Nursing Assessment and Priorities of Care for Pancreatitis Patient

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Introduction
The following essay is based on the case study of Mr. John Hayes, a 75 year old man
who is suffering from pancreatitis. He was admitted to the hospital with severe pain in the
abdomen along with right quadrant. The essay will initiate with the comprehensive nursing
assessment that are required to be undertaken in order to highlight the clinical priority. This
will be followed by the nursing interventions passed of the priorities of care within 1 to 2
hours post hospitalization. At the end, the essay will illustrate a discharge planning based on
the social justice framework for health.
Systematic Assessment
CNS Assessment
According to the case study the Glasgow coma scale score of Mr. John Hayes is 15.
This is the maximum score in the Glasgow parameter. His scores helps in understanding that
the all the vital sensory organs (eyes, verbal and motors) are working under full
synchronization and further indicating limited chances of brain injury. 15 scores signifies
normal opening of eyes with proper baseline blinking (score: 4), proper movements of the
limbs in response to commands (score: 6). Body temperature of Mr. John Hayes is 36.5T and
it is the normal body temperature (DiCenso, Guyatt & Ciliska 2014).
CVS Assessment
Pulse rate is 102 (normal range: 70 to 100 beats per minute) and is beating at regular
interval. The respiratory rate (RR) is 28 beats per minute (normal range: 12 to 20 beats per
minute) and the blood pressure level is 100/60 (normal range: 120/80 mm Hg) (Lewis et al.
2016). Though the patient reported no signs of sweating however, decrease in blood pressure
significantly below the normal range results in generation of shock that causes rapid
breathing, high pulse rate and excessive sweat. In extreme cases there occurs blue coloration
of the oxygen when the oxygen value falls below the normal range and the condition is
known as cyanosis. John’s conditions indicate that his RR is high along with low blood
pressure; the pulse rate is slightly elevated that that is not alarming. There was no change in
skin colour and oxygen saturation within the body is not significantly low (SpO2: 94%)
(Lewis et al. 2016).

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RESP Assessment
Inspection: High respiratory rate and this is indicated with laboured breathing. SpO2
is 94% indicating normal oxygen saturation. John has past illness of pulmonary embolus (20
years ago at the age of 55).
Palpation: The measurement of pain in done with the help of the PQRST framework
Provocation (P): indicates that the pain is in the abdominal area. There is no reported cases of
rib fracture at the time of admission
Quality (Q): The pain is distressing in nature as indicated by the facial expression
Region (R): Upper right quadrant of the abdomen that is radiating to the back
Severity (S): The pain severity is 9 out of 10 thus indicating severe pain with
not signs of slowing down
Time (T): The sensation of pain stated after the dinner (1800 hours) and after 2
hours (2000 hours) he was admitted to the emergency department of the
hospital. He has chops and vegetables in the dinner.
Percussion: No wheezing sound while breathing
Ausculation: No difference in the breathing sound, He is not suffering from
severe dyspnoea (Lewis et al. 2016)
ABDO Assessment
a. Inspection: No scare is the abdomen. Abdomen is distended and patient showed
signs of nausea along with vomiting tendencies
b. Ausculation: Pain is in the upper right quadrant of the abdomen and thus might be a
sign of gall stones. However, this does not rule out the chances of pancreatitis. There
was no hyper or hypo bowel sounds
c. Percussion: Gas sounds is present (tympanic sound) along with abdominal
distension
d. Palpation: Pain score is 9 out of 10

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Renal Assessment
No significant anomaly in the renal assessment
Others
Additional haematological assessments that must be undertaken include: complete
blood count test. The possible signs of gastro-intestinal infection will be indicated through
high level of neutrophills and macrophages. The signs of haemorrhage in the gastro-intestinal
tract will be indicated by high erythrocyte sedimentation rate (Van Leeuwen & Bladh 2017).
Additional blood test will include amylase and lipase test. Amylase and lipase are two
important digestive enzymes secreted by the pancreas. Amylase helps in breaking down
starch and lipase helps in digestion of fat. Malfunction of pancreas as in pancreatitis hamper
the secretion of these two enzymes and leading to in-digestion. Vegetables contain high level
of starch and thus pancreatitis might be a reason behind why John was experiencing severe
pain just after having the dinner (Van Leeuwen & Bladh 2017).
Additional pathological test include
Stool test: It will help to detect the presence of micro-organisms in stool or presence
of occult blood. John has no trave history thus presence of giardia infection is low (Van
Leeuwen & Bladh 2017)
Upper Abdominal USG: It will help to get a detailed picture of the abdomen and thus
helping to indicate any possible signs of inflammation or tumour formation (Van Leeuwen &
Bladh 2017)
BGL: Blood glucose level will help to understand the signs of diabetes (Van Leeuwen
& Bladh 2017)
ERCP test (Endoscopic Retrograde Cholangio-Pancreatography): Will help in
accessing the concentration of the pancreatic enzymes and the bile secreted from the gall
bladder. However, (Van Leeuwen & Bladh 2017) states that ERCP test is might increase the
chances of pancreatitis further (5 to 10%)