Running Head: Small Bowel Obstruction
Small Bowel Obstruction
Jack Green
Liberty University
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SMALL BOWEL OBSTRUCTION
Patient Profile Worksheet
A. Personal Information
Room # 375 Gender: F Ethnicity: Black Age if < 90: 48
Place of Residence: Lynchburg MD: Dr. Kovtoun
EmergencyContact Father MaritalStatus: Single
Admitting Diagnosis: Unspecified intestinal obstruction
Co-Morbidities: Diverticula disease, asthma
Date of Admission: 2/10/17 Date of Surgery: 02/10/17 Allergies: Lortab
Code Status: Full Code Mental Status: oriented x4
B. Activity and Nutrition
Diet order: Regular Route/Rate: 3 meals a day Last Wt: N/A
Level of Activity (bedrest, up ad lib, BRP, turning): up ad lib
Level of self-care: assist x 1
C. Nursing Care:
Drainage devices (foley, NGT, JPs, T-tube, etc): N/A
NGT Flushes: N/A
Wound care/Dressing (be specific): ileostomy – empty when 1/3 full
IV access (peripheral, central, location, care): Picc line – right basilic
IVF: Ns20kc @ 125 mL/hr Saline Lock: No TPN: N/A
Frequency of vital signs (including pulse oximetry): QID
Frequency of Glucometer: AC and HS Supplemental oxygen: room air OSA: High Risk
Falls Risk: High risk
Precautions: The patient is a high falls risk and is allergic to Lortab
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Most Recent Labs (include date of labs):
Common Hematology/Chemistries/RFTs
Date of Labs Taken 1/31/17 2/02/17
Na 137 136-145 mEq/L
K 3.8 3.5-5.1 mEq/L
Cl 101 98-110 mEq/L
TCO225 20-28 mEq/L
Anion Gap 11 5-15 mEq/L
Glucose 209 70-100 mg/dL
Urea Nitrogen 15 5-23 mg/dL
Creatinine 1.0 0.5-1.3 mg/dL
Ca+2 9.4 8.5-10.4 mg/dL
GFR >60 >60mL/min/1.73m
RBC 5.14 4.20-5.50 m/uL
Hgb 13.7 14.0-18.0 g/dL
HCT 44.3 41.0-51.0%
WBC 9.7 4.0-10.0 k/uL
Platelet 191 150-450 k/uL
Other Pertinent Labs (make sure to document important trends):
Patient History Worksheet:
Chief Complaint: Abdominal pain
History of Present Illness (discuss clinical course from admission until current date):
Patient 374 is a 48 year-old female who presented due to to abdominal pain that began
the night before she was admitted. She reported the onset of pain starting after she finished
dinner. The patient also reported four episodes of nausea and vomiting. It was thought that she
most likely had a bowel obstruction. She then had an exploratory laparotomy done with lysis of
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adhesions. During the procedure, a tight single adhesive band from a previous low transverse
incision was found.
Past Medical History:
The patients medical history includes Vitamin D deficiency, and GERD
Past Surgical History:
The patients surgical history includes a hystectomy, a right salpingectomy, and an
appendectomy.
Family History:
The patient’s family history includes renal disease
Tobacco: denies Alcohol: denies Illegal Drugs: denies
Occupational Status: N/A
Religious Preference: none
Cultural Support Needs: none
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SMALL BOWEL OBSTRUCTION
The II. Medications
Student should also have medication cards or book available on clinical.
Include PRNs that have been administered with the last 24 hours.
Medication
Generic &
Trade
Route Dosage &
Freq
uenc
y
Category/Mechanism
of Action
Contraindications /
Cautions
Side Effects Use for this
patient
Pantoprazole
(Protonix)
PO 4mg Daily Proton pump inhibitor;
suppresses gastric
secretion by inhibiting
hydrogen/potassium
ATPase enzyme system in
gastric parietal cell;
characterized as gastric
acid pump inhibitor, since
it blocks final step of acid
production (Skidmore-
Roth, 2011, p. 868)
Hypersensitivity (Skidmore-
Roth, 2011)
Headache, diarrhea,
abdominal pain,
rash, pneumonia
(Skidmore-Roth,
2011)
This reduces
the patient’s
gastric
secrections.
Toradal
(Ketoralac)
PO 15 mg Q6H Nonsteroidal anti-
inflammatory/nonopioid
analgesic; inhibits
prostaglandin synthesis by
decreasing an enzyme
needed for biosynthesis;
analgesic, anti-
inflammatory, antipyretic
effects (Skidmore-Roth,
2011, p.642)
Pregnancy (D) 3rd trimester,
hypersensitivity, asthma, hepatic
disease, peptic ulcer disease, CV
bleeding (Skidmore-Roth, 2011)
Drowsiness,
seizures, CV
thrombotic events,
MI, stroke, GI
bleeding,
perforation,
hepatitis, hepatic
failure,
nephrotoxicity,
dysuria, hematuria,
oliguria, azotemia,
blood dyscrasias,
angioedema,
Stevens-Johnson
syndrome, toxic
Control mild
to moderate
pain.
