Part I: Small Bowel Obstruction
NextGen Unfolding Reasoning
.
Mary O’Reilly, 55 years old
Primary Concept
Elimination
Interrelated Concepts (In order of emphasis)
∙ Patient Education
∙ Clinical judgment
NCLEX Client Need Categories Covered in NCSBN Clinical Covered in
Case Study Judgment Model 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:
- CT of her abdomen/pelvis revealed - High-grade bowel obstruction would be the admitting
high-grade small bowel obstruction. diagnosis and priority for plan of care for this patient.
- Abd. is firm, slightly distended, with - Abd. Assessment abnormal, should not be distended.
tympanic bowel sounds. - If there’s no change in input and decrease in output,
- Pt. reports decreased output in concerning.
colostomy - sign of infection.
- WBC: 14.7 - Signs of sepsis.
- Lactate: 2.8 - Higher risk of recurrent obstruction.
- History of bowel obstruction - Slightly elevated; monitor for trends.
- T: 99.8 - High; dehydration, risk for AKA
- Creatinine: 1.35 - Low end of normal; vomiting = at risk for hypokalemia
- Potassium: 3.7
After receiving report, you quickly review this patient’s past medical
NextGen Unfolding Reasoning
.
Mary O’Reilly, 55 years old
Primary Concept
Elimination
Interrelated Concepts (In order of emphasis)
∙ Patient Education
∙ Clinical judgment
NCLEX Client Need Categories Covered in NCSBN Clinical Covered in
Case Study Judgment Model 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:
- CT of her abdomen/pelvis revealed - High-grade bowel obstruction would be the admitting
high-grade small bowel obstruction. diagnosis and priority for plan of care for this patient.
- Abd. is firm, slightly distended, with - Abd. Assessment abnormal, should not be distended.
tympanic bowel sounds. - If there’s no change in input and decrease in output,
- Pt. reports decreased output in concerning.
colostomy - sign of infection.
- WBC: 14.7 - Signs of sepsis.
- Lactate: 2.8 - Higher risk of recurrent obstruction.
- History of bowel obstruction - Slightly elevated; monitor for trends.
- T: 99.8 - High; dehydration, risk for AKA
- Creatinine: 1.35 - Low end of normal; vomiting = at risk for hypokalemia
- Potassium: 3.7
After receiving report, you quickly review this patient’s past medical
