Med-Surg+Case+Study+3

Scenario C.W., 36 yr-old female was admitted with a diagnosis of recurrent inflammatory bowel disease (IBD) and possible small bowel obstruction (SBO). C.W. is married and has an 11 yr-old son, both whom are supportive. There is no extended family in the area. She has had IBD for 15 yrs and has been on mesalamine (Asacol) for 15 yrs and prednisone 40mg/day for 5 yrs. C.W.’s life has become dominated by the disease. She confides in you that sexual activity is difficult “It always causes diarrhea, nausea and lots of pain”. She is very weak and cannot stand without help. Anorexia Lactase deficiency Profound fatigue a7a Frequent hospitalizations Dehydration Osteoporosis Crippling abdominal pain that occurs unexpectedly 10/10 pain scale; relieved only with small dose of diazepam (Valium), Pedialyte, and total bed rest. 10 loose stools a day
 * Subjective Data**
 * Objective Data**

1. What is IBD? What are the clinical manifestations? IBD is an autoimmune disease. Both genetic and environmental factors seem to play a role. IBD affects the small bowel (Crohns disease) and the Large Bowel (Ulcerative colitis). Symptoms include; diarrhea, bloody stools, weight loss, abdominal pain, fever, and fatigue. Symptoms are mild to severe, with exacerbations , tha occurr over unpredictable intervals over years. (jr) 2. Identify 6 priority problems for C.W. 1. Inbalanced nutrition r/t decreased intake. 2.fluid volume deficet r/t malabsortion of warer and electrolytes. 3. Anxiety r/t possible social embarassment. 4. Complications from IBM such as hemmorage, toxic megacolon, anemia due to bleeding. 5. ineffective family coping r/t disease process and family support overload. 6. Weakness r/t malabsorbtion of water. (jr) 3. Considering C.W.’s weakness, chronic diarrhea, and lower-than-desired body wt, what interventions should be implemented to prevent skin breakdown? Nutritional education with foods that lesson inflamation and diarrhea. Proper hygene to prevent rectal skin breakdown. Supplement to prevent malnutrition. Medications to reduce symptoms. (jr) In addition to these skin breakdown can be reduced by encouraging proper positioning to reduce pressure in these areas, proper clothing materials to wear to reduce skin irritation and possible barrier creams to help protect the skin further. (mk) C.W.’s condition deteriorates on the 3rd day after admission; she experiences intractable abdominal pain and nausea & vomiting (n/v). C.W. is taken to the OR for probable SBO and is readmitted to your unit from the PACU. During surgery, 38 inches of her small bowel were found to have severe stenosed with 2 areas of visible perforation. Most of the remaining bowel is severely inflamed and a total of 5 ft of distal ileum and 2 feet of colon have been removed with a temporary Ileostomy was established. She has a Jackson-Pratt (JP) drain to bulb suction to her RLQ, her wound is packed and left open. She has 2 peripheral IVs, NGT to continuous low wall-suction (LWS) & foley. VS 112/72, 86, 24, 100.8˚ F. 4. You begin a thorough Postop assessment of C.W.’s abdomen. What does your assessment include? Peristomal skin integrity must be monitored. Ileostomy output may be as high as 1500-2000 ml per 24 hours. Observe for signs of hemorrhage, abscess, small bowel obstruction, dehydration. If an NG tube is used, it will be removed when bowel function returns. Peri anal skin care is important to protect the area from mucous drainage.