Nursing

Copyright © 2020 Keith Rischer, d/b/a KeithRN. All Rights reserved.

Part II: Perforated Bowel/Sepsis/ICU NextGen Unfolding Reasoning

Mary O’Reilly, 55 years old

Primary Concept Infection/Inflammation

Interrelated Concepts (In order of emphasis)  Gas Exchange

 Perfusion

 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 

Copyright © 2020 Keith Rischer, d/b/a KeithRN. All Rights reserved.

Part I: Initial Nursing Assessment

History of Present Illness: Mary O’Reilly is a 55-year-old female with a prior history of partial colectomy w/colostomy who was admitted to the

medical/surgical unit for small bowel obstruction. Yesterday she developed severe RLQ abdominal pain and CT revealed

a perforated small bowel with free intraperitoneal air. Before she was brought to the operating room (OR) for an

exploratory laparotomy, her lactate was 4.9, WBC 18.9, and her systolic BP began to drop to 65-75, with a mean arterial

pressure (MAP) of 50-55. She received a total of 2500 mL of 0.9% NS preop and piperacillin-tazobactam 4.5 g. IVPB.

Her last BP before she went to the OR was 94/52 w/MAP 65.

What data is RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential)

RELEVANT Data: Clinical Significance:

Present Problem: Mary had an exploratory laparotomy that required extensive lysis of adhesions and was found to have a perforated

jejunum with fecal peritonitis. Mary has a 7.0 mm endotracheal tube (ET) that is well secured, 23 cm at the lips. Current

vent settings are: CMV/AC rate 12, TV 500 mL, PEEP +5, FiO2 35%. She has an arterial line placed in the right radial

artery and a central line was placed in the right internal jugular (RIJ). Placement was confirmed by chest x-ray. Mary

received 2.5 liters of LR during the case and had an estimated blood loss (EBL) of 375 mL. To maintain adequate

perfusion during surgery, she required norepinephrine IV gtt, currently at 10 mcg. Her SBP was consistently in the 90-

100s during surgery with a mean arterial pressure (MAP) of 65-70 and CVP: 12. She has a wound VAC applied to her

open abdominal incision with an intact dressing at 125 mm suction with no drainage and a 14 Fr. Salem Sump NG, 68 cm

in the left nare.

What data is RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential)

RELEVANT Data: Clinical Significance:

Mary is coming to ICU after surgery and the OR

nurse provides you with the following report:

Copyright © 2020 Keith Rischer, d/b/a KeithRN. All Rights reserved.

Patient Care Begins: Cardiac Telemetry Strip (6 seconds):

Regular/Irregular: P wave present? PR: QRS: QT:

Interpretation:

Clinical Significance:

Current VS: T: 99.4 F/37.4 C (oral)

P: 94 (regular)

R: 20 (AC: 12)

Arterial BP: 92/55 MAP: 67

O2 sat: 96% w/FiO2 35% ventilator

What VS data are RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential Reduction of Risk Potential/Health Promotion and Maintenance)

RELEVANT VS Data: Clinical Significance:

Current Head to Toe Nursing Assessment:

GENERAL SURVEY: Body relaxed, no grimacing, appears to be resting comfortably with no restlessness noted. Peripheral IV and central line well secured w/dressings intact, no redness or signs of

infection present, LIS suction w/NGT, ET 23 cm at lip, NGT 68 cm, tape secure on nasal

bridge and NG tube.

NEUROLOGICAL: PERRLA-3 mm, opens eyes briefly when name called, but then goes back to sleep, limited

spontaneous movements of all extremities noted

HEENT: Head normocephalic with symmetry of all facial features, sclera white bilaterally,

conjunctival sac pink bilaterally. Lips, tongue, and oral mucosa pink and moist. Biteblock for

ET properly placed.

RESPIRATORY: Breath sounds coarse bilat but clear after deep suctioning with equal aeration on inspiration and expiration in all lobes anteriorly, posteriorly, and laterally. Vent settings confirmed: AC

rate 12, TV 500 mL, PEEP +5, FiO2 35%. Total RR 20, peak inspiratory pressures 16-20.

Actual TV: 500-600. Moderate amount of clear, creamy oral secretions requiring suctioning,

small amount of tan, thick secretions suctioned from ETT.

After receiving report from the nurse in PACU, the patient is brought

back to ICU and you collect the following assessment data:

Copyright © 2020 Keith Rischer, d/b/a KeithRN. All Rights reserved.

