NU371 HESI Case Study: Pancreatitis
The client shares with the nurse that they have been drinking alcohol every day for the last few years and admits to drinking a little more than usual last night. The client also reports smoking 2 packs of cigarettes a day for the last 20 years. To further evaluate the client's condition, the health care provider (HCP) prescribes several laboratory tests.
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The nurse continues to discuss strategies to prevent further attacks with the client.
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The nurse develops a plan of care for the client.
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The nurse is preparing to hang the client's second bag of TPN. TPN bag #1 has finished infusing at 75 mL/hour, but TPN bag #2 has not been delivered from the pharmacy. The pharmacy is called and the nurse is told that TPN bag #2 is not ready.
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Three hours after being admitted to the ED, the client is transferred to the medical unit in stable condition. Previous Section
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Assessment
The nurse is completing the client's Emergency Department (ED) admission assessment.
After listening to the nurse explain AA, the client asks the nurse how much it will cost to go to these meetings.
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Since the client is asking questions and seems very interested in the discussion concerning complications of chronic pancreatitis, the nurse continues to talk about interventions that the client can implement at home.
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The TPN is prescribed to run at 75 mL per hour and is available in a 1000 mL bag. The nurse should anticipate that the TPN bag will be empty in how many hours?
1000/75= 13
After receiving further explanation by the HCP, the client signs the procedure permit form and the nurse completes the pre-procedure assessment.
After the nurse completes the assessment and the client undergoes the ERCP without any problems. Click for Image
Follow-Up Appointment
At the client's follow-up visit after the ERCP, the clinic nurse asks the client if they are complying with the discharge teaching. The client tells the nurse that they do not drink much alcohol and they have cut down on smoking. The client adds that they have been drinking tea and cola, but they have to have a morning coffee. The client tells the nurse that their stomach hasn't been hurting too much, but reports that their stools look fatty, appear bubbly and frothy, float on top of the water, and are extremely malodorous.
Nutritional Needs
Four days after admission, the client is still unable to tolerate any foods or fluids, so the HCP prescribes total parenteral nutrition (TPN).
Emergency Department Nursing Interventions
The ED nurse starts an intravenous (IV) infusion of 5% Dextrose and sodium chloride 0.45% at 125 mL/hour with a 20 gauge angiocatheter in the client's left forearm. The client complains of severe abdominal pain rated 9 on a 0-10 numerical pain scale. The client's abdomen is soft and tender in the upper quadrants. The nurse notes audible bowel sounds in all 4 quadrants. Click for Image
Long-Term Complications
The client did not realize how serious chronic pancreatitis can be even though they received some information when first diagnosed.
The client's HCP has prescribed pancrelipase, a pancreatic enzyme, to help reduce the fatty, frothy, foul-smelling stools.
The client's HCP explains to the client that their chronic pancreatitis is getting worse and that they need to comply with the previous teaching as well as take additional medications. Along with pancreatic enzymes, the HCP prescribes omeprazole. The nurse discusses the new prescriptions with the client.
Referral to Alcoholics Anonymous (AA)
The clinic nurse is concerned that the client continues to smoke cigarettes, however the inability to abstain from drinking alcohol is a greater priority. The nurse encourages the client to attend an AA meeting. The client asks the nurse how will this meeting help with the ability to quit drinking.
Nursing Interventions on the Medical Unit
The nasogastric tube is draining green bile, and the client reports pain rated 4 on a 0 to 10 pain scale.
Management
The nurse, with the assistance of an unlicensed assistive personnel (UAP), is assigned to care for five clients, including the client in this scenario.
How should the nurse respond? a) Explain that AA is a support group that uses a 12-step recovery program to quit drinking. b) Tell the client that if they go to these meetings instead of bars, drinking will be less available. c) Reinforce that a person cannot quit drinking on their own without some kind of help. d) Relay to the client that AA discusses medications that can curb the desire to drink alcohol.
a) Explain that AA is a support group that uses a 12-step recovery program to quit drinking. - AA is a program of total abstinence. According to AA, sobriety is maintained through sharing experience, strength and hope at group meetings and through the suggested 12 Steps for recovery from alcoholism.
Which question should the nurse ask the client prior to the ERCP? a) When was the last time you had anything to eat or drink? b) When was the last time you had a bowel movement? c) Have you consumed any alcohol in the last 48 hours? d) Do you have any difficulty swallowing or chewing?
a) When was the last time you had anything to eat or drink? - To reduce the risk of aspiration, clients should not have anything to eat or drink for at least 8 hours prior to the procedure.
