Student Nurses Community

NURSING CARE PLAN Acute Pancreatitis

ASSESSMENT
SUBJECTIVE:
Masakit ang
tiyan ko (I'm
having severe
abdominal pain)

as
verbalized by the
patient.

OBJECTIVE:

Abdominal
guarding
behavior
Inability to
concentrate.
Irritability
V/S taken as
follows
T: 37.0C
P: 67
R: 18
BP: 110/ 80

DIAGNOSIS

INFERENCE

PLANNING

Acute pain. May

be related to
obstruction of
pancreatic,
biliary ducts,
chemical
contamination
of peritoneal
surfaces by
pancreatic
exudate,
autodigestion of
pancreas, and
extension of
inflammation to
the
retroperitoneal
nerve plexus.

Acute pancreatitis
is a serious and
at times lifethreatening
inflammatory
process of the
pacreas. This
process is caused
by a premature
activation of
pancreatic
enzymes that
destroy ductal
tissue and
pancreatic cells,
resulting in
autodigestion and
fibrosis of the
pancreas. The
pathologic
changes occur in
variable degrees.
The severity
ofpancretitis
depends on the
extent of
inflammation and
tissue
destruction.

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.

INTERVENTION
Independent
Investigate verbal
reports of pain,
noting specific
location and
intensity.

Maintain bed rest

during acute attack
and provide quiet,
restful environment.

Promote position of
comfort.

Keep environment
free of food odors.

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

RATIONALE
Pain is often
diffuse, and
unrelenting in
acute or
hemorrhagic
pacreatitis.
Severe pain is
often the major
symptom in a
patient with
chronic
pancreatitis.
Decrease
stimulation of
pancreatic
secretions,
thereby reducing
pain.
Reducing
abdominal
pressure and
tension.
Sensory
stimulation can
activate
pancreatic
enzymes.
Pancreatic
enzymes can
digest the skin
and tissues of
the abdominal
wall, creating
abscesses and

EVALUATION
After 4 hours of
nursing
interventions, the
Patient was able
to report pain is
relieved; follow
prescribed
therapeutic
regimen; and
demonstrate use
of methods that
provide relief.

Student Nurses Community

ulceration.
Collaborative
Administer
intravenous
analgesics as
prescribed.

Withhold food and

fluid, as indicated.

Severe or
prolonged pain
can aggravate
shock and is
more difficult to
relieve, requiring
larger doses of
medication,
which can mask
underlying
problems and
complications.
Patient should be
kept noting by
mouth status
until pain and
nausea subside
to limit or reduce
release of
pancreatic
enzymes and
resultant pain.