Part I: Small Bowel Obstruction NextGen SKINNY Reasoning

Part I: Small Bowel Obstruction NextGen SKINNY Reasoning Mary O’Reilly, 55 years old Primary Concept Elimination Interrelated Concepts (In order of emphasis) • Clinical judgment NCLEX Client Need Categories Covered in Case Study NCSBN Clinical Judgment Model Covered in 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  Present Problem: Part I: Initial Nursing Assessment 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 • 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: Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment: T: 99.5 F/37.5 C (oral) Provoking/Palliative: No change in position or movement influences pain P: 94 (regular) Quality: cramping R: 16 (regular) Region/Radiation: Generalized abdomen BP: 118/64 Severity: 5/10 O2 sat: 98% room air Timing: continuous 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: Clinical Significance: Current Head to Toe Nursing Assessment: GENERAL SURVEY: Pleasant, calm, body tense, grimacing, appears uncomfortable NEUROLOGICAL: Alert & oriented to person, place, time, and situation (x4); muscle strength 5/5 in both upper and lower extremities bilaterally. HEENT: Head normocephalic with symmetry of all facial features. PERRLA, sclera white bilaterally, conjunctival sac pink bilaterally. Lips, tongue, and oral mucosa tacky dry RESPIRATORY: Breath sounds clear with equal aeration on inspiration and expiration in all lobes anteriorly, posteriorly, and laterally, nonlabored respiratory effort on room air. CARDIAC: No edema, heart sounds regular S1S2, 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. ABDOMEN: Abdomen round, firm, and generalized abdominal tenderness. BS tympanic in upper quadrants, hypoactive in lower quadrants GU: Voiding without difficulty, urine clear/dark amber INTEGUMENTARY: Skin pink, warm, dry, intact, normal color for ethnicity. No clubbing of nails, cap refill <3 seconds, Hair soft-distribution normal for age and gender. Skin integrity intact, skin turgor elastic, no tenting present. What assessment data is 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/Health Promotion & Maintenance) RELEVANT Assessment Data: Clinical Significance: Part II: Put it All Together to Think Like a Nurse 1. What is the pathophysiology of the priority problem? (NCLEX Management of Care/Physiologic Adaptation) Priority Problem: Pathophysiology of Problem in OWN Words: 2. 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: GOAL of Care: Nursing Interventions: Rationale: Expected Outcome: Collaborative Care: Medical Management 3. 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 0.9% NS IV 100 mL/hour Hydromorphone 0.25-0.5 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 (BMP) in morning Complete blood count (CBC) in morning Lactate in morning Consult general surgery