The Homeless Patient Evaluation & Management Plan

Yisell Garcia Calcines

ST Thomas University

The Homeless Patient Evaluation & Management Plan

Considering the patient’s homelessness and lack of insurance, what action should the practitioner take?

In approaching the case, the nurse practitioner (NP) should focus on the patient’s present health care needs but also consider his financial capabilities. Essentially, the presented symptoms are severe and call for immediate medical attention, especially for elevations of blood pressure, severe abdominal pain, and symptoms that are indicative of a systemic infection. The NP should detail the seriousness of his situation, and convey the pertinent information of need for hospital assessment and care (Koh, 2020). Moreover, the NP can as well help in search for some resources or social services that can help with admission of that patient to the hospital since the patient does not have an insurance cover. This might involve getting in touch with county health departments, non-profit organizations, or hospital social workers who work with uninsured people. Explaining to the patient that failure to seek further treatment may be fatal should also be paramount.

When the patient asks why his condition cannot be managed outside of the hospital, how should the practitioner respond?

There is a need for the NP to inform the patient that his symptoms are possibly indicative of a serious and complicated disease, which may be acute pancreatitis or another severe pathology of the abdominal organ. These conditions often call for exhaustive procedures of diagnosis, ongoing tests and even rigorous treatments that can only be administered in a hospital. The NP should explain to the patient that his high blood pressure, elevated temperature, tachycardia, and tachypnea are indicative of systemic involvement with a possible infection, which requires administering intravenous medications and fluids but may require emergency surgery (Steo et al., 2021). The practitioner should also have to avoid disagreement with the patient on the fact that hospitals have proper steps about the patients who do not have insurance and the first concern is the patient’s health and wellbeing.

When the patient arrives at the hospital for further diagnostic work-up, what tests will likely be performed to evaluate the patient’s condition?

Once the patient arrives at the hospital, blood tests will be conducted in order to understand the cause of the symptoms and also define the degree of the illness. The examinations which will probably be done include the complete blood count (CBC) to detect any signs of infection, inflammation, the liver function tests (LFTs), and pancreatic enzymes (amylase and lipase) to confirm pancreatitis. Also, an electrolyte panel, as well as the renal function tests, can be determined from a comprehensive metabolic panel (CMP) (Liu & Hwang, 2021). Definitive abdominal ultrasound or contrast enhanced-abdominal CT scan will be useful in assessing the pancreas and demonstrate any complications like pseudocyst or necrosis. Sepsis is another reason why blood cultures may also be given.

How will the severity of the pancreatitis be assessed when the patient is hospitalized?

The severity of pancreatitis is also determined by clinical scores which include Ranson’s criteria, APACHE II, and BISAP scores. These scoring systems takes into account of age, white blood cell counts, blood glucose levels, serum LDH levels, and liver enzymes. Moreover, other current and past medical conditions that are likely to be associated with severity include: hypotension, renal failure, respiratory failure, and the extent of pancreatic necrosis seen on imaging (Koh, 2020). They assist clinicians in determining how the disease is likely to evolve, what possible complications the patient is likely to be faced with, and the acuity of care required.

How should the patient’s condition be managed when hospitalized?

Several important care steps will therefore be important in the management of the patient’s condition. First of all, patient should undergo immediate ‘volume replacement’ with intravenous fluids to reverse hypoperfusion and maintain adequate renal blood flow. Pain control is very important, and may sometimes call for the use of opioids. If it is suspected or confirmed that an infection has occurred, then broad spectrum antibiotics may be prescribed. The patient will be on no oral intake (NPO) to rest the pancreas, with supplemental enteral nutrition if the patient is to be on prolonged fasting (Szatmary et al., 2022). Hydration status will be restored to allow for optimal electrolyte balance and monitoring of blood glucose levels specially having in mind the patients previous alcoholism in which he may be at risk of developing hypocalcaemia or hypoglycemia. For severe cases, they may be admitted to an intensive care unit where monitoring is required. Necrosis of the breast may require a surgical consult along with abscesses or other complications.

What patient education should be included after the pancreatitis is resolved?

After the resolution of acute pancreatitis, patient counseling plays a significant role in avoiding relapse and managing the care of the patient. The patient should limit or avoid alcohol consumption as much as possible because alcohol is known to be a trigger for acute pancreatitis. Dietary interventions need to be given to the patients emphasizing low fat diet due to high stimulation of the pancreas. Focus should be made on the regular medical checkups to evaluate his general state and the presence of chronic diseases including high blood pressure. Considering his status of homelessness, the NP should refer him to various resources that would enable him to get housing help, other support services for addiction, and primary care services (Szatmary et al., 2022). Patient education on how to identify early signs of pancreatitis’ relapse and to consult a doctor immediately should help in avoiding future aggravations. Also, obesity, smoking cessation, and physical activity should still be addressed and become a future plan for the said patient.

Module 3 Discussion: Homeless Patient

Jisel Llerena

St. Thomas University

NUR509: ADVD FNP Adults

Dr. Janice Batista

May 30, 2024

Considering the patient’s homelessness and lack of insurance, what action should the practitioner take?

