Philippine Christian University Mary Johnston College of Nursing 415 Morga St. Tondo, Manila

A Case Study on
Acute Pancreatitis
Secondary to
Cholelithiasis

Submitted by:
Abad, Edryan
Calara, Sharika Loradel
Casul Mark Jury
Corpuz, Trisha
Dela Cruz, Marjori
Gamboa, Jonalyn
Lebico, Elmarie
Lopez, Anica
Tapawan, Ansherina
Tuazon, Serleen

March 09, 2012
Acknowledgement

We would like to thank the following to the development of this case study.

Mrs. Edna Oraye-Imperial, Dean, PCU – Mary Johnston College of Nursing, for her support and for allowing us to have our related learning experiences in the clinical area that hone our knowledge skills and attitude to be a competent, caring, Christian nurses.

Ms. Ma. Lourdes Galima, Clinical Instructor, for continually guiding and supporting us throughout our duty at the Surgery ward, for helping us in enhancing and improving our skills in the area. For the patience that she showed us despite of our attitude and mistakes. Ms. Loreto Vicarme, School Librarian, for allowing us to utilize the library books and references for our case study. To the staff nurses on duty at the Surgery Intensive Care Unit and Ward of Mary Johnston Hospital for the support and providing us with enough information about the routines in the area which we were able to apply. To our fellow group members for their continuous support and sharing their knowledge and experiences for polishing this case study. To the patient, as well as her family members, for being cooperative and compliant to our nursing care and health teachings, which enabled as to dig deeper in knowing and studying the patient’s case. Above all, we want to give our deepest gratitude to the Lord God Almighty, who gave us the opportunity to be with our patient and have the experience of sharing every bit of quality nursing care with her and for sustaining us in doing this case study.

Objectives of the Study

General Objective At the end of the case study, the student nurses will be able to discuss fully and obtain information on the basic concepts and nursing process in caring for a client with Acute Pancreatitis as evidenced by being able to determine and apply different interventions appropriate for the condition of the client.

Specific Objectives

At the end of the case study, the student nurses will be able to:

PSYCHOMOTOR 1. Utilize assessment skills such as Nursing History taking, Physical Examination, Gordon’s Functional Health Pattern to gather baseline data for the client’s current health condition. 2. Utilize the Nursing Care Process in delivering quality care in addressing the client’s current health condition. 3. Provide nursing and collaborative interventions appropriate to the identified needs of the client in reference of a nursing theory.
COGNITIVE
1. Identify and prioritize nursing problems and health needs of the client. 2. State the relationship of the laboratory results and medications to the disease condition of the client. 3. Explain the risk factors, signs and symptoms and pathophysiology of Acute Pancreatitis.
AFFECTIVE
1. Appreciate the disease process of Acute Pancreatits.

Introduction

This is a case study about a 40 year old male occasional alcoholic beverage drinker, non-diabetic hypertensive patient who complained about acute severe abdominal pain which started to gradually increase in intensity 6 months prior to admission. He was suspected to have cholelithiasis (calculi or gallstones) which usually form in the gallbladder from constituents of bile and vary greatly in size, shape and composition. He was scheduled for cholecystectomy but was deferred due to upon further assessment through physical examination and several laboratory and diagnostic examinations, the health care team was able to diagnose the client’s case as acute pancreatitis. It is a serious disorder that can range in severity from a relatively mild, self-limiting disorder to a rapidly fatal disease that does not respond to any treatment. The client exhibited major symptoms of the disease primarily severe abdominal pain in the mid-epigastrum accompanied by abdominal distention which is more severe after meals, nausea and vomiting, fever, mental confusion and agitation, increased serum amylase and lipase levels and positive ultrasound results for cholelithiasis and acute pancreatitis.

The student nurses then was able to provide 5 nursing care plans with the following diagnoses which were given appropriate nursing and collaborative care which are as follows: * Alteration in thermoregulation: Hyperthermia related to inflammatory response to infection * Acute Pain related to excess stimulation of pancreatic stimulation secondary to present disease condition: Acute Pancreatitis * Imbalancd Nutrition: Less than body requirements r/t inability to ingest food s/t NPO status * Actual Infection related to inadequate primary defenses * Self Care Deficit: Grooming, Hygiene, Feeding, Ambulation related to present health condition

Reason for Choosing the client

The student nurses chose the client’s case due to the following reasons: * Several members of the group was able to give primary care to the client in the Surgery ICU * The student nurses were interested in knowing more about the client’s condition to provide more effective and appropriate care * The student nurses were able to monitor the client’s prognosis from his admission until his discharge * The client was very willing, compliant and cooperative for the care given to him by the student nurses

Demographic Data
NAME: W. A. F.
AGE: 40y/o
GENDER: Male
ADDRESS: Tondo, Manila
OCCUPATION: Vegetable Vendor
RELIGION: Roman Catholic
CIVIL STATUS: Married
Nursing History
HISTORY OF PRESENT ILLNESS: * 6 months PTA the client experienced abdominal pain specifically in mid epigastrium area every after eating hence no consultation done * hot compress was done which provided temporary relief * 8 hours PTA the client still experienced mid epigastrium abdominal pain now with increased severity accompanied by vomiting, seek consultation to MJH, advised admission hence admitted at Surgery Ward.

PAST HEALTH HISTORY: * Client is known Hypertensive and taking Clonidine 75 mg as maintenance * No history of DM * First time to be hospitalized * No history of respiratory , cardiovascular diseases

FAMILY HISTORY: * With history of Hypertension- Both sides * With history of Diabetes Mellitus – Mother side * No history of cancer

SOCIAL HEALTH HISTORY: * Client is occasional drinker ( estimately 3 times a month) * Non-smoker * No noted allergy to any food or drugs

Gordon’s Functional Health Pattern

Health Perception-Health Management Pattern:
Informant: Client and relative-wife * “masakit yung tyan nya kaya di sya healthy ” client’s relative verbalized * Does not have any annual or monthly check up * Takes his maintenance drug for his hypertension * Takes a bath everyday and observes proper hygiene * First time to be hospitalized

Nutritional-Metabolic Pattern: * Eat all kinds of food; does not have specific food preferences but usually eating larger amount of meat * Occasional alcoholic drinker ( estimately 3 times a month) * Enjoys eating spicy and fatty foods. * From NPO (5 days in SICU and a day ward), she had clear liquids (for 2 days in the ward) to general liquids(2 days in the ward), then soft diet (for 2 days) introduced to him.
Elimination Pattern: * At younger age (Mid-twenty’s) client’s bowel movement is irregular; every 2-3 days * Defecates at least once daily. Sometimes, stool is soft and yellowish * Voiding freely everyday without pain and difficulty

Activity-Exercise Pattern: * Carry Vegetables to be sold in the market * Does not have any formal exercise program

Sleep-Rest Pattern: * Does not have regular circadian rhythm. * During confinement he only has 3 hours of sleep but during her non-sleep days, client can have 6-7 hours of sleep daily * Easily awaken by external stimuli such as noise and warm temperature
Coping-Stress Tolerance Pattern: * “Manonood lang ng TV” client stated * Compensates with stress through eating his favourite foods * Enjoys watching television shows as a relaxation technique

Self Perception Pattern: * Look himself as burden for his family as he was hospitalized.

