(62) A 78-year-old man is admitted from home to the medical unit with acute pancreatitis secondary to a history of gallstones, hypertension, osteoarthritis, and type 2 diabetes mellitus. He has lost 20 pounds (9.0 kg) in the past 2 months and reports severe boring-like abdominal pain, fatigue, and weakness. On physical assessment, he has decreased bowel sounds in all quadrants, crackles in the bases of his lungs, and signs of dehydration. Vital signs are: T, 100° F; P, 110; R, 36; and BP, 102/58.
1. What is the priority for this patient’s care at this time? What current evidence supports your answer? Where would you look for current evidence that would help you answer this question? (Be specific in your answer.)
This patient displays hypotension and tachycardia, which can indicate pancreatic hemorrhage or early signs of sepsis from toxicity because of enzymes leaking into the abdominal cavity. This patient is also at increased risk for atelectasis and pneumonia caused by amylase effusion, which can occur when pancreatic enzymes pass from the peritoneal cavity into the pleural cavity via the lymph channels across the diaphragm. The risk for acute respiratory distress syndrome (ARDS) also exists. Support for this answer can be obtained from the most current literature on the management of pancreatitis and complications related to the condition. Current evidence related to nursing management of pancreatitis may be retrieved from nursing specialty organizations such as the American Association of Critical Care Nurses, particularly if the patient experiences sepsis or hypovolemic shock from hemorrhage.
2. What laboratory findings would you expect him to have? Why?
Expected laboratory findings that indicate pancreatic cell damage include an increased serum amylase, elevated serum lipase, elevated serum trypsin, and elevated serum elastase. Elevated serum glucose is caused by impaired carbohydrate metabolism and decreased insulin release. Decreased serum calcium and magnesium levels occur when calcium combines with fatty acids and causes necrosis along with elevated leukocytes that indicate an inflammatory response.
3. With whom should you collaborate to meet the desired outcomes for his care?
Collaboration with a registered dietitian is important related to the patient’s dietary intake and requirements. Case management involvement may assist in placing the patient into rehabilitation when he is ready. Family and social support groups can also help. Respiratory therapy can assist in monitoring the patient for potential ARDS. Physical therapy can improve activity intolerance related to generalized weakness. The medical staff, patient, and significant others will also be involved in the management, decision making, and care of this patient while he is in the hospital and after discharge.
4. What community support and health teaching is he going to require when he is discharged?
The patient will need home care after discharge because of physical weakness from the acute episode. This can be arranged through a case manager or social worker. The patient will need to be educated on the disease process and its potential to become a chronic problem. Diet and nutrition and pain management should also be discussed. Information about support groups for the patient and family, such as Alcoholics Anonymous (AA), should be provided.