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History of Present Problem:
Jim Sanderson is a 65-year-old male who is admitted for acute lower abdominal pain which was the result of a ruptured appendix. He had an open appendectomy and is now post-operative day three. He refuses to use the incentive spirometer or get up in the chair and requires encouragement to get out of bed and ambulate on the unit. His appetite is poor, and he eats a small portion of his meals but tolerates and drinks fluids readily. He has had 2200 mL intake to 1800 mL urine output the past 24 hours. He denies nausea and has not had a bowel movement since surgery despite receiving milk of magnesia and senna tabs daily. His abdomen is obese, rounded, firm and tender to palpation with hypoactive bowel sounds. His incision site in his RLQ has no drainage. Swelling and mild erythema noted along the edge of the incision.
Current Complaint:
Jim puts on his call light. When you arrive, he states he feels nauseated. He has an order for ondansetron 4 mg IV every 4 hours PRN for nausea, and this is administered. Thirty minutes later he puts his call light on again, stating that his nausea has gotten worse. While in the room, he begins to wretch and has a small bile green emesis. What PRIORITY data from the story and current complaint do you NOTICE as RELEVANT and why is it clinically significant? (Reduction of Risk Potential/Health Promotion and Maintenance) (list 2 for each section) RELEVANT Data-Present Problem: Clinical Significance: Refuses to use incentive spirometer After abdominal surgery, the breathing pattern can change and result in various pulmonary complications. Incentive spirometry is beneficial for patients affected in this way as it promotes deep breaths, which will aid their recovery. His appetite is poor.
. abdomen is obese, rounded, firm and tender to palpation Good nutrition is necessary to keep the immune system strong to fight off infection. Abdominal tenderness is generally a sign of inflammation or other acute processes in one or more organs RELEVANT Data-Current Complaint: Clinical Significance: nausea Check to see if Zofran is available for patient wretch and has a small bile green emesis. Possibility of bile reflux. According to Mayo clinic Bile reflux can also be a side effect of surgeries to the gallbladder or gastrointestinal tract or can be caused by peptic ulcers blocking the pyloric valve. Intestinal activity has slowed down. Nursing Assessment Begins:
Current VS: Most Recent VS: Current WILDA:
T: 99.2 F/37.3 C (oral) T: 99.4 F/37.4 C (oral) W ords: ache/cramp P: 92 (reg) P: 74 (reg) I ntensity: 5/ R: 24 (reg) R: 18 (reg) L ocation: generalized abdomen BP: 168/88 BP: 142/80 D uration: ongoing-started last hour O2 sat: 93% room air O2 sat: 98% room air A ggravate: movement A lleviate: rest
Current Assessment:
GENERAL
APPEARANCE:
Patient’s body and facial expression appears tense, uncomfortable RESP: Breath sounds clear with equal aeration bilaterally, diminished in the bases bilaterally, nonlabored respiratory effort CARDIAC: Skin color is pink, warm & dry, no edema, heart sounds strong, regular with no abnormal beats, pulses 3+, equal with palpation at radial/pedal/post-tibial landmarks NEURO: Alert & oriented to person, place, time, and situation (x4) GI: Abdomen firm-tender to palpation, distended, with rare, high pitched tympanic bowel sounds GU: Voiding without difficulty, urine clear/yellow SKIN: Skin integrity intact, abdomen incision edges intact with mild erythema along edges, staples intact What clinical data do you NOTICE that is RELEVANT and why is it clinically significant? (Reduction of Risk Potential/Health Promotion and Maintenance)
RELEVANT VS Data: Clinical Significance: TREND:
Improve/Worsening/Stable: Blood pressure is 168/88 High b/p showing pain need for manual blood pressure to be taken to verify results. worsened RELEVANT Assessment Data: Clinical Significance: Temp 99. Monitor temperature by continuous reassessment to check to make sure the low-grade fever is caught before it becomes a real fever even though it decreased from 99.4 continue to monitor patient to see if decrease in temperature will continue. This could be a possibility of sepsis. n/a
1. What additional clinical data would you need to collect to identify the primary problem to guide your plan of care? (Management of Care) (think along the lines of laboratory testing or imaging to consider) Abdominal CT scan or blood work such as CBC for infection.
