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©Altmiller Mr. Schmidt’s Case by Gerry Altmiller, EdD, MSN, APRN
©Altmiller Mr. Schmidt went to the ED C/O severe LUQ pain radiating to his back and shoulder that started suddenly four hours ago. He claims the pain was aggravated by eating and was not relieved when he vomited. He C/O nausea. He arrives on the step down unit via stretcher lying in the fetal position. Physical assessment findings: T 100.6, P 98, R 26, BP 102/64 Abdominal guarding Bluish discoloration of the flanks Ecchymosis of the umbilical area Hypoactive Bowel sounds Dyspnea, crackles in lungs, cyanosis Jaundice What else do you want to know?
©Altmiller Mr. Schmidt’s immediate orders: NPO Bedrest Morphine 5mg IV q 3 hours PRN abdominal pain IVF LR 125 cc/hr NGT to LIS
©Altmiller The laboratory personnel calls with results from serum drawn in the ED and asks to speak with Mr. Schmidt’s nurse. She explains that she has a critical value report. What is the procedure to be followed for a critical lab value? Which of the following does the nurse identify as abnormal? Na 148 Chloride 99 Glucose 263 Potassium 5.3 Carbon Dioxide 25 BUN 20 Creatinine 0.9 Calcium 7.5 Magnesium 1.8 Phosphorus 3.8
©Altmiller Critical Lab Values Na 148 Chloride 99 Glucose 263 Potassium 5.3 Carbon Dioxide 25 BUN 20 Creatinine 0.9 Calcium 7.5 Magnesium 1.8 Phosphorus 3.8
©Altmiller Diagnostic lab Findings Serum Amylase 244 Serum Lipase 196 Urinary Amylase (24 hr) 4060 Random blood glucose 263 Serum Ca 7.5 (critical value) Triglycerides 430 What other diagnostic tests could be done? What diagnosis are you forming for Mr. Schmidt?
©Altmiller Acute Pancreatitis Acute inflammatory process ranging from mild edema to severe hemorrhage Prevalence Middle aged Effects men > women Potentially life-threatening Sequelae may develop chronic pancreatitis
©Altmiller Etiology of Acute Pancreatitis Alcoholism Gall bladder disease (biliary tract disease) Trauma (post-abdominal surgery) Post GI procedures (Endoscopic Retrograde Cholangiopancreatography: ERCP) Viral infections (mumps, coxsackievirus) Penetrating duodenal ulcers, cysts, abscesses Idiopathic Medications (steriods, NSAIDS, thiazides, etc)
©Altmiller The Pancreas Located behind the stomach Large, compound gland consisting of the head, body and tail Has endocrine and exocrine functions
©Altmiller Exocrine Function of the Pancreas Pancreatic juice contains enzymes for digesting fats, proteins, & carbohydrates Trypsin is the most abundant enzyme Stored in its inactive form, trypsinogen; activated by enterokinase when released into the small intestine via the pancreatic duct
©Altmiller Endocrine Function of the Pancreas Occurs in the islets of Langerhans Beta cells secrete insulin Alpha cells secrete glucagon Delta cells secrete somatostatin
©Altmiller Acute Pancreatitis Auto-digestion of the gland The etiologic factors cause injury to the pancreatic cells or activation of the enzymes while still in the pancreas Premature activation of trypsin which begins to digest the pancreas Elastase activated by trypsin and causes hemorrhage by dissolving elastic fibers of the blood vessels
©Altmiller Acute Pancreatitis Phospholipase A also activated by trypsin, and bile salts, causes fat necrosis within the pancreas Unknown whether alcohol causes increased HCL acid production, which causes pancreatic enzyme stimulation or if regurgitation of duodenal contents into the pancreatic duct causes the inflammation
©Altmiller What are the priority nursing diagnosis?
©Altmiller Nursing Diagnosis for Pancreatitis Acute pain Deficient fluid volume Imbalanced nutrition: less than body requirements Ineffective therapeutic regimen management
©Altmiller Mrs. Schmidt comes to the nurse’s station to tell the nurse that Mr. Schmidt is complaining of severe abdominal pain. The nurse goes to Mr. Schmidt’s room to assess and determines he requires pain medication. The nurse goes to the medication cabinet and selects Hydromorphone 10 mg dose, places it in a carpuject and wastes 5 mg in the presence of another nurse. As she is walking to Mr. Schmidt’s room, she stops and takes a time out. What does she discover?
©Altmiller What is the nursing responsibility for this near miss? What is the red rule regarding medication administration?
©Altmiller What is the nursing responsibility for this near miss? Discard meperidine with a witness Complete incident/occurrance report Report near miss to immediate supervisor Medicate Mr. Schmidt with correct medication and dose What is the red rule regarding narcotic administration? Never administer medications without reviewing MAR first; 3 checks of medication
©Altmiller Incident/Occurrence Reports Used to document any unusual occurrence that results in or has potential to result in harm to a patient, employee, or visitor Should not be referred to in nursing notes Used for quality improvement to identify risks Records facts about an incident in case of litigation May be used in court as evidence
©Altmiller What complications are you concerned could occur for Mr. Schmidt?
©Altmiller Complications: Pancreatic Pseudocyst or Abscess Cavity continuous with, surrounding or within the pancreas fills with necrotic products and liquid secretions Leakage of enzymes inflame adjacent tissues Sx: abdominal pain, N&V, palpable epigastric mass, anorexia, persistently amylase levels, Leukocytosis, Fever May be visible on abdominal CT scan May resolve or rupture causing peritonitis Rx: prompt surgical drainage to prevent sepsis
©Altmiller Systemic Complications: Pulmonary: pleural effusion, atelectasis, pneumonia which are all caused by enzyme induced inflammation from the passage through transdiaphragmatic lymph channels. Pt can develop ARDS CV: Hypotension & shock due to hemorrhages into pancreas or activated enzymes forming kinins which cause vasodilation, capillary permeability,& vascular tone Neuro: Tetany due to hypocalcemia
©Altmiller At this time, what patient outcomes/goals do you want for Mr. Schmidt?
©Altmiller Goals Relief of pain Prevention or alleviation of shock Reduction of pancreatic secretions Normal fluid & electrolyte balance Removal of the precipitating causes Prevention of complications Prevention of recurrent attacks
©Altmiller How will you stablize Mr. Schmidt?
©Altmiller Collaborative Care Aggressive hydration with LR or volume expanders (dextran, albumin) CVP readings to guide fluid replacement Dopamine to systemic vascular resistance (SVR) for ongoing hypotension Pain Management: may use MSO4 with an anti- spasmotic Management of metabolic complications
©Altmiller What collaborative interventions can be done to resolve Mr. Schmidt’s pancreatitis?
©Altmiller Collaborative Care Minimize pancreatic stimulation NPO NGT to suction H2 blocking agents or Proton pump inhibitors Antacids Prevent infections as necrotic pancreatic tissue is a good medium for growth May require peritoneal lavage or dialysis
©Altmiller Nursing Care Monitor vital signs IV fluids to correct volume deficit and combat hypotension Assess respiratory function (potential ARDS) Cough & deep breathe, IS Frequent mouth care NGT to LWS- check patency and placement
©Altmiller Nursing Care Assess for fever as prone to infection Monitor for signs of hypocalcemia Assess for Chvostek or Trousseau signs Monitor lab values Monitor blood glucose Control pain & restlessness Position for comfort; flexed, semi-fowlers
©Altmiller Collaborative Care: Nutritional Therapy NPO status initially to reduce pancreatic secretion As pancreatitis resolves, small, frequent feedings High-carb, low-fat, high-protein diet Bland diet No alcohol or caffeine (stimulants) Supplemental fat-soluble vitamins Supplemental commercial liquid preparations TPN
©Altmiller For what reasons might Mr. Schmidt require surgical intervention?
