Keith RN unfolding case study small bowel obstruction PDF

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Summary

Small bowel obstruction case study Keith RN Part II for nursing care of the adult 417. Part II of two. Mary O’Reilly is a 55-year-old female with a prior history of partial colectomy w/colostomy who was admitted to the medical/surgical unit for small bowel obstruction....

Description

Part II: Perforated Bowel/Sepsis/ICU NextGen Unfolding Reasoning

Mary O’Reilly, 55 years old

Primary Concept Infection/Inflammation

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  Reduction of Risk Potential  Physiological Adaptation

Gas Exchange Perfusion Clinical judgment

Covered in Case Study   

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

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

Covered in Case Study      

Part I: Initial Nursing Assessment History of Present Illness: Mary O’Reilly is a 55-year-old female with a prior history of partial colectomy w/colostomy who was admitted to the medical/surgical unit for small bowel obstruction. Yesterday she developed severe RLQ abdominal pain and CT revealed a perforated small bowel with free intraperitoneal air. Before she was brought to the operating room (OR) for an exploratory laparotomy, her lactate was 4.9, WBC 18.9, and her systolic BP began to drop to 65-75, with a mean arterial pressure (MAP) of 50-55. She received a total of 2500 mL of 0.9% NS preop and piperacillin-tazobactam 4.5 g. IVPB. Her last BP before she went to the OR was 94/52 w/MAP 65. What data is RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential) RELEVANT Data: Clinical Significance:

RLQ abdominal pain perforated small bowel with free inraperitoneal air Lactate 4.9 WBC 18.9 Systolic BP 65-75 during surgery

Correlates with perforated bowel symptoms Surgical intervention is necessary to prevent infection/damage/further damage Lactate is building up indicating client's status is declining WBCs indicate infection BP could indicate shock/sepsis/hypovolemia

Mary is coming to ICU after surgery and the OR nurse provides you with the following report: Present Problem: Mary had an exploratory laparotomy that required extensive lysis of adhesions and was found to have a perforated jejunum with fecal peritonitis. Mary has a 7.0 mm endotracheal tube (ET) that is well secured, 23 cm at the lips. Current vent settings are: CMV/AC rate 12, TV 500 mL, PEEP +5, FiO2 35%. She has an arterial line placed in the right radial artery and a central line was placed in the right internal jugular (RIJ). Placement was confirmed by chest x-ray. Mary received 2.5 liters of LR during the case and had an estimated blood loss (EBL) of 375 mL. To maintain adequate perfusion during surgery, she required norepinephrine IV gtt, currently at 10 mcg. Her SBP was consistently in the 90100s during surgery with a mean arterial pressure (MAP) of 65-70 and CVP: 12. She has a wound VAC applied to her open abdominal incision with an intact dressing at 125 mm suction with no drainage and a 14 Fr. Salem Sump NG, 68 cm in the left nare. What data is RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential) RELEVANT Data: Clinical Significance:

Endotracheal tube Mechanical ventilation Arterial and central line Norepinepherine IV at 10 mcg MAP 65-70 CVP 12 VAC applied to open abdominal incision NG tube

Client requires respiratory assistance with mechanical ventilation, low LOC Arterial and central line indicated for long term medication administration or for ICU patients, easy access to obtain blood specimen Low MAP indicates poor cardiac output High CVP indicates cardiac dysfunction VAC assists with faster healing time NG tube for enteral feeding or decompression

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

After receiving report from the nurse in PACU, the patient is brought back to ICU and you collect the following assessment data:

Patient Care Begins: Cardiac Telemetry Strip (6 seconds):

Regular/Irregular: P wave present? PR: QRS: QT: Interpretation: Yes, 0.12 PR interval, 0.8 QRS interval, 0.32 QT interval Clinical Significance:

Normal Sinus Rhythm

Current VS: T: 99.4 F/37.4 C (oral) P: 94 (regular) R: 20 (AC: 12) Arterial BP: 92/55 MAP: 67 O2 sat: 96% w/FiO2 35% ventilator 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:

RR 20(12 AC) Arterial BP 92/55 MAP

Clinical Significance:

The client is partially breathing on her own BP is still low but improving MAP is also still low but improving. Both indicare increased perfusion

Current Head to Toe Nursing Assessment: GENERAL SURVEY: Body relaxed, no grimacing, appears to be resting comfortably with no restlessness noted. Peripheral IV and central line well secured w/dressings intact, no redness or signs of infection present, LIS suction w/NGT, ET 23 cm at lip, NGT 68 cm, tape secure on nasal bridge and NG tube. NEUROLOGICAL: PERRLA-3 mm, opens eyes briefly when name called, but then goes back to sleep, limited spontaneous movements of all extremities noted HEENT: Head normocephalic with symmetry of all facial features, sclera white bilaterally, conjunctival sac pink bilaterally. Lips, tongue, and oral mucosa pink and moist. Biteblock for ET properly placed. RESPIRATORY: Breath sounds coarse bilat but clear after deep suctioning with equal aeration on inspiration and expiration in all lobes anteriorly, posteriorly, and laterally. Vent settings confirmed: AC rate 12, TV 500 mL, PEEP +5, FiO2 35%. Total RR 20, peak inspiratory pressures 16-20. Actual TV: 500-600. Moderate amount of clear, creamy oral secretions requiring suctioning, small amount of tan, thick secretions suctioned from ETT. Copyright © 2020 Keith Rischer, d/b/a KeithRN. All Rights reserved.

CARDIAC:

ABDOMEN:

GU: INTEGUMENTARY:

Pink, warm & dry, no edema, heart sounds regular, 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. Moderate generalized edema with 2+ pitting edema in lower extremities Abdomen large, round, firm to touch. Midline open abdominal incision appx 6” (15 cm) in length and 1.5” (4 cm) wide filled with intact transparent dressing. Wound V.A.C. at 125 mm suction-no drainage. BS absent in all 4 quadrants, colostomy bag intact with small amount of dark brown stool in bag, stoma pink, with brisk refill 65.  Vasopressin 0.04 IV infusion  0.9% NS IV infusion 100 mL hour  Fentanyl IV infusion 10-125 mcg/hour. RASS goal -3 (Mod. Sedation)  Dexmedetomidine IV infusion 0.2-1 mcg/kg/hour. RASS goal -3 (Mod. Sedation)  Piperacillin-tazobactam 3.375 g (D5 100 mL) IVPB. Infuse over 4 hours every 6 hours  Chlorhexidine 15 mL oral/swab every 12 hours  Famotidine 20 mg IV every 12 hours  Heparin 5000 units SQ every 8 hours

Rationale:

The clients airway is the priorty followed by increasing cardiac output and increasing BP, and keeping the client hydrated with adequate fluid volume.

NS IV infusion Fentanyl IV unfusion Dexmedetomidine IV infusion

We want to maintain sedation and then place wound VAC to seal surgical site and promote healing

Wound VAC Piperacillin IVPB Chlorhexidine oral swab Farmotidine IV Heparin IV

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

Next we would administer prophylactic medications to prevent infection, ulcers, and thrombus formation, and also perfrom oral hygiene to maintain oral integrity.

6. What nursing priority(ies) and goal will guide how the nurse RESPONDS to formulate a plan of care? (NCSBN: Step 4 Generate solutions/Step 5: Take action/NCLEX Management of Care)

Nursing PRIORITY:

Impaired spontaneous breathing

GOAL of Care:

To maintain adequate oxygenation for patient

Nursing Interventions: Place client in a semi-fowler's position

Rationale:

Expected Outcome:

For optimal lung expansion

Patient breaths comfortably

Perform suctioning

To maintain a patent airway

Monitor VS

Patient maintains a patent airway

To identifying worsening symptoms

Assess patients LOC

To maintain edequate sedation while on mechanical ventilation

Patients vitals remain stable Patient remains sedated while ventilated

7. What is the worst possible/most likely complication(s) to anticipate based on the primary problem? (NCLEX: Reduction of Risk Potential/Physiologic Adaptation)

