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NR 224/226 Clinical / Simulation Make-up Assignment
Instructions: All questions apply to this case study. Your Reponses should be brief and to the point. When asked to provide several answers, list them in order of priority or significance. Do not assume information that is not provided. Please print or write clearly.
In?ammatory Bowel Disease with Small Bowel Obstruction
Part 1: Case study-Scenario
C.W., a 36-year-old woman, was admitted several days ago with a diagnosis of recurrent in?ammatory bowel disease (IBD) and possible small bowel obstruction (SBO). C.W. is married, and her husband and 11-year-old son are supportive, but she has no extended family in-state. She has had IBD for 15 years and has been taking mesalamine (Asacol) for 15 years and prednisone 40 mg/day for the past 5 years.
She is very thin; at 5¢2≤ she weighs 86 pounds and has lost 40 pounds over the past 10 years. She has an average of 5 to 10 loose stools per day. C.W.'s life has gradually become dominated by her disease (anorexia; lactase de?ciency; profound fatigue; frequent nausea and diarrhea; frequent hospitalizations for dehydration; and recurring, crippling abdominal pain that often strikes unexpectedly). The pain is incapacitating and relieved only by a small dose of diazepam (Valium), Pedialyte, and total bed rest.
She con?des in you that sexual activity is dif?cult: "It always causes diarrhea, nausea, and lots of pain. It's dif?cult for both of us." She is so weak she cannot stand without help. You write complete bed rest (CBR) with side rails up on the char. (You also make a mental note of the probability that she has osteoporosis secondary to long-term steroid use.)
1. Identify six priority problems for C.W. A, she is malnourished, she has lost weight over the last 10years and she weigh 86 pounds. B, life has become unbearable and has develop insomnia due to her disease (anorexia; lactase de?ciency fatigue, frequent nausea and diarrhea, frequent hospitalizations for dehydration; and recurring, crippling abdominal pain that often strikes unexpectedly) C, her sexual life suffers and that affects her husband as well because she confided in me that sex is difficult). D, her social life and physical activities suffers due to the fact that she is week and cannot stand without help. E, she suffers from abdominal pain and has to take valium. F, she is in complete bed rest with rails up on the chart so she can't normally do things she likes.
2. You enter C.W.'s room and note that she has been crying. You ask what's wrong, and she explains that the nurse who admitted her to the hospital the last time said, "Welcome to death row!" C.W. says that she is knowledgeable about her condition, but she still can't seem to shake that "death row" feeling. She was afraid to come to the hospital this time.
What can you do to help this woman?
CASE STUDY PROGRESS
C. W. states, "Treat me with respect, and as a person, not a disease. Act like I have the right and intelligence to understand my condition. Recognize that I probably know what I'm talking about when I refuse a delicious milkshake. When I'm NPO or nauseated, please don't pop popcorn where I can smell it! It's pure torture!"
3. Considering C.W.'s weakness, chronic diarrhea, and lower-than-desired body weight, what interventions should minimize skin breakdown?
CASE STUDY PROGRESS
C.W.'s condition deteriorates on the third day after admission; she experiences intractable abdominal pain and unrelenting nausea and vomiting (N/V). C.W. is taken to the operating room (OR) for probable SBO and is readmitted to your unit from the postanesthesia care unit (PACU). During surgery, 38 inches of her small bowel were found to be severely stenosed with 2 areas of visible perforation. Much of the remaining bowel is severely in? amed and friable. A total of 5 feet of distal ileum and 2 feet of colon have been removed, and a temporary ileostomy was established. She has a Jackson-Pratt (JP) drain to bulb suction in her right lower quadrant (RLQ), and her wound was packed and left open. She has two peripheral IVs, a nasogastric tube (NGT), and a Foley catheter. Her vital signs (VS) are 112/72, 86, 24, 100.8° F (tympanic).
4. You begin a thorough postoperative assessment of C.W.'s abdomen. What does your assessment include? List these steps in the order in which the assessment should be completed.
5. A nursing student enters C.W.'s room and auscultates her abdomen. She looks at you and excitedly announces that she hears good bowel sounds. You take the opportunity to teach her the proper method of auscultating bowel sounds on a patient who has NGT to continuous low wall suction (LWS). How would you correct her error?
CASE STUDY PROGRESS
The nursing student follows your advice and listens again. She says "You're right, I didn't hear a thing." You tell her that she can impress her classmates while educating them in the correct technique.
6. C.W. is 4 days postop. During the routine dressing change, you note a small pool of yellow-green drainage in the deepest part of the wound. You realize the physician will want a wound culture. How will you culture C.W.'s wound?
7. You obtain a wound culture, complete the dressing change, obtain a full set of VS, note a temperature of 100.4° F, and assess increased tenderness in C.W.'s abdomen. You call to notify the physician and ask for additional orders. What orders do you anticipate?