CARDIAC: Pink, warm & dry, no edema, heart sounds regular, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill. Heart tones audible and regular, S1 and S2

noted over A-P-T-M cardiac landmarks with no abnormal beats or murmurs. No JVD noted

at 30-45 degrees. Moderate generalized edema with 2+ pitting edema in lower extremities

ABDOMEN: Abdomen large, round, firm to touch. Midline open abdominal incision appx 6” (15 cm) in

length and 1.5” (4 cm) wide filled with intact transparent dressing. Wound V.A.C. at 125

mm suction-no drainage. BS absent in all 4 quadrants, colostomy bag intact with small

amount of dark brown stool in bag, stoma pink, with brisk refill <1 second with blanching of

stoma.

GU: Urinary catheter secured on thigh, 100 mL urine clear/yellow in drainage bag/urometer the

past hour

INTEGUMENTARY: Skin warm, dry, intact, normal color for ethnicity. No clubbing of nails, cap refill <3

seconds, Hair soft-distribution normal for age and gender. Skin integrity intact, skin turgor

elastic, no tenting present.

What assessment data is RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential Reduction of Risk Potential/Health Promotion & Maintenance)

RELEVANT Assessment Data: Clinical Significance:

Based on your nursing assessment, use the CPOT to rate the pain in an intubated patient. Is her pain

adequately controlled using the parameters of this tool?

Critical Care Pain Observation Tool (CPOT):

Intubated? Yes/no Yes

Facial Expression: Relaxed: 0/Tense: +1/Grimacing: +2 0

Body Movements: Absence: 0/Protection: +1/Restlessness: +2 0

Muscle Tension: Relaxed: 0/Tense/rigid: +1/Very tense/rigid: +2 0

Total Score: 0

Based on your nursing assessment, use the RASS to rate the sedation level. What level of sedation is

ordered? Is sedation adequate?

Richmond Agitation-Sedation Scale (RASS) Combative: +4 Overtly combative or violent, immediate danger to staff.

Very Agitated: +3 Pulls on or removes tubes or catheters or is aggressive.

Agitated: +2 Frequent non-purposeful movement or ventilator dyssynchrony.

Restless: +1 Restless, anxious or apprehensive but movements not aggressive or vigorous.

Alert and Calm: 0 Alert and calm.

Drowsy: -1 Drowsy, but sustains more than 10 seconds awake, with eye opening in response to

verbal command.

Light Sedation: -2 Awakens briefly (less than 10 seconds) with eye contact to verbal command.

Moderate Sedation: -3 Any movement, except eye contact, in response to command.

Deep Sedation: -4 No response to voice, but any movement to physical stimulation.

Unarousable Sedation: -5 No response to voice or physical stimulation.

Copyright © 2020 Keith Rischer, d/b/a KeithRN. All Rights reserved.

Critical Care Skills/Standards of Care Identify nursing priorities/standards of care with these critical care interventions

Ventilator Management: Nursing Standards of Care: Rationale:

Arterial Line Nursing Standards of Care: Rationale:

Central Line/Dressing Care Nursing Standards of Care: Rationale:

Wound Vacuum Assisted Closure (VAC) Nursing Standards of Care: Rationale:

Copyright © 2020 Keith Rischer, d/b/a KeithRN. All Rights reserved.

Part II: Put it All Together to Think Like a Nurse 1. Interpreting all clinical data collected, what are the current problems? Rank by priority. Which problem is most

serious? Why? (NCSBN: Step 3 Prioritize hypotheses)

Likely Problems: Rank by Priority: Rationale:

2. What is the pathophysiology of the priority problem? (NCLEX Management of Care/Physiologic Adaptation)

Priority Problem: Pathophysiology of Problem in OWN Words:

3. What body system(s) will you assess most thoroughly based on the primary/priority problem? Identify correlating

specific nursing assessments. (NCLEX Reduction of Risk Potential/Physiologic Adaptation)

PRIORITY Body System: PRIORITY Nursing Assessments:

Collaborative Care: Medical Management 4. State the rationale and expected outcomes for the medical plan of care. (NCLEX Pharm. and Parenteral Therapies)

Care Provider Orders: Rationale: Expected Outcome:

Ventilator settings: CMV/AC rate 12,

TV 500 mL, PEEP +5, FiO2 35%.

