Post-Op Ileus-Case Study-Keith RN PDF

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Post-Op Ileus-Case Study-Keith RN...

Description

Nasogastric Intubation Primary Concept

Skills Elimination & Reasoning Interrelated Concepts (In order of emphasis) • Clinical Judgment

NCLEX Clien

Covered in Case Study

Safe and Effective Care  Management of C  Safety and Infecti Health Promotion and M Psychosocial Integrity Physiological Integrity

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 Basic Care and C  Pharmacological  Reduction of Risk  Physiological Ad

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Jim Sanderson, 65 years old

History of Present Problem: Jim Sanderson is a 65-year-old male who is admitted for acute lower abdominal pain which was the result of a ruptured appendix. He had an open appendectomy and is now post-operative day three. He refuses to use the incentive spirometer or get up in the chair and requires encouragement to get out of bed and ambulate on the unit. His appetite is poor, and he eats a small portion of his meals but tolerates and drinks fluids readily. He has had 2200 mL intake to 1800 mL urine output the past 24 hours. He denies nausea and has not had a bowel movement since surgery despite receiving milk of magnesia and senna tabs daily. His abdomen is obese, rounded, firm and tender to palpation with hypoactive bowel sounds. His incision site in his RLQ has no drainage; swelling and mild erythema along the edge of the incision.

Current Complaint: Jim puts on his call light. When you arrive, he states he feels nauseated. He has an order for ondansetron 4 mg IV every 4 hours PRN for nausea, and this is administered. Thirty minutes later he puts his call light on again, stating that his nausea has gotten worse. While in the room, he begins to wretch and has a small bile green emesis. What data from the story and current complaint do you NOTICE as RELEVANT and why is it clinically significant? (Reduction of Risk Potential/Health Promotion and Maintenance)

RELEVANT Data-Present Problem:

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Presents with acute lower abdominal pain which was the result of a ruptured appendix. Pt

Clinical Significance: 

After abdominal surgery, the breathing pattern can change and result in various pulmonary complications. Incentive

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

 

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had an open appendectomy and is now post-operative day three. Refuses to use the incentive spirometer or get up in the chair and requires encouragement to get out of bed and ambulate on the unit. Appetite is poor. Denies nausea and has not had a bowel movement since surgery despite receiving milk of magnesia and Senna tabs daily. Abdomen is obese, rounded, firm and tender to palpation with hypoactive bowel sounds.

RELEVANT Data-Current Complaint:  Pt sates he feels nauseated.  Thirty minutes later, nausea has worsened and pt began to wretch upon your entry and has a small bile green emesis.

spirometry is beneficial for patients affected in this way as it promotes deep breaths, which will aid their recovery. 

Adequate nutrition is necessary to keep the immune system strong to fight off infection. During rapid weight loss, muscle is lost rather than fat, this can diminish strength during the recovery process.

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Indicates buildup of fluid in the abdomen

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Intestinal activity has slowed

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Can be from lack of appetite, as well as a blockage in the intestines.

Clinical Significance:  Indicates possible intestinal blockage.

Nursing Assessment Begins: Current VS:

Most Recent VS:

Current WILDA:

T: 99.2 F/37.3 C (oral) P: 92 (reg) R: 24 (reg) BP: 168/88 O2 sat: 93% room air

T: 99.4 F/37.4 C (oral) P: 74 (reg) R: 18 (reg) BP: 142/80 O2 sat: 98% room air

Words: ache/cramp Intensity: 5/10 Location: generalized abdomen Duration: ongoing-started last hour Aggravate: movement Alleviate: rest

Current Assessment: GENERAL APPEARANCE: RESP: CARDIAC: NEURO: GI: GU:

Patient’s body and facial expression appears tense, uncomfortable Breath sounds clear with equal aeration bilaterally, diminished in the bases bilaterally, nonlabored respiratory effort Skin color is pink, warm & dry, no edema, heart sounds strong, regular with no abnormal beats, pulses 3+, equal with palpation at radial/pedal/post-tibial landmarks Alert & oriented to person, place, time, and situation (x4) Abdomen firm-tender to palpation, distended, with rare, high pitched tympanic bowel sounds Voiding without difficulty, urine clear/yellow

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SKIN:

Skin integrity intact, abdomen incision edges intact with mild erythema along edges, staples intact

What clinical data do you NOTICE that is RELEVANT and why is it clinically significant? (Reduction of Risk Potential/Health Promotion and Maintenance)

RELEVANT VS Data:

Clinical Significance:

TREND: Improve/Worsening/Stable:

BP: 168/88 P: 92 (reg) R: 24 (reg) O2 sat: 93% room air Pain: 5/10, generalized abdomen, ongoingstarted last hour.