When the nurse is discussing the complications of chronic pancreatitis with the client, which information should be included in the teaching? (Select all that apply. One, some, or all options may be correct.) a) The need to report any painful urinating or dribbling. b) The signs and symptoms of hypovolemic shock. c) The importance of checking bilirubin levels. d) The need to monitor blood glucose levels. e) That recurring attacks tend to become more severe in nature.
d) The need to monitor blood glucose levels. e) That recurring attacks tend to become more severe in nature. - Because diabetes mellitus can develop secondary to chronic pancreatitis, blood glucose levels should be monitored. Because recurring attacks tend to be more severe, it is important for the client to seek medical attention at the first signs of an attack. Submit
The ED nurse prepares to transfer the client to the medical floor.
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The HCP inserts a right subclavian catheter, and TPN bag #1 is administered via an infusion pump at 75 mL/hr.
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The HCP writes admitting prescriptions for the client.
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The client acknowledges the discharge teaching and states, that they will try to comply with the discharge instructions but states their job is very stressful, and it is going to be very hard to quit drinking and smoking. The client's spouse is present and very skeptical and indicates that the client will not be compliant with any of the discharge teaching. Previous Section
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The client does not experience any complications secondary to the ERCP and is discharged home. The client has a follow-up appointment in 2 days with the HCP to discuss the results of the ERCP and the treatment plan. Previous Section
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The client states that they don't know if they will be able to stop drinking. The client states that they have been drinking every day for the last 20 years.
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The nurse continues teaching the client about administration of the enteric-coated pancreatic enzyme.
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Which intervention should the nurse implement prior to transferring the client to the floor? A) Insert a nasogastric tube and connect to low, intermittent suction. B) Notify the case manager of the client's admission. c) Place a 16-gauge indwelling urinary catheter. d) Insert a second large bore IV catheter.
A) Insert a nasogastric tube and connect to low, intermittent suction. - Nasogastric suction is used to relieve nausea and vomiting, to decrease painful abdominal distention and paralytic ileus, and to remove hydrochloric acid so that it does not enter the duodenum and stimulate the pancreas.
Discharge Teaching
After the client receives TPN for 3 days, the nasogastric tube is removed. The client is started on a clear liquid diet, which is tolerated without pain. The HCP plans to remove the diet restrictions gradually, decrease the TPN, and discharge the client within the next 2 days.
Therapeutic Communication
The nurse is concluding the teaching session when the client asks if they will die if they keep drinking.
Diagnostic Tests
Three weeks after the client is discharged home, they are admitted to the day procedure area for an endoscopic retrograde cholangiopancreatography (ERCP). When the nurse asks the client to sign the procedure permit, they hesitate and relay that they don't understand why the procedure is needed since the pain is gone. The client tells the nurse to cancel the test.
Which statement accurately explains the scientific rationale for the use of omeprazole? a) Omeprazole decreases gastric secretions. b) Omeprazole decreases pancreatic enzyme secretion. c) Omeprazole decreases the propulsion of food through the small intestine. d) Omeprazole decreases the number of stools and steatorrhea.
a) Omeprazole decreases gastric secretions. - Omeprazole is a proton-pump inhibitor (PPI) that decreases gastric secretions. Proton-pump inhibitors, such as omeprazole, reduce the production of acid by blocking the enzyme in the wall of the stomach that produces acid.
Which intervention should the nurse include in the plan of care? a) Encourage the client to ambulate in the hall. b) Administer oxygen via nasal cannula. c) Irrigate the nasogastric tube every 4 hours. d) Keep the client's room humidified and warm.
b) Administer oxygen via nasal cannula. - Oxygen will help decrease the workload of the respiratory system and the tissue's utilization of oxygen.
Which intervention should the nurse implement to address the client's desire to cancel the procedure? a) Explain that the test will allow the HCP to visualize the pancreas. b) Contact the HCP to discuss the procedure details again with the client. c) Have the client explain their hesitation in wanting this procedure. d) Tell the client that the procedure is not done when the client is in pain.
b) Contact the HCP to discuss the procedure details again with the client. - The procedure cannot be performed unless the client has been fully informed. The client's comments indicate that he does not fully understand the need for the procedure, and it is the HCP's responsibility to explain the procedure to the client.
Which action should the nurse include when providing discharge teaching? a) Provide the client with a written list of high-protein snack foods. b) Discuss ways to deal with stressful situations and avoid stress if possible. c) Encourage daily exercise and teach the proper way to perform isotonic exercises. d) Teach the client to limit coffee, tea, and colas to no more than 2 a day.
b) Discuss ways to deal with stressful situations and avoid stress if possible. - Stress stimulates the pancreas to secrete pancreatic enzymes. Effective management of highly stressful situations can help decrease inflammation of the pancreas.
