Acute Pancreatitis and Its Aetiology - Essay Example

?While I was on a placement on an assessment unit a patient was admitted with severe upper abdominal pain radiating through her back, while her abdominal muscle had shown some sign of tender .She also had nausea and vomiting with anorexia. The patient was a 59-year-old woman and for the sake of upholding confidentiality, the patient will henceforth be referred to as Mrs A (Nursing and Midwifery Council, 2010). The very first assessment involved collecting the patient’s blood sample for testing and the results indicated that she had increased levels of digestive enzymes known as serum amylase. When these enzymes leak out of a malfunctioning pancreas, some is taken up into the blood, where high levels may be detected. As with other inflammatory condition, C-reactive protein (CRP) was also reported to be high. Higher levels of CRP indicate other serious diseases with a poor prognosis. Together with such signs and symptoms as sudden bloated stomach, abdominal pain, and ultrasound, the above increases attested to the presence of gall stones. In addition, a swollen pancreas was an indication that Mrs A was suffering from acute pancreatitis. This essay will define acute pancreatitis; explains its aetiology; its associated pathophysiology; as well as its pertinent epidemiology. It also looks at two interventions (examination of the levels of blood glucose and intravenous paracetamol administration) that were applied in the management of the patient’s condition and gives an appraisal of the care applied towards meeting her needs. Although pancreatitis may be acute or chronic (Smith & Fawcett, 2006), the focus of this paper is on acute pancreatitis. As Smith & Fawcett (2006) explain, the pancreas is an elongated, slender organ located at the left upper side of the abdomen. Acute pancreatitis refers to a kind of inflammation that occurs rapidly causing an elevated level of pancreatic enzymes in the blood as well as upper abdominal pain (Zara, 2010). Acute pancreatitis occurs in two types namely necrotizing acute pancreatitis and interstitial pancreatitis, which accounts for eighty percent of all cases of acute pancreatitis (Zara, 2010). Research by the British Society of Gastroenterology (BSG) (2005) indicates that in the United Kingdom, the frequency of acute pancreatitis is getting higher – it ranges from 150-420 cases for every million populations. Acute pancreatitis may result from surgery, drugs, or trauma (Burruss & Holz, 2005). However, alcohol and gallstones bring lead to about eighty per cent of this condition (BSG, 2005). Nevertheless, Sargent (2006) explains that ten percent of acute pancreatitis could be idiopathic, meaning that a diagnostic cause has not been recognized. Ultra sound results on Mrs A confirmed that she had gallstones. Finding out her condition’s underlying root could consequently greatly enhance her condition’s management and it may as well assist in the prevention of more attacks. Even though it is generally agreed that this condition entails an intricate flow of incidents that begin in the acinar cell of the pancreas, it is not clear the way in which the particular method through which acute pancreatitis arises (Madhav et al., 2005). According to Parker (2004), one generally acceptable and common presumption is the fact this condition results from pancreatic acini’s disruption or injury, which allows the seepage of such enzymes from the pancreas as elastase, chymotrypsin as well as trypsin into pancreatic tissue. The seeped enzymes are activated in this tissue, thereby instigating auto digestion as well as acute pancreatitis, as Parker explains (2004). Elastase, trypsin, and lipase activation breaks the cell membranes as well as the tissue down, leading to vascular destruction, haemorrhage, necrosis, as well as oedema (Madhav, et al., 2005). Once this takes place, it leads to an abrupt incisive pain in the upper abdominal region further (Holcomb, 2007). In most cases, the ache spreads out s to the backside and in most cases, it is linked to vomiting along with nausea. The patient might at times exhibit such symptoms as diarrhoea, upper, abdominal distension, abdominal tenderness without rigidity hypo-active bowel sounds and anorexia (Holcomb, 2007). In critical conditions, peritoneal signs such as rebound tenderness and guarding may be observed (Holcomb, 2007). The patient in question (Mrs A) presented with nausea and vomiting, hypoactive bowel sounds and upper abdominal pain spreading to the back. Discussed below are some of the interventions that were applied in the management of Mrs A’s condition. Pancreatitis is a very painful condition that requires rapid pain-relieving (analgesic) treatment (Holcomb, 2007). Paracetamol is usually effective in the management of mild to moderate pain. However, opioids (such as Morphine) are predominant component of analgesia in the management of pain in patients with acute pancreatitis as well as other extremely ill patients (Api et al, 2009) and (Holcomb, 2007). In addition, in conjunction with Morphine, weak opioids and Non Steroidal Anti inflammatory Drugs (NSAIDs), paracetamol is an effective component in multimodal analgesia. It helps in the reduction of opiate side effects in addition to improving the patient’s comfort (Maund et al., 2011 & Api et al., 2009). In order to manage Mrs A’s pain successfully, intravenous paracetamol was used along with morphine patient controlled analgesia (PCA). Consequently, one of the successful interventions used for the management