I.

INTRODUCTION
Pancreatitis is the inflammation of the pancreas. The pancreas is damaged when digestive
enzymes are activated before they are secreted to the duodenum and began attacking the
pancreas. There are two types of pancreatitis, acute, and chronic.
Acute pancreatitis is a sudden inflammation by a short period of time. Most of the cases
of acute pancreatitis are primarily caused by gallstones or heavy alcohol use. Some of the causes
are medications, infections, trauma, metabolic disorders, and surgery, but up to 30% of people
with this disease, the cause is unknown. In very severe cases, acute pancreatitis can result in
bleeding into the gland, serious tissue damage, infection, and cyst formation. In some cases it can
also affect vital organs such as the heart, lungs, and the liver.
Chronic pancreatitis is commonly caused by an on-going pancreatitis. About 45% of the
people, chronic pancreatitis is caused by prolonged alcohol use. Other causes include gallstones,
hereditary disorders of the pancreas, cystic fibrosis, high triglycerides, and certain medicines.
Excessive alcohol use may not cause symptoms for many years, but he/she then suddenly
develop severe pancreatic symptoms like severe pain, and loss of pancreatic function, that results
digestion and blood sugar abnormalities.
Gallstones are small particles that develop in the gall bladder when, bile, form hard,
crystal-like particles. Gallstones are composed of 80 % cholesterol and 20 % pigment stones.
Cholesterol stones are usually white or yellow in colour and primarily made of cholesterol.
Pigment stones are small, dark stones made of bilirubin and calcium salts that are found in bile.
Gallstones vary in size that varies as small as a grain of sand or as large as a golf ball.

1 | Page

In the Philippines, there is 0.29 % of the total population who has pancreatitis as of year
2009. Worldwide, the incidence of pancreatitis ranges between 5 and 80 per 100,000 populations.
As of 2006, there are 5,073,040 people reported that have gallstones in the population of
86,241,697. (According to http://www.rightdiagnosis.com/g/gallstones/stats-country.htm)
Pancreatitis can be treated through pharmacologic treatments or surgical management. It
depends upon the prognosis and type of disease occurring in a specific client.
The group chose this case because it appears to be unique and interesting among the
cases available in the Surgery Ward.

II.OBJECTIVES:

2 | Page

General Objective:
This study aims to acquire knowledge about gallstones, pancreatitis, the disease process,
its prognosis, complications, and treatment and to apply the nursing interventions suitable for the
client with effectiveness and efficiency.

Specific Objectives:

Assess the client properly and gain baseline data by building rapport with the client and
his/her significant others.

Formulate the correct diagnosis based from the thorough assessment done to the client.

Plan the nursing actions that are to be done through the problem which has been
addressed and found through the assessment.

Apply the appropriate nursing interventions with efficiency and with observance to the 11
core competencies.

Achieve the expected outcomes and gain a positive response from the client with the
interventions done.

III.NURSING HISTORY

3 | Page

BIOGRAPHICAL DATA
Name
Age
Gender
Address
Civil Status
Nationality
Religion
Birthdate
Hospital

: Patient X
: 31
: Male
: Sta. Cruz, Makati
: Single
: Filipino
: Catholic
: February 14, 1982
: Ospital ng Makati, Surgery Ward

Date of Admission

: June 16, 2013

Date of Interview

: June 24, 2013

Informant

: Patient X and significant other

Reliability

: 90%

Source of information

: Patient and Significant other

Criteria for reliability

A. Extent of data gathered demographics, history habits = 30%

B. Level of consciousness of interviewee condition, willingness to disclose info = 35%
C. Completeness of correlating facts Fluidity of transpiring events = 25%

CHIEF COMPLAINT:
Abdominal pain radiating to the back
4 | Page

HISTORY OF PRESENT ILLNESS:

Patient X, a 31 year old male was admitted to the hospital with a complaint
of abdominal pain.
1 month prior to admission, client was experiencing pain in his left upper
quadrant part of the abdomen but he just ignores it. Pain was intermittent and he doesnt take in
pain medication. He also experiences the same kind of pain when he is full or whenever he just
finished his meal. Client also feels fullness of the stomach and indigestion. Client did not go to
the hospital for check-up because he did not take it seriously. He was fond of eating foods rich in
fat and he is an occasional alcohol drinker.
1 week prior to admission, pain experience became continuous even to the
point that he is having a hard time to go to sleep making him feel restless. One event that he feels
fullness he drank 1 bottle of coke and red horse to make himself burp. However, there was no
relief of symptoms upon burping.
1 day prior to admission, client experience extreme pain and he is having
difficulty of breathing that is why he sought for medical assistance.
Client was admitted at the emergency room of Ospital ng Makati June 16,
2013 at around 2pm-3pm, he experienced 1 episode of vomiting and no relief from abdominal
pain now located in the epigastric area, crampy in character, radiating to the back. Client was
hooked to 1L PNSS x 8 hours. He also stated that blood was extracted from him for laboratory
purposes. Client was moved to the Surgery Ward June 17, 2013.
5 | Page

PAST MEDICAL HISTORY:

Client doesnt have hypertension or diabetes. He has no known allergies.
His last hospital visit was 2006 in Ospital ng Makati, Malugay due to tonsillitis.

PERSONAL AND SOCIAL HISTORY

Patient X was a habitual smoker since he was 15 years old. He consumes
5-10 sticks of cigarette a day. He is also a frequent alcohol drinker and he consumes 3 bottles of
500ml of red horse beer to make himself sleep.

