eNCP 44-1

eNCP 44-1 NURSING CARE PLAN

Patient with Acute Pancreatitis
NURSING DIAGNOSIS

Acute pain related to distention of pancreas, peritoneal irritation, obstruction of biliary tract, and ineffective pain and comfort
measures as evidenced by communication of pain descriptors, guarding behavior, behaviors indicative of pain (e.g., moaning),
diaphoresis, changes in blood pressure, pulse, and respiratory rate
1. Reports adequate pain control
2. Uses nondrug techniques of pain management to reduce need for pain medication

PATIENT GOALS
OUTCOMES (NOC)
Pain Control

INTERVENTIONS (NIC) AND RATIONALES

Pain Management

Uses analgesics as recommended _____

Uses nonanalgesic relief measures _____
Reports changes in pain symptoms to
health professional _____
Reports uncontrolled symptoms to
health professional _____
Reports pain is controlled _____

Perform a comprehensive assessment of pain to include location, characteristics, onset/duration, frequency, quality, intensity or severity of pain, and precipitating factors to plan appropriate interventions.
Provide the person optimal pain relief with prescribed analgesics to ensure more effective relief of pain.
Evaluate the effectiveness of the pain-control measures used through ongoing assessment of the pain
experience to adjust pain medication administration in order to provide ongoing relief of pain.
Teach the use of nonpharmacologic techniques (e.g., relaxation, guided imagery, hot/cold application,
and massage) before, after, and, if possible, during painful activities; before pain occurs or increases;
and along with other pain-relief measures to assist in reducing the restlessness that usually accompanies the pain.
Notify physician if measures are unsuccessful or if current complaint is a signicant change from patients past experience of pain since increasing pain can indicate complications of peritonitis or necrotizing pancreatitis.

Measurement Scale
1 = Never demonstrated
2 = Rarely demonstrated
3 = Sometimes demonstrated
4 = Often demonstrated
5 = Consistently demonstrated

NURSING DIAGNOSIS

Decient uid volume related to nausea, vomiting, restricted oral intake, and uid shift into the retroperitoneal space as
evidenced by decreased urine output, decreased blood pressure, increased heart rate, decreased peripheral pulse volume,
thirst, and dry skin and mucous membranes.
Maintains uid and electrolyte balance within normal limits.

PATIENT GOAL
OUTCOMES (NOC)
Fluid Balance

INTERVENTIONS (NIC) AND RATIONALES

Vomiting Management

Blood pressure _____

Radial pulse rate _____
Moist mucous membranes _____
Peripheral pulses _____
Serum electrolytes _____
Urine-specic gravity _____

Measurement Scale
1 = Severely compromised
2 = Substantially compromised
3 = Moderately compromised
4 = Mildly compromised
5 = Not compromised

Ensure that effective antiemetic drugs are given to prevent vomiting when possible to reduce uid loss
by preventing vomiting.
Measure or estimate emesis volume as indicators of replacement needs and effectiveness of treatment.

Fluid/Electrolyte Management
Obtain laboratory specimens for monitoring of altered uid or electrolyte levels (e.g., hematocrit, blood
urea nitrogen [BUN], protein, sodium, and potassium), as appropriate to evaluate effectiveness of
treatment.
Maintain intravenous solution containing electrolytes at a constant ow rate to prevent uid or electrolyte
overload.
Consult physician if signs and symptoms of uid and/or electrolyte imbalance persist or worsen because
these may indicate development of complications.

NURSING DIAGNOSIS

Imbalanced nutrition: less than body requirements related to anorexia, dietary restrictions, nausea, loss of nutrients
from vomiting, and impaired digestion as evidenced by weight loss, weakness, fatigue, and weight below normal for height
and age
1. Maintains weight appropriate for height
2. Maintains food and uid intake adequate to meet nutritional needs

PATIENT GOALS
OUTCOMES (NOC)
Nutritional Status

INTERVENTIONS (NIC) AND RATIONALES

Nutrition Therapy

Monitor laboratory values as indicators of patients response to treatment.

Administer enteral (and possible parenteral) nutrition to provide carbohydrates, lipids, and amino acids
to prevent negative nitrogen balance.
Provide oral care before meals to decrease foul taste and odor that inhibit appetite.
Ensure availability of progressive therapeutic diet to avoid overstimulation of the pancreas.
Provide needed nourishment within limits of prescribed diet.

Food intake _____

Fluid intake _____
Energy _____
Weight/height ratio _____

Measurement Scale
1 = Severe deviation from normal range
2 = Substantial deviation from normal range
3 = Moderate deviation from normal range
4 = Mild deviation from normal range
5 = No deviation from normal range

Nutrition Management
Weigh patient at appropriate intervals to monitor nutritional status.

