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Small Bowel Obstruction

Small Bowel Obstruction Case Study. Small Bowel Obstruction Case Study

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Nursing Care of Adults 2 (NURS 9314)

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Northwest Arkansas Community College

Academic year: 2021/2022

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Larissa Mills

Northwest Arkansas Community College

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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 obs爀ction three months ago that resolved with bowel rest and required no surgical intervention. Three days ago Mary developed a sudden onset of sh爀턀 generalized abdominal pain 眀椀th nausea, vomiting and decreased output 昀爀om 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 昀爀om the emergency department (ED) nurse: - CT of her 愀戀domen/pelvis revealed high-grade small bowel obstruction. - Lactate 2, WBC 14, Sodi甀洀 143, Potassium 3, Creatinine 1. - An NG was placed and she is on low intennittent suction. She had NG output of225 mL of bile green liquid. - Received hydromorphone 0 mg IV 昀漀r pain one hour ago. Abdominal pain decreased 昀爀om 9/10 to 3/1 O and she is resting more com昀漀rtably. - Abd. is 昀椀rm, slightly distended, with tympanic bowel sounds. - Initial HR/BP was 102 and 92/48. - Most recent vital si最渀s: T: 99 (o) P: 78 (reg) R: 18 BP: 108/52 a昀琀er 1000 mL 0% NS bolus 20 g. peripheral IV in le昀琀昀漀rearm.

What data 昀爀om the history are RELEVANT and mnst be NOTICED as clinically signi昀椀cant by the nurse? '㸀ⴀTCSBN: Sten 1 Reco�nize cues/NCLEX Reduction of Risk Potential) RELE嘀䄀NT Da氀愀昀爀om Present Problem: Clinical Si�ni昀椀cance:. . '

After receiving report, you quickly review this patient's past medical

history and home medications in the electronic health record:

WHY is your patient receiving these home medications? Draw lines to connect the medication to the problem it 1s most l'l 1 㰀攀 yI treatmg, (NCLEX: P 1armaco ogtc anl 1. d Past Medical Historv:. COPD Paroxysmal a爀񐀀al 昀椀brillation Coronary artery disease Diverticulitis Small bowel obstruction

Parenteral Therapies) Home Medications:

Aspirin 81 mg PO daily Furosemide 20 mg PO daily Lisinopril 5 mg PO daily Metoprolol 25 mg PO BID Simvastatin 20 mg PO daily Partial colectomy w/colostomy Umeclidinium-vilanterol 62/25 mcg i渀栀aler 1 pu昀昀 daily Non-dilated cardiomyopathy-EF 25% Albuterol 0% neb solution 3 mL every 6 hours P刀一

Mary is trans昀攀rred 昀爀om the cart to her bed on the medical/surgical unit. You

introduce yourself, and collect the 昀漀llowing clinical data:

Albuterol; Umeclidinium-vilanterol Metoprolol Aspirin; Simvastatin

Furosemide; Lisinopril

High-grade bowel obstruction would be the admitting diagnosis and priority for plan of care for this patient.
Abd. Assessment abnormal, should not be distended.
BP has dropped after IV treatment and pain assessment from 108/52, to 99/48 which puts her as hypotensive.
If there’s no change in input and decrease in output, concerning.
Increased from normal; sign of infection.
Signs of sepsis.
Higher risk of recurrent obstruction.
Slightly elevated; monitor for trends. 9; dehydration, risk for AKA 10 end of normal; vomiting = at risk for hypokalemia

1 of her abdomen/pelvis revealed high-grade small bowel obstruction. 2. Abd. is firm, slightly distended, with tympanic bowel sounds. 3. BP : 108/52; Initial 99/ 4. Pt. reports decreased output in colostomy 5. WBC: 14. 6. Lactate: 2. 7. History of bowel obstruction 8. T: 99. 9: 1. 10: 3.

1. Pain; 5/

2. Uncomfortable; Grimacing and tense

3. Scared; history of obstruction (last

resorted in a colostomy)

4. Weak

5. Dehydrated; Dry oral mucosa

Offer pain interventions; Medications ordered, determine rate quality and source of pain.
Offer extra pillows and or blankets. Determine is frequent repositioning is needed and what positions do the patient feel most comfort in.
Offer assistance in moving, frequently offer ice chips to keep hydration.
NG tube is in place, offer oral care Q2h, as well as ice chips while IV hydration treatment is in place.

