Reference no: EM133842847

Question

Case Study: pancreatitis

Marie, a 48-year-old, came to the emergency department (ED) with acute abdominal pain. This pain had been present for approximately two days but had increased in severity over the last 6-hours with no relief of pain. Marie's brother, who accompanies her to the ED, reported that she no longer uses IV drugs but has continued to drink at least a fifth of hard liquor a day. Marie admitted to having a past problem with alcohol and drug use but stated that she is now "clean". Marie agreed to having blood drawn for analysis and gave permission to have blood alcohol and drug screening tests done.

Vital and laboratory results obtained in the ED were as follows:

BP 134/76 mmHg

HR 68 bpm

Respirations 24 breaths/min

Temperature 38.6o C NIT

SpO2 96%

Pain level 9/10

Complete bloodwork revealed the following:

WBC 11 x 103 x mm3

RBC 11 x 106 x mm3

Hgb 12.3 g/dL

HCT 52%

Na 141 mEq/L

K 3 mEq/L

Mg 1.3 mg/dL

Ca 7.3 mg/dL

Glucose 266 ml/dL

Total protein 4.9 g/dL

Albumin 2.4 g d/L

Amylase 505 U/L

Lipase 519 U/L

Alkaline phosphatase 120 U/L

AST 397 U/L

LDH 891 U/L

Blood alcohol 205 mg/dL

Drug screen results are pending. Arterial blood gases are:

pH 7.35

PaCO2 33 mmHg

PaO2 90 mm Hg

HCO3 25 mm Hg

Base excess +1

SaO2 91%

After a 2-hour stay in the ED, Marie reported increased pain in the upper-left abdominal quadrant. She vomited 100 mL of brown liquid with no relief of pain. Her vital signs were as follows:

BP 90/60 mmHg

HR 100 bpm

Respirations 28 breaths/min

Temperature 39.4o C NIT

SpO2 96%

Pain level 10/10

On physical examination her abdomen was tender with guarding in all abdominal quadrants and bowel sounds were hypoactive. A nasogastric tube (NGT) was inserted and an IV line was started in the ED. Marie was transferred to the intensive care unit (ICU) with a preliminary diagnosis of acute pancreatitis. The following orders accompanied Marie to the ICU:

1. IV infusion oof 0.45% normal saline (NS) solution with 20 mEq KCL to run at 150 mL/hr

2. Daily CBC, amylase and lipase levels, and basic metabolic profile.

3. ABGs in the morning

4. Morphine sulfate 3 mg IV push q2h prn for severe pain

5. Nothing by mouth (NPO), includes no ice chips

6. NGT to intermittent suction

7. Two sets of blood cultures if not done in the ED

8. Gentamicin (Garamycin) 80 mg IV piggyback q8h after blood for cultures is drawn

9. Famotidine (Pepcid) 20 mg IV every 6 hours

Marie's lab results after the first 24 hours in the ICU were as follows:

WBC 14.6 x 103 x mm3

RBC 3.82 x 106 x mm3

Hgb 10.3 g/dL

HCT 42%

Na 139 mEq/L

K 3.2 mEq/L

Mg 1.3 mg/dL

Ca 7.8 mg/dL

Glucose 203 ml/dL

Total protein 4.6 g/dL

Albumin 2.2 g d/L

Amylase 575 U/L

Lipase 789 U/L

Alkaline phosphatase 139 U/L

AST 436 U/L

LDH 798 U/L

Drug screen results NEG

pH 7.22

PaCO2 26 mmHg

PaO2 84 mm Hg

HCO3 10 mm Hg

Base excess +6

SaO2 80%

Additional orders received included the following:

1. Change IV infusion to 0.45% saline with 30 mEq of potassium and 9 mEq of magnesium per IV bag to run at 125 mL/hr

2. Administer oxygen at 2 L via nasal cannula

3. Repeat basic metabolic profile and ABG's in the morning.

Marie's heart monitor revealed a normal sinus rhythm with a prolonged QT interval. Marie's pain subsided after 72 hours, bowel sounds were heard, and she was started on ice chips and progressed to a clear liquid diet. After 24 hours without pain, Marie was transferred to a medical-surgical unit.

1. What is the analysis of the latest set of ABG's?

2. What does "Base excess" mean? Do you think this number is correct?

3. What is the significance of a prolonged QT interval? What could be the etiology?

4. Discuss the pathophysiology of acute pancreatitis.

5. Describe the classic assessment findings that support a diagnosis of acute pancreatitis. Relate Marie's history and physical assessment findings to this description.

6. Compare and contrast chronic and acute pancreatitis.

7. Discuss significant diagnostic studies that assist in confirming or in monitoring the progress of acute pancreatitis. Relate the diagnostic studies completed on Marie to this discussion.

8. Marie requested pain medication. What should be the initial nursing action?

9. Discuss the appropriateness of administering gentamycin (Garamycin) to patients with acute pancreatitis.

10. Discuss the reason for ordering the famotidine (Pepcid).

11. Discuss the dietary management of a patient with acute pancreatitis. What is the purpose of the nasogastric tube and the NPO status?

12. Identify complications of acute pancreatitis. Based on the change in vital signs, lab data, which complications has most likely occurred in this case study?

13. Using Ranson's criteria, what is her score and her mortality prediction?

14. What does the nurse anticipate for this patient regarding alcohol withdrawal?

15. What measures should be taken to prevent withdrawal?

16. Describe 5 appropriate nursing diagnoses seen with acute pancreatitis.

17. Provide the goal for each of the nursing diagnoses.

18. Provide the appropriate nursing interventions for each of the five nursing diagnoses.