CONCEPT MAP Nursing Diagnosis Nursing Diagnosis Acute Pain evidenced by grimacing and guarding behaviors Risk for infection related to immunosuppression Subjective Data: Pt states that she has pain in the upper quadrants of her abd that spread to her back Subjective Data: I am immunocompromised Objective Data: increased lipase and amylase lab values Objective Data: Elevated Lipase Reason for Seeking Health Care (Admitting Diagnosis) Acute Pancreatitis Nursing Diagnosis Nursing Diagnosis Risk for deficient fluid volume related to N/V and gastric suctioning Risk for imbalanced nutrition: Less than body requirements Subjective Data: I feel week and I am dehydrated Subjective Data: I do not feel like eating Objective Data: Increased BUN and creatinine levels Objective Data: PT has lost four pounds in one week PLAN OF CARE PRIORITY #1 Nursing Diagnosis: Intervention (s) The nurse will Maintain bedrest during acute attack and provide peaceful environment Provide odor free environment Administer Meds as ordered by HCP Antacids Rationale Decreases metabolic rate and Gi stimulation reducing pancreatic activity Sensory stimulation can activate pancreatic enzymes, increasing pain Meperidine is effective in relieving pain and may be preferred over morphine Neutralize gastric acid to reduce prod. Of pancreatic enzymes Expected Outcome: The patient will report controlled pain PRIORITY #2 Nursing Diagnosis: Intervention (s) The nurse will Aseptic technique when changing surgical dressing and working with IV lines Hand washing Observe for fever and resp. distress in conjunction with jaundice Increased abd pain and tenderness, recurrent high fever, hypotension, chills Rationale Limits sources of infection and bacteria Reduces risk for cross contamination and HAI Cholestatic jaundice may be first sign of sepsis Abscesses can occur 2 wks or more after onset of pancreatitis Expected Outcome: The patient will achieve timely healing and no signs of infection PRIORITY #3 Nursing Diagnosis: Intervention (s) The nurse will Note poor skin turgor, dry skin and mucous membranes and increased thirst Monitor BP and measure CVP if available Measure I&O Observe and report peripheral and dependent edema Rationale Further physiological indicators of dehydration Pancreatic ischemia can result in hypotension Indicator of replacement needs and specific therapy Edema and fluid shifts occur as a result of increased vascular permeability Expected Outcome: The patient will maintain hydration with stable vital signs, skin turgor, cap refill and stron peripheral pulses. PRIORITY #4 Nursing Diagnosis: Intervention (s) The nurse will Assess bowel sounds and abd distention and reports of nausea Assist pt in selecting foods and fluids that meet needs and restrictions Test urine for sugar and acetone Maintain NPO and gastric suctioning Rationale If this is present this can result lack of appetite To cater to their appetite Early detection of inadequate glucose may prevent development of ketoacidosis Prevents stimulation and release of pancreatic enzymes Expected Outcome: The patient will experience no signs of malnutrition