Nursing assessment for small bowel obstruction

Case Study

NCSBN Clinical

Judgment Model

Covered in

Case Study Safe and Effective Care Environment Step 1: Recognize Cues 

 Management of Care  Step 2: Analyze Cues 

 Safety and Infection Control Step 3: Prioritize Hypotheses 

Health Promotion and Maintenance  Step 4: Generate Solutions 

Psychosocial Integrity Step 5: Take Action 

Physiological Integrity Step 6: Evaluate Outcomes 

 Basic Care and Comfort

 Pharmacological and Parenteral

Therapies



 Reduction of Risk Potential 

 Physiological Adaptation 

Copyright © 2020 Keith Rischer, d/b/a KeithRN. All Rights reserved.

Part I: Initial Nursing Assessment Present Problem: Mary O’Reilly is a 55-year-old woman with a prior history of partial colectomy w/colostomy and small bowel obstruction

three months ago that resolved with bowel rest and required no surgical intervention. Three days ago Mary developed a

sudden onset of sharp generalized abdominal pain with nausea, vomiting and decreased output from her colostomy bag.

She has had two small glasses of water today. Mary is admitted to the medical/surgical unit and you will be the nurse

caring for her. You receive the following highlights of report from the emergency department (ED) nurse:

 CT of her abdomen/pelvis revealed high-grade small bowel obstruction.

 Lactate 2.8, WBC 14.7, Sodium 143, Potassium 3.7, Creatinine 1.35

 An NG was placed and she is on low intermittent suction. She had NG output of 225 mL of bile green liquid.

 Received hydromorphone 0.5 mg IV for pain one hour ago. Abdominal pain decreased from 9/10 to 3/10 and she

is resting more comfortably.

 Abd. is firm, slightly distended, with tympanic bowel sounds.

 Initial HR/BP was 102 and 92/48.

 Most recent vital signs: T: 99.8 (o) P: 78 (reg) R: 18 BP: 108/52 after 1000 mL 0.9% NS bolus 20 g. peripheral IV

in left forearm.

What data from the history are RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential)

RELEVANT Data from Present Problem: Clinical Significance:

1. WHY is your patient receiving these home medications? Draw lines to connect the medication to the problem it

is most likely treating. (NCLEX: Pharmacologic and Parenteral Therapies) Past Medical History: Home Medications:

COPD

Paroxysmal atrial fibrillation

Coronary artery disease

Diverticulitis

Small bowel obstruction

Partial colectomy w/colostomy

Non-dilated cardiomyopathy-EF 25%

Aspirin 81 mg PO daily

Furosemide 20 mg PO daily

Lisinopril 5 mg PO daily

Metoprolol 25 mg PO BID

Simvastatin 20 mg PO daily

Umeclidinium-vilanterol 62.5/25 mcg inhaler 1 puff daily

Albuterol 0.083% neb solution 3 mL every 6 hours PRN

After receiving report, you quickly review this patient’s past medical

history and home medications in the electronic health record:

Mary is transferred from the cart to her bed on the medical/surgical unit. You

introduce yourself, and collect the following clinical data:

Copyright © 2020 Keith Rischer, d/b/a KeithRN. All Rights reserved.

Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment: T: 99.5 F/37.5 C (oral) Provoking/Palliative: No change in position or movement influences pain

P: 94 (regular) Quality: cramping

R: 16 (regular) Region/Radiation: Generalized abdomen

BP: 118/64 Severity: 5/10

O2 sat: 98% room air Timing: continuous

What VS data are RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential Reduction of Risk Potential/Health Promotion and

Maintenance)

RELEVANT VS Data: Clinical Significance:

Current Head to Toe Nursing Assessment:

GENERAL SURVEY: Pleasant, calm, body tense, grimacing, appears uncomfortable NEUROLOGICAL: Alert & oriented to person, place, time, and situation (x4); muscle strength 5/5 in both upper

and lower extremities bilaterally.

