Reference no: EM134034086
Situation - You are assigned to care for Mrs. Janan Kim, an 80-year-old woman that was just admitted to your unit with abdominal tenderness, pain, and vomiting for the last 3 days. She has been constipated for the last week.
Background - Mrs. Kim has a history of having abdominal surgery three years ago for a large bowel obstruction and removal of a nonmalignant tumor. She did well after surgery. Lately she has been having more of a problem with off and on nausea and occasionally vomiting. Last week she stated that she noticed that she was not going to the bathroom as often as she normally did. Her usual pattern is for daily bowel movements without taking a laxative or increasing her fiber intake. In the last week she had one small bowel movement and has not had one since. As stated above, she has had abdominal tenderness, generalized abdominal pain, has not been able to keep food or fluids down in 3 days.
Assessment - Mrs. Kim is awake and alert, but unsure what day it is or the exact time. You notice that her lips are very dry and are starting to crack. Her tongue is very dry and furrowed. You also note tenting on the skin on the back of her hands. Her lungs are clear with good aeration. Heart tones are normal with an S1, S2 heard. Her peripheral pulses are thready. Abdomen is distended with tenderness with slight palpation. Her pain level is 8 out of 10 when asked. However, she remains very stoic and refuses pain medication. Her vital signs are as follows: HR - 130, BP - 100/50 (67), RR - 24, T - 100.2° F (37.8° C), Oxygen saturation is 92% on room air.
Points to assess: Is this Acute or Chronic? Is the patient Unstable or Stable? Is this Urgent or Nonurgent?
Recommendation(s) -
What do you think are the primary alterations in health with this patient (diagnosis)?
What is the pathophysiology related to the patient's problems?
What are the risk factors for this patient, and do they contribute to the current primary problem?
What assessment(s) (expected finding) should be your focus? (Hint: Identify the relevant information first to determine what is most important.) What signs and symptoms are commonly seen with this diagnosis?
What data should you analyze (laboratory and diagnostic procedures) and report to the health care provider? (Hint: Think about priority collaborative problems that support and contradict the information presented in this situation.) What lab values may be abnormal?
What would your plan (nursing care) and recommendation(s) be to the health care provider? (Hint: Consider all possibilities and determine their urgency and risk for this client.)
What intervention(s) (therapeutic procedures and/or medications) would be your priority with this patient? (Hint: Determine the desired outcome first to decide which interventions are appropriate and those that should be avoided.) Which intervention would be best for this patient?
What data/clinical information would you evaluate to support the plan to improve the patient's outcome? (Hint: Think about signs that would indicate an improvement, decline, or unchanged client condition.) What changes to the patient's condition would I expect to see happen or have happened?
What interprofessional care would be involved in the care of the patient? (Other disciplines -for example RT, ECG, social worker, etc.)
What patient education would be important for this patient?
Are there any specific safety considerations that should be included in your care?
What is the dry, furrowed tongue and skin tenting indicative of?
The health care provider orders Mrs. Kim to have a nasogastric tube inserted. Explain the procedure.
What would be done to verify placement? Name two things.
What procedure may need to be done? Explain what the patient needs to know before, during, and after surgery.
What type of nutrition may be ordered to meet her caloric needs?
If the patient has an ostomy placed, could it be reversed?
What type of medications are given to treat nausea?
List the mechanism of action for each one.
If her nasogastric tube were to put out a large amount of drainage, what acid-base balance is she be at risk for developing.
What electrolyte imbalances would the patient be at risk for developing with a large amount of NG tube drainage?
If the patient were to have a problem with diarrhea, what acid-base balance would she be at risk for developing?
What is the worst possible/most likely complication(s) to anticipate based on the primary problem (to prevent death)?
What nursing assessments/interventions will identify/initiate EARLY to prevent this from developing?