Pancreatitis and Diabetes - Case Study Example

Nursing Case Study Student’s Name Institution Name Abstract Mr. Chris Callaghan attended a football party hosted by his friend John where he imbibed copious amounts of alcohol, chips and a hamburger. His friend John spotted him unconscious on his front veranda the next day approximately twelve hours since when he left the party in a pool of blood and vomits. John notified the ambulance services that responded and transferred Mr. Callaghan to the emergency department upon stabilizing his symptoms. Mr. Callaghan is a known diabetic and has a previous history of acute pancreatitis. Mr. Callaghan sustained injuries with a laceration on top of his left eye as well as bruises on the left part of his face (Han, Feng, & Wang, 2007). This case study delves into the specifics of the underlying medical conditions for the case of Mr. Chris Callaghan and succinctly evaluates the potential impact of these conditions on the current event. In addition, the review will evaluate the collaborative care needs for Mr. Chris Callaghan namely pain control, blood glucose monitoring, energy and nutrition, fluid and electrolyte balance as well as self-care. The study will also culminate into the formulation of a nursing care plan to address the identified needs of Mr. Chris Callaghan (Hua, 2005). The interventions are centered on ensuring adequate pain control, maintaining optimal blood sugar levels, restoration of fluid and electrolyte balance, reducing the risk for infection and alleviating anxiety (Carpenito-Moyet, 2009). Finally, the review analyses the various ethical and legal issues arising from the care of Mr. Chris Callaghan with a keen focus on the custody of his two daughters bearing in mind his state of health due to ongoing court proceedings on the same matter (Ackley & Ladwig, 2008). Table of Contents Abstract 2 Mr. Chris Callaghan attended a football party hosted by his friend John where he imbibed copious amounts of alcohol, chips and a hamburger. His friend John spotted him unconscious on his front veranda the next day approximately twelve hours since when he left the party in a pool of blood and vomits. John notified the ambulance services that responded and transferred Mr. Callaghan to the emergency department upon stabilizing his symptoms. Mr. Callaghan is a known diabetic and has a previous history of acute pancreatitis. Mr. Callaghan sustained injuries with a laceration on top of his left eye as well as bruises on the left part of his face (Han, Feng, & Wang, 2007). 2 Table of Contents 3 Introduction 4 Pancreatitis and diabetes 4 Collaborative care needs for Mr. Chris Callaghan. 5 Pain control 5 Blood glucose control and nutrition 6 Fluid and electrolyte balance 6 Self-care 6 Nursing care plan for Mr. Chris Callaghan 7 Primary assessment 7 Secondary assessment 7 Nursing priorities 8 Nursing diagnoses and the planned interventions 8 Legal and ethical issues regarding the care of Mr. Chris Callaghan 13 Conclusion 13 References 15 Introduction This is a case study review of Mr. Chris Callaghan, a 36-year-old who was found unconscious on his front veranda more than twelve hours after he left a football party where he ingested significant amounts of alcohol, chips, and hamburgers. Mr. Callaghan had sustained bruises on the left side of his face and an 8cm laceration above his left eye. The patient also presented with a history of vomiting and bleeding following this incident. In addition, he is a known diabetic on daily short-acting insulin and has had two incidences of acute pancreatitis in the last five months (Garg, Chen, & Pendergrass, 2010). The case study reviews the implications of the underlying conditions of Mr. Callaghan's current illness during which he lost consciousness after ingesting alcohol. In addition, the case study reviews the various collaborative needs for Mr. Callaghan and develops nursing care plans for his condition in the emergency department (Petrov & Windsor, 2010). Pancreatitis and diabetes Pancreatitis is an inflammatory condition of the pancreas characterized by abdominal pains as well as elevated levels of pancreatic enzymes in the serum (Whitcomb, 2006). Gallstones, alcohol ingestion, some drugs, congenital pancrease divisum, microlithiasis, and some metabolic states cause pancreatitis (Pezzilli et al., 2010). It is usually of sudden onset with the potential to injure the pancreas as well as other distant and adjacent organs considerably. The symptoms of pancreatitis range from mild abdominal discomfort to an acute abdomen as well as shock. The patient may also present with nausea, vomit, respiratory failure, fever, confusion, coma, hypotension, tachycardia, pleural effusion, and