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
- Document: Thoroughly document the assessment findings, the patient's refusal, the explanation and information provided regarding the severity, the legal obligations of hospitals, and the options for financial assistance and transportation discussed.
2. Response to Patient's Question About Management Outside the Hospital:
The practitioner should respond with empathy, clear medical explanation, and reassurance about the financial aspect, already addressed the financial aspect. The response should focus on the urgency and complexity of his current condition:
"Mr. [Patient's Last Name], I understand you're worried about the cost and don't want to go to the hospital. I completely understand those concerns. However, I'm really concerned about your symptoms right now. You have very high blood pressure, a fast heart rate, you're breathing quickly, you have a fever, and your skin is cool and clammy – all signs that your body is under a lot of stress. Your severe abdominal pain and the fact that you look jaundiced (the yellowing in your eyes) make me very worried that something serious is going on, possibly related to your pancreas like you suspect, but we can't be sure without tests. This kind of situation can get worse very quickly, and it requires specific treatments and monitoring, like IV fluids, pain medication, and tests like blood work and imaging, that we simply don't have the equipment or capabilities to do here in the clinic. While we can manage some things here, this situation needs the resources of a hospital emergency room right now to make sure you get the care you need to get better and stay safe. And remember, even without insurance, the hospital is required by law to take care of anyone with an emergency condition."
3. Tests Likely Performed at the Hospital:
- Laboratory Tests:
- Complete Blood Count (CBC): To check for anemia (hemolysis, bleeding), infection (leukocytosis).
- Lipase and Amylase: Key enzymes; significantly elevated levels are highly suggestive of acute pancreatitis.
- Liver Function Tests (LFTs): Abnormalities (e.g., elevated bilirubin, ALT, AST, Alkaline Phosphatase) can indicate complications like bile duct involvement, gallstones (a common cause of pancreatitis), or sepsis.
- Electrolytes, BUN, Creatinine: To assess hydration status, renal function (which may be affected by pancreatitis, sepsis, or pre-existing conditions).
- Lactate: Can indicate tissue hypoperfusion or shock.
- Blood Cultures: If sepsis is suspected.
- Type and Screen: In case blood transfusion is needed due to significant internal bleeding or severe anemia.
- Urinalysis: To check for ketones, infection, or other issues.
- Radiologic Tests:
- CT Abdomen/Pelvis (often with contrast): Often considered the gold standard for assessing the extent of pancreatic inflammation, necrosis, collections (fluid, abscesses), or complications like a ruptured AAA. Contrast helps visualize the pancreas and surrounding structures.
- Abdominal Ultrasound: Often first-line, especially to look for gallstones (a common cause) and assess the pancreas. May be less effective if the patient has significant gas or if the pancreas is obscured.
- MRI/MRCP: Less common initially but can be useful in specific situations.
4. How Severity of Pancreatitis Will Be Assessed:
Severity is typically assessed using a combination of factors:
- Clinical Parameters: Presence of systemic inflammatory response syndrome (SIRS) criteria (fever, tachycardia, tachypnea, leukocytosis), hypotension, tachycardia, hypoxia, altered mental status, presence of organ failure (renal, respiratory, cardiovascular, hematologic, neurological).
- Laboratory Markers: Elevated white blood cell count, elevated C-reactive protein (CRP), elevated lactate, evidence of organ dysfunction (e.g., elevated BUN/creatinine, elevated liver enzymes, low oxygen saturation).
- Imaging Findings: The CT scan is crucial. It can show:
- Edematous Pancreatitis: Inflammation without tissue death (mild).
- Necrotizing Pancreatitis: Tissue death within the pancreas (moderate/severe).
- Presence of Complications: Pseudocysts, abscesses, fluid collections, phlegmons, retroperitoneal or pleural effusions.
- Scoring Systems: Tools like the Revised Atlanta Classification, Ranson criteria, or the Acute Physiology and Chronic Health Evaluation (APACHE II) score are used to objectively quantify the severity and predict outcomes.
5. How the Patient's Condition Will Be Managed When Hospitalized:
Management depends on the severity but generally includes:
- Supportive Care (Core):
- NPO (Nil Per Os - Nothing by Mouth): To rest the pancreas.
- Intravenous (IV) Fluid Resuscitation: Aggressive hydration (often isotonic saline) is critical, especially in the first 24-48 hours, to restore intravascular volume, maintain renal perfusion, and prevent complications. Careful monitoring is needed to avoid fluid overload, especially in patients with CHF or CKD.
- Pain Management: IV analgesics, typically opioids like morphine, often given in conjunction with antiemetics (like ondansetron) to control nausea and vomiting.
- Nutritional Support: Once the acute phase subsides (typically after several days when inflammation markers decrease and pain improves), enteral nutrition (often via nasogastric or nasojejunal tube) is started, as it has been shown to be superior to parenteral nutrition for many patients.
- Monitoring: Close monitoring of vital signs, pain, laboratory values, fluid balance, and signs of complications.
- Management of Complications: Treating infections (antibiotics if infected necrosis or sepsis), managing pseudocysts or abscesses (often requires interventional radiology or surgery), managing diabetes (insulin may be needed due to transient hyperglycemia), treating shock.
- Addressing Underlying Cause: If gallstones are the cause, planning for cholecystectomy after the acute phase. If alcohol is the cause, initiating or referring for alcohol detoxification and counseling.
- Specialist Consultation: Gastroenterology is typically involved. Surgery, infectious disease, critical care, and interventional radiology may be consulted depending on complications.
6. Patient Education After Resolution of Pancreatitis:
- Address the Underlying Cause:
- Alcohol Cessation: If alcohol misuse was a factor, strong counseling, referral to addiction specialists or support groups (e.g., AA), and setting clear goals for abstinence are crucial. Explain the high risk of recurrence and potential for much more severe outcomes with further episodes.
- Gallstones: If gallstones were the cause, explain the need for gallbladder removal (cholecystectomy) to prevent recurrence. Discuss the timing of surgery (often after recovery from pancreatitis).
- Lifestyle Modifications:
- Diet: Explain the importance of a balanced, low-fat diet, especially if gallstones were present or if fat malabsorption is an issue. Discuss potential need for pancreatic enzyme supplements if malabsorption occurs.
- Avoiding Triggers: Reinforce avoiding alcohol completely if it caused the pancreatitis.
- Recognizing Recurrence: Educate him on the signs and symptoms of recurrent pancreatitis (severe epigastric pain radiating to the back, nausea, vomiting, fever) and emphasize seeking medical attention promptly at a hospital or clinic if these occur.
- Ongoing Health Management: Reinforce the importance of managing his known health conditions (CHF, CKD) and the need for regular follow-up with healthcare providers, even if challenging due to homelessness. Discuss the importance of seeking care for symptoms earlier rather than waiting for them to become severe.
- Smoking Cessation: If he smokes, discuss the negative impact on overall health, wound healing (if surgery is needed), and the increased risk of complications. Offer resources for quitting.