(jr) The abdomen should be assessed for skin intergrity and monitored for changes such as redness, texture changes, or swelling, assess the stoma (should be pink) and the pouching system making sure it provides adequate protection to the skin and collects drainage, drainage amounts should be monitored (a new ileostomy will have a volume output of 1000 to 1800ml/day but that will decrease to about 500ml), frequently assess the patient for fluid and electrolyte imbalances because of where this stoma is, the patient has less of a chance to absorb fluids and electrolytes properly. (mk). 5. How would you auscultate bowel sounds on a patient with an NGT to continuous low wall suction? Tun the suction off, listen in all 4 quads. (jr) Listen for 5 minutes in all four quadrants for a total of 20 minutes. (mk) Post op day 4, you are changing C.W.’s abdominal dressing and notices a small pool of greenish-yellow draining. Then you obtain a culture before completing the dressing change, obtains a full set of VS, temp 101.8 and assesses tenderness of the abdomen. 6. You call the physician, what orders do you anticipate? Start on antibiotic IV therapy. (jr) Administration of an anti-pyretic to reduce fever. (mk) 7. The physician asks how C.W.’s stoma and drainage look. How should a healthy stoma and usual drainage look like? A healthy stoma should be pink and moist. A dusky blue stoma indicates ischemia and a brown-black soma indicates necrosis. Healthy stoma drainage varies depending on where the stoma is located. The higher it is along the intestine, the more liquid the drainage. (ss) Because this stoma is in the ileum and is new we expect 1000-1800ml/day of drainage. (mk) 8. Will any aspect of C.W.’s hx significantly affect the wound healing process? How? Yes, there are many aspects of CW’s hx that will affect the wound healing process. She is very undernourished (anorexia, lactase deficiency, n&v) she is weak, dehydrated, on total bed rest and is taking medications that depress her immune system and promote bone loss (prednisone) If someone is undernourished, their body does not have what it needs to heal. The physician tells you she will be in to examine C.W. After the examination it is determined she will need to go back to the OR for an exploratory laparotomy. This revealed another area of perforated bowel, generalized peritonitis, and a fistula tract to the abdominal surface. Another 12 inches of ileum were resected. The peritoneal cavity was irrigated with normal saline (NS), and 3 drainage tubes placed; another JP, catheter to irrigate wound bed and sump drain to remove irrigation. The initial JP is still in place. 9. C.W. returns from PACU on your shift. What do you do when they roll the bed into the room? Assess mental status, get a set of vitals, find out if there were any complications during surgery, do a head to toe assessment, what meds is she on? O2? Assess IV infusion, assess surgical site- what type of drainage, is there any bleeding? 10. You are assessing the original surgical dressing and note it is saturated with fresh bloody drainage. What should you do? Follow protocol, reinforce the dressing and call the doctor. Mark the drainage on the dressing. (mk) 11. C.W. has 4 tubes in her abdomen, as well as a NGT. What information do you want to know about each? Each tube should be clearly labeled. You want to know type of tube each one is, how it works and what is supposed to be draining from them Gage of tubing, when it was placed. Where it specifically goes to in the patient. Is the NGT for continuous low suction? Tubes should have hatch marks to indicate any movement of the tube in the patient. (mk)