RELEVANT Assessment Data: GENERAL APPEARANCE: Patient’s body and facial expression appears tense, uncomfortable. RESP: Diminished in the bases bilaterally, nonlabored respiratory effort. GI: Abdomen firmtender to palpation, distended, with rare, high pitched tympanic bowel sounds.

The trend is showing the pt Elevated BP and P indicates the possibility of is worsening. the heart compensating for the problem in the abdomen and a response to pain.  Elevated RR indicates the possibility of the lung compensating for the problem in the abdomen and a response to pain.  Pain isn’t being controlled well and has been ongoing for quite some time which indicates an issue within the abdomen. Clinical Significance: 

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The trend is showing the pt Indicates pt is experiencing pain. is worsening. Indicates lungs are compensating for another issue within the body. Abdomen being firm/tender and distended is an indication of fluid build-up within the abdomen. High pitched bowels sounds are usually an indication of an abdominal blockage.

1. What additional clinical data you need to collect to identify the primary problem to guide your plan of care? (Management of Care)

The RN would need to collect lab values for WBC, Hgb, and Platelets. This is to determine the body’s ability to fight an infection if one is present, the body’s ability to transfer O2 to the tissues, and to monitor for possible thrombocytosis.

2. INTERPRETING relevant clinical data, what is the primary problem? What primary health related concept(s) does this problem represent? (Management of Care/Physiologic Adaptation) Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved.

Problem:

Pathophysiology of Problem in OWN Words:

Primary Concept(s):

Could be related to the open surgery three days prior and the fact that the pt is refuses to get out of bed to ambulate which would assist in bowel movement within the colon.

Elimination

Intestinal Blockage

3. What nursing priority(ies) will guide your plan of care that determines how you decide to RESPOND? (Management of Care) The priority is to address the lack of bowel Nursing PRIORITY: movement and s/s showing possible blockage.

PRIORITY Nursing Interventions:

Rationale:

Expected Outcome:

Perform GI assessment, encourage pt to sit up in chair or go for short walks, encourage pt to try and have a bowel movement by visiting the bathroom at least once an hour, address s/s of blockage, and notify provider.

Movement assists the muscles within the colon to move any fecal matter down to the sphincter. Staying in bed and not moving may cause a blockage within the intestines.

Pt will have successful BM and not have to have interventions to assist with bowel output. If intestinal blockage is present, the RN must expect that pt. may not be able to go on own.

4. What will you communicate with the primary care provider to concisely and accurately report the current problem?

Situation: 

Elevated blood pressure.

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Decreased O2 sat on RA.

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Distended tender abdomen with high pitched bowel sounds.

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Achy 5/10 abdominal pain that increases with movement.

Background: Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved.

    

Presented with acute lower abdominal pain which was the result of a ruptured appendix. Pt had an open appendectomy and is now post-operative day three. Refused to use the incentive spirometer or get up in the chair and requires encouragement to get out of bed and ambulate on the unit. Appetite is poor. Denies nausea and has not had a bowel movement since surgery despite receiving milk of magnesia and Senna tabs daily. Abdomen is obese, rounded, firm and tender to palpation with hypoactive bowel sounds.

Assessment: T: 99.2 F/37.3 C (oral)

BP: 168/88 P: 92 (reg) R: 24 (reg) O2 sat: 93% room air Pain: 5/10, generalized abdomen, ongoing-started last hour.  Elevated BP and P indicates the possibility of the heart compensating for the problem in the abdomen and a response to pain.  Elevated RR indicates the possibility of the lung compensating for the problem in the abdomen and a response to pain.  Pain isn’t being controlled well and has been ongoing for quite some time which indicates an issue within the abdomen. GENERAL APPEARANCE: Patient’s body and facial expression appears tense, uncomfortable. RESP: Diminished in the bases bilaterally, nonlabored respiratory effort. GI: Abdomen firm-tender to palpation, distended, with rare, high pitched tympanic bowel sounds.  Indicates pt is experiencing pain.  Indicates lungs are compensating for another issue within the body.  Abdomen being firm/tender and distended is an indication of fluid build-up within the abdomen.  High pitched bowels sounds are usually an indication of an abdominal blockage.

Pt may be experiencing an intestinal blockage based on these findings.

Recommendation: Continue to monitor, notify provider, and request a CT scan to confirm or deny blockage.

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In response to your concise and well organized SBAR, the primary care provider agrees with your concern and orders an abdominal CT that confirms dilated proximal small intestinal loops suggestive of paralytic ileus with no evidence of gas in the large intestine. You receive the following orders: • Insert nasogastric tube [NGT] • Connect NGT to LIS [low intermittent suction] • NPO [nothing by mouth] except small amount of ice chips PRN [as needed] Medical Management: Rationale for Treatment & Expected Outcomes Care Provider Orders: Insert NGT to LIS

Rationale: To remove fecal/gastric contents from stomach.