Wound V.A.C. 125 mm to open

abdominal incision

Norepinephrine IV infusion (0.5-30

mcg/min) to maintain MAP >65.

Vasopressin 0.04 IV infusion

Copyright © 2020 Keith Rischer, d/b/a KeithRN. All Rights reserved.

0.9% NS IV infusion 100 mL hour

Fentanyl IV infusion 10-125 mcg/hour.

RASS goal -3 (Mod. Sedation)

Dexmedetomidine IV infusion 0.2-1

mcg/kg/hour. RASS goal -3 (Mod.

Sedation)

Piperacillin-tazobactam 3.375 g (D5 100

mL) IVPB. Infuse over 4 hours every 6

hours

Chlorhexidine 15 mL oral/swab every 12

hours

Famotidine 20 mg IV every 12 hours

Heparin 5000 units SQ every 8 hours

5. Which orders do you implement first? Why?

Care Provider Orders: Order of Priority: Rationale:

Though the patient arrived from the

operating room with these orders already

implemented, it is the nurse’s responsibility

to know what sequence to perform safety

checks to ensure that the orders are correct.

 Ventilator settings: CMV/AC rate 12, TV 500 mL, PEEP +5, FiO2 35%.

 Wound V.A.C. 125 mm to open abdominal incision

 Norepinephrine IV infusion (0.5-30 mcg/min) to maintain MAP >65.

 Vasopressin 0.04 IV infusion

 0.9% NS IV infusion 100 mL hour

 Fentanyl IV infusion 10-125 mcg/hour. RASS goal -3 (Mod. Sedation)

 Dexmedetomidine IV infusion 0.2-1 mcg/kg/hour. RASS goal -3 (Mod.

Sedation)

 Piperacillin-tazobactam 3.375 g (D5 100 mL) IVPB. Infuse over 4 hours every 6

hours

 Chlorhexidine 15 mL oral/swab every 12 hours

 Famotidine 20 mg IV every 12 hours

 Heparin 5000 units SQ every 8 hours

Copyright © 2020 Keith Rischer, d/b/a KeithRN. All Rights reserved.

6. What nursing priority(ies) and goal will guide how the nurse RESPONDS to formulate a plan of care? (NCSBN:

Step 4 Generate solutions/Step 5: Take action/NCLEX Management of Care)

Nursing PRIORITY:

GOAL of Care:

Nursing Interventions: Rationale: Expected Outcome:

7. What is the worst possible/most likely complication(s) to anticipate based on the primary problem?

(NCLEX: Reduction of Risk Potential/Physiologic Adaptation)

Worst Possible/Most Likely

Complication to Anticipate:

Nursing Interventions to

PREVENT this Complication:

Assessments to Identify Problem

EARLY:

Nursing Interventions to Rescue:

8. What psychosocial/holistic care PRIORITIES need to be addressed for this patient/family? (Psychosocial Integrity/Basic Care and Comfort)

Psychosocial PRIORITIES:

PRIORITY Nursing Interventions: Rationale: Expected Outcome:

Copyright © 2020 Keith Rischer, d/b/a KeithRN. All Rights reserved.

Part II: Interpreting Diagnostic Data

Radiology Reports: What diagnostic results are RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential/Reduction of Risk Potential/Physiologic Adaptation)

Radiology: Chest X-Ray

Results: Clinical Significance:

Endotracheal tube at the distal

tracheal level, 2 cm above the

carina

Lungs and pleural spaces: No

pleural effusion or pneumothorax.

Lab Results: Complete Blood Count (CBC)

WBC HGB PLTs % Neuts Bands

Current: 22.5 11.2 225 91 1

Yesterday: 18.9 12.9 189 84 0

What lab results are RELEVANT and must be recognized as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential Reduction of Risk Potential/Physiologic Adaptation)

RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable:

Basic Metabolic Panel (BMP)

Na K Gluc. Creat. BUN

Current: 132 4.1 162 1.32 35

Yesterday: 136 3.9 148 0.98 15

What lab results are RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential Reduction of Risk Potential/Physiologic Adaptation)

RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable:

After arriving in the ICU from the OR, the primary care provider orders

the following diagnostic tests and the results just posted in the electronic

health record:

Copyright © 2020 Keith Rischer, d/b/a KeithRN. All Rights reserved.

Misc.

