A CASE STUDY REPORT

ON

Acute Pancreatitis

KATHMANDU UNIVERSITY

SCHOOL OF MEDICAL SCIENCES

DHULIKHEL, KAVRE

Submitted to: Submitted by

Mrs. Jamuna Bajracharya Yamuna Limbu

Lecturer BNS 2 nd year

KUSMS Roll No:06

ACKNOWLEDGEMENT

I would like to extend my sincere acknowledgement towards Kathmandu

University for providing the marvelous opportunity to do the “case study” as a
part of our curriculum of the subject Adult nursing in Bachelor in Nursing
science 2nd year. Similarly, I would like to thank “Dhulikhel Hospital” for posting
us, in its surgical ward and providing us continuous support in building up our
experiences in upgrading required knowledge and skill.

I heartily like to thank madam Mrs.Jamuna Bajracharya for guiding me

to do the case study on the topic “Acute Pancreatitis”. Likewise, I am also
thankful to all the staffs of Surgical ward for their wonderful support in
fulfilling of my objectives of doing case study.I am also thankful to the librarian
for providing me the related books and computer for study. I also express a
tone of thanks to the patient and the family members for providing true
information and history and helping me to do this study possible positively and
co-operatively.

Aggregately, I am thankful to all those who have directly and indirectly

provided me their kind support, co-operation and time in every step for
successful completion of my case study.
INTRODUCTION

I am Yamuna Limbu, Bachelor in Nursing Science in 2 nd year student studying at

Kathmandu University, School of Medical Sciences. Altogether we are 10
students in our batch. According to the curriculum of, we have clinical posting
in the surgical Ward for total four weeks. And during this period of four weeks
posting in Dhulikhel Hospital, we were supposed to do case study on one of
the topics of disease condition available in surgical Ward.

So, being based on the criteria, I did case study on “Acute Pancreatitis” of 69
years old female. I choose of Acute Pancreatitis because it is one of the
disease of gastro-intestinal system seen in all age group and it is the cause of
death if not managed promptly.

I got an opportunity to care her for 6 days and got lots of information about
the disease condition and its management.
OBJECTIVES OF DOING CASE STUDY:

1) To strengthen my capacity to build Inter-personal relationship with the

patient.
2) To develop skill on history taking and physical examination of the
patients.
3) To obtain the detailed knowledge on the studied case.
4) To apply appropriate nursing theory for the management of the
respective disease.
5) To implement nursing care appropriately.
6) To know the rationale behind every intervention given for care of the
patient.
7) To provide the therapeutic management to the patient with “acute
pancreatitis”.
8) To learn to use different diversional therapy used to reduce the anxiety
of the patient.
TABLE OF CONTENT

Demographic data…………………………………………..…………….....6

History taking…………………………………………………...…………. …..2

Family history……………………………………………………………………8

Physical examination……………………………………………….............12

Conclusion………………………………………………………………………….15

Disease portion……………………………….……………….…………………16

Clinical Manifestations………………………………………………………..17

Investigations report of my patients……………………………………19

Nursing management………………………………………………………….20

Drugs profile……………………………………………………………………….22

Application of nursing theory ………….…………………………………..27

Nursing care plan of my patient……………………………………………28

Daily progress note……………………………………………………………….34

Developmental needs and task (Havighrust)………………………..…36

Health teaching provided to my patient during hospitalization..37

Discharge teaching…………………………………………………………….…….39

Learning from case study………………………………………………………..40

Summary of my case study…………………………………………………….41

Conclusion……………………………………………………………………………..42

References………………………………………………………………………………43
 DEMOGRAPHIC DATA

NAME – SUKRIM KUMARI GOLE

AGE – 69 YEARS

SEX - FEMALE

REGD. NO - 173851
ETHNIC GROUP – TAMANG

RELIGION – BUDDHIST

EDUCATION - ILLITERATE
ADDRESS – SINDHULI-7

WARD - SURGICAL WARD

BED NO-12 ‘E’
ADMISSION DATE – 2018/03/30
DIAGNOSIS – ACUTE PANCREATITIS
DISCHARGE DATE -2018/04/05
WEIGHT- 55Kg

HEIGHT- 160 CM
DURATION OF STAY- 6 DAYS

INFORMANT- PATIENT AND HIS RELATIVES

HISTORY TAKING
Chief complain:

-epigastric pain

-nausea

-vomiting

-fever since since 2 pm of 2018/03/29

History of present illness:

My patient was apparently well 2 days back when she started having
epigastric pain which later diffused to involve whole abdomen, pain was
associated with tenderness, anorexia, nausea, vomiting since 2pm of
2018/03/29

For this reason their family members decided to visit dhulikhel

hospital directly as there were no any hospital facility in their hometown and
arrived at 8 am in emergency department of dhulikhel hospital at
2018/03/30.Then investigations was done that includes chest x-ray,
ultrasonography, blood grouping, electrocardiography.

Personal History:

Patient sleeps about 6-8 hours in night . She wakes up early in morning and
involves in her activities of daily living. She is non-alcoholic and non smoker.
She is non-vegetarian. She is homemaker. She has normal bowel and bladder
habit before onset of the following disease.
Family History:

While other members are apparently healthy. There is no history of any other
chronic diseases in family like leprosy, TB, diabetes, hypertension hereditary
disease, genetic abnormalities and psychiatric illness.