4. What will you communicate with the primary care provider to report the current problem concisely and accurately?
S ituation:
Nurse name: Candice Patient: Jim Sanderson is a 65-year-old male. Situation: This pt. recently had surgery he is post op day 3 and currently complains of lower abdominal pain.
B ackground:
n/a
A ssessment:
His abdomen is obese, rounded, firm and tender to palpation with hypoactive bowel sounds. His incision site in his RLQ has no drainage. Swelling and mild erythema noted along the edge of the incision.
R ecommendation:
Based on the situation I recommend an order for abdominal CT, I will also suggest an order for an NGT and increase the order for Zofran.
In response to your concise and well organized SBAR, the primary care provider
agrees with your concern and orders an abdominal CT that confirms dilated
proximal small intestinal loops suggestive of paralytic ileus with no evidence of gas
in the large intestine.
You receive the following orders:
• Insert nasogastric tube [NGT]
• Connect NGT to LIS [low intermittent suction]
• NPO [nothing by mouth] except small amount of ice chips PRN [as needed]
Medical Management: Rationale for Treatment & Expected Outcomes
Care Provider Orders: Rationale: Expected Outcome: Insert NGT to LIS (^) By inserting a nasogastric tube, you are gaining access to the stomach and its contents. This enables you to drain gastric contents, decompress the stomach, obtain a specimen of the gastric contents, or introduce a passage into the GI tract. This will allow you to treat gastric immobility, and bowel obstruction. Removed stomach content
Care Provider Orders: Rationale: Expected Outcome: NPO-may have ice chips Swallowing of small sips of water may enhance passage of tube into esophagus. Easy glide of NGT.
Procedural Safety Principles
1. What supplies does the nurse need to gather to perform this skill?
1. Wash the hands thoroughly and dry them before donning sterile gloves. Gather the following
materials: suction, non-allergic tape, NG tube (rubber or plastic), towel or protective pad, water-
soluble lubricant, rubber band, 60cc irrigating syringe, gloves, stethoscope, curved basin, and safety
pin.
2. Explain the procedure to the patient and answer any of their questions before moving forward with
the procedure.
3. The nurse should now position an unconscious patient in a lying position on the left side of the body,
and position a patient who is awake in a sitting position.
4. To minimize the possibility of aspirated gastric content from coming in contact with the patient, place
a towel or protective pad over the chest of the patient.
5. Using the NG tube, measure the length from the earlobe to xiphoid process and from the nose to the
earlobe to determine the length that the NG tube must be.
6. After adding the two measurements together, use a piece of tape to mark the total distance on the
tube.
7. Inspect the patient’s nostrils for obstructions. An alert patient may need to blow the nose to clear the
opening.
8. Use a water-soluble lubricant to lubricate the NG tube’s first six inches. Use the nostril with the
largest opening to insert the NG tube down the back of the nostril to the nasopharynx.
9. Ask the patient to swallow once the tube enters the pharynx. If the patient is not able to mimic the
swallowing action, ask the patient to sip water. An alert patient should place the chin on the chest to
aid the tube’s passage. Continue directing the tube until it reaches the location marked by the tape.
10. Verify that the tube is in the stomach by performing two of the following options: submerging the
tube’s open end into a cup of water (bubbles indicate the tube passed down the larynx); chest X-ray;
request that the patient talk or hum (choking and coughing means the tube passed down the larynx);
use the irrigation syringe for aspirating gastric contents; or use a stethoscope to listen over the
patient’s epigastrum while using an irrigation syringe to instill a 30cc air bolus ( a whooshing sound
5. What will you communicate to the patient to educate them about the need for nasogastric tube insertion and what to expect? (Health Promotion and Maintenance) (List 2) Occasionally, NG feeding is used to prepare malnourished patients for major abdominal surgery in the pre- operative period Following upper gastrointestinal surgery where a high anastomosis must be protected in the initial post- operative period
Evaluation:
After the NG tube has been placed, 800 mL of green bile drainage from the stomach
is removed over the next 15 minutes. Jim states that the nausea is improved and
appears to be more comfortable.