8. What information do you need to send to the lab with the wound culture specimen?
9. The physician calls back and asks you to describe C.W.'s wound. What key aspects of the wound should be included?
10. The physician asks you how C.W.'s stoma and drainage look. What should a healthy stoma and usual drainage look like? Will any aspect of C.W.'s history signi?cantly affect the wound healing process? How?
11. With a fairly signi?cant wound infection developing, why is C.W.'s temperature relatively low?
12. The physician tells you that she will be over to examine C.W. As you tell C.W. that her doctor is coming to talk to her, C.W. says that she feels something wet running down her side. You ?nd some leakage of intestinal drainage onto the skin. What should you do?
Part 2: CASE STUDY PROGRESS
You change the ileostomy appliance before the physician arrives. C.W. is evaluated, and it is determined that she should return to surgery for an exploratory laparotomy.
In?ammatory Bowel Disease with Peritonitis
Scenario (Continuation of above Case Study)
C.W. is a 36-year-old woman admitted 7 days ago for in?ammatory bowel disease (IBD) with small bowel obstruction (SBO). She underwent surgery 3 days after admission for a colectomy and ileostomy. She developed peritonitis and 4 days later returned to the operating room (OR) for an exploratory laparotomy, which revealed another area of perforated bowel, generalized peritonitis, and a ?stula tract to the abdominal surface. Another 12 inches of ileum were resected (total of 7 feet of ileum and 2 feet of colon). The peritoneal cavity was irrigated with normal saline (NS), and 3 drainage tubes were placed: a Jackson-Pratt (JP) drain to bulb suction, a rubber catheter to irrigate the wound bed with NS, and a sump drain to remove the irrigation. The initial JP drain remains in place. A right subclavian triple-lumen catheter was inserted.
13. C.W. returns from post-anesthesia recovery unit (PACU) on your shift. What do you do
14. You pull the covers back to inspect the abdominal dressing and ?nd that the original surgical dressing is saturated with fresh bloody drainage. What should you do?
15. C.W. has a total of 4 tubes in her abdomen, as well as a nasogastric tube (NGT). What information do you want to know about each tube?
16. The sump irrigation ?uid bag is nearly empty. You close the roller clamp, thread the IV tubing through the infusion pump, check the irrigation catheter connection site to make certain it is snug, and then discover that the nearly empty liter bag infusing into C.W.'s
abdomen is D5W, not NS. Does this require any action? If so, give rationale for actions, and explain the overall situation.
CASE STUDY PROGRESS
The physician arrives on the unit and removes C.W.'s surgical dressing. There is a small "bleeder" at the edge of the incision, so the physician calls for a suture and ties off the bleeder. You take the opportunity to ask her about a morphine patient-controlled analgesia (PCA) pump for C.W., and the physician says she will write the orders right away.
17. Postoperative pain will be a problem for C.W. after the anesthesia wears off. How do you plan to address this?
18. Pharmacy delivers C.W.'s ?rst bag of total parenteral nutrition (TPN). The physician has instructed you to start the TPN at a rate of 60 ml/hr and decrease the maintenance IV rate by the same amount. What is the purpose of this order?
19. The physician did not speci?cally order glucose monitoring, but you know that it should be initiated. You plan to conduct a ?ngerstick blood test every 2 hours for the ?rst several hours. What is your rationale?
20. C.W.'s blood glucose increased temporarily, but by the next day it dropped to an average of 70 to 80 mg/dl and has remained there for 2 days. Her VS are stable, but her abdominal wound shows no signs of healing. She has lost 1 kg over the past 3 days. What do these
data mean?
CASE STUDY PROGRESS
You discuss your concerns with C.W.'s physician, and she agrees to request a consult from a registered dietitian (RD). After gathering data and making several calculations, the RD makes recommendations to the attending physician. The TPN orders are adjusted, C.W. begins to gain weight slowly, and her wound shows signs of healing. Nutritional problems in clinical populations can be complex and often
require special attention.
21. You and a co-worker read the following in C.W.'s progress notes: "Wound healing by secondary closure. Formation of granular tissue with epithelialization noted around edges. Have requested dietitian to consult on ongoing basis. Will continue to follow." Your
co-worker turns to you and asks whether you know what that means. How would you explain?
22. Both of you start to discuss what speci?c digestive dif?culties C.W. is likely to face in the future. What problems might C.W. be prone to develop after having so much of her bowel removed?
23. The RD consults with C.W. about dietary needs. You attend the session so that you will be able to reinforce the information. What basic information is the RD likely to discuss with C.W.?
24. After 3 days of dressing changes, C.W.'s skin is irritated, and a small skin tear has appeared where tape was removed. How can you minimize this type of skin breakdown and help this area heal?
25. What speci?cs of ostomy teaching do you plan to do?
CASE STUDY PROGRESS
C.W. successfully battled peritonitis. Gradually, tubes were removed as she grew stronger with TPN and time. C.W. learned how to change her ostomy appliance and was discharged home.