Continued

Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

eNCP 44-1

eNCP 44-1 NURSING CARE PLANcontd

Patient with Acute Pancreatitis
NURSING DIAGNOSIS Risk for electrolyte imbalance related to uid imbalances, altered pancreatic secretion, and third uid spacing
PATIENT GOALS Maintains normal electrolyte balance
OUTCOMES (NOC)
INTERVENTIONS (NIC) AND RATIONALES
Electrolyte Management: Hypocalcemia
Electrolyte and Acid-Base Balance

Serum calcium _____

Serum magnesium _____
Serum potassium _____
Serum pH _____
Serum glucose _____
Serum triglycerides _____
Sensation in extremities _____

Measurement Scale
1 = Severe deviation from normal range
2 = Substantial deviation from normal range
3 = Moderate deviation from normal range
4 = Mild deviation from normal range
5 = No deviation from normal range

Monitor for clinical manifestations of hypocalcemia (e.g., tetany [classic sign]; tingling in tips of ngers,
feet, or mouth; spasms of muscles in face or extremities; Trousseaus sign; Chvosteks sign; altered
deep tendon reexes; seizures [late sign]) to provide appropriate intervention.
Monitor for central nervous system (CNS) manifestations of hypocalcemia (e.g., personality disturbances, anxiety, irritability, depression, and psychosis).
Monitor for electrolyte imbalances associated with hypocalcemia (e.g., hyperphosphatemia, hypomagnesemia), and alkalosis to provide appropriate intervention.
Administer appropriate prescribed calcium salt (e.g., calcium carbonate, calcium chloride, and calcium
gluconate) using only calcium diluted in D5W, administered slowly with a volumetric infusion pump, to
prevent adverse effects.

Electrolyte Management
Monitor patients response to prescribed electrolyte therapy to evaluate effectiveness of therapy.
Consult physician if signs and symptoms of uid and/or electrolyte imbalance persist or worsen so that
corrective therapy can be initiated.

NURSING DIAGNOSIS
PATIENT GOALS

Ineffective self health management related to lack of knowledge of preventive measures, diet restrictions, restriction
of alcohol intake, and follow-up care as evidenced by verbalization of the problem, request for information, and inaccurate
follow-through on instructions
1. Describes therapeutic regimen with regard to disease process and management
2. Expresses commitment to lifestyle changes and participation in treatment for alcohol dependence

OUTCOMES (NOC)
Knowledge: Disease Process

INTERVENTIONS (NIC) AND RATIONALES

Teaching: Disease Process

Specic disease process _____

Effects of disease _____
Measures to minimize disease
progression _____
Signs and symptoms of
complications _____

Appraise patients current level of knowledge related to disease processes to establish baseline for
teaching.
Explain pathophysiology of the disease and how it relates to anatomy and physiology.
Discuss lifestyle changes that may be required to prevent future complications and/or control the
disease process.
Instruct the patient on which signs and symptoms to report to health care provider to prevent recurrence.
Refer the patient to local community agencies/support groups for support in treatment of alcohol
dependency.
Explain pathophysiology of the disease and how it relates to anatomy and physiology.
Discuss lifestyle changes that may be required to prevent future complications and/or control the disease process.
Instruct the patient on which signs and symptoms to report to health care provider to prevent recurrence.

Measurement Scale
1 = No knowledge
2 = Limited knowledge
3 = Moderate knowledge
4 = Substantial knowledge
5 = Extensive knowledge

NURSING GOALS
Potential Complications
Monitor for signs of hypovolemia
Initiate appropriate medical and nursing
interventions

COLLABORATIVE PROBLEMS
NURSING INTERVENTIONS AND RATIONALES
Hypovolemia/Shock related to increased capillary permeability caused by release of vasoactive
compounds during the autodigestion of the pancreas and uid shifts into the retroperitoneal space.
Monitor circulatory status: blood pressure, skin color, skin temperature, heart rate and rhythm, presence
and quality of peripheral pulses, and capillary rell for early detection of hypovolemic shock.
Maintain strict NPO status (no ice chips) to reduce or stop secretion of pancreatic enzymes, which decreases the inammatory process.
Maintain patency of gastric suction to prevent uid loss from vomiting and to prevent gastric juices from
entering the duodenum where they stimulate secretion of pancreatic enzymes.
Monitor electrolyte status, especially serum potassium, sodium and chloride, since these electrolytes
are lost with vomiting and gastric suction.
Monitor for renal insufciency (e.g., urine output <30 mL/hr, elevated urine sodium, elevated urine specic gravity, and elevated BUN because hypovolemia activates the renin-angiotensin system, reducing
renal plasma ow and glomerular ltration rate.

Mosby items and derived items 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.