Assessment

  1. Obtain a detailed medical history, including previous episodes of pancreatitis, alcohol or drug use, and any underlying medical conditions.
  2. Assess the patient’s vital signs, including temperature, heart rate, blood pressure, and respiratory rate.
  3. Monitor and document the patient’s pain level using a pain scale.
  4. Assess the patient’s abdominal pain, tenderness, and distention.
  5. Monitor the patient’s gastrointestinal symptoms, including nausea, vomiting, and diarrhea.
  6. Observe for signs of dehydration, such as dry mucous membranes, decreased urine output, and poor skin turgor.
  7. Evaluate the patient’s nutritional status and intake, noting any changes in appetite or weight loss.
  8. Assess the patient’s emotional and psychological state, as pancreatitis can cause significant distress.

Nursing Diagnosis

  1. Acute pain related to inflammation of the pancreas.
  2. Risk for imbalanced fluid volume related to vomiting and inadequate oral intake.
  3. Imbalanced nutrition less than body requirements related to malabsorption and altered dietary intake.
  4. Deficient knowledge about the condition, treatment, and self-care measures related to pancreatitis.

Planning

  1. The patient will experience reduced pain and discomfort.
  2. The patient will maintain adequate fluid balance.
  3. The patient’s nutritional status will be improved.
  4. The patient and their family will demonstrate understanding of the disease process, treatment, and self-care measures.

Implementation

  1. Administer prescribed analgesics as ordered and monitor for effectiveness.
  2. Encourage the patient to assume a position of comfort, such as lying on their side with knees flexed.
  3. Apply heat or cold packs to the abdomen as appropriate, based on the patient’s preference.
  4. Provide relaxation techniques, such as deep breathing exercises, guided imagery, or distraction techniques.
  5. Monitor the patient’s intake and output closely.
  6. Encourage oral fluid intake, offering small, frequent sips of water or clear fluids if tolerated.
  7. Administer intravenous fluids as prescribed, ensuring proper rate and monitoring for signs of fluid overload.
  8. Monitor daily weights to assess fluid status accurately.
  9. Collaborate with a dietitian to develop a plan for the patient’s dietary needs.
  10. Start with a clear liquid diet and gradually advance to a low-fat, high-carbohydrate diet as tolerated.
  11. Provide small, frequent meals to minimize stress on the pancreas.
  12. Monitor serum glucose levels regularly if the patient has diabetes or develops hyperglycemia.
  13. Administer pancreatic enzyme replacement therapy, as ordered, to aid in digestion and absorption of nutrients.
  14. Educate the patient and their family about the underlying causes, signs, and symptoms of pancreatitis.
  15. Teach the patient about prescribed medications, including their purpose, dosage, and potential side effects.
  16. Instruct the patient on the importance of maintaining a low-fat diet and avoiding alcohol and tobacco.
  17. Provide information on support groups and resources for managing pancreatitis.
  18. Discuss the importance of follow-up appointments and the need for ongoing monitoring of pancreatic function.

Evaluation

  1. The patient reports a decrease in pain intensity and demonstrates pain relief measures effectively.
  2. The patient maintains adequate fluid balance as evidenced by stable vital signs and normalized urine output.
  3. The patient’s nutritional status improves, with weight stabilization or gain and improved laboratory values.
  4. The patient and their family demonstrate understanding of the disease process, treatment, and self-care measures.

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