mild jaundice (Petrov, Shanbhag, Chakraborty, Phillips, & Windsor, 2010). Diabetes mellitus type 1 is a condition whereby the body secretes very low amounts of insulin or none at all than the body requirements hence the need insulin injections daily to prevent elevated blood sugar levels (Handelsman et al., 2011). This occurs as sequelae to autoimmune destruction of pancreatic beta cells contributed by genetic predisposition and environmental triggers such as infections and stress. The condition presents with polyuria, polydipsia, as well as polyphagia and may progress to life-threatening diabetes ketoacidosis, coma, and death when no or insufficient insulin is administered. On the other hand, excessive administration of insulin or lack of food intake leads to hypoglycemia, seizures and loss of consciousness (Collaboration & others, 2010). Mr. Chris Callaghan was found unconscious more than twelve hours after ingesting copious amounts of alcohol, hamburgers, and hot chips at John’s football party. Worth noting is the fact that Mr. Callaghan vomited the food he had ingested primarily because of the exacerbation of pancreatitis secondary to alcohol ingestion (Petrov et al., 2010). Consequently, very little amount of the ingested food reached his circulation possibly leading to hypoglycemia. Moreover, alcohol ingestion causes dehydration and worsens hypoglycemia (Crowther et al., 2005). Therefore, Mr. Callaghan passed out just when he got to his front veranda and possibly knocking his head on some object thereby sustain the injuries that he presented with at the hospital (Collaboration & others, 2010). Collaborative care needs for Mr. Chris Callaghan. Pain control Mr. Callaghan presented with acute epigastric pain to the emergency department. The sources of this pain include the exacerbated pancreatitis following ingestion of large amounts of alcohol. In addition, Mr. Callaghan suffers from gastric ulcers whose pain would easily worsen when there is no food in the gastrointestinal tract considering that he had vomited and consumed alcohol as well as cigarettes thus triggering production of more gastric acid (Carpenito-Moyet, 2009). The paramedics reported that leaning forward helped relieve the pain but definitely more aggressive pain control measures are required. Finally, Mr. Callaghan requires control of pain arising from the sustained injuries on his face namely the 8cm laceration on his above his left eye as well as the bruises on the left side of his face (Handelsman et al., 2011). Blood glucose control and nutrition The last meal consumed by Mr. Callaghan was hours before midnight of the previous night and according to the paramedics' reports, he had vomited it out leading to fatigue due to lack of energy supply. Definitely, the patient requires glucose supply depending on the assessment findings of his blood glucose levels at the time of his admission (Björvell, Thorell-Ekstrand, & Wredling, 2000). The blood glucose should also be monitored to ensure it falls within the acceptable range during the period of his hospitalization. To achieve effective control of his blood sugar, Mr. Callaghan will require administration of short-acting insulin (8 units) before he commences feeding as prescribed by the physician (Collaboration & others, 2010). Fluid and electrolyte balance The patient had lost considerable amounts of fluids through vomiting, bleeding, and possibly urination triggered by alcohol consumption. Electrolyte imbalance set in following vomiting hence the need to correct this before the patient moves into complications (Schultz & Videbeck, 2009) . Consequently, Mr. Callaghan will also require prompt monitoring of his urea, electrolytes, and creatinine (UEC) levels as the interventions are undertaken. In addition, the patient also requires monitoring of the hemoglobin levels due to the blood levels. Depending on the depth of the laceration above his left eye, Mr. Callaghan will require either stitching or dressing with an antiseptic solution to achieve complete hemostasis (Association & others, 2010). Self-care Mr. Callaghan passed out just when he got to his house and at the time of his admission, his self-care needs were yet to be met. Consequently, he will require assistance with his self-care needs namely oral hygiene, general body hygiene including a bath, change of clothing, and care of his hair (Edward, Rasmussen, & Munro, 2010). Mr. Callaghan's mother will also be useful in his care hence, there will be a need to inform her since the patient did not want his wife to learn of this incident. In addition, assessment findings revealed that the patient lacked orientation to time and place hence the need to restore normalcy to his