Med-Surg+Case+Study+3

GI Case Studies Appendicitis & Pancreatitis Client Profile: Mr. W. is a 38-year-old registered nurse who has specialized in psychiatric nursing. He is 5’4” and weighs 210 pounds. Mr. W. is brought by a neighbor to the emergency department (ED), accompanied by his wife. The mode of transportation is a car. Case Study: Mr. W denies past medical or surgical history. He reports that while preparing to leave for his place of employment, he had an unusually sharp pain in his abdomen. He tells the triage nurse that he had been having “on and off” pain in the abdominal area and that, at times, the pain was continuous. He said today he felt “unusually cool” but thought it was due to the weather. However, when the pain shifted to his right lower quadrant and remain localized at the area halfway between the umbilicus and the right iliac crest (McBurney’s point), he informed his wife of the need to go to the ED. On arrival at the ED, Mr. W is complaining of nausea, and begins vomiting. He is assisted to a stretcher, and immediately positions himself on his side with his legs flexed. The ED health care provider is notified and the triage nurse continues to gather the history by focusing on Mr. W’s description of the origin of the pain, intensity, and duration. Upon completion of the pain assessment, the nurse proceeds to perform a physical examination, using the system’s approach, then examines the most tender quadrant of the abdomen last. The lungs are clear on auscultation and normal breath sounds are present, ruling out any relationship with the abdominal pain and lower lobe pneumonia. The ED nursing technician monitors the vital signs and reports: Blood pressure: 110/70 Pulse: 80 Respirations: 18 Temperature: 100.0°F The ED health care provider sees MR. W and history and assessment examination are completed. Mr. W is transferred to a medical surgical unit in preparation for further evaluation and probable emergency surgery. He is given morphine sulfate 4mg IM. He is on NPO (“nothing by mouth”) status but has intravenous fluid 0.9% sodium chloride at 125 mL/hr. Electrocardiogram (EKG) and chest X-ray results are normal. Results from serum labs drawn on arrival to the ED reveal: White blood cell (WBC) count: 20,000/mm3 Hematocrit (HCT): 30% Hemoglobin (Hgb): 15 mg/dL Urinalysis reveals hematuria, albuminuria, and pyuria. Blood culture reveals gram-negative anaerobic bacilli. Ultrasound study shows the presence of appendicitis. Diagnostic tests and lab results done in the ED are reviewed, and a diagnosis of appendicitis is confirmed. Mr. W is informed of the need for surgery, an order for type and cross match for two units of packed red blood cells (PRBCs) is placed, an informed consent is signed, and the operating room staff is notified. Ampicillin sodium/sulbactam sodium (Unasyn) 1 g IV is administered stat, and the client is waiting “on call” to the operating room for an appendectomy.

· NPO, start IV fluid D5 0.45% NaCL at 125 mL per hour · Metoclopramide HcL (Reglan) 10 mg IV q6h PRN, Dilute in 50 mL normal saline and infuse over 30 minutes. · Morphine sulfate (Duramorph) 8 mg q4h PRN pain · Ampicillin sodium/sulbactam sodium (Unasyn) 1.5 g IV x one before surgery · Gentamicin sulfate (Garamycin) 80 mg loading dose IV x one before surgery · Metronidazole (Flagyl) 15 mg/kg IV before surgery 1. Define appendicitis Acute inflammatory process of the pancreas, which ranges from mild edema to severe hemorrhagic necrosis. Most common in middle aged men and women, affecting more men than women. inflammation of the appendix 2. Discuss the etiology and pathophysiology of appendicitis. Obstruction of the lumen by accumulated feces, foreign bodies, a tumor of the cecum or appendix, or intramural thickening resulting from hypergrowth of lymphoid tissue.Obstruction results in distention, venous engorgement, and the accumulation of mucus and bacteria which leads to gangrene and perforation.
 * The following are prescribed:**
 * Questions:**

3. Discuss the classic manifestations of appendicitis and some diseases that mimic appendicitis. [|jacksonn64] Diseases that mimic appendicitis are diverticulitis, crohns disease, cholecystitis. ||
 * Periumbilical pain followed by anorexia, nausea and vomiting. [[image:http://www.wikispaces.com/i/icon_16_page_link.gif width="12" height="12" caption="permalink" link="http://teamrednurses.wikispaces.com/message/view/Med-Surg+Case+Study+3/23595363"]] ||
 * [[image:http://www.wikispaces.com/i/user_none_lg.jpg width="48" height="48" caption="jacksonn64" link="http://www.wikispaces.com/user/view/jacksonn64"]] || **re: #3**

4. Discuss the complications associated with acute appendicitis. Perforation, peritonitis, and abscesses 5. Discuss the collaborative management for appendicitis. The patient with abdominal pain should avoid self treatment. Laxatives and enemas are especially dangerous because the resulting increased peristalsis my cause perforation of the appendix. Nothing should be taken by mouth to ensure that the stomach is empty if surgery is needed. An ice bag may be applied to the right lower quadtant to decrease the flow of blood to the area and impede the imflammatory process. Surgery, generally perfromed laparoscopically is performed as soon the diagnosis is made. Lewis p 1049