Which nursing intervention has the highest priority when preparing the client for discharge? A) Discuss the need to avoid spicy foods. b) Explain the importance of alcohol abstinence. c) Refer the client to Alcoholics Anonymous (AA). d) Instruct the client to eat a high-carbohydrate, low-fat diet.
b) Explain the importance of alcohol abstinence. - Alcohol intake is the number one cause of an attack of acute pancreatitis, and continued use will do further damage to the pancreas. Since the client was consuming alcohol daily, this intervention has the highest priority.
Which action should the nurse take? a) Notify the charge nurse that the TPN bag #2 is not on the unit. b) Instruct the pharmacy to bring the bag to the floor immediately. c) Administer 10% Dextrose via the infusion pump at 75 mL/hr. d) Hang 5% Dextrose via the infusion pump at a keep-vein-open rate.
c) Administer 10% Dextrose via the infusion pump at 75 mL/hr. - The TPN solution has high glucose content. If the solution is stopped abruptly, the client may experience rebound hypoglycemia. To prevent this, an available IV solution containing a high percentage of glucose should be infused at the same rate as the TPN solution until the next bag of TPN is ready.
Which diet should the nurse expect the HCP to prescribe for the client? a) Regular diet. b) Low-fat diet. c) Clear-liquid diet. d) Nothing by mouth.
d) Nothing by mouth. - All oral intake is withheld to inhibit pancreatic stimulation and the secretion of pancreatic enzymes.
Meet the Client
A client is admitted to the emergency department (ED) complaining of severe abdominal and back pain with vomiting for the last 24 hours. The client was diagnosed with chronic pancreatitis 2 years ago and this is the fourth admission for an acute exacerbation of pancreatitis.
Which additional instruction regarding the use of pancrelipase is important for the nurse to include? a) Take the medication with meals or snacks. b) Chew the medication 30 minutes before eating. c) Spread the capsule crystals over food and chew thoroughly. d) Swallow the capsule twice a day in the morning and at bedtime.
a) Take the medication with meals or snacks. - Pancrelipase enhances the digestion of starches and fats in the GI tract by supplying an exogenous source of the pancreatic enzyme. This medication promotes nutrition and decreases the number of bowel movements.
What intervention has the highest priority when caring for the client after the procedure? a) Monitor the client's IV fluids. b) Assess the client's pulse and blood pressure. c) Check the client's abdomen for pain and tenderness. d) Evaluate the client's hemoglobin and hematocrit.
b) Assess the client's pulse and blood pressure. - Because esophageal and/or duodenal perforation can occur during the procedure, monitoring the client for manifestations of hypovolemia has the highest priority.
To support the admitting diagnosis of acute pancreatitis, what information should the nurse obtain from the client? a) History or current use of tobacco products. b) How often alcohol is consumed and date of last drink. c) Medication taken in the last 24 hours. d) Weight loss or gain in the last 6 months.
b) How often alcohol is consumed and date of last drink. - Long-term use of alcohol is commonly associated with the development of chronic pancreatitis, and alcohol ingestion is the primary cause of an acute exacerbation of pancreatitis.
Which task can the nurse delegate to the UAP when caring for this client? a) Change the subclavian site dressing. b) Obtain a blood glucose reading. c) Check placement of the nasogastric tube. d) Evaluate the 24-hour intake and output.
b) Obtain a blood glucose reading. - Clients on TPN should have their blood glucose levels checked every 4-6 hours. The UAP can perform this task, but the nurse must analyze the findings to determine if any action should be taken based on the results.
How should the nurse respond to the client's question? a) Acknowledge the client's fear of dying from this disease. b) Tell the client if they don't stop drinking, this disease may kill them. c) Reply that no one can answer that question. d) Question the client's concerns.
b) Tell the client if they don't stop drinking, this disease may kill them. - Chronic pancreatitis is a serious disease that can lead to disability and death. Since the risk of premature death may be reduced if abstinence from alcohol is maintained, the nurse should give the client a straightforward answer.
Which action should the nurse encourage the client to take? a) Rest in bed as much as possible. b) Weigh weekly and report any significant weight loss. c) Increase fluid intake to 3-4 liters of water a day. d) Decrease the amount of dietary fiber.
b) Weigh weekly and report any significant weight loss. - Weight loss is a major problem for clients with chronic pancreatitis. It is usually caused by decreased dietary intake secondary to anorexia or fear that eating will precipitate another attack.
