M.J.. is a 65-year-old woman who is admitted to the step-down unit from the emergency

M.J.. is a 65-year-old woman who is admitted to the step-down unit from the emergency department (ED) with nausea and vomiting and epigastric and left upper quadrant abdominal pain that is severe, sharp, and boring and radiates through to her mid back. The pain started 24 hours ago and awoke her in the middle of the night. M.J. is a divorced, retired sales manager who smokes a half-pack of cigarettes daily. The ED nurse reports that M.J. is anxious and demanding, she denies using alcohol. Her vital signs are as follows: 100/70, 97, 30, 100.2° F (37.9° C) (tympanic), SpO2 88% on room air and 92% on 2 L of oxygen by nasal cannula (NC). She is in normal sinus rhythm. She is under the care of the hospitalist service. She has no primary care provider and has not seen a physician “in years.” You are assisting the RN and the RN informs you that the ED nurse reported that the admitting diagnosis is acute pancreatitis of unknown etiology. An abdominal ultrasound showed “no cholelithiasis, gallbladder wall thickening, or choledocholithiasis. The pancreas was not well visualized due to overlying bowel gas.” An abdominal CT is scheduled for the morning.Admission labs have been drawn; a clean-catch urine specimen was sent to the lab, and the urine was dark in color.

• What are the usual causes of pancreatitis?

Autoimmune diseases, excessive drinking of alcohol, infections, gallstones, medications, metabolic disorder, surgery, and trauma

• What other information do you need from the ED nurse regarding M.J.s

care?

• Medication list
• History of surgery
• Family history
• Any history of GI disease
• allergies
• Nutrition (what kind of diet?)

CASE STUDY PROGRESS - Chart View Medication Administration Record Esomeprazole 40 mg IV push daily Metoclopramide 10 mg IV push every 6 hrs Metronidazole 500 mg IV piggyback every 8 hrs Morphine sulfate 5 mg IV push every 4 hrs as needed Ondansetron 4 mg IV push every 6 hrs as needed This study source was downloaded by 100000819885058 from CourseHero.com on 02-08-2022 05:32:46 GMT -06:00

https://www.coursehero.com/file/109821811/NCLEX-challenge-2docx/

• Indicate the expected outcome associated with each medication she is receiving.
• Esomeprazole: treat the symptoms of GERD and other conditions involving excessive

stomach acid.

• Metoclopramide: increases muscle contractions in the upper digestive tract. This speeds up the

rate at which the stomach empties into the intestines.

• Metronidazole: antibiotic used to treat bacterial infections of the vagina, stomach, liver, skin,

joints, brain and spinal cord, lungs, heart, or bloodstream.

d. Morphine: opioid medication to treat moderate to severe pain.

e. Ondansetron: prevent nausea and vomiting.

• Which admission order would you question

• What preparation is needed for M.J.’s CT scan?

If M.J’s CT scan is ordered with contrast, she cannot eat anything three hour prior to the CT scan. Clear liquid is allowed.

CASE STUDY PROGRESS

Upon assessment you note the following abnormalities: M.J. is restless and alert, lying on her right side in a semi-fetal position. Assessment findings are as follows: Skin is cool, diaphoretic, and pale with poor skin turgor; mucous membranes are dry. ECG shows sinus tachycardia, rate 106, heart sounds without murmurs or rubs. Peripheral pulses are palpable at 1+ in four extremities. Respiration rate 24, but unlabored on 2 L O2/NC with Spo2 90%. Breath sounds are extremely diminished in lower left lobe (LLL) posteriorly—otherwise, clear to auscultation throughout. She complains of nausea and is having dry heaves. Bowel sounds are hypoactive throughout. Abdomen is distended, firm, and tender in a diffuse fashion to light palpation, with guarding noted. The admission chest x-ray report reads, “moderate pleural effusion in the left lower lobe.”

• Your institution uses electronic charting. Based on the assessment given, document your

findings.

☐ Neurologic:

☐ Respiratory: sinus tachycardia, RR 24, SpO2 90 % with nasal cannula 2L/min, breath sounds diminished on LLL posteriorly.☐ Cardiovascular pulse rate 106/min, heart sound regular without murmurs, peripheral pulse grade +1 in all four extremities.☐ Gastrointestinal: hypoactive bowel sound, dry heaves, abdomen distended, firm and tender when palpated with guarding noted.☐ Genitourinary This study source was downloaded by 100000819885058 from CourseHero.com on 02-08-2022 05:32:46 GMT -06:00

https://www.coursehero.com/file/109821811/NCLEX-challenge-2docx/

☐ Musculoskeletal

☐ Skin: cool, diaphoretic, pale, and poor skin turgor. Dry mucous membrane

☐ Psychosocial: restless and alert.

☐ Pain: side lying on her right side in a semi-fetal position

• Based on your assessment, what is your nursing priority right now?

Relieving pain and discomfort

• Name 3 interventions you would initiate based on this priority.
• Relieve pain and discomfort by administering pain medication
• IV therapy to relieve dehydration and imbalnced electrolytes
• Switching to non-rebreather mask to increase SpO2

• Besides giving as-needed medications, what other interventions would

help with M.J.’s pain management?Endoscopic ultrasound or surgery to block nerves that send pain signals from the pancreas to the brain Cold and hot therapy

• M.J.. turns on her call light. Despite the nausea, she complains of thirst

and demands something to drink. Her orders indicate “NPO, except sips and chips.” What is your response to her request? What might help her?Due to scheduled surgery, you can’t eat or drink anything until then, would you like me to get you some ice chips?Chart View Admission Laboratory Test Results Lipase3000 units/L Amylase2000 units/L This study source was downloaded by 100000819885058 from CourseHero.com on 02-08-2022 05:32:46 GMT -06:00

https://www.coursehero.com/file/109821811/NCLEX-challenge-2docx/

ALP350 units/L (6 µkat/L) ALT90 units/L (1.53 µkat/L) AST150 units/L (2.55 µkat/L) Total bilirubin2.0 mg/dL (34.2 µmol/L) Albumin3.0 g/dL (4.35 µmol/L) BUN24 mg/dL (8.57 mmol/L) Creatinine1.4 mg/dL (124 mcmol/L) WBC count17,500/mm 3 (17.5 x 10 9 /L)

• Which laboratory results support a diagnosis of pancreatitis?

Elevated lipase, amylase, ALP, ALT, AST, BUN, creatinine, and decreased albumin

• Which laboratory results are the most important to monitor in acute

pancreatitis? Why are they significant?Elevated lipase and amylase lab results are most important to monitor in acute pancreatitis because they are essential digestive enzymes and are produced by pancreas, so if there is a damage in pancreas, it will affect the level of lipase and amylase in the bloodstream.

• What do the BUN and creatinine tell you

about her renal function and volume status?High BUN and creatinine shows that M.J is having a acute kidney problems because it means the kidney is not filtering out the waste products properly.

• Why are the WBCs elevated?

The body detected an inflammation/infection, producing more WBC to fight them.

CASE STUDY PROGRESS

M.J. eventually falls asleep and seems to be sleeping peacefully. Several hours later, you hear an alarm on her pulse oximeter and enter her room to investigate. You find M.J. This study source was downloaded by 100000819885058 from CourseHero.com on 02-08-2022 05:32:46 GMT -06:00

https://www.coursehero.com/file/109821811/NCLEX-challenge-2docx/