# A nurse is caring for a 45-year-old patient admitted with severe epigastric pain radiating to the back, nausea, vomiting, elevated serum amylase (500 U/L) and lipase (900 U/L) levels, restlessness, and shallow breathing with oxygen saturation of 92% on room air. The patient has a history of chronic alcohol use. Which nursing intervention should be the highest priority?

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## 문제

A nurse is caring for a 45-year-old patient admitted with severe epigastric pain radiating to the back, nausea, vomiting, elevated serum amylase (500 U/L) and lipase (900 U/L) levels, restlessness, and shallow breathing with oxygen saturation of 92% on room air. The patient has a history of chronic alcohol use. Which nursing intervention should be the highest priority?

## 보기

1. Administer prescribed analgesics for pain management
2. Encourage oral fluid intake to prevent dehydration
3. Monitor respiratory status and maintain patent airway **✔ 정답**
4. Provide emotional support and patient education

**정답: 3**

## 해설

In acute pancreatitis, respiratory complications like ARDS can develop rapidly, making airway assessment the highest priority per ABC framework. Pain management, oral fluids, and emotional support are important but secondary to ensuring adequate oxygenation.

## 심화 해설

Clinical Reasoning and Priority Setting

The patient presents with classic manifestations of severe acute pancreatitis (SAP), evidenced by severe epigastric pain radiating to the back, markedly elevated serum amylase (500 U/L) and lipase (900 U/L), and a history of chronic alcohol use. The most immediately life-threatening finding is the combination of restlessness, shallow breathing, and an oxygen saturation of 92% on room air. This clinical picture strongly suggests the development of acute respiratory distress syndrome (ARDS) or significant pleural effusion with atelectasis, both of which are common and severe pulmonary complications in SAP. In SAP, activated pancreatic enzymes and systemic inflammatory mediators increase alveolar-capillary permeability, leading to non-cardiogenic pulmonary edema and impaired gas exchange [1].

Applying the nursing process and Maslow’s hierarchy of needs, physiological airway and breathing needs take absolute precedence. The ABC (Airway, Breathing, Circulation) framework dictates that any compromise in oxygenation and ventilation must be addressed first. The patient’s restlessness could be a sign of hypoxemia, and shallow breathing indicates impending respiratory muscle fatigue. Failure to immediately monitor and secure the airway could lead to rapid decompensation and respiratory arrest. Therefore, continuously monitoring respiratory status, assessing breath sounds for crackles or diminished sounds, and ensuring a patent airway with readiness to administer oxygen and support ventilation is the highest priority nursing intervention [1].

While the other options are important components of care for SAP, they are secondary to a critical respiratory compromise. Administering prescribed analgesics (Option 1) is essential for pain control but does not address the immediate threat of hypoxemia. Encouraging oral fluid intake (Option 2) is contraindicated in the acute phase of SAP; the standard of care is to maintain NPO (nothing by mouth) status with intravenous fluid resuscitation to rest the pancreas and correct third-spacing of fluids. Providing emotional support and patient education (Option 4) is a psychosocial need that can be addressed once physiological stability is achieved. The recovery outcomes for SAP patients are significantly influenced by a meticulous, individualized nursing approach that prioritizes early recognition and management of systemic complications, with respiratory failure being a primary concern [1].References (research sources)

- [1]Application effect of individualized nursing in rehabilitation nursing of patients with severe acute pancreatitis.Research articleChen J, Ma Y, Shi MR, Li J. (2025) · DOI: 10.1097/md.0000000000045828

## 임상 시나리오

Acute Pancreatitis: Respiratory PriorityRecognizing and Managing Impending ARDS
In severe acute pancreatitis, activated enzymes and systemic inflammatory mediators damage the alveolar-capillary membrane, leading to non-cardiogenic pulmonary edema. The earliest signs of ARDS include restlessness, tachypnea, shallow breathing, and refractory hypoxemia (SpO2 < 93% on room air).

The ABC (Airway, Breathing, Circulation) framework mandates immediate intervention. Continuously monitor respiratory rate, depth, breath sounds, and SpO2. Prepare for rapid escalation, including high-flow oxygen, non-invasive ventilation, or mechanical ventilation if the patient shows signs of respiratory muscle fatigue.

CautionDo not delay respiratory support to administer analgesics or fluids. The patient must remain NPO for pancreatic rest; oral fluid intake is contraindicated. Restlessness is often a sign of hypoxemia, not just pain.

## 핵심 개념

- **Acute Respiratory Distress Syndrome (ARDS)** — A severe pulmonary complication of acute pancreatitis where systemic inflammation increases alveolar-capillary permeability, causing non-cardiogenic pulmonary edema and refractory hypoxemia.
- **ABC Framework** — A prioritization model in nursing (Airway, Breathing, Circulation) that dictates life-threatening compromises in oxygenation and ventilation must be addressed before other needs.
- **Pancreatic Rest** — A core management principle for acute pancreatitis that includes keeping the patient NPO, often with nasogastric suction, to reduce pancreatic enzyme secretion.

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