The practitioner should take the following steps with the situation of the patient (homelessness and lack of insurance). The nurse practitioner needs to provide for the patient’s urgent needs, encourage a cooperative and nonjudgmental connection, channel decency and civility, and uphold the wishes of the patient. When interacting with the patient, the practitioner should also avoid stereotyping and being very considerate. Lastly, considering that the patient’s life may be in danger, the physician should find an expedient way to get the patient to the closest medical facility. These facilities provide charitable and impoverished care programs for people who are uninsured, destitute, or in need of immediate assistance. Hospital emergency rooms are mandated to serve patients in the US regardless of their insurance status or financial situation (Srakocic, 2022). In addition, a large number of hospitals offer standard treatment to individuals without insurance. Any care you receive will need payment, but there are methods to obtain healthcare for less money (Srakocic, 2022). After that, the practitioner can take responsibility in following up to make sure he has insurance coverage under certain programs that helps the homeless community. 

When the patient asks why his condition cannot be managed outside of the hospital, how should the practitioner respond?

           When a patient inquires as to why his illness cannot be treated outside of the clinic, they should be made aware that they require immediate medical attention as well as resources for more testing. The patient must also be aware that some needs cannot be met in the health clinic located within the homeless shelter; for this reason, they must be seen at the hospital in order to receive an examination, a diagnosis, and safe, high-quality care. This may be by specific lab tests and radiographic photos. Lastly, the patient should know that the indigent healthcare system will provide him with care even if he does not have insurance, Medicaid, or even financial resources because it receives a large portion of its funding from public or charitable sources.

When the patient arrives at the hospital for further diagnostic work-up, what tests will likely be performed to evaluate the patient’s condition?

           The tests that are likely to be performed to assess the patient’s condition upon arrival to an emergency institution should be determined by the results of the assessment and the patient’s medical history. Complete blood counts (CBCs) and blood tests should be included of the examinations. One common blood test that is frequently included in every visit is a complete blood count. A number of conditions, such as infections, anemia, immune system problems, and blood malignancies, can be identified with the use of complete blood counts (National Library of Medicine, 2022). The purpose of blood testing for this patient would be to monitor the increase of pancreatic enzymes like lipase and amylase. Based on the patient’s medical history of stomach discomfort, testing for blood pancreatic enzymes can assist determine whether or not the patient has pancreatitis.

How will the severity of the pancreatitis be assessed when the patient is hospitalized?

              For one, the doctors will go over medical history, physical exam, and lab and imaging tests. The patients’ symptoms will also be considered. Lab tests such as amylase and lipase, blood sugar, lipids, and white blood cell count will all be done. Ultrasounds, computed tomography scan (CT), or magnetic resonance cholangiopancreatography (MRCP, can all be done to further examine the pancreas (National Institute of Diabetes and Digestive and Kidney Diseases, 2019). A pancreatic function test can also be done to see how the pancreas responds to secretin, a hormone. Treatment options for either acute or chronic pancreatitis may include an IV drip to replenish lost fluids, oral fluids if able to swallow, pain medication, and oral or intravenous (IV) antibiotics if your pancreas is infected pancreas (National Institute of Diabetes and Digestive and Kidney Diseases, 2019). A low-fat diet, or intravenous (IV) nutrition if patient is unable to eat is also part of the treatment pancreas (National Institute of Diabetes and Digestive and Kidney Diseases, 2019).  Depending on the type of pancreatitis it is, the doctor may refer to a surgeon or gastroenterologist.

What patient education should be included after the pancreatitis is resolved?

               The patient is recommended to start consuming clear liquids such as soup broth and gelatin once the pancreatitis has subsided. The diet must be followed by the patient until all symptoms subside. When the situation improves, they can gradually resume eating other meals. They should give up drinking, give up smoking, increase their hydration intake, and adopt a low-fat diet.

Weekly Clinical Experience 3

Yisell Garcia Calcines

ST Thomas University

NUR 509 ADVD FNP CLINICAL III

May 29, 2024

Weekly Clinical Experience 3

         The clinical experience for this week turned out to be quite interesting and educative. One of the patients I saw was an older adult female who presented with RUQ pain. This case provided a rich learning experience to examine various differential diagnoses and approaches for treating abdominal and endocrine complaints in elderly patients. Nevertheless, I faced challenges in caring for this patient due to relationship and communication issues with her. According to Reynolds 3rd et al. (2022), communication in older adults can be hindered by sensory loss, slower processing of information, decline in memory, and lessening of influence and power over their lives. My success with the elderly patient was based on being patient, using appropriate speech style, and creative a conducive environment for her.

         Mrs. M. a 74-year-old Caucasian female, come to the clinic with a 3-day history of worsening RUQ pain, which she described as severe, spreading o her right shoulder, and affecting her sleep. She also complained of nausea and vomiting. Her pain started following high-fat meal during a church supper 3 day prior to this visit. Upon further questioning, the patient admitted feeling tenderness over her abdomen when she touched her belly. Her past medical history was significant for hypertension, diagnosed 10 years ago and managed with medications and lifestyle modifications. There were no any other complaints or known allergies reported.