NPO-may have ice chips

Cannot eat due to blockage and low intermittent suction happening. Ice chips are used to keep mouth and throat moist.

Expected Outcome: To prevent infection and further blockage to occur.

Procedural Safety Principles 1.

What supplies does the nurse need to gather to perform this skill?

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2.

14- or 16-Fr NG tube Water-soluble lubricant pH test strips Tongue blade Flashlight Emesis basin Asepto bulb or catheter-tipped syringe 2.5-cm (1-inch) wide hypoallergenic tape or commerical fixation device Safety pin and rubber band Clamp, drainage bag, or suction machine with pressure gauge if wall suction id to be used Towel Glass of water with straw Facial tissues Normal saline Tincture of benzoin (optional) Suction equipment Stethoscope Clean gloves

Review nasogastric tube insertion and summarize essential steps and knowledge that the nurse will use in this scenario to safely place the tube. (Management of Care)

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What does the Nurse Need to KNOW to Be Safe in Practice: Identify pt with two identifiers, perform hand hygiene, inspect the nares, ask pt if they have history of nasal surgery or congestion or allergies and not id deviated nasal septum is present, listening for bowel sounds, palpate pt’s abdomen for distention, pain, and rigidity, and assess the pt’s level of consciousness and ability to follow instructions. How will you measure the correct length to insert? Measure distance from tip of pt’s nose to earlobe to xiphoid process of the sternum. How will you validate that the tube is correctly placed? Follow order for bedside x-ray film and notify radiology for examination of chest and abdomen. While waiting for x-ray film to be performed, follow these procedures: Attach asepto bulb or catheter-tipped syringe to end of tube. Aspirate gently back on syringe to obtain gastric contents, observing amount, color, and quality of return. Use pH test paper to measure aspirate for pH with color-coded pH paper. Be sure that paper range of pH is at least from 1.0 to 11.0. How many people will you need to assist you with insertion and what will their role be? You and one other RN? What other safety concerns are present when inserting a NGT? Secure NG tube in place by using a device or paper tape. Ensure you haven’t placed the NG into the lung by having the pt swallow while inserting the tube.

3. What will you communicate to the patient to educate them about the need for nasogastric tube insertion and what to expect? (Health Promotion and Maintenance)

The need for a NG tube is due to an intestinal blockage. It’s a temporary hollow tube that is inserted through the nasal passage into the stomach and will aid in keeping the stomach empty until normal peristalsis returns.

Evaluation: After the NG tube has been placed, 800 mL of green bile drainage from the stomach is removed over the next 15 minutes. Jim states that the nausea is improved and appears to be more comfortable. 1. What data do you NOTICE as RELEVANT and why is it clinically significant? (Reduction of Risk Potential/Health Promotion and Maintenance)

RELEVANT Data:

 800 mL of green bile drainage from the stomach is removed over the next 15 minutes.  Pt’s nausea is improved and

Clinical Significance:



This means that the abdominal discomfort has improved and further investigation into the blockage can be performed.

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appears to be more comfortable.

2. Has the status improved or not as expected to this point? Does your nursing priority or plan of care need to be modified in any way after this evaluation assessment? (Management of Care, Physiological Adaptation)

Evaluation of Current Status:

Modifications to Current Plan of Care:

The status of the pt has improved, however, the cause of the blockage needs to still be determined and address as the NG is supposed to be temporary.

Continue NG to LIS until stomach contents slow or cease or a successful bowel movement is had.

3. Based on your current evaluation, what are your CURRENT nursing priorities and plan of care? (Management of Care)

CURRENT Nursing PRIORITY:

Bowel Elimination

PRIORITY Nursing Interventions:

Rationale:

Continue NG to LIS when in bed. To have the return of normal peristalsis and to be Encourage pt to sit up in chair still having active in trying all solutions first before having to have a surgery to correct the blockage issue. NG to LIS. Encourage pt to visit the bathroom once an hour and go for short walks.

Expected Outcome: The pt will have a successful bowl movement.

Use Reflection to THINK Like a Nurse What did I learn from this scenario? How can I use what has been learned from this scenario to improve patient care in the future?

I enjoyed this case study because it really showed what it’s like to have to go through specific channels to get a pt comfortable. We always speak hypothetically, saying that we will talk to the provider to request items needed for the pt, utilizing SBAR, and the Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved.

different steps we have to take (contact, wait on order for CT, wait on results of CT to be viewed by provider, wait on order for NG, place NG). Also, the difference between the open and laparoscopic appendectomies is important to note because they are two very different procedures and affect the body differently post operatively.

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