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
- Involve Social Services: Connect the patient with social workers or other healthcare professionals who can provide support and resources.
- Document the Encounter: Thoroughly document the patient's condition, the recommendations made, and the patient's refusal of care. This documentation can be crucial in case of legal or ethical concerns.
Responding to the Patient's Question:
The NP should explain to the patient that his condition requires immediate medical attention to manage pain, prevent complications, and monitor his vital signs. The hospital setting provides access to specialized care, medications, and monitoring equipment that are not available at the clinic. The NP can emphasize the importance of early intervention to avoid a worsening of his condition.
Diagnostic Tests at the Hospital:
To evaluate the patient's condition, the hospital will likely perform the following tests:
- Blood Tests: Complete blood count (CBC), comprehensive metabolic panel (CMP), amylase, lipase, liver function tests, and inflammatory markers.
- Imaging Studies: Abdominal ultrasound or CT scan to assess the pancreas and surrounding organs.
Assessing the Severity of Pancreatitis:
The severity of pancreatitis is often assessed using the Ranson criteria, which considers factors such as age, blood glucose, serum calcium, serum LDH, serum AST, and base deficit. Other factors, such as the patient's clinical presentation and vital signs, are also considered.
Management of Acute Pancreatitis:
The primary goals of treatment are to manage pain, prevent complications, and support organ function. Hospital management may include:
- Pain Management: Intravenous pain medications, such as opioids or non-opioid analgesics.
- Fluid Resuscitation: Intravenous fluids to prevent dehydration.
- Nutritional Support: Initially, the patient may require total parenteral nutrition (TPN) to rest the pancreas. As the condition improves, a low-fat diet may be introduced.
- Infection Control: Antibiotics may be prescribed to prevent or treat infections.
- Monitoring: Close monitoring of vital signs, blood tests, and imaging studies to assess the patient's response to treatment.
Patient Education:
After the pancreatitis resolves, the patient should receive education on:
- Risk Factors: Alcohol abuse, smoking, and certain medications can increase the risk of pancreatitis.
- Symptom Recognition: Teach the patient to recognize the early signs and symptoms of pancreatitis.
- Preventive Measures: Encourage the patient to avoid alcohol and smoking and to maintain a healthy diet.
- Follow-up Care: Schedule regular follow-up appointments with a healthcare provider to monitor for complications and recurrence.
By addressing the patient's concerns, providing clear explanations, and offering support, the nurse practitioner can help ensure that the patient receives the necessary care and improves his overall health.
Sample Answer
Assessing the Patient's Condition and Planning the Next Steps
Considering the Patient's Homelessness and Lack of Insurance:
Given the patient's severe symptoms, lack of insurance, and potential diagnosis of acute pancreatitis, the nurse practitioner should strongly encourage the patient to seek immediate medical attention at the nearest hospital. The NP can:
- Explain the Risks: Clearly communicate the potential dangers of delayed treatment, such as severe complications, organ damage, or even death.
- Offer Assistance: Assist the patient in finding affordable or free healthcare options, such as community health clinics, emergency medical services, or government assistance programs.