JMJ Marist Brothers

Notre Dame of Marbel University

College of Arts and Sciences – Nursing Department
Koronadal City, South Cotabato

CASE-BASED SCENARIO 5: ACUTE PANCREATITIS

February 26, 2021 9:00 AM. Mr. Chrisean Andre P. Conderno, is a 55-year-old male
was admitted because of knifelike pain on the abdominal area. Upon assessment, Mr.
Conderno had a history of chronic alcoholism, as per his wife. Hence, an admitting
diagnosis of T/C acute pancreatitis and was referred to an internist for management.

DOCTOR’S ORDER
Date Time Progress Notes Order C A R E D
02/26/21 09:00AM (+) abdominal pain x 3 Please admit under the service of Dr. Yee /
days; knifelike
(+) restless Secure consent to care. /
(+) Bluish discoloration NPO / /
in flank area
Hx of alcohol intake Labs: CBC PC, UA, CXR-PA / /
24h ago
S. amylase, lipase, Ca+, RBS / / /
A: t/c Acute IVF: PNSS IL x 12o / / / /
pancreatitis
V/S q4o and record / /
I & O q shift and record / /
Meds:

Ceftriaxone 1g q12 o ANST ( - ) / /

Omeprazole 40 mg IV now then OD / / /
Tramadol 100mg SIVP Q8h for moderate pain / / /
Inform AP. /
Refer accordingly. /

Dr. Pama
Jamaica Jea D. Acha,SN/ Michell Jane B. Cagurol,
RN
03/05/21 9:30AM
Legend: C – Carried Out A – Administered R – Requested E – Endorsed D - Discontinued

Patient’s Name: _Chrisean Andre P. Conderno __ Age/Sex: _55/M__ Hospital No.:_000003_______

Attending Physician: _Dr. Yee________________________ Room No.: _105-E___

Date Time Progress Notes Order C A R E D

02/26/21 10:00AM (+) abdominal pain x 3 Thank you for this referral.
days; knifelike 8/10
Chronic alcoholism Patient seen and examined.
S. Ca+ 5.0 mg/dl Carry out lab and meds order of Dr. Pama. /
A: t/c Acute Meperidine (Demerol) 50mg IVTT now and Q12h / / /
pancreatitis PRN for severe pain
For abdominal utz once stable. / / /
Change IVF to: D5LR IL x 12o / / /
 JMJ Marist Brothers
Notre Dame of Marbel University
College of Arts and Sciences – Nursing Department
Koronadal City, South Cotabato

Increase VS monitoring to q2 o / /
Refer accordingly. /

Dr. Yee
Jamaica Jea D. Acha,SN/ Michell Jane B. Cagurol,
RN
03/05/21 10:30AM

Legend: C – Carried Out A – Administered R – Requested E – Endorsed D - Discontinued

MEDICATION SHEET
Date MEDICINES Date 03/05/21 Date
Ordered Discontinued
Shift Time Initial Time Initial Time Initial Time Initial
o
03/05/21 Ceftriaxone 1g q12 6A-2P 9:08A JJA
ANST ( - ) M
2P-10P
10P-6A
03/05/21 Omeprazole 40 mg IV 6A-2P
OD 2P-10P
10P-6A
6A-2P
2P-10P
10P-6A
6A-2P
2P-10P
10P-6A
6A-2P
2P-10P
10P-6A
 JMJ Marist Brothers
Notre Dame of Marbel University
College of Arts and Sciences – Nursing Department
Koronadal City, South Cotabato

PRN
Date MEDICINES Date Date
Ordered Discontinued
Shift Time Initial Time Initial Time Initial Time Initial
03/05/21 Meperidine (Demerol) 6A-2P
50mg IVTT Q12 PRN 2P-10P
for severe pain 10P-6A
03/05/21 Tramadol 100mg SIVP 6A-2P
Q8h for moderate pain 2P-10P
10P-6A

