847392

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BSN, RN

Name:

Michael Rodriguez

MRN:

847392

Admitting Diagnosis:

Acute Pancreatitis

Room Number:

415

Isolation:

None

Code Status:

Full Code

Weight:

90 kg

Height:

5'10"

Michael Rodriguez

42 y/o

Male

Provider:

Dr. Sarah Chen, MD

Allergies:

Penicillin (hives), Shellfish

Emergency Contact:

Casey Rodriguez (Wife) | 555-XXX-5309

Insurance:

Blue Cross Blue Shield

Chief Complaint

Severe epigastric pain radiating to back, onset 6 hours after heavy alcohol consumption and fatty meal. Associated with nausea, vomiting, and diaphoresis.

Medical History

- Type 2 Diabetes (diagnosed 3 years ago)
- Hypertension
- Hyperlipidemia
- History of alcohol abuse (1-2 bottles of wine daily)

Home Medications

- Metformin 1000mg PO BID
- Lisinopril 10mg PO daily
- Atorvastatin 40mg PO daily

12/26/2024 02:45

Patient arrived in severe distress, clutching abdomen and actively vomiting. Placed in left lateral position. Two large-bore IVs established (18G right AC, 20G left forearm). Initial bolus of NS started. Patient received morphine 4mg IV with improvement in pain from 9/10 to 6/10. Continues to have nausea, administered ondansetron 4mg IV. Placed on continuous pulse oximetry. Abdomen tender to light palpation in epigastric region with guarding noted. Will continue to monitor closely.

Date/Time: 12/26/2024 02:30

Chief Complaint: Severe epigastric pain radiating to back

HPI: 42-year-old male presents with sudden onset of severe epigastric pain radiating to back, which started approximately 6 hours ago after consuming a large fatty meal and excessive alcohol. Pain is rated 9/10, constant, sharp, and associated with nausea and multiple episodes of vomiting. Patient reports drinking 2 bottles of wine earlier in the evening.

Physical Examination:

General: Acute distress, diaphoretic
HEENT: Dry mucous membranes
Cardiovascular: Tachycardic, regular rhythm
Respiratory: Clear bilateral breath sounds
Abdomen: Severe epigastric tenderness, guarding, decreased bowel sounds
Skin: Warm, diaphoretic

Assessment: Acute pancreatitis likely secondary to alcohol use and hyperlipidemia

Plan:

NPO status
IV fluid resuscitation
Pain management
Labs and imaging
Admission to medical floor

What is the pathophysiological mechanism causing this patient's elevated lipase and amylase levels?

The pancreas produces enzymes like lipase and amylase to aid in digesting fats and carbohydrates. In acute pancreatitis, the pancreas becomes inflamed, causing these enzymes to leak into the bloodstream instead of being released into the digestive tract. This leads to the significantly elevated levels seen in the lab results.

Based on the patient's presentation and lab values, what complications should the nurse monitor for?

Key complications to monitor:

Hypovolemia/Dehydration: Due to fluid shifts caused by inflammation and vomiting.
Electrolyte Imbalances: Low calcium and other derangements may occur.
Systemic Inflammatory Response Syndrome (SIRS): Signs include fever, increased heart rate, and elevated respiratory rate.
Acute Respiratory Distress Syndrome (ARDS): Pancreatic enzymes can damage lung tissues, causing breathing difficulties.
Pancreatic Necrosis/Infection: A severe complication from prolonged inflammation.
Shock: From severe fluid loss or infection.

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Michael Rodriguez

42 y/o

Male

Provider:

Dr. Sarah Chen, MD

Allergies:

Penicillin (hives), Shellfish

Emergency Contact:

Casey Rodriguez (Wife) | 555-XXX-5309

Insurance:

Blue Cross Blue Shield

Chief Complaint

Severe epigastric pain radiating to back, onset 6 hours after heavy alcohol consumption and fatty meal. Associated with nausea, vomiting, and diaphoresis.

