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

Assessing and Managing the Patient with Suspected Pancreatitis

Immediate Action:

Given the patient’s severe symptoms, lack of insurance, and potential life-threatening condition, the NP should strongly encourage the patient to seek immediate medical attention at the nearest hospital. The NP can assist the patient by:

  • Explaining the Severity: Clearly communicate the seriousness of the patient’s condition and the potential risks of delaying treatment.
  • Assisting with Transportation: If possible, help the patient arrange transportation to the hospital, such as calling an ambulance or a social worker to assist with transportation arrangements.
  • Providing Pain Relief: If feasible, administer over-the-counter pain relievers like acetaminophen or ibuprofen to temporarily alleviate pain.
  • Informing the Hospital: Contact the hospital emergency department to alert them of the incoming patient and provide a brief overview of their condition.

Responding to the Patient’s Concerns

If the patient continues to resist hospitalization, the NP can explain the following:

  • Risk of Complications: Detail the potential complications of untreated pancreatitis, such as severe infection, organ failure, and death.
  • Limited Treatment Options: Explain that the clinic’s limited resources and equipment are insufficient to adequately manage such a serious condition.
  • Access to Specialized Care: Emphasize the importance of specialized care available at the hospital, including pain management, IV fluids, and medications.

Diagnostic Tests at the Hospital

To evaluate the patient’s condition, the hospital will likely perform the following tests:

  • Blood tests: To assess pancreatic enzymes (amylase and lipase), liver function, kidney function, and complete blood count.
  • Imaging tests: Abdominal ultrasound, CT scan, or MRI to visualize the pancreas and surrounding organs.

Assessing the Severity of Pancreatitis

The severity of pancreatitis is often assessed using the Ranson’s criteria or the APACHE II score. These scoring systems consider factors such as age, blood tests, and clinical signs to predict the risk of severe complications.

Hospital Management of Pancreatitis

Hospital management of pancreatitis typically involves:

  • Pain management: Administering pain medications, such as opioids or non-opioid analgesics.
  • Intravenous fluids: To prevent dehydration and electrolyte imbalances.
  • NPO status: Initially withholding food and drink to rest the pancreas.
  • Nutritional support: Providing nutritional support through intravenous fluids or a nasogastric tube.
  • Antibiotics: If infection is suspected.
  • Close monitoring: Continuous monitoring of vital signs, blood tests, and pain levels.

Patient Education After Resolution of Pancreatitis

Once the pancreatitis has resolved, the patient should be educated on:

  • Risk factors: Alcohol abuse, gallstones, and certain medications.
  • Prevention: Avoiding alcohol, managing gallstones, and using medications as prescribed.
  • Symptoms: Recognizing early signs and symptoms to seek prompt medical attention.
  • Healthy lifestyle: Adopting a healthy diet, maintaining a healthy weight, and quitting smoking.
  • Follow-up care: Scheduling regular check-ups with a healthcare provider.

By addressing the patient’s concerns, providing clear explanations, and offering support, the NP can encourage the patient to seek the necessary medical care and improve their chances of a positive outcome.

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