms of pancreatitis include upper abdominal pain, fever, nausea, vomiting, and tenderness. Patient A.B is a 56-year-old female Irish Traveller with severe abdominal pain and irritable stomach. She arrived in a wheelchair, vomiting profusely, and had stones in her gall bladder. She has low blood pressure, fever, and is overweight. She is a non-smoker, addicted to alcohol, has high blood pressure, type 2 diabetes, and forgets to take medications. A.B had irritable stomach and pain for 6 months and the pain became unbearable 3 days before admission. She made no physical consultation to manage the pain.

Running head: NURSING
Nursing
Name of the Student
Name of the University
Author Note

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Case Study
Introduction
Pancreas is a long, flat gland that is located behind the stomach, in the upper portion
of the abdomen. The role of pancreas in the digestive system is to secret digestive enzymes
and hormones to help regulate the process of digestion and glucose uptake. Pancreatitis is
defined as acute inflammation of the pancreas that initially involve the adjacent and the
remote organs (Banks et al. 2013). Pancreatitis occurs when the digestive enzymes become
activated while they are not released from the pancreases and thereby irritating pancreatic
cells and causing inflammation. The inflammation of the pancreas causes damage of the
pancreatic cell leading to loss of function. Although the pancreatic function and structure
gradually return to normal, there lays an increase risk of recurrent attacks unless precipitating
causes are eradicated from the grass-root level (Lerch and Gorelick 2013). The initial
manifestation of the disease includes upper abdominal pain, fever, nausea, vomiting and
tenderness of the skin of the abdomen. The inflammation begins in the perilobular and
peripancreatic fatty issues, manifested by edema along with necrosis of the spotty fats. In
extreme cases, the disease might progress to peripheral acinar cells, blood vessels, pancreatic
ducts and other bordering organs like the gall bladder and liver. (Wu and Banks 2013)
Patient’s Profile
 Name: A.B
 Gender: Female
 Age: 56 years
 Nationality: Ireland
 Religion: Roman Catholic
 Ethnicity: Irish Traveller (ethnic minority residing in Ireland)
 Chief Complain: Severe abdominal pain and irritable stomach for last few months

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 Mode of Arrival: Wheel-chair: vomiting profusely and severe abdominal pain
 Source of Information: Patient complaint
 Final Diagnosis: Acute Pancreatitis with stones in the gall bladder
 Low blood pressure: 90/60
 Fever: 39 degree C
 Over-weight
Nursing History
The patient is a non-smoker and is addicted to alcohol. She also suffers from high
blood pressure and takes Amlodipine 10 mg (once daily) in order to manage her illness.
Patient’s stays alone after the death of her husband before 2 years. She has type 2 diabetes,
taking Metformin medication. She mainly thrives on fast food, ordered online and frequently
skips meals. She also forgets to take medications as there is no one in her home to remind her
the time and the dosage of medication.
History of preset illness
According to patient, she used to have irritable stomach along with pain for the past 6
months. The pain was initially mild and used to subdue upon intake of pain killer. 3-day
before the admission, the pain became unbearable along with frequent signs of nausea and
vomiting and irritability. She felt unconscious in his lawn as she was unable to tolerate the
pain and her neighbours rescued her and admitted to hospital. She has made no physical
consultation in order to manage the pain.
Family History
Patient has a family history of gastritis.
Laboratory test
Test Purpose Normal values Abnormal results

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Serum amylase Detect the level of amylase in
the blood sample. It will help to
evaluate the possible pancreatic
injury caused by abdominal
trauma
26 to 102 units
per litter
A marked increase in the serum
amylase level: 150 unites per litter:
Pancreatitis
Serum lipase Helps in the determination of
lipase in blood sample
Less than 160
units/L
170 units/L confirming pancreatitis
Ultrasonograph
y
To detect the possible signs of
the abdominal anomaly
Alteration of the size and the shape
of the pancreas. Enlarged pancreas
with decreased echogenicity along
will gall stone
ECG Condition of heart as blood
pressure was low
Tachycardia is a signs of
hypovolaemia
Blood Test In response to gall stone in
order to check the level of
triglycerides in body and level
of blood glucose
Hypertriglyceridemia and
hyperglycemia, poor electrolyte
balance
Patient’s Complaint
Apart from pain in the abdomen, AB also complained that she stressed while alone at
home and fails to take food on time. She said, “I drink in order to fight with my stress”. She
mentioned that she fails to take medicines regularly. She also mentioned that she did not like
to refer to doctors as her previous bad experience in hospital as she found other nurses
culturally incompetent. While in hospital, the patient was refusing to co-operate with the
nurses and was feeling stressed and constantly pressuring for urgent discharge.

