Nursing Situation Pancreatitis

Brief Patient History:
Mr. C is a 38-year-old Hispanic male admitted to the intensive care unit from the emergency department (ED) in hypovolemic shock. Mr. C was initially diaphoretic, unresponsive, and pale with a blood pressure of 70 systolic. After fluid resuscitation in the ED, his blood pressure increased to 90 systolic and responsiveness was restored. Mr. C is a migrant worker from Mexico who speaks limited English and is married with four children. All family members live in Mexico, except his uncle. Mr. C’s uncle verbalizes that his nephew has been complaining of severe abdominal pain for the past few days, with frequent episodes of nausea and vomiting.

Clinical Assessment:
Mr. C is in a fetal position, complaining of nausea and intolerable knifelike abdominal pain, radiating to his back. A physical examination reveals that Mr. C is restless, obeys commands, and moves all extremities. Bilateral breath sounds are diminished with bibasilar crackles, S1 S2 without murmur, and capillary refill greater than 3 seconds, and peripheral pulses are 1+. Abdomen is distended and tenderness and guarding, hypoactive bowel sounds, and tympany are noted. Trousseau’s sign (carpopedal spasm with inflation of blood pressure cuff) and Chvostek’s sign (muscle spasm of the face with tap on facial nerve) are present. Skin is cool, pale, and dry. IV fluids are Ringer solution at 200 mL/hr and Foley catheter draining amber urine at 20 mL/hr.

Diagnostic Procedures:
Mr. C’s vital signs include blood pressure of 92/68 mm Hg, pulse of 122 beats/min that is thready and weak, respiratory rate of 26 breaths/min, temperature of 100.8° F, and SpO2 of 92% on O2 at 4 L per nasal cannula. His arterial blood gasses are: pH of 7.48, PaO2 of 80 mm Hg, PaCO2 of 48 mm Hg, HCO3 level of 38 mEq/L. He has an O2 saturation of 95% on an FIO2 of 36%.

Diagnostic values for Mr. C are as follows:
WBC, 19,600 units/L; hematocrit (Hct), 48.3%; hemoglobin (Hgb), 11.6 g/dL;
blood urea nitrogen (BUN), 18 mg/dL; serum creatinine, 1.2 mg/dL; serum glucose, 220 mg/dL; serum amylase, 280 Somogyi units/mL; serum lipase, 13.5 Somogyi units/mL; serum sodium, 140 mEq/L; serum potassium, 2.9 mEq/L; serum calcium, 5.8 mg/dL; serum albumin, 2.8 mg/dL; serum magnesium, 0.9 mg/dL; serum C-reactive protein, 140 mg/dL; and serum lactate, 3 mmol/L.

Medical Diagnosis
Acute Pancreatitis/Ranson criteria of 4

Questions

1. What problems or risks do you identify for this patient? 
2. What major outcomes do you expect to achieve for this patient?
3. What interventions must be initiated to monitor, prevent, manage, or eliminate the problems and risks identified?
4. What possible learning needs would you anticipate for this patient?
5. What cultural and age-related factors may have a bearing on the patients plan of care?