Cognitive-Perceptual Pattern:

* Communicates thought freely but does not maintain lengthy conversation * no impairment in hearing and other senses * not wearing any assistive devices

Sexuality-Reproductive Pattern:

* Wears appropriate clothes according to gender

Roles-Relationship Pattern:

* A loving husband to his wife * With good relationship to her family members and relatives.

Values-Beliefs Pattern: * Belongs to the Roman Catholic denomination * No superstitious beliefs that may affect health

Physical Assessment

1st Day | 2nd day(SICU) | 3rd day(SICU) | 4th day (WARD) | 5th day (WARD) | Vital Signs * B.P 110/70mmHg * PR-RR: 115bpm-25bpm * Temp.: 37oCSkin: * dry skin noted * pale skin noted * with brown complexion notedHead / Hair: * symmetrical facial features * no pediculosis * no seborrheic dermatitis * no lumps and lesions * no hematoma Eyes: * symmetrical in shape * can close eyes with eyelids * with white sclera * with pale conjunctivae * with darkish pigmentation around the eyes * with pupil equally round and reactive to light accommodation * no discharges notedEars * symmetrical in shape * aligned in the outer canthi of the eyes * no inflammation noted * no lesions noted * no hearing or assistive devices used.Nose * with high bridge nose * with two symmetric nostrils * with clear watery discharge * no bleeding or epistaxis notedLips / mucosa / mouth * dry lips noted * pale lips noted * dry mucosa noted * pale gingival area noted * with halitosis noted Teeth * doesn’t have dentures or braces. * yellowish in color * with complete set of teeth Neck * supple neck * palpable inflamed cervical lymph nodes * can move according to ROM * no jugular vein distension * with palpable lymph nodes noted.Chest * Symmetrical chest expansion * Rales lung sounds as auscultatedAbdomen * Flabby tender abdomen * With complaints of pain noted. * With hypoactive bowel sounds noted * Ascites noted * Guarding behavior on abdomenGenitals * with presence of pubic hair * no discharges noted * no sores or any lesions noted * no inflammation in any partUpper extremities * with capillary refill more than 2 seconds in fingernails * with short clean fingernails and nail polish * able to overcome gravity and resistance with grade of 5 out of 5 as highest in muscle strength in both extremities Lower extremities * with capillary refill of less than 1 seconds in toenails * with slightly long and dirty toenails * able to overcome gravity but not with resistance with grade of 5 out of 5 as highest in muscle strength in both extremities | Vital Signs: * BP: 150/90 mmHg * RR: 23bpm * PR: 87bpm * T: 37.6 °C * CVP reading: 20 mmHgSkin * Warm to touch * Dry skin notedEyes: * Teary eyes noted * Cannot maintain eye contact | Vital Signs: * BP: 140/90 mmHg * RR: 23bpm * PR: 87bpm * T: 37.6 °C * CVP reading: 20 mmHgAbdomen * Has radiating flank pain | Vital Signs: * BP: 140/90 mmHg * RR: 23bpm * PR: 87bpm * T: 37.4 °C * CVP reading: 20 mmHgAbdomen * Had his first flatus * No complaints of pain | Vital Signs: * BP: 130/80 mmHg * RR: 20bpm * PR: 88bpm * T: 37 °C * CVP reading: 20 mmHg |

Risk Factors
Increased fat and cholesterol intake * Bile functions in emulsifying fats in one’s system. Thus an increase in fat intake stimulates more production of bile which predisposes the risk of gallstone formation
( cholelithiasis).

Occasional alcohol intake

* It is thought that alcohol-induced precipitates to induce stone formation in the liver and aggravates the inflammatory process of pancreatitis
Obesity
* Recent studies found that obesity is a major risk factor for severe pancreatitis. It is thought that increased deposits of fat around the pancreas mar predispose people with pancreatitis to more extensive pancreatic necrosis. (Black, 2008)

Pathophysiology

LABORATORY AND DIAGNOSTICS FINDINGS
Hematology:
| Feb 20 ‘12 | Feb 22 ‘12 | Feb 24 ‘12 | Normal Values | Hemoglobin | | 122 LOW | 130 | 125 - 165 g/L | Hematocrit | | 0.41 | 0.41 | 0.37 – 0.42 | Leukocytes | | 13.9 HIGH | 17 HIGH | 5 – 10 x 10 g/L | Segmentars | | 0.93HIGH | 0.89HIGH | 0.66 | Lymphocyte | | 0.07 LOW | 0.1 LOW | 0.22 – 0.40 | Monocyte | | | 0.01 | | PT - ControlPatientActivity | 131290 | | | |

Interpretation: The complete blood count is a collective overview of the peripheral blood. The test provides a great deal of information about the hematologic system as well as other organ systems. This test is a screening test. It is usually performed on every patient admitted to the hospital.

Hemoglobin (Hb), which transports oxygen, is the main component of a red blood cell (RBC). Each RBC contains about 250 million molecules of Hb. Therefore, Hb concentration correlates closely with the RBC count. Low Hb concentration may indicate anemia, recent hemorrhage, or fluid retention, which can cause hemodilution. Hematocrit (HCT) levels reflect the proportion of blood occupied by RBC. The value is within normal range. But we may consider high HCT which indicate hemoconcentration resulting from blood loss and dehydration.

Leukocytes or the white blood cell measures the number of WBCs in a microliter of whole blood. An elevated WBC count (leukocytosis) commonly signals infection, such as an abscess, meningitis appendicitis, or tonsillitis. Segmentars are one of the types of neutrophils found in the blood. They would be elevated if the overall white count is up, usually due to infection. A lymphocyte is a type of white blood cell in the vertebrate immune system. A low normal to low absolute lymphocyte concentration is associated with increased rates of infection after surgery or trauma or immune diseases. Monocytes are a type of white blood cell that attack bacteria or viruses, which is in normal range. Prothrombin time (PT) is a blood test that measures the time it takes for the fibrin clot to form in a citrated plasma sample after the addition of calcium ions and tissue thromboplastin, which is in normal range also.