The surgical physician assistant (PA) arrives on the unit and removes the surgical dressing. There is a small “bleeder” at the edge of the incision line, the PA calls for a suture and ties off the bleeder. At this time you address C.W.’s pain control issues and suggest a morphine patient –controlled pump (PCA). 12. What education do you need to give C.W. about the PCA? What non-pharmacological interventions can you educate C.W. on? I would teach the pt the mechanics of getting a drug dose and how to titrate the drug to achieve good pain relief, I would teach the pt to administer the drug before the pain became too intense and they need to be reassured that they cannot overdose because the pump is programmed to deliver a maximum number of doses per hour. If the max amount is not enough, the nurse can administer an additional bolus if they are included in the Dr. orders Some non-pharmacological interventions are deep breathing, guided imagery, music and distraction. Teach the patient that it is unlikely that she will become addicted to the pain medication. Patients can still overdose if their bodies are not equipt to handle even small doses of a medication. Though nurse will be checking on patient throughout therapy it is still important for the patient to notify the nurse if she feels that something is wrong with her respiratory status or if she is having itching or burning which can indicate an allergic reaction to the pain medication. (mk)

13. The physician orders total parental nutrition (TPN) to start at 60 ml/hr and to reduce the IV fluids by the same rate. What is the purpose of this order? Because CW is severely undernourished, she needs supplemental nutrition to encourage the healing process. The reason you would want to reduce the IV fluids is so she does not go into fluid volume overload or blow a vein. If a pt

Patient CW also is on an NGT which removes gastric excretions, but does not insert nutrients. This patient is likely on an NPO status, but it is still very important for the patient to have adequate nutrients. A TPN will give lipids, proteins and electrolyte which are all very important for organ functions and healing. TPN will supplement CWs body with nutrients necessary for life. (mk) 14. The physician did not order glucose monitoring and you know it should be initiated. You plan to conduct finger sticks q 2 hrs for the 1st several hours. What is your rationale? Glucose abnormalities are common with TPN and one way to avoid hyperglycemia is to monitor the blood sugar closely and giving insulin as needed. Hypoglycemia can occur when the TPN is suddenly stopped so careful monitoring is important.

Patient is receiving prednisone a steroid which causes secondary diabetes in some patients. It causes blood glucose to be elevated. This patient just received multiple surgeries which causes stress on the body also causing elevated blood glucose levels for patients. (mk) 15. C.W.’s blood glucose increased temporarily, but by the next day it dropped to an average of 70 – 80mg/dl and remained there for 2 days. HerVS are stable, but her abdominal wound shows no signs of healing. She has lost 1 kg over the past 3 days. What does this mean? Most likely her abdominal wound is not healing because she is still undernourished and not getting the nutrients she needs to heal. The weight loss can be secondary to drainage tubes and location of ostomy. Additionally patient is only receiving TPN nutrients which does not carry the physical weight of a regular meal. (mk) You discuss your concerns with the physician and she agrees to consult from a registered dietitian (RD). The RD makes a recommendation to the attending, C.W. begins to gain weight slowly, and her wound shows signs of healing. Nutritional problems in clinical populations can be complex and often require special attentions. 16. What digestive difficulties is C.W. likely to face in the future? What may she be prone to with having so much of her bowel removed? Because so much of her bowel is removed, she will have trouble absorbing nutrients from the food and may develop short bowel syndrome. This is characterized by failure to maintain protein-energy, fluid, electrolyte and micronutrient balances on a standard diet. She may have multiple vitamin and mineral deficiencies or bacterial overgrowth. Fluids will be lost at a higher-than-normal rate due to loss in bowel length reducing the chance for the intestines to reabsorb liquids, additionally she will likely have loose stools. (mk) 17. What basic information is the RD likely to include? The RD would likely include information regarding how to balance meals, A diet high in carbs, low in fat supplemented with soluble fiber, pectin, glutamine and parental growth hormone is recommended. She may teach that six small meals a day should be eaten to increase the time of contact between food and the small intestine and that oral intake can be supplemented with additional vitamins and minerals. 18. What specific ostomy teaching should you plan? I would teach the pt how to care for the ostomy, how to assess for ischemia or necrosis, I would show them how to apply the bag or pouch, how to protect the skin from breakdown and the importance of emptying the bag before it gets too full because the weight will pull it away from the skin. I would find out if they had any questions or fears regarding how it will impact their life or affect their body image and provide them with a list of foods they should avoid that may cause odor, diarrhea, gas or an obstruction.

