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NUR 200 Week 8 Practice Case Study

C.N., a 56-year-old alcoholic businessman, was brought to the emergency department by a friend experiencing severe abdominal pain and vomiting. He has a history of chronic pancreatitis and this is his fourth admission for an acute exacerbation. Upon assessment, he has a fever, rapid heart rate, guarding and severe pain on palpation of his distended abdomen. He is oriented but restless with hand tremors. The HCP orders his admission, NG tube, IV fluids, pain medications and monitoring.

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123 views2 pages

NUR 200 Week 8 Practice Case Study

C.N., a 56-year-old alcoholic businessman, was brought to the emergency department by a friend experiencing severe abdominal pain and vomiting. He has a history of chronic pancreatitis and this is his fourth admission for an acute exacerbation. Upon assessment, he has a fever, rapid heart rate, guarding and severe pain on palpation of his distended abdomen. He is oriented but restless with hand tremors. The HCP orders his admission, NG tube, IV fluids, pain medications and monitoring.

Uploaded by

Hannah Marie
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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NUR 200 Week 8 Practice Case Study

C.N. is a 56-year-old businessman who is brought to the emergency department by a friend whom he
met at Alcoholics Anonymous (AA). C.N. had called his friend because he was in such pain that he could
not drive himself. He has been drinking heavily during the past 3 days and started vomiting yesterday. In
addition to the continued vomiting, this morning he developed severe mid-epigastric pain radiating to
his back that motivated him to call his friend. C.N. has a long history of alcoholism with many periods of
abstinence and relapse. C.N. is divorced, lives alone, and rarely sees his two children, who are in college
in another state. He was diagnosed with chronic pancreatitis two years ago and this is his forth
admission for acute exacerbation of pancreatitis.

Assessment:
• Vital Signs: 100.2° F (37.9° C), 116, 32, 106/70
He has a distended abdomen with guarding, severe pain on gentle palpation, and hypoactive bowel
sounds. He is awake, alert, and oriented ×3, restless, and has a fine tremor of his hands. He grades his
pain as “9” on a scale of 0 to 10, says that he cannot lie flat, and assumes a sitting position with his back
and hips flexed. He vomits a small amount during the physical assessment, and the hemoccult testing
of the vomitus is negative.

HCP Orders:
 Admit to medical-surgical unit
 Insert NG tube and place to LIWS
 Strict NPO
 Blood glucose daily x 3
 Hydromorphone (Dilaudid) 1-2 mg Q2H IVP
 Pantoprazole (Protonix) 40mg IV daily
 Ondansetron (Zofran) 4 mg Q4H PRN nausea vomiting
 IVF to run at 150 mL/hr

Tanner’s Clinical Judgment Step Definition of thinking Skill Application of thinking Skill to
Case Study
Identifying Signs and Symptoms

Gathering Complete and Accurate


Data

Assessing Systematically and


Comprehensively

Predicting (and Managing)


Potential Complications
NUR 200 Week 8 Practice Case Study
Identifying Assumptions

Clustering Related Information

Recognizing Inconsistencies

Checking Accuracy and Reliability

Distinguishing Relevant from


Irrelevant

Determining the Importance of


Information

Comparing and Contrasting Data

(Predicting and) Managing


Potential Complications

Judging How Much Ambiguity is


Acceptable

Using Legal, Ethical, Professional


Guidelines

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