Acute Pancreatitis Nursing Care Plan

Nursing Diagnosis 1: Acute Pain

Acute Pain related to Acute pancreatitis: revised Atlanta criteria. 2 of 3: characteristic abdominal pain, lipase > 3× ULN, characteristic imaging findings as evidenced by Severe epigastric pain radiating to the back; Pain rated > 7/10 on a 0–10 scale; Facial grimacing, guarding, fetal positioning; Tachycardia, hypertension, diaphoresis (autonomic response); Pain worsened by eating; sometimes relieved by leaning forward.

Interventions

• Assess pain using a 0–10 numeric scale at intervals matched to clinical acuity (commonly every 1–2 hours) and approximately 30 minutes after each intervention, per facility protocol.
• Characterize pain: location, radiation to the back, quality, onset, duration, and aggravating or relieving factors.
• Monitor vital signs (HR, BP, RR) and autonomic signs (diaphoresis, pallor) at intervals matched to clinical acuity.
• Assess for nonverbal pain indicators (grimacing, guarding, restlessness), especially when the patient is sedated or unable to verbalize.
• Reassess pain control adequacy at each handoff and before activity (turning, ambulation, deep breathing).
• Administer prescribed opioid analgesia (commonly hydromorphone, fentanyl PCA, or morphine) on the ordered schedule; titrate within provider parameters.
• Set up and educate the patient on PCA pump use when ordered; verify lockout interval and loading dose with a second RN per facility high-alert-medication policy.
• Position the patient in semi-Fowler with knees flexed, or support leaning forward when the patient prefers.
• Maintain NPO status when ordered for vomiting or ileus; coordinate advancement to clear liquids and a soft low-fat diet per provider order and facility protocol in mild AP.
• Provide non-pharmacologic adjuncts: dim lighting, a quiet environment, guided imagery, repositioning support.
• Coordinate with the provider team on antiemetic scheduling (commonly ondansetron) to support vomiting prevention and reduce vomiting-induced pain spikes.
• Teach the patient to report pain early (around 3–4/10) rather than waiting until it is severe.
• Educate on PCA safety when PCA is ordered: only the patient presses the button; no family-controlled dosing.
• Teach deep breathing and splinting techniques to support pulmonary toilet with cough and ambulation.
• Notify the provider for pain unresponsive to ordered PCA and adjuncts, a sudden change in pain character, or new peritoneal signs.
• Coordinate a pain-management or palliative-care consult per facility protocol for refractory pain.

Outcome: Patient reports pain at a patient-defined comfort-function goal (commonly ≤ 4/10) on ordered analgesia within 24 hours; Patient demonstrates a relaxed facial expression and posture when clinical state allows; Vital signs return toward baseline after ordered analgesia.

Nursing Diagnosis 2: Fluid Volume Deficit

Fluid Volume Deficit related to Acute pancreatitis: revised Atlanta criteria. 2 of 3: characteristic abdominal pain, lipase > 3× ULN, characteristic imaging findings as evidenced by Persistent vomiting and NPO status; Third-spacing into the retroperitoneum from capillary leak; Tachycardia and orthostatic hypotension; Dry mucous membranes; decreased skin turgor; Urine output < 0.5 mL/kg/hr.

