Mr Schmidts Case by Gerry Altmiller Ed D

Mr. Schmidt’s Case by Gerry Altmiller, Ed. D, APRN, ACNS-BC, ANEF, FAAN

Mr. Schmidt went to the ED C/O severe LUQ pain radiating to his back and shoulder that started suddenly four hours ago. He claims the pain was aggravated by eating and was not relieved when he vomited. He C/O nausea. He arrives on the step down unit via stretcher lying in the fetal position. Physical assessment findings: T 100. 6, P 98, R 26, BP 102/64 Abdominal guarding Bluish discoloration of the flanks Grey Turner sign Ecchymosis of the umbilical area Cullen’s sign Hypoactive Bowel sounds Dyspnea, crackles in lungs, cyanosis Jaundice What else do you want to know?

Mr. Schmidt’s immediate orders: n n n NPO Bedrest Morphine 5 mg IV q 3 hours PRN abdominal pain IVF LR 75 cc/hr NGT to LIS TPN 75 cc/hr

The laboratory personnel calls with results from serum drawn in the ED and asks to speak with Mr. Schmidt’s nurse. She explains that she has a critical value report. What is the procedure to be followed for a critical lab value? Which of the following does the nurse identify as abnormal? Na 148 Chloride 99 Glucose 263 Potassium 5. 3 Carbon Dioxide 25 BUN 20 Creatinine 0. 9 Calcium 7. 5 Magnesium 1. 8 Phosphorus 3. 8

Critical Lab Values Na 148 Chloride 99 Glucose 263 Potassium 5. 3 Carbon Dioxide 25 BUN 20 Creatinine 0. 9 Calcium 7. 5 (9 -11) Magnesium 1. 8 (1. 5 -2. 5) Phosphorus 3. 8 (2. 8 -4. 5)

Diagnostic lab Findings Serum Amylase 244 (0 -130) Serum Lipase 196 (0 -160) Urinary Amylase (24 hr) 4060 (1 -17) Random blood glucose 263 Serum Ca 7. 5 (critical value) (9 -11) Triglycerides 430 (40 -150) What other diagnostic tests could be done? What diagnosis are you forming for Mr. Schmidt?

Theory Burst Acute Pancreatitis n n Acute inflammatory process ranging from mild edema to severe hemorrhage Prevalence- 185, 000 cases/year in US n Middle aged n Effects men > women Potentially life-threatening (25% progress to severe complications; 4 -9% die) Sequelae may develop chronic pancreatitis

Etiology of Acute Pancreatitis n n n n Alcoholism Gall bladder disease (biliary tract disease) Trauma (post-abdominal surgery) Post GI procedures (Endoscopic Retrograde Cholangiopancreatography: ERCP) Viral infections (mumps, coxsackievirus) Penetrating duodenal ulcers, cysts, abscesses Idiopathic Medications (steriods, NSAIDS, thiazides, etc)

The Pancreas n n n Located behind the stomach Large, compound gland consisting of the head, body and tail Has endocrine and exocrine functions

Exocrine Function of the Pancreas Pancreatic juice contains enzymes for digesting fats, proteins, & carbohydrates n Trypsin is the most abundant enzyme n Stored in its inactive form, trypsinogen; activated by enterokinase when released into the small intestine via the pancreatic duct n

Endocrine Function of the Pancreas Occurs in the islets of Langerhans n Beta cells secrete insulin n Alpha cells secrete glucagon n Delta cells secrete somatostatin n

Acute Pancreatitis n n Auto-digestion of the gland The etiologic factors cause injury to the pancreatic cells or activation of the enzymes while still in the pancreas Premature activation of trypsin which begins to digest the pancreas Elastase activated by trypsin and causes hemorrhage by dissolving elastic fibers of the blood vessels

Acute Pancreatitis n n Phospholipase A also activated by trypsin, and bile salts, causes fat necrosis within the pancreas Unknown whether alcohol causes increased HCL acid production, which causes pancreatic enzyme stimulation or if regurgitation of duodenal contents into the pancreatic duct causes the inflammation

What are the priority nursing diagnosis?