Lactate

Current: 2.1

Yesterday: 4.9

What lab results are RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential Reduction of Risk Potential/Physiologic Adaptation)

RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable:

Liver Panel

Albumin Total Bili Alk. Phos. ALT AST

Current: 2.2 1.2 72 79 75

Yesterday: 2.4 0.9 58 42 38

What lab results are RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential Reduction of Risk Potential/Physiologic Adaptation)

RELEVANT Lab(s): Clinical Significance: TREND: Improve/Worsening/Stable:

Arterial Blood Gas (ABG)

pH pCO2 pO2 HCO3 O2 sat

Current: 7.24 38 112 15 99%

RELEVANT Lab(s): Clinical Significance:

What is your interpretation of this arterial blood gas?

When you update the primary care provider with the ABG results, she orders sodium bicarbonate 100

mEq/50 mL IV. Why?

Copyright © 2020 Keith Rischer, d/b/a KeithRN. All Rights reserved.

Part IV: Evaluation: Eight Hours Later

1. Interpret clinical data to determine if the patient status is improving, declining, or reflects no change. (NCSBN: Step 6 Evaluate outcomes/NCLEX: Management of Care)

RELEVANT Assessment Data: Clinical Significance: Improving-Declining

No Change:

2. Has the overall status of your patient improved, declined, or remain unchanged? If your patient has not improved,

what other interventions need to be considered by the nurse? (NCSBN: Step 6 Evaluate outcomes/NCLEX: Management of Care)

Overall Status: Additional Interventions to Implement: Expected Outcome:

To maintain a RASS of -3, Mary is currently receiving fentanyl 100 mcg IV infusion,

dexmedetomidine 0.6 mcg/hr. Her norepinephrine has been decreased from 10 mcg/min to 5

mcg/min to maintain MAP >65. She has had 60 mL blood-colored serosanguinous drainage

from the wound VAC. She has 200 mL clear yellow urine and 20 mL of light green bile

drainage from the NG the last 2 hours. Her weight is 68.9 kg. Her last weight 24 hours ago

was 65.2 kg.

Her breath sounds are clear, diminished in the bases. ET suctioning every 2-4 hours

results in small amounts of clear to white thin secretions. Her abdomen is firm, with absent

bowel sounds.

Most recent set of VS: T: 99.5 F/37.5 C (oral)/HR: 80 (reg) RR: 16 BP: 118/58 (MAP-78)

O2 sat: 96% FiO2: 30%

Because of the excellent nursing care you provided for your patient,

Mary was extubated the next day, and transferred to the

medical/surgical unit. Mary will be discharged to home in the next 1-2

days. What educational priorities need to be taught to successfully

manage her current problem and maintain an optimal state of health?

Copyright © 2020 Keith Rischer, d/b/a KeithRN. All Rights reserved.

3. What educational/discharge priorities are needed to develop a teaching plan for this patient and/or

family?(Health Promotion and Maintenance)

Education PRIORITY:

PRIORITY Topics to Teach: Rationale:

Reflect on Your Thinking to Develop Clinical Judgment 4. To develop clinical judgment, reflect on your thinking that was used to complete this case study by answering the

following questions:

What did you do well in this case study? What knowledge gaps did you identify?

What did you learn? How will you apply learning caring for future patients?