1. What data do you NOTICE as RELEVANT and why is it clinically significant? (Reduction of Risk Potential/Health Promotion and Maintenance) 6. RELEVANT Data: (Refer to evaluation) Clinical Significance: green bile drainage Possibility of bile reflux 2. Has the status improved or not as expected to this point? Does your nursing priority or plan of care need to be
modified in any way after this evaluation assessment? (Management of Care, Physiological Adaptation)
Evaluation of Current Status: Modifications to Current Plan of Care:
The status of patient has improved following bile removal from stomach. There doesn’t need to be modification as patient still needs to be assessed which was my first nursing priority.
3. Based on your current evaluation, what are your CURRENT nursing priorities and plan of care? (Management of Care)
CURRENT Nursing PRIORITY:
(Based on evaluation of previous nursing intervention and orders received)
PRIORITY Nursing Interventions: Rationale: Expected Outcome:
Assess patient Patient vital signs showed possibility of SIRS or sepsis. Regulated vital signs. Use Reflection to THINK Like a Nurse
1. What did I learn from this scenario? How can I use what has been learned from this scenario to improve patient care in the future? (List 3)
What Did You Learn? How to Use to Improve Future Patient Care:
Patient feedback is essential Communicate with patient about pain and discomfort. Gather supplies before stating procedure Always try to be prepared for what to happen with pt. Follow orders doctor gave. Not following orders may lead to harm to pat.
Example: 0800 Complaint of dyspnea, RR shallow at 24/min, even, with diminished breath sounds throughout both lung fields, Oxygen saturation 89% on room air. O 2 at 3L/NC applied. Dr. Heart notified (^) through phone with orders carried out.
6. Evaluation: Evaluate each STG as met, or not met and care plan status as discontinued, continue, or revise. Example: Goal not met. Revise care plan. Note for teaching care plan: In order for learning to have taken place, the client must verbalize or demonstrate something. Example: Verbalized how to read labels on canned goods for sodium content.
Nursing Care Plan: Template Nursing Diagnosis: Acute pain r/t pressure, abdominal distention. Assessment OUTCOMES^ INTERVENTIONS^ RATIONALES^ EVALUATION Objective: Pt. rate pain 5/ Subjective: / 168/88 blood pressure tells possibly of infection due to pain. NOC: Pain Control S.T. Goals:
1. Use a self-report pain tool to identify current pain intensity level and establish a comfort function goal By end of shift 0700 L.T. Goal: 1. Describe nonpharmacologic al methods that can be used to help achieve comfort function goal by end of discharge teaching 03/7/ @ 1500 2. Perform activities of recovery or activities of daily living easily within two weeks at follow visit with provider 3/21/ NIC: Pain management 1. During the initial assessment and interview if the client is experiencing pain, or when pain first occurs conduct and document a comprehensive pain assessment using appropriate pain assessment tools. 2. Assess if patient is able to provide a self-report of pain intensity, and if so, assess pain intensity level using a valid and reliable self-report pain tool such as 0-10 numerical pain rating scale. . Determining location, temporal aspects pain intensity characteristics and effects of pain on function and quality of life are critical to determine the underlying causes of pain and effectiveness of treatment (Drew and Peltier, 2018) Self-reporting is considered one of the most reliable indicator of pain presence and intensity and single-demensin pain rating are valid and reliable as measures of pain intensity level ( Drew& Peltier 2018). Routinely check on client as surgery could cause pain while doing activity. Client is able to use self report tool effectively to identify pain intensity. Client is able to perform ADLs pain free and has been successful at incorporating non pharmacological methods to relieve pain.