HEENT: Head normocephalic with symmetry of all facial features. PERRLA, sclera white bilaterally,

conjunctival sac pink bilaterally. Lips, tongue, and oral mucosa tacky dry

RESPIRATORY: Breath sounds clear with equal aeration on inspiration and expiration in all lobes anteriorly, posteriorly, and laterally, nonlabored respiratory effort on room air.

CARDIAC: No edema, heart sounds regular S1S2, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill. Heart tones audible and regular, S1 and S2

noted over A-P-T-M cardiac landmarks with no abnormal beats or murmurs. No JVD noted

at 30-45 degrees.

ABDOMEN: Abdomen round, firm, and generalized abdominal tenderness. BS tympanic in upper

quadrants, hypoactive in lower quadrants

GU: Voiding without difficulty, urine clear/dark amber

INTEGUMENTARY: Skin pink, warm, dry, intact, normal color for ethnicity. No clubbing of nails, cap refill <3

seconds, Hair soft-distribution normal for age and gender. Skin integrity intact, skin turgor

elastic, no tenting present.

What assessment data is RELEVANT and must be RECOGNIZED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential Reduction of Risk Potential/Health Promotion & Maintenance)

RELEVANT Assessment Data: Clinical Significance:

Copyright © 2020 Keith Rischer, d/b/a KeithRN. All Rights reserved.

Caring and the “Art” of Nursing What is the patient likely experiencing/feeling right now in this situation? What can you do to engage yourself with

this patient’s experience, and show that he/she matters to you as a person? (Psychosocial Integrity)

What Patient is Experiencing: How to Engage:

Part II: Put it All Together to Think Like a Nurse 1. What is the pathophysiology of the priority problem? (NCLEX Management of Care/Physiologic Adaptation)

Priority Problem: Pathophysiology of Problem in OWN Words:

2. What body system(s) will you assess most thoroughly based on the primary/priority problem? Identify correlating

specific nursing assessments. (NCLEX Reduction of Risk Potential/Physiologic Adaptation)

PRIORITY Body System: PRIORITY Nursing Assessments:

3. What nursing priority(ies) and goal will guide how the nurse RESPONDS to formulate a plan of care? (NCSBN: Step 4 Generate solutions/Step 5: Take action/NCLEX Management of Care)

Nursing PRIORITY:

GOAL of Care:

Nursing Interventions: Rationale: Expected Outcome:

Copyright © 2020 Keith Rischer, d/b/a KeithRN. All Rights reserved.

4. What is the worst possible/most likely complication(s) to anticipate based on the primary problem?

(NCLEX: Reduction of Risk Potential/Physiologic Adaptation)

Worst Possible/Most Likely

Complication to Anticipate:

Nursing Interventions to

PREVENT this Complication:

Assessments to Identify Problem

EARLY:

Nursing Interventions to Rescue:

5. What psychosocial/holistic care PRIORITIES need to be addressed for this patient? (Psychosocial Integrity/Basic Care and Comfort)

Psychosocial PRIORITIES:

PRIORITY Nursing Interventions: Rationale: Expected Outcome:

CARE/COMFORT:

Caring/compassion as a nurse

Physical comfort measures

Collaborative Care: Medical Management 6. State the rationale and expected outcomes for the medical plan of care. (NCLEX Pharm. and Parenteral Therapies)

Care Provider Orders: Rationale: Expected Outcome:

NPO w/ice chips

0.9% NS IV 100 mL/hour

Hydromorphone 0.25-0.5 mg IV

every 2 hours PRN pain

NG low intermittent suction (LIS)

Hold all home meds while NPO

Assess colostomy output every 4

hours

Basic metabolic panel (BMP) in

morning

Complete blood count (CBC) in

morning

Lactate in morning

Consult general surgery

Copyright © 2020 Keith Rischer, d/b/a KeithRN. All Rights reserved.

