CARE OFCLIENTS WITH PROBLEM IN

NUTRITION, AND GASTRO-INTESTINAL,

METABOLISM AND ENDOCRINE,
PERCEPTION AND COORDINATION, (ACUTE
AND CHRONIC)
STUDENT’S ACTIVITY SHEET BS NURSING / THIRD YEAR
Session # 11 (2 hours and 30 minutes)

LESSON TITLE: REVIEW OF ENDOCRINE SYSTEM; Materials:

ACUTE AND CHRONIC PANCREATITIS Book, pen and notebook, projector

References:
LEARNING OUTCOMES:
Smeltzer, S., Bare, B., Hinkle, J., & Cheever, K.
Upon completion of this lesson, the nursing student can:
(2008). Brunner &Suddarth’s Textbook of
1. Review the Endocrine glands and hormones.
Medical-Surgical Nursing 12th Edition.
2. Discover the laboratory/diagnostic findings of pancreatitis.
Lippincott Williams &Wilkins
3. Identify the medical and nursing management of acute and
chronic pancreatitis.

LESSON REVIEW / PREVIEW OR HOOK ACTIVITY (1 minute)

List at least 3 hormones associated with endocrine glands.

MAIN LESSON (2 hours and 9 minutes)

The students will study and read their book about this lesson (Chapter 40 of the book).

ENDOCRINE GLANDS AND HORMONES

Source Hormone Major Action
Hypothalamus Releasing & Inhibiting hormones: Controls the release of pituitary
• Corticotropin-releasing hormones
hormone (CRH)
• Thyrotropin-releasing Inhibits growth hormone & thyroid
hormone (TRH) stimulating hormone
• Growth-hormone-releasing
hormone (GHRH)
• Gonodotropin-releasing
hormone (GnRH)
• Somastatin

Anterior Pituitary Growth Hormone (GH) Stimulates growth of bone & muscle,
promotes protein synthesis and fat
metabolism, decreases carbohydrate
metabolism
Adrenocorticotropic hormone (ACTH) Stimulates synthesis & secretion of
adrenal cortical hormones
Thyroid-stimulating hormone (TSH) Stimulates synthesis & secretion of
thyroid hormone
Follicle-stimulating hormone (FSH) Female: stimulates growth of ovarian
follicle, ovulation
Male: stimulates sperm production

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 Luteinizing hormone (LH) Female: stimulates production of
corpus luteum, release of oocyte,
production of estrogen &
progesterone
Male: stimulates secretion of
testosterone, development of
interstitial tissue of testes
Posterior Pituitary Antidiuretic hormone (ADH) Increases water reabsorption by
kidney
Oxytocin Stimulates contraction of pregnant
uterus, milk ejection from breasts
after childbirth
Adrenal Cortex Mineralocorticosteroids, mainly Increases sodium reabsorption,
aldosterone potassium loss by kidney
Glucocorticoids, mainly cortisol Affects metabolism of all nutrients,
regulates blood glucose level, affects
growth, has anti- inflammatory action,
& decreases effects of stress
Adrenal androgens, mainly Have minimal intrinsic androgenic
dehydroepiandrosterone (DHEA) & activity; they are converted to
androstenedione testosterone & dihydrotestosterone in
the periphery
Adrenal Medulla Epinephrine Increases blood glucose, stimulating
Norepinephrine ACTH, glucocorticoids

Increases rate & force of cardiac

contractions

Constricts blood vessels in skin,

mucous membranes, & kidneys

Dilates blood vessels in skeletal

muscles, coronary & pulmonary
arteries
Thyroid (follicular cells) Thyroid hormones: triiodothyronine Increase the metabolic rate
(T3), thyroxine (T4)
Increase protein& bone turnover

Increase responsiveness to
catecholamines; necessary for fetal &
infant growth & development

T4 contains four iodine atoms in each

while T3 contains only 3

These hormones are synthesized &

stored bound to proteins in the cells of
the thyroid gland until needed for
release into the bloodstream

Thyroid C cells Calcitonin Lowers blood calcium & phosphate

levels
Parathyroid glands Parathyroid hormone Regulates serum calcium
Pancreatic islet cells Insulin Lowers blood glucose by facilitating
glucose transport across cell
membranes of muscle, liver, &
adipose tissue

