Part I: Small Bowel Obstruction
NextGen Unfolding Reasoning
Mary O’Reilly, 55 years old
Primary Concept
Elimination
Interrelated Concepts (In order of emphasis)
Patient Education
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
Present Problem:
Copyright © 2020 Keith Rischer, d/b/a KeithRN. All Rights reserved.
, Part I: Initial Assessment
Nursing
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:
-A hx of partial colectomy w/colostomy and small bowel obstruction three months ago, -Partial colectomy and postsurgical scar tissue from adhesions can put the patient at risk of recurrent obstruction.
that resolved with bowel rest and required no surgical intervention. -A sudden onset of sharp generalized abdominal pain with nausea, vomiting and decreased output from her
-Three days ago, Mary developed a sudden onset of sharp generalized abdominal pain colostomy bag are symptoms of bowel obstruction.
with nausea, vomiting and decreased output from her colostomy bag.
-She is at risk for dehydration.
-She has had two small glasses of water today.
-CT of her abdomen/pelvis revealed high-grade small bowel obstruction -This confirms a bowel obstruction.
-Lactate 2.8 -Normal lactate levels are 0.5-1 mmol/L. She has moderately elevated lactate level, which can still put her at risk
-WBC 14.7 for metabolic acidosis
-Potassium 3.7 -Normal WBC for females between 5.0-11.0 Her elevated WBC may be an indication of an acute infection or
-Creatinine 1.35 inflammation related to bowel obstruction.
-An NG was placed and is on low intermittent suction. She had NG output of 225 mL of -Normal serum potassium levels are 3.5-5 mEq/L. Her potassium level is in normal range, but the fact she has
bile green liquid. been nauseated and vomiting for three days put her at risk for hypokalemia.
-Received hydromorphone 0.5 mg IV for pain one hour ago. Abdominal pain decreased -Normal serum creatinine is 0.601.2 mg/dL. Her creatinine is slightly elevated, which can indicate dehydration.
from 9/10 to 3/10 and she is resting more comfortably. -Because the patient is experiencing bowel obstruction, bile green nasogastric drainage is expected.
-Abdomen is firm, slightly distended, with tympanic bowel sounds.
-Patient has received narcotic analgesic. We should provide her comfort and monitor for recurrent pain.
-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% -These findings are some of the symptoms of small bowel obstruction.
NS bolus. -Tachycardia and hypotension are indications of dehyd rati on .
-Her vital signs return to normal after administering her fluids.
After receiving report, you quickly review this patient’s past medical
history and home medications in the electronic health record:
1. WHY is your patient receiving these home medications? Draw lines to connect the medication to the problem it
is most likely treating. (NCLEX: Pharmacologic and Parenteral Therapies)
Past Medical History: Home Medications:
COPD Aspirin 81 mg PO daily
Paroxysmal atrial fibrillation Furosemide 20 mg PO daily
Coronary artery disease Lisinopril 5 mg PO daily
Diverticulitis Metoprolol 25 mg PO BID
Small bowel obstruction Simvastatin 20 mg PO daily
Partial colectomy w/colostomy Umeclidinium-vilanterol 62.5/25 mcg inhaler 1 puff daily
Non-dilated cardiomyopathy-EF 25% Albuterol 0.083% neb solution 3 mL every 6 hours PRN
Mary is transferred from the cart to her bed on the medical/surgical unit. You
introduce yourself, and collect the following clinical data:
Copyright © 2020 Keith Rischer, d/b/a KeithRN. All Rights reserved.
NextGen Unfolding Reasoning
Mary O’Reilly, 55 years old
Primary Concept
Elimination
Interrelated Concepts (In order of emphasis)
Patient Education
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
Present Problem:
Copyright © 2020 Keith Rischer, d/b/a KeithRN. All Rights reserved.
, Part I: Initial Assessment
Nursing
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:
-A hx of partial colectomy w/colostomy and small bowel obstruction three months ago, -Partial colectomy and postsurgical scar tissue from adhesions can put the patient at risk of recurrent obstruction.
that resolved with bowel rest and required no surgical intervention. -A sudden onset of sharp generalized abdominal pain with nausea, vomiting and decreased output from her
-Three days ago, Mary developed a sudden onset of sharp generalized abdominal pain colostomy bag are symptoms of bowel obstruction.
with nausea, vomiting and decreased output from her colostomy bag.
-She is at risk for dehydration.
-She has had two small glasses of water today.
-CT of her abdomen/pelvis revealed high-grade small bowel obstruction -This confirms a bowel obstruction.
-Lactate 2.8 -Normal lactate levels are 0.5-1 mmol/L. She has moderately elevated lactate level, which can still put her at risk
-WBC 14.7 for metabolic acidosis
-Potassium 3.7 -Normal WBC for females between 5.0-11.0 Her elevated WBC may be an indication of an acute infection or
-Creatinine 1.35 inflammation related to bowel obstruction.
-An NG was placed and is on low intermittent suction. She had NG output of 225 mL of -Normal serum potassium levels are 3.5-5 mEq/L. Her potassium level is in normal range, but the fact she has
bile green liquid. been nauseated and vomiting for three days put her at risk for hypokalemia.
-Received hydromorphone 0.5 mg IV for pain one hour ago. Abdominal pain decreased -Normal serum creatinine is 0.601.2 mg/dL. Her creatinine is slightly elevated, which can indicate dehydration.
from 9/10 to 3/10 and she is resting more comfortably. -Because the patient is experiencing bowel obstruction, bile green nasogastric drainage is expected.
-Abdomen is firm, slightly distended, with tympanic bowel sounds.
-Patient has received narcotic analgesic. We should provide her comfort and monitor for recurrent pain.
-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% -These findings are some of the symptoms of small bowel obstruction.
NS bolus. -Tachycardia and hypotension are indications of dehyd rati on .
-Her vital signs return to normal after administering her fluids.
After receiving report, you quickly review this patient’s past medical
history and home medications in the electronic health record:
1. WHY is your patient receiving these home medications? Draw lines to connect the medication to the problem it
is most likely treating. (NCLEX: Pharmacologic and Parenteral Therapies)
Past Medical History: Home Medications:
COPD Aspirin 81 mg PO daily
Paroxysmal atrial fibrillation Furosemide 20 mg PO daily
Coronary artery disease Lisinopril 5 mg PO daily
Diverticulitis Metoprolol 25 mg PO BID
Small bowel obstruction Simvastatin 20 mg PO daily
Partial colectomy w/colostomy Umeclidinium-vilanterol 62.5/25 mcg inhaler 1 puff daily
Non-dilated cardiomyopathy-EF 25% Albuterol 0.083% neb solution 3 mL every 6 hours PRN
Mary is transferred from the cart to her bed on the medical/surgical unit. You
introduce yourself, and collect the following clinical data:
Copyright © 2020 Keith Rischer, d/b/a KeithRN. All Rights reserved.