BD is a auto**Scenario** B.K. is a 63 yr-old female admitted to the med-surg floor from the ED with N/V and epigastric and LUQ abdominal pain that is severe, sharp, & radiating to her mid-back. The pain started 24 hrs ago and awoke her in the middle of the night. B.K. is divorced, retired sales manager who smokes a half-pack of cigarettes daily. The ED nurse reports B.K. is anxious and demanding. Her VS 100/70, 97, 30, 100.2˚ F, 88% on RA and 92% on 2L O2. She has a normal sinus rhythm (NSR). She has not been to a doctor in “years”. She has no primary care physicians. The ED nurse giving you report states that the admitting diagnosis is acute pancreatitis of unknown etiology. Unfortunately the CT scanner is down and will not be fixed until the am. However, an US of the abdomen was performed and “no Cholelithiasis, gallbladder wall thickening or choledocholithiasis was seen. The pancrease was not well visualized due to overlying bowel gas.” Labs include: Lipase 3000 Amylase 2000 Alkaline phosphatase 350 ALT 90 AST 150 Total bilirubin 2.0 Albumin 3.0 BUN 26 Creatinine 1.0 WBC 17.5 HCT 36 Urine was sent and is dark amber color.- U/A & C&S 1. What are the possible causes of pancreatitis? Acute pancreatitis is an acute inflamitory process of the pancreas. The degree of inflammation varies from mild edema to severe hemorrhagic necrosis. Acute pancreatitis is the most common in middle-age men and women. It affects women and men equally. The severity of the disease varies according to the extend of the pancreatic destuction. The most comon cause for women is biliary tract disease and alcohol for men. I n the United States the most common cause is gallbladder disease 2. What are clinical manifestations associated with pancreatitis? Abdominal pain is the predominant symptom of acute pancreatitis The pain is usually located in the left upper quadrant, but it may be in the midepigastrium. It commonly radiates to the back because of the retroperitoneal location of pancreas. The pain has an sudden onset and is described as severe, deep, piercing and continuous or steady. It is aggravated by eating, and frequently has its onset when the patient is recumbent, it is not relieved by vomiting. The pain may be accompanied by, flushing, cyanosis, and dyspnea. The pain is due to distention pancreasa, peritoneal irritation and obstruction of the biliary tract.

3. If CT scan is planned for the am, what orders would you expect? Contrast - enhanced CT (CECT) of the pancreas, Pt should have no metal objects on body (jewelry, bra hooks, etc) Patient NPO for prior 6 hours (mk)

4. What other information do you need for this patient before you assume responsibility for this patient? Past med history ; Drug/ETOH abuse hx; Allergies; (jr) Allergies to the dye used in the contrast medium for the CT scan. (jr) History of GI and endocrine issues, family history of these, prior surgeries that may have had an effect on the pancreas (pancreas can go into a shock and metabolize itself if it was touched in a prior surgery). (mk) 5. What approach would you use to obtain a psychosocial history and complete your nursing assessment? Matter of fact approach (jr) Direct and thorough(mk) You complete your assessment and note the following assessment findings; A&O x3, she is restless and lying on her right side in a semifetal position Respirations are rapid but unlabored on 2L O2 NC with 90% O2 Sat. Breath sounds absent in LLL posteriorly, otherwise CTA. Heart rate is regular but tachycardic, without murmurs Peripheral pulses are faintly palpable in 4 extremities Bowel sounds hypoactive, abdomen distended, firm and guarding noted. She is C/O nausea and is having dry heaves. Skin is cool, diaphoretic, pale with poor skin turgor, mucous membranes are dry. 6. Which labs are the most important to monitor in acute pancreatitis? Why are they significant? primary lab work, Serum amylase, serum lipase, urinary amylase. secondary lab work, hyperglycemia, hyperlipidmia, and hypocalcemia 7. What are some medications you may use to help with the N/V? Nasogastric (NG) suction may be used to reduce vomiting and gastric distention and to prevent gastric juices from entering the duodenum. Drugs that neutralize or suppress formation of hydrochloric acid in the stomach, such as antacids, histamines antagonists (zantac) Anti-emetics such as zofran, Promethazine, Prochlorperazin, Neurokinin Receptor Antagonists, or Serotonin Receptor Antagonists are also helpful with n/v (mk) ```and proton pump inhibitors (e.g.protonix, prilosec)