6. If the client starts to vomit, what interventions should be carried out by the nurse, in order of priority? Interventions for vomiting would be 1. provide client with emesis basin 2. provide mouth care 3. see if client has an order for an antiemetic medication and administer it 4. provide ice chips to replace fluid loss 5. make sure client has clean dry bedding and clothing

7. What are the purposes for the prescribed medications? Medications given to his patient; Reglan-given to prevent nausea and vomiting. Duramorph-pain medication Unasyn- injectible antibacterial Garamycin-antibiotic Flagyl-kills anaerobic bacteria and some parasites 8. What are the most common adverse reactions to the prescribed medications? adverse effects of these medications- Reglan- Drowsiness, fatigue, restlessness. may cause tardive dyskinesia in older people. Duramorph-respiratory depression and/or respiratory arrest. Unasyn-Mild diarrhea; pain, swelling, or redness at injection site. garamycin-burning or stinging Flagyl-Appetite loss; constipation; diarrhea; dizziness; headache; metallic taste; nausea; stomach upset; vomiting. 9. Discuss the drug-to-drug and drug-to-food/herbal interactions for the prescribed medications. Reglan- no significant food or herbal interactions. May interact with other CNS depressants Duramorph-Herbal interactions-Gotu kola, kava kava, St john's Wort, valerian may increase CNS depression. no known fod interaction. Unasyn- drug interactions-Allopurinol may increase incidence of rash. Probenecid may increase concentration and toxicity risks. Medication may decrease effects of oral contraceptives. No significant fod or herbal interactions. Garamycin-drug interactions- Nephrotoxic, ototoxic medications may increase risk of nephrotoxicity, ototoxicity. may increase neuromuscular blockade with concurrent use of neuromuscular blockers. No significant fo or herbal interactions. Flagyl- interactions- alcohol may cause disulfrium type action. Disulfrium may increase risk of toxicity. May increase effects of oral anticoagulants. no food or herbal interactions.

Case Study Pancreatitis

Mrs. Miller is an 88 year old woman who presented with complaints of nausea, vomiting, and abdominal pain. Her vital signs on admission are temperature 99.6 F (37.6C), blood pressure 113/82, pulse 84, and respiratory rate 20.

Her laboratory test reveal: · white blood cell count (WBC) 13,000/mm3, · potassium (K) · aspartate aminotransferase (AST) 142 U.L, · alanine aminotransferase (ALT) 390 U/L.

Physical examination reveals a distended abdomen that is very tender on palpation. Bowel sounds are present in all four quadrants, but hypoactive.

Mrs. Miller is admitted with a diagnosis of acute pancreatitis.

Orders Received: · NPO · Intravenous fluid of D5 ½ NS with 40 mEq of potassium chloride (KCL) per liter at 100 cc per hour · The health care provider prescribes continued administration of her preadmission medications, that is: · Pantoprazole sodium and levothyroxine sodium (in IV form since the client is NPO) · Spironolactone (available in oral form), · IV metoclopramide · Morphine sulfate 4mg IV q 4 hrs. · Nasogastric (NG) tube is inserted and attached to low wall suction · Kidneys, ureters and bladder (KUB) abdominal x-ray in the morning.

CASE STUDY Mrs. Miller’s NG tube is draining yellow-brown drainage. Her pain is being managed effectively with IV morphine 4 mg every four hours. She is NPO and awaiting transport to radiology for a KUB. Mrs. Miller is anxious and has many questions for the nurse: “What is the test I am having done today? What is pancreatitis? Will I need to have surgery? Why did they put this tube in my nose? When will I be able to eat real food?”

Questions:

1. Briefly explain acute pancreatitis and discuss its incidence.

its incidence is about 1 in 5,882 or 0.02%. || [|acruver] Acute pancreatitis is a serious disease of the pancreas, an organ and gland in the upper abdominal area. It is characterized by a sudden and severe inflammation of the pancreas and can be life-threatening and led to other serious complications. its incidence is about 1 in 5,882 or 0.02%. ||
 * Pancreatitus is swelling or infection of the pancreas that cause digestive complaints.
 * [[image:http://www.wikispaces.com/i/user_none_lg.jpg width="48" height="48" caption="acruver" link="http://www.wikispaces.com/user/view/acruver"]] || **re: CS2 #1**

