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NURS/Part I: Small Bowel Obstruction NextGen Unfolding Reasoning Mary O’Reilly, 55 years old
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NURS/Part I: Small Bowel Obstruction NextGen Unfolding Reasoning Mary O’Reilly, 55 years old
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Part I: Small Bowel ObstructionNextGen Unfolding Reasoning
Mary O’Reilly, 55 years old
Primary Concept
Elimination
Interrelated Concepts (In order of
emphasis)
• Patient Education
• Clinical judgment
NCLEX Client Need Covered NCSBN Clinical Covered in
Categories in Case Judgment Model Case Study
Study
Page 1 of 34
,Safe and Effective Step 1: Recognize Cues ✓
Care Environment
•Management of Care ✓ Step 2: Analyze Cues ✓
•Safety and Infection Control Step 3: Prioritize Hypotheses ✓
Health Promotion and ✓ Step 4: Generate Solutions ✓
Maintenance
Psychosocial Integrity Step 5: Take Action ✓
Physiological Integrity Step 6: Evaluate Outcomes ✓
•Basic Care and Comfort
•Pharmacological and ✓
Parenteral
Therapies
•Reduction of Risk Potential ✓
•Physiological Adaptation ✓
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
Page 2 of 34
, • 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: Clinical Significance:
A history of partial colectomy w/colostomy and Partial colectomy and postsurgical scar
small bowel obstruction three months ago, that tissue from adhesions can put the patient
resolved with bowel rest and required no surgical at risk of recurrent obstruction.
intervention.
A sudden onset of sharp generalized
Three days ago, Mary developed a sudden onset of abdominal pain with nausea, vomiting and
sharp generalized abdominal pain with nausea, decreased output from her colostomy bag are
vomiting and decreased output from her colostomy symptoms of bowel obstruction.
bag.
She is at risk for dehydration.
She has had two small glasses of water today.
This confirms a bowel obstruction.
CT of her abdomen/pelvis revealed high-grade
small bowel obstruction Normal lactate levels are 0.5-1 mmol/L. She
has moderately elevated lactate level, which
Lactate 2.8 can still put her at risk for metabolic acidosis
Normal WBC for females between 5.0-11.0
Her elevated WBC may be an indication of
WBC 14.7 an acute infection or inflammation related to
bowel obstruction.
Normal serum potassium levels are 3.5-5
mEq/L. Her potassium level is in normal
range, but the fact the she has been nauseated
Potassium 3.7 and vomiting for three days put her at risk
for hypokalemia.
Normal serum creatinine is 0.601.2 mg/dL.
Creatinine 1.35 Her creatinine is slightly elevated, which can
indicate dehydration.
Page 3 of 34
, Because the patient is experiencing bowel
An NG was placed and is on low intermittent suction.
She
Page 4 of 34
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