6 | Page

FAMILY HISTORY OF ILLNESS

Father

Mother
(+) Gallstones

Sister

Sister

Brother

Patient X

Sister
(+) Gallstones

Sister
(+) HPN

Legend:
Female

Male

Deceased
7 | Page

IV. GORDONS FUNCTIONAL HEALTH PATTERN

PATTERN OF
HEALTH
I. Health Perception
and Health
Management
Pattern

II. Nutritional and

Metabolic Pattern

PRIOR TO
HOSPITALIZATION
According to the
patient, he is not fond
of going to the hospital
whenever he feels
something wrong with
his body. He often
ignores it and just goes
to the hospital if he can
no longer tolerate the
feeling of alteration.
Client doesnt take his
health seriously
because he believes
that he needs to enjoy
life. Client is a habitual
smoker. He started
smoking when he was
15 years old and
consumes 5-10 sticks a
day. He said that he is
an occasional alcohol
drinker but then he
stated that everyday is
an occasion for him.
When he drinks with
friends, he said Tulog
na silang lahat ako
umiinom pa. Every
night he takes in 3
bottles of red horse
which is 500 ml per
bottle.

DURING
ANALYSIS AND
HOSPITALIZATION INTERPRETATION
According to the
Readiness for
patient, he now sees
enhanced self-Health
the importance of
Management
health as an integral
part of life. He is now
conscious about his
health especially when
the nurses or the
student nurses are
administering his
drugs.

According to the
patient, he likes eating
foods high in fat such
as liempo, and lechong

According to the
Imbalanced Nutrition:
patient, he is not able
Less than body
to eat anything since he requirements
is in NPO from the day

(Page 425 of Nurses

Pocket Guide 12th
Edition by Doenges
et., al)

8 | Page

III. Elimination
Pattern

IV. Sleep Rest

Pattern

kawali. He drinks 8
glasses of water a day.
He has a good appetite
and he eats more than 1
cup of rice especially
when his viand is high
in fats. He drinks
alcoholic beverages
especially beer. He also
loves drinking soft
drinks. He seldom eats
vegetables and fruits.
According to the
patient he normally has
his bowel movement
once daily in the
morning. Stool
characteristics were
usually formed, dark
brown in color, hard
and dry. He doesnt
feel constipation. He
never used laxatives.
When he knew that he
didnt have his bowel
movement he usually
feels uncomfortable
and he will do
management such as
drinking water to pass
out stool. He urinates
regularly and more
frequent when he takes
in alcoholic beverages.
Urine characteristics
were usually amberyellow in color and
dont have any foul
odor.
According to the
patient he usually

of his admission. He
acknowledges that he
gets nutrition from the
intravenous lines
connected to him.

According to the
patient, he still has his
bowel movement once
a day but now stool
characteristic is fluid
since he is in NPO.
Client also has an
indwelling foley
catheter.

According to the
patient, he doesnt

(Page 564 of Nurses

Pocket Guide 12th
Edition by Doenges
et., al)

Altered defecation
due to diet

(Page 1228 of
Fundamentals of
Nursing 7th Edition by
Kozier et., al)
Disturbed sleep
pattern
9 | Page

sleeps 8 hours or more

during the night. He
doesnt sleeps nor
takes an afternoon nap.
After sleeping he feels
rested and energized.

V. Activity and
Exercise Pattern

VI. Cognitive
Perceptual Pattern

sleep 8 hours during

his hospital stay. He
only sleeps about 4
hours or less due to the
hospital activities and
because of the pain. He
sometimes feels
unrested and whenever
he gets awaken by a
health care provider.
He is experiencing
difficulty going back to
sleep again because he
is in hourly
monitoring.
According to the client, According to the client,
he doesnt do exercise
he cannot perform the
daily. He seldom plays activities of daily
basketball. He can
living by himself. He
perform activities of
often needs assistance
daily living without
and he cannot move
any assistance.
freely because his pain
increases especially
when he is moving.

(Page 775 of Nurses

Pocket Guide 12th
Edition by Doenges
et., al)

Activity Intolerance

(Page 69 of Nurses
Pocket Guide 12th
Edition by Doenges
et., al)
According to the client, According to the client, Readiness for
he has normal vision
he still has normal
enhanced Comfort
and hearing. He
senses. His perception
doesnt experience
about his life is still the
difficulty in terms of
same. The client stated
reading,
that gusto ko ng
comprehending, and
gumaling.
communicating with
others. He can speak
both in Filipino and
English. He can easily
interact with others. He
said that he has a good
tolerance in pain that
10 | P a g e

VII. Coping
Stress Tolerance
Perception/ Self
Concept Pattern

VIII. Sexuality and

Reproductive
Pattern

he doesnt want to take

pain medications. He is
a college undergrad.
Client perceives
everything as part of
life and everything
happens for a reason.
According to the client,
family and friends are
very important for him.
He likes the company
of his friends and
specially his special
someone. Whenever he
is stressed, he often
drinks alcohol with his
friends.
According to the client
he had his first coitus
when he was 19 years
old. He has been
sexually active and he
uses condom for his
protection. He only has
1 sexual partner.

(Page 188 of Nurses

Pocket Guide 12th
Edition by Doenges
et., al)

According to the
patient, he accepts his
condition and he said
that he cannot stop his
vices when he gets
discharged from the
hospital

According to the client

his feeling of sexuality
is a little bit affected
because he has foley
catheter.