7. Which orders do you implement first? Why?

Care Provider Orders: Order of Priority: Rationale:

 NPO w/ice chips

 Consult general surgery

 0.9% NS IV 100 mL/hour

 Hydromorphone 0.25-0.5

mg IV every 2 hours PRN

pain

 NG low intermittent

suction (LIS)

 Hold all home meds while

NPO

Part II: Interpreting Diagnostic Data

Lab Results:

Complete Blood Count (CBC)

WBC HGB PLTs % Neuts Bands

Current: 12.2 11.9 145 84 0

Yesterday: 14.7 12.2 158 89 0

What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential Reduction of Risk Potential/Physiologic Adaptation)

RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable:

Basic Metabolic Panel (BMP)

Na K Gluc. Creat.

Current: 142 3.5 142 0.95

Yesterday: 143 3.9 152 1.29

What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential Reduction of Risk Potential/Physiologic Adaptation)

RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable:

The next morning, the following lab results are posted. Identify the

most relevant labs to this patient, the clinical significance and if the

trend suggests an improvement, worsening or no change in status.

Copyright © 2020 Keith Rischer, d/b/a KeithRN. All Rights reserved.

Misc.

Lactate

Current: 0.9

Most Recent: 2.8

What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential Reduction of Risk Potential/Physiologic Adaptation)

RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable:

Part III: Evaluation: Three Hours Later…

1. The nurse evaluates the patient by assessing after implementing the plan of care. Interpret clinical data to determine if the patient status is improving, declining, or reflects no change.

(NCSBN: Step 6 Evaluate outcomes/NCLEX: Management of Care)

RELEVANT Assessment Data: Clinical Significance: Improving-Declining

No Change:

2. Has the overall status of your patient improved, declined, or remain unchanged? If your patient has not improved,

what other interventions need to be considered by the nurse? (NCSBN: Step 6 Evaluate outcomes/NCLEX: Management of Care)

Overall Status: Additional Interventions to Implement: Expected Outcome:

Mary puts on her call light and lets the nurse know that her abdominal pain

suddenly became much worse and is now 10/10, has chills and feels nauseated. She

appears anxious and in obvious discomfort, pale, and diaphoretic. Abdomen is

firm/rigid.

Current VS: T: 101.7 F/38.7 C (o) P: 118 (reg) R: 24 BP: 139/88 O2 sat: 98% RA

Copyright © 2020 Keith Rischer, d/b/a KeithRN. All Rights reserved.

Radiology: Abdominal CT

Results: Clinical Significance:

Probable perforated small bowel

with free intraperitoneal air.

Situation: Name/age:

BRIEF summary of primary problem:

Background: Primary problem/diagnosis:

RELEVANT past medical history:

RELEVANT background data:

Assessment: Vital signs:

RELEVANT body system nursing assessment data:

RELEVANT lab values:.

Recommendation: Suggestions to advance plan of care:

The primary care provider orders a stat. abdominal CT, and

increases the hydromorphone to 0.5-1 mg IV every 2 hours

PRN. The CT just resulted in the electronic health record:

Use SBAR to communicate your

concern to the primary care provider:

Copyright © 2020 Keith Rischer, d/b/a KeithRN. All Rights reserved.

3. Based on the current status of your patient, what are the CURRENT nursing priorities and plan of care?

(Management of Care)

CURRENT Nursing PRIORITY:

PRIORITY Nursing Interventions: Rationale: Expected Outcome:

4. To develop clinical judgment, reflect on your thinking by answering the following questions:

What did you do well in this case study? What knowledge gaps did you identify?

What did you learn? How will you apply learning caring for future patients?

You contact the primary care provider with these findings who

then contacts the surgeon on call to prepare for emergent surgery

as soon as the team can be assembled.

