Small Bowel Obstruction Case Study Help! Please!

[savexpigoo]

hello everyone, i have to do a case study on small bowel obstruction. i've tried answering most of the questions, but i am not sure if they are correct. i was hoping you guys can help out...adding or changing anything. thank you in advance! i would appreciate it!

scenario: while you are working as a nurse on a gastrointestinal/genitourinary (gi/gu) floor, you receive a call from your affiliate outpatient clinic notifying you of a direct admission, eta (estimated time of arrival) 60 minutes. she gives you the following information: a.g. is an 87-year-old woman with a 3-day history of intermittent abdominal pain, abdominal bloating, and nausea and vomiting (n/v). a.g. moved from italy to join her grandson and his family only 2 months ago, and she speaks little english. all information was obtained through her grandson. past medical history (pmh) includes colectomy for colon cancer 6 years ago and ventral hernia repair 2 years ago. she has no history of coronary artery disease (cad), diabetes mellitus (dm), or pulmonary disease. she takes only ibuprofen occasionally for mild arthritis. allergies include sulfa drugs and meperidine. a.g.'s tentative diagnosis is small bowel obstruction (sbo) secondary to adhesion. a.g. is being admitted to your floor for diagnostic work-up. her vital signs are stable, she has an iv of d51/2ns with 20 meq kci at 100 ml/hr, and 3 l oxygen by nasal cannula (o2/nc).

1.based on the nurse's report, what signs of bowel obstruction did a.g. manifest?

-intermittent abdominal pain - most sbo cause waves of cramping abdominal pain around the periumbilical area.

-abdominal bloating - blockages may cause bloating in the lower abdomen. you may also hear gurgling sounds coming from your belly. with a complete obstruction, your doctor may hear high-pitched sounds when listening with a stethoscope. the sounds decrease as movement of the bowel slows.

-nausea and vomiting - the vomit is usually green if the obstruction is in the upper small intestine and brown if it is in the lower small intestine.

2.are there other signs and symptoms that you should observe for while a.g. is in your care?

-continuous severe pain in one area can mean that the blockage has cut off the bowel's blood supply. this is called a bowel strangulation and requires emergency treatment.

-elimination problems - constipation (late finding) and inability to pass gas are common signs of a bowel obstruction. however, when the bowel is partially blocked, you may have diarrhea (early finding) and pass some gas. if you have a complete obstruction, you may have a bowel movement if there is stool below the obstruction.

-fever and tachycardia - late sign; may be related to strangulation

-peritoneal signs

-abdominal distention

-hyperactive bowel sounds occur early as gi contents attempt to overcome the obstruction; hypoactive bowel sounds occur late

-gross or occult blood - late strangulation or malignancy

-masses - obturator hernia

3.a.g. and her grandson arrive on your unit. you admit a.g. 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 complete a physical examination and take a history. what will you do first?

-build up a relationship of trust; attempt to obtain patient's cooperation

4.the grandson, an attorney, tells you elderly italian women are extremely modest and may not answer questions completely. how might you gather info in this case?

-explaining to the patient that the info she gives will be treated as confidential, and maintaining this confidentiality

-give the patient an understanding of her problem

-be non-judgmental

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

- ask about the location, duration, intensity, and frequency of abdominal pain

- onset, frequency, color, odor, and amount of vomitus

- bowel and renal functioning

- nutritional/diet

-health/medical history

-any other allergies?

-dates and type of immunizations received

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

-sbo pain is colicky, cramp-like, and intermittent

-lbo pain is low-grade, cramping abdominal pain

7.with some difficulty, you insert a nasogastric tube into a.g. and connect it to intermittent low wall suction. how will you check for placement of the ngt? pg. 1267

-ask the patient to hum or talk. coughing, cyanosis, and choking may indicate that the ngt has passed through the larynx.

-inspect posterior pharynx for coiled tube.

-aspirate gently to collect gastric content and test for ph - 4 or less is expected.

-obtain an x-ray to verify placement before instilling any feedings/medications or if you have concerns about the placement of the tube.

-injecting air into the tube and listening over the abdomen is not acceptable practice because it does not guarantee tube position.

8.list, in order, the structures through which the ngt must pass as it is inserted.

-patient's nostrils

-nasopharynx

-oropharynx

-pharynx

-esophagus

-stomach

9.what comfort measures are important for a.g. while she has an ngt?

-proper positioning

-provide frequent oral hygiene

-clean the nostril and tube with moistened, cotton-tipped applicators

-secure tubing to the client's gown

10.you note that a.g.'s ngt has not drained in the last 3 hours. what can you do to facilitate drainage?

-reverse trendelenburg

11.the ngt suddenly drains 575 ml; then it slows down to about 250 ml over 2 hours. is this an expected amount?

-no

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

-auscultate for bowel sounds

-fever or tachycardia

-abdominal masses

-tenderness, site, size

13.which lab values are of concern to you? why? pg. 1061

1. serum chemistries: results are usually normal or mildly elevated.
   
2. bun level: if the bun level is increased, this may indicate decreased volume state (eg, dehydration).
   
3. creatinine level: creatinine level elevations may indicate dehydration.
   
4. cbc: wbc count may be elevated with a left shift in simple or strangulated obstructions. increased hematocrit is an indicator of volume state (ie, dehydration).
   
5. lactate dehydrogenase tests
   
6. urinalysis
   
7. type and crossmatch - the patient may require surgical intervention.
   

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

[Daytonite, BSN, RN]

10.you note that a.g.'s ngt has not drained in the last 3 hours. what can you do to facilitate drainage?

-reverse trendelenburg

this is not correct. (1) the patient might not tolerate trendelenburg position (2) they could aspirate and choke on the secretions (3) the bed may not got into a trendeleburg positiojn

11.the ngt suddenly drains 575 ml; then it slows down to about 250 ml over 2 hours. is this an expected amount?

-no

i say the answer is "yes".

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

-auscultate for bowel sounds

-fever or tachycardia

-abdominal masses

-tenderness, site, size

all are wrong. there is only one way to determine whether there is a +/- change in the abdominal distention.

[savexpigoo]

How do i determine whether there is a change in the abdominal distention?

[Daytonite, BSN, RN]

How do i determine whether there is a change in the abdominal distention?

distension - inflation, expansion

change - an equivalent sum in different denominations

• Make comparisons of daily abdominal girth measurements.