C.W.
, a 36-year-old woman, was admitted several days ago with a diagnosis
of recurrent inflammatory bowel disease (IBD) and possible small bowel
obstruction (SBO). C.W. is married, and her husband and 11-year-old son are
supportive, but she has no extended family in-state. She has had IBD for 15
years and has been taking mesalamine (Asacol) for 15 years and
prednisone 40 mg/day for the past 5 years. She is very thin; at 5 feet 2
inches she weighs 86 pounds and has lost 40 pounds over the past 10
years. She has an average of 5 to 10 loose stools per day. C.W.'s life has
gradually become dominated by her disease (anorexia; lactase deficiency;
profound fatigue; frequent nausea and diarrhea; frequent hospitalizations
for dehydration; and recurring, crippling abdominal pain that often strikes
unexpectedly). The pain is incapacitating and relieved only by a small dose
of diazepam (Valium), oral electrolyte solution (Pedialyte), and total bed
rest. She confides in you that sexual activity is difficult: “It always causes
diarrhea, nausea, and lots of pain. It's difficult for both of us.” She is so
weak she cannot stand without help. You indicate complete bed rest on the
nursing care plan.
1. Identify at least six priority problems for CW
-incapacitating pain
-sexual dysfunction
-malnutrition
-weight loss
-she is at risk for skin breakdown
-risk for depression
-profound fatigue
-frequent hospitalizations could impact her finances, she has no other
family in the state other than her husband and 11y/o son so if she is
hospitalized it effects them also.
-dehydration.
2. Considering C.W.'s weakness, chronic diarrhea, and lower-than-desired
body weight,
what nursing interventions need to be implemented to minimize skin
breakdown? Name
at least six.
-ambulatory care
-frequent skin checks, especially over boney areas
-meticulous perineal care
-position patient differently q 2 hours
-barrier cream over boney areas
-IV fluids due to dehydration, poor skin turgor means risk for tears
-try to keep patient at optimal nutrition
3. What is the mechanism of action of the mesalamine (Asacol) in relation to
the IBD?
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-blocks prostaglandin production and stops colon inflammation
C.W.’s condition deteriorates on the third day after admission; she experiences
intractable abdominal pain and unrelenting nausea and vomiting (N/V). C.W. is
taken to the operating room (OR) for probable SBO and is readmitted to your
unit from the post anesthesia care unit (PACU). During surgery, 38 inches of
her small bowel were found to be severely stenosed with 2 areas of visible
perforation. Much of the remaining bowel is severely inflamed and friable. A
total of 5 feet of distal ileum and 2 feet of colon have been removed, and a
temporary ileostomy was established. She has a Jackson-Pratt (JP) drain to
bulb suction in her right lower quadrant (RLQ), and her wound was packed
and left open. She has two peripheral IVs, a nasogastric tube (NGT), and a
Foley catheter. Her vital signs (VS): 112/72, 86, 24, 100.8° F.
4. You begin a thorough postoperative assessment of C.W.'s abdomen. What
does your assessment include? List the steps in the order in which the
assessment should be completed.
-An abdominal assessment is done in this order: inspect, auscultate,
palpate, percuss. So first I would inspect. I would check her stoma color
(you want it to be red), and check for drainage. I would check for any
other skin lesions or visible abnormalities. Then, I would auscultate. I
would listen to her abdomen with my stethoscope. After that, if she
had a tube placed I would check the PH of the drainage to ensure the
placement (Im sure an xray has already been done if she does have a
tube) and make sure that the equipment is properly hooked up and not
in any position that it would cause skin breakdown. I don’t think I would
personally do much palpating after an abdominal surgery but I may
feel around and note any areas of tenderness. I would not percuss her
abdomen after surgery.
5. A nursing student enters CW’s room and auscultates her abdomen. She
looks at you and excitedly announces that she hears good bowel sounds. You
take the opportunity to teach her the proper method of auscultating bowel
sounds on a patient who has NGT to low-continuous wall suction. How would
you correct her error?
-I would correct her error by telling her that she should listen to each
quadrant of the abdomen for at least two minutes if sounds are
present, listen for 5 minutes before saying that they are absent and
then have someone else listen. She also described the bowel sounds as
good when they should be described as hyperactive, hypoactive, or
absent. Also the patient is hooked up to suction and you should turn
that off so that you hear only the patient and not the machines. She
entered the room and automatically began auscultating.
6. Four hours later, you measure the drainage from the JP tube. Look at the
following figure and state how much drainage you obtained?
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- 20 mL of drainage
7. What else will you note about the drainage?
- I would note color, odor, consistency
8. Describe the proper method for reestablishing suction on the JP drain after
you have emptied the bulb container.
-You would first squeeze the bulb and hold it, then you would reinsert it
9. C.W. asks you, "I know why I have the pouch. Why do I have to have this
other little tube?" How will you explain the purpose of the JP drain?
- I would explain to CW that the JP drain removes the blood and fluid
from the surgical site and helps to prevent fluid drainage and prevents
infection.
It is four days after CWs surgery. During the routine dressing change, you
note a small pool of yellow-green drainage in the deepest part of the wound.
You obtain an order for a wound culture.
10. How will you obtain a culture specimen from C.W.'s wound?
-When you obtain a culture you want to be sure that the wound has
been cleaned. You use a sterile swab, place it in a sterile container and
sent with an order from the PCP to the lab for analysis. After culture is
obtained redress the wound appropriately and give pain meds if
needed, sometimes the cultures can cause pain.
11. What information do you need to send to the laboratory with the wound
culture
specimen?
-patient’s information (name, birthdate, hospital ID, etc.) usually on the
container
-what type of wound it was collected from
-nurse initials, date, time collected
12. You obtain a wound culture specimen, complete the dressing change,
obtain a full set of VS, note a temperature of 100.4° F (38° C), and assess
increased tenderness in C.W.'s abdomen. What orders do you anticipate
receiving once you notify the physician of C.W.'s condition?
-possible order for pain medication due to tenderness and abx
13. The physician calls back and asks you to describe C.W.'s wound. What
key aspects of the wound should be included?
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-if there is any bleeding, discoloration, tenderness, drainage and
details of drainage (color, odor, amount). If there is any tunneling of
the wound.
14. As you assess C.W.'s stoma and drainage, what would indicate that they
are healthy? Select all that apply.
c. The stoma will be a uniform medium cherry red in color
e. The skin around the stoma should be intact.
15. Will any aspect of C.W.'s history significantly affect the wound healing
process? If
so, how?
-Yes it will- she has been hospitalized many times for poor nutrition and
dehydration. Both of these things make you at risk for skin breakdown. Poor
nutrition leads to delayed wound healing.
16. With a fairly significant wound infection developing, why is C.W.'s
temperature relatively low?
-dehydration
17. The physician tells you she will be over to examine C.W. As you tell C.W.
that her doctor is coming to talk to her, C.W. says that she feels something
wet running down her side. You find some leakage of intestinal drainage onto
the skin. What should you do?
- I would clean her up, reapply any dressings or devices as needed and
notify the physician if needed.
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