2. Mrs. Miller’s admitting diagnosis is acute pancreatitis. Can a person have chronic pancreatitis? If so, what is the incidence, and how would you define chromic pancreatitis? Yes you can have chronic pancreatitis. Chronic pancreatitis is inflammation of the pancreas that does not heal or improve, gets worse over time, and leads to permanent damage. The condition is most often caused by alcohol abuse over many years. Repeat episodes of acute pancreatitis can lead to chronic pancreatitis. Genetics may be a factor in some cases. Sometimes the cause is not known Other conditions that have been linked to chronic pancreatitis: Autoimmune problems (when the immune system attacks the body) Blockage of the pancreatic duct or the common bile duct, the tubes that drain enzymes from the pancreas Complications of cystic fibrosis High levels of a fat called triglycerides in the blood (hypertriglyceridemia) Hyperparathyroidism Use of certain medicationss (especially estrogens, corticosteroids, thiazide diuretics, and azathioprine) Chronic pancreatitis occurs more often in men than in women. The condition often develops in people ages 30 - 40 3. Discuss the common clinical manifestations of acute pancreatitis. common manifestations of appendicictis: abdominal pain rebound tenderness muscular rigidity spams patient may lie very still and take only shallow respirations becasue movement causes pain. abdominal distention or ascites, fever,tachycardia, tachypnea, nausea, vomiting and altered bowel habits may be present. 4. Briefly discuss the diagnostic tests that help confirm the diagnosis of pancreatitis. Peritoneal aspiration may be performed and fluid analyzed for blood.bile, pus, bacteria, fungas and amylase content Ultra sound and ct scan 5. Identify the assessment findings in Mrs. Miller’s case that are consistent with acute pancreatitis. assessment if the patient's pain, including the location. assessed for the presence and quality of bowel sounds, increasing abdominal distention, abdominal guarding, nausea,fever, and manifeststaion of hypovolemic Stroke 6. Mrs. Miller asks, “What is the test I am having done today?” How would the nurse describe a KUB to Mrs. Miller? KUB is a diagnotic medical imaging technique of the abdomen. Stands for Kideys, Ureters and Bladder 7. Identify the possible causes of acute pancreatitis. Discuss the physiology of the two major causes of acute pancreatitis in the United States, and note which individuals are at greatest risk. Gallbladder disease, alcoholism, trauma (post surgical, abdominal), viral infections(mumps, coxsackievirus B, HIV), penetrating duodenal ulcer, cysts, abcesses, cystic fibrosis,, Karposi sarcoma, certain drugs (corticosteroids, thiazide diuretics, oral contraceptives, sulfonamides, NSAIDS,) metabolic disorders (hyperparathyroidism, hyperlipidemia, renal failure) and vascular diseases, or idiopathic. The two major causes of acute pancreatitis in the United States are gallbladder disease(gallstones) in women; and chronic alcohol intake (men). Lewis p 1118 8. Briefly discuss the treatment options for pancreatitis, and explain why Mrs. Miller has an NG tube to low wall suction. How will the nurse determine if the NG tube is functioning? The primary diagnostic tests for acute pancreatitis are serum amylase and lipase. The serum amylase level is usually elevated early and remains elevated for 24-72 hrs. Serum lipase level is also elevated in acute pancreatitis. Diagnostic evaluation of acute pancreatitis is also directed at determining the cause. An abdominal ultrasound, x-ray, or CECT can be used to identify pancreatic problems. Treatment is focused on supportive care, including aggressive hydration, pain management, management of metabolic complications, and minimizing pancreatic stimulation. It is important to reduce or suppress pancreatic enzymes to decrease stimulation of the pancreas and allow it to rest, such as patient being NPO; and using NG suction to reduce vomiting and gastric distention and to prevent gastric acidic contents from entering the duodenum. The NG tube is determined to be functioning if there is drainage in the wall suction container, and if patient reports less pain and nausea. Lewis p 1120 10. Discuss the complication that can arise if pancreatitis is not treated. The main systemic complications of acute pancreatitis are pulmonary (pleural effusion, atelectasis, and pneumonia) and cardiovascular (hypotenstion) complications and tetany caused by hypocalcemia. When hypocalcemia occurs, it is a sign of severe disease, due in part to the combining of calcium and fatty acids druing fat necrosis. Lewis p1119-1120

11. Evaluate Mrs. Miller’s potassium level. Should the nurse question the health care provider’s prescription for the diuretic spironolactone? Why or why not? Mrs. Miller's K level is unclear and needs to be verified. spironolactone (Aldactone) is a diuretic that promotes sodium and water excretion but blocks potassium excretion by blocking receptors for aldosterone in the distal renal tubules. It would be used if Mrs. Miller has hypokalemia (K<3.5 mEq/L 12. Because Mrs. Miller is NPO, the nurse must administer the oral spironolactone via the NG tube. Is it appropriate to crush this medication? Why or why not? What intervention should the nurse take following administration of the medication to facilitate absorption? It is appropriate to crush spironolactone and it must be crushed and diluted in water to flow thru the NG tube. 13. Which type to diet will Mrs. Miller advance to when her NPO status is discontinued? What types of liquids are allowed on this diet? The diet following NPO status is clear liquids which includes water, fruit juice without pulp, carbonated beverages, clear tea, black coffee, clear broth, jello.