Help with case study

mandajane4 · Nov 13, 2010

I am taking a nursing synthisis class and we have been given our first case study. I dont really know where to start. Any advise would be very helpful. Thanks

Case Study

Nursing Care of the Patient with

Gastrointestinal Dysfunction

© You are working as a nurse on a Medical Surgical unit and receive a call from an outpatient clinic notifying you of a direct admission. The estimated time of arrival is approximately one (1) hour. She gives you the following information: PB is an 87 year-old woman with a three day history of intermittent abdominal pain, abdominal bloating and nausea and vomiting. PB moved from Italy to join her grandson and his family two months ago. She speaks very little English. All information was obtained through her grandson. PMH is significant for a colectomy for colon cancer six years ago, ventral hernia repair two years ago. No history of heart disease, diabetes or pulmonary disease. She takes only ibuprofen occasionally for mild arthritis. Allergies include sulfa drugs and meperidine. PB's tentative diagnosis is small bowel obstruction (SBO) secondary to adhesions. PB is admitted to your floor for diagnostic work-up. Her VS are stable, she has an IV of 1000 mL D5½ NS with 20 mEq KCl at 100 mL/hr, and O2 @ 3L per NC.

1. Based on the nurse's report, what signs of bowel obstruction did PB present?

2. Are there other signs and symptons that you should observe for while PB is in your care?

3. PB and her grandson arrive on your unit. You admit PH to her room and introduce yourself as her nurse. As her grandson interprets for her, she pats your hand. You know that you need to do a complete physical assessment and take a history. What will you do first?

4. The grandson, an attorney, tells you elderly women are extremely modest and may not answer questions completely. Ho might you gather information in this case?

5. What key questions must you ask this patient while you have the use of an interpreter?

6. How would the description of PB's pain differ if she has a small versus large bowel obstruction?

7. List in order, the structures through which the NGT must pass to be inserted.

8. With some difficulty, you insert an NGT into PH and connect it to intermittent LWS. How will you check placement of the NGT?

9. What comfort measures are important for PB while she has an NGT?

10. You note that PB's NGT has not drained in the last 3 hours. What can you do to facilitate drainage?

11. The NGT suddenly drains 575 mL; then it slows down to about 250 mL/2hr. Is this an expected amount?

12. You enter PB's room to initiate your shift assessment. PB has been hospitalized 3 days and her abdomen seems to be more distended than yesterday. How would you determine whether PB's abdominal distention has changed?

© After 3 days of NGT suction, PB's symptoms are unrelieved. She reports continued nausea, crampy, and sometimes very strong abdominal pain; her hand grips are weaker; and she seems to be increasingly lethargic. You look up her latest laboratory values and compare them with the admission data. Her sodium has changed from 136 to 130 mmol/L, potassium has changed from 3.7 to 2.5 mmol/L, Chloride from 108 to 97 mmol/L, glucose 126 to 65 mg/dL, albumin from 3.0 to 2.1 g/dL, and protein from 6.8 to 4.9 g/dL.

13. Which lab values are of concer to you? Why?

14. What measures do you anticipate to correct each of the imbalances described in question #13?

© In view of PB's continued slow deterioration, the surgeon meets with the patient and her family and they agree to surgery. The surgeon releases an 18 inch section of proximal ileum that has been constricted by adhesions. Several areas looked ischemic, so these are excised, and an end-to-end anastomosis was done. PB tolerated the procedure well and recovered rapidly from the anesthesia in the postanesthesia care unit (PACU). Once on the unit, her recovery was slow but steady. PB went home in the care of her grandson and his wife on the seventh post-op day. Discharge plans included walking several times per day in the house; importance of cough and deep breathing (C&DB) and use of incentive spirometer (IS) Q2H; and observing the wound for signs and symptoms of infection.

In reviewing the beginning of this care, it is clear that PB's nutritional status has been poor. It would be appropriate for her to have a medical nutritional therapy regarding long-term nutrient needs. Be sure the grandson is included in any plans