Video Case Study - Caring for Patients With Pancreatitis

Nurse Gerdie works on a medical-surgical unit and is caring for Leo, a 47-year-old who was admitted for acute pancreatitis secondary to chronic alcohol use.

In collaboration withthe registered nurse, RN Don, Nurse Gerdie goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Leo's care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.First, Nurse Gerdie recognizes important cues, including Leo’s vital signs, which include blood pressure 145/90 mmHg, heart rate 88 beats per minute, temperature 99.2 °F, and respirations 18 breaths per minute.

Nurse Gerdie notices Leo is diaphoretic, his gown is damp, and he’s holding an empty emesis bag. She also sees that he has IV fluids infusing in his right forearm.Nurse Gerdie: Hi Leo, it looks like you're not feeling well.

What's your pain level right now on the 0 to 10 pain scale?Leo: My pain is a six. It feels like I can’t lie down on my back or get comfortable at all.

And I’m nauseated.Nurse Gerdie: I understand, I’m going to help you feel more comfortable.Next, Nurse Gerdie analyzes these cues.

She reviews the electronic health record, or EHR, and notes that Leo’s prescriptions include hydromorphone IV every 3 hours as needed, and his last dose was given two and a half hours ago; and she sees sublingual ondansetron is ordered PRN for nausea, but he hasn’t yet received a dose today.Nurse Gerdie understands that acute pancreatitis refers to the sudden inflammation and destruction of the pancreas, which is a long gland located in the upper abdomen, or the epigastric region, behind the stomach.She knows that the pancreas has acinar cells that produce pancreatic juice, which contains digestive enzymes like trypsin, amylase, and lipase, that’s released into the duodenum to help digest food.

Nurse Gerdie recognizes that pancreatitis can be caused by a variety of conditions, and in Leo’s case, chronic alcohol use likely injured his acinar cells, leading to the release and activation of digestive enzymes within the pancreas, causing inflammation and tissue destruction, a process called autodigestion.Nurse Gerdie also realizes that the main symptom of acute pancreatitis is abdominal pain in the left upper quadrant or epigastric region, which can radiate to the back, but patients can also experience nausea and vomiting due to impaired digestion of foods.

She recognizes that Leo needs effective pain and nausea management to improve his comfort.Now, using the information she's gathered, along with Leo’s medical history, Nurse Gerdie reports her findings to RN Don, and together they choose a priority hypothesis of impaired comfort.Then, they generate solutions to address Leo’s pain and nausea that will include pharmacologic and nonpharmacologic interventions; and they establish the expected outcome that after intervening, Leo will report increased comfort within one hour.Nurse Gerdie then takes action to implement these solutions.

She recognizes Leo cannot have his next dose of IV hydromorphone for another 30 minutes, so she gathers supplies and enters Leo’s room.Nurse Gerdie: Hi Leo, I have your nausea medication, called ondansetron, that dissolves under your tongue.Leo: Okay, thank you.

That really helped me yesterday; but what about my pain medicine?Nurse Gerdie: You’re not due for that yet, but in about 30 minutes Nurse Don will bring that in for you.Leo: Okay, good.Nurse Gerdie then administers the ondansetron according to the principles of safe medication administration.

She also helps Leo change out of his damp gown and assists him in putting on a new dry one. She then dims the lights, covers him with a warm blanket, and places his call light within reach.Thirty minutes later, RN Don administers the IV hydromorphone.One hour later, Nurse Gerdie re-enters Leo’s room to evaluate the outcome of her actions.

Leo’s vital signs are blood pressure 126/82 mmHg, heart rate 70 beats per minute, and respirations 16 breaths per minute.

He appears more comfortable and is sitting up in bed eating ice chips.Nurse Gerdie: How are you feeling now, Leo?Leo: Muc h better.

The pain is still there, but it’s only 3 out of 10, and I don’t feel nauseous anymore. The medications you and Nurse Don gave me really helped.Nurse Gerdie: Great!Alright, as a quick recap....

Nurse Gerdie recognized and analyzed cues related to Leo's pancreatitis and, in collaboration with RN Don, prioritized hypotheses, and generated solutions to address this problem.

Nurse Gerdie and RN Don then implemented pharmacologic and nonpharmacologic measures and evaluated Leo's outcomes and compared them to the expected outcome.

Since Leo reported increased comfort within one hour, they determined the plan of care was successful.