S.N Name Relation Age/Sex Education Occupation

with
patient

1. Sukrim kumari patient 69/F Illiterate Homemaker

gole

2. Ram kumar gole Son 45/M Class 5 Farmer

3. Saili gole Daughter 41/F Illiterate Homemaker

in law

Family Tree
Index

Male

Female

Patient

Death
Environmental History:

Patient lives in a 1 strayed cemented house having 1 room with attached

kitchen .Drinks water from direct tap water.They use chulo for cooking their
food as a fuel source.They have water seal latrines with proper drainage
system.Wash his hand with soap after using toilet.They make manure from
degradable wastes and spread in their field and burn non-degradable waste.

Psychological History:

Patient has positive attitude towards life and her disease. She have good
relationship with her family and her neighbours. She usually share problems
with her son and daughter in law. She is well cooperating and friendly during
treatment procedure.

Socio-economic history:

Socio-economic status of my patient’s family is adequate for the living as well

as are able do do savings.

Spiritual/cultural History:

She believes in god. She used to do kul deuta pooja once a year.She usually
visit clinic and hospital for treating her disease. She also believes in traditional
healers like dhammi and jhankri.
Current Health status:

Patient’s general condition is improving. Patient is in NPO AND I/V fluid

continued.

Today’s Vitals are:

Pulse: 68/min

Temperature: 36.60C

Respiratory rate: 20/m

Blood Pressure:110/80 mm of Hg

SPO2 without O2 :95% at room air

 PHYSICAL EXAMINATION
S.N Health History Yes No Physical Examination Findings
. (Subjective data)
1. General  Patient is alert and active
is well oriented with time
 Fever NO
,place and person.
 Chills NO

 General malaise YE
S

 Weight loss YE
S
2. Head and face

 Normal YE  Dry hair

S  Gray hair
 Dandruff present
 Headache NO
 Square face
 Injury NO
3. Ear

 Pain NO

 Discharge NO  Dirty ear

  Hearing NO  Normal wax present
Problems  Normal eardrum
 Tinnitus NO  Normal hearing
 Care Habit NO
4. Nose

 Injury No

 Bleeding No  Nasal patency present

 Polyps absent
 Blockage No  No deviated nasal septum
 Discharge No (DNS)
 Nasal discharges present
5. Mouth, throat and
neck

 Sore on lip and NO  Dry lips

gums  Buccal mucosa was pink, no
 Bleeding from NO any lesions, bleeding and
the gums tenderness
 Toothache NO  Dental caries present

 Missing tooth NO  Normal, pink palate with no

bony or soft tissue defect
 Teeth care NO  Uvula centrally located
 Thyroid and lymph nodes not
 Difficulty in NO
palpable.
swallowing
6. Lungs  On inspection, no scars, no
swelling and intercostal
 Scars on the NO
drawing was present
chest
 symmetrical chest expansion
 Symmetrical NO with equal air entry
expansion of the  Resonance on percussion
chest
 no crepitation present on
 Wheezes and NO auscultation.
crept on  bilaterally decreased air entry.
auscultation
7. Cardiovascular System

 Chest pain NO
  Dyspnoea NO  On inspection, heart located at
the left side, no cyanosis,
 Bleeding tendencies NO
edema present

8. Gastro Intestinal
system

 Vomiting NO

 Loss of appetite YE  Soft, epigastric pain and

tenderness in abdomen
S
 No renal enlargement
 Diarrhoea NO  No hepatomegaly seen
 Constipation present
 Constipation YE  Dull sound present
S  No distended abdomen.
 Flatulence NO  No scar present

 Blood and NO
mucus in stool On auscultation: Bowel sound
 Abdominal pain YE diminished
and distension S

 Itching around NO
anus
 Passing of NO
worms
9. Genito-urinary system

 Painful micturation NO

 Enuresis NO  Patient had normal bladder

habit
 Hematuria NO

 Urinary retention NO
 Change in urine NO
color
10. Musculoskeletal
system
  Joint pain NO  No any bone deformity
 Normal and symmetrical
 Muscle weakness NO
mobility of both right and the
 Fractures NO left leg
 Equal and normal strength of
the muscle
11. Skin and appendages

 Rashes NO

 Itching NO
 Wrinkled brownish skin
 Change in texture of NO  No lesions and scar present on
hair hands and infection present at
 Skin changes NO the foot
 Touch sensation present
12. Nervous system
 Oriented to time place and
 Convulsion NO
person
 Speech problems NO  Normal speech development
 Normal biceps, triceps, brachio
 Problem with rest NO radialis, patellar, ankle plantar
and sleep reflex present.
12. Nervous system  Oriented to time place and
person
 Convulsion No  Normal speech
 Speech problems development
 Problem with No
 Normal biceps, triceps,
rest and sleep No brachio radialis, patellar,
ankle plantar reflex
present.