STAT ORDERS
Date MEDICINES Date 03/05/21 Date
Ordered Discontinued
Shift Time Initial Time Initial Time Initial Time Initial
03/05/21 Omeprazole 40 mg IV 6A-2P 9:15AM JJA
now 2P-10P
10P-6A
03/05/21 Meperidine (Demerol) 6A-2P 10:20A JJA
50mg IVTT now M
2P-10P
10P-6A

MEDICATION NURSE
Shift Full Name & Initial Full Name & Initial Full Name & Initial Full Name &
Initial
6A-2PM Jamaica Jea D.
Acha,SN/ JJA
2P-10P
10P-6A

Patient’s Name: _Chrisean Andre P. Conderno __ Age/Sex: _55/M__ Hospital No.:_000003_______

Attending Physician: _Dr. Yee________________________ Room No.: _105-E___

FLUID INTAKE AND OUTPUT

Date Shift Venoclysis Hypodermocl Oral TOTAL Urine Secretions Vomitu TOTAL Initial
ysis s
03/05/21 6A-2P PNSS 90 mL NPO 453 mL 150 mL Not None 150 mL JJA
D5LR 350 mL measured
Omeprazole 10ml
Meperidine 1 mL
Tramadol 2ml

2P-10P

10P-6P

TOTAL

6A-2P

2P-10P

10P-6P
 JMJ Marist Brothers
Notre Dame of Marbel University
College of Arts and Sciences – Nursing Department
Koronadal City, South Cotabato

TOTAL

6A-2P

2P-10P

10P-6P

TOTAL

6A-2P

2P-10P

10P-6P

TOTAL

6A-2P

2P-10P

10P-6P

TOTAL

6A-2P

2P-10P

10P-6P

TOTAL

MONITORING STAFF

Full Name & Initial Full Name & Initial Full Name & Initial
Jamaica Jea D. Acha,SN/ JJA

Chrisean Andre P. Conderno 55/M 105-E Dr. Yee 000003

Patient’s Name Age/Sex Room No. Attending Physician Patient No.

 JMJ Marist Brothers
Notre Dame of Marbel University
College of Arts and Sciences – Nursing Department
Koronadal City, South Cotabato

NURSES NOTES AND TREATMENT RECORD

DATE SHIFT
TIME
FOCUS DOCUMENTATION SIGNATURE
6A-2P Received pt. awake, sitting on bed c #1 PNSS 1L @ 28 gtts/min infusing well @ L
metacarpal vein, patent, intact and infusing well
9:10 AM F: Acute pain r/t chemical contamination of the peritoneal surface by pancreatic
excaudate as evidence by reports of pain. ----------------------------------------------
D: -“Sakit sakit gid as in”, as verbalized. -------------------------------------------------------
-(+) knife-like abdominal pain for 3 days. --------------------------------------------
- Bluish discoloration in the flank
area-------------------------------------------------
-Pain scale: 8/10 ---------------------------------------------------------------------------
-(+) abdominal guarding. -----------------------------------------------------------------
-(+) facial grimace. -------------------------------------------------------------------------
-(+) restlessness. --------------------------------------------------------------------------
-(+) cold, clammy hands.-----------------------------------------------------------------
- Diaphoresis noted. -----------------------------------------------------------------------
- T: 36.7 oC.
----------------------------------------------------------------------------------
- BP: 100/70 mmHg. ----------------------------------------------------------------------
10 AM
-CR: 102 bpm. ------------------------------------------------------------------------------
A - Vital signs taken and recorded. ----------------------------------------------------
- Assessed characteristics of pain, duration, location and intensity. ---------
12 PM -Assisted to a one side with knees flexed, semi-fowler and leaning forward
to promote comfort ------------------------------------------------------------------------
- Put the pt. on NPO, as ordered. ------------------------------------------------------
1 PM - Provided quiet and calm environment. ---------------------------------------------
- Maintain bedrest during acute attack. ----------------------------------------------
- Provided alternative comfort measures
- Encouraged relaxation techniques such as guided imagery/ visualization
- Administered Omeprazole 40 mg IV, as ordered. -------------------------------
- Administered Meperidine (Demerol) 50mg IVTT, as prescribed. ------------
- Replaced IVF solution to D5LR to run for 12O, as ordered. -------------------
-Administered Tramadol 100mg SIVP, as ordered. -------------------------------
-Provided frequent simple explanations about the treatment. ------------------
R: - “Medyo nag-arang arang pero ara gihapon ang sakit”, as verbalized. -----------
- (+) Abdominal pain ----------------------------------------------------------------------
- Pain scale: 5/10 --------------------------------------------------------------------------
- (-) abdominal guarding. -----------------------------------------------------------------
- Occasional facial grimace. -------------------------------------------------------------
- (-) restlessness. --------------------------------------------------------------------------
-(-) cold, clammy hands. -----------------------------------------------------------------
VS taken as follows: ----------------------------------------------------------------------
- T: 36.9 oC -------------------------------------------------------------------------------------------
S
- BP: 100/80 mmHg --------------------------------------------------------------------------------
- CR: 96 bpm -----------------------------------------------------------------------------------------
2PM - RR: 20 cpm. ---------------------------------------------------------------------------------------
-Endored pt. to NOD awake, alert, on semi-Fowler’s position c #2 D5LR 670mL @ 30
gtts/min infusing well @ L metacarpal vein intact and infusing well --------------------------

