Patient’s homelessness and lack of insurance

The nurse practitioner (NP) is working at a health clinic in a homeless shelter during the early evening. A 48-year-old African American man approaches the practitioner and asks to have his blood pressure taken, saying that he has not had it checked “in a while.” The man appears to be in some type of distress and experiencing pain. The man walks slowly, using a guarded manner, and he appears diaphoretic. His mucous membranes also appear pale. The patient’s blood pressure is 210/98. The patient reports that he has not been diagnosed with hypertension previously. The patient reveals that he has severe abdominal pain that is radiating to his back. The nurse finds a heart rate of 110, respirations 30 with shallow inspirations, and temperature 102.2°F. The patient’s skin is cool and clammy.

The patient reports a history of alcoholism, homelessness, and lack of access to health care. He says that the symptoms have been present and worsening over 3 days. The man says he thinks he might have pancreatitis again, which he had “a couple years ago.” The NP recommends that the man should be seen at a hospital for his condition, but the patient says he does not have health insurance, so he does not want to go.

The NP proceeds with a physical examination, finding severe abdominal pain in the epigastric area, yellowed sclera, no abdominal distention, and hypoactive bowel sounds. The clinic is equipped with basic materials but no means to conduct lab or radiologic testing.

Case Questions

  1. Considering the patient’s homelessness and lack of insurance, what action should the practitioner take?
  2. When the patient asks why his condition cannot be managed outside of the hospital, how should the practitioner respond?
  3. When the patient arrives at the hospital for further diagnostic work-up, what tests will likely be performed to evaluate the patient’s condition?
  4. How will the severity of the pancreatitis be assessed when the patient is hospitalized?
  5. How should the patient’s condition be managed when hospitalized?
  6. What patient education should be included?