(Page 250 of Nurses

Pocket Guide 12th
Edition by Doenges
et., al)
Ineffective sexuality
pattern

(Page 748 of Nurses

Pocket Guide 12th
Edition by Doenges
et., al)

IX. Role
According to the client
Relationship Pattern he is not yet married
but he has a girlfriend
and they are together
for 2 years already. He
is currently
unemployed though he
used to work as a staff
in the City Hall.

According to the client,

whenever a family
member or his
girlfriend is in the
hospital to take care of
him, he feels loved and
enjoys how they treat
him.

X. Value Belief
Pattern

His belief in God

becomes stronger and
he believes that God
will never leave him.

Client is catholic. He
believes that God is
always there for him
and He hears his

Defensive coping

Readiness for
enhanced Relationship

(Page 669 of Nurses

Pocket Guide 12th
Edition by Doenges
et., al)
Readiness of spiritual
well-being
(Page 432 of NANDA
11 | P a g e

prayers.

Book)

V. REVIEW OF SYSTEM
SYSTEMS

SYMPTOMS

Integumentary

Medyo masakit ang tinurukan sa aking braso

Respiratory

Minsan nahihirapan akong huminga

Gastrointestinal

Masakit ang aking tyan, sa tagiliran hanggang

likod lalo na kapag gumagalaw ako
P provokes mobilization,
Palliates - immobilization
Q - cramping
R epigastric to back
S 10/10
T during mobilization and ambulation.

12 | P a g e

VI. PHYSICAL ASSESSMENT

Date: June 24, 2013
Time: 8:06 am
General survey:
Client was lying on the bed on a moderate high back rest, conscious and coherent. Facial
features of the client were symmetrical with movements. Skin color is even, intact except from
his right forearm which has his peripheral parenteral nutrition and noticeable bruise his left
forearm due to IV insertion. Body parts look equally bilateral and proportioned to each other.
The initial vital signs were taken as follows:
Height:
Weight:
BMI:
Blood Pressure:
Temperature:
Heart Rate:
Respiratory Rate:
Organ/ System
Skin

170.6cm
53kg
18.2; Underweight
120/80 mmHg
37 C
77bpm
18cpm

Technique
Inspection

Normal Findings
Color: Pinkish

Actual Findings
Color: Fair skin

Interpretation
Normal
13 | P a g e

Palpation

depending upon
the skin tone

tone, even

Moisture: Moist

(+) moist

Normal

Texture: Smooth

(+) smooth

Normal

Normal

Turgor: skin
Skin quickly
quickly returns to returns to
its original
original shape
shape.
Normal
Hair

Inspection

Temperature:
warm
Even distribution

Symmetrical
facial features

(+)warm
Evenly
distributed
Color: Black and
has strains of
gray hair
Symmetrical
facial features

(-) area of
deformity

(-) area of
deformity

Normal

(-) lesions
Symmetrical

Normal
Normal

Eye lids:
(-) lesion
(-)redness

(-) lesions
Symmetrical
eyes
Eye lids:
(-) lesion
(-)redness

(-)discharges

(-)discharges

Normal

Conjunctiva:
Pinkish in color
Clear and Shiny

Conjunctiva:
Pale in color
Clear and Shiny

Abnormal;
indication of low
RBC or anemia
Normal

Sclerae: white or
buffy

Sclerae: white

Color: Black
Head

Eyes

Inspection

Inspection

Normal

Normal

Normal
Normal

Normal
Pupil: PERRLA

Pupil: PERRLA
4mm
14 | P a g e

Eyelids:
(-) Masses
Palpation
Ears

Nose

Mouth

Inspection

Inspection

Inspection

Normal
Eyelids:
(-) Masses

Symmetrical

Symmetrical

Normal

(-) discharges

(-) discharges

Normal

(-) lesions

(-) lesions

Normal

(-) nodules

(-) nodules

Normal

(-) redness

(-) redness

Normal

Symmetrically
aligned

Symmetrically
aligned

Normal

(-) discharge

(-) discharge

Normal

(-) flaring of
nares
Lips
Color: Pinkish

(-) flaring of
nares
Lips
Color: Dark Pale

Normal

(+)Moist

(+) dryness

Abnormal, may
indicate
dehydration due
to NPO diet

(-) lesions

(-) lesions

Normal

(-) lumps

(-) lumps

Normal

(-) mass

(-) mass

Normal

Tongue:
Color: Pink red

Tongue:
Color: Pink but

Normal

Abnormal; dark
color of lips
indicate the long
term of smoking;
paleness is an
indication of
anemia due to
blood loss

Palpation

Inspection

15 | P a g e

with whitish film

Neck

Inspection

(-) lesions

(-) lesions

Normal

(-) thrush

(-) thrush

Normal

Teeth:
Color: white

Teeth:
Color: white

Normal

Gums:

Gums:

Color: Pink
Red

Color: Pink
Red

Normal

Oral Mucosa:
Color: Pinkish

Oral Mucosa:
Color: Pale- pink

Abnormal;
indication of low
RBC or anemia

(+) Moisture

(+) Moisture

Normal

(-) lesions

(-) lesions

Normal

(-) odor

(-) odor

Normal

Symmetrically
aligned

Symmetrically
aligned

Normal

(-) scars

(-) scars

Normal

(-) mass

(-) mass

Normal

(-) swelling

(-) swelling

Normal

(+) symmetrical
expansion with
respiration

(+) symmetrical
expansion with
respiration

Normal

(-) use of
accessory muscle

(+) use of
accessory muscle

Abnormal; may
indicate
difficulty of
breathing

Palpation

Respiratory
System
Chest /Thorax/
Lungs

Inspection

16 | P a g e

Palpation

Auscultation

Heart

Upper
Extremities

Inspection

Auscultation
Inspection

Palpation

(-) retraction

(-) retraction

Normal

(+) smooth

(+) smooth

Normal

(+) warm

(+) warm

Normal

(+) dry

(+) dry

Normal

(+) normal
breath sounds

(+) normal
breath sounds

Normal

(-) adventitious
sound

(-) adventitious
sound

(-) visible PMI

(-) visible PMI

Normal

(+) regular
rhythm

(+) regular
rhythm

Normal

(-) thrills

(-) thrills

Normal

(-) murmurs
Upper
Extremities
(-) pallor

(-)murmurs
Upper
Extremities
(-) pallor

Normal

(-) rashes

(-) rashes

Normal

(-) bruise

(+) bruise on the

left forearm

Abnormal; bruise
is due to the 1st
insertion of the
IV cannula

(-) contraptions

(+) peripheral
parenteral
nutrition
insertion

Normal

(+) tattoo on left

deltoid area

Normal

(-) swelling

(-) swelling

Normal

(-) edema

(-) edema

Normal
17 | P a g e

Nails

Abdomen

(+) Radial and

Brachial Pulses

(+) Radial and

Brachial Pulses

Normal

Color: Pinkish

Color: Pale

Abnormal; may
indicate anemia

Contour: slightly
curved or flat

Normal

Symmetrical

Contour: flat
Long and has
stains
Symmetrical

(+) globular
shape

(+) globular
shape

Normal

(-) masses

(-) masses

Normal

(-) lesions

(-) lesions

Normal

Auscultation

(+) bowel sounds

(+)bowel sounds

Normal

Percussion

(+) dull sounds

when organs are
percussed

(+) dull sounds

Normal

Palpation

(-) masses

(-) masses

Inspection

Inspection

(+) bulge in the

LUQ to LLQ

Genitalia

Inspection

Normal

(-) tenderness

(+) tenderness

(-) rigidity

(+) rigid

(-) pallor

(-) pallor

Abnormal; may
indicate organ
enlargement
Abnormal; may
indicate organ
enlargement
Abnormal; may
indicate organ
enlargement
Normal

(-) edema

(-) edema

Normal

(-) redness

(-) redness

Normal

(-) swelling

(-) swelling

Normal

18 | P a g e

Lower
Extremities

Inspection

(-) pallor

(+) indwelling
foley catheter
(-) pallor

Normal

(-) rashes

(-) rashes

Normal

(-) bruise

(-) bruise

Normal

(-) swelling

(-) swelling

Normal

(-) edema

(-) edema

Normal

(+) popliteal,
posterior tibial,
and dorsalis
pedis pulses

(+) popliteal,
posterior tibial,
and dorsalis
pedis pulses

Normal

(Analysis and Interpretation Reference: Essentials of Anatomy and Physiology, 6th edition;
Health Assessment Made Incredibly Visual)

VII. COURSE IN THE WARD

DATE & SHIFT

DOCTORS
ORDER

NURSES
RESPONSIBILITIES

PT. REACTION/
EVALUATION

19 | P a g e

June 24, 2013

-Maintain on NPO

-Continue VS and
I&O monitoring q1

June 25, 2013

-Explain to the client

the importance of the
order.

-Patient understand
the importance of the
order.

-Maintain oral hygiene

and give sips of water
to prevent dryness of
the lips and relieve
thirst.

-Patient feels
comfortable and thirst
has been relieved.

-Monitor Vital Signs

hourly and document
- Client was
monitored and
checked thoroughly

-Continue giving
meds

-Administer medication
with the right dosage,
route and frequency;
and without adding
injury to the patient.

-Refer accordingly

-Refer if there are

alterations

-NPO

-Explain to the client

the importance of the
order.

-Patient understood
the importance of the
order.

-Maintain oral hygiene

and give sips of water
to prevent dryness of
the lips and relieve
thirst.

-Patient feels
comfortable and thirst
has been relieved

-Make sure that client

receives the right
solution without adding
injury and assuring
aseptic technique.

-Patient received the

proper nutrition
needed.

-PPN 1400 kcal 2L x

24hrs

20 | P a g e

-IVF PNSS 12 hrs x

14gtts/min

-Monitored and
-Client did not
regulated the IV fluid to experience fluid
prevent fluid deficit or
deficit or overload.
overload.
-Check the IV site for
signs of phlebitis or
infiltration

-Client did not have

any signs of phlebitis
or infiltration.