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epidermal
necrolysis
(Skidmore-Roth,
2011)
Heparin SQ 5000 units
Q8hr
Anticoagulant,
antithrombotic; prevents
conversion of fibrinogen
to fibrin and prothrombin
to thrombin by enhancing
inhibitory effects of
antithrombin II
(Skidmore-Roth, 2011,
p.570)
Hypersensitivity, hemophilia,
leukemia with bleeding, peptic
ulcer disease, severe
thrombocytopenic purpura,
severe renal/hepatic disease,
blood dyscrasias, severe
hypertension, subacute bacterial
endocarditis, acute nephritis
(Skidmore-Roth, 2011)
Fever, hematuria,
hemorrhage,
thrombocytopenia,
anemia, rash,
anaphylaxis
(Skidmore-Roth,
2011)
This will help
prevent DVT
Morphine
sulfate
IV 1 mg
PCA pump
PRN
Opioid analgesic;
depresses pain impulse
transmission at the spinal
cord level by interacting
with opioid receptors
(Skidmore-Roth, 2011,
p.744)
Hypersensitivity, addiction
(opioid), hemorrhage, bronchial
asthma, increased intracranial
pressure (Skidmore-Roth, 2011)
Seizures,
bradycardia, shock,
cardiac arrest,
tachycardia,
thrombocytopenia,
respiratory
depression,
respiratory arrest,
apnea (Skidmore-
Roth, 2011)
To relieve
moderate to
severe pain
V. Top Three Prioritized Medical and Nursing Diagnosis
1. Small bowel obstruction: Risk for deficient fluid volume RT: stasis of stool AEB: bloated abdomen, abdominal pain, nausea, and
vomiting
2. Small bowel obstruction: Risk for infection RT: symptoms of gout AEB: joint stiffness, inability to ambulate, joint swelling, bedrest
3. Small bowel obstruction: Acute pain RT: symptoms of gout AEB: joint stiffness, morbidly obese, can’t ambulate, swelling in joints.
Care Plan
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SMALL BOWEL OBSTRUCTION
Medical & Nursing Dx Nursing Outcomes (NOC) Nursing Interventions (NIC) Evaluation
1. Small bowel obstruction:
deficient fluid volume RT: stasis
of stool AEB: bloated abdomen,
abdominal pain, nausea, and
vomitting
1. At the end of the day the
patients fluid
requirements will be met
AEB normal BP, moist
mucous membranes
2. At the end of the day the
patient will have
reduced nausea and
vomiting AEB less
episodes of vomiting
1a. Administer IV fluid Ns20kc
as prescribed
Rationale: This will help
maintain intravascular volume
1b. Maintain strict I and Os
Rationale: This will help keep
track of the patient’s fluid
balance.
1c. Elevate HOB above 30
degrees
Rationale: This will help with
the patient’s nausea and
vomiting.
2a. Administer the patient’s
Pantoprazole
Rationale: This will help reduce
the patients stomach secretions
and the urge to vomit.
2b. Remove any foul smells
from the patient’s room
Rationale: This will reduce the
patients from vomiting
1. At the end of the day the
patients pain was a 4.
2. The swelling was
reduced at the end of the
day.
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3. At the end of the day the
patient’s pain will be
reduced AEB Rating
pain below a 5 on a 0-10
pain scale
2c. put a cool cloth on the
patients forehead
Rationale: This will help reduce
the patients nausea
3a. Administer the patients
oxycodone
Rationale: This will help
control the patients pain
3b. Teach the patient guided
imagery
Rationale: This will help take
the patients focus off of their
pain.
3c. Turn on the television
Rationale: This will distract the
patient from their pain.
3. The patient displayed
good hydration at the
end of the day.
References
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SMALL BOWEL OBSTRUCTION
Becker, M. A. (2017, February 8). Pathophisiology of gouty arthritis. Retrieved February 13, 2017, from https://www-uptodate-
com.ezproxy.liberty.edu/contents/pathophysiology-of-gouty-arthritis?source=search_result&search=gout&selectedTitle=4~150
Hwang, J. L., & Weiss, R. E. (2014). Steroid-Induced diabetes: a clinical and molecular approach to understanding and treatment. HHS Public
Access, 2, . doi:10.1002/dmrr.2486
Lewis, S. L. (2014). Medical-Surgical Nursing (9th ed.). St. Louis, Missouri: Elsevier.
Mayo Clinic Staff. (). Type 2 Diabetes. Retrieved February 13, 2017, from http://www.mayoclinic.org/diseases-conditions/type-2-
diabetes/symptoms-causes/dxc-20169861
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