Part II: Perforated Bowel/Sepsis/ICU NextGen Unfolding Reasoning Mary O’Reilly, 55 years old (complete) latest 2021

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 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  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?