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 Glucagon Increases blood glucose
concentration by stimulation of
glycogenolysis & glyconeogenesis
Somatostatin Delays intestinal absorption of
glucose
Ovaries Estrogen Affects development of female sex
organs & secondary sex
characteristics
Progesterone Influences menstrual cycle; stimulates
growth of uterine wall; maintains
pregnancy
Androgens, mainly testosterone Affects development of male sex
organs & secondary sex
characteristics; aids in sperm
production

THE PANCREAS
Located in the upper abdomen, has endocrine as well as exocrine functions. 1). The exocrine functions
include secretion of pancreatic enzymes into the gastrointestinal (GI) tract through the pancreatic duct. The
endocrine functions include secretion of insulin, glucagon, and somatostatin directly into the bloodstream.

The Exocrine function:

• The secretions of the exocrine pancreas are digestive enzymes high in protein content and an
electrolyte-rich fluid. The secretions, which are very alkaline because of their high concentration of
sodium bicarbonate, are capable of neutralizing the highly acid gastric juice that enters the
duodenum.
• The enzyme secretions include amylase, which aids in the digestion of carbohydrates; trypsin,
which aids in the digestion of proteins; and lipase, which aids in the digestion of fats.

The Endocrine Pancreas

• The islets of Langerhans, the endocrine part of the pancreas, are collections of cells embedded in
the pancreatic tissue. They are composed of alpha, beta, and delta cells. The hormone produced
by the beta cells is called insulin; the alpha cells secrete glucagon, and the delta cells secrete
somatostatin.

Endocrine Control of Carbohydrate Metabolism

Glucose required for energy is derived by metabolism of ingested carbohydrates and also from proteins by
the process of gluconeogenesis. Glucose can be stored temporarily in the form of glycogen in the liver, muscles,
and other tissues. Through the action of hormones, blood glucose is normally maintained at less than 100 mg/dL
(5.5 mmol/L). Insulin is the primary hormone that lowers the blood glucose level. Hormones that raise the blood
glucose level are glucagon, epinephrine, adrenocorticosteroids, growth hormone, and thyroid hormone.

PANCREATITIS
• Is the inflammation of the pancreas. Acute pancreatitis can be a medical emergency associated
with a high risk of life-threatening complications and mortality, whereas chronic pancreatitis often
goes undetected until 80% to 90% of the exocrine and endocrine tissue is destroyed.
• Acute pancreatitis does not usually lead to chronic pancreatitis unless complications develop.
However, chronic pancreatitis can be characterized by acute episodes.

ACUTE PANCREATITIS
Acute pancreatitis ranges from a mild, self-limited disorder to a severe, rapidly fatal disease that does not
respond to any treatment. Mild acute pancreatitis is characterized by edema and inflammation confined to the
pancreas. Minimal organ dysfunction is present, and return to normal function usually occurs within 6 months.
Enzymes damage the local blood vessels, and bleeding and thrombosis can occur.

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 Pathophysiology
1. Self-digestion of the pancreas by its own proteolytic enzymes, principally trypsin, causes acute pancreatitis.
2. Although the mechanisms causing pancreatic inflammation are unknown, pancreatitis is commonly described
as autodigestion of the pancreas. It is believed that the pancreatic duct becomes temporarily obstructed,
accompanied by hypersecretion of the exocrine enzymes of the pancreas. These enzymes enter the bile duct,
where they are activated and, together with bile, back up (reflux) into the pancreatic duct, causing pancreatitis.
3. Gallstones enter the common bile duct and lodge at the ampulla of Vater, obstructing the flow of pancreatic
juice or causing a reflux of bile from the common bile duct into the pancreatic duct, thus activating the powerful
enzymes within the pancreas. Activation of the enzymes can lead to vasodilation, increased vascular
permeability, necrosis, erosion, and hemorrhage.
4. The overall mortality rate of patients with acute pancreatitis is high (2% to 10%) because of shock, anoxia,
hypotension, or fluid and electrolyte imbalances.
5. Attacks of acute pancreatitis may result in complete recovery, may recur without permanent damage, or may
progress to chronic pancreatitis.

