perforated bowel?

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    I'm in my 3rd week of clinicals and I went to meet my client for Thursday today and the nurse said he had critical BUN and creatine values Monday and now had a perforated bowel. He has a cath and has been taking off meds and food. In other words he's probly not going to last long. Its sad, but I still have to take care of him Thurs. and Fri. if he's still with us. I have to do my care plan and my question is his original patho was dementia. Should I stick with that or put perforated bowel or something similar for the patho? We have to use our nursing fund. or med-surg. books for reference, but I could'nt find anything about perforated bowel or intestines in them. Any ideas what I should do?
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    From my understanding is he now total comfort care, and just waiting for hime to die? If thats the case, my priorities would be pain management, a perforated bowel probably wont be the most comfortable thing in the world, and there should be info on that in a med/surg text. Keeping the patient comfortable, as well as helping the family to cope if this was unexpected, there may be issues.

    Hope this help somewhat

    Cher
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    Correct, he is now on comfort care and seems to be incoherant. I'm not sure if he is on pain meds or not, there is no IV. I looked again and could'nt find anything on a perforated bowel. What else could it be under? Maybe I should just stick with dementia and note his recent condition. This is not the "real" care plan as I'm just assisting with his care as more or less a nurses aid, but we are in the process of learning how to do the care plan and need to turn it in on Friday...
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    Lower intestine perforation. Or google bowel perforation. It is very hard taking care of comfort patients, but it is easy work, but digs into the soul at the same time. So look within yourself, and be prepared to handle the event if it happens on your watch.
    Take care - remember, we're all here if you need to talk. If this is your first one, you never know how it will affect you.
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    medsport. . .ok, let me give you a little direction here. the goal, now, with the care of this patient is going to be comfort care. the nursing staff at the direction of the doctor, and most likely with the approval of the family, is going to allow the patient to die. you are going to see this happening a lot more in the acute hospitals than it used to. basically, what is being said is medical care to sustain his life is being declined, or withheld. so, you are looking for the pathophysiology of all this. what you want to do is look at what happens with a perforated bowel and carry it to it's end (death) when untreated because that is what is going to happen here. this is probably going to be different from pathophysiologies you might have done before because there is going to be no intervening treatment. so, what you are going to be looking for is, basically, how the body breaks down and fails from something like this. in addition, i am sure that there is some disease or medical problem that led up to this bowel perforation. you should mention it as the reason for the progression to the perforation. however, any treatment of that disease(s) is now irrelevant since the perforated bowel trumps it all in seriousness.

    my pathophysiology book doesn't have much on a perforated bowel. you want to look at perforated bowel. when the bowel perforates, beside the pain the patient experiences, bowel contents leak out into the abdominal cavity. that includes bacteria that pours in the bowel. untreated, the patient develops peritonitis. here are some articles on the web to help you understand the pathophysiology of what is going on because this is probably what is going to ultimately cause this man's death.
    now, with a dementia patient, you are not necessarily going to see the patient able to verbalize his symptoms except in his behavior which may be abnormal anyway. in doing your pathophysiology of this, you want to carry this through to the sepsis, multi-organ failure and shock that is going to occur. ultimately, it all will contribute to his death. so, you will need to explore a little on each of these subjects: sepsis, multi-organ failure, and shock, and how they are going to affect him physiologically.

    as for your care plan. . .since you are not going to be treating these problems, other than providing what is called comfort care, your care plan is going to primarily address self-deficit issues in performing adls, safety and some preventative care. so, look at the self-care deficit diagnoses for bathing and hygiene, grooming, and toileting. feeding you are not going to worry about. remember to address safety issues since this man does have an underlying dementia. the last thing you need is for him to roll, or try to climb, out of bed and fall. you might also want to look at risk for impaired skin integrity because he is most likely going to develop some pretty bad ascites and will be totally bedridden. if there are family members present you may also want your care plan to address any issue they have with coping with this situation. many of your nursing interventions are going to be very basic nursing care things like performing mouth care, keeping linens dry, turn and reposition the patient, etc. don't be disappointed that you won't have complicated nursing instructions on this care plan. most of it is going to be straight, basic nursing care and preparing the patient's family for the death.

    one place you can look for some information on comfort care is in hospice resources. hospices have a great deal of information on the dying process from a caregiver perspective in the resources they give out to families. if your nursing textbook does not have a chapter on hospice, see if you can find something about hospice care in a library or call a couple of local hospices and see if they will give you some of the free information they give out to their new clients on providing comfort care. in my early nursing days we saved everyone in the hospital and they were put on ventilators and kept alive until their hearts gave out. that is not so today.

    as you assess your patient tomorrow, really hone in on the adls. hope that helps get you started.
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    Quote from Medsport
    Correct, he is now on comfort care and seems to be incoherant. I'm not sure if he is on pain meds or not, there is no IV. I looked again and could'nt find anything on a perforated bowel. What else could it be under? Maybe I should just stick with dementia and note his recent condition. This is not the "real" care plan as I'm just assisting with his care as more or less a nurses aid, but we are in the process of learning how to do the care plan and need to turn it in on Friday...

    It might be under perforated viscous, or under diverticulitius which can turn into a perforation. My patho book has it listed under "perforation.....in appendicitis, in duodenal cancer, in inestinal obstruction.........".

    Do you know the cause of the perforation? You could go with that and say, he's now having complications from the original cause.

    Too bad you can't use the internet.

    Personally, I'm like you and wouldn't want to go with dementia. That's a condition he's probably had. Was his admitting diagnosis "dementia".
    Last edit by Tweety on Oct 18, '06


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