Primary Concept
Elimination
Interrelated Concepts (In order of emphasis)
● Patient Education
● Clinical judgment
NCLEX Client Need Categories Covered in
Case Study
NCSBN Clinical
Judgment Model
Covered in
Case
...
Primary Concept
Elimination
Interrelated Concepts (In order of emphasis)
● Patient Education
● Clinical judgment
NCLEX Client Need Categories Covered in
Case Study
NCSBN Clinical
Judgment Model
Covered in
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 ✔
Present Problem:
Part I: Initial Nursing Assessment
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:
- Partial colectomy w/ colostomy
- Small bowel obstruction 3 months ago
- Sudden onset of sharp pain with N/V,
decreased output from colostomy bag
- Small bowel obstruction
- Lactate 2.8 (HIGH)
- WBC 14.7 (HIGH)
- Creatinine 1.35 (HIGH)
- Indicates patient cannot excrete normally due to partial
colectomy
- Highly likely that current problem is a small bowel
obstruction since she has a history of it
- S/S indicate small bowel obstruction. S/S also indicate pt
may have electrolyte imbalances d/t obstructed digestion
- CT reveals pt does, indeed, have an SBO
- Normal = 0.5-1. High levels may indicate Type B lactic
acidosis d/t regional ischemia.
- Normal = 4-11K. High WBC’s may indicate infection
and/or physical or emotional stress.
- Normal = 07-1.2. Elevated creatinine levels signify
impaired kidney function or kidney disease. Dehydration
can also cause this, which is supported by patient’s recent
vomiting.
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