21 | P a g e

VIII. DIAGNOSTICS
June 16, 2013 HEMATOLOGY
Component

Normal Values

Results

Prothrombin Time

10.4-14.0 seconds

11.1 seconds

Analysis and
Interpretation
Normal

% Activity

73-127%

118.1%

Normal

INR

0.88-1.21

0.93

Normal

Activited PTT

30.4-41.2seconds

37.2 seconds

Normal

June 17, 2013

Component

Normal Values

Results

Prothrombin Time

10.4-14.0 seconds

11.1 seconds

Analysis and
Interpretation
Normal

% Activity

73-127%

118.1%

Normal

INR

0.88-1.21

0.93

Normal

Activited PTT

30.4-41.2seconds

37.2 seconds

Normal

June 22, 2013

Component
Hemoglobin
Hematocrit
WBC Count

RBC Count

Normal Values
14-18g/L
0.40-0.54
4.11x10^9L

5.0-6.4

Results
12.2
0.37
15.6

4.1

Analysis and
Interpretation
Normal
Normal
Abnormal; Increased;
Indication for
infection
(Essentials of
Anatomy and
Physiology, 6th edition
pg. A-4)
Abnormal;
Decreased ; may
22 | P a g e

indicate anemia
(Essentials of
Anatomy and
Physiology, 6th edition
pg. A-4)
Differential Count
Eosinophils
Neutrophils
Segmenters

Lymphocytes
Monocytes

0.02-0.04

0.01

Abnormal; decreased

0.50-0.70

0.82

Abnormal; Increased;
Indication for
infection

0.20-0.40
0.02-0.05

Platelet Count

(Essentials of
Anatomy and
Physiology, 6th edition
pg. A-4)
Abnormal; decreased
Abnormal; increase
may indicate chronic
infection

0.10
0.07

150-450x10^9/L

(Essentials of
Anatomy and
Physiology, 6th edition
pg. A-4)
Normal

239

June 17, 2013 ABG

June 16, 2013 CHEMISTRY SECTION

Test Name

S.I
Results Normal
Values

Unit

Conventional
Result Normal
Unit
Values

Amylase

654

U/L

654

28-100

28-100

U/L

Analysis and
Interpretation
Abnormal;
increased;
indication for
23 | P a g e

pancreatitis
(Essentials of
Anatomy and
Physiology, 6th
edition, pgA-2)
BUN/CREA
UREL/BUN
CREATININE

3.03
79

2.1-7.1
45.0104.0

mmol/L
umol/L

8.48
0.89

6.0-20.0
0.51-1.18

mg/dL
mg/dL

Normal
Normal

141
3.9
104

136-145
3.5-5.1
98-107

mmol/L
mmol/L
mmol/L

141
3.9
104

136-145
3.5-5.1
98-107

mEq/L
mEq/L
mEq/L

Normal
Normal
Normal

PANEL 3
Sodium (Na)
Potassium (K)
Chloride (Cl)
Test Name

Normal Values

Serum Glutamic
0-40
Pyruvate Transaminase/
Alanine Transaminase
(SGOT/AST)

Result
739

Unit
U/L

Analysis and
Interpretation
Abnormal;
increased may
indicate liver
dysfunction due
to drug and
alcohol intake
also gallbladder
disease
(Biochemistry
4th edition)

Serum Glutamic
0-41
Oxaloacetic
Transaminase/Aspartate
transaminase
(SGPT/ALT)

594

U/L

Abnormal;
increased may
indicate liver
dysfunction due
to drug and
alcohol intake
also gallbladder
disease
(Biochemistry
24 | P a g e

4th edition)

Albumin
Lactate Dehydrogenase
(LDH)

35-52
135-225

52
842

g/L
U/L

Normal
Abnormal;
increased may
indicate tissue
damage.

June 17, 2013

S.I
Results Normal
Values

Test Name

Unit

CONVENTIONAL
Results Normal
Unit
Values

mmol/L
umol/L

13.22
0.98

Analysis and
Interpretatio
n

BUN/CREA

UREL/BUN 4.72
Creatinine
87

2.1-7.1
45.0-104.0

6.0-20.0
0.51-1.18

mg/dL
mg/dL

Normal
Normal

June 18, 2013

Test
Name

S.I
Results
Normal
Values

Creatinin 78
e
June 22, 2013

Unit

45.0-104.0 umol/L

S.I

CONVENTIONAL
Results Normal
Unit
Values
0.88

0.51-1.18 mg/dL

Analysis and
Interpretatio
n
Normal

CONVENTIONAL
25 | P a g e

Test
Name

Results

Normal
Values

Unit

Results

Normal
Values

Unit

Amylase

86

28-100

U/L

86

28-100

U/L

Analysis and
Interpretatio
n
Normal

Computed Tomography with IV Contrast Result:

Date: June 20, 2013
Generalized enlargement of pancreas with inhomogenous demity. Peripancreatic contour
is unsharp with thickening of adjacent retroperitoneal tissues and resenting lateral thickening.
Pancreatic duct not dilated.
IX. DIFFERENTIAL DIAGNOSIS
SIGNS AND
SYMPTOMS
Abdominal pain
(epigastric area that
radiates to the LLQ)
Fever
Tenderness
Bulging
Rigidity
Lower Back Pain
Vomiting

Gallstones,
Pancreatitis

Cholecystitis

Peritonitis

26 | P a g e

X. Anatomy & Physiology

The pancreas is located

retroperitoneal, posterior to the
stomach in the inferior part of the
left upper quadrant.
Parts:
Head located near the midline of
the body
Tail extends to the left and
touches the spleen
The pancreas acts both
endocrine and exocrine.
The endocrine part of the pancreas consists of pancreatic islets (Islets of Langerhans).
The islets cells produce the hormones insulin and glucagon, which enter the blood. These
hormones are very important in controlling blood levels of nutrients such as glucose and amino
acids.

27 | P a g e

The exocrine part of the pancreas is responsible for producing digestive enzymes. The
acini produce digestive enzymes, clusters of it are connected by small ducts which join to form
larger ducts and form the pancreatic duct. The pancreatic duct joins the common bile duct and
empties into the duodenum.