NCLEX Client Need Categories:
Covered in Case StudySafe and Effective Care Environment:
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Step 2 Analyze Cues:
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Psychosocial Integrity:
Step 5 Take Action:
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Physiological Integrity:
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RELEVANT Data from Present ProblemRow1:
Clinical SignificanceRow1:
Past Medical History:
Home Medications:
COPD Paroxysmal atrial fibrillation Coronary artery disease Diverticulitis Small bowel obstruction Partial colectomy wcolostomy Nondilated cardiomyopathyEF 25:
Current VS:
PQRST Pain Assessment:
P 94 regular:
Quality:
cramping:
R 16 regular:
Generalized abdomen:
BP 11864:
Severity:
510:
Timing:
continuous:
RELEVANT VS DataRow1:
Clinical SignificanceRow1_2:
Current Head to Toe Nursing Assessment:
Pleasant calm body tense grimacing appears uncomfortable:
NEUROLOGICAL:
HEENT:
RESPIRATORY:
CARDIAC:
ABDOMEN:
GU:
Voiding without difficulty urine cleardark amber:
INTEGUMENTARY:
RELEVANT Assessment DataRow1:
Clinical SignificanceRow1_3:
What Patient is ExperiencingRow1:
How to EngageRow1:
Priority ProblemRow1:
Pathophysiology of Problem in OWN WordsRow1:
PRIORITY Body SystemRow1:
PRIORITY Nursing AssessmentsRow1:
Nursing PRIORITY:
GOAL of Care:
Nursing InterventionsRow1:
RationaleRow1:
Expected OutcomeRow1:
Worst PossibleMost Likely Complication to Anticipate:
Nursing Interventions to PREVENT this ComplicationRow1:
Assessments to Identify Problem EARLYRow1:
Nursing Interventions to RescueRow1:
Psychosocial PRIORITIES:
RationaleCARECOMFORT Caringcompassion as a nurse Physical comfort measures:
Expected OutcomeCARECOMFORT Caringcompassion as a nurse Physical comfort measures:
RationaleNPO wice chips 09 NS IV 100 mLhour Hydromorphone 02505 mg IV every 2 hours PRN pain NG low intermittent suction LIS Hold all home meds while NPO Assess colostomy output every 4 hours Basic metabolic panel BMP in morning Complete blood count CBC in morning Lactate in morning Consult general surgery:
Expected OutcomeNPO wice chips 09 NS IV 100 mLhour Hydromorphone 02505 mg IV every 2 hours PRN pain NG low intermittent suction LIS Hold all home meds while NPO Assess colostomy output every 4 hours Basic metabolic panel BMP in morning Complete blood count CBC in morning Lactate in morning Consult general surgery:
fill_1:
fill_2:
Complete Blood Count CBCRow1:
Current:
RELEVANT LabsRow1:
Clinical SignificanceRow1_4:
TREND ImproveWorseningStableRow1:
Basic Metabolic Panel BMPRow1:
Creat:
Current_2:
095:
129:
RELEVANT LabsRow1_2:
Clinical SignificanceRow1_5:
TREND ImproveWorseningStableRow1_2:
MiscRow1:
Lactate:
Current_3:
09:
28:
RELEVANT LabsRow1_3:
Clinical SignificanceRow1_6:
TREND ImproveWorseningStableRow1_3:
RELEVANT Assessment DataRow1:
Clinical SignificanceRow1_7:
ImprovingDeclining No ChangeRow1:
Overall StatusRow1:
Additional Interventions to ImplementRow1:
Expected OutcomeRow1_2:
Situation:
Nameage BRIEF summary of primary problem:
Background:
Primary problemdiagnosis RELEVANT past medical history RELEVANT background data:
Assessment:
Vital signs RELEVANT body system nursing assessment data RELEVANT lab values:
Recommendation:
Suggestions to advance plan of care:
Results:
Clinical SignificanceProbable perforated small bowel with free intraperitoneal air:
CURRENT Nursing PRIORITY:
PRIORITY Nursing InterventionsRow1:
RationaleRow1_2:
Expected OutcomeRow1_3:
What did you do well in this case studyRow1:
What knowledge gaps did you identifyRow1:
What did you learnRow1:
How will you apply learning caring for future patientsRow1: