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학습 자료 둘러보기 →In acute pancreatitis, the systemic inflammatory response can cause severe pulmonary complications like ARDS or massive pleural effusion from a pancreatic-pleural fistula. Always apply the ABC framework first. The priority assessment is monitoring for respiratory distress—tachypnea, dyspnea, and decreasing oxygen saturation.
Immediate nursing action is to maintain the client in Semi-Fowler's position (head of bed elevated 30-45 degrees). This position maximizes chest expansion, reduces pressure on the diaphragm from abdominal distension or ascites, and improves ventilation-perfusion matching.
Pain management, NPO status, and electrolyte monitoring are critical but secondary. A sudden drop in SpO2 or increased work of breathing can signal rapid decompensation into hypoxemic respiratory failure and must be addressed before other interventions.
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