CHAPTER 4 GASTROINTESTINAL DISORDERS CASE STUDY 45 Small bowel obstruction Case Study 45 Name Class/Group Date Group Mem

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CHAPTER 4 GASTROINTESTINAL DISORDERS CASE STUDY 45 Small bowel obstruction Case Study 45 Name Class/Group Date Group Members INSTRUCTIONS All questions apply to this case study. Your responses 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. If your response is not legible, it will be marked as ? and you will need to rewrite it. 4 Gastrointestinal Scenario While you are working as a nurse on a gastrointestinal/genitourinary (GI/GU) unit, you receive a call from your affiliate outpatient clinic notifying you of a direct admission, with an estimated time of arrival of 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 very little English. All infor- mation was obtained through her grandson. Past medical history includes colectomy for colon cancer 6 years ago and ventral hernia repair 2 years ago. She has no history of coronary artery disease, diabetes mellitus, or pulmonary disease. She takes only ibuprofen (Motrin) occasionally for mild arthritis. Allergies include sulfa drugs and meperidine. A.G's tentative diagnosis is small bowel obstruction (SBO) second- ary to adhesions. A.G. is being admitted to your floor for diagnostic workup. Her vital signs (VS) are stable, she has an IV of D5Y2NS with 20 mEq KCl infusing at 100 mL/hr, and 3L oxygen by nasal cannula (O,/NC). 1. Based on the nurse's report, what signs of bowel obstruction does A.G. manifest? 2. Are there other signs and symptoms that you should observe for while A.G. is in your care? 3. While A.G. is on the way, you have secured the hospital's interpreter service on the telephone. A.G. arrives on your unit with her grandson. You admit A.G. to her room and introduce yourself as her nurse. As her grandson introduces her, she pats your hand. You know that you need to complete a physical examination and take a history. What will you do first? 4. Before you begin your examination, you ask the grandson to excuse himself, explaining the hospital's confidentiality policies. The grandson, an attorney, tells you that elderly Italian women are extremely modest and might not answer questions completely. How might you gather information, in this case?

47 PM PDF.js viewer PART 1 MEDICAL-SURGICAL CASES 5. What key questions must you ask this patient while you have the use of an interpreter? 6. For each characteristic listed, specify whether it is a characteristic of small-bowel obstruction (SBO), large bowel obstruction (LBO), or both (B). a. Intermittent lower abdominal cramping b. Abdominal discomfort or pain accompanied by visible peristaltic waves in the upper and middle abdomen c. Upper or epigastric abdominal distention d. Distention in the lower abdomen e. Obstipation f. Ribbon-like stools 8. Nausea and early, profuse vomiting, which may contain fecal material h. Minimal or no vomiting i. Severe fluid and electrolyte imbalances 7. What is obstipation? 8. With some difficulty, you insert a Salem Sump nasogastric tube (NGT) into A.G. and connect it to intermittent low wall suction. How will you check for placement of the NGT?

CHAPTER 4 GASTROINTESTINAL DISORDERS CASE STUDY 45 10. A.G.'s grandson asks you, "What is that blue thing at the end of the tube? Shouldn't it be connected to something?" How do you answer? 11. What comfort measures are important for A.G. while she has an NGT? 12. You note that A.G.'s NGT has not drained in the last 3 hours. What can you do to facilitate drainage? 13. The NGT suddenly drains 575 mL; then it slows down to about 250 mL over 2 hours. Is this an expected amount? 14. You enter A.G.'s room to initiate your shift assessment. A.G. has been hospitalized for 3 days, and her abdomen seems to be more distended than yesterday. How would you determine whether A.G.'s abdominal distention has changed? CASE STUDY PROGRESS After 3 days of NGT suction, A.G's symptoms are unrelieved. She reports continued nausea, cramps, and sometimes 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.

PDF.js viewer PART 1 MEDICAL-SURGICAL CASES H Chart View 4 Gastrointestinal Laboratory Test Results Test Admission Sodium 136 mEq/L Potassium 3.7 mEq/L Chloride 108 mEq/L Carbon dioxide 25 mEq/L BUN 19 mg/dL Creatinine 1 mg/dL Glucose 126 mg/dL Albumin 3.0 g/dL Protein 6.8 g/dL Hospital Day 3 130 mEq/L 2.5 mEq/L 97 mEq/L 31 mEq/L 38 mg/dL 2.2 mg/dL 65 mg/dL 3.1 g/dl 4.9g/dL 15. Which lab values are of concern to you? Why? 16. What measures do you anticipate to correct in each of the imbalances described in Question 15?