Nursing Implication:

This hematology result reveals an inflammation. Management may include maintaining adequate fluid intake by maintaining proper regulation of intravenous fluids, administering antipyretic and antibiotic as a collaborative management, using strict aseptic technique and stressing importance of good hand washing, observing for signs of infection for fever and respiratory distress and increased abdominal pain, rigidity/ rebound tenderness, diminished / absent bowel sound.

Serum Diagnostics Feb 20 ‘12 Amylase | 611 U/L HIGH | 30-110 U/L | Lipase | 2059 U/L HIGH | 230-1300 U/L | ALT | 562 U/L HIGH | 9-72 U/L | ALKP | 56 U/L | 38-126U/L |

Interpretation:
The table shows that the amylase, lipase, ALT is above normal or in high range while ALKP is in normal range. Amylase (alpha-amylase or AML) is an enzyme that helps the body digest starch and glycogen in the mouth, stomach, and intestine. In cases of suspected acute pancreatic disease, measurement of serum or urine amylase is the most important laboratory test. Alpha-amylase is synthesised primarily in the pancreas and salivary glands and secreted into the GI tract. Serum amylase measurement helps distinguish between acute pancreatitis and other causes of abdominal pain and with this case the client was confirmed to have acute pancreatitis. Lipase has also a marked increase in levels. Lipase is produced in the pancreas and secreted into the duodenum, where it converts triglycerides and other fats into fatty acids and glycerol. Destruction of pancreatic cells, which occurs in acute pancreatitis, releases large amounts of lipase into the blood. High levels clearly suggest acute pancreatitis. Alanine aminotransferase (ALT) is an enzyme necessary for tissue energy production. ALT is found in the liver – with lesser amounts in the kidneys, heart, and skeletal muscles – and is relatively specific indicator of acute hepatocellular damage. This high level may indicate arrest of bile secretion or cholecystitis or early and improving acute pancreatitis. Lastly, alkaline phosphatase (AKLP) influences bone calcification and lipid and metabolite transport. In this case, it is in normal range.
Nursing Implication:

With this result, we may prioritize: intervening pain such as encouraging deep breathing, assisting the patient to assume the position of comfort as on bed rest, turning and repositioning every 2 hours, administering pain medications as a collaborative management.

Serum Diagnostics Feb 21 ‘12 BUN | 6.8 HIGH | 2.5-6.1 | Calcium | 2.17 LOW | 2.2-2.6 | Glucose (RBS) | 14.4 HIGH | 7.7 | AST | 358 HIGH | 14-59 | LDH | 1394 HIGH | 319-618 |

Interpretation:
This table shows that BUN, Glucose, AST and LDH are all above normal or in high range while the Calcium is in low level. Urea is a chief end product of protein metabolism. Elevated BUN levels occur in dehydration, urinary tract obstruction and increase protein metabolism. Evaluation of serum calcium levels measures the total amount of calcium circulating in the blood. The total calcium level helps evaluate endocrine function, calcium metabolism, and acid-base balance. Decreased serum levels may follow calcium loss in acute pancreatitis. While, increased glucose levels can also result from pancreatitis, and recent acute illness. Aspartate aminotransferase (AST) is an enzyme responsible in catalyzing conversion of the nitrogenous portion of amino acid, and moderate increase may indicate acute pancreatitis and fatty liver as confirmed in the patient. Lastly, Low-density lipoproteins in increased may add to the risk of having CAD.

Nursing Implication:

Management includes monitoring blood pressure, temperature, rate and characteristic of respirations and breath sounds, encouraging deep breathing, asking the patient to report unrelieved pain or increasing intensity and severity of pain, withholding food and fluids as indicated and ordered but maintaining adequate fluid intake by maintaining proper regulation of intravenous fluids and administer antipyretic and antibiotic as a collaborative management.
Serum Diagnostics Feb 22 ‘12 Urea | 5.6 | 2.5-7.1 | Crea | 71 | 62-133 | Na | 142 | 135-145 | K | 3.8 | 3.6-5.0 | Ca | 2.06 LOW | 2.10-2.55 |

Interpretation:
The table shows that the results of urea, Creatinine, Na, K are in normal level while Calcium is decreased.Urea is the chief end product of protein metabolism. Formed in the liver from ammonia and excreted by the kidneys, urea constitutes 40% to 50% of the blood's nonprotein nitrogen. The BUN test evaluates renal function and helps diagnose renal disease and hydration level.

Potassium is the major intracellular cation. Evaluation of serum potassium measures the extracellular levels of this electrolyte. It is important in maintaining cellular electrical neutrality. The sodium-potassium active transport pump maintains the ratio of intracellular potassium to extracellular potassium that determines the resting membrane to potential necessary for nerve pulse transmission. The serum potassium is in normal range but also can be considered low. Hypokalemia or decreased potassium level occurs with depletion of total body potassium caused by shifts from extracellular fluid to intracellular fluid. Depletion may be due to diabetic ketoacidosis, GI and renal disorders, vomiting, diarrhea, gastric suctioning, and diuretics.

Decreased calcium implies that acute pancreatitis precipitates in the abdomen, causing hypocalcemia. When the pancreas is damaged, free fatty acids are generated by the action of pancreatic lipase.

Nursing Implication: Interventions includes assisting the patient to assume the position of comfort; turn and reposition every 2 hours, maintaining patient on bed rest, providing touch therapy, keeping environment free of food odors, withholding food and fluids as indicated and ordered, maintaining adequate fluid intake by maintaining proper regulation of intravenous fluids, weighing patient daily and recording intake and output accurately.

Urinalysis 02/20/12 Color | Yellow | Specific Gravity | 1.020 | Character | Slightly Turbid | Epithelial Cell | Few | Bacteria | Few | Protein | Few | Reaction | 6.0 | Sugar | Negative | WBC | 2-3 | RBC | 25-40 |

Interpretation:

Urinalysis serves as many functions. It can be used to screen patients for kidney and urinary tract disease and can help detect metabolic or systemic disease. Presence of protein thus indicates excess protein serum in urine- from renal failure. Presence of WBC and RBC may indicate infection, obstruction, inflammation, trauma, tumors, or other causes. Epithelial cells and bacteria may indicate genitourinary tract infection or contamination of external genitalia. Also, presence of protein should not be seen. Protein in the urine is a warning sign. It may indicate kidney damage or disease or it may be a transient elevation due to an infection, medication, vigorous exercise, or emotional or physical stress.

