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A community health nurse is caring for a patient whose multiple health problems include chronic pancreatitis. During the most recent visit, the nurse notes that the patient is experiencing severe abdominal pain and has vomited 3 times in the past several hours. What is the nurses most appropriate action?
- A. Administer a PRN dose of pancreatic enzymes as ordered.
- B. Teach the patient about the importance of abstaining from alcohol.
- C. Arrange for the patient to be transported to the hospital.
- D. Insert an NG tube, if available, and stay with the patient.
Correct Answer: C
Rationale: Chronic pancreatitis is characterized by recurring attacks of severe upper abdominal and back pain, accompanied by vomiting. The onset of these acute symptoms warrants hospital treatment. Pancreatic enzymes are not indicated and an NG tube would not be inserted in the home setting. Patient education is a later priority that may or may not be relevant.
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An adult patient has been admitted to the medical unit for the treatment of acute pancreatitis. What nursing action should be included in this patients plan of care?
- A. Measure the patients abdominal girth daily.
- B. Limit the use of opioid analgesics.
- C. Monitor the patient for signs of dysphagia.
- D. Encourage activity as tolerated.
Correct Answer: A
Rationale: Due to the risk of ascites, the nurse should monitor the patients abdominal girth. There is no specific need to avoid the use of opioids or to monitor for dysphagia, and activity is usually limited.
A nurse is preparing a plan of care for a patient with pancreatic cysts that have necessitated drainage through the abdominal wall. What nursing diagnosis should the nurse prioritize?
- A. Disturbed Body Image
- B. Impaired Skin Integrity
- C. Nausea
- D. Risk for Deficient Fluid Volume
Correct Answer: B
Rationale: While each of the diagnoses may be applicable to a patient with pancreatic drainage, the priority nursing diagnosis is Impaired Skin Integrity. The drainage is often perfuse and destructive to tissue because of the enzyme contents. Nursing measures must focus on steps to protect the skin near the drainage site from excoriation. The application of ointments or the use of a suction apparatus protects the skin from excoriation.
A patient has been scheduled for an ultrasound of the gallbladder the following morning. What should the nurse do in preparation for this diagnostic study?
- A. Have the patient refrain from food and fluids after midnight.
- B. Administer the contrast agent orally 10 to 12 hours before the study.
- C. Administer the radioactive agent intravenously the evening before the study.
- D. Encourage the intake of 64 ounces of water 8 hours before the study.
Correct Answer: A
Rationale: An ultrasound of the gallbladder is most accurate if the patient fasts overnight, so that the gallbladder is distended. Contrast and radioactive agents are not used when performing ultrasonography of the gallbladder, as an ultrasound is based on reflected sound waves.
A patient is receiving care in the intensive care unit for acute pancreatitis. The nurse is aware that pancreatic necrosis is a major cause of morbidity and mortality in patients with acute pancreatitis. Consequently, the nurse should assess for what signs or symptoms of this complication?
- A. Sudden increase in random blood glucose readings
- B. Increased abdominal girth accompanied by decreased level of consciousness
- C. Fever, increased heart rate and decreased blood pressure
- D. Abdominal pain unresponsive to analgesics
Correct Answer: C
Rationale: Pancreatic necrosis is a major cause of morbidity and mortality in patients with acute pancreatitis because of resulting hemorrhage, septic shock, and multiple organ dysfunction syndrome (MODS). Signs of shock would include hypotension, tachycardia and fever. Each of the other listed changes in status warrants intervention, but none is clearly suggestive of an onset of pancreatic necrosis.
A patients assessment and diagnostic testing are suggestive of acute pancreatitis. When the nurse is performing the health interview, what assessment questions address likely etiologic factors? Select all that apply.
- A. How many alcoholic drinks do you typically consume in a week?
- B. Have you ever been tested for diabetes?
- C. Have you ever been diagnosed with gallstones?
- D. Would you say that you eat a particularly high-fat diet?
- E. Does anyone in your family have cystic fibrosis?
Correct Answer: A,C
Rationale: Eighty percent of patients with acute pancreatitis have biliary tract disease such as gallstones or a history of long-term alcohol abuse. Diabetes, high-fat consumption, and cystic fibrosis are not noted etiologic factors.