Interventions

• Monitor vital signs (HR, BP, including orthostatics when feasible) at intervals matched to clinical acuity during the first 24 hours.
• Maintain strict hourly I&O; notify the provider for UOP < 0.5 mL/kg/hr sustained for 2 consecutive hours.
• Trend Hct, BUN, Cr, and lactate per provider order during initial resuscitation.
• Assess mucous membranes, skin turgor, capillary refill, and mental status at intervals matched to clinical acuity.
• Auscultate lungs at intervals matched to clinical acuity during resuscitation.
• Weigh the patient daily on the same scale at the same time when clinical state allows.
• Administer prescribed Lactated Ringers at the provider-ordered, goal-directed rate (commonly around 1.5 mL/kg/hr maintenance in mild-to-moderate AP; higher rates such as up to ~3 mL/kg/hr or 250–500 mL/hr reserved for severe disease or documented hypovolemia per provider order and facility protocol). Reassess every 4–6 h and titrate to UOP, HR, MAP, and Hct/BUN trends.
• Reassess volume status every 4–6 h and coordinate de-escalation of the fluid rate with the provider team once UOP ≥ 0.5 mL/kg/hr, HR and MAP are within ordered parameters, and Hct and BUN are trending toward baseline.
• Adjust IV fluid rate per provider order based on UOP, HR, BP, and Hct/BUN trends; avoid running a flat rate without reassessment, per facility protocol.
• Maintain a Foley catheter per provider order when hourly UOP measurement is required in severe AP.
• Administer ordered electrolyte replacement (K⁺, Mg²⁺, Ca²⁺, PO₄^3-) per facility protocol.
• Maintain two large-bore peripheral IVs or central access in severe AP per provider order and facility protocol.
• Teach the patient and family the rationale for IV fluids and the daily weight protocol.
• Educate on signs of dehydration to report at home post-discharge: dizziness, dry mouth, dark urine, weakness.
• Reinforce the ordered NPO status or dietary advancement plan and the reasoning behind it.
• Notify the provider for UOP < 0.5 mL/kg/hr for 2 consecutive hours, MAP < 65 mmHg, HR > 120, or a rising lactate.
• Coordinate ICU transfer per facility protocol for persistent organ failure or refractory hypotension.

Outcome: Urine output is monitored and reported within ordered parameters (commonly ≥ 0.5 mL/kg/hr) within 12 hours; HR and BP are monitored and reported within ordered parameters; Hct and BUN trend is documented and reported toward baseline.

Nursing Diagnosis 3: Impaired Nutritional Status

Body Nutrition Deficit related to Acute pancreatitis: revised Atlanta criteria. 2 of 3: characteristic abdominal pain, lipase > 3× ULN, characteristic imaging findings as evidenced by Prolonged NPO status in moderately severe or severe AP; Pain with eating; food fear; Nausea and vomiting limiting oral intake; Hypermetabolic state from systemic inflammation; Increased protein-calorie requirements during recovery.

Interventions

• Assess baseline nutrition status: weight, BMI, recent weight loss, albumin, prealbumin, and dietary history.
• Assess for nausea, vomiting, abdominal distention, bowel sounds, and passage of flatus or stool each shift.
• Reassess pain response to diet advancement at each meal in mild AP per facility protocol.
• Monitor for refeeding syndrome (low K⁺, Mg²⁺, PO₄^3-) when nutrition is initiated after prolonged NPO.
• Assess for alcohol withdrawal using CIWA-Ar per facility protocol in patients with alcohol-related AP.
• Coordinate with the provider team and dietitian on early enteral nutrition (commonly within 24–72 hours) in moderately severe and severe AP, per provider order and facility protocol.
• Coordinate NJ tube feeding past the Ligament of Treitz over TPN when oral intake is not tolerated, per provider order.
• Advance mild-AP patients to oral feeding (soft, low-fat diet) within 24–48 hours when pain improves and the provider team orders advancement, even without complete pain resolution, per facility protocol.
• Administer ordered antiemetics and pre-meal analgesia in patients with food fear, per facility protocol.
• Administer ordered electrolyte replacement (K⁺, Mg²⁺, PO₄^3-) before and during refeeding per facility protocol.
• Coordinate with the registered dietitian for individualized calorie and protein targets (commonly 25–35 kcal/kg/day in critically ill patients), per facility protocol.
• Educate the patient on a low-fat diet (commonly < 30% calories from fat) during recovery and the rationale.
• Reinforce the importance of complete alcohol cessation as a key step to support recurrence prevention in alcohol-related AP.
• Teach NJ tube care (flushing, securing, signs of dislodgment) if the patient is discharged with home enteral nutrition.
• Coordinate referral to dietitian for outpatient follow-up and to social work or addiction services for alcohol use disorder when applicable, per facility protocol.
• Notify the provider for inability to tolerate diet advancement, recurrent vomiting, or signs of refeeding syndrome.
• Coordinate same-admission cholecystectomy for mild gallstone pancreatitis per provider order and facility protocol when the patient is medically appropriate.