Medical History

- Type 2 Diabetes (diagnosed 3 years ago)
- Hypertension
- Hyperlipidemia
- History of alcohol abuse (1-2 bottles of wine daily)

Home Medications

- Metformin 1000mg PO BID
- Lisinopril 10mg PO daily
- Atorvastatin 40mg PO daily

Patient's condition continues to deteriorate, exhibiting increased respiratory effort and worsening abdominal pain despite the current pain management regimen. Abdomen noted to be significantly more distended with hypoactive bowel sounds. Pain remains poorly controlled. Urine output has decreased to 20 mL/hr over the past 2 hours, indicating potential worsening of hemodynamic status. Nasogastric (NG) tube inserted and connected to low intermittent suction to manage nausea, vomiting, and abdominal distention. Preparing for transfer to ICU for closer monitoring and advanced interventions. Continuous monitoring of vital signs and mental status ongoing. Family remains at the bedside and has been updated on the patient's current condition and plan of care.

Date/Time: 12/26/2024 10:30

Interval History: Patient reports worsening abdominal pain despite morphine administration. Has had continued nausea with two episodes of vomiting since admission. CT shows pancreatic inflammation with surrounding fluid collection.

Physical Examination:

General: Increased distress
Cardiovascular: Tachycardic
Respiratory: Slightly labored breathing
Abdomen: Increased distention, diffuse tenderness
Skin: Cool, clammy

Assessment: Acute pancreatitis with early signs of systemic inflammatory response syndrome (SIRS)

Plan:

Upgrade to ICU level of care
Increase IV fluids
Start PCA for pain control
Consider NG tube placement

What specific SIRS criteria is the patient exhibiting, and what is the significance of the elevated lactate?

SIRS Criteria Present:

Temperature > 38°C
Heart rate > 90 bpm
Respiratory rate > 20 breaths/min
Elevated WBC count (>12,000 cells/mcL)

Elevated Lactate: This indicates tissue hypoperfusion (poor oxygen delivery to tissues), which could be due to inflammation, fluid loss, or reduced blood flow. It suggests the body is beginning to use anaerobic metabolism, signaling worsening systemic response and potential organ dysfunction.

Why is the patient's hematocrit elevated, and what does this suggest about fluid status?

Elevated hematocrit suggests hemoconcentration, which occurs when there is a loss of plasma volume, often due to fluid shifts into inflamed tissues or third-spacing. This indicates the patient is likely dehydrated and needs aggressive fluid resuscitation.

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Michael Rodriguez

42 y/o

Male

Provider:

Dr. Sarah Chen, MD

Allergies:

Penicillin (hives), Shellfish

Emergency Contact:

Casey Rodriguez (Wife) | 555-XXX-5309

Insurance:

Blue Cross Blue Shield

Chief Complaint

Severe epigastric pain radiating to back, onset 6 hours after heavy alcohol consumption and fatty meal. Associated with nausea, vomiting, and diaphoresis.

Medical History

- Type 2 Diabetes (diagnosed 3 years ago)
- Hypertension
- Hyperlipidemia
- History of alcohol abuse (1-2 bottles of wine daily)

Home Medications

- Metformin 1000mg PO BID
- Lisinopril 10mg PO daily
- Atorvastatin 40mg PO daily

Patient demonstrates marked improvement over the past 16 hours. Pain is well-controlled with PCA, with patient rating it as 3/10. NG tube remains in place and clamped. Patient is tolerating ice chips and small sips of water and juice without nausea or vomiting. Bowel sounds are gradually returning. Urine output has improved to 50 mL/hr. Patient has expressed interest in alcohol cessation resources. Family remains supportive at the bedside and actively engaged in the care plan.

Date/Time: 12/27/2024 02:30

Interval History:

Patient showing significant signs of improvement following aggressive fluid resuscitation, pain management, and nasogastric (NG) tube decompression. The NG tube remains in place, connected to low intermittent suction, with reduced abdominal distention and improved comfort. Patient is now tolerating small sips of water. Pain is better controlled with PCA, allowing for increased participation in care.

Physical Examination:

General: Appears less distressed, engaging with care team.
Cardiovascular: Heart rate stabilized within normal limits.
Respiratory: Breathing effortless and regular.
Abdomen: Softer, less distended; NG tube output decreasing.
Skin: Warm, dry, with improved perfusion.