          In the initial evaluation, the focus was based on history-taking and physical examination. The physical assessments revealed the following: vital signs included blood pressure of 130/80 mmHg, pulse rate as 85 beats/minute, respiratory rate of 20 breaths/minute, a temperature of 99. 0°F, BMI of 24.2, and pain of 7/10. Specifically, the abdominal exam confirmed tenderness in the RUQ area and revealed Murphy’s sign, suggesting inflammation in the gallbladder (Altshuler & Case, 2020). As for the differential diagnosis, we had to consider such conditions as acute cholecystitis, biliary colic due to stones in the gallbladder, and acute pancreatitis. Nevertheless, acute cholecystitis was a primary consideration because of the RUQ pain and tenderness, a positive Murphy’s sign, and history of consuming fatty foods that could trigger gallstones, and the presence of nausea and omitting (Giles et al., 2020).

         Since the diagnosis of cholecystitis was suspected, some diagnostic tests were necessary. Biological analysis with simple blood test involving a CBC showed leukocytosis, indicating an inflammatory process. Liver function tests (LFTs) were mildly elevated; which could be attributed to biliary involvement. An abdominal ultrasound was done and this showed the presence of gallstones and features typical of cholecystitis, including gall bladder wall thickening and pericholecystic fluid. In the care plan for Mrs. M, the prioritized goals were centered on treating the acute presentation of cholecystitis. For this purpose, admission was recommended for intravenous fluids, analgesics using NSAIDs, and intravenous antibiotics to target the different bacteria associated with gallbladder inflammation (Giles et al., 2020). There were also the considerations of consulting a surgeon for a possible cholecystectomy.

         In summary, several important learning outcomes can be noted concerning this week’s clinical experience. It emphasized the role of effective communication, detailed history taking, and thorough physical examination in the diagnosis and treatment of gastrointestinal disorders in older adults. The case also brought out the importance of performing the relevant tests to validate clinical suspicions and inform effective management interventions.

Clinical Experience Week 3

Jisel Llerena

St. Thomas University

NUR509CL: ADVD FNP Clinical III

Dr. Erica Ochoa

May 30th, 2024

Did you face any challenges, any success? If so, what were they?

         My goal during clinicals is to acquire the knowledge and abilities necessary to evaluate and treat patients that come in with a variety of needs and issues. The clinical experience I had this week was challenging, educative, and instructive. One challenge I faced this week was dealing with a patient who had a congenital disorder that I had not ever learned about. The disorder is called arthrogryposis multiplex congenita (AMC). This is a disorder that causes developments of multiple joint contractures affecting two or more areas of the body prior to birth (John Hopkins, 2022). There is no cure for this disease, but it can be managed. Operable and non-operable methods can be done to improve range of motion (John Hopkins, 2022). This patient had had prior surgery to his legs and is able to ambulate and get around independently. To me, it was a challenge to deal with a patient who had something uncommon, but at the same thing a success to be able to learn something new.

Describe the assessment of a patient, detailing the signs and symptoms (S&S), assessment, plan of care, and at least 3 possible differential diagnosis with rationales.

            The same patient with the congenital disorder mentioned above, had many other things going on as well. The primary concern for this patient was hypertension, which is new. The patient is 44 years old and has not had any history of high blood pressure. The patient describes having frequent headaches along with the high blood pressure. During the assessment of the patient, his body mass index (BMI) was elevated as well as his blood pressure. The patient also mentioned urinating frequently as well as drinking a lot of water. The plan of care included lab work that was ordered, including a Hemoglobin A1C. This will confirm any underlying conditions and possible diabetes for the patient. The patient was also prescribed losartan to manage blood pressure, two times a day. A follow up appointment was scheduled for one week to review test results and see how the patient is doing with their blood pressure. Some differential diagnoses include essential hypertension, possible type two diabetes, as well as being overweight. These are related to the headaches and elevated blood pressure, the frequent urination and increased thirst, and the high BMI.

Mention the health promotion intervention for this patient.

            To be healthy and improve this patients’ blood pressure and possible diabetes, many things can be recommended. For one, being physical for at least 30 minutes for 5 days a week is important (National Institute on Aging, 2023). Including many fruits, vegetables, and limiting carbohydrates should be part of the patient’s diet (National Institute on Aging, 2023). As well as foods low in added sugars, fats, and sodium (National Institute on Aging, 2023). Aside from this, whole grains and lean protein can help as well. Overall, losing weight would be beneficial for this patient.

What did you learn from this week’s clinical experience that can be beneficial for you as an advanced practice nurse?

              As mentioned above, I learned about a new condition that could be beneficial in the future. The disorder is called arthrogryposis multiplex congenita (AMC). This is a disorder that causes developments of multiple joint contractures affecting two or more areas of the body prior to birth. In the future, if I ever have another patient with this disorder, I will have the background knowledge. Also, I learned that one as a professional, will still not always know EVERYTHING. As times go by, we will all still learn new things which will improve our practice in the future.