Functions of the Pancreas

The exocrine secretions of the pancreas include HCO3-, which neutralize the acidic
chyme that enters the small intestine from the stomach. The increased pH resulting from the
secretion of HCO3-stops pepsin digestion but provides the proper environment for the function of
pancreatic enzymes. Pancreatic enzymes are also present in the exocrine secretions and are
important for the digestion of all major classes of food. Without the enzymes produced by the
pancreas, lipids, proteins, and carbohydrates are not adequately digested.
The major proteolytic (protein-digesting) enzymes are trypsin, chymotrypsin, and
carboxypeptidase. These enzymes continue the protein digestion that started in the stomach, and
pancreatic amylase continues the polysaccharide digestion that began in the oral cavity. The
pancreatic enzymes also include a group of lipid-digesting enzymes called pancreatic lipases.
Nucleases are pancreatic enzymes that reduce DNA and ribonucleic acid to their component
nucleotides.
The exocrine secretory activity of the pancreas is controlled by both hormonal and neural
mechanisms. Secretin initiates the release of a watery pancreatic solution that contains large
amount of HCO3 -. The primary stimulus for secretin release is the presence of acidic chime in
the duodenum. Cholecystokinin stimulates the pancreas to release an enzyme-rich solution. The
primary stimulus for cholecystokinin release is the presence of fatty acids and amino acids in the
duodenum, and the enzymes secreted by the pancreas digest fatty acids and amino acids.
Parasympathetic stimulation through the vagus nerves also stimulates the secretion of pancreatic
juices rich in pancreatic enzymes. Sympathetic action potential inhibits pancreatic secretions.

The gallbladder is a small sac found just under

the liver. It stores bile made by the liver. Bile helps you
digest fats. Bile moves from the gallbladder to the small
intestine through tubes called the cystic duct and common
bile duct.

28 | P a g e

Reference: Essentials of Anatomy and Physiology by Seeley, Sixth Edition, p.467-468

29 | P a g e

XI.PATHOPHYSIOLOGY
Modifiable:

Non-Modifiable

High fat diet

Smoking
High alcohol
intake
Health belief/

Age: 31 years
old
(+) family
history of
gallstones

Liver secretes bile

that is high in
cholesterol

Excessive bile salts

and water are
reabsorbed in the
gall bladder during
bile concentration
May enter the
common bile duct

Bile becomes less

soluble

Cellular injury caused

by intoxication of
acinar cell from
alcohol

Cellular trafficking
and increase
pancreatic secretions

Fusion of lysozomal
and zynogens

30 | P a g e

Early activation of
trypsinogen to
trypsin

Gallstone
Formation

Dislodge in the
ampulla of vater

Premature
activation of
other pancreatic
enzymes

Extrusion of
secretory vesicles
from basolateral
membrane to
interstitium

Reflux of bile
from common
bile duct to
pancreatic duct

Obstruction
Chemoattraction to
inflammatory of
molecular
fragments

Abdominal
tenderness

Destruction of
ductal tissue and
pancreatic cells

LLQ rigidity

Fever

Inflammation

Vomiting

Drug Name

Pain in the LLQ

that radiates to
Classification
the back Dosage /Route/
Abdominal
bloating

Pancreatitis

Action

Nursing Considerations

Evaluation

Frequency

31 | P a g e

Generic Name:

Pharmacologic:

Tramadol
hydrochloride

Opiod antagonist

Brand Name:
Ulmam

50mg/ TIV/ q8

Action:

>Assess clients pain.

Binds with mu
receptors

>Check if client is
allergic to the drug.
>Reassess clients level
of pain at least 30 mins.
After administration.

Therapeutic:

Inhibits
reuptake of
Norepinephrin >Assess IV site for signs
e and serotonin of phlebitis and
infiltration.
Indication:
>Monitor heart rate and
Pain
respiratory status
withhold dose if clients
respirations are slow or
rate is below 12bpm.

Analgesic

Pain experience of client

is decreased and
controlled.

There is no adverse
reaction experienced.

Client and family state

understanding about the
drug therapy.

>Monitor bowel and

bladder function.

Drug Name

Classification

Dosage /Route/
Frequency

Action/
Indication

Nursing Considerations

Evaluation

32 | P a g e

Generic Name:

Pharmacologic:

Pantoprazole
sodium

Proton pump inhibitor

Brand Name:
Protonix, protonix
IV

40 mg/ TIV/ OD

Action:
Inhibits the
hydrogen
potassiumadenosinetr
iphosphatas
e in the
gastric
parietal
cells

Therapeutic:
Gastrointestinal agent,
Antiulcer

>Assess clients
condition before the drug
therapy.

>Drug was administered

to the patient safely.

>Assess the site for

infiltration ad phlebitis.

>Client state
understanding about the
dug therapy.

>Flush I.V. line with D5W,

normal saline
solution, or lactated
Ringers injection before
and after giving drug.
>Explain the drug therapy

Inhibits final to the client and significant

step in
other
gastric acid
production

Prevents H
from entering
the stomach
and additional
HCl from
forming
Indication:
GERD
Drug Name

Classification

Dosage /Route/

Action

Nursing Considerations

Evaluation

33 | P a g e

Frequency
Generic Name:

Pharmacologic:

4.5g/ IV/ q8 ANST

Piperacillin
Tazobactam

Penicillin, betalactamase inhibitor

Piperacillin

Brand Name:
Tazocin, Zosyn

Action:

Therapeutic:
Anti-infective

>Assess clients
condition before the drug
therapy.