Clinical Manifestations
1. Severe abdominal pain is the major symptom; abdominal pain and tenderness and back pain result from
irritation and edema of the inflamed pancreas, increased tension on the pancreatic capsule, and obstruction of
the pancreatic ducts.
Typically, the pain occurs in the midepigastrium. Pain is frequently acute in onset, occurring 24 to 48 hours
after a very heavy meal or alcohol ingestion, and it may be diffuse and difficult to localize. It is generally more
severe after meals and is unrelieved by antacids. Pain may be accompanied by abdominal distention; a poorly
defined, palpable abdominal mass; decreased peristalsis; and vomiting that fails to relieve the pain or nausea.
2. Abdominal guarding
3. A rigid or boardlike abdomen may develop and is generally an ominous sign, usually indicating peritonitis.
4. Ecchymosis (bruising) in the flank or around the umbilicus may indicate severe pancreatitis (Cullen’s sign)
5. Nausea and vomiting are common in acute pancreatitis (emesis is usually gastric in origin but may also be bile
stained)
6. Fever, jaundice, mental confusion, and agitation may also occur
7. Hypotension is typical and reflects hypovolemia and shock caused by the loss of large amounts of protein-rich
fluid into the tissues and peritoneal cavity
8. Tachycardia, cyanosis, and cold, clammy skin may develop
9. Acute renal failure is common
10. Respiratory distress and hypoxia are common, and the patient may develop diffuse pulmonary infiltrates,
dyspnea, tachypnea, and abnormal blood gas values
11. Myocardial depression, hypocalcemia, hyperglycemia, and disseminated intravascular coagulation may also
occur with acute pancreatitis

Assessment and Diagnostic Findings

1. History of abdominal pain, the presence of known risk factors, physical examination findings
2. Elevated serum amylase and lipase levels (used in making the diagnosis of acute pancreatitis; elevated within
24 hours of the onset of the symptoms; serum amylase usually returns to normal within 48 to 72 hours, but
serum lipase levels may remain elevated for a longer period, often days longer than amylase)
3. Elevated urinary amylase levels, and remain elevated longer than serum amylase levels
4. Elevated white blood cell count
5. Hypocalcemia
6. Hyperglycemia and glucosuria
7. Elevated serum bilirubin levels
8. X-ray studies of the abdomen and chest may be obtained to differentiate pancreatitis from other disorders that
can cause similar symptoms and to detect pleural effusions
9. Ultrasound and contrast-enhanced CT scans are used to identify an increase in the diameter of the pancreas
and to detect pancreatic cysts, abscesses, or pseudocysts
10. Hematocrit and hemoglobin levels are used to monitor the patient for bleeding
11. Peritoneal fluid, obtained through paracentesis or peritoneal lavage, may contain increased levels of pancreatic
enzymes

Medical Management
- All oral intake is withheld to inhibit stimulation of the pancreas and its secretion of enzymes.
- Enteral/parenteral nutrition plays an important role in the nutritional support of patients with severe
acute pancreatitis, particularly in those who are debilitated and those with a prolonged paralytic ileus

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 (more than 48 to 72 hours)
- Nasogastric suction to relieve nausea and vomiting and to decrease painful abdominal distention and
paralytic ileus.
- Histamine-2 (H2) antagonists such as Cimetidine (Tagamet) and Ranitidine (Zantac) to decrease
pancreatic activity by inhibiting secretion of gastric acid; Proton pump inhibitors such as pantoprazole
(Protonix) may be used for patients who do not tolerate H 2 antagonists or for whom this therapy is
ineffective.
- Adequate administration of analgesia: parenteral opioids such as Morphine, Fentanyl (Sublimaze), or
Hydromorphone (Dilaudid)
- Antiemetic agents may be prescribed to prevent vomiting

Surgical Management
May be performed to assist in the diagnosis of pancreatitis (diagnostic laparotomy), to establish pancreatic
drainage, or to resect or debride a necrotic pancreas. The patient who undergoes pancreatic surgery may have
multiple drains in place postoperatively, as well as a surgical incision that is left open for irrigation and repacking
every 2 to 3 days to remove necrotic debris.

