Pancreatitis/Assessment and Symptom Management: Maria
Gonzales (G.LO #1-6)
Learning Objectives:
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Student will utilize principles of nursing informatics to document a patient experience.
Student will navigate through a patient’s electronic health record (EHR) to identify risk
factors for pancreatitis.
Student will choose priority nursing interventions for a patient experiencing acute
pancreatitis.
Student will create a care plan for a patient experiencing acute pancreatitis.
Student will document assessment findings that will indicate a patient is ready for
discharge after an admitting diagnosis of acute pancreatitis.
Case Overview:
Ms. Gonzales is a 46-year old patient who is admitted to the progressive care unit for acute
pancreatitis. She is in acute pain and is nauseated and biliary tract disease is suspected.
DocuCare Activity/Assignment Prep:
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Review the Clinical Decision Support Tool (Green Lippincott Advisor links) provided
throughout your patient’s chart:
o Pancreatitis
o Hydromorphone
o Promethazine
o Normal saline
o Green Lippincott Advisor links included with orders and MAR
Hinkle, J. & Cheever, K. Assessment and Management of Patients with Biliary
Disorders. Brunner & suddarth’s textbook of medical-surgical nursing. Philadelphia, Pa.:
Wolters Kluwer Health/Lippincott Williams & Wilkins.
Review Ms. Gonzales’s chart including Patient Information, Notes, Diagnostics, Vital
Signs, and Current Orders
Activities/Assignments:
Part One: EST TIME: 15 MIN
Maria Jones, RN has to leave early and you are taking over the care of Ms. Gonzales. You are
given report and start reviewing Ms. Gonzales’s history.
Assignment 1.1: (20 points)
Document the risk factors you identify in Ms. Gonzales’s chart for pancreatitis. Document in the
Notes section>Nursing Note-Progress Note.
Part Two: Clinical Judgment Activity: EST TIME: 60 MIN
While reviewing Ms. Gonzales’s notes, recent assessment findings, vital signs, and diagnostics,
you start to ask yourself the following questions.
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Assignment 2.1: (10 points each- 40 points)
Document the answer to the following questions in the Notes section>Nursing Note-Progress
Note.
 What data in Ms. Gonzales’s chart stands out to you? (Recognizing Cues/Assessing)
 What does this information make you think? (Analyzing Cues/Diagnosing)
 What is the priority in this patient situation? (Prioritize Hypotheses/Diagnosing &
Planning)
 What nursing interventions are indicated at this time? (Generate Solutions/Planning)
Assignment 2.2: (20 points)
Review Ms. Gonzales’s orders. Document two priority nursing interventions you would perform
while caring for this patient. (Take Action/Implementing)
Part Three: Clinical Judgment: EST TIME: 30 MIN
Two days later you are the nurse caring for Ms. Gonzales. While receiving report from the
offgoing nurse, you are told Ms. Gonzales will most likely be discharged.
Assignment 3.1: (20 points)
Document the assessment findings, vital signs and diagnostic results the nurse would expect to
observe in Ms. Gonzales if she was improving and ready for discharge. (Evaluate
Outcomes/Evaluating) Document the answer to the following questions in the Assessment, Vital
Signs and Diagnostic tabs.
Debriefing Questions (Do not need to turn in…things to think about)
1. Discuss the rationale for keeping a patient NPO with pancreatitis?
2. What potential complications should the nurse monitor when caring for Ms. Gonzales?
3. If you were providing teaching to Ms. Gonzales during this admission, what do you feel
would have been the priority information Ms. Gonzales needed during this visit?
© 2020 Wolters Kluwer Health. All Rights Reserved.