CONCLUSION:

Overall assessment of my patient was normal except gray hair was present,
epigastric pain, loss of appetite, constipation, diminished bowel sound, icterus,
dental caries and wrinkled skin was present.
 DISEASE PORTION
Acute Pancreatitis

Pancreatitis

Pancreatitis is inflammation pf the pancreas, which is a large organ behind the

stomach that produces digestive enzymes and a number of hormones.

Types

There are two main types of pancreatitis:-

 Acute pancreatitis:- Acute pancreatitis is a sudden inflammation of the

pancreas which can minimal organ dysfunction is present and return to
normal usually within months and may have severe complications and
high mortality despite treatment.
 Chronic pancreatitis:- Chronic inflammation of pancreas may present as
episodes of acute inflammation superimposed on a previously injured
pancreas or as chronic damage with persistent pain and malabsorption.

Causes

 Gall stones(45%)
 Alcohol ingestion(35%)
 Postoperative (abdominal, Non abdominal)
 Post-ERCP
 Trauma
 Metabolic:-
  Renal failure
 After renal transplantation
 Hypertriglyceridaemia
 Hypercalcemia
 Acute fatty liver of pregnancy
 Infections(viral hepatitis, mumps, ascariasis, mycoplasma)
 Drug induced:-
 Definite association:-
Sulfonamides,oestrogens,frusemide,thiazides, tetracycline,
valproic acid
 Probable association:-Acetaminophen,ethacrynic acid,
procainamide, metronidazole, NSAID’s, ACE inhibitors
 Connective tissue disorders:-SLE, thrombotic thrombocytopenic purpura
 Penetrating peptic ulcer
 Obstruction to ampulla of vater(regional enteritis, duodenal diverticulum)
 Hereditary pancreatitis

Pathophysiology
Duct obstruction due to gall stones, chronic alcoholism

Interstitial oedema

Impaired blood flow

Ischaemia

Acinar cell injury

Activated enzymes

 Interstitial inflammation oedema

 Proteolysis(Proteases)

 Fat necrosis(lipase,Phospholipase)

 Haemorrhage(elastase

Clinical manisfestations
A acute pancreatitis present following sign and symptoms:-

ACCORDING TO BOOK IN MY PATIENT

Abdominal pain Present
Nausea Present
Vomiting Present
Low grade fever Present
Abdominal distension Present
Tachycardia Absent
Hypotension Absent
Jaundice Present
Pleural effusion Present
Cullen’s sign(bluish around umbilicus) Absent
Erythematous skin nodules Absent

DIAGNOSIS

According to book:-

The diagnosis of acute pancreatitis is based on a history of abdominal pain, the

presence of known risk factors, physical examination findings and diagnostic
findings.

In blood investigations serum amylase and lipase levels are used in making the
diagnosis of acute pancreatitis. In 90% cases these are rised within 24 hours.
Hypocalcemia is present in many patients.The white blood cell count,blood
sugar and serum bilirubin is usually elevated.

Haemoglobin levels are used to monitor the patient for bleeding.x- ray studies
of the abdomen and chest may be obtained to differentiate pancreatitis from
other disorders that may cause similar symptoms and to detect pleural
effusions.

IN MY PATIENT:-

Blood investigations, USG, CHEST X-RAY, ECG, was done

INVESTIGATIONS REPORT OF MY PATIENT

Haematology report (30/03/2018):-

Blood component In my patient Referance range

 Glucose, Random 144.0 60-150 mg/dL
Urea 44.0 10-45 mg/dL
Creatinine 0.5 0.4-1.1 mg/dL
Amylase 1211.0 30-100 IU/L
Sodium, Serum 142.0 135-148 mEq/L
Potassium 4.2 3.5-5.3 mEq/L
Bilirubin, Total 1.7 0.3-1.4 mg/dL
Bilirubin, Direct 0.7 <0.5 mg/dL
ALT(SGPT) 292.0 5-40 IU/L
AST(SGOT) 591.0 5-40 IU/L
Gamma-GT 393.0 15-80 IU/L
Total protein 7.0 6.5-8.2 g/dL
Albumin 4.1 3.5-5 g/dL
Alkaline phosphate 199.30 42-128 IU/L
WBC 13.2 4-11*10 3/uL
DLC %
Neutrophils 94 40-75%
Lymphocytes 04 20-45%
Monocytes 01 2-8%
Eosinophils 01 1-6%
Basophils 00 0-1%
Haemoglobin 14.9 12-16g/dL
Platelets 168 150-450*10 3/uL
INR 16 14(ISI-1.0)
Prothrombin time 1.1
Calcium Total 9.7 8.5-11.5mg/dL
CRP Quantitative <5.0 <5.0

Haematology report (04/04/2018):-

Bilirubin, Total 0.7 0.3-1.4 mg/dL

Bilirubin, Direct 0.1 <0.5 mg/dL
Alkaline phosphate 109.0 42-128 IU/L
ALT(SGPT) 25.0 5-40 IU/L
AST(SGOT) 18.0 5-40 IU/L
Amylase 62.0 30-100 IU/L

