Last updated on December 28th, 2023
Here we will formulate sample Acute Pancreatitis nursing care plans based on a hypothetical case scenario.
It will include three acute pancreatitis nursing care plans with NANDA nursing diagnoses, nursing assessment, expected outcome, and nursing interventions with rationales.
Acute Pancreatitis Case Scenario
A 44-year-old male presents to the ED with complaints of severe abdominal pain, nausea, and vomiting.
The patient has a history of ETOH abuse and admits to drinking 8-10 beers a day. He had a previous hospital admission 1 year ago for acute pancreatitis and his last beer was 36 hours ago.
He says he has been experiencing severe abdominal pain for 2 days. The pain is primarily in his upper abdomen but radiates to the back and seems to be worse after eating. Because of this, the patient hasn’t eaten or drunk anything in 2 days.
Upon assessment, the patient is alert and oriented but is seen hunched over holding his stomach. He rates his pain as 9 out of 10.
His temperature is 38.3 ˚C, heart rate is 110 BPM, blood pressure is 93/60 mmHg, respirations are 28 breaths per minute, and oxygen saturation is 98% on room air.
His abdomen is distended and is very tender upon palpation. His lung and heart sounds are unremarkable.
The patient’s blood work reveals WBCs of 12.43 K/mcL, lipase of 624 U/L, and amylase of 589 U/L.
The patient is taken for a stat CT of the abdomen, which reveals diffuse parenchymal enlargement and edema consistent with interstitial edematous pancreatitis.
The patient is admitted for Acute Pancreatitis.
#1 Sample Acute Pancreatitis Nursing Care Plan – Acute pain
Acute pancreatitis nursing assessment
Subjective Data:
- The patient reports abdominal pain which radiates to the back and is worse after eating and while lying down.
Objective Data:
- The patient is observed hunched over and holding his stomach.
- He rates his pain as 9/10.
Acute pancreatitis nursing diagnosis
Acute pain related to pancreatic autodigestion as evidenced by 9/10 abdominal pain.
Goal/desired outcome for acute pancreatitis
Short-term goal: By the end of the shift the patient will experience a reduction of pain to an acceptable level.
Long-term goal: The patient will comply with the treatment regime and will stop abusing alcohol.
Acute pancreatitis nursing interventions – Acute pain
| Nursing Interventions | Rationales |
| Perform a pain assessment at least every 4 hours and before and after administration of pain medications. | Monitoring pain levels will guide treatment and assess progress. |
| Administer narcotics for pain relief. | Narcotics such as fentanyl (Sublimaze) and meperidine (Demerol) are recommended for pain relief. Morphine is not recommended due to the potential for biliary-pancreatic spasms. |
| Administer Histamine-2 (H2) receptor antagonists and/or proton pump inhibitors (PPIs). | These medications decrease hydrochloric acid secretion, which reduces pancreatic stimulation, and thus, decreases pain. |
| Place and maintain NG tube to suction. | This helps relieve nausea and vomiting, decreases distention, and prevents an ileus from forming. |
| Maintain strict NPO. | Strict NPO is maintained to inhibit pancreatic stimulation and the subsequent secretion of pancreatic enzymes. |
| Maintain bed rest and decrease stimulation. | Minimal movement and stimulation help prevent pancreatic stimulation. |
| Utilize non-pharmacological pain relief measures. | Application of heat or cold, meditation, and guided imagery are a few examples of non-pharmacological pain relief measures. The patient should also be encouraged to lay on one side with the knees flexed, or hunch forward, to reduce abdominal pressure and pain. |
#2 Sample Acute Pancreatitis Nursing Care Plan – Deficient fluid volume
Acute pancreatitis nursing assessment
Subjective Data:
- The patient hasn’t eaten or drunk anything in 2 days.
- The patient reports vomiting.
Objective Data:
- The patient’s heart rate is 110 BPM and blood pressure is 93/60 mmHg.
Acute pancreatitis nursing diagnosis
Deficient fluid volume related to vomiting secondary to inflammation of the pancreas as evidenced by tachycardia, hypotension, and inability to eat or drink.