mental functioning (Brunner, Smeltzer, Bare, Hinkle, & Cheever, 2010). Nursing care plan for Mr. Chris Callaghan Primary assessment Mr. Callaghan was brought to the emergency department with a history of loss of consciousness, epigastric pain, vomiting, and bleeding from a laceration above his left eye. On initial assessment, his vitals were within normal range except for his altered level of consciousness with the last GCS score of 14 and his blood glucose levels due to prolonged starvation. Mr. Callaghan was no longer bleeding from his laceration as well as the vomiting had stopped and the patient was receiving his first bottle of 0.9% normal saline at a rate of 250mls/hr (Brunner et al., 2010). A quick assessment of the laceration revealed no injuries to the rest of the eye. Leaning forward was a relieving factor for his epigastric pain that promoted Mr. Callaghan’s comfort. The patient was very anxious during his admission because of his strife to maintain custody of his two daughters from his wife who would otherwise use his hospitalization as compelling evidence in the ongoing custody proceedings (Garg et al., 2010). Secondary assessment A detailed history of Mr. Callaghan's presenting illness was taken accompanied by physical examination and evaluation of laboratory investigations conducted to establish the severity of his illness. The patient's vitals were within the normal range during the secondary assessment. There was a positive history of acute pancreatitis diagnosed approximately five months ago. In addition, Mr. Callaghan had comorbid diabetes mellitus type 1 and gastric ulcers exacerbating his symptoms. Physical examination revealed moderate dehydration, a minor laceration on the left eye, guarding of the abdomen during the examination, hypoactive bowel sounds, and generalized fatigue (Petrov & Windsor, 2010). Investigations included half-hourly blood glucose monitoring, an abdominal ultrasound scan to visualize the inflamed pancreas, hematological studies including hemoglobin levels as well as UECs, and GCS monitoring. The mental status assessment revealed progressive improvement in the consciousness statuses particularly orientation to time and place. The patient had self-awareness and an intact memory due to the recall of the incidences prior to the incidence as well as other key facts such as custody of his daughters in the ongoing proceedings (Collaboration & others, 2010). Nursing priorities Nursing priorities for Mr. Callaghan include pain control arising from, blood sugar control, restoration of fluid and electrolyte balance, prevention of complications, relieving anxiety, minimizing the risk for infection due to the lacerations and bruises, as well as correcting any metabolic abnormalities (Benner, Tanner, & Chesla, 2009). The patient’s care aims at achieving homeostasis, prevention of complications, improving his self-care and ensuring his needs are met, stoppage of the disease process, and correcting the underlying causes (Brunner et al., 2010). Nursing diagnoses and the planned interventions Nursing diagnosis: Acute pain related to obstruction of the bile ducts as evidenced by the patient verbalizing pain, facial grimacing, guarding behaviors and leaning forward. Desired Outcomes The interventions will aim at ensuring that the patient reports adequate pain control and that he receives pain medication prescribed by the physician during his admission Nursing Interventions and Rationale Nursing interventions for Mr. Callaghan will include investigating the source of pain and its intensity. Pain from the right upper quadrant confirms involvement of the pancreas’ head whereas lower upper quadrant pain shows pancreatic tail’s involvement. The pain will then be monitored using a pain scale to ensure the patient regains some degree of comfort. In addition, promoting rest for Mr. Callaghan by minimizing any destructions in his admission room will speed up his recovery. This is because rest reduces activity of the pancreas by reducing the metabolic rate (McFarland & McFarlane, 2007). Comfortably positioning Mr. Callaghan laterally with flexed knees, leaning forward and sitting up reduces pressure on the abdomen hence minimal pain. Similarly, diversion therapies such as a back rubs, listening to the radio, and watching television will reduce pain sensations and promote relaxation of the patient. Finally, the nurses should the environment is free from odors because sensory stimulation activates pancreatic enzymes thereby increasing pain. Finally, the nurse should administer the pain medication prescribed by the physician since the painkillers interact with pain receptors reducing pain sensation (Carpenito-Moyet, 2009) Nursing diagnosis: Imbalanced nutrition less than body requirements related to nausea, vomiting, insulin deficiency, and reduced food intake as evidenced by patient’s reports Desired Outcomes It is expected that Mr. Callaghan will ingest adequate calorie amounts and will have usual level of energy following the nursing interventions. Nursing Interventions and Rationale Some interventions to be undertaken by the nurse include administration of intravenous fluids with electrolytes and nutrients. The intravenous route is preferred in cases of altered consciousness and poor bowel function as is the case for Mr. Callaghan.In addition, the nurse should administer the prescribed amount of short acting insulin intravenously because insulin promotes uptake of glucose by cells and the intravenous route is useful for faster absorption as compared to subcutaneous route (Carpenito-Moyet, 2009). Moreover, the nurse will monitor the patient for any signs of hypoglycemia with the help of a blood glucose monitor due to the risk of hypoglycemia when blood glucose reduces and carbohydrates metabolism resumes following insulin administration. Finally, the nurse will administer metoclopramide which corrects nausea and vomiting by modulating the chemotactic trigger zone (CTZ) (Brunner et al., 2010). Nursing diagnosis: Deficient fluid volume related to vomiting, urination and alcohol consumption as evidenced by poor skin turgor, weak peripheral pulses, and poor capillary refill (Dossey, Certificate, Keegan, Association, & others, 2012). Desired Outcomes It is expected that Mr. Callaghan will achieve normal hydration status as well as stable vital signs, normal skin turgor, strong peripheral pulse, and good capillary refill following the nursing interventions. Nursing Interventions and Rationale The nurse should monitor Mr. Callaghan’s blood pressure because of the possibility of pancreatic ischemia, which triggers bleeding, fluid sequestration, and bleeding causing profound hypotension. In addition, the nurse should be keen to note reports of thirst, dry mucous membranes, dry skin, and poor skin turgor because these symptoms indicate the degree of dehydration. Lastly, the nursing team should investigate any sensory related changes to Mr. Callaghan’s status since such changes have a close association with hypoxia, hypovolemia, and electrolyte imbalance (Ackley & Ladwig, 2008). Nursing diagnosis: Risk for infection related to high levels of glucose reduced functioning of leukocytes, open lacerations as well as bruises, and hospitalization (Ackley & Ladwig, 2008). Desired Outcomes The nursing actions will be geared towards identifying interventions for preventing infections. In addition, the nursing personnel should be able to demonstrate infection prevention techniques to Mr. Callaghan during his period of hospitalization (Dossey et al., 2012). Nursing Interventions and Rationale The nursing interventions for Mr. Callaghan include periodic monitoring for signs of infection such as fever, cloudy urine, flushed appearance, etc since such symptoms depict active infections. In addition, the nurse should adhere to good hygienic practices such as hand washing before handling Mr. Callaghan in order to reduce chances of cross contamination. The nurse should observe aseptic techniques while attending to the patient because this prevents introduction of disease-causing agents into Mr. Callaghan's environment (Ackley & Ladwig, 2008). Moreover, Mr. Callaghan should be placed in a semi-Fowler’s position, which facilitates the expansion of lungs thus reducing chances of aspiration and infection. All wounds and lacerations should be stitched and/or dress the lacerations with antiseptic solution since this eliminates disease causing agents and interrupts the infection cycle. Finally, the nurse on duty should administer all the prescribed antibiotics in order to counteract and prevent further sepsis (Brunner et al., 2010). Nursing diagnosis: Disturbed sensory perception related to endogenous biochemical alteration as evidenced by lack of orientation to time and place (Ackley & Ladwig, 2008) Desired Outcomes It is expected that Mr. Callaghan will regain full level of consciousness following nursing interventions. Nursing Interventions and Rationale The nursing team will undertake the following interventions during the care of Mr. Chris Callaghan. In the first place, they will monitor the mental status as well as vital signs, which will provide baseline data for comparison with abnormal findings. Secondly, the nurses will orient Mr. Callaghan to time and place in order to reduce the confusion of the patient and ensure compliance to the care given (Dossey et al., 2012). Similarly, the nursing team will develop a schedule of all nursing interventions so that Mr. Callaghan is afforded uninterrupted periods of rest during his hospitalization. Lastly, the primary nurse will assist the Mr. Callaghan with ambulation and changing of positions in order to promotes the safety of the patient before he regains good balance (Ackley & Ladwig, 2008). Nursing diagnosis: Anxiety related to the disease process as evidenced by the patient’s restlessness, crying and verbalizing fear (Dossey et al., 2012) Desired Outcomes It is expected that the patient will be calm and manifest minimal signs of anxiety following the planned interventions by the nursing personnel. Nursing Interventions and Rationale The nurse will constantly reassure Mr. Callaghan on the prognosis of the disease and provide any new information in good time since this helps in promoting the patients calmness. In addition, providing good explanations on the disease process to the patient as well as all the procedures to be performed will enhance the patient’s understanding of the disease process thus becoming less anxious. Finally, in the event the anxiety goes beyond the expected limit, the nurse will administer anxiolytics to Mr. Callaghan, which Corrects anxiety by modulating receptors in the central nervous system (Brunner et al., 2010). Legal and ethical issues regarding the care of Mr. Chris Callaghan Mr. Callaghan and his ex-wife Annette have been to court in regards to the custody of their two daughters Kate and Sharon aged eight and ten years respectively. It is obvious that if the court learned of this incident, it would reconsider its directive on the custody of the children. Mr. Callaghan’s daughters require adequate attention from a parent figure and apparently, he is failing in this but wouldn’t let go off the custody of his children to his wife. He is trusting the health professions to help him conceal this incident as a secret from his who would otherwise use it in court to deny him custody of his daughters (Benner et al., 2009). From the ethics point of view, health workers have a duty to ensure confidentiality of the patient’s information by not revealing it to persons who are not involved in the patient’s care. In this case, Mr. Callaghan’s ex-wife is not involved in his care and her knowledge of this incident would otherwise jeopardize his deteriorating health. In addition, the caregivers have no professional responsibility to Annette but Mr. Callaghan who is under their care. As requested by Mr. Callaghan, the caregivers are professionally safe to inform only his mother regarding the current illness (Brown, Wickline, Ecoff, & Glaser, 2009). On the other hand, the caregivers are in possession of valuable information that would compel the court to make an informed decision regarding the custody of Kate and Sharon. However, it is not their legal obligation to provide this information unless when ordered to do so by a court of law with competent jurisdiction (Melnyk & Fineout-Overholt, 2011). Conclusion The case study review considered the underlying conditions that exacerbated Mr. Callaghan’s current illness during which he passed out after he left a football party and was found more than twelve hours later in the front of his veranda with sustained facial injuries, vomits, and blood. The review established the needs of Mr. Callaghan’s such as pain control, blood glucose control, nutrition, fluid volume balance, electrolyte balance and self-care needs. A care plan was developed prioritizing his needs while detailing the interventions that would restore his health to optimal functioning. Finally, the ethical and legal issues likely to arise from his care were also considered in this review. References Ackley, B. J., & Ladwig, G. B. (2008). Nursing diagnosis handbook: an evidence-based guide to planning care. Mosby. Association, A. D., & others. (2010). Diagnosis and classification of diabetes mellitus. Diabetes Care, 33(Supplement 1), S62–S69. Benner, P. E., Tanner, C. 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Organ failure and infection of pancreatic necrosis as determinants of mortality in patients with acute pancreatitis. Gastroenterology, 139(3), 813–820. Petrov, M. S., & Windsor, J. A. (2010). Classification of the Severity of Acute Pancreatitis: How Many Categories Make Sense&quest. The American Journal of Gastroenterology, 105(1), 74–76. Pezzilli, R., Zerbi, A., Di Carlo, V., Bassi, C., Delle Fave, G. F., Pancreatitis, W. G. of the I. A. for the S. of the P. on A., & others. (2010). Practical guidelines for acute pancreatitis. Pancreatology, 10(5), 523–535. Whitcomb, D. C. (2006). Acute pancreatitis. New England Journal of Medicine, 354(20), 2142–2150.  Read More