USG FINDINGS
  Acute pancreatitis
 Cholecystolithiasis

MANAGEMENT:- The basic principles of management are:-

1. Nil per orally
2. I/V fluids and colloids to maintain intravascular volume
3. Pain relief using analgesics
4. Nasogastric suction to decrease gastrin release from stomach
5. Managing the causes causing pancreatitis
6. Monitor vital, urine output, serum amylase, serum lipase, glucose,
calcium and blood gases.
7. Laparotomy and debridement in haemorrhagic pancreatitis
8. Antibiotic therapy using agents that achieve high pancreatic tissue
concentration decreases the mortality especially in necrotising
pancreatitis.The agents includes imipenam, ofloxacin and ciprofloxacin.
9. Other drugs with variable efficacy include:-
 Glucagon
 H2 receptor blocker
 Protease inhibitor-aprotinin
 Glucocorticoids
 Calcitonin
 NSAIDs
 Octreotide
 Lexipafant-platelet activating factor inhibitor
 Gabexate methylate-an antiprotease

IN MY PATIENT:- My patient was planned for LAP. cholecystectomy however

her surgery was cancelled due to pleural effusion and she was planned for
interval LAP. Cholecystectomy after 2 weeks.

Nursing management focuses on

 Providing psychological support:-

The nurse helps the patient to express to express fears, concerns and grief
about the diagnosis. It is important to answer the patient question honestly
and to encourage the patient to participate in the treatment decisions. Some
patients mourn the loss of body part and perceive their surgery as a type of
mutilation. Some express disbelief and need time and support to accept the
diagnosis.

The nurse offers the emotional support and involves family members and
significant others whenever possible. This includes recognizing mood swings
and defense mechanisms (e.g; denial, rationalization, displacement,
regression) and reassuring the patient, family members and significant others
that emotional responses are normal and expected. The nurse projects an
empathetic attitude and spend time with the patient.

Reducing anxiety:

A relaxed, nonthreatening atmosphere is provided so the patient can express

fears, concerns, and possibly anger about the diagnosis and prognosis. The
nurse encourages the family and significant others to support the patient,
offering reassurance and supporting positive coping measures. The nurse
advises patient about any procedures and treatment so that the patient knows
what to expect.

Promoting optimal nutrition:

The nurse encourages the patient to eat small, frequent portion of

nonirritating foods to decrease gastric irritation. Food supplements should be
high in calories, as well as Vitamin A and C and iron, to enhance tissue repair. If
the patient is unable to eat adequately prior to surgery to meet nutritional
requirements, parenteral nutrition may be necessary.

Relieving pain:

The nurse administers analgesic agents as prescribed. The nurse routinely

assesses the frequency, intensity and duration of the pain to determine the
effectiveness of an analgesic agent. The nurse works with the patient to help
manage pain by suggesting nonpharmacological method for pain relieve, such
as position change, imagery, distraction, relaxation exercises (using relaxation
audiotapes), back rubs, massage and period of rest and relaxation.
DRUG PROFILE

Medication used in my patient.

1) Inj. Pantop 40 mg I/V BD

2) Inj Paracetamol 1gm I/V TDS
3) Inj. Buscopan 10 mg I/V OD
4) Inj. Ketorolac 30 mg I/V TDS
5) Inj. Cefotaxime 1gm I/V BD
6) Inj. Metron 500mg I/V TDS
7) Syrup lactulose 15ml P/O HS

1. PANTOPRAZOLE

Therapeutic category:
 proton pump inhibitor
MOA:
 It suppresses the final step in gastric acid production by coval)ently
binding to the (h+,k+)-ATpase enzyme system at the secretory surface of
the gastric parietal cell. This effect leads to the inhibition of both basal
and stimulated gastric acid secretion irrespective of the stimulus.
Indications:
 GERD, Erosive oesophagitis
 Lonf term Pathologic gastric hypersecretory conditions like
Zollinger – Ellison syndrome
Contraindication:
 Hypersensitivity
 Children < 8 years
Dosage regimen
  Adult: PO 40 mg OD, IV 40mg daily
Adverse effects:
 Headache,abdominal pain, facial edema, generalized edema, chest pain,
diarrhea, constipation, pruritis, rash, flatulence, hyperglycemia, nausea ,
vomiting, photosensitivity
Nursing consideration:
 Assess for bowel sounds, abdomen for pain, swelling, anorexia in GI
system
 Assess AST, ALT, Alkaline phosphatase during treatment
 Do not crush the tablet

2. PARACETAMOL
Therapeutic category: NSAID, Antipyretic
MOA:
 Paracetamol is a centrally acting anlagesics and antipyretic which
reduces pain by inhibiting the central prostaglandin synthesis,
specifically COX-2 and an elevation of the pain threshold. It
reduces fever by inhibiting the release of prostaglandins in the
CNS and inhibition of endogenous pyrogens at the hypothalamic
thermoregulatory centers.
Indication:
 Post operative pain, fever, pain associated with musculoskeletal
and joint disorder.
Dosage regimen:
 Adult : 500-1000 mg PO BD
Adverse effect:
 Headache, dizziness, nausea, malaise, flatulence
Contraindication
 Hypersensitivity
Nursing consideration
 Assess for allergies and impaired hepatic function
 Explain the adverse effect to the patient

