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Part II: Perforated Bowel/Sepsis/ICU NextGen Unfolding Reasoning
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Part II: Perforated Bowel/Sepsis/ICU NextGen Unfolding Reasoning
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Part II: Perforated Bowel/Sepsis/ICUNextGen Unfolding Reasoning
NURSING
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
Copyright © 2020 Keith Rischer, d/b/a KeithRN. All Rights reserved.
, 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:
Lactate 4.9 Lactate is not being excreted from the blood and could indicate organs are
WBC 18.9 not functioning properly.
Systolic BP 65-75 Increased WBCs indicate infection.
MAP 50-55 Low systolic BP and low MAP could indicate sepsis.
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:
7.0 mm endotracheal tube Patient probably went into respiratory arrest during surgery.
CMV/AC rate 12, TV 500 mL, PEEP +5, Patient is unable to breath on her own requiring ventilation.
FiO2 35% Blood loss could decrease blood pressure.
Estimated blood loss 375 mL SBP and MAP is stabilizing.
SBP 90-100s High CVP indicates decreased cardiac output.
MAP 65-70 NG for decompression.
CVP 12
14 Fr. Salem sump NG
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