Nursing Implication: The management mainly focuses in preventing further inflammation: using strict aseptic technique when changing surgical dressings or working with IV lines, indwelling catheter, changing soiled dressings promptly, stressing the importance of good hand washing, observing rate and characteristic of respirations, breath sounds, encouraging frequent position changes and observing for signs of infection: fever, respiratory distress, increased abdominal pain, rigidity/ rebound tenderness, diminished / absent bowel sound, and administering antibiotic therapy as a collaborative management.

Electrocardiogram 02/20/12
Normal Sinus rhythm
Early repolarization V2-V3

Interpretation: ECG, the most commonly used test for evaluating cardiac status, graphically records the electrical current (potential) generated by the heart. This current radiated from the heart in all directions and on, reaching the skin, measured by electrodes connected to an amplifier and strip chart recorder.

Normal sinus rhythm indicates that the P waves in leads I and II must be upright (positive) if the rhythm is coming from the sinus node.V2 and V3 are part of the Precordial leads. Early repolarization or the ST segment elevation with concave upward appearance may also be seen in other leads; although it's a term with little physiologic meaning.

Nursing implication:

Continuous monitoring for the cardiac status is important and intervening with it abruptly. Pacing of activity should also be encouraged.

Chest X-ray 02/21/12
Opacity is seen in left lung base pneumonia
Increase transverse diameter of lungs

Interpretation:

In radiography, X-ray beams penetrate bone and tissue and react on specially sensitized film. Normal tissue is radiolucent on film, whereas abnormalities (such as infiltrates, foreign bodies, fluids, and tumors) appear as densities. It also helps detect consolidation and effusion.

Chest X-ray was obtained to clearly determine the extent and pattern of the patient’s lung involvement to his condition. Opacity is seen in left lung base or visible (usually not visible) of the bronchi indicates pneumonia. While the increase transverse diameter of lungs may indicate pleural effusion or tumor, fibrosis or collapsed lung. One of the complications of acute pancreatitis is pneumonia.

Nursing Implication: Management includes respiratory support as needed, nutritional support and fluid and electrolyte management and promote proper hygiene to prevent further infections and complications. Oxygen should be administered as ordered and bronchodilator medications, postural drainage, chest physiotherapy/ bronchial tapping, and NG suctioning may be used to maintain airway patency.

Ultrasound (Abdomen) 02/20/12 | 02/21/12 | Mild Fatty liverCholelitiasis | Suggest acute pancreatitisGB stone |

Interpretation: The Ultrasound shows presence of mild fat in the liver characterized by the accumulation of fat. Although fatty liver disease is reversible with treatment, if left untreated, people living with fatty liver can encounter potentially serious complications such as permanent liver damage and scarring of the liver.

Cholelithiasis is solid crystalline precipitates in the biliary tract, usually formed in the gallbladder. Gallstones, derived from the bile, consist mainly of calcium, cholesterol, or bilirubin.

On the other hand, acute pancreatitis is sudden swelling and inflammation of the pancreas. The pancreas is an organ located behind the stomach that produces chemicals called enzymes, as well as the hormones insulin and glucagon. Most of the time, the enzymes are only active after they reach the small intestine, where they are needed to digest food. When these enzymes somehow become active inside the pancreas, they eat and digest the tissue of the pancreas. This causes swelling, bleeding (hemorrhage), and damage to the pancreas and its blood vessels. Acute pancreatitis affects men more often than women. Certain diseases, surgeries, and habits make you more likely to develop this condition. The condition is most often caused by alcoholism and alcohol abuse (70% of cases in the United States).

Nursing Implication:

Management includes pain medicines, fluids given through a vein (IV), and stopping food or fluid by mouth to limit the activity of the pancreas. In some cases, therapy is needed to drain fluid that has collected in or around the pancreas, remove gallstones and relieve blockages of the pancreatic duct.

Arterial Blood Gas | 02/21/12 | 02/22/12 | pH | 7.42 | 7.49 (alkaline) | PCO2 | 36 | 43.3 | PO2 | 67.9 | 73.3 | HCO3 | 22.8 | 32.6 (alkaline) | O2 Saturation | 94 % | 98.7% |

Interpretation: ABG analysis evaluates gas exchange in the lungs by measuring the partial pressures of oxygen (PaO2) and carbon dioxide (Paco2) as well as the pH of an arterial sample. PaO2 measures the pressure exerted by the oxygen dissolved in the blood and evaluates the lungs' ability to oxygenate blood. PaCO2 measures the pressure exerted by carbon dioxide dissolved in the blood and reflects adequacy of ventilation by the lungs. The pH measures the blood's hydrogen ion concentration and it’s the best way to tell whether blood is too acidic or too alkaline. Bicarbonate (HCO3) is a measure of the bicarbonate ion concentration in the blood, which is regulated by the kidneys. Oxygen content (O2CT) measures the actual amount of oxygen in the blood and isn't commonly used in blood gas evaluation. The result of this ABG indicates that there is uncompensated metabolic alkalosis. Metabolic alkalosis is a state of relative excess of base in body fluids from a gain of bicarbonate or a loss of fixed acids. This condition results from severe or prolonged vomiting, diuretic therapy, and prolonged GI suctioning. Loss of gastric fluids via nasogastric suction or vomiting further contributes to metabolic alkalosis because of loss of HCl. The common cause of alkalosis is hyperventilation. One of the first symptoms seen in these cases is dizziness. Nursing implication: Acute pancreatitis is commonly associated with fluid loss resulting from emesis. Management of this involves replacing lost fluids and restoring electrolyte balance. Therapy to decrease these enzymes may include NG suction to prevent gastrin to enter duodenum. NG suctioning should not be prolonged to prevent metabolic alkalosis. Monitor vital signs for changes in pulse rate and blood pressure (fluid volume changes) as well as respiratory rate (acid-base balance).

Drug Study
CEFUROXIME
Date Ordered: Admission Day – February 20,2012
Dosage, Time and Route: 1.5 gm.then 750 mg q 8 ;TIV
Date Discontinued:February 21, 2012
Classification:Second Generation Cephalosporins
Action:Binds to bacterial cell wall membrane, causing cell death.
Indication:Treatment for infections due to susceptible organisms. Contraindication:For patients with hypersensitivity to cephalosporins
Adverse Reaction: Nausea and vomiting, diarrhea, rashes, phlebitis at IV site. Nursing Consideration:Obtain history to determine previous use and reactions to cephalosporins. Perform anti – negative skin test to client before administration.
Why is it given:It is given to treat infection from acute pancreatitis and pneumonia of the client by binding to the cell wall of microorganisms thereby causing cellular death.

OMEPRAZOLE
Date Ordered: Admission Day – February 20,2012
Dosage, Time and Route: 40 mg OD; TIV
Classification:Gastric acid pump inhibitor
Action:Binds to an enzyme on gastric parietal cells in the presence of acidic gastric pH, preventing the final transport of hydrogen ions into the gastric lumen.
Indication: Management of GERD that has not responded to conventional therapy with histamine H2 – receptor blocking agents.
Contraindication: Hypersensitivity.
Adverse effects: Weakness, headache, abdominal pain, constipation.
Nursing Considerations:Assess routinely for epigastric or abdominal pain.
Why is it given: This is given to prevent abdominal pain which may be cause by increase gastric secretion due to the NPO status of the client. The abdominal pain is prevented by this drug by preventing too much gastric secretion through binding on the parietal cells.

KETOROLAC
Date Ordered: Admission Day – February 20,2012
Dosage, Time and Route: 30 mg prn for pain; TIV
Date Discontinued:February 21, 2012
Classification:Nonopioid analgesic, Nonsteroidal anti –inflammatory agent
Action:Inhibits prostaglandin synthesis producing peripherally mediated analgesia. Also have anti- inflammatory and antipyretic properties.
Indication: Short – term management of pain.
Contraindication:Hypersensitivity, pre- operative use.
Adverse Reaction: drowsiness, dizziness, dyspnea, abnormal taste, bleeding
Nursing Consideration: Assess pain prior and 1 – 2 hours after administration.
Why is it given:Given to manage pain felt by the client caused by acute pancreatitis - wherein the pain felt by the client is at right upper quadrant radiating to the back - by inhibiting synthesis of prostaglandin which is responsible for the sensation of pain being felt.

CETRIAXONE (KEPTRIX)
Date Ordered: 1st Day of hospitalization – February 21,2012
Dosage, Time and Route: 1 gm q8; TIV
Date Discontinued:03/24/12
Classification: 3nd gen. cephalosporin drugs, anti-infective drug
Action: Inhibits bacterial wall synthesis, rendering cell wall osmotically unstable, leading to cell death.
Indication:Tx of susceptible infections includes chancroid, gastroenteritis. Pre-operative prophylaxis to reduce chance of post-operative surgical infections.
Contraindication: Pain, induration, phlebitis after IV administration, rash, diarrhea, eosinophilia, casts in urine, thrombocytosis and leucopenia.
Nursing Consideration: Teach patient to report sore throat, bruising, bleeding and joint pain, this may indicate blood dyscrasia.
Why is it given: Given to prevent infection or to manage infection from acute pancreatitis and pneumonia by binding to the cell wall of microorganisms thereby causing cellular death.

PARACETAMOL
Date Ordered: 1st Day of hospitalization – February 21,2012
Dosage, Time and Route: 300 mg TIV q 4 for temperature 38.5 C and above
Date Discontinued:
Classification:Nonopioid analgesic, Antipyretic
Action: inhibits the synthesis of prostaglandins that may serve as mediators of pain and fever.
Indication:Mild to moderate pain. Fever.
Contraindication:Hypersensisivity.
Nursing Consideration:Assess overall health status and alcohol usage before administration.
Why is it given:This is given as PRN order for fever; to aid in decreasing or lowering body temperature to normal value by inhibiting prostaglandins which is responsible for fever and pain or for the inflammatory process of the body.

FUROSEMIDE
Date Ordered: 1st Day of hospitalization – February 21, 2012
Dosage, Time and Route: 20 mg TIV as now order
Date Discontinued:
Classification: Loop Diuretic, Antihypertensive
Action: Inhibits reabsorption of sodium and chloride from the loop of henle and distal renal tubule.
Indication:Mangement of edema secondary to congestive heart failure, hepatic or renal disease.
Contraindication:Hypersensitivity, not for patients who are known with alcohol intolerance.
Nursing Consideration:Assess fluid status throughout therapy. Monitor daily weight, edema, lung sounds, skin turgor, and mucous membrane. Monitor BP before and after administration.
Why is it given: This is given to the client to aid in the treatment for the client’s ascites and congestion as indicated by the incresed CVP reading – 20 mmHg through its diuretic effect.

NICARDIPINE DRIP
Date Ordered: 2ndt Day of hospitalization – February 22, 2012
Dosage, Time and Route: D5W 90 ml + 1 amp Nicardipine 0.5 mg/hr - 3 mg/hr
Date Discontinued:
Classification: Calcium Channel Blockers (Antihypertensive, Antiarrhythmics, Antianginal)
Action: Inhibits transport of calcium into myocardial and vascular smooth muscle cells, resulting in inhibition of excitation - contraction coupling and subsequent contraction.
Indication:Management of hypertension, angina pectoris and vasopastic angina.
Contraindication:Hypersensitivity, low Blood Pressure, severe ventricular dysfunction.
Nursing Consideration:Monitor BP and PR prior to therapy; monitor I and O.
Why is it given: This is given to manage the BP of the client or maintaining normal BP through inhibiting Calcium from entering the Myocardial and vascular smooth muscle cells which then causes systemic vasodilation thereby results to decreased BP.

TRAMADOL DRIP
Date Ordered: 2ND Day of hospitalization – February 22, 2012
Dosage, Time and Route: D5W 250 cc + Tramadol 250 mg X 24 hours
Classification: Analgesic
Action: Binds to mu – opioid receptors; Inhibits reuptake of serotonin and nor – epinephrine in the CNS.
Indication:Treatment of moderate to moderately severe pain.
Contraindication:Hypersensitivity; not for patients who are acutely intoxicated by alcohol.
Nursing Consideration:Assess and monitor BP, PR and RR before and during the therapy.
Why is it given:This is given to manage the pain felt by the client caused by acute pancreatitis in replacement for Ketorolac.

CLONIDINE
Date Ordered: 2nd Day of hospitalization – February 22, 2012
Dosage, Time and Route: 75 mg OD
Date Discontinued: 02/23/12
Classification: Antihypertensive
Action: Stimulates alpha – adrenergic receptors in the CNS.
Indication:Management of mild to moderate hypertension
Contraindication: Hypersensitivity.
Nursing Consideration: assess and monitor for BP and PR before and during therapy.
Why is it given:The client is known hypertensive. This is given to decrease the BP of the client by stimulating the alpha – adrenergic receptors in the CNS resulting to inhibition of cardioacceleration and vasoconstriction center causing vasodilation thereby decreasing BP.