Nursing Diagnosis for Pancreatitis n Acute pain (the auto-digestion leaks toxic substances into the peritoneal cavity causing inflammation) Deficient fluid volume n Imbalanced nutrition: less than body requirements n Ineffective therapeutic regimen management n

Mrs. Schmidt comes to the nurse’s station to tell the nurse that Mr. Schmidt is complaining of severe abdominal pain. The nurse goes to Mr. Schmidt’s room to assess and determines he requires pain medication. The nurse goes to the medication cabinet and selects Hydromorphone 10 mg dose, places it in a carpuject and wastes 5 mg in the presence of another nurse. As she is walking to Mr. Schmidt’s room, she stops and takes a time out. What does she discover?

What is the nursing responsibility for this near miss? What is the red rule regarding medication administration?

What is the nursing responsibility for this near miss? Discard hydromorphone with a witness Complete incident/occurrence report Report near miss to immediate supervisor Medicate Mr. Schmidt with correct medication and dose What is the red rule regarding narcotic administration? Never administer medications without reviewing MAR first; 3 checks of medication

Incident/Occurrence Reports n n n Used to document any unusual occurrence that results in or has potential to result in harm to a patient, employee, or visitor Should not be referred to in nursing notes Used for quality improvement to identify risks Records facts about an incident in case of litigation May be used in court as evidence

What complications are you concerned could occur for Mr. Schmidt?

Complications: Pancreatic Pseudocyst or Abscess n n n Cavity continuous with, surrounding or within the pancreas fills with necrotic products and liquid secretions Leakage of enzymes inflame adjacent tissues Sx: abdominal pain, N&V, palpable epigastric mass, anorexia, persistently amylase levels, Leukocytosis, Fever May be visible on abdominal CT scan May resolve or rupture causing peritonitis Rx: prompt surgical drainage to prevent sepsis

Systemic Complications: n n n Pulmonary: pleural effusion, atelectasis, pneumonia which are all caused by enzyme induced inflammation from the passage through transdiaphragmatic lymph channels. Pt can develop ARDS CV: Hypotension & shock due to hemorrhages into pancreas or activated enzymes forming kinins which cause vasodilation, capillary permeability, & vascular tone Neuro: Tetany due to hypocalcemia

At this time, what patient outcomes/goals do you want for Mr. Schmidt?

Goals n n n n Relief of pain Prevention or alleviation of shock Reduction of pancreatic secretions Normal fluid & electrolyte balance Removal of the precipitating causes Prevention of complications Prevention of recurrent attacks

How will you stablize Mr. Schmidt?

Collaborative Care n n Aggressive hydration with LR or volume expanders (dextran, albumin) CVP readings to guide fluid replacement Dopamine to systemic vascular resistance (SVR) for ongoing hypotension Pain Management n n n may use MSO 4 with an anti-spasmotic NGT to stimulation of enzymes Management of metabolic complications

What collaborative interventions can be done to resolve Mr. Schmidt’s pancreatitis?

Collaborative Care n n n Minimize pancreatic stimulation n NPO Strict-not even ice chips n NGT to suction n H 2 blocking agents or Proton pump inhibitors n Antacids Prevent infections as necrotic pancreatic tissue is a good medium for growth May require peritoneal lavage or dialysis

Nursing Care n n n Monitor vital signs IV fluids to correct volume deficit and combat hypotension Assess respiratory function (potential ARDS) Cough & deep breathe, incentive spirometry Frequent mouth care NGT to LWS- check patency and placement

Nursing Care n n Assess for fever as prone to infection Monitor for signs of hypocalcemia n n n Assess for Chvostek or Trousseau signs Monitor lab values Monitor blood glucose Control pain & restlessness Position for comfort; flexed, semi-fowlers

Collaborative Care: Nutritional Therapy n n n NPO status initially to reduce pancreatic secretion As pancreatitis resolves, small, frequent feedings High-carb, low-fat, high-protein diet (fats stimulate pancreas) n n n Bland diet No alcohol or caffeine (stimulants) Supplemental fat-soluble vitamins & bile salts Supplemental commercial liquid preparations TPN

For what reasons might Mr. Schmidt require surgical intervention?

