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?
Full Answer Section
- Coordinate with the hospital: Contact the hospital emergency department to provide a brief overview of the patient's condition and ensure a smooth transition of care.
2. Responding to the Patient's Concerns:
The NP should explain the seriousness of the patient's condition in clear and understandable terms. The NP could say something like:
"Your symptoms suggest a serious medical condition that requires immediate attention. While we can provide some initial care here, a hospital can offer the specialized tests and treatments you need. Delaying treatment could lead to serious complications."
3. Diagnostic Tests:
At the hospital, the following tests may be performed to evaluate the patient's condition:
- Blood tests: To assess liver function, pancreatic enzymes (amylase and lipase), complete blood count, and electrolyte levels.
- Imaging tests: Abdominal ultrasound or CT scan to visualize the pancreas and surrounding organs.
4. Assessing the Severity of Pancreatitis:
The severity of pancreatitis is often assessed using the Ranson criteria or the APACHE II score. These scoring systems consider factors such as age, blood test results, and clinical findings.
5. Hospital Management of Pancreatitis:
Hospital management of acute pancreatitis typically involves:
- Pain management: Medications to relieve pain.
- Intravenous fluids: To prevent dehydration and electrolyte imbalances.
- NPO status: Initially, the patient may be kept NPO (nothing by mouth) to rest the pancreas.
- Nutritional support: As the condition improves, the patient may be transitioned to a low-fat diet or receive nutritional support through a nasogastric tube or parenteral nutrition.
- Antibiotics: In cases of severe pancreatitis with infection, antibiotics may be prescribed.
6. Patient Education:
Once the acute phase of pancreatitis has resolved, the patient should receive education on:
- Risk factors for pancreatitis: Alcohol abuse, gallstones, and certain medications.
- Prevention strategies: Limiting alcohol consumption, maintaining a healthy weight, and managing underlying medical conditions.
- Symptom recognition: Knowing the signs and symptoms of pancreatitis to seek prompt medical attention.
- Dietary modifications: Following a low-fat diet and avoiding alcohol.
- Medication adherence: Taking prescribed medications as directed.
By addressing the patient's immediate needs and providing education, the NP can help improve the patient's overall health and well-being.
Sample Answer
Assessing and Managing the Patient's Condition
1. Action to Take:
Given the patient's severe symptoms, lack of insurance, and potential diagnosis of acute pancreatitis, the NP should prioritize immediate medical attention. The NP should:
- Advocate for the patient: Explain the severity of his condition and the potential risks of delayed treatment.
- Assist with transportation: Help the patient arrange transportation to the hospital, if necessary.