NUR 2032C Perforated bowel Part II _Sepsis/ ICU_NextGen Unfolding Reasoning

Name: Shelby Baker
Class: MMH – CM2 – Trad 2


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)
 Gas Exchange
 Perfusion
 Clinical judgment
NCLEX Client Need Categories Covered in NCSBN Clinical Covered in
Case Study Judgment Model Case Study
Safe and Effective Care Environment Step 1: Recognize Cues 
 Management of Care  Step 2: Analyze Cues 
 Safety and Infection Control Step 3: Prioritize Hypotheses 
Health Promotion and Maintenance  Step 4: Generate Solutions 
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
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:
-Hst. of colectomy w/colostomy - History of symptoms is parallel with presenting symptoms.
- Severe RLQ abdominal pain going on one day - Pain severity needs to be addressed, as well as consistency,
-CT revealed Perforated small bowel with free quality and pain rating.
intraperitoneal air - Perforated small bowel with free intraperitoneal air require
-Lactate 4.9 immediate intervention as it is a sepsis risk.
-WBC 18.9 - Over twice as much as the normal Lactate level of 0.5-1 mmol/L
- BP 94/52 - WBC is increased over normal; signs for sepsis and infection.
- BP is still low from normal 12-/80; but is trending to improving.




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 90-
100s 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:
- extensive lysis of adhesions - Adhesions may be root cause of perforation.
-perforated jejunum with fecal peritonitis -Fecal Matter within the body cavity.
-7.0 mm endotracheal tube (ET) that is well - 23 cm is baseline and needs to be monitored to confirm secure placement.
secured, 23 cm at the lips. Current vent Patient is no longer on “room air” and needs to be monitored for proper
settings are: CMV/AC rate 12, TV 500 mL, oxygenation.
PEEP +5, FiO2 35%. - Severe amount of blood loss can effect blood pressure.
- 2.5 liters of LR during the case and had an - wound VAC has adequate suction without drainage; monitor for changes
estimated blood loss (EBL) of 375 mL in VAC and adequate suction.
- wound VAC applied to her open abdominal
incision with an intact dressing at 125 mm
suction with no drainage and a 14 Fr.