3. Buscopan
Therapeutic category: Atispasmodic
MOA:
 Hyoscine competitively blocks muscarinic receptors and has
central and peripheral actions. It relaxes smooth muscles and
reduces gastric and intestinal motility.
Indication:
  To relieve cramps in the stomach, intestines or bladder
 In treatment of motion sickness
 Postoperative nausea and vomiting
Dosage regimen:
 Adult : 10 mg IV/IM OD
Adverse effect:
 Flushing, postural hypotension, tachycardia, fibrillation, dizziness
rarely psychotic reactions
Contraindication:
 Hypersensitivity
Nursing consideration:
 Advise patient to follow the medication
 Suggest not to double the dose if missed
 Advise patient to stop consuming alcohol as this may cause serious side
effects

4. KETOROLAC

Therapeutic category:
 Analgesics, NSAID
MOA:
 Ketorolac promethamine reversibly inhibits COX-1 and COX-2 enzymes,
which results in decrease formation of prostaglandin precursor. It is
more effective than aspirin in inhibiting collagen-induced and
arachidonic acid-induced aggregation of human platelets but is not
involved with theee pppathways that relate to adenosine diphosphate
or thromboxane A-2.
Indication:
 Short term management of moderate to severe post operative pain
Dosage regimen:
 Adult : 10mg every 4-6 hr if necessary
10mg IM/IV followed by 10-30mg every 4-6 hr
Adverse effect:
 GI ulcer, bleeding and perforation, Headache, dizziness, sweating,
Hypotension, chest pain, oedema
Contraindication
 Hypersensitivity, Pregnancy, lactation, Asthma
Caution
 Elderly, Heart failure, Decreased renal or hepatic function
Nursing consideration
  Assess for allergies and impaired renal or hepatic function

5. CEFOTAXIME
Therapeutic category:
 3rd generation parenteral cephalosporin
MOA:
 Cefotaxime binds to penicillin-binding proteins which in turn inhibit the
final transpeptidation step of peptidoglycan synthesis in the bacterial
cell wall. This arrest in bacterial cell wall assembly eventually leads to
bacterial lysis via bacterial cell wall autolytic enzyme activity.
Indication:
 Susceptible bacterial infection
 Gonorrhea
 Caesarean section
 Endometritis
 Epiglottitis
 Urinary tract infection
 Osteomyelitis
Dosage regimen:
 Adult : 1gm IV BD
Adverse effect:
 GI ulcer, bleeding and perforation, Headache, dizziness, sweating,
Hypotension, chest pain, oedema
Contraindication
 Hypersensitivity to cefotaxime, beta lactam antibiotics
Nursing consideration
 Assess patient to maintain adequate hydration
 Advise patient to report any case of diarrhea, fever, chills, unhealed
sores, bloody urine/stools, muscle pain, mouth sores and difficulty in
breathing with cefotaxime use

6. Metronidazole
Therapeutic category:
 Antibiotic, Anti protozoal
MOA:
 Metronidazole upon chemical reduction of its nitrogroup gives short-
lived nitroso free radical. These reduced form of metronidazole and free
radicals interact with DNA resulting in inhibition of DNA synthesis and
DNA degradation leading to the death of the bacteria.
Indication:
  Bacterial vaginosis
 Trichomoniasis
 Colorectal surgical infection
 Amoebiasis
 Giardiasis
 Pelvic inflammatory disease
Dosage regimen:
 Adult : 500mg IV TDS
Adverse effect:
 Loss of appetite
 Diarrhea
 Dizziness
 Headache
 Vomiting
 Dark urine
Contraindication
 Hypersensitivity to metronidazole or any component of the formulation
 Pregnancy(1st trimester)
 Use of disulfiram within past 2 weeks
Nursing consideration
 Advise patient to take on an empty stomach
 Advise patients to take with food , if GI upset occurs
 Advise patients to avoid alcohol beverages when taking metronidazole
and for 3 days afterwards

7. Lactulose

Therapeutic category:
 Synthetic disaccharide/ stool softener
MOA:
 Bacterial degradation of lactulose in the colon acidifies the colonic
contents. The acidification of colonic contents results in the tetention of
ammonia in the colon and converts NH3 to the ammonium ion (NH4)+.
The acid colonic contents enhance the diffusion of NH3 from the blood
into the gut where conversion to NH4+ occurs, produces an osmotic
effect in the colon with resultant distention promoting peristalsis and
reduces blood ammonia concentration, thereby lowering the degree of
portal systemic encephalopathy.
Indication:
  Constipation
 Portal systemic encephalopathy prophylaxis
Dosage regimen:
 Adult : 15-30ml PO HS
Adverse effect:
 Increase in osmotic pressure of colon,
 flatulence
 discomfort
Contraindication:
 Hypersensitivity
Nursing consideration:
 Evaluate for nausea and vomiting
 Moitor for fluid and electrolyte imbalance