.8. What other assessments would concern you? Pain be accompanied by flushing, cyanosis, and dyspnea., N /V low grade fever, leukocytosis, hypotension, tachycardia, and jaundice. Abdominal tenderness, bowel sounds decrease or absent, abdominal distention, lungs are frequently involved, with crackles, What would you do with these assessment findings? T reatment is primarily focused on supportive care, including aggressive hydration, pain management, management of metabolic complications, and minimizing pancreatic stimulation. A primary consideration in the treatment of acute pancreatitis is the relief and control of pain. IV morphine may be used. Pain medication may be combined with antispasmodic agent. However atropine like drugs should be avoided when paralytic ileus is present because they may contribute to the problem. If shock is present, blood volume replacement are used. Fluids and electrolytes imbalances are corrected with lactated ringers and other electrolyte solutions. 9. What do the BUN and creatinine tell you about her renal function and volume status? T he BUN and Creatinine levels are elevated in kidney failure.An elevated BUN level must be interpreted with caution because dehydration, corticosteroids and catabolism resulting from infections, fever, severe injury or GI bleeding can also elevate BUN. The best serum indicator of renal failure is creatinine because it is not significantly altered by other factors. 10. Why are the WBCs elevated? WBC is elevated r/t infection., low grade fever and leukocytosis 11. B.K. turns on her call light. She c/o thrist and demands something to drink. Her orders indicate “NPO, except sips and chips.” How should you respond? What nursing action would help her complaints? I t is important to reduce or suppress pancreatic enzymes to decrease stimulation of the pancreas and allow it to rest.This is accomplished in several ways. First the Pt. is allowed nothing by mouth (NPO) Second < NG suctions may be used reduce vomitting We will allow the patient a small amount to drink or offer ice chips and encourage good oral hygiene to decrease the feeling of dryness in the mouth and throat. (mk)

An abdominal CT scan is completed and shows a “moderately severe pancreatitis, but no local fluid collection or pseudocysts. No ileus or evidence of neoplasia was noted.” It is now 72 hrs since admission and her labs are showing improvement: BUN 9.0 and creatinine 1.0. She has adequate urine output 55 mL/hr (normal urine output is 30 mL/hr) Amylase & lipase are also coming down, so the MD advances B.K.’s diet to full iquids. 12. How would you know if the advancement in diet weren’t tolerated? No complaint of abd pain; No nausea and vomiting. increased appetite. (jr) No dramatic changes in the lab values (mk) 13. If B.K. does not tolerate the advancement in diet, what physiologic need should staff be prepared to address at 72 hrs? Hydration and nutrition needs need to be assessed. (jr)

Later that afternoon, 3rd day, she becomes agitated with unintentional tremors, some disorientation, and auditory hallucinations. Her pulse and BP are elevated, although her pain has not increased, nor has the pain medication schedule changed. B.K. has had no visitors since the being admitted. 14. What is B.K. most likely experiencing, and what actions should you take? Alcohol withdrawal delirium. Contact doctor; Prepare for orders to treat the withdrawal symptoms, e.g. Benzodiazepams, Beta-blocking agents (Atenolol, Propranol) and or antiepileeptics. Monitor patient closely for seizures and fall prevention. (jr).

You contact the physician with your observations, and he orders schedule diazepam 5mg PO and a social work consult to evaluate and treat possible alcohol abuse. B.K. eventually admits to drinking “3 or 4 scotch-on-the-rocks” daily, a good4 fingers deep each.” You also discover that B.K. is estranged from her family because of the drinking. Three days later, B.K. is tolerating clear liquids, and her pain is controlled with oral pain medications. The MD advances her diet to “low-fat/low-cholesterol” and writes orders to discharge that evening if she tolerates the advancement of her diet, which she does. 15. What should you include in your discharge teaching? Instruct patient on the dangers of continued alcohol use/abuse and assist her to find a local rehab program or support groups. Teach patient that her pancreas has recovered at this point but it is not guaranteed to do so in the future. Instruct the patient on what kind of diet would be best suited to minimize the strain on her pancreas. (mk)