Worst Possible/Most Likely Complication to Anticipate: Nursing Interventions to PREVENT this Complication:

Administer antibiotics Maintain fluid hydration Monitor VS frequently Monitor surgical wound Practice aseptic techniques

Septic Shock Assessments to Identify Problem EARLY:

Assess vital signs frequently Assess skin for swelling, coolness, or clammy Assess lungs for fluid Assess lab values

Nursing Interventions to Rescue:

Notify provder. Administer antibiotics, fluids, vasopressors, and anticoagulants. Monitor vs closely

8. What psychosocial/holistic care PRIORITIES need to be addressed for this patient/family? (Psychosocial Integrity/Basic Care and Comfort)

Psychosocial PRIORITIES:

Fear of injury or dying

PRIORITY Nursing Interventions: Rationale: Establish trust with the client The client will feel more comfortable with the nurse if they trust them Offer support and communicate with therapeutic techniques. To help calm the client Bring in family for support

Family can bring comfort to the client

Provide a relaxing environment

To reduce stiumulation and calm the client

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

Expected Outcome:

The client will feel comforted and less fearful

Part II: Interpreting Diagnostic Data After arriving in the ICU from the OR, the primary care provider orders the following diagnostic tests and the results just posted in the electronic health record: Radiology Reports: What diagnostic results 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/Physiologic Adaptation)

Results: Endotracheal tube at the distal tracheal level, 2 cm above the carina

Radiology: Chest X-Ray Clinical Significance:

The endotracheal tube is placed correctly and the lungs are healthy

Lungs and pleural spaces: No pleural effusion or pneumothorax.

Lab Results: Current: Yesterday:

WBC 22.5 18.9

Complete Blood Count (CBC) HGB PLTs 11.2 225 12.9 189

% Neuts 91 84

Bands 1 0

What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential Reduction of Risk Potential/Physiologic Adaptation)

RELEVANT Lab(s):

Clinical Significance:

TREND: Improve/Worsening/Stable:

Patient likely has an infection low HGB means the patient is anemic High nuetrophils are related to high WBC because of infection and low Bands indicated infection as well

WBC 22.5 HGB 11.2 Neuts 91% Bands 1

Current: Yesterday:

Na 132 136

Basic Metabolic Panel (BMP) K Gluc. 4.1 162 3.9 148

Worsening worsening worsening Worsening

Creat. 1.32 0.98

BUN 35 15

What lab results 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/Physiologic Adaptation)

RELEVANT Lab(s):

Clinical Significance:

TREND: Improve/Worsening/Stable:

Na 132 Gluc. 162 Creat 1.32 BUN 35

The electrolyte imbalance indicates renal dysfunction and the elevated glucose is likely caused by stress/infection

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

worsening worsening worsening worsening

Misc. Current: Yesterday:

Lactate 2.1 4.9

What lab results 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/Physiologic Adaptation)

RELEVANT Lab(s):

Clinical Significance:

TREND: Improve/Worsening/Stable:

Lactate 2.1

Current: Yesterday:

A decreased level of lactate to 2 is indicative of sepsis

Albumin 2.2 2.4

Total Bili 1.2 0.9

Liver Panel Alk. Phos. 72 58

Worsening

ALT 79 42

AST 75 38

What lab results 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/Physiologic Adaptation)

RELEVANT Lab(s):

Clinical Significance:

TREND: Improve/Worsening/Stable:

Albumin 2.2 ALT 79 AST 74

Current:

low albumin indicates impaired liver function A high ALT indicates liver damage High AST indicates liver damage or perfusion problems with the heart

pH 7.24

RELEVANT Lab(s): pH 7.24 HCO3 15

Arterial Blood Gas (ABG) pCO2 pO2 38 112

Worsening Worsening Worsening

HCO3 15

O2 sat 99%

Clinical Significance: Blood is acidic with low bicarbonate

What is your interpretation of this arterial blood gas? metabolic acidosis When you update the primary care provider with the ABG results, she orders sodium bicarbonate 100 mEq/50 mL IV. Why? Sodium bicarbonate is a base that reduces acid levels in the blood, this will bring up the pH to a normal range Copyright © 2020 Keith Rischer, d/b/a KeithRN. All Rights reserved.