Inhibits
bacterial cell
wall synthesis

>Perform skin testing to

check if client has
hypersensitivity with the
drug.

Cell death

>Assess IV site for signs

of phlebitis and
infiltration.

Indication:
Infection

>Clients infection is
controlled.
>Client did not experience
any adverse effects of
drug.

>Monitor for signs and

symptoms of
superinfection.
>Be aware that high
doses of drug may cause
seizures.
>Explain the importance
of the drug therapy to the
client and significant
other.

CUES

NURSING

INFERENCE

GOAL

NURSING

RATIONALE

EVALUTATION
34 | P a g e

DIAGNOSIS

INTERVENTIONS

Subjective
> Masakit ang
Pain related to
tyan ko sa may
current disease
tagiliran
condition
hanggang sa
likod. As
verbalized by the
patient.
P provokes
mobilization,
Palliates immobilization
Q - cramping
R epigastric to
back
S 10/10
T during
mobilization and
ambulation.
Objective:

Organ
inflammation
(pancreatitis)

Abdominal
rigidity and
tenderness

Short-term
Goal:
After 30 mins of
nursing
intervention,
clients pain
experience will
be lessening
from the scale of
10 to 6.

Independent:
> Encourage the
client to verbalize
about the pain.

>Promotes
cooperation and it
can help in the
thorough
assessment.

>Promote comfort
measures and deep
breathing exercise.

>These activities
calm the patient
and making
him/her feel pain
relief.

>Goal partially
met.

>Encourage the
client to do
diversionary
activities such as
listening to music or
reading books or
newspaper.

> To divert
clients attention
away from pain
thus making
him/her lessen the
cognition about
pain.

> After 2 days of

nursing
intervention,
client knows how
to manage his
pain.

Long term
Goal:
Pain
After 2 days of
nursing
intervention,
client will
eventually know
how to manage
his pain.

> After 30 mins of

nursing
intervention,
clients pain was
relieved from the
pain scale of 10 to
7.

Dependent:
>(+) facial
grimace
(+) guarding
behavior

>Administer pain
medications such as
tramadol as ordered
35 | P a g e

(+) rigid LUQ to

LLQ
(+) abdominal
tenderness (LUQ
to LLQ)

by the attending
physician.

36 | P a g e

CUES

NURSING
DIAGNOSIS

Subjective:
Nahihirapan
akong huminga
lalo na kapag
nagsasalita

Ineffective
breathing
pattern related
to pain

Objective:
(+) use of
accessory
muscle when
breathing

INFERENCE

Diaphragmatic
breathing

Affects the site

of pain

Increases pain
specially when
talking

RR= 22 cpm
Client breathes
more frequent

GOAL

After 20
minutes of
nursing
intervention,
clients
breathing will
be improved
and RR will be
normalized

NURSING
INTERVENTION

Independent:
-Maintain or put
client on high back
rest or in fowlers
position.

RATIONALE

- To promote
lung expansion
- To assist client
in taking
control of the
situation.

-Encourage client to
take slower and
deeper respirations.

EVALUATION

After 20 mins of
nursing
interventions,
client experienced
relief and RR was
normalized from
22 to 18.

-To check if
-Teach client to learn client is having
respiratory
breathing exercise.
acidosis or
alkalosis.
-Assist client in the
use of relaxation
techniques.

Increased RR
Collaborative:
>Monitor ABG
Ineffective
breathing
pattern

37 | P a g e

CUES

NURSING
DIAGNOSIS

INFERENCE

GOAL

NURSING
RATIONALE
INTERVENTION

EVALUATION

38 | P a g e

Subjective:
Ang hirap
gumalaw dahil
sumasakit ang
tagiliran ko
Objective:
(+) Guarding
behavior
(+) Facial
grimace
Limited range
of motion
Difficulty
turning
(+) LLQ
cramping pain
that radiates to
the back with a
pain scale of 10
during
mobilization
and ambulation.

Activity
intolerance r/t
pain or
discomfort

Pain
Difficulty in
moving

Decreased
movement

Activity
intolerance

After 30 minutes
of therapeutic
communication,
the client will be
able to verbalize
understanding
and gain
cooperation of
his situation.

Independent:
- Instruct use of
side rails overhead
trapeze roller pads
for position
changes or transfer.
- Support affected
body parts using
pillow/rolls; air
mattress especially
the bony
prominences.
- Provide for safety
measure and as
indicated by
individual situation
including,
environmental
management/ fall
prevention.

The patient
- To promote
verbalized
safety to the
understanding of
client.
his situation or
risk factors and
individual
- To prevent
treatment
ulceration and or regimen and
bed sores.
safety measures.

-To enhance
ability to
-Note clients
report of weakness, participate in
activities.
fatigue pain
-Promote comfort
measures and
provide for relief
of pain
39 | P a g e

40 | P a g e

CUES

NURSING
DIAGNOSIS

Subjective:
Di na ako
makatulog ng
maayos dahil sa
sakit na
nararamdaman
ko
Objective:
(+) periorbital
puffiness
(+) restlessness

Disturbed
sleeping
pattern related
to pain

INFERENCE

Current
medical
condition

Pain

Disturbance to
sleep

Restlessness

GOAL

NURSING
RATIONALE
INTERVENTION

Short term:
After 15 mins
of therapeutic
communication
client will
verbalize of
understanding
on how to
improve
sleeping pattern

Independent:
- Advice client to
do his routine
before sleeping
- Advice client to
do relaxation
techniques
-Determine client
and significant
others
expectations of
adequate sleep.
-Promote comfort
measures such as
therapeutic touch,
change of position
in bed.
Dependent:
-Administer pain
medications as
ordered.

