Clinical Abstract

Submitted by: Michael Gino S. Sarenas

BSN IV-E, Group 4

I. Presentation of the Client

This the case of L.G.C., 73 year old male diagnosed with acute pancreatitis, diabetes
mellitus type 2, acute kidney injury on top of chronic kidney disease, and hypertension. Client
was born on February 17, 1937 and currently resides in Paranaque City.
History of present illness started eight hours prior to admission. Client had just eaten
breakfast when he suddenly experienced vague, severe epigastric pain, associated with four
episodes of vomiting with acidic tasted, non-bloody, non-bilious vomitus. He took domperidone
which offered no relief. Abdominal pain increased in severity to 10/10, radiating to the back,
which prompted consult and subsequent admission.
Past medical history reveals that client was diagnosed with Diabetes Mellitus type 2 and
was on maintenance medications: Metformin (500mg) and Glimepiride (2mg). Client also has
hypertension and takes Ramipril (10mg). Client also had a spinal surgery in 2006.
Family history reveals that both mother and father’s side has history of hypertension and
diabetes mellitus type 2. Personal history reveals that client is fond of eating fatty and oily foods,
a previous alcoholic beverage drinker and a non-smoker.
On the day of admission last November 8, 2010, client had a chief complaint of
abdominal pain and chills. Client was conscious and coherent, not in distress, and comfortable.
Vital signs reveal temperature of 36.5 °C, HR: 108, RR: 26, BP: 150/80, PS: 10/10. Client has
anicteric sclera, pink conjunctivae, no lymphadenopathies, no neck vein distention, equalchest
expansion, clear breath sounds, globular abdomen, normoactive bowel sounds, and soft. Severe
epigastric pain tenderness, liver not enlarged. Client is not cyanotic, not edematous, and has full
pulses.
Ultrasound of whole abdomen shows that pancreas appears thickened although no focal
lesions were seen. The spleen is normal in size and homogenous in echopattern.
1740H: client was admitted under the service of Dr. J.D.F. Vital signs are to be
monitored every 4 hours.
2115H: client was in orthopaedic device on cervical area, less abdominal pain with grade
of 4/10, nonradiating. BP: 140/80, 80 bpm, afebrile, clear breath sounds, abdomen is flabby,
normoactive bowel sounds, soft, nontender.
2130H: client was ordered for esophagogastroduodenoscopy at 0845 the following day,
nothing per orem was also ordered.
2230H: capillary blood glucose monitoring was ordered to be monitored every 4 hours,
results to be relayed. Insulin novorapid 5 units subcutaneously for CBG of more than 200 mg/dL
was also ordered.
November 9 at 1019H-1023H: esophagogastroduodenoscopy was performed by Dr. E.F.
November 10: arterial blood gas results reveal PO2- 67.8; pH- 7.43; PCO2- 30.2; HCO3-
19.9; O2 sat.- 94.4% with an interpretation of compensated respiratory alkalosis.
 2-D echocardiogram shows aortic wall calcification, aortic and mitral annuli calcification.
Calcified margins of right and non-coronary cusps of the valve leaflet with normal leaflet
nobility. Color flow and Doppler study: mitral regurgitation, trace. Reversed mitral E/A ratio
indicative of decreased left ventricular relaxation.
November 12: chest x-ray shows that follow-up study after one day shows hilar or
parahilar haziness which couls be due to pulmonary congestion. The heart is not enlarged. The
rest of the chest structures are the same.
November 15 at 0749H: haemoglobin- 11.80 g/dL (n.v.- 14.-17.5), hematocrit- 34.3%
(n.v.- 41.5-50.4), RBC- 3.74 x106/uL (n.v.- 4.5-5.9), WBC- 13.04 x 103 u/L (n.v.- 4.4-11.0),
basophils- 2% (n.v.- 0-1), segmenters- 80% (n.v.- 40-70), lymphocytes- 3% (n.v.- 22-43),
monocytes- 11% (0-7).
0750H: nephrology noted that client can tolerate feeding, no abdominal pain, or
tenderness. BP: 130/70, HR: 80bpm, with crackles on right base of lung.
0920H: CBG: 125-162 mg/dL (stable)
1034H: clinical chemistry of blood shows liver function test- ALT (SGPT)- 52 u/L (n.v.-
10-50), alkaline Phosphatase- 254 u/L (n.v.- 110-130), and albumin- 30 g/L (n.v.- 35-52)
1045H: Dr. E.F. noted that client has not enough calories in the diet. Client was ordered
to have full liquid diet, strictly low fat, Vamin glucose was recommended to be retained until
there are enough oral or enteral calories. Oral feeding was ordered to be held if client develops
abdominal pain. Client may also have decaffeinated coffee, no regular coffee or dairy products.
1340H: endocrinology had no objection for client to be transferred to regular room, as
well as cardiology.
1400H: Student nurse was assigned to MICU 7 and received endorsement, reviewed
client’s chart and medications. Student nurse performed initial assessment upon introduction to
client. Received client in moderate back rest with nasogastric tube clamped, O2 cannula at 4 liters
per min, intravenous secalon at right antecubital vein with ongoing intravenous fluids of:
catapres 150mg in D5W 100ml, nicardipine 20 mg drip in NSS 80ml, and PNSS 500x20 ml/hr,
pulse oximeter at right index finger, voiding freely. Client is conscious, coherent, and responsive
to pain stimulation. Pupils equally round, reactive to light accommodation, anicteric sclera, pink
conjunctiva, no palpable lymph nodes, equal chest expansion, crackles on left lower lobe. Bowel
sounds are normoactive, non-distended stomach, tender on left upper quadrant (4/10), non-
radiating, no nodules or palpable masses. Bladder is not distended, with yellow urine. Vital signs
are 36.7 °C; 88 bpm; 25 cpm; 130/90; 4/10. In previous assessment, client noted tenderness on
left upper quadrant of abdomen. Deep breathing exercises were taught. Diversional activities
such as listening to the radio were also encouraged. Client was also encouraged to rest and have
a relaxed mood. Lights were dimmed and performed nursing procedures at ease to prevent
disturbing the client’s rest period.
1500H: diaper was changed and performed back clapping and turned client to side.
Nasogastric tube was drained 15 minutes prior, patency of tube was also checked, and prescribed
osterized feeding was given with a tolerable flow rate. Vital signs were recorded: 36.5 °C; 80
bpm; 22 cpm; 130/80; 3/10.
 1530H: feeding was consumed, assisted bedside nurse in administration of medications,
and nasogastric tubing was clamped.
1600H: student nurse gathered all things of the client for transfer to a regular room. Vital
signs were recorded: 36.6 °C; 82 bpm; 22 cpm; 120/80; 0/10. Client can no longer feel any pain
on left upper quadrant and was in a relaxed mood. Client was turned to side and performed back
clapping and encouraged deep breathing exercises. Client was also taught about ROM exercises
such as stretching of arms and feet, and head rotation. Client performed the exercises with ease.
1645H: pulse oximeter was ordered to be discontinued and as well as cardiac monitor
when transferred to room.
1700H: client was transferred to a regular room, endorsed client to the receiving bedside
nurse, bade goodbye and said ‘thank you’, student nurse-client interaction terminated.

II. Problem list:

1. Impaired gas exchange related to ventilation perfusion imbalance as evidenced by
abnormal ABG results (compensated respiratory alkalosis) and RR= 25 cpm
2. Acute pain related to inflammatory processes as evidenced by piercing-like pain on
left upper quadrant with a scale of 4/10
3. Risk for imbalanced nutrition: less than body requirements related to inability to
ingest food
4. Risk for infection related to necrotic pancreatic tissue
5. Risk for activity intolerance related to prolonged bed rest