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Treatment Given
Surgical Ward: Medications for Pancreatitis and scheduled cholecystectomy later to
prevent recurrence of pancreatitis and removal of gall stones after lowering the blood glucose
level. She was administered with Metoprolol IV stat and continuous monitoring with CCU
Admission initially and as per prognosis changed to normal ward.
Nursing Interventions Proposed
 Proper monitoring of conditions: blood glucose level, blood pressure, serum amylase
and CRP (for detection of the level of infection within the body)
 Management of hypotension (however has history of Hypertension)
 Adherence of therapy: Proper intake of antibiotic, antiemetic and insulin
 Recovery from pancreatitis: Framing proper diet plan: Avoidance of spicy food, lower
intake of fat for the improvement of hypertriglyceridemia and optimal hydration
 Pain management: Music therapy for diversion in order to recover pain
 Management of nutritional status and electrolyte balance
 Rehabilitation: Assistance to quit alcohol and physical activity to promote weight-loss
 Effective communication and culturally competent interaction for the generation of
therapeutic relationship and effective stress management
The following paper will perform the critical analysis of the rationale behind framing of the
each nursing interventions and gaps in nursing interventions for Mrs. X.
Justification of the nursing interventions proposed
Monitoring of the patient’s conditions
At the time of the hospital admission, the pathological assessment revealed that
patient is suffering from hypotension (low blood pressure), high blood glucose level and high

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level of serum albumin and amylase along with high level of the CRP due high level of
infection within the body. According to Sudhakaran and Surani (2015), management of the
glycemic levels under the peri-operative settings is important especially among the diabetic
patients. The effect of surgical stress along with anaesthesia has unique affect on the level of
blood glucose and thus must be taken under active consideration in order to maintain an
optimum level of glycemic control. Proper maintenance of the blood glucose level is also
important for the faster recovery of wound. Since Mrs. X has two upcoming major surgeries
like cholecystectomy and gall stones removal thus proper monitoring of the blood glucose
level and proper administration of metformin is important. Monitoring of the blood glucose
level will help to know the right time for operation and at the same time helping to regulate
the dosage of the metformin. According to Sudhakaran and Surani (2015), establishment of
certain glycemic target levels must be less than 180 mg/dL among the critical patients and
less than 140 mg/dL among the stable patients.
Adamina et al. (2015) are of the opinion that there is significant clinical utility of peri-
operative CRP testing under general surgery. As per the NICE guideline, CPR is a non-
specific marker released into the blood in response to various inflammatory triggers and
infections. Measurement of CRP in people suspected with any type of organ inflammation (in
this case inflammation of pancreatitis) will help in the differentiating of the viral and the self-
limiting infections from serious bacterial infection that helps immediate administration of
antibiotics. In case Mr. X regular monitoring of the CRP will be helpful in detecting the level
and the status of inflammation before the surgery. It would also help in monitoring of the
severity of pancreatitis upon the administration of the medications.
Monitoring of the serum amylase is regarded as an important indicator of the status of
the pancreatitis. It is recommended to monitor the serum amylase in weekly basis in order to
detect severity of the pancreatitis and to bring modification in antibiotic medications.

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However, monitoring of the serum lipase is regarded as a better choice in comparison to the
serum amylase for the diagnosis of the pancreatitis.
However, fetching blood samples in a weekly manner for monitoring of the blood
glucose level, blood amylase level and detection of the CRP might generate a sensation of
pain in Mr. X leading to further increase in the level of stress and restless. According to
Zengin et al. (2013), effective use of the music therapy can help in significant decrease in the
stress hormone levels and thereby helping to control the psychological parameters for control
of the procedural pain. Korhan et al. (2014) are of the opinion that the effective use of the
music therapy helps to control neuropathic pain. However, the nursing professionals must
undertake the implementation of the music therapy under the use of the effective
communication.
Blood pressure management
Management of the blood pressure is also important for Mrs. X as while brought to
hospital she was suffering from hypotension but have a history of hyper-tension, ECG reports
shows the symptoms of Tachycardia and at the same she is on blood pressure medication
(Olshansky and Sullivan 2013).
Adherence of Therapy
Adherence of Therapy is crucial for the improving the overall outcome of care. The
analysis of the case study highlighted that the Mrs. X fails to undertake time of time
medication and thus after the discharge of the patient post surgery or post hospital care might
increase the level of complications. According to Shore et al. (2014) older adults who are
leaving alone, at times suffer from lack of proper adherence of medication. Procurement of
the group interventions might prove to be helpful towards increasing the therapy adherence of
the patients. The group interventions mainly encompass modification of the patient’s beliefs,

