SOLVED11

 

B.K. is a 63-year-old woman who is admitted to the step-down unit from the emergency department (ED)

with nausea and vomiting (N/V) and epigastric and left upper quadrant (LUQ) 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. B.K. is a divorced, retired sales manager who smokes a half-pack of cigarettes

daily. The ED nurse reports that B.K. is anxious and demanding. B.K. denies using alcohol. Her vital

signs (VS) 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 will be admitted to the hospitalist

service. She has no primary care provider (PCP) and has not seen a physician “in years.”

The ED nurse giving you the report states that the admitting diagnosis is acute pancreatitis of

unknown etiology. A computed tomography (CT) scan has been ordered, but unfortunately the CT scanner

is down and will not be fixed until morning. However, an ultrasound of the abdomen was performed,

and “no cholelithiasis, gallbladder wall thickening, or choledocholithiasis was seen. The pancreas was not

well visualized due to overlying bowel gas.” Admission labs have been drawn; a clean-catch urine specimen

was sent to the lab, and the urine was dark in color.

 

 

1. What are the possible causes of pancreatitis?

 

2. What other information do you need from the ED nurse before you assume responsibility for

the patient?4

Gastrointestinal Disorders

3. What preparation is needed for B.K.’s CT scan?

 

Case Study Progress

You complete your admission assessment and note the following abnormalities: B.K. is restless and alert,

lying on her right side in a semifetal position. Assessment findings are as follows: Skin is cool, diaphoretic,

and pale with poor skin turgor; mucous membranes are dry. Heart rhythm is regular, rate 96, without murmurs

or rubs. Peripheral pulses are faintly palpable in four extremities. Respiration rate 24, but unlabored

on 2 L O2/NC with Spo2 90%. Breath sounds are absent in lower left lobe (LLL) posteriorly—otherwise,

clear to auscultation throughout. She complains of nausea and is having dry heaves. Bowel sounds are

hypoactive. Abdomen is distended, firm, and tender in a diffuse fashion to light palpation, with guarding

noted.

 

4. Your institution uses electronic charting. Based on the assessment given, which of the

following systems would you mark as “abnormal” as you document your findings? Mark

abnormal findings with an X and provide a brief narrative.

X Abnormal

☐ Neurologic

☐ Respiratory

☐ Cardiovascular

☐ Gastrointestinal

☐ Genitourinary

☐ Musculoskeletal

☐ Skin

☐ Psychosocial

☐ Pain

Disorders

Chart View

Admission Laboratory Test Results

Lipase 3000 units/L

Amylase 2000 units/L

ALP 350 units/L

ALT 90 units/L

AST 150 units/L

Total bilirubin 2.0 mg/dL

Albumin 3.0 g/dL

BUN 24 mg/dL

Creatinine 1.4 mg/dL

WBC count 17,500/mm3

5. Which specific laboratory results point to a diagnosis of pancreatitis?

 

6. Which laboratory results are the most important to monitor in acute pancreatitis? Why are

they significant?

 

7. What do the BUN and creatinine tell you about her renal function and volume status?

 

8. Why are the WBCs elevated?

S

tudy Progress

During your physical examination of B.K., you noted “respirations rapid, rate 24, but unlabored on 2 L

O2 per nasal cannula with Spo2 90%. Breath sounds are absent in LLL posteriorly—otherwise, clear to

auscultation throughout.” The admission chest x-ray report reads, “small pleural effusion in the left lower

lobe.”

9. Identify three actions you could initiate to help correct this situation.

 

10. B.K. turns on her call light. 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

nursing action would help her complaints?

Study Progress

B.K. 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 B.K. moaning softly; her oximeter

reads 87%.

11. What will you do next?

 

 

12. B.K.’s respirations become increasingly labored, and you call the rapid response team.

While waiting for the team to arrive, you continue a quick assessment, with findings as

follows: Lung sounds absent in the LLL and very diminished in the right lower lobe (RLL).

You percuss a dull thud over the left middle lobe (LML) and LLL up to the scapula tip. On

percussion, you hear resonance over the entire right lung and left upper lobe (LUL). What is

the significance of your findings?

Disorders

Case Study Progress

The physician orders a STAT CXR examination, which shows a significant pleural effusion developing in

the LLL, with extension into the RLL.

13. Based on the evolving pleural effusion with evidence of decompensation (hypoxia) by the

patient, what treatment would the physician likely pursue, and what preparations would you

be responsible for?

Case Study Progress

14. How would you know if B.K. was not able to tolerate the advancement in diet?

 

 

15. If B.K. does not tolerate the advancement in diet, what physiologic need should be addressed

at 72 hours?

 

SCIENCE
HEALTH SCIENCE
NURSING
COMPLEX CR NR 341

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