Part IV: Evaluation: Eight Hours Later To maintain a RASS of -3, Mary is currently receiving fentanyl 100 mcg IV infusion, dexmedetomidine 0.6 mcg/hr. Her norepinephrine has been decreased from 10 mcg/min to 5 mcg/min to maintain MAP >65. She has had 60 mL blood-colored serosanguinous drainage from the wound VAC. She has 200 mL clear yellow urine and 20 mL of light green bile drainage from the NG the last 2 hours. Her weight is 68.9 kg. Her last weight 24 hours ago was 65.2 kg. Her breath sounds are clear, diminished in the bases. ET suctioning every 2-4 hours results in small amounts of clear to white thin secretions. Her abdomen is firm, with absent bowel sounds. Most recent set of VS: T: 99.5 F/37.5 C (oral)/HR: 80 (reg) RR: 16 BP: 118/58 (MAP-78) O2 sat: 96% FiO2: 30% 1. Interpret clinical data to determine if the patient status is improving, declining, or reflects no change. (NCSBN: Step 6 Evaluate outcomes/NCLEX: Management of Care)

RELEVANT Assessment Data:

VS Weight gain 3.7lbs in 24 hours

Clinical Significance:

Improving-Declining No Change:

Temperature has decreased. Pulse and respiratory rate have regulated and BP has increased to a more stale rate.

Improving Worsening

Rapid weight gain means fluid retention possible kidney dysfunction

2. Has the overall status of your patient improved, declined, or remain unchanged? If your patient has not improved, what other interventions need to be considered by the nurse? (NCSBN: Step 6 Evaluate outcomes/NCLEX: Management of Care)

Overall Status:

Improved

Additional Interventions to Implement:

The client may have some kidney complications but overall her status has improved

Expected Outcome:

Patient will continue improving

Because of the excellent nursing care you provided for your patient, Mary was extubated the next day, and transferred to the medical/surgical unit. Mary will be discharged to home in the next 1-2 days. What educational priorities need to be taught to successfully manage her current problem and maintain an optimal state of health?

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

3. What educational/discharge priorities are needed to develop a teaching plan for this patient and/or

family?(Health Promotion and Maintenance) Education PRIORITY: PRIORITY Topics to Teach: How to clean surgical wound

Risk for infection Rationale:

How to identify signs of infection and when to call the provider

Cleaning surgical wound will clear bacteria and promote healing Infections can be detected early if signs are identified and addressed quickly

Taking prescribed antibiotics

Antibiotic use is used to treat infection

How to monitor intake and output

Client should monitor intake and output while recovering in order to identify further complications like kidney dysfunction

Reflect on Your Thinking to Develop Clinical Judgment 4. To develop clinical judgment, reflect on your thinking that was used to complete this case study by answering the following questions: What did you do well in this case study? What knowledge gaps did you identify?

This was a tough case study and I felt like I still There were a lot of gaps throughout this case study have a lot of room for growth, but I do feel like for me, particularly with the interpreation of the I did a good job and putting the whole picture mechanical ventilator readings and the VAC device. together. I was able to see how a small bowel obstruction could lead to serious complications. What did you learn?

I learned about mechanical ventilation terms and settings. I have never worked with ventilators so I was very unfamiliar with terminology and how to interpret readings.

How will you apply learning caring for future patients?

I definitely feel like a learned a lot and would be able to care for a client like Mary in the future. I would use my knowledge of how to identify signs of a perforated bowel in a client who was suffering from a small bowel obstruction.

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