Post-acute Management
1. Antacids
2. Oral feedings that are low in fat and protein are initiated gradually
3. Caffeine and alcohol are eliminated from the diet
4. Follow- up may include ultrasound, x-ray studies, or ERCP to determine whether the pancreatitis is resolving
and to assess for abscesses and pseudocysts

Nursing Management
1. Relieve Pain and Discomfort
1. Administer analgesics: parenteral opioids, including morphine, hydromorphone, or fentanyl via patient-
controlled analgesia.
2. Frequently assess the pain and the effectiveness of the pharmacologic (and nonpharmacologic)
interventions.
3. Provide nonpharmacologic interventions: proper positioning, music, distraction, and imagery.
4. Withhold oral feedings to decrease the secretion of secretin.
5. Administer fluids and electrolytes to restore and maintain fluid balance.
6. Provide frequent oral hygiene and care to decrease discomfort from the nasogastric tube and relieve
dryness of the mouth.
7. Maintain the patient on bed rest to decrease the metabolic rate and reduce the secretion of pancreatic and
gastric enzymes.
8. Report for increasing severity of pain, because the patient may be experiencing hemorrhage of the
pancreas or the dose of analgesic may be inadequate.
9. Provide frequent and repeated but simple explanations about the need for withholding fluids, maintenance
of gastric suction, and bed rest.
2. Improve Breathing Pattern
1. Maintain the patient in a semi-Fowler’s position to decrease pressure on the diaphragm by a distended
abdomen and to increase respiratory expansion.
2. Frequent changes of position to prevent atelectasis and pooling of respiratory secretions.
3. Monitor pulse oximetry or arterial blood gases
4. Instruct the patient in techniques of coughing and deep breathing and in the use of incentive spirometry to
improve respiratory function.
5. Assist the patient to perform these activities every hour.
3. Improve Nutritional Status
1. Oral food or fluid intake is not permitted.
2. Monitor laboratory test results and daily weights.
3. Enteral or parenteral nutrition may be prescribed.
4. Monitor serum glucose levels every 4 to 6 hours.
5. As the acute symptoms subside, reintroduce oral feedings are gradually.
6. Between acute attacks, provide a diet that is high in carbohydrates and low in fats and proteins.
7. Advise patient to avoid heavy meals and alcoholic beverages.
4. Maintain Skin Integrity
The patient is at risk for skin breakdown because of poor nutritional status, enforced bed rest, restlessness,

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 and multiple drains or an open surgical incision.
1. Assess the wound, drainage sites, and skin for signs of infection, inflammation, and breakdown.
2. Carry out wound care as prescribed and takes precautions to protect intact skin from contact with drainage.
3. Turn the patient every 2 hours; use of specialty beds may be indicated to prevent skin breakdown.
5. Promote Home and Community-Based Care
1. Teaching Patients Self-Care
- Avoid high-fat foods, heavy meals, and alcohol.
- Give the patient and family verbal and written instructions about signs and symptoms of acute
pancreatitis and possible complications that should be reported promptly to the physician.
- Avoid all alcohol.

CHRONIC PANCREATITIS
Chronic pancreatitis is an inflammatory disorder characterized by progressive destruction of the pancreas.
As cells are replaced by fibrous tissue with repeated attacks of pancreatitis, pressure within the pancreas increases.
The result is obstruction of the pancreatic and common bile ducts and the duodenum. Additionally, there is atrophy
of the epithelium of the ducts, inflammation, and destruction of the secreting cells of the pancreas.

Risk Factors/Causes
1. Alcohol consumption and malnutrition - major causes
- Excessive and prolonged consumption of alcohol accounts for approximately 70% to 80% of all cases of
chronic pancreatitis. Long-term alcohol consumption causes hypersecretion of protein in pancreatic
secretions, resulting in protein plugs and calculi within the pancreatic ducts. Alcohol also has a direct toxic
effect on the cells of the pancreas.
- Damage to these cells is more likely to occur and to be more severe in patients whose diets are poor
in protein content and either very high or very low in fat.
2. Between 37 to 40 years
3. Smoking

Clinical Manifestations
1. Recurring attacks of severe upper abdominal and back pain, accompanied by vomiting. Attacks are often so
painful that opioids, even in large doses, do not provide relief. As the disease progresses, recurring attacks of
pain are more severe, more frequent, and of longer duration.
2. Some patients experience continuous severe pain, and others have dull, nagging constant pain.
3. In some patients, chronic pancreatitis is painless.
4. Weight loss is a major problem caused by decreased dietary intake secondary to anorexia or fear that eating
will precipitate an- other attack.
5. Malabsorption occurs late: stools become frequent, frothy, and foul-smelling because of impaired fat digestion,
which results in stools with a high fat content (steatorrhea).
6. As the disease progresses, calcification of the gland may occur, and calcium stones may form within the ducts.

Assessment and Diagnostic Findings

1. Endoscopic retrograde cholangiopancreatography (ERCP)- most useful study; provides details about the
anatomy of the pancreas and the pancreatic and biliary ducts; also helpful in obtaining tissue for analysis and
differentiating pancreatitis from other conditions, such as carcinoma.
2. Magnetic Resonance Imaging (MRI), CT scans, and Ultrasound
3. Glucose tolerance test - evaluates pancreatic islet cell function and provides necessary information for making
decisions about surgical resection of the pancreas. An abnormal glucose tolerance test may indicate the
presence of diabetes associated with pancreatitis.
4. Increased serum amylase levels
5. Steatorrhea

Medical Management
Treatment is directed toward preventing and managing acute attacks, relieving pain and discomfort, and
managing exocrine and endocrine in- sufficiency of pancreatitis.
Nonsurgical approaches may be indicated for the patient who refuses surgery, who is a poor surgical risk,
or whose disease and symptoms do not warrant surgical intervention.
1. Endoscopy - removes pancreatic duct stones, correct strictures, and drains cysts to manage pain and
relieve obstruction

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 2. Nonopioid agents - manage pain
3. Yoga - for pain reduction and for relief of other coexisting symptoms of chronic pancreatitis
4. Avoidance of alcohol and foods that have produced abdominal pain and discomfort in the past
5. Pancreatic enzyme replacement - for patient with malabsorption and steatorrhea

Surgical Management
Surgery may be indicated to relieve persistent abdominal pain and discomfort, restore drainage of
pancreatic secretions, and reduce the frequency of acute attacks of pancreatitis and hospitalization.
1. Pancreaticojejunostomy
- Also referred to as Rouxen- Y, with a side-to-side anastomosis or joining of the pancreatic duct to the
jejunum, allows drainage of the pancreatic secretions into the jejunum.
- Pain relief occurs within 6 months in more than 85% of the patients who undergo this procedure, but
pain returns in a substantial number of patients as the disease progresses.
2. Whipple resection
- Pancreaticoduodenectomy, can be carried out to relieve the pain of chronic pancreatitis.
3. Beger or Frey Operations
- Remove most of the head of the pancreas except for a shell of pancreatic tissue posteriorly.
- Provide permanent pain relief and avoid endocrine and exocrine insufficiency.
4. Endoscopic and Laparoscopic procedures: Distal Pancreatectomy
- Longitudinal decompression of the pancreatic duct, nerve denervation, and stenting have been
performed in patients with jaundice or recurrent inflammation and are being refined.

**Patients who undergo surgery for chronic pancreatitis may experience weight gain and improved
nutritional status. However, morbidity and mortality after these surgical procedures are high because of the
poor physical condition of the patient before surgery and the concomitant presence of cirrhosis. Even after
undergoing these surgical procedures, the patient is likely to continue to have pain and impaired digestion
secondary to pancreatitis, unless alcohol is avoided completely.

CHECK FOR UNDERSTANDING (15 minutes)

The instructor will prepare 10-15 questions that can enhance critical thinking skills. Students will work by themselves to
answer these questions and write the rationale for each question.
Multiple Choice

(For 1-10 items, please refer to the questions in the Rationalization Activity)

RATIONALIZATION ACTIVITY (DURING THE FACE TO FACE INTERACTION WITH THE STUDENTS)
The instructor will now rationalize the answers to the students and will encourage them to ask questions and to discuss
among their classmates for 20 minutes.

