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Nursing Case Scenario...

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Name: Course:

Part I: Small Bowel Obstruction NextGen Unfolding Reasoning

Mary O’Reilly, 55 years old

Primary Concept Elimination

Interrelated Concepts (In order of emphasis)  

NCLEX Client Need Categories Safe and Effective Care Environment  Management of Care  Safety and Infection Control Health Promotion and Maintenance Psychosocial Integrity Physiological Integrity  Basic Care and Comfort  Pharmacological and Parenteral Therapies

Patient Education Clinical judgment

Covered in Case Study  

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NCSBN Clinical Judgment Model Step 1: Recognize Cues Step 2: Analyze Cues Step 3: Prioritize Hypotheses Step 4: Generate Solutions Step 5: Take Action Step 6: Evaluate Outcomes

Covered in Case Study      

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Reduction of Risk Potential Physiological Adaptation

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Part I: Initial Nursing Assessment Present Problem: Mary O’Reilly is a 55-year-old woman with a prior history of partial colectomy w/colostomy and small bowel obstruction three months ago that resolved with bowel rest and required no surgical intervention. Three days ago Mary developed a sudden onset of sharp generalized abdominal pain with nausea, vomiting and decreased output from her colostomy bag. She has had two small glasses of water today. Mary is admitted to the medical/surgical unit and you will be the nurse caring for her. You receive the following highlights of report from the emergency department (ED) nurse:  CT of her abdomen/pelvis revealed high-grade small bowel obstruction.  Lactate 2.8, WBC 14.7, Sodium 143, Potassium 3.7, Creatinine 1.35  An NG was placed and she is on low intermittent suction. She had NG output of 225 mL of bile green liquid.  Received hydromorphone 0.5 mg IV for pain one hour ago. Abdominal pain decreased from 9/10 to 3/10 and she is resting more comfortably.  Abd. is firm, slightly distended, with tympanic bowel sounds.  Initial HR/BP was 102 and 92/48.  Most recent vital signs: T: 99.8 (o) P: 78 (reg) R: 18 BP: 108/52 after 1000 mL 0.9% NS bolus 20 g. peripheral IV in left forearm. What data from the history are RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential)

RELEVANT Data from Present Problem:

Cl i ni c a lSi g ni fic a nc e :

Copyright © 2020 Keith Rischer, d/b/a KeithRN. All Rights reserved.

1 . CTo fh e ra b d o me n / p e l v i sr e v e a l e d h i g h g r a d es ma l lb o we lo b s t r u c t i o n . 2 . Ab d . i sfir m, s l i g h t l yd i s t e n d e d , wi t h t y mp a n i cb o we ls o u nd s . 3 . Pu l s e:7 8 ;I ni t i a l1 0 2 4 . BP:1 08 / 5 2 ;I n i t i a l9 9/ 48 5 . Pt . r e po r t sde c r e a s e do u t p u ti n c ol o s t o my 6 . WBC:1 4 . 7 7 . La c t a t e :2 . 8 8 . Hi s t o r yo fb o we lo b s t r u c t i o n 9 . T:9 9. 8 1 0 .Cr e a t i ni ne :1 . 35 1 1 .Po t a s s i u m:3 . 7

1 . Hi g hgr a d ebo we lob s t r u c t i o nwo ul dbet hea d mi t t i n g d i a g n os i sa ndp r i o r i t yf o rp l a no fc a r ef o rt hi sp a t i e nt . 2 . Ab d . As s e s s me n ta bn or ma l ,s h ou l dn o tbed i s t e n d e d . 3 . Pu l s eha sd r o pp e da f t e rI Vt r e a t me n ta ndp a i n i n t e r v e nt i onf r o m1 02t o78whi c hp ut she ra s b r a d y c a r di c . 4 . BPh a sd r op p e da f t e rI Vt r e a t me n ta n dp a i na s s e s s me n t f r om10 8 / 5 2 , t o9 9 / 4 8whi c hp ut she ra sh yp o t e n s i v e . 5 .I ft h e r e ’ sn oc ha n g ei ni n p u ta ndd e c r e a s ei no ut pu t , c on c e r n i n g . 6 .I nc r e a s e df r o mn o r ma l ;s i g nofi n f e c t i o n . 7 . Si g nso fs e ps i s . 8 . Hi g he rr i s ko fr e c u r r e ntob s t r u c t i o n . 9 . Sl i g ht l ye l e v a t e d ;mo ni t o rf o rt r e nd s . 1 0 .Hi g h;d e h y d r a t i o n ,r i s kf o rAKA 1 1 .Lo we ndo fno r ma l ;v omi t i n g=a tr i s kf orh y p o ka l e mi a

Copyright © 2020 Keith Rischer, d/b/a KeithRN. All Rights reserved.

After receiving report, you quickly review this patient’s past medical history and home medications in the electronic health record: 1. WHY is your patient receiving these home medications? Draw lines to connect the medication to the problem it is most likely treating. (NCLEX: Pharmacologic and Parenteral Therapies) Past Medical History: Home Medications: COPD Albuterol; Umeclidinium-vilanterol Aspirin 81 mg PO daily Paroxysmal atrial fibrillation M e t o p r o l o l Furosemide 20 mg PO daily Coronary artery disease- Aspirin, Simvastatin Diverticulitis Lisinopril 5 mg PO daily Small bowel obstruction Partial colectomy Metoprolol 25 mg PO BID w/colostomy Non-dilated cardiomyopathy-EF 25% - Furosemide; Lisinopril Simvastatin 20 mg PO daily Umeclidinium-vilanterol 62.5/25 mcg inhaler 1 puff daily Albuterol 0.083% neb solution 3 mL every 6 hours PRN

Mary is transferred from the cart to her bed on the medical/surgical unit. You introduce yourself, and collect the following clinical data:

Patient Care Begins: Current VS: T: 99.5 F/37.5 C (oral) P: 94 (regular) R: 16 (regular) BP: 118/64 O2 sat: 98% room air

P-Q-R-S-T Pain Assessment: Provoking/Palliative: No change in position or movement influences pain cramping Quality: Generalized abdomen Region/Radiation: 5/10 Severity: continuous Timing:

Copyright © 2020 Keith Rischer, d/b/a KeithRN. All Rights reserved.

What VS data are RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential Reduction of Risk Potential/Health Promotion and Maintenance)

RELEVANT VS Data: 1 . T:9 9. 5F 2 . BP:11 8 / 64 3 . Cr a mpi n gi n a b d ome n . 4 .5 / 1 0Con t . pa i n

Clinical Significance: 1 . Te mpe r a t u r ei ss l i g h t l ye l e v a t e df r o mn o r ma l9 7 . 5F . 2 . Hy p o t e n s i v e , Bpi sbe l o wn o r ma l1 2 0 / 8 0 3 . Cr a mp i n gi na b d ome na f t e rdi a g n o s i so fh i g hg r a d ebo we lob s t r uc t i o nme a n spr o b l e m i ss t i l lp r e s e n ta ndn e e dst ob er e s o l v e d . 4 . Pa i ni smo d e r a t e ;q u a l i t yi sc r a mp i n ga ndp a i ni sc o n t i n u ou s .

Current Head to Toe Nursing Assessment: GENERAL SURVEY: Pleasant, calm, body tense, grimacing, appears uncomfortable NEUROLOGICAL: Alert & oriented to person, place, time, and situation (x4); muscle strength 5/5 in both upper and lower extremities bilaterally. HEENT: Head normocephalic with symmetry of all facial features. PERRLA, sclera white bilaterally, conjunctival sac pink bilaterally. Lips, tongue, and oral mucosa tacky dry RESPIRATORY: Breath sounds clear with equal aeration on inspiration and expiration in all lobes anteriorly, posteriorly, and laterally, nonlabored respiratory effort on room air. CARDIAC: No edema, heart sounds regular S1S2, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill. Heart tones audible and regular, S1 and S2 noted over A-P-T-M cardiac landmarks with no abnormal beats or murmurs. No JVD noted at 30-45 degrees. ABDOMEN: Abdomen round, firm, and generalized abdominal tenderness. BS tympanic in upper quadrants, hypoactive in lower quadrants GU: Voiding without difficulty, urine clear/dark amber INTEGUMENTARY: Skin pink, warm, dry, intact, normal color for ethnicity. No clubbing of nails, cap refill...