Goal/desired outcome acute pancreatitis
Short-term goal: By the end of the shift the patient will receive IV fluids and the heart rate and blood pressure will return to normal limits.
Long-term goal: The patient will maintain adequate hydration and will have no subsequent occurrences of pancreatitis.
Acute pancreatitis nursing interventions – Deficient fluid volume
| Nursing Interventions | Rationales |
| Administer IV fluids. | Acute pancreatitis causes a severe fluid deficit due to vomiting, decreased intake, and fluid shifts. Fluid resuscitation must be undertaken to prevent organ damage. |
| Closely monitor I&O. | Urine output, emesis, NG tube output, and IV fluid administration should be closely monitored to assess fluid status. |
| Assess markers of fluid status. | Indicators of fluid status are blood pressure, heart rate, CVP, skin turgor, dry skin, and dry mucous membranes. |
| Monitor electrolytes. | Fluid deficits and dehydration can cause dangerous electrolyte shifts. A metabolic panel should be monitored frequently and electrolytes should be replaced and managed as needed. |
| Perform a daily weight. | To assess fluid status, a daily weight should be taken at the same time and via the same route (bed scale, standing scale, etc.) |
#3 Acute Pancreatitis Nursing Care Plan – Ineffective health maintenance
Acute pancreatitis nursing assessment
Subjective Data:
- The patient has a history of ETOH abuse and admits to drinking 8-10 beers a day.
Objective Data:
- The patient’s lipase is 624 U/L and amylase is 589 U/L.
- He has a previous admission for pancreatitis.
Acute pancreatitis nursing diagnosis
Ineffective health maintenance related to effects of chronic alcoholism as evidenced by elevated lipase and amylase.
Goal/desired outcome acute pancreatitis
Short-term goal: By the end of the shift the patient will state the correlation between alcohol abuse and pancreatitis.
Long-term goal: The patient will utilize community support systems and will maintain sobriety.
Acute pancreatitis nursing interventions – Ineffective health maintenance
| Nursing Interventions | Rationales |
| Determine the cause of acute pancreatitis. | Acute pancreatitis can be caused by bacteria, viruses, alcoholism, gallstone impaction, trauma, or drug reactions. Lab values and imaging can assist in determining the cause. |
| Prepare for endoscopy or surgery. | Depending on the cause, surgery or endoscopy may be recommended to remove the gallstone, drain fluid, or debride necrotic tissue. |
| Educate the patient about the link between alcohol and pancreatitis. | Alcohol consumption and pancreatitis are directly linked. Alcohol creates more viscous pancreatic secretions which can cause protein plugs, which create calculi, which cause inflammation and fibrosis. Pancreatitis can be deadly and patients should be encouraged to quit drinking. |
| Encourage alcohol cessation and provide community resources. | Treatment programs, rehabilitation, support groups, and social workers may all be helpful for patients trying to stop drinking. |
Conclusion
To conclude, here we have formulated a scenario-based sample nursing care plan for Acute Pancreatitis. Prioritized nursing diagnosis includes acute pain, deficient fluid volume, and ineffective health maintenance.
Additionally, these sampleAcute Pancreatitis nursing care plans comprise nursing assessment, NANDA nursing diagnosis, goals, and interventions with rationales.
Recommended Readings & References
Ackley, B., Ladwig, G., Makic, M., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing Diagnoses Handbook: An Evidence-based Guide to Planning Care (12th ed.). Elsevier.
Comer, S. and Sagel, B. (1998). CRITICAL CARE NURSING CARE PLANS. Skidmore-Roth Publications.
Doenges, M., Moorhouse, M., & Murr, A. (2013). Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales (13th ed.). F. A. Davis Company.
Herdman, T., Kamitsuru, S. & Lopes, C. (2021). NURSING DIAGNOSES: Definitions and Classifications 2021-2023 (12th ed.). Thieme.
Swearingen, P. (2016). ALL-IN-ONE CARE PLANNING RESOURCE (4th ed.). Elsevier/Mosby.