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imparting knowledge, effective patient communication, helping to recovery from the bias and
evaluating the level of adherence. However, Costa et al. (2015) are of the opinion that the
numerous interventions done in order to improve the medication adherence failed to fetch
successful disease outcomes and thus the level of non-adherence of medication remain the
same. Thus the implementation of the medication adherence intervention might be framed
with a person-centred approach. However, the proposed nursing interventions for the
medication adherence for Mrs. X failed to highlight person centred approach. The main
reason behind the lack of proper adherence of medication in case of Mrs. X will be lack of
proper support at the residence. At home, Mrs. X stays alone; she feels lonely and might be
due to loneliness, she fails or refuse to take proper medications. The lack of proper uptake or
synchronised uptake of medication is reflected in her poor management of the blood pressure
and diabetes level. The medication adherence for Mrs. X must be given under residential care
settings and that too under the constant under supervision of the residential care nurses (Shore
et al. 2014).
Recovery from pancreatitis under proper diet plan
The main concern for the hospital admission for Mrs. X is increased pain and
vomiting arising from pancreatitis. Thus primary nursing interventions for Mrs. X will be
recovery from the pancreatitis. According to the National Institute of Diabetes and Digestive
and Kidney Diseases (NIDDK) (2019) diet plays an important role in management for
pancreatitis. The people suffering from pancreatitis are advised to drink plenty of medicines
and limit the intake of caffeine. NIDDK strictly forbids the intake of alcohol even under the
mild symptom of pancreatitis. As per the case study, Mrs X is addicted to alcohol. Thus the
primary dietary or the healthy living advice will deal with the proper assistance towards
reduction of alcohol intoxication. Bertholet et al. (2014) stated that alcohol-related
interventions must be directed towards the daily counselling and rehabilitation program under

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the support of the community health-nursing professionals. NIDDK also states that high
intake of fat and calories can lead to high level of fat intake within the body and this raises
the risk of pancreatitis. Thus the diet for Mrs. X must deal with limited intake of fat and
increase in the intake of green vegetables and fruits. The framing of the diet plan for Mr. X
must be done under the controlled supervision of professionals based on Mrs. X height,
weight and age. Moreover, Mrs. X is also over-weight. Thus proper regulation of diet will
also help to effective management of weight (Hall and Guo 2017). While framing of the diet
plan for Mrs. X, her cultural and the spiritual values must be taken under active
consideration. According to the nursing professional code of conduct, it is the duty of the
nursing professionals to procure therapy plan while respecting the cultural and the spiritual
thoughts of the service users. Mrs. X is a Roman Catholic. According to the spiritual norms
of the Roman Catholic, every Catholics are instructed to abstain from having meat during
Wednesday and Good Fridays. Moreover, only two full meals are permitted as long as no
other food is consumed in the interim (Hornsby-Smith 2017). National Institute of Diabetes
and Digestive and Kidney Diseases (NIDDK) (2019) are of the opinion that an effective diet
plan for the patients, suffering from pancreatitis will include consumption of the small meals
after an interval of every 2 to 3 hours. But during Good Fridays and Ash Fridays, taking
meals after the 2 hours of interval might hamper her cultural and spiritual beliefs. In that case
it can be recommended that before the implementation of the diet plan, it would be duty of
the nursing professionals to educate Mrs. X about her prevailing condition and how taking
two broad meals or fasting can hamper the disease prognosis. Kourkouta and Papathanasiou
(2014) are of the opinion proper education of the about the disease progression will help to
earn the informed consent and thereby helping to restore the ethical principle of autonomy
and nursing professional standards of respecting the dignity and the spiritual thoughts of the
service users.