Assessment:

Improving acute pancreatitis with resolving systemic inflammatory response syndrome (SIRS).

Plan:

Continue current management plan.
Clamp the NG tube for 4-6 hours to evaluate the patient's tolerance of oral intake.
1. If the patient remains comfortable without nausea, vomiting, or increased abdominal distention during this period, remove the NG tube.
2. Monitor for any signs of intolerance post-removal and be prepared to reinsert if necessary.
Advance diet to clear liquids as tolerated.
Initiate addiction counseling for alcohol cessation.
Begin discharge planning, focusing on outpatient support and follow-up care.

New Orders

Continue current IV fluids at maintenance rate.
Clamp NG tube for 4-6 hours to assess patient tolerance of oral intake. If no significant nausea, vomiting, or abdominal distention occurs, proceed with NG tube removal.
Advance diet to clear liquids as tolerated.
Continue PCA for pain management.
Order addiction medicine consult to support alcohol cessation efforts.
Initiate physical therapy evaluation for mobilization and recovery.

What criteria should be met before advancing the patient's diet further?

Diet advancement criteria:

Resolution of Nausea and Vomiting: The patient should tolerate oral intake without experiencing nausea or vomiting.
Reduction in Abdominal Distention: This indicates improved gastrointestinal function.
Return of Bowel Sounds: Active bowel sounds suggest the gastrointestinal system is ready to process food.
Pain Control: Pain should be manageable and not aggravated by oral intake.

What discharge planning elements should be prioritized to prevent readmission?

Priority discharge planning elements:

Alcohol Cessation Support: Refer the patient to counseling or support groups to address alcohol abuse.
Dietary Education: Teach the patient to avoid fatty meals and foods that may irritate the pancreas.
Follow-Up Appointments: Schedule visits with a primary care provider, a gastroenterologist, and possibly a dietitian.
Medications and Monitoring: Provide instructions for taking home medications and signs of complications, such as recurrent pain, vomiting, or fever.
Health Monitoring: Educate the patient on monitoring blood sugar levels due to diabetes and maintaining blood pressure and cholesterol control.
Emergency Plan: Teach the patient when to seek medical attention (e.g., severe abdominal pain, fever, vomiting).

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Vital Sign	Value	Normal Range
Temperature	38.2°C	36.1°C - 37.2°C
Heart Rate	118 bpm	60 - 100 bpm
Respiratory Rate	24 breaths/min	12 - 20 breaths/min
Blood Pressure	142/88 mmHg	<120/<80 mmHg
Oxygen Saturation	96% on RA	95% - 100%
Pain Level	6/10	Subjective

Lab Test	Result	Normal Range
Lipase	1850 U/L	10 - 140 U/L
Amylase	420 U/L	60 - 180 U/L
WBC	15,600 cells/mcL	5,000 - 11,000 cells/mcL
Glucose	185 mg/dL	60 - 100 mg/dL
Triglycerides	420 mg/dL	< 150 mg/dL
Total Calcium	7.8 mg/dL	8.5 - 10 mg/dL

Vital Sign	Value	Normal Range
Temperature	38.8°C	36.1°C - 37.2°C
Heart Rate	128 bpm	60 - 100 bpm
Respiratory Rate	28 breaths/min	12 - 20 breaths/min
Blood Pressure	108/68 mmHg	<120/<80 mmHg
Oxygen Saturation	93% on RA	95% - 100%
Pain Level	8/10	Subjective

Lab Test	Result	Normal Range
WBC	18,200 cells/mcL	5,000 - 11,000 cells/mcL
Hematocrit	52%	42 - 52%
BUN	28 mEq/L	10 - 20 mEq/L
Creatinine	1.6 mg/dL	0.6 - 1.2 mg/dL
Lactate	2.8 mmol/L	0.5 - 2.2 mmol/L

Vital Sign	Value	Normal Range
Temperature	37.4°C	36.1°C - 37.2°C
Heart Rate	88 bpm	60 - 100 bpm
Respiratory Rate	18 breaths/min	12 - 20 breaths/min
Blood Pressure	122/76 mmHg	<120/<80 mmHg
Oxygen Saturation	98% on RA	95% - 100%
Pain Level	3/10	Subjective

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