--------------------------------------------------------------------------- JAMAICA JEA ACHA, SN-------

Patient’s Name: _Chrisean Andre P. Conderno __ Age/Sex: _55/M__ Hospital No.:_000003_______

Attending Physician: _Dr. Yee________________________ Room No.: _105-E___

 JMJ Marist Brothers
Notre Dame of Marbel University
College of Arts and Sciences – Nursing Department
Koronadal City, South Cotabato

VITAL SIGNS MONITORING SHEET

Date/Shift/Time T PR RR BP Date/Shift/Time T PR RR BP T
03/05/21; 6-2 36.7 C 102 23 120/70
9AM BPM CPM mmhg
03/05/21; 6-2 37.3 C 105 26 110/70
11AM BPM CPM mmhg
03/05/21; 6-2 37.1 C 96 22 110/80
1PM BPM CPM mmhg

MONITORING STAFF

Full Name & Initial Full Name & Initial Full Name & Initial
Jamaica Jea D. Acha,SN/ JJA

Chrisean Andre P. Conderno 55/M 105-E Dr. Yee 000003

Patient’s Name Age/Sex Room No. Attending Physician Patient No.

 JMJ Marist Brothers
Notre Dame of Marbel University
College of Arts and Sciences – Nursing Department
Koronadal City, South Cotabato

PARENTERAL FLUID SHEET

I. INTRAVENOUS FLUIDS
Date Bottle Solution Incorporation Rate Time Signature Date/Time Signature Remarks
No. Started Discontinued
03/05/21 1 PNSS 28gtts/min 9AM 03/05/21
1L 10:00AM
x 12 o
03/05/21 2 D5LR 28gtts/min 10:05AM
1L
x 12 o

II. SIDE DRIPS

Date Bottl Solution Incorporation Rat Time Signature Date/Time Signature Remarks
e No. e Started Discontinued

III. BLOOD TRANSFUSIONS

Date Bag Blood Serial Rate Time Signature Date/Time Signature Remarks
No. Type No. Started Discontinued

Chrisean Andre P. Conderno 55/M 105-E Dr. Yee 000003

Patient’s Name Age/Sex Room No. Attending Physician Patient No.

 JMJ Marist Brothers
Notre Dame of Marbel University
College of Arts and Sciences – Nursing Department
Koronadal City, South Cotabato