APPLICATION OF NURSING THEORY

I applied Virginia henderson’s independence theory to develop nursing care
plan of my patient. The outcome of 14 nursing problems according to this
theory are as follows:
S.N Virginia henderson’s 14 component Yes No
1 Breathe normally 
2 Eat and drink adequately 
3 Eliminate body wastes 
4 Move and maintain desirable postures 
5 Sleep and rest 
6 Select suitable clothes-dress and undress 
7 Maintain body temperature within normal range by 
adjusting clothing and modifying environment
8 Keep the body clean and well groomed and protect the 
integument
9 Avoid dangers in the environment and avoid injuring 
others
10 Communicate with others in expressing emotions,needs, 
fears or opinions
11 Worship according to one’s faith 
12 Work in such a way that there is a sense of 
accomplishment
13 Play or participate in various forms of recreation 
14 Learn, discover or satisfy the curiosity that leads to 
normal development and health and use the available
health facilities
According to the applied theory and basis of history and physical examination ,I
have made the following nursing diagnosis by prioritizing the important ones
and thus developed the nursing care plan according to the nursing diagnosis.
Actual Problem:
 I have pain in abdomen
 Its paining in the cannula insertion site
 I am not feeling well. I think I have fever
Actual nursing diagnosis:
 Acute pain related to autodigestion of pancreas
 Risk for infection related to insertion of I/V cannula
 Impaired bowel habit related to inadequate dietary intake and
immobility
 Elevate body temperature related to disease condition
Potential diagnosis:
 Risk for infection related to invasive procedures

NURSING CARE PLAN

NURSING NURSING EXPECTED PLAN OF IMPLEMENTA RATIONA EVALUATI

ASSESSM DIAGNOSI GOAL/OUTCO ACTION TION LE ON
ENT S MES
Subjectiv Acute Report pain is I will: my goal
e data: I pain relieved - was
have pain related to within 30min investigate investigated Short completel
in autodiges of nursing verbal verbal reports term y met as
abdomen tion of interventions reports of of pain, pain is in client was
pancreas pain, noting pain acute client
Objective noting score of 6/10. pancreati pain
data: specific tis and if score was
On location pain in decrease
assessme and LUQ d to 2/10
nt intensity(0 suggest within 1
-Fatigue -10). involvem hour.
-poor ent of
facial pancreati
expressio c tail,
n localized
- pain may
indicate
pseudoc
ysts or
 abscess
-maintain
bedrst -maintained -
during bedrest decrease
acute during acute s
attack.pro attack.provid metaboli
vide quiet ed quiet and c rate
and restful restful and GI
environme environment. stimulati
nt on,
therby
reducing
pancreati
c activity.
-promote
position of - promoted -reduces
comfort position of abdomin
on one comfort on al
side with one side with pressure
knees knees flexed, and
flexed, sitting up and tension
sitting up leaning
and forward
leaning
forward

-provide -provided -
alternative back rub and promote
s informal s
measures teaching as relaxatio
alternative n and
measures enables
measures patient
to
refocus
attention
, my
enhance
coping
-
administer Inj. Ketorolac Severe
analgesics 10 mg IV was and
in timely given as pain prolonge
manner was not d pain
relieved can
aggravat
e shock
 and is
more
difficult
to relieve

NURSING NURSIN EXPECTED PLAN OF IMPLEMENTA RATIONAL EVALUATI

ASSESSM G GOAL/OUTCO ACTION TION E ON
ENT DIAGNO MES
SIS
Subjective Risk for The risk for I will: My goal
data:’Its infectio infection will -assess -IV site was -Helps to was
paining at n be reduced the IV assessed know completel
the related site about the y met as
cannula to status of patient
insertion insertio IV site was
site” n of I/V provided
cannula -remove -I/V cannula -Prevents with
Objective IV was removed from proper
data cannula if further care of IV
On needed complicati site
assessme ons
n:t
-redness -flush the -The cannula -prevents
-pain cannula was flushed from
with with normal irritation
normal saline after of vein at
saline every cannula
after medication site
 every
medicatio
n

-Change -IV tape was -Prevents

IV tape if changed from
needed ascending
infection
-
-apply Thrombophob -Reduces
thrombo was applied at swelling
pho at swelling site
swelling
site

NURSING NURSIN EXPECTED PLAN OF IMPLEMENTA RATION EVALUAT

ASSESSMENT G GOAL/OUTC ACTION TION ALE ION
DIAGNO OMES
SIS
Objecive Impaire Patient will I will: My goal
data:on d bowel pass stool -auscultate the -bowel sound -To was
assessment,p habit after the end bowel sound was ensure complete
atient hasn’t related of and assess for auscultated peristal ly met as
passed stool to intervention abdominal and tic patient
for 3 days. inadequ distension. abdominal movem passed
Her abdomen ate distension ent stool
was slightly dietary was assessed after the
distended and intake end of
was irritable and interventi
immobil -encourage -patient was -helps on
ity patient to encouraged to
increase fluid to increase soften
intake fluid intake stool

-encourage Patient was

patient to encouraged -Helps
intake fiber rich to intake to
diet fibrous diet soften
the
 -administer the -The stool
prescribed prescribed
medication(lact medication -helps
ulose) was to
administered lubricat
e the
stool

