Scenario While as a nurse on a gastrointestinal (GI) unit, you receive a call fr

Question

Scenario
While as a nurse on a gastrointestinal (GI) unit, you receive a call from an affiliate outpatient clinic notifying
you of a direct admission with an estimated time of arrival of 60 minutes. The clinic nurse gives you
the following information: A.G. is an 82-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 information 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) secondary to adhesions. A.G. is being admitted
to your floor for diagnostic workup. Her vital signs (VS) are stable, she is receiving an intravenous (IV)
infusion of D5 ½ NS with 20mEq KCl at 100mL/hr, and 2L oxygen by nasal cannula.

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?     

While A.G. is on the way, you secure 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?

Before you begin your examination, the grandson, an attorney, tells you that elderly Italian
women are extremely modest and might not answer questions completely. He indicates that
he'd like to stay in the room during the examination. How will you proceed?

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

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
_______ g. Nausea and early, profuse vomiting, which may contain fecal material
_______ h. Minimal or no vomiting
_______ i. Severe fluid and electrolyte imbalances

What is obstipation?

. During your examination, you note that she does not have muscle guarding and rebound
tenderness on palpation. Is this important? Explain your answer.

Case Study Progress
The physician orders the insertion of a Salem Sump nasogastric tube (NGT). You insert the NGT into A.G.
and connect it to intermittent low wall suction.

9. How will you check for placement of the NGT?

10. List, in order, the structures through which the NGT must pass as it is inserted

11. 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?

12. What comfort measures are important for A.G. while she has an NGT?

13. You note that A.G.'s NGT has not drained in the last 3 hours. What can you do to facilitate
drainage?
14. The NGT suddenly drains 575mL; then drainage slows down to about 250mL over 2 hours.
Is this an expected amount?
15. You enter A.G.'s room to initiate your shift assessment. A.G.'s abdomen seems to be more
distended than yesterday. How would you determine whether A.G.'s abdominal distention
has changed?
Case Study Progress
After 24 hours, 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.
Chart View
Laboratory Test Results
Test Admission Hospital Day 3
Sodium 136mEq/L 130mEq/L
Potassium 3.7mEq/L 2.5mEq/L
Chloride 108mEq/L 97mEq/L
Carbon dioxide 25mEq/L 31mEq/L
BUN 19mg/dL 38mg/dL
Creatinine 1mg/dL 2.2mg/dL
Glucose 126mg/dL 65mg/dL
Albumin 3.0g/dL 3.1g/dL
Protein 6.8g/dL 4.9g/dL

16. Which laboratory values are of concern to you? Why?

17. What measures do you anticipate to correct in each of the imbalances described in
Question 16?
Case Study Outcome
In view of A.G.'s continued 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 had been constricted by
adhesions. Several areas look ischemic, so these are excised, and an end-to-end anastomosis is done. A.G.
tolerates the procedure well. Her recovery is slow but steady. A.G. goes home in the care of her grandson
and his wife on the seventh postoperative day. Discharge plans include a home health nurse, home
health aide, in-home physical therapy, and dietitian consultation. The grandson is included in the plans.

Explanation / Answer

1.Ans-
Based on the nurse’s report, some signs of bowel obstruction that A.G. include-

a)   Abdominal pain
b)   Adominal distention
c)   Nausea & vomiting (N/V).

2. Ans-
Yes. There are some other signs and symptoms that should observe while A.G. that include:
a)   Constipation
b)   hypoactive/hyperactive bowel sounds
c)   cramping
d)   fever
e)   tachycardia
f)   fecal vomiting
3. Ans-
Try to build up a relationship of trust and obtain patient's cooperation

4.Ans-
a)   try to explain to the patient that the information about the treatment is confidential, and maintaining this confidentiality
b)   give the patient an understanding of her problem

c)   be non-judgmental

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