©Altmiller Collaborative Care: Surgical Therapy Indications Presence of gallstones ERCP, laproscopic cholecystectomy to decrease potential for recurrence Uncertain diagnosis Unresponsive to conservative therapy Abscess, pseudocyst or severe peritonitis
©Altmiller Mr. Schmidt has a CT scan which is negative. He is scheduled in the “Same Day Procedures Unit” for an ERCP. What are the nursing responsibilities prior to handing off Mr. Schmidt’s care to the nurse in “Same Day Procedures Unit”?
©Altmiller Nursing Responsibilities prior to hand-off to “Same Day Procedures Unit” Accurate Identification of Mr. Schmidt 2 patient identifiers Known last meal for patient Safe transport to Unit via stretcher with side rails up Psychosocial support for Mr. Schmidt and his family Patent IV with D5.45NS infusing at 50cc/hr Mr. Schmidt voids before pre-procedure medications Pre-procedure dose of Ativan 0.5 mg IV given once on stretcher Signed consent form is in the chart Accurate identification of patient and scheduled procedure Done in holding room with physician present
©Altmiller One hour later, Mr. Schmidt is ready to return to his room. Mr. Schmidt’s ERCP is negative. No gall stones were found. His VS are T 98.7, P88, R 20 with pulse oximetry of 96% on room air, BP 118/78. He is drowsy but arousable and oriented to person, place and time. Using SBAR, how will the nurse handoff Mr. Schmidt’s care to the nurse in the step-down unit?
©Altmiller Later that evening, the nurse is called to the phone for an inquiry about Mr. Schmidt. The caller identifies herself as Mr. Schmidt’s sister. She wants to know his condition. What should the nurse tell the caller?
©Altmiller Confidentiality Protecting & maintain privacy of all patient information whether spoken, written or saved in computer Includes confirmation that a patient is admitted to institution Health Insurance Portability and Accountability Act (HIPAA) Disclosure requires signed authorization from patient
©Altmiller HIPAA Permitted Disclosure Public health activities for infectious disease or danger Law enforcement and judicial proceedings Deceased individuals Incidental Disclosure Use of sign in sheets Overheard conversation provided attempt at privacy made Use of White boards X-ray light boards seen by passers-by Calling out names in waiting room Leaving appointment reminders on voicemail
©Altmiller What teaching does Mr. Schmidt require prior to discharge?
©Altmiller Home Care & Health Promotion Assessment for predisposing factors Treatment of cholelithiasis Physical therapy for loss of muscle reserve & strength during extended hospitalization Counseling regarding abstinence from alcohol, caffeine, and smoking Dietary teaching: high carb, low-fat diet Teach signs of infection Teach about medications Indications that pancreatitis is becoming a chronic condition
©Altmiller How will Mr. Schmidt know if his condition is becoming chronic pancreatitis?
©Altmiller Clinical Manifestations of Chronic Pancreatitis Heavy, gnawing feeling, burning and cramp-like in LUQ or mid-epigastic area Malabsorption & weight loss Constipation Steatorrhea Mild jaundice with dark urine Diabetes mellitius Increased serum amylase Increased serum bilirubin Increased alkaline phosphatase Mild leukocytosis Elevated sedimentation rate Hyperglycemia Arteriography or X-ray shows fibrosis and calcification ERCP indicates biliary disease (chronic obstructive or chronic calcifying pancreatitis)
©Altmiller How is Chronic pancreatitis managed?
©Altmiller Collaborative Care for Chronic Pancreatitis Prevention of attacks Relief of pain with analgesics Control of pancreatic exocrine and endocrine insufficiency Bland, low-fat, high-carb, high-protein diet Pancreatic enzyme replacement Pancreatin or pancrelipase Bile salts to absorption of fat soluble vits (A, D, E, K) Control of Diabetes if it develops Total elimination of alcohol Acid-neutralizing and acid-inhibiting drugs Surgery indicated when biliary disease is present or if obstruction or pseudocyst develops
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