Outcome: Patient tolerates ordered oral or enteral nutrition without pain escalation within 72 hours; Patient maintains weight within ~5% of admission weight when clinical state allows; Albumin and prealbumin trend is documented and reported as stable or improving.

Nursing Diagnosis 4: Risk For Infection

Infection Risk related to Acute pancreatitis: revised Atlanta criteria. 2 of 3: characteristic abdominal pain, lipase > 3× ULN, characteristic imaging findings as evidenced by Necrotizing pancreatitis on imaging (sterile necrosis at risk of becoming infected); Translocation of gut bacteria into necrotic tissue; Invasive lines (central, arterial, Foley, NG/NJ); Prolonged ICU stay and immobility; Hyperglycemia from stress or pancreatic injury.

Interventions

• Monitor temperature at intervals matched to clinical acuity (commonly every 4 hours); notify the provider for > 38.3°C (101°F) or < 36°C.
• Monitor WBC, CRP, and procalcitonin trend per provider order.
• Assess invasive lines (central, arterial, Foley, NJ) daily for signs of infection and ongoing necessity per facility protocol.
• Monitor for signs of sepsis: HR > 90, RR > 20, hypotension, new mental-status change, hyperglycemia.
• Assess surgical, ERCP, and drain sites for erythema, drainage, warmth, and dehiscence each shift.
• Trend glucose every 4–6 hours; commonly target 140–180 mg/dL per facility glycemic-control protocol.
• Do not administer prophylactic antibiotics in sterile necrosis; coordinate with the provider team to administer antibiotics only when ordered for confirmed or strongly suspected infected necrosis, per facility protocol.
• When ordered for infected necrosis, administer carbapenems (commonly imipenem or meropenem) on schedule per provider order and facility protocol.
• Implement strict hand hygiene before and after every patient contact.
• Perform daily CHG bathing in ICU per facility protocol; maintain CLABSI and CAUTI prevention bundles.
• Maintain head-of-bed elevation at 30–45° for ventilated or sedated patients with NG or NJ tubes, per facility VAP-prevention protocol.
• Provide oral care with chlorhexidine every 4 hours for ventilated patients per facility VAP-prevention protocol.
• Teach patient and family the signs of infection to report: fever, chills, redness or drainage at any site, increased pain, confusion.
• Educate visitors on hand hygiene and the importance of limiting bedside contact when the patient is immunocompromised.
• Educate the patient and family on the rationale for the step-up approach (percutaneous drainage, then endoscopic or minimally invasive necrosectomy) when infected necrosis is identified, per provider plan.
• Notify the provider promptly for new fever after day 7, hemodynamic instability, or rising inflammatory markers.
• Coordinate IR, endoscopy, or surgery consultation per provider order for image-guided drainage of confirmed infected necrosis or WON.
• Coordinate urgent ERCP within ~24 hours per provider order and facility protocol for gallstone pancreatitis with concurrent acute cholangitis or persistent biliary obstruction; routine urgent ERCP is not used in all gallstone AP.

Outcome: Temperature is monitored and reported within ordered parameters (commonly 36.5–37.5°C); WBC trend is documented and reported toward baseline; No new fever, chills, or hemodynamic instability after 48 hours.