Collaborative Care: Surgical Therapy Indications n n Presence of gallstones n ERCP, laproscopic cholecystectomy to decrease potential for recurrence Uncertain diagnosis Unresponsive to conservative therapy Abscess, pseudocyst or severe peritonitis

Mr. Schmidt has a CT scan which is negative. He is scheduled in the “Same Day Procedures Unit” for an ERCP. What are the nursing responsibilities prior to handing off Mr. Schmidt’s care to the nurse in “Same Day Procedures Unit”?

Nursing Responsibilities prior to hand-off to “Same Day Procedures Unit” n Accurate Identification of Mr. Schmidt n n n n n 2 patient identifiers Known last meal for patient Safe transport to unit via stretcher with side rails up Psychosocial support for Mr. Schmidt and his family Patent IV with D 5. 45 NS infusing at 50 cc/hr Mr. Schmidt voids before pre-procedure medications Pre-procedure dose of Ativan 0. 5 mg IV given once on stretcher Signed consent form is in the chart Accurate identification of patient and scheduled procedure n Done in holding room with physician present

One hour later, Mr. Schmidt is ready to return to his room. Mr. Schmidt’s ERCP is negative. No gall stones were found. His VS are T 98. 7, P 88, R 20 with pulse oximetry of 96% on room air, BP 118/78. He is drowsy but arousable and oriented to person, place and time. Using SBAR, how will the nurse handoff Mr. Schmidt’s care to the nurse in the step-down unit?

Later that evening, the nurse is called to the phone for an inquiry about Mr. Schmidt. The caller identifies herself as Mr. Schmidt’s sister. She wants to know his condition. What should the nurse tell the caller?

Confidentiality n n n Protect & maintain privacy of all patient information whether spoken, written or saved in computer Includes confirmation that a patient is admitted to institution Health Insurance Portability and Accountability Act (HIPAA) n Disclosure requires signed authorization from patient

HIPAA Incidental Disclosure Permitted Disclosure n n n Public health activities for infectious disease or danger Law enforcement and judicial proceedings Deceased individuals n n n Use of sign in sheets Overheard conversation provided attempt at privacy made Use of White boards X-ray light boards seen by passers-by Calling out names in waiting room Leaving appointment reminders on voicemail

What teaching does Mr. Schmidt require prior to discharge?

Home Care & Health Promotion n n n n Assessment for predisposing factors Treatment of cholelithiasis Physical therapy for loss of muscle reserve & strength during extended hospitalization Counseling regarding abstinence from alcohol, caffeine, and smoking Dietary teaching: high carb, low-fat diet Teach signs of infection Teach about medications Indications that pancreatitis is becoming a chronic condition

n How will Mr. Schmidt know if his condition is becoming chronic pancreatitis?

Clinical Manifestations of Chronic Pancreatitis n n n Heavy, gnawing feeling, burning and cramp-like in LUQ or mid-epigastic area Malabsorption & weight loss Constipation Steatorrhea Mild jaundice with dark urine Diabetes mellitius n n n n Increased serum amylase Increased serum bilirubin Increased alkaline phosphatase Mild leukocytosis Elevated sedimentation rate Hyperglycemia Arteriography or X-ray shows fibrosis and calcification ERCP indicates biliary disease (chronic obstructive or chronic calcifying pancreatitis)

How is Chronic pancreatitis managed?

Collaborative Care for Chronic Pancreatitis n n n n n Prevention of attacks Relief of pain with analgesics Control of pancreatic exocrine and endocrine insufficiency Bland, low-fat, high-carb, high-protein diet Pancreatic enzyme replacement n Pancreatin or pancrelipase Bile salts to absorption of fat soluble vits (A, D, E, K) Control of Diabetes if it develops Total elimination of alcohol Acid-neutralizing and acid-inhibiting drugs Surgery indicated when biliary disease is present or if obstruction or pseudocyst develops