Part I: Small Bowel Obstruction NextGen Unfolding Reasoning Mary O’Reilly, 55 years old. 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...
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
Part I: Initial Nursing Assessment
Present Problem:
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:
, 1. CT of her abdomen/pelvis revealed 1. High-grade bowel obstruction would be the admitting
high-grade small bowel obstruction. diagnosis and priority for plan of care for this patient.
2. Abd. is firm, slightly distended, with 2. Abd. Assessment abnormal, should not be distended.
tympanic bowel sounds. 3. Pulse has dropped after IV treatment and pain
3. Pulse : 78; Initial 102 intervention from 102 to 78 which puts her as
4. BP : 108/52; Initial 99/48 bradycardic.
5. Pt. reports decreased output in 4. BP has dropped after IV treatment and pain assessment
colostomy from 108/52, to 99/48 which puts her as hypotensive.
6. WBC: 14.7 5. If there’s no change in input and decrease in output,
7. Lactate: 2.8 concerning.
8. History of bowel obstruction 6. Increased from normal; sign of infection.
9. T: 99.8 7. Signs of sepsis.
10. Creatinine: 1.35 8. Higher risk of recurrent obstruction.
11. Potassium: 3.7 9. Slightly elevated; monitor for trends.
10. High; dehydration, risk for AKA
11. Low end of normal; vomiting = at risk for hypokalemia
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