Nursing Diagnosis 5: Anxiety

Anxiety related to Acute pancreatitis: revised Atlanta criteria. 2 of 3: characteristic abdominal pain, lipase > 3× ULN, characteristic imaging findings as evidenced by Severe abdominal pain with autonomic activation; Fear of unknown diagnosis, complications, or death; Unfamiliarity with hospital procedures (ERCP, CT, central lines, possible ICU transfer); Prolonged NPO status and food fear; Concerns about alcohol use disorder, recurrence, and lifestyle change (when applicable).

Interventions

• Assess anxiety level using a 0–10 scale at the start of every shift and PRN.
• Identify the patient’s stated triggers (pain, NPO status, fear of complications, ICU transfer, alcohol use concerns).
• Observe for physical signs of anxiety: tachycardia out of proportion to clinical state, restlessness, hand-wringing, hypervigilance.
• Assess sleep quality and contributors (pain, alarms, lighting, frequent interventions) daily.
• Provide a calm, reassuring presence; speak clearly and at a measured pace.
• Explain procedures and findings in plain, patient-friendly terms before performing them.
• Cluster cares to allow uninterrupted rest periods when clinical state allows.
• Limit non-essential nighttime stimuli (overhead lights, loud conversations, unnecessary alarms) per facility protocol.
• Facilitate family presence within facility visitation policy, including video or phone visits when in-person is restricted.
• Coordinate with chaplaincy, social work, or interpreter services per patient preference and facility policy.
• Teach diaphragmatic breathing and grounding techniques the patient can use independently.
• Educate the patient and family on acute pancreatitis: common causes, why fluids and NPO are ordered, what early feeding looks like, and the typical recovery trajectory.
• When alcohol use is a contributing factor, frame cessation in plain, non-judgmental language and offer referral to social work or addiction services per facility policy.
• Coordinate with chaplaincy, social work, or psychiatric services per facility protocol if anxiety persists or worsens despite non-pharmacologic measures.
• Notify the provider for severe or persistent anxiety unresponsive to non-pharmacologic measures.

Outcome: Patient verbalizes decreased anxiety; Patient demonstrates at least one coping strategy (diaphragmatic breathing, grounding, music); Patient sleeps in approximately 4-hour blocks when clinical state allows.

Acute pancreatitis (AP) begins with premature intra-pancreatic activation of digestive zymogens (trypsinogen → trypsin, with secondary activation of lipase and elastase), triggering autodigestion of the pancreas and surrounding peripancreatic tissues. Gallstones (~40%) and alcohol (~30%) account for roughly 70% of cases (I GET SMASHED mnemonic: Idiopathic, Gallstones, EtOH, Trauma, Steroids, Mumps/Malignancy, Autoimmune, Scorpion sting, Hyperlipidemia/Hypercalcemia, ERCP, Drugs). Local injury releases inflammatory cytokines that drive a systemic inflammatory response (SIRS) and can progress to ARDS, AKI, and multi-organ failure (MOF). The revised Atlanta classification stratifies severity into mild (no organ failure, no complications), moderately severe (transient organ failure < 48 h or local/systemic complications), and severe (persistent organ failure > 48 h, often multi-organ). Pathology ranges from interstitial edematous pancreatitis (mild) to necrotizing pancreatitis (mortality 15–30% when necrosis becomes infected). Late complications include pancreatic pseudocyst (≥ 4 weeks), walled-off necrosis (WON), and splanchnic vein thrombosis. Day-1 severity prediction uses BISAP (BUN > 25, Impaired mentation, SIRS, Age > 60, Pleural effusion; score ≥ 3 is associated with high mortality), which outperforms older Ranson criteria that require 48 h to complete. Management follows the 2024 ACG and 2018 AGA Institute clinical guidelines.

• Pain control: Opioid PCA commonly used; morphine acceptable
• IV fluids (0–24 h): Lactated Ringers, goal-directed (WATERFALL 2022)
• Enteral nutrition: Commonly initiated within 24–72 h when tolerated
• Mild AP, tolerating: Early oral feed (soft, low-fat) per provider order
• CT timing: 72–96 h for necrosis (earlier scans may miss it)

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