NCLEX Client Need Categories:
Covered in Case StudySafe and Effective Care Environment:
undefined:
Step 2 Analyze Cues:
undefined_2:
fill_3:
undefined_3:
undefined_4:
undefined_5:
Psychosocial Integrity:
Step 5 Take Action:
undefined_6:
Physiological Integrity:
undefined_7:
undefined_8:
undefined_9:
undefined_10:
undefined_11:
RELEVANT DataRow1:
Clinical SignificanceRow1:
RELEVANT DataRow1_2:
Clinical SignificanceRow1_2:
Cardiac Telemetry Strip 6 secondsRow2:
Clinical SignificanceRow1_3:
Current VS:
T 994 F374 C oral:
P 94 regular:
R 20 AC 12:
RELEVANT VS DataRow1:
Clinical SignificanceRow1_4:
Current Head to Toe Nursing Assessment:
GENERAL SURVEY:
NEUROLOGICAL:
HEENT:
RESPIRATORY:
CARDIAC:
ABDOMEN:
GU:
INTEGUMENTARY:
RELEVANT Assessment DataRow1:
Clinical SignificanceRow1_5:
Critical Care Pain Observation Tool CPOT:
Intubated:
Yesno:
Yes:
Relaxed 0Tense 1Grimacing 2:
0:
Absence 0Protection 1Restlessness 2:
0_2:
Relaxed 0Tenserigid 1Very tenserigid 2:
0_3:
0_4:
Richmond AgitationSedation Scale RASS:
Combative:
Overtly combative or violent immediate danger to staff:
Very Agitated:
Pulls on or removes tubes or catheters or is aggressive:
Agitated:
Restless:
Alert and calm:
Drowsy:
1:
Light Sedation:
Deep Sedation:
No response to voice or physical stimulation:
Nursing Standards of CareRow1:
RationaleRow1:
Nursing Standards of CareRow1_2:
RationaleRow1_2:
Nursing Standards of CareRow1_3:
RationaleRow1_3:
Nursing Standards of CareRow1_4:
RationaleRow1_4:
Likely ProblemsRow1:
Rank by PriorityRow1:
RationaleRow1_5:
Priority ProblemRow1:
Pathophysiology of Problem in OWN WordsRow1:
PRIORITY Body SystemRow1:
PRIORITY Nursing AssessmentsRow1:
Care Provider Orders:
RationaleVentilator settings CMVAC rate 12 TV 500 mL PEEP 5 FiO2 35 Wound VAC 125 mm to open abdominal incision Norepinephrine IV infusion 0530 mcgmin to maintain MAP 65 Vasopressin 004 IV infusion:
Expected OutcomeVentilator settings CMVAC rate 12 TV 500 mL PEEP 5 FiO2 35 Wound VAC 125 mm to open abdominal incision Norepinephrine IV infusion 0530 mcgmin to maintain MAP 65 Vasopressin 004 IV infusion:
09 NS IV infusion 100 mL hour Fentanyl IV infusion 10125 mcghour RASS goal 3 Mod Sedation Dexmedetomidine IV infusion 021 mcgkghour RASS goal 3 Mod Sedation Piperacillintazobactam 3375 g D5 100 mL IVPB Infuse over 4 hours every 6 hours Chlorhexidine 15 mL oralswab every 12 hours Famotidine 20 mg IV every 12 hours Heparin 5000 units SQ every 8 hours:
Care Provider Orders_2:
fill_1:
fill_2:
Nursing PRIORITY:
GOAL of Care:
Nursing InterventionsRow1:
RationaleRow1_6:
Expected OutcomeRow1:
Worst PossibleMost Likely Complication to Anticipate:
Nursing Interventions to PREVENT this ComplicationRow1:
Assessments to Identify Problem EARLYRow1:
Nursing Interventions to RescueRow1:
Psychosocial PRIORITIES:
PRIORITY Nursing InterventionsRow1:
RationaleRow1_7:
Expected OutcomeRow1_2:
Results:
Clinical SignificanceEndotracheal tube at the distal tracheal level 2 cm above the carina Lungs and pleural spaces No pleural effusion or pneumothorax:
Complete Blood Count CBCRow1:
Current:
RELEVANT LabsRow1:
Clinical SignificanceRow1_6:
TREND ImproveWorseningStableRow1:
Basic Metabolic Panel BMPRow1:
Current_2:
RELEVANT LabsRow1_2:
Clinical SignificanceRow1_7:
TREND ImproveWorseningStableRow1_2:
MiscRow1:
Lactate:
Current_3:
21:
49:
RELEVANT LabsRow1_3:
Clinical SignificanceRow1_8:
TREND ImproveWorseningStableRow1_3:
Liver PanelRow1:
Current_4:
RELEVANT LabsRow1_4:
Clinical SignificanceRow1_9:
TREND ImproveWorseningStableRow1_4:
Arterial Blood Gas ABGRow1:
Current_5:
RELEVANT LabsRow1_5:
Clinical SignificanceRow1_10:
RELEVANT Assessment DataRow1_2:
Clinical SignificanceRow1_11:
ImprovingDeclining No ChangeRow1:
Overall StatusRow1:
Additional Interventions to ImplementRow1:
Expected OutcomeRow1_3:
Education PRIORITY:
PRIORITY Topics to TeachRow1:
RationaleRow1_8:
What did you do well in this case studyRow1:
What knowledge gaps did you identifyRow1:
What did you learnRow1:
How will you apply learning caring for future patientsRow1:
Answer1:

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