of Mrs A’s condition has been the administration of paracetamol. According to British National Formulary (BNF) (2010), paracetamol is a widely used pain-relieving agent used in the treatment of mild to moderate pain as well as pyrexia. Although it has been in use for many decades, the way in which Paracetamol reduces pyrexia and reliefs pain is still not completely understood (Waterfield, 2008). Clycooxygenase (COX) enzymes react on arachidonic acid thereby synthesizing prostaglandin, and for this to happen, COX must be in an oxidised state (Woo, 2008). The presence of paracetamol normally reduces this oxidised form thus rendering the enzyme to be less efficient (Woo, 2008). Analgesic effect is thought to emanate from a decrease in the prostaglandins’ production in the spinal cord and in the brain (Aronoff et al, 2006). Certain types of injury as well as diseases trigger the production of prostaglandins in the body in order to sensitise nerve endings, in such a way that injury stimulation will bring about pain (Waterfield, 2008). In addition, paracetamol is believed to lead to increased pain threshold seeing that it leads to the reduction of the production of nerve sensitising prostaglandins, in such a way that even though the injury remains, the patient will not feel pain (Waterfield, 2008). A decrease in the stimulation of pancreatic secretions is of assistance in inflammation reduction as well as auto-digestion of the pancreas. For this reason, patients suffering from this condition are supposed to remain Nil By Mouth (NBM) (Zara, et al., 2010). In the management of Mrs A’s pain, therefore, rather than oral paracetamol, Intravenous (IV) Paracetamol (Perfalgan) was the best preference. As BNF (2010) directs, Mrs A received Perfalgan one thousand milligram in one-hundred mils for fifteen minutes. IV paracetamol’s pain-relieving outcome is said to start subsequent to the fifteen minutes following the termination of infusion, with the highest concentrations being attained within one hour with a period of roughly four to six hours (Api, et al., 2009). In order not to ensure that pain was not established prior to the next dose, timing for pain control was followed strictly (Dougherty & Lister, 2008). Nevertheless, in order to minimize side effects, not more than 4g was to be administered on a daily each day (Dougherty & Lister, 2008). According to Api, et al. (2009), it is confirmed that paracetamol’s bio-availability varies subject to the route of administration. In their study, Api and his co-authors (2009) discovered that rectal form of paracetamol is not as effectual as IV paracetamol. In addition, studies by the New South Wales Therapeutic Advisory Group Inc (2005) revealed that when used for mild, moderate and acute pain, IV paracetamol provides sufficient analgesic outcome as a single agent. Other researches have as well confirmed the fact that when used in tandem with opioids for instance, morphine; paracetamol usually lessens morphine-linked outcomes (Tan and Schug, 2006 & Beaulieu, 2007). This is for the reason that diverse morphine’s action modes as well as non-opioid prescriptions for example paracetamol permit the maintenance of optimal analgesia with reduced dose of morphine thus decreasing side effects that are morphine-related (Maund, et al., 2011). The most significant aspect of adequate management of acute pain is the regular as well as objective evaluation of the pain that the patient is going through (Carol, 2001). The assessment aims to discount non-physical as well as physical factors that may have an effect on pain perception in the patient (Dougherty & Lister, 2008). A numerical rating scale was employed to facilitate easy the assessment of Mrs A’s pain (Dougherty & Lister, 2008). On requesting Mrs A to rate her pain on a scale of 0-10, she more often than not rated her pain as zero, which was evidence that pain was well managed. As Dougherty & Lister (2008) explain, it is however important to note that a conclusion of the pain that a patients is going through cannot be obtained exclusively from using a pain scale. In this case, nonverbal characteristics were also looked into in order to come up with a reliable conclusion regarding the efficiency of pain management in Mrs A. The next step included monitoring Mrs A’s blood glucose. According to research, acute illness interferes with glucose metabolism in the patient’s body (Langdon & Shriver, 2004 and Clement et al., 2004). Langdon and Shriver (2004) explain that these alterations emanate from adaptive endocrine responses’ activation and in addition to increased mortality and morbidity, this may lead to more far-reaching metabolic alterations during long-standing critical illness. In normal cases, an increase in the levels of blood glucose triggers the release of insulin from a healthy person’s pancreas who is not suffering from diabetes (Crosser and McDowell, 2007). Insulin helps in glucose uptake and represses gluconeogenesis with the purpose of maintaining the blood glucose’s stability inside the body (Robinson and VanSoeren, 2004). In patients who are seriously ill for instance, those with acute pancreatitis, there is metabolism change, which can lead to substantial alterations in the metabolism of energy (Mizock, 2001). Moreover, Crosser and McDowell (2007) record that acute illness triggers the production of such stress hormones as glucagon, cortisol epinephrine, hormone associated with growth, and non-epinephrine. These give rise to augmented gluconeogenesis and insulin resistance in addition to