CHAPTER 4 GASTROINTESTINAL DISORDERS CASE STUDY 45

Case Study 45
Name Class/Group Date
Group Members
INSTRUCTIONS All questions apply to this case study. Your responses should be brief and to the point. When
asked to provide several answers, list them in order of priority or significance. Do not assume information that
is not provided. Please print or write clearly. If your response is not legible, it will be marked as ? and you will
need to rewrite it.

4 Gastrointestinal
X
Scenario
While you are working as a nurse on a gastrointestinal/genitourinary (GI/GU) unit, you receive a call from
your affiliate outpatient clinic notifying you of a direct admission, with an estimated time of arrival of
60 minutes. She gives you the following information: A.G. is an 87-year-old
82-year-old woman with a 3-day history
of intermittent abdominal pain, abdominal bloating, and nausea and vomiting (N/V). A.G. moved from
Italy to join her grandson and his family only 2 months ago, and she speaks very little English. All infor-
mation was obtained through her grandson. Past medical history includes colectomy for colon cancer
6 years ago and ventral hernia repair 2 years ago. She has no history of coronary artery disease, diabetes
mellitus, or pulmonary disease. She takes only ibuprofen (Motrin) occasionally for mild arthritis. Allergies
include sulfa drugs and meperidine. A.G.'s tentative diagnosis is small bowel obstruction (SBO) second-
ary to adhesions. A.G. is being admitted to your floor for diagnostic workup. Her vital signs (VS) are stable,
she has an IV of D5½NS with 20 mEq KCl infusing at 100 mL/hr, and 32LL oxygen by nasal cannula (O2/NC).

1. Based on the nurse's report, what signs of bowel obstruction does A.G. manifest?

2. Are there other signs and symptoms that you should observe for while A.G. is in your care?

3. While A.G. is on the way, you have secured the hospital's interpreter service on the telephone.
A.G. arrives on your unit with her grandson. You admit A.G. to her room and introduce
yourself as her nurse. As her grandson introduces her, she pats your hand. You know that you
need to complete a physical examination and take a history. What will you do first?

4. Before you begin your examination, you ask the grandson to excuse himself, explaining the
hospital's confidentiality policies. The grandson, an attorney, tells you that elderly Italian
women are extremely modest and might not answer questions completely. How might you
gather information, in this case?

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 PART 1 MEDICALSURGICAL CASES

5. What key questions must you ask this patient while you have the use of an interpreter?
4 Gastrointestinal

6. For each characteristic listed, specify whether it is a characteristic of small-bowel obstruction

(SBO), large-bowel obstruction (LBO), or both (B).
____a. Intermittent lower abdominal cramping
____b. Abdominal discomfort or pain accompanied by visible peristaltic waves in the upper
and middle abdomen
____c. Upper or epigastric abdominal distention
____d. Distention in the lower abdomen
____e. Obstipation
____f. Ribbon-like stools
____g. Nausea and early, profuse vomiting, which may contain fecal material
____h. Minimal or no vomiting
____i. Severe fluid and electrolyte imbalances

8. During you examination,

you note that she does not
7. What is obstipation?
(before #9)
have muscle guarding and
Case Study Progress. The
rebound tenderness on
physician orders the insertion of
palpation. Is this important?
Explain your answer.
9 With some difficulty, you insert a Salem Sump nasogastric tube (NGT) into A.G. and
8. a Salem Sump nasogastric tube
connect it to intermittent low wall suction. How will you check for placement of the NGT? (NGT).You insert the NGT into
A.G. and connect it to
intermittent low wall suction.

10.9. List, in order, the structures through which the NGT must pass as it is inserted.

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 CHAPTER 4 GASTROINTESTINAL DISORDERS CASE STUDY 45

11. A.G.'s grandson asks you, “What is that blue thing at the end of the tube? Shouldn't it be
10.
connected to something?” How do you answer?

11. What comfort measures are important for A.G. while she has an NGT?
12.

4 Gastrointestinal
12. You note that A.G.'s NGT has not drained in the last 3 hours. What can you do to facilitate
13.
drainage?

13. The NGT suddenly drains 575 mL; then it slows down to about 250 mL over 2 hours. Is this
14.
an expected amount?

14. You enter A.G.'s room to initiate your shift assessment. A.G. has been hospitalized for 3 days,
15.
and her abdomen seems to be more distended than yesterday. How would you determine
whether A.G.'s abdominal distention has changed?

CASE STUDY PROGRESS

After24
After 3 days of A.G.’s
hours, NGT suction, A.G.'s
symptoms aresymptoms
unrelieved.are
Sheunrelieved. She reports
reports continued continued
nausea, cramps, nausea, cramps,strong
and sometimes and
sometimes strong
abdominal pain; herabdominal
hand grips pain; her hand
are weaker; andgrips
she are weaker;
seems to beand she seems
increasingly to be increasingly
lethargic. lethargic.
You look at her latest
You look up her latest laboratory values
valuesand
andcompare
comparethem
themwith
withthe
theadmission
admission data.
data.

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 PART 1 MEDICALSURGICAL CASES

■ Chart View

Laboratory Test Results

Test Admission Hospital Day 3
Sodium 136 mEq/L 130 mEq/L
Potassium 3.7 mEq/L 2.5 mEq/L
Chloride 108 mEq/L 97 mEq/L
4 Gastrointestinal

Carbon dioxide 25 mEq/L 31 mEq/L

BUN 19 mg/dL 38 mg/dL
Creatinine 1 mg/dL 2.2 mg/dL
Glucose 126 mg/dL 65 mg/dL
Albumin 3.0 g/dL 3.1 g/dL
Protein 6.8 g/dL 4.9 g/dL

15. Which lab values are of concern to you? Why?

16.

17. What measures do you anticipate to correct in each of the imbalances described in Question 15?
16. 16?

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 CHAPTER 4 GASTROINTESTINAL DISORDERS CASE STUDY 45

CASE STUDY OUTCOME

In view of A.G.'s continued slow deterioration, the surgeon met with the patient and her family, and
they agreed to surgery. The surgeon released an 18-inch section of proximal ileum that had been con-
stricted by adhesions. Several areas looked ischemic, so these were excised, and an end-to-end anasto-
mosis was done. A.G. tolerated the procedure well. Her recovery was slow but steady. A.G. went home
in the care of her grandson and his wife on the seventh postop day. Discharge plans included a home
health nurse, home health aide, in-home physical therapy, and dietitian consult. The grandson was

4 Gastrointestinal
included in the plans.

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