Long term goal:

After 2 days of
nursing
intervention,
client will
report of
enhanced
sleeping pattern

-To promote better

way of getting to
sleep.
-To help client fall
asleep faster.
-Provide
opportunity to
address
misconceptions or
unrealistic
expectations.

-To provide
nonpharmacologica
l pain management
and promote sleep.

EVALUATION

After 15 mins of
therapeutic
communication
client verbalized
understanding
on how to
improve
sleeping pattern.

After 2 days of
nursing
intervention,
client stated of
enhanced
sleeping pattern

-To lessen or
eliminate feeling of
41 | P a g e

pain and achieve

sedation effect.

CUES

NURSING
DIAGNOSIS

INFERENCE

GOAL

NURSING
INTERVENTIONS

RATIONALE

EVALUATION

42 | P a g e

Objective:
(+) Foley
Catheter
(+) IV Fluid

Risk for
infection r/t
inadequate
primary
defenses

Disease process

Lowered
primary
defences

(+) Peripheral
Parental
Nutrition

After 1 hr of
nursing
interventions
the client
verbalize
understanding
of individual
causative or risk
factor.

- Monitor clients
visitors for
respiratory illnesses

- To limit
exposures, thus
reducing cross
contamination

- Administer
medication regimen.

- To determine
effectiveness of
therapy or
presence of side
effects

- Recommend
routine or
preoperative body
shower or scrubs
when indicated

-To reduce
bacterial
colonization

-Stress proper hand

hygiene to health
care provide and
client.

-A first line
defense against
nosocomial
infection.

-Provide regular
perineal care

-To reduce risk

of ascending
UTI

Risk for
infection

After 8 hrs. of
nursing
intervention the
client was able
to verbalize
understanding of
individual
causative or risk
factor.

43 | P a g e

-Maintain aseptic
technique when
giving IV meds and
PPN

-To prevent
contamination
of the IV line.

44 | P a g e

XIV.DISCHARGE PLAN:

Medicines
o

Instructed the client and his significant others to continue the medications as
ordered by the physician.

o Stress the importance of compliance to prescribed medication.

Exercise:
o Advised the client to do light exercises.
o Stressed to the client the importance of rest.
o Encourage patient rest and deep breathing exercise
o Encourage patient to resume daily activities which aides in achieving and
maintaining an optimum level of wellness and heath.
Treatment
o Encourage the patient to seek nearest hospital as soon as possible if symptoms are
observed and cant be relieved by the medications.
o Advise the patient to comply prescribed medications

Health Teaching
o Instructed the client on the time of the administration of the drug.
o Instructed the client about the drugs side effects or adverse effects such as:
diarrhea, increased heart rate etc.
o Instructed the client to take the prescribed medicines.

45 | P a g e

o Teach the client or significant to others on how to clean the operative site to
prevent infection.
o Teach the patient or significant to others to wash hands before changing and after
disposing of dressing.
o Teach the patient when to notify the physician of complications (infection , an
unhealed wound and anxiety and to report any sudden chest pain or difficulty of
breathing )
o Explore the patients drinking pattern.

Out Patient
o Instructed the client to have follow-up check up to monitor her condition.

Diet
o Encourage the client to eat foods less in fat and sodium
o

Encourage the client to increase oral fluid intake and restrain from drinking
alcoholic beverages.

Height 56
Weight 53 kg
Desired Body Weight (DBW)
DBW = 5x12 = 60 + 6 = 66 x 2.54
= 167.64 100 = 67.64 6.76
= 60.88 = 61
DBW = 60.88 kg

Total Energy Requirement

TER = DBW/ weight of patient x activity
TER = 60 x 35 = 2100
BMI= 60/ (1.67)(1.67)
BMI = 21.5-------- NORMAL
CHO= 2100 kcal x .60 = 1260 kcal 4
46 | P a g e

= 315grams
CHON= 2100kcal x .15 = 315 kcal 4
= 78.75 grams
Fat = 2100kcal x .25 = 525kcal 9
= 58.33 grams
SAMPLE ACTUAL MEAL PLAN:
Breakfast:
1 slice of toasted bread
1 cup low fat milk
cup oatmeal
1 small banana
Lunch:
1 cup of rice
4 ounces of breast chicken fried in vegetable oil
1 cup adobong kangkong
Salad with 1 tablespoons of low fat salad dressing
PM snack:
1 cup of low fat milk
1 turon
Dinner:
1 cup of rice
1 cup stir fried vegetables
1 slice of apple

Spiritual
o Encourage the client to keep, praying and visiting their church.
47 | P a g e

XV. EVALUATION
In this case study, we were able to assess the client properly and gain baseline data by
building rapport with the client and his significant others. We have formulated the correct
diagnosis based from the thorough assessment done to the client. And based from it we were able
plan the actions that are to be done through the problem which has been addressed and found
through the assessment. We have been able to give the appropriate nursing interventions with
efficiency and observance to the 11 core competencies and able to achieve the expected
outcomes and gain a positive response from the client with the interventions done.

48 | P a g e