Small Bowel Obstruction

A small bowel obstruction is when a physical or nonphysical issue (twisting of intestines or decreased peristalsis) in the intestines causes blockage of the movement of stool, thereby obstructing proper elimination

What body system(s) will you assess most thoroughly based on the primary/priority problem? Identify correlating specific nursing assessments. (NCLEX Reduction of Risk Potential/Physiologic Adaptation)

PRIORITY Body System: PRIORITY Nursing Assessments:

GI

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: Risk for Fluid Volume Deficit/ Electrolyte Imbalance

GOAL of Care: Safely restore fluids and necessary electrolytes to the body

Nursing Interventions: Rationale: Expected Outcome:

Recognize symptoms of cyanosis, cold clammy skin, weak thread pulse, confusion, and oliguria as late signs of hypovolemia.
Monitor BP hourly.
Monitor I & O’s every four hours-Note color of urine, urine osmolarity, and specific gravity.
Hydrate the client with ordered isotonic IV solutions if prescribed
Review lab data as ordered and report deviations to the provider.

Patient will be re-hydrated and stable

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:

Peritonitis, tissue death caused by decreased blood supply leading to perforation and leaking of intestinal contents into peritoneum and developing an infection. Nursing Interventions to PREVENT this Complication:

Assessments to Identify Problem EARLY:

Nursing Interventions to Rescue:

Monitor vital signs for sepsis indicators: Fever more than 100 F, rapid HR, RR, cold/clammy skin, decreased LOC.

Inspection, palpation and auscultation of the abdomen Elimination (I/O of urine, output of colostomy bag) Fluid and electrolytes Pain

Knowing and recognizing signs of hypovolemia, will help for early intervention and rescue care.
BP is an indicator of fluid deficit; too low can indicate dehydration status, too high could indicate fluid overload.
Monitoring I&O’s can help determine kidney function and fluid retention. Change in color, osmolarity, and specific gravity could indicate dehydration, fluid retention, as well as indicate if care plan is therapeutic
If dehydrated, NPO with isotonic solution will rehydrate straight to bloodstream. Faster acting than oral fluids.
The nurse can indicate trends and determine if intervention is needed and plan of care is therapeutic

Neuro: confusion and disorientation are signs of sepsis.

Administer antibiotic treatment Administer fluids RAPID team

Collaborative Care: Medical Management

State the rationale and expected outcomes for the medical plan of care. (NCLEX Pharm. and Parenteral Therapies) Care Provider Orders: Rationale: Expected Outcome:
NPO w/ice chips
0% NS IV 100 mL/hour
Hydromorphone 0.25-0 mg IV every 2 hours PRN pain
NG low intermittent suction (LIS)
Hold all home meds while NPO
Assess colostomy output every 4 hours
Basic metabolic panel in morning
Complete blood count (CBC) in morning
Lactate in morning
Consult general surgery
In case the patient needs to have surgery
Since the patient is NPO, the patient would need to be hydrated
For pain that the obstruction is causing.
To help decompress the air and fluid from the bowel.
In case the patient needs to have surgery. Lowers risk of aspiration of pills and ensures anesthesia can be administered without interacting with other meds.
The nurse does not want the patients bag to become full of stool because it could leak and cause skin breakdown
BMP shows the electrolytes. The nurse can see if the patient is having an electrolyte imbalance
The nurse would want to look at the to see if there is an infection or the is high due to dehydration.
The nurse will want to monitor the patient’s lactate because of the suction from the NGT or if the patient was vomiting.
Surgeon can consult with patient and proceed with plan of care
The patient will not feel thirsty, maintain adequate hydration with lowered risk of aspiration during surgery.
The patient will remain hydrated for the duration
The patient will not complain of pain.
Tube will not adhere to the gut wall; fluid will not build up in intestines, thereby preventing vomiting.
Patient is adequately prepared for surgery
The patient’s colostomy bag will not become irritated around the skin or become too full.
The nurse will find the patient to have slight electrolyte imbalances due to the suctioning, NPO, and from the decreased bowel sounds.
The nurse will find the patient to be within normal limits if the obstruction was caught in time.
The lactate may be more basic due to the suctioning from the NGT.
The surgeon with perform surgery to correct the obstruction
Which orders do you implement first? Why? Care Provider Orders: Order of Priority: Rationale:

Part II: Interpreting Diagnostic Data

Lab Results:

Complete Blood Count (CBC) WBC HGB PLTs % Neuts Bands Current: 12 11 145 84 0 Yesterday: 14 12 158 89 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)

NPO w/ice chips

Consult general surgery

0% NS IV 100 mL/hour

Hydromorphone 0-0. mg IV every 2 hours PRN pain

NG low intermittent suction (LIS)

Hold all home meds while NPO

NG low intermittent suction (LIS)
Hydromorphone 0.25-0 mg IV every 2 hours PRN pain
0% NS IV 100 mL/hour
Hold all home meds while NPO
NPO w/ice chips
Consult general surgery
Stomach decompression and the removal of stomach content takes priority due to the ABC approach because unremoved stomach content can lead to aspiration of stomach contents.
Managing the patients pain and keeping it at an acceptable level should be the next priority to keep the patient comfortable.
Patient is exhibiting signs of dehydration; amber urine, and lips, tongue, and oral mucosa are tacky dry so keeping the patient hydrated is important.
Holding all medications should be done next to avoid any interruptions if surgery is required.
Providing ice chips is a comfort measure that should be done throughout the shift.
Consulting the general surgeon can take place after ABC management and comfort measures have taken place since the patient is not in need of immediate surgery.

RELEVANT Lab(s): Clinical Significance: TREND:

Improve/Worsening/Stable:

Part III: Evaluation: Three Hours Later...

The nurse evaluates the patient by assessing after implementing the plan of care. 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: Clinical Significance: Improving-Declining No Change:
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: Additional Interventions to Implement: Expected Outcome:

/ DFWDWH

T: 101 F

2. P: 118

3. R: 24

4. BP:139/

Pain 10/10; Sudden onset
Appears anxious, uncomfortable, pale, and sweaty

Increased temperature, above normal for 97 F; Warning sign of sepsis 2. Increased pulse above normal 99-100 bpm; Warning sign of sepsis 3. Increased respiratory rate above normal 12-18;Shallow breathing is a warning sign for sepsis. 4. Decreased BP from normal 120/80; Warning sign for sepsis. 5. Sudden onset pain would be indicator that obstructed bowel may have perforated. 6. Anxious, pale, and sweaty are all warning signs for sepsis

All declining

Declining

contact provider

CT for diagnosis confirmation

plan pre-op for emergency surgery

Improved overall status after

surgical intervention

correcting perforation of small

bowel.

Possible indication of improved circulation and

oxygen perfusion in the obstructed small intestines Improving

Situation:

Name/age:

BRIEF summary of primary problem:

Background:

Primary problem/diagnosis:

RELEVANT past medical history:

RELEVANT background data:

Assessment:

Vital signs:

RELEVANT body system nursing assessment data:

RELEVANT lab values:.

Mary O’Reilly, 55 years old

pt admitted with complaints of sharp abdominal pain with N/V and decreased colostomy bag output spanning over 3 days. Diagnosis of small bowel obstruction as indicated by CT scan. Patient was initially stabilized upon admittance to the med-surg floor, but is now experiencing a sudden decline. She is currently experiencing 10/10 abdominal pain, is diaphoretic, and her abdomen is firm and rigid.

Small bowel obstruction

Partial colectomy w/ colostomy

Small bowel obstruction 3 months ago that required no surgical intervention.

T 101, P 118, R 24, BP 139/88, O2 98%, pain 10/

GI: firm, rigid abdomen with localized 10/10 pain; nausea

K 3 (trending down, WNL)

Creatinine 0 (trending down, WNL)

Lactate 0 (trending down, WNL)

To develop clinical judgment, reflect on your thinking by answering the following questions: What did you do well in this case study? What knowledge gaps did you identify?

What did you learn? How will you apply learning caring for future patients?

Applied knowledge learned about SBO to

determine the priorities problems and possible

complications with this patient.

Analyzing lab values

Interventions that can be used during the care of a

patient with SBO, and their significance and

purpose.

Performing interventions for the current needs of a patient

but also in anticipation of what the patient’s condition

may escalate to, in this case surgery.

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