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However, taking the age, physiological health and living status of Mrs. X into
consideration, it can be stated that lack of proper diet plan is mainly attribute to her social
living status. Mrs. X lives alone after the death of her husband and thus mainly thrives on fast
food ordered online. According to Joyner, Gearhardt and White (2015) fast food or the junk
food are the main source of the fat. Moreover, over-consumption of the fast food leads to the
generation of an addiction towards the fast food and thereby leading to problematic eating
outcomes. Thus in order to increase the adherence of the healthy diet, Mrs. X must be shifted
under the residential care settings and assisted living. Freedman and Spillman (2014) stated
that assisted care living will help to increase in the therapy adherence and at the same time
will help to increase the adherence of the healthy lifestyle like proper diet and regular
practice of physical exercise.
Autonomy and Therapy Plan
According to Freedman and Spillman (2014), the residential care set-up under the
assisted living helps to satisfy the unmet needs of the older adults. However, transfer of Mrs.
X under the assisted care living will require the informed consent of Mrs. X otherwise it will
lead to the violation of the ethical principle of autonomy. According to the code of conduct of
the nursing profession, it is the duty of the nursing professionals to vouch for informed
consent form the patients or their family members before the implementation of the therapy
plan and its intended outcomes. Since Mrs. X leaves alone, the onus of informed consent
solely imparts on her shoulder. It will be the duty of the nursing professionals to educate Mrs.
X about how staying under the assisted case settings will help to recover from her current
health care conditions. The education will also be given regarding how assisted care living
will be helpful in reducing the chances of the accidental fall, like the one she encountered in
her lawn leading to the hospital admission (Freedman and Spillman 2014).

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However, from the case study it is evident that Mrs. X is not comfortable under the
company of the nursing professionals, she is getting aggressive or restless and at the same
time, she is refusing to co-operate with the nurses. Under such circumstance, Mrs. X might
refuse enroll under the residential care settings. Thus in order to retain the ethical principle of
the autonomy and creating provision for the informed consent, it would be the duty of the
nursing professionals to develop a therapeutic relationships with the client (Mrs. X). The
development of the therapeutic relationship will be done by the proper execution of the
effective communication skills (verbal and non-verbal communication skills) (Kourkouta, L.
and Papathanasiou 2014). Active listening, maintenance of the eye contact and showing the
compassionate attitude towards Mrs. X might help to increase her faith over the nursing
professionals and thereby increase the level of co-operation coming from Mrs. X. It would be
easier for the nursing professionals to make Mrs. X agree to enroll under residential care
setup when she develops a cooperative attitude towards the nursing professionals and work
they execute.
Management of the nutritional status and electrolyte balance
According to National Institute of Diabetes and Digestive and Kidney Diseases
(NIDDK) (2019), proper maintenance of the nutritional diet is important for the effective
management of the pancreatitis. Ahmed et al. (2016) are of the opinion that pre-operative
management of the fluid and the electrolyte balance is extremely important in order improve
the level of prognosis among the acute or severe pancreatitis patients. Proper intake of the
water helps in flushing out of the extra toxins or the reactive oxygen species from the body
and thereby promoting salvation. The proper management of the electrolyte balance for the
pre-operative patients can be done by the use of the oral rehydration therapy. The oral
rehydration therapy is suitable in comparison to the preoperative intravenous therapy for
increasing the provision for the water, carbohydrates and electrolytes balance in the body.

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The abstaining from the intravenous administration and giving preference to the oral
administration will also help to reduce the level of stress arising out of pain and anxiety
among the older adults (Ahmed et al. 2016). It will be duty of the nursing care professionals
in the residential care settings to regulate and monitor the nutritional status of the Mrs. X by
taking into account to her food intake under the periodic interval.
Gaps in nursing intervention framed
The main gap in framing of the nursing interventions include, the interventions does
not cover proper regulation and monitoring of the vital parameters apart from the blood
pressure. The main vital parameters that must be monitored for Mrs. C body temperature,
increase in the level of the body temperature will provide an indication towards the internal
inflammation or infection (Rowley and Alford 2013). The nursing intervention has also failed
to cover the weekly monitoring of the body weight of Mrs. X and monitoring of the level of
the tri-glycerides. Increase in the level of tri-glycerides or LDL (low-density lipo-protein)
will increase the threat towards cardiac complications (Mrs. X has already symptoms of
tachycardia) along with increase chances of hepatic-toxicity and gain in weight (Robinson et
al. 2017). Proper monitoring of the triglyceride level will be effective management of the
health of Mrs. X and prognosis of pancreatitis.
Thus from the above discussion, it can be concluded that the majority of the
interventions that has been framed for the Mrs X covers the ethical consideration of the
nursing research along with respect towards the dignity of the spiritual rights of patients. The
interventions also gave importance towards covering the mental and the physical needs of the
patients while creating provision for the development of the inter-personal relationship.