Which laboratory data indicates that the client is experiencing acute pancreatitis? a) Hemoglobin (Hgb) 12.9 g/dL (129 g/L) and hematocrit (HCT) 42% (0.42 Proportion of 1.0). b) White blood cell count of 10,000/uL (10 x109/L). c) Amylase of 982 U/L (16.4 mckat/L) and lipase of 400 U/L (6.68 ukat/L). d) Blood alcohol (ethanol) level of 75 mg/dL (16.28 mmol/L).
c) Amylase of 982 U/L (16.4 mckat/L) and lipase of 400 U/L (6.68 ukat/L). - Serum amylase and lipase levels can increase to an excess of 3 times their normal upper limits within 24 hours of an acute exacerbation of pancreatitis. Normal levels are amylase < 160 U/L (2.67 ukat/L) and lipase < 160 U/L (2.67 ukat/L).
Which intervention should the nurse implement prior to administering TPN? a) Assess the patency of the nasogastric tube. b) Restart the client's IV with an 18-gauge angiocath. c) Assist the HCP with a subclavian line insertion. d) Consult with a registered dietician about the formula.
c) Assist the HCP with a subclavian line insertion. - Because TPN has a high glucose content which exerts osmotic pressure that is injurious to the intimal lining of peripheral veins, it is administered into the vascular system through a central venous catheter, often inserted into the subclavian vein.
How should the nurse proceed when teaching the client about this medication? a) Instruct the client to let the tablet dissolve in their mouth. b) Advise the client to check their stool daily for occult blood. c) Determine if the client is allergic to any type of pork. d) Explain that joint pain may occur, but will resolve over time
c) Determine if the client is allergic to any type of pork. - Because pancrelipase is made from the pancreas gland of a hog, the nurse should determine if the client is allergic to pork products.
Which nursing intervention will be most beneficial in helping the client plan for the future if they are unable to modify their lifestyle? a) Encourage the client's family to admit the client to a substance abuse unit. b) Refer the client for care to a home health care agency. c) Discuss the need to complete an Advance Directive. d) Suggest that the client's family attend Al-Anon meetings.
c) Discuss the need to complete an Advance Directive. - If the client does not quit drinking, they are likely to die from complications of chronic pancreatitis and alcohol abuse. Completing an Advance Directive will help the client's family. It will help so the family will not be forced to make difficult decisions later on if the client becomes unconscious or is dying and unable to speak.
Which intervention regarding positioning should the nurse implement to help alleviate the client's pain? a) Ensure that the client remains in a supine position. b) Place 6-inch blocks under the foot of the bed. c) Encourage side lying with legs drawn to chest. d) No specific position will help the client's pain.
c) Encourage side lying with legs drawn to chest. - The pain from pancreatitis is caused by stretching of the peritoneum secondary to edema caused by the inflamed pancreas. Sitting up, leaning forward, or lying in a fetal position helps alleviate this pain.
Which intervention should the nurse implement to address the client's conversation? a) Tell the client a stool specimen is needed for laboratory evaluation. b) Ask the client if they have eaten fatty foods in the last few days. c) Explain that this is common with chronic pancreatitis. d) Reinforce that this happens with the consumption of any alcohol.
c) Explain that this is common with chronic pancreatitis. - Clients with chronic pancreatitis have steatorrhea (fatty, frothy, foul-smelling stools) due to a decrease in pancreatic enzyme production.
Which medication should the nurse expect to administer to relieve the client's pain? a) Ondansetron 0.15 mg IV push diluted and administered over 15 minutes. b) Ranitidine IV piggy back administered over 30 minutes. c) Morphine 5 mg IV push administered diluted over 5 minutes. d) Promethazine 25 mg deep intramuscular injection.
c) Morphine 5 mg IV push administered diluted over 5 minutes. - Morphine is considered a first line opioid analgesic and one of the most commonly prescribed opioids for moderate to severe pain.
Which independent nursing action regarding the client's nutritional status should the nurse include when caring for the client? a) Monitor his abdominal girth. b) Offer high-protein snacks frequently. c) Obtain and record a daily weight. d) Change the TPN IV tubing every 72 hours.
c) Obtain and record a daily weight. - Short-term weight changes (over hours or days) accurately reflect the client's fluid balance which can be influenced by the pancreatitis; weight changes over days or weeks reflects the client's nutritional status.
How should the nurse respond? a) There is a nominal fee charged for attending the meetings. b) AA meetings are supported by nonmember contributions. c) There are no dues or fees to attend the meetings. d) Monthly dues encourage members to attend the meetings.
c) There are no dues or fees to attend the meetings. - Although AA has a long-held tradition of being fully self-supporting, there are no dues or fees to attend the meetings.
