Patient Scenario: 63 year-old-male admitted with abdominal discomfort and blurred vision. Wife was at beside. Patient resting in bed when entered room on the Surgical unit.
Pathophysiology of Current Disease: Diverticulitis: Inflammation of one or more diverticula. Results when undigested food is retained and compromises the blood supply to the area. Can perforate and cause intra-abdominal perforation, with peritonitis.
Nursing Diagnosis: Acute pain related to inflamed bowel.
Past Medical History: Client presents with past medical history including; Hypertension, hemorrhoids, kidney stones, urinary tract infection, cystitis, diabetes mellitus type 2, depression and anxiety, appendectomy, and an unknown status of the chicken pox.
Social History: Wife was at bedside during hospital stay. Did not talk much of children or other family members. Wife seems to be primary support and caregiver, although patient is able to take care of himself.
Assessment Data: Subjective Data: Patient complaining of some abdominal pain. During time taking care of, patient reported no pain, no nausea, and no vomiting. Just wanted to sleep. Objective Data: Client alert and oriented x4, pupils PERRL, no facial droop, Heart rate regular rate and rhythm, pulses equal bilaterally, capillary refill <3 seconds, lung sounds clear bilaterally, vital signs posted below, skin warm, dry, intact, pain indicated in lower abdomen, rated between 0 and 1, dilaudid given before beginning patient care, denies need for further pain medication, bowel sounds active in all 4 quadrants, no recorded stool during care of patient. Wanted to rest, lights