decreasing peripheral glucose uptake, which then bring about hyper-glycaemia (Crosser and McDowell, 2007). Some form of acute or chronic conditions can also give rise to hypoglycaemia (Hassal and Butler-Williams, 2010). For that reason, the examination of blood glucose is vital in hyperglycaemia aversion in very ill patients for instance those suffering from the condition under discussion since changes in the functioning of the pancreatic generally bring an effect on the levels of blood glucose (Sargent, 2006). Also important to note is the facts that patients receiving treatment for hyperglycaemia by means of insulin therapy can also suffer from hypoglycaemia (Bagshaw, et al., 2009). Blood glucose levels’ readings can be derived from arterial samples of blood in the assessment unit, but is preferable for monitoring blood glucose alone and regularly. In any clinical setting, a capillary monitoring of blood glucose is a minimally insidious and convenient method of regulating the levels of blood glucose, according to Hassal and Butler-Williams (2010). During the assessment of capillary concentration of blood glucose, a finger-piercing device is employed for obtaining samples of blood that a small Point of Care Testing (POCT) meter subsequently processes (Hassal and Butler-Williams, 2010). Hassal & Butler-Williams (2010) further explain that a POCT meter measures blood’s glucose levels and it is made up of other tools including single use retractable lancets, testing strips and a control solution. Prior to using this device on a patient, it is important to ensure that test strips had been stored in accordance with directions and the monitor attuned in date to be made use alongside the test strips. Moreover, the quality control test must be previously conducted as well as documented. This is to ensure accuracy of the results could be ensured as well as to adhere to quality control procedure (Hassal & Butler-Williams, 2010). Rubin (2009) explains that the aforementioned test strip contains an enzyme that on reacting with blood glucose, the electrons that this strip produces change the electrons’ quantity into blood-glucose readings. The standard levels of blood glucose generally lies on a scale of four to eight millimoles for every litre, but it goes high following food ingestion (Hassal & Butler-Williams, 2010). As World Health Organisation (2006) explains, if the readings of blood glucose exceed 11.1millimoles for every litre, the condition is deemed as hyperglycaemia. According to Bagshaw and his co-authors (2009), hyperglycaemia results when blood glucose levels go below 12 millimoles for every litre. There is still insufficient proof as to how often the levels of blood glucose in patients with specific conditions or those who are critically ill should be monitored (Crosser & McDowell, 2007). For this reason, when monitoring the levels of blood glucose in Mrs A, a ward policy was considered – according to this policy, if the readings rose above 12 millimoles for every litre, the state was deemed as hyperglycaemia and insulin would be dispensed. In the same way, levels of blood glucose below four millimoles for every litre were considered as hypoglycaemia and Dextrose would be dispensed. If the blood glucose level of the patient were out of normal range, the rate of blood glucose examination would be raised. For instance, if the levels went out of the standard range, it would be observed after every thirty minutes to sixty minutes until the patient became stable. According to a study by Vincent and his co-authors (2002), subsequent to beginning an insulin protocol, the frequency of monitoring the levels of blood glucose should range from thirty to sixty minutes until the patient becomes stabilized, following which the frequency goes to every four hours. Additionally, Adams & Osborne (2006) asserted the need for close monitoring of blood glucose alterations in patients with acute pancreatitis and that hyperglycaemia is usually controlled with the titration of infusion of insulin to the patient’s blood glucose concentration. Elevated level of blood glucose in acutely/seriously ill patients among them beng those suffering from acute pancreatitis is linked with soaring levels of mortality as well as morbidity, in addition to increased fluid loss and osmolarity (Holcomb, 2007 & Krinsley, 2004). Although there were no instructions as to how often one should monitor blood glucose levels in patients suffering from acute pancreatitis, the local policy was adhered to in the management as well as monitoring of the blood glucose levels of Mrs A. all through, it was possible to maintain the patient’s blood glucose within range. Conclusion Apparently, acute pancreatitis is a severe condition that brings about much pain and discomfort in patients. Moreover, the illness increases mortality as well as morbidity rates. Consequently, there is great need to manage patients presenting with this condition timely and appropriately. It is also important to ensure that appropriate interventions are not missed, therefore enabling the patient to obtain optimal care. In the United Kingdom, acute pancreatitis is on the increase, with the most frequent causes being gallstones and alcohol. For that reason, there is need to diagnose the underlying cause of this condition in order to be able to manage it effectively. Monitoring the levels of blood glucose in these patients is also very essential because more often than not, changes in pancreatic function affect the levels of the patient’s blood glucose. Read More