1. When teaching a client about pancreatic function, the nurse understands that pancreatic lipase performs which function?
A. Transports fatty acids into the brush border.
B. Breaks down fat into fatty acids and glycerol.
C. Triggers cholecystokinin to contract the gallbladder.
D. Breaks down protein into dipeptides and amino acids.
ANSWER: ________
RATIO:_________________________________________________________________________________________
_______________________________________________________________________________________________
________________________________________________________

2. What laboratory finding is the primary diagnostic indicator for pancreatitis?

A. Elevated blood urea nitrogen (BUN)
B. Elevated serum lipase
C. Elevated aspartate aminotransferase (AST)
D. Increased lactate dehydrogenase (LD)
ANSWER: ________
RATIO:_________________________________________________________________________________________
_______________________________________________________________________________________________
________________________________________________________

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3. Pierre who is diagnosed with acute pancreatitis is under the care of Nurse Bryan. Which intervention should the nurse
include in the care plan for the client?
A. Administration of vasopressin and insertion of a balloon tamponade
B. Preparation for a paracentesis and administration of diuretics
C. Maintenance of nothing-by-mouth status and insertion of nasogastric (NG) tube with low intermittent suction
D. Dietary plan of a low-fat diet and increased fluid intake to 2,000 ml/day
ANSWER: ________
RATIO:_________________________________________________________________________________________
_______________________________________________________________________________________________
________________________________________________________
.

4. Britney, a 20 y.o. student is admitted with acute pancreatitis. Which laboratory findings do you expect to be abnormal for
this patient?
A. Serum creatinine and BUN
B. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST)
C. Serum amylase and lipase
D. Cardiac enzymes
ANSWER: ________
RATIO:_________________________________________________________________________________________
_______________________________________________________________________________________________
________________________________________________________
.

5. Michael, a 42 y.o. man is admitted to the med-surg floor with a diagnosis of acute pancreatitis. His BP is 136/76, pulse
96, Resps 22 and temp 101. His past history includes hyperlipidemia and alcohol abuse. The doctor prescribes an NG tube.
Before inserting the tube, you explain the purpose to patient. Which of the following is a most accurate explanation?
A. “It empties the stomach of fluids and gas.”
B. “It prevents spasms at the sphincter of Oddi.”
C. “It prevents air from forming in the small intestine and large intestine.”
D. “It removes bile from the gallbladder.”
ANSWER: ________
RATIO:_________________________________________________________________________________________
_______________________________________________________________________________________________
________________________________________________________

6. Ralph has a history of alcohol abuse and has acute pancreatitis. Which lab value is most likely to be elevated?
A. Calcium
B. Glucose
C. Magnesium
D. Potassium
ANSWER: ________
RATIO:_________________________________________________________________________________________
_______________________________________________________________________________________________
________________________________________________________

7. For Rico who has chronic pancreatitis, which nursing intervention would be most helpful?
A. Allowing liberalized fluid intake.
B. Counseling to stop alcohol consumption.
C. Encouraging daily exercise.
D. Modifying dietary protein.
ANSWER: ________
RATIO:_________________________________________________________________________________________
_______________________________________________________________________________________________
________________________________________________________

8. Leigh Ann is receiving pancrelipase (Viokase) for chronic pancreatitis. Which observation best indicates the treatment is
effective?
A. There is no skin breakdown.
B. Her appetite improves.

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C. She loses more than 10 lbs.
D. Stools are less fatty and decreased in frequency.
ANSWER: ________
RATIO:_________________________________________________________________________________________
_______________________________________________________________________________________________
________________________________________________________

9. To inhibit pancreatic secretions, which pharmacologic agent would you anticipate administering to a patient with
chronic pancreatitis?
A. Nitroglycerin
B. Somatostatin
C. Pancrelipase
D. Pepcid
ANSWER: ________
RATIO:_________________________________________________________________________________________
_______________________________________________________________________________________________
________________________________________________________

10. A clinical manifestation of chronic pancreatitis is epigastric pain. Your nursing intervention to facilitate relief of pain would
place the patient in a:
A. Knee-chest position
B. Semi-Fowler’s position
C. Recumbent position
D. Low-Fowler’s position
ANSWER: ________
RATIO:_________________________________________________________________________________________
_______________________________________________________________________________________________
________________________________________________________

LESSON WRAP-UP (5 minutes)

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help
you track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.

Minute Paper
Answer the following questions:
1. What was the most useful or the most meaningful thing you learned this section?
2. What question(s) do you have as we end this section?

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