NURSING NURSIN EXPECTED PLAN IMPLEMENT RATIONA EVALUAT

ASSESSM G GOAL/OUTC OF ATION LE ION
ENT DIAGNO OMES ACTIO
SIS N
Subjectiv Elevate Patient fever I will: Determin My goal
e data:I body will be - ation and was
am not tempera reduced -identified managem complete
identif
feeling ture within 1 y the the ent of the ly
well. I related hour triggering underlyin achieved
trigerr g cause
think I to ing factors as
have disease are patient
factor necessary
fever conditio s fever
to
n was
recovery.
Objective reduced
data: to 36.2C
On - within 1
inspectio Monit HR and hour
n or the -Monitored BP
- patient the patient’s increase
Hot,flush ’s HR, HR, BP as
ed skin BP, hyperther
- mia
weaknes progresse
s s.
-T-37.6 C
- Elimin
ate Eliminate d
excess excess Exposing
clothin clothing and skin to
g and covers room air
covers decreases
. warmth
and
increases
evaporati
ve
cooling

-
-cold -promotes
provid
compression cooling
e cold was provided
and helps
compr
to lower
ess the
temperatu
re
DAILY PROGRESS NOTE:

My patient presented with diagnosis of acute pancreatitis . The daily

progressive note of my patient is as follows:

2nd day of admission(1/04/2018)

Vitals:

Time Temperature RR Pulse BP SPO2

12MD 37.6C 18b/m 88b/m 90/60 92%

Patients g/c is ill looking.pts is in sips diet. I/V drip continue, pain score was
4/10. Nail and hair care was provided.V/S within normal range .I/O
maintained. Pts has not passed stool since 3 days. pts fever was reduced to
36.2C from 37.6C. prescribed medication provided. No any chief complain
except mentioned above.

3rd day of admission(2/04/2018)

Time Temperature RR Pulse BP SPO2

12MD 36.6C 20b/m 74b/m 100/60 92%

Pts G/C seems satisfactory.V/S are monitored and within normal range. Pts
is in liquid and fat free diet. Has regular bladder and bowel habit. Inj. D5%
is running @21 drops/min over III pint. Vein site is patent.pain score
2/10.medication as per cardex . no any specific complain in duty hour.

4th day of admission(3/04/2018)

Time Temperature RR Pulse BP SPO2

12MD 36.3C 20b/m 72b/m 110/70 96%
Pts G/C satisfactory and is in IV lock. V/S within normal range.pts is in soft diet
and fat free diet. Pts has normal bowel and bladder pattern. Intake output
maintained, pain score 1/10. Pts is planned for lap. Cholecystectomy on
5/04/2018. PAC to be done. Medication as per cardex. No any specific
complain.

5th day of admission(4/04/2018)

Time Temperature RR Pulse BP SPO2

12MD 36.3C 18b/m 74b/m 130/80 93%

Pts G/C satisfactory and is in IV Lock. V/S within normal range . pts is in soft
diet and fat free diet . pts is planned for lap.cholecystectomy. intake output
maintained. Pain score 1/10. Medication as per cardex. Pts was provided
informal health teaching about the procedure. No any specific complain.

6th day of admission(5/04/2018)

Time Temperature RR Pulse BP SPO2

12MD 36.2C 20b/m 64b/m 110/80 95%

Her surgery was cancelled due to pleural effusion. She is now planned for
interval lap. Cholecystectomy after 2 weeks. She is stable at the time of
discharge. She was called for follow up after 1 week in URO OPD.
Developmental needs and task (Havighrust)

Developmental task In my client

i)selecting a mate Present
ii) learning to live with partner Present
iii)starting family Present
iv)rearing children Present
v)managing home Present
vi)taking on civic responsibility Present
vii)Getting started in occupation Present
vii)Finding a congenial social group Present
HEALTH TEACHING PROVIDED TO MY PATIENT DURING HOSPITALIZATION:

Health teaching during hospitalization play important role for the prompt
recovery of patient. Good health is a good indicator patient's well adjustment
to changed life due to disease condition. Health education is important in
preventing disease; promoting health and to cure disease without any
complication. So, I provided following teaching to the patient and his family.

The objectives of health education are as follows:

 To promote health by using locally available resources.

 To prevent illness and infection.
 To recover from illness and achieve normal health.
 To prevent complications.
 To maintain and fulfill the nutritional status of the patient.
 To provide good family environment.

I gave health education on following topic to achieve the above objective:

 Nutrition: Providing healthy and well balanced diet is most for the quick
recovery of the patient. As my patient was case of acute pancreatitis I
provided patient to intake fat free diet and more fluid intake , intake of
fresh juice and vegetables and fruits like papaya,kiwi etc. which helps to
cleanse the pancreas. I recommend Patient to limit red meat,fried
foods,butter,pastries and desserts with added sugars which can further
affect pancreas.
 Personal hygiene: Personal hygiene and cleanliness is important for all.
Maintain personal hygiene of client regarding bed bath, oral care, nail
 care, changing clean clothes, food hygiene and perineal hygiene to
prevent infection.
 Bladder and Bowel Care: Encourage the patient to take about 2 to 3
liters per day. Encourage the patient to take diet high in fiber like green
vegetables, carrot, apple with their skin, cucumber etc. which help to
ease defecation. Keep the perineal area clean and dry to prevent
excoriation of skin.
 Rest and sleep: I encouraged the patient to take adequate rest and sleep
well because rest and sleep reduces fatigue and need for oxygen
consumption. Due to physical condition, at first she was not unable to
sleep at night due to pain. Later on her sleeping pattern improved with
decreased pain.
 Medications: Provide health teaching to the visitors not to take self
medications. If they see any unusual symptoms, report promptly.
Encourage the visitors to ask questions if they have any queries
regarding the medicines.
 Pain management:I encouraged to do the yoga and meditation whch
helps to reduce the pain caused by disease condition. I also encouraged
to find a comfortable position during acute attack which helps to ease
the pain.
DISCHARGE TEACHING:

Discharge teaching plan is an integral part of the nursing process. It is the most
needed responsibility of the nurse to plan and suggest the patient and family
for the continuity of care at home. Health teaching during discharge and
hospitalization are important for preventing complications, promoting health
and restoring the sound health, maintaining normal and actual living style.

Objectives of discharge teaching plan:

a. To promote and maintain health and prevent from illness in home
after discharge.
b. To consider primary health care concept in health teaching.
c. To provide holistic care to the patient.
d. To provide need based health education.

My patient was discharged on 5 April 2018, but I was not there at the time of
discharge. So if I were there , I would have given following discharge teaching.

 Explain patient party about discharge and follow up visits

 Advise patient party to have the right medication on right time.
 Advice patient party to provide adequate nutritious fluids.
 Maintain optimum personal hygiene.
 Encourage family members to involve patient in activities of daily livings
 Perform passive range of motion exercises and deep breathing and
coughing exercises
 Advice the patient to come to hospital like persistent belly pain, nausea,
vomiting, jaundice and fever.
  Encourage the patient to involve in diversional therapy like yoga and
meditation to ease the pain.

Learning from the case study:

During the case study period, learning was done on following:

Skill development in history taking and physical examination.

Detail knowledge about the disease condition, its sign and symptom,
diagnosis, treatment and management
Nursing management and care of the patient with such disease.
Application of nursing theory in patient care.
Participation in care of patient on the basis of well prepared nursing
care plan.
Detail knowledge about the drugs used in my patient.
SUMMARY OF MY CASE STUDY

During my 4 weeks BNS 2nd year, I chose the “Acute pancreatitis” for my case
study, patient name Sukrim kumara gole 69 years female admitted in surgical
ward. Was from sindhuli,sunkosi-7. She was admitted to ward with the
complain of epigastric pain, nausea, vomiting, fever since since 2 pm of
2018/03/29.

I had provided holistic nursing care to the patient according to her need by
considering the physical, mental, socio-cultural, spiritual and economic aspect.
I provided nursing care based on Virginia Henderson’s theory. During
hospitalization I also provided necessary health education regarding health
promotion, maintenance, prevention from infection and discharge teaching
that She needed to cope with her disease condition.

During interaction with my patient, She and her family members behaved co-
operatively with me so there was no difficulty for providing care and collecting
informations. I respect them, their culture, custom and way of living and
thinking, so they trusted me and co-operated very much. They were really
greatful for me.
CONCLUSION

Case study is one of the most important aspects of nursing practice in the
hospital setting. It provides us an opportunity for comprehensive study of one
selected case in comparison with book and helps to provide holistic nursing
care to the patient according to developmental milestone.
Acute pancreatitis can be important experiences for all learning personnel for
getting clear and up to date knowledge about disease condition. This will not
only help us to promote safe and healthy living in the family and the
community but also it will help to reduce morbidity and mortality rates. Such
detailed case study gives knowledge about what are problems, its causes, sign
and symptoms and nursing consideration. Case study also helps us to do
research.
During hospitalization, I provided her holistic nursing care and diversional
therapy in every aspects like physical, emotional, economical and socio-
cultural view. I also gained knowledge about nursing theory and its application
in real situation. So, the case study not only gives the cognitive domain but also
provide us the opportunity to develop psychomotor domain, which is very
important in nursing field. So, the patient is main source of converting
knowledge in practice.

I also got opportunity to know about my patient, family, socio-cultural,

economic status, religious background which helped me in providing care
effectively. I also identified the stress, anxiety in my patient and used
psychotherapy and diversional therapy to reduce it.

In this way, this case study provided me a good opportunity to gain deep
knowledge on Nephrolithiasis, so I am completely satisfied with my case study.

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Nursing,9th edition;2014.Elsevier
2. Basavanthappa B.T. Medical surgical nursing. 2nd edition; 2009. Jaypee
3. Smeltzer S.N. Medical Surgical Nursing.10th edition. Lippincott Williams and Wilkins
4. Black J.M, Hawks J.H. Medical Surgical Nursing. 8th edition; 2013.Elsevier
5. Hinkle J.L,Cheever K.H,Brunner and suddharth’s textbook of medical surgical
nursing.13th edition;2015.Wolters Kluwer
6. Walsh M.Watson’s clinical nursing and related science .6th edition;2002
7. Tripathi K.D. Essentials of medical pharmacology.4th edition. Jaypee;2000
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