NUR 302 Module 7 Project Two Plan of Care Example

Discharged to Where? A Holistic Plan of Care for Alcohol-Related Acute Pancreatitis in a Man Without Stable Housing

[Student Name]

Southern New Hampshire University

NUR 302: Clinical Judgment and Holistic Assessment in Nursing

Project Two

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Discharged to Where? A Holistic Plan of Care for Alcohol-Related Acute Pancreatitis in a Man Without Stable Housing

A plan of care for acute pancreatitis can be written almost entirely from a guideline: fluids, pain control, early feeding and monitoring for complications. That plan would be correct and would still fail Mr. T., because the conditions that brought him to the hospital are waiting for him in the parking lot. This paper presents a holistic plan of care for a composite patient, Mr. T., built from a full assessment of his physical, psychological and social situation. The plan argues that his second admission will not be his last unless the care team treats his drinking and his lack of housing as clinical problems with the same structure of goals, interventions and evaluation as his pancreas.

Assessment Summary

Mr. T. is a 46-year-old man admitted through the emergency department with severe epigastric pain radiating to his back, nausea and vomiting. His lipase was more than five times the upper limit of normal, and imaging confirmed acute pancreatitis without necrosis. This is his second episode in 14 months. He reports drinking eight to ten beers a day for several years, with his last drink the evening before admission. His AUDIT-C score was 11 of 12, well above the threshold that suggests hazardous drinking (Bush et al., 1998). On admission his heart rate was 112, blood pressure 104/68 and pain 8 of 10.

His social assessment explains the timing of both admissions. He works day labor on construction crews when work is available. He was evicted two months ago after falling behind on rent and has slept in his car since. He has no primary care provider, no health insurance and a sister in the same city with whom he has a strained relationship. He said he drinks to sleep in the car and to manage pain in his back from work. He wants to keep working and is worried about losing his place in the hiring line if he stays in the hospital long. Strengths include his work history, his clear wish to avoid a third admission and his willingness to talk openly about his drinking.

Prioritized Problems and Goals

Four problems were identified and ranked by immediate risk. Table 1 summarizes them with measurable goals.

Table 1

Prioritized Problems and Goals for Mr. T.

Note. Mr. T. is a composite patient. Goals are written so they can be evaluated by the nurse or the discharge team.

Problem 1: Pain, Fluids and Early Feeding

The American College of Gastroenterology guideline emphasizes early, goal-directed management in acute pancreatitis, including fluid resuscitation that is monitored rather than open-ended and early oral feeding as tolerated instead of prolonged fasting (Tenner et al., 2024). Nursing interventions follow that direction. The nurse assesses pain with a numeric scale every two to four hours and after each dose, gives prescribed analgesics on a schedule during the first day rather than waiting for pain to peak, and records intake, output, heart rate and blood pressure to show whether fluids are restoring volume. The nurse also watches for signs of fluid overload, such as rising respiratory rate or new crackles, because more fluid is not always better. Once nausea settles and pain is improving, the nurse offers a low-fat oral diet and documents tolerance, rather than keeping him on nothing by mouth out of habit.

Problem 2: Withdrawal Risk

With heavy daily drinking and a last drink the evening before admission, Mr. T. is at risk of withdrawal during the first several days. The nurse scores withdrawal with the CIWA-Ar, the revised scale published by Sullivan et al. (1989), whose ten items include tremor, sweating, anxiety, agitation and disturbances of perception, and repeats it as often as the unit protocol requires. Scores guide symptom-triggered treatment ordered by the provider. The nurse also keeps the environment calm and well lit, reorients him if confusion appears, and reports any rise in heart rate or blood pressure that pain alone does not explain. Asking him directly about past withdrawal, including seizures, belongs on the first shift, because a prior history raises the level of vigilance.

Problem 3: Hazardous Alcohol Use

The admission is a moment when Mr. T. is willing to talk about drinking, and the plan uses it. The nurse shares his AUDIT-C result and the link between alcohol and both of his pancreatitis episodes in plain language, without lecturing, and asks what he thinks about it. Because he drinks partly to sleep in his car and to manage back pain, the conversation addresses those reasons directly rather than treating drinking as a moral issue. With his agreement, the nurse requests an addiction medicine or social work consultation so he can hear what help exists: a medicine the provider may prescribe to reduce craving, and outpatient or community programs he could reach without a fixed address. Evaluation is his own stated goal, written in his words in the chart, and whether he accepts a referral before discharge.

Problem 4: Housing and Follow-Up

A discharge back to his car would expose Mr. T. to cold nights, poor food, no place to recover and the same drinking pattern. The nurse begins discharge planning on the first day by referring him to social work and case management. Options include a medical respite program, which offers short-term recovery care for people without housing who are too ill for a shelter but no longer need a hospital bed. A systematic review by Doran et al. (2013) found that medical respite programs reduced later hospital admissions, inpatient days and readmissions and improved housing outcomes, although the studies varied in quality. The team also explores whether his sister could offer short-term shelter, helps him apply for Medicaid coverage and schedules a follow-up visit at a community health center before he leaves. The goal is met if he leaves to a safe setting with an appointment on paper.

Evaluation

By day three, Mr. T.'s pain was controlled at 3 of 10 on oral medication, his heart rate was 88 and he was eating a low-fat diet without vomiting. His CIWA-Ar scores peaked at a moderate level on day two and responded to symptom-triggered treatment. He set a goal of stopping drinking for three months and accepted an outpatient treatment referral. He was discharged to a medical respite bed with a primary care appointment ten days later. The plan will be judged again at that visit, when readmission, drinking and housing can be reassessed together.

References

Bush, K., Kivlahan, D. R., McDonell, M. B., Fihn, S. D., & Bradley, K. A. (1998). The AUDIT alcohol consumption questions (AUDIT-C): An effective brief screening test for problem drinking. Archives of Internal Medicine, 158(16), 1789-1795. https://doi.org/10.1001/archinte.158.16.1789

Doran, K. M., Ragins, K. T., Gross, C. P., & Zerger, S. (2013). Medical respite programs for homeless patients: A systematic review. Journal of Health Care for the Poor and Underserved, 24(2), 499-524. https://doi.org/10.1353/hpu.2013.0053

Sullivan, J. T., Sykora, K., Schneiderman, J., Naranjo, C. A., & Sellers, E. M. (1989). Assessment of alcohol withdrawal: The revised Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar). British Journal of Addiction, 84(11), 1353-1357. https://doi.org/10.1111/j.1360-0443.1989.tb00737.x

Tenner, S., Vege, S. S., Sheth, S. G., Sauer, B., Yang, A., Conwell, D. L., Yadlapati, R. H., & Gardner, T. B. (2024). American College of Gastroenterology guidelines: Management of acute pancreatitis. The American Journal of Gastroenterology, 119(3), 419-437. https://doi.org/10.14309/ajg.0000000000002645