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References
Adamina, M., Steffen, T., Tarantino, I., Beutner, U., Schmied, B.M. and Warschkow, R.,
2015. Meta‐analysis of the predictive value of C‐reactive protein for infectious complications
in abdominal surgery. British Journal of Surgery, 102(6), pp.590-598.
Ahmed, A., Azim, A., Gurjar, M. and Baronia, A.K., 2016. Hypocalcemia in acute
pancreatitis revisited. Indian journal of critical care medicine: peer-reviewed, official
publication of Indian Society of Critical Care Medicine, 20(3), p.173.
Banks, P.A., Bollen, T.L., Dervenis, C., Gooszen, H.G., Johnson, C.D., Sarr, M.G., Tsiotos,
G.G. and Vege, S.S., 2013. Classification of acute pancreatitis—2012: revision of the Atlanta
classification and definitions by international consensus. Gut, 62(1), pp.102-111.
Bertholet, N., Adam, A., Faouzi, M., Boulat, O., Yersin, B., Daeppen, J.B. and Clerc, D.,
2014. Admissions of patients with alcohol intoxication in the Emergency Department: a
growing phenomenon. Swiss Med Wkly, 144(w13982), pp.1-8.
Costa, E., Giardini, A., Savin, M., Menditto, E., Lehane, E., Laosa, O., Pecorelli, S., Monaco,
A. and Marengoni, A., 2015. Interventional tools to improve medication adherence: review of
literature. Patient preference and adherence, 9, p.1303.
Freedman, V.A. and Spillman, B.C., 2014. The residential continuum from home to nursing
home: size, characteristics and unmet needs of older adults. Journals of Gerontology Series
B: Psychological Sciences and Social Sciences, 69(Suppl_1), pp.S42-S50.
Hall, K.D. and Guo, J., 2017. Obesity energetics: body weight regulation and the effects of
diet composition. Gastroenterology, 152(7), pp.1718-1727.

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Hornsby-Smith, M.P., 2017. The changing identity of Catholics in England. In Religion,
Identity and Change (pp. 54-68). Routledge.
Joyner, M.A., Gearhardt, A.N. and White, M.A., 2015. Food craving as a mediator between
addictive-like eating and problematic eating outcomes. Eating behaviors, 19, pp.98-101.
Korhan, E.A., Uyar, M., Eyigör, C., Yönt, G.H., Çelik, S. and Khorshıd, L., 2014. The effects
of music therapy on pain in patients with neuropathic pain. Pain Management Nursing, 15(1),
pp.306-314.
Kourkouta, L. and Papathanasiou, I.V., 2014. Communication in nursing practice. Materia
socio-medica, 26(1), p.65.
Lerch, M.M. and Gorelick, F.S., 2013. Models of acute and chronic
pancreatitis. Gastroenterology, 144(6), pp.1180-1193.
National Institute for Health and Care Excellence. 2016. QuikRead go for C-reactive protein
testing in primary care. Access date: 11th February 2019. Retrieved from:
https://www.nice.org.uk/advice/mib78
National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). 2019. Eating,
Diet, & Nutrition for Pancreatitis: Can what I eat help or prevent pancreatitis?. Access date:
11th February 2019. Retrieved from: https://www.niddk.nih.gov/health-information/digestive-
diseases/pancreatitis/eating-diet-nutrition
Olshansky, B. and Sullivan, R.M., 2013. Inappropriate sinus tachycardia. Journal of the
American College of Cardiology, 61(8), pp.793-801.
Robinson, J.G., Rosenson, R.S., Farnier, M., Chaudhari, U., Sasiela, W.J., Merlet, L., Miller,
K. and Kastelein, J.J., 2017. Safety of very low low-density lipoprotein cholesterol levels

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with alirocumab: pooled data from randomized trials. Journal of the American College of
Cardiology, 69(5), pp.471-482.
Rowley, J.J. and Alford, R.A., 2013. Hot bodies protect amphibians against chytrid infection
in nature. Scientific Reports, 3, p.1515.
Shore, S., Carey, E.P., Turakhia, M.P., Jackevicius, C.A., Cunningham, F., Pilote, L.,
Bradley, S.M., Maddox, T.M., Grunwald, G.K., Barón, A.E. and Rumsfeld, J.S., 2014.
Adherence to dabigatran therapy and longitudinal patient outcomes: insights from the
veterans health administration. American heart journal, 167(6), pp.810-817.
Sudhakaran, S. and Surani, S.R., 2015. Guidelines for perioperative management of the
diabetic patient. Surgery research and practice, 2015.
Wu, B.U. and Banks, P.A., 2013. Clinical management of patients with acute
pancreatitis. Gastroenterology, 144(6), pp.1272-1281.
Zengin, S., Kabul, S., Al, B., Sarcan, E., Doğan, M. and Yildirim, C., 2013. Effects of music
therapy on pain and anxiety in patients undergoing port catheter placement
procedure. Complementary therapies in medicine, 21(6), pp.689-696.