QuestionAnswered step-by-stepScenario C.W. is a 36-year-old woman admitted 7 days ago for…Scenario C.W. is a 36-year-old woman admitted 7 days ago for inflammatory bowel disease (IBD) with small bowel obstruction (SBO). She underwent surgery 3 days after admission for a colectomy and ileostomy. She developed peritonitis and 4 days later returned to the operating room (OR) for an exploratory laparotomy, which revealed another area of perforated bowel, generalized peritonitis, and a fistula tract to the abdominal surface. Another 12 inches of ileum were resected (total of 7 feet of ileum and 2 feet of colon). The peritoneal cavity was irrigated with normal saline (NS), and 3 drainage tubes were placed: a Jackson-Pratt (JP) drain to bulb suction, a rubber catheter to irrigate the wound bed with NS, and a sump drain to remove the irrigation. The initial JP drain remains in place. A right subclavian triple-lumen catheter was inserted.1. C.W. returns from postanesthesia recovery unit (PACU) on your shift. What do you do when her bed is rolled into her room? 2. You pull the covers back to inspect the abdominal dressing and find that the originalsurgical dressing is saturated with fresh bloody drainage. What should you do? 3. C.W. has a total of 4 tubes in her abdomen, as well as a nasogastric tube (NGT). What information do you want to know about each tube?4. The sump irrigation fluid bag is nearly empty. You close the roller clamp, thread the IV tubing through the infusion pump, check the irrigation catheter connection site to make certain it is snug, and then discover that the nearly empty liter bag infusing into C.W.’s abdomen is D5W, not NS. Does this require any action? If so, give rationale for actions, and explain the overall situation.CASE STUDY PROGRESSThe physician arrives on the unit and removes C.W.’s surgical dressing. There is a small “bleeder” at the edge of the incision, so the physician calls for a suture and ties off the bleeder. You take the opportunity to ask her about a morphine patient-controlled analgesia (PCA) pump for C.W., and the physician says she will write the orders right away.5.Postoperative pain will be a problem for C.W. after the anesthesia wears off. How do you plan to address this? 3. C.W. has a total of 4 tubes in her abdomen, as well as a nasogastric tube (NGT). What information do you want to know about each tube?4. The sump irrigation fluid bag is nearly empty. You close the roller clamp, thread the IV tubing through the infusion pump, check the irrigation catheter connection site to make certain it is snug, and then discover that the nearly empty liter bag infusing into C.W.’s abdomen is D5W, not NS. Does this require any action? If so, give rationale for actions, and explain the overall situation.CASE STUDY PROGRESSThe physician arrives on the unit and removes C.W.’s surgical dressing. There is a small “bleeder” at the edge of the incision, so the physician calls for a suture and ties off the bleeder. You take the opportunity to ask her about a morphine patient-controlled analgesia (PCA) pump for C.W., and the physician says she will write the orders right away.5.Postoperative pain will be a problem for C.W. after the anesthesia wears off. How do you plan to address this? 6. Pharmacy delivers C.W.’s first bag of total parenteral nutrition (TPN). The physician has instructed you to start the TPN at a rate of 60 ml/hr and decrease the maintenance IV rate by the same amount. What is the purpose of this order? 7. The physician did not specifically order glucose monitoring, but you know that it should be initiated. You plan to conduct a fingerstick blood test every 2 hours for the first severalhours. What is your rationale? 8. C.W.’s blood glucose increased temporarily, but by the next day it dropped to an average of 70 to 80 mg/dl and has remained there for 2 days. Her VS are stable, but her abdominal wound shows no signs of healing. She has lost 1 kg over the past 3 days. What do thesedata mean? CASE STUDY PROGRESSYou discuss your concerns with C.W.’s physician, and she agrees to request a consult from a registered dietitian (RD). After gathering data and making several calculations, the RD makes recommendations to the attending physician. The TPN orders are adjusted, C.W. begins to gain weight slowly, and her wound shows signs of healing. Nutritional problems in clinical populations can be complex and often require special attention.9. You and a co-worker read the following in C.W.’s progress notes: “Wound healing by secondary closure. Formation of granular tissue with epithelialization noted around edges. Have requested dietitian to consult on ongoing basis. Will continue to follow.” Your co-worker turns to you and asks whether you know what that means. How would youexplain? 10. Both of you start to discuss what specific digestive difficulties C.W. is likely to face in the future. What problems might C.W. be prone to develop after having so much of her bowel removed? [11. The RD consults with C.W. about dietary needs. You attend the session so that you will be able to reinforce the information. What basic information is the RD likely to discuss with C.W.? 12. After 3 days of dressing changes, C.W.’s skin is irritated, and a small skin tear has appeared where tape was removed. How can you minimize this type of skin breakdown and help this area heal? 13. What specifics of ostomy teaching do you plan to do? Health ScienceScienceNursingMED SURGIC nu2530Share Question

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