The nurse practitioner (NP) is working at a health clinic in a homeless shelter

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The nurse practitioner (NP) is working at a health clinic in a homeless shelter during the early evening. A 48-year-old African American man approaches the practitioner and asks to have his blood pressure taken, saying that he has not had it checked “in a while”.

The man appears to be in some type of distress and experiencing pain. The man walks slowly, using a guarded manner, and he appears diaphoretic. His mucous membranes also appear pale. The patient’s blood pressure is 210/98. The patient reports that he has not been diagnosed with hypertension previously. The patient reveals that he has severe abdominal pain that is radiating to his back. The nurse finds a heart rate of 110, respirations 30 with shallow inspirations, and temperature 102.2°F. The patient’s skin is cool and clammy.

The patient reports a history of alcoholism, homelessness, and lack of access to health care. He says that the symptoms have been present and worsening over 3 days. The man says he thinks he might have pancreatitis again, which he had “a couple of years ago”. The NP recommends that the man should be seen at a hospital for his condition, but the patient says he does not have health insurance, so he does not want to go.

The NP proceeds with a physical examination, finding severe abdominal pain in the epigastric area, yellowed sclera, no abdominal distention, and hypoactive bowel sounds. The clinic is equipped with basic materials but no means to conduct lab or radiologic testing. Discuss the following:

Considering the patient’s homelessness and lack of insurance, what action should the practitioner take?
When the patient asks why his condition cannot be managed outside of the hospital, how should the practitioner respond?
When the patient arrives at the hospital for further diagnostic work-up, what tests will likely be performed to evaluate the patient’s condition?
How will the severity of the pancreatitis be assessed when the patient is hospitalized?
How should the patient’s condition be managed when hospitalized?
What patient education should be included after the pancreatitis is resolved?

Sample Solution

 

 

 

This patient presents a challenging situation due to his homelessness, lack of insurance, and severe symptoms suggestive of acute pancreatitis. Here’s how the NP should approach the situation:

Considering the patient’s homelessness and lack of insurance, what action should the practitioner take?

  • Advocate for the Patient: The NP should strongly encourage the patient to seek immediate medical attention at the hospital, emphasizing the severity of his condition and potential complications.

  • Explore Options: The NP should inquire about potential resources for the patient, such as:

    • Free or sliding-scale clinics: These clinics may be able to offer some services or assist with connecting the patient to resources.

    • Social services: The NP should connect the patient with the shelter’s social workers or other social services who may be able to help with navigating the healthcare system and accessing financial assistance.

    • Emergency medical services (EMS): If the patient absolutely refuses to go to the hospital, the NP should assess the risk of delaying care. In cases where the patient’s condition appears life-threatening, EMS should be called.

  • Document Thoroughly: The NP should document the patient’s condition, the conversation, and the attempts made to convince the patient to seek hospital care. This documentation is crucial for legal and ethical reasons.

When the patient asks why his condition cannot be managed outside of the hospital, how should the practitioner respond?

  • Explain the Risks: The NP should explain in clear and simple terms the dangers of delaying treatment for acute pancreatitis, which can include severe pain, fluid buildup in the abdomen, infection, and organ failure.

  • Emphasize the Need for Testing: The NP should emphasize the need for lab tests, imaging (like CT scan), and potentially other procedures to accurately diagnose and monitor the severity of the pancreatitis. These tests cannot be performed at the clinic.

  • Address Concerns about Costs: The NP can try to alleviate the patient’s anxiety about costs by explaining that hospitals often offer financial assistance programs or payment plans.

When the patient arrives at the hospital for further diagnostic work-up, what tests will likely be performed to evaluate the patient’s condition?

  • Blood tests: To check for elevated levels of pancreatic enzymes (amylase and lipase), signs of infection (white blood cell count), and other indicators of organ function.

  • Imaging studies: A CT scan of the abdomen is often the gold standard for visualizing the pancreas and detecting inflammation, fluid buildup, or complications.

 

 

  • Other tests: Depending on the patient’s symptoms and risk factors, other tests may be performed, such as:

    • Ultrasound: To evaluate the pancreas.

    • Endoscopy: To examine the upper gastrointestinal tract and assess the pancreas.

    • Biopsy: To confirm the diagnosis or rule out other conditions.

How will the severity of the pancreatitis be assessed when the patient is hospitalized?

The severity of pancreatitis is typically assessed using the Ranson criteria or the APACHE II score. These scoring systems consider multiple factors, including:

  • Initial lab values: Blood sugar, white blood cell count, and other parameters.

  • Clinical presentation: Pain, fever, heart rate, etc.

  • Complications: Organ failure, fluid buildup, infection, etc.

How should the patient’s condition be managed when hospitalized?

  • Pain management: Strong pain medications (usually opioids) will be administered intravenously to manage the intense pain.

  • Fluid resuscitation: Intravenous fluids will be given to replenish fluids and maintain hydration.

  • Nutritional support: The patient may need to receive nutrition through intravenous fluids or a feeding tube until the pancreas heals.

  • Antibiotics: If there is evidence of infection, antibiotics will be administered.

  • Monitoring: The patient will be closely monitored for vital signs, lab values, and signs of complications.

What patient education should be included after the pancreatitis is resolved?

  • Abstinence from alcohol: This is the most important factor in preventing future episodes of pancreatitis.

  • Healthy diet: A balanced diet low in fat can help prevent further pancreatic inflammation.

  • Medications: The patient may be prescribed medications to help manage pain or other symptoms.

  • Follow-up care: Regular follow-up appointments with a healthcare provider are essential to monitor the pancreas and prevent complications.

  • Support groups: Connecting with other patients with pancreatitis can provide support and coping strategies.

  • Social services: The NP should connect the patient with social services for support with housing, food, and other needs.

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