Demerol
Date Ordered: February 22, 2012
Dosage, Time and Route: 0.5 mg every 6 hours TIV
Classification: Opioid Analgesic (agonist)
Action: Binds to opiate receptors in the CNS. Alters the perception of and response to painful stimuli, while producing generalized CNS depression.
Indication: Drug of choice for acute pancreatitis. Management of moderate to severe pain
Contraindication:Hypersensitivity, low Blood Pressure,and RR.
Nursing Consideration: Monitor BP and PR prior to therapy; monitor I and O.
Why is it given: the client by now hws a diagnosis of Acute pancreatitis and dememrol is the drug of choice for acute pancreatitis in terms of the relief of pain.

NIFEDIPINE
Date Ordered: 3rdDay of hospitalization – February 23, 2012
Dosage, Time and Route: 10 mg SC q 8
Date discontinued: 02/25/12
Classification: Calcium Channel Blockers (Antihypertensive, Antiarrhythmics, Antianginal)
Action:Inhibits transport of calcium into myocardial and vascular smooth muscle cells, resulting in inhibition of excitation - contraction coupling and subsequent contraction.
Indication:Management of hypertension, angina pectoris and vasopastic angina.
Contraindication:Hypersensitivity, low Blood Pressure, severe ventricular dysfunction.
Nursing Consideration: Monitor BP and PR prior to therapy; monitor I and O.
Why is it given: This is given to manage the BP of the client or maintaining normal BP through inhibiting Calcium from entering the Myocardial and vascular smooth muscle cells which then causes systemic vasodilation thereby results to decreased BP.

PIPPERACILLIN-TAZOBACTAM (VIGOCID)
Date Ordered: 4th Day of hospitalization – February 24, 2012
Dosage, Time and Route: 4.5gm BID TIV
Date Discontinued:
Classification: Anti - infective
Action: Binds to bacterial cell wall membrane and inhibits beta – lactamase, an enzyme that can destroy penicillin.
Indication:Treatment of serious infections due to susceptible orgnisms.
Contraindication:Hypersensitivity
Nursing Consideration:Obtain history, perform ANST before administration.
Why is it given: This is given in replacement for Ceftriaxone to treat the serious infection from acute pancreatitis and pneumonia by destroying the part of the cell which destroys the penicillin (beta – lactamase) so the action of the pipperacillin - which is binding to the bacterial cell wall causing cell death – is achieved.
LANOXIN
Date Ordered: 4th Day of hospitalization – February 24, 2012
Dosage, Time and Route: Date Discontinued: 0.125 mg IV now then q8
Classification: Inotropic Agent, Antiarrhythmic
Action: Increases the force of myocardial contraction. Prolongs the refractory period of the AV node and decreases conduction through the SA and AV node.
Indication:Treatment for Congestive Heart Failure
Contraindication:Hypersensitivity, uncontrolled ventricular arrhythmias, AV block
Nursing Consideration:Monitor BP, ECG, monito I & O, assess for edema and auscultate lungs.
Why is it given: This is given to improve the cardiac perfusion and contraction of the heart which may aid in decreasing the CVP level or congestion.

TELMISARTAN
Date Ordered: 5TH Day of hospitalization – February 25, 2012
Dosage, Time and Route: 40 mg/tab 1 tab OD
Date Discontinued:
Classification: Antihypertensive ( Angiotensin II receptor Antagonist)
Action: Blocks the vasoconstrictor and aldosterone – producing effects of angiotensin II at various recptor sites, including vascular smooth muscle and in the adrenal glands.
Indication:Management for hypertension.
Contraindication:Hypersensitivity; Pregnancy
Nursing Consideration:Assess BP and Pulse throughout the therapy.
Why is it give: The client is known hypertensive. This is given to maintain / decrease the BP of the client through blocking the receptors of angiotensin II and also aldosterone which is a potent vasoconstrictor thereby decreasing the blood pressure.

VERAPAMIL
Date Ordered: 5TH Day of hospitalization – February 25, 2012
Dosage, Time and Route: \40 mg/tab 1 tab OD
Date Discontinued:
Classification: Calcium Channel Blockers
Action: Inhibits transport of calcium into myocardial and vascular smooth muscle cells, resulting in inhibition of excitation - contraction coupling and subsequent contraction.
Indication: Management of hypertension, angina pectoris and vasopastic angina.
Contraindication: Hypersensitivity, low Blood Pressure, severe ventricular dysfunction.
Nursing Consideration: Monitor BP and PR prior to therapy; monitor I and O.
Why is it given: This is given to manage the BP of the client or maintaining normal BP along with the other Calcium Channel Blockers, through inhibiting Calcium from entering the Myocardial and vascular smooth muscle cells which then causes systemic vasodilation thereby results to decreased BP.

Course in the Ward
Day 1 * Awake, in supine position * pale looking * cannot maintain eye contact * restless as noted * with CVP on right arm #1 PNSS 1L x 8 @left metacarpal vein regulated @ 41-42 gtts/min * NGT-CDU draining whitish phlegm like discharges * Foley Catheter-CDU draining yellowish to orange colored urine moderate in amount * With 0xygen via nasal canula at 4-6 lpm

Day 2 * on semi fowler’s * teary eyes noted * cannot maintain eye contact * with NGT-CDU draining whitish phlegm like discharges * Foley Catheter-CDU draining light yellow to yellowish colored urine moderate in amount * with CVP on right arm #2 PNSS 1L x 8 @left metacarpal vein regulated @ 41-42 gtts/min * with side drip A nicardipine drip D5W 90 cc + 1 amp Nicardipine 3 mg/hr @ right peripheral line regulated @ 30 gtts/min * with side drip B D5W + 1 amp Tramadol X 24 hours * With O2 via nasal cannula @ 4-6 L/min

Day 3 * on semi fowler’s * with CVP on right arm #2 PNSS 1L x KVO @left metacarpal vein * with side drip A nicardipine drip D5W 90 cc + 1 amp Nicardipine 1.5 mg/hr @ right peripheral line regulated @ 30 gtts/min * with side drip B D5W + 1 amp Tramadol X 24 hours * With O2 via nasal cannula @ 4-6 L/min

Day 4 * on semi fowler’s * with #5 PNSS 500 cc x KVO @ peripheral line on right arm * able to smile * able to tolerate general liquid diet * without Foley catheter * without NGT

Day 5 * on semi fowler’s * able to tolerate feeding * with #6 PNSS 500 cc x KVO @ peripheral line on right arm * able to ambulate * able to do ADL’s with minimal assistance

Nursing Theory
ADAPTATION MODEL BY SISTER CALLISTA ROY
“The model provides a way of thinking about people and their environment that is useful in any setting. It helps one prioritize care and challenges the nurse to move the patient from survival to transformation.” – Sister Callista Roy In Roy’s model, she views a person as a biopsychosocial being in constant interaction with a changing environment; one who uses coping skills to deal with different stressors that can be found in the environment. Moreover, she defines environment as conditions, circumstances and influences that surround and affect the development and behavior of the person. She claimed that there are four adaptive modes which are interrelated through perception; Physiological, self-concept, role function and interdependence adaptive modes. Physiological adaptive mode is the way a person responds as a physical being to stimuli from the environment. Self-concept is the psychological and spiritual characteristics of the person which consist of all beliefs and feelings that one has formed about oneself. Moreover, role is defined in this model as a set of expectations about how a person occupying one’s position behaves towards a person occupying another. Lastly, interdependence encompasses the coping mechanism from close relationship which results to giving and receiving of love, respect and value. It occurs between the person and the most significant other or between the person and the support system. Nursing process is utilized also in this theory which is the problem-solving approach for gathering data, identifying the capacities and needs of the human adaptive system, selecting and implementing approaches for nursing care and evaluation of the care provided. Six step of the nursing process are the following: 1. Assessment of Behavior 2. Assessment of Stimuli 3. Nursing Diagnosis 4. Goal Setting 5. Intervention 6. Evaluation
As student nurses, it is very important to provide a holistic nursing care which can be guided by the utilization of nursing care with regards to clients’ adaptation to a certain situation or circumstances. In this case study, the patient has the task to become adapted with the stimuli on the environment in order for him to survive, grow and develop. This can be attained with the help of the student nurses and other members of health care team that will be providing effective nursing care from assessment to evaluation of actions done. Utilization of nursing process under this theory will be beneficial to identify the coping mechanism of the client to his current situation and how these coping mechanisms could affect his adaptation. Nursing in this case is about the decrease, enhancement, modification and alteration of the stimulus to achieve adaptation.

NURSING CARE PLANS
Problem # 1 Pain
ASSESSMENT
Subjective Data: * “Sobrang sakit ng tiyan ko. Hindi ko na kaya. Operahan niyo na ako ngayon na!” * “Parang pinipiga yung tiyan ko!” * Pain scale of 10 out of 10
Objective Data: * Pale conjunctivae noted * Dry lips and buccal mucosa * Irritable * Cool and clammy skin * RR: 25 breaths per minute * BP: 140/90mmHg * Facial grimacing observed * Guarding behaviour on right upper quadrant of abdomen noted * With right upper quadrant tenderness * Ascites noted

NURSING DIAGNOSIS Acute Pain related to increase in prostaglandin release in the blood stream in response to the present health condition: acute pancreatitis

GOAL / PLANNING At the end of the nursing interventions, the client will be able to report pain relief and discomfort as manifested by: * Verbalization of pain relief * Normal values of vital signs * Decreased pain scale from 10/10 to 5-6/10

NURSING INTERVENTIONS: 1. Encouraged deep breathing
Rationale: Deep breathing exercise enhances and aids in smooth muscle relaxation contributing to pain relief. 2. Assist the patient to assume the position of comfort; turn and reposition every 2 hours.
Rationale: Frequent turning relieves pressure and assists in preventing pulmonary and vascular complications. 3. Report unrelieved pain or increasing intensity and severity of pain.
Rationale: Pain may increase pancreatic enzymes and may also indicate pancreatic haemorrhage. 4. Maintain patient on bed rest.
Rationale: Bed rest decreases body metabolism and thus reduces pancreatic and gastric secretions which may be a factor of the pain experience. 5. Provide tactile/cutaneous stimulation
Rationale: Gate control theory suggests that cutaneous stimulation closes the pain pathways. 6. Keep environment free of food odours.
Rationale: Sensory stimulation can activate pancreatic enzymes. 7. Withhold food and fluids as indicated and ordered.
Rationale: Patient should be kept noting by mouth status until pain and nausea subside to limit or reduce release of pancreatic enzymes and resultant pain. 8. Administer pain medications as ordered, Ketorolac and Tramadol drip.
Rationale: Severe or prolonged pain can aggravate shock and is more difficult to relieve, requiring larger doses of medication, which can mask underlying problems and complications

EVALUATION: At the end of the nursing interventions done with regards to pain management, the patient was able to verbalize relief of pain and discomfort as manifested by a pain scale of 5 out 10.

Problem # 2
ASSESSMENT: Nutrtion
Subjective Data: * “Gutom na ako. Gusto ko na kumain.”
Objective Data: * With nasogastric tube in left nares * Patient is on NPO status as ordered * Hypoactive bowel sounds auscultated * Dry and pale lips noted * Dry buccal mucosa * Baseline weight upon admission : 90 kg * Current estimated body weight : 85kg * Weight loss : 5 kg

NURSING DIAGNOSIS
Imbalancd Nutrition: Less than body requirements r/t absence of food intake s/t NPO status
GOAL/PLANNING
At the end of the nursing interventions, the patient will be able to experience no signs of malnutrition as evidenced by maintained baseline body weight.

NURSING INTERVENTIONS: 1. Maintain adequate fluid intake by maintaining proper regulation of intravenous fluids.
Rationale: One of the sources of nutrition of the patient is through intravenous fluids. Proper regulation enables adequacy of electrolyte and nutrient delivery in the patient’s body 2. Obtain baseline weight. Weigh patient daily.
Rationale: Weight is the one of the parameters of determining the nutritional status of an individual. Weight loss may indicate nutrition deficiencies. 3. Record intake and output accurately.
Rationale: Enables monitoring of the fluid and electrolyte status of the patient. 4. Maintain patient on bed rest.
Rationale: Activity requires more calories and nutrients. Maintaining patient on bed rest helps in decreasing body’s metabolic demands of the patient which then decreasing the body’s demand for more calories and nutrients to be used for carrying out physical activity.

EVALUATION: At the end of the nursing intervention, the client was able to maintain the current body weight. No further weight loss was observed. Goal Met!

Problem # 4
Assessment:
Subjective: “ Parang ang init ng pakiramdam ko”, stated by the patient. Objective: * Febrile with body temperature of 38.50C * Whole abdomen ultrasound suggested a mild fatty liver that suggest acute pancreatits and cholelitisis * With result of leukocyte of 13.9 * With result of segmentars of 0.93 * With result of lymphocyte of 0.007 * With hot flushed skin * Diaphoresis as noted

Diagnosis: Actual Infection related to active immune defenses s/t present condition
Planning:
At the end of 8 hours nursing interventions , the patient will able to maintain V/S within normal value, and participate in activities to reduce infection.
Intervention:
1. Practiced strict aseptic technique when changing surgical dressings or working with IV lines, indwelling catheter, Change soiled dressings promptly.
R: Limits sources of infection, which can lead to sepsis in a compromised patient.
2. Stress importance of good handwashing
R: reduces risk of cross - contamination
3. observe rate and characteristic of respirations, breath sounds.
R: Fluid accumulation and limited mobility predisposes to respiratory infection. Accumulation of ascites fluid may cause elevated diaphragm and shallow abdominal breathing.
4. Encourage frequent position changes , deep – breathing and coughing.
R: Enhances ventilation of all lung segments and promotes mobilization of secretions
5. Observe for signs of infection; a) Fever and respiratory distress b) Increased abdominal pain, rigidity/ rebound tenderness, diminished / absent bowel sound
Collaborative:
1. Administer antibiotic therapy R: Broad – spectrum antibiotics are generally recommended for sepsis , however therapy will be based on the specific organism cultured.

Evaluation: At the end of the 8 hours nursing intervention, the patient had a decreased body temperature from 38.5 to 37.5.

Problem # 4
ASSESSMENT
Subjective: “ pakilakasan naman yung aircon kasi parang ang init ko “ stated by the client Objective * Slightly irritable as noted * Teary eyes noted * With dry lips and buccal mucosa noted * Flushed skin noted * Warm to touch skin noted * With good skin turgor * Temperature of 38.0 * Warm breath noted

DIAGNOSIS Alteration in Thermoregulation; Hyperthermia related to inflammatory body response to infection.
PLANNING
At the end of the 8 hours duty, the patient will have a decrease of temperature from 38.0 to 36.5 – 37.6 , which is the normal range.
INTERVENTION
Independent:
.
1. Manipulated room temperature
R: Room temperature / number of blanket should be altered to maintain near normal body temperature. 2. Provided tepid sponge bath, avoid using alcohol.
R: it may help decrease body temperature through evaporation. Avoid alcohol use to prevent drying of skin 3. Advised to wear loose clothes and white shirt or cotton clothes.
R: Loose clothing aid in promoting heat loss and light coloured clothes does not attract or absorb too much heat.

Collaborative 1. Administer antipyretic.
R: used to reduce fever by its central action on the hypothalamus , however fever may be beneficial in limiting growth of organism and enhancing auto destruction of infected cells.

EVALUATION At the end of the 8 nursing intervention, the patient’s temperature decreases from 38.00C to 37.50C. Goal Met.

Problem #.5
ASSESSMENT
Subjective Data: * “Nahihirapan ako sa kalagayan ko ngayon.”
Objective Data: * Uncombed hair noted * Halitosis * With nasogastric tube * On NPO status * On bed rest * Unable to carry out activities of daily living independently

NURSING DIAGNOSIS Self Care Deficit: Grooming, Hygiene, Feeding, Ambulatory incapability related to prolonged hospitalization and bed rest

GOAL/PLANNING At the end of the nursing interventions, the client will be able to participate with the activities to be done like AM care to promote self – enhancement with minimal assistance.

NURSING INTERVENTIONS 1. Assist patient on grooming (e.g combing his hair for him)
Rationale: The patient cannot perform activities by himself due to his present condition. Assisting him encourages good care and better feeling during the course of hospitalization. 2. Provide sponge bath.
Rationale: The patient cannot perform hygiene for himself. This is when the nurse comes to provide AM care for the patient’s need for proper hygiene. This does not only pertain to cleanliness of oneself but it also helps in preventing spread of infection. 3. Maintain patient on NPO status as ordered. Assist patient in feeding and let him feed himself to regain independence as soon as there is an order to resume his diet.
Rationale: Relating to the patient’s condition, the client is restricted on NPO status to prevent stimulation of the pancreas to secrete enzymes contributing to pain experience. Once diet is resumed encouraging the patient to feed himself gives him confidence and independence to return to his normal routine and function. 4. Provide frequent encouragement and assistance as needed with dressing.
Rationale: To reduce energy expenditure and frustration. 5. Provide patient with appropriate utensils (spoon, fork, straw, food guard) to aid in self feeding.
Rationale: These items increase opportunities for success. 6. Ensure that needed utensils are close by or within the patient’s reach.
Rationale: Conserve energy and optimize safety. 7. Assist with ambulation.
Rationale: Stand on patient’s weak side to assist with balance and support. 8. Turn patient side to side every 2 hours.
Rationale: Bed mobility assistance is important to facilitate body activities keeping the client’s body in function.

EVALUATION: At the end of the nursing interventions, the client was able to feed himself, perform personal hygiene, and ambulate, and was discharged with complete and independent functioning in carrying out activities.

Health Teaching

1. Educated client on the effects of alcohol drinking. 2. Encourage to take a well-balanced meals, thus, limiting fat in the diet. Fresh fruits and vegetables could also be part of the meal. 3. Instructed to avoid alcohol, spicy foods, caffeine-containing foods and heavy meals. 4. Instructed to increase fluid intake. Dehydration may aggravate the pain by irritating the pancreas, causing, too much discomfort on the client. 5. Encouraged a healthy lifestyle. Stop gradually any vices (drinking, smoking) that may cause further harm to him. 6. Encouraged to have regular exercise. 7. Educated about pain management. Different relaxation techniques may be effective such as deep breathing techniques, music therapy 8. Encouraged to verbalize any concerns related to current health status / situation. 9. Encouraged to take prescribed medications especially for sudden pain felt on duration of its attack. 10. Encouraged to avoid strenuous activities or other things that may cause stress, relaxation is very important. 11. Encouraged to pray in accordance to their beliefs. Ask for God’s help for faster recovery.

References/ Bibliography
Books:
* Textbook of Medical-Surgical Nursing 11th edition by Brunner and Suddarth Volume II * Medical –Surgical Nursing 8th edition by Black and Hawks Volume II * Essentials of Anatomy and Physiology 6th edition by Seeley, Stephen and Tate * Health Assessment and Physical Examination 3rd edition by Estes * Nursing Theories in the Philippines by Octaviana * 2009 and 2010 Lippincott’s Nursing Drug Guide by Karch * Merriam-Webster’s Medical Dictionary * Microsoft ® Encarta ® 2009.

WEBSITES: * http://www.springerlink.com/content/e2322616n82666q1/ * http://www.ingentaconnect.com/content/klu/423/2008/00000393/00000003/00000200