A nurse is caring for a client who has acute pancreatitis.

Exhibits

 

 

 

Vital Signs

Day 2:

Heart rate: 92/min

Respiratory rate: 20/min

BP: 122/58 mm Hg

Oxygen saturation: 96% on room air

Nurses Notes:

Oriented to person, place, and time; reports extreme fatigue.

Client rates pain as 3 on a 0 to 10 pain scale following administration of pain medication 30 min ago.

S1, S2 noted on auscultation. Pulses palpable.

Respirations even, unlabored. Chest clear on auscultation.

Bowel sounds hypoactive in all four quadrants. Client vomiting brown liquid and reports continuing nausea. Reports passing flatus. Urinating without difficulty, urine is clear yellow.

• Heart rate: 92/min: Improved from 109/min on Day 1, showing better autonomic control.
  A heart rate within normal range indicates reduced stress or inflammation. This suggests pain management and fluid status have improved.

• Respiratory rate: 20/min: Improved from 26/min, now within normal limits. This reflects decreased respiratory effort and better oxygenation. The labored breathing on Day 1 has also resolved.

• Oxygen saturation: 96% on room air: Increased from 93% on Day 1, indicating improved gas exchange. No supplemental oxygen was required, suggesting stable pulmonary function.
  This is a positive sign especially given the initial diminished breath sounds.

• Client rates pain as 3/10 after medication: The pain is down from 8/10 on Day 1, showing effective analgesia. Pain control improves patient comfort and respiratory status. The pain was likely contributing to tachypnea and lethargy on Day 1.

• Respirations even and unlabored; chest clear on auscultation: Improved from "rapid, labored" with "diminished" breath sounds on day 1 which suggests resolution of respiratory compromise and pain-related restriction. Likely associated with improved oxygen saturation and decreased fatigue..

• Passing flatus: This indicates return of peristalsis and some bowel activity. These findings were not present on Day 1, showing progress. Flatus passage often precedes return to full bowel function.

• Urinating without difficulty; urine clear yellow: These findings indicate stable renal function, no hematuria or concentration issues. The findings were maintained across both days, with no signs of obstruction or dehydration which uggests effective fluid balance and kidney perfusion.

Rationale for Incorrect Findings:

• Bowel sounds hypoactive in all quadrants: No change from Day 1, suggests slow GI recovery. Hypoactivity may reflect paralytic ileus or continued inflammation.
  Despite passage of flatus, bowel function remains impaired.

• Client vomiting brown liquid and reports continuing nausea: This is a new symptom on Day 2, worsening GI symptoms despite earlier improvement. Brown emesis may suggest delayed gastric emptying or possible GI bleeding.

• Reports extreme fatigue: Fatigue is more severe than Day 1's lethargy and may reflect nutritional deficits, systemic inflammation, or sleep disruption. Despite improved pain and respiratory status, overall energy is low.

A. The patient requires painful stimuli to elicit a response and has no purposeful movement: This indicates a severe decrease in consciousness where the patient is minimally responsive, unable to respond to verbal stimuli, and shows no purposeful movement. It reflects significant brain dysfunction and is often seen in severe brain injury or coma.

B. The patient is drowsy but responds to verbal stimuli appropriately: This describes mild to moderate impairment of consciousness, where the patient is lethargic but still able to respond meaningfully to verbal commands, indicating a less severe condition.

C. The patient responds to commands but is slow to do so: A slowed response suggests some cognitive or neurological impairment but not a severe decrease in consciousness. The patient remains alert enough to follow instructions, albeit slowly.

D. The patient can follow simple commands like "open your eyes": This shows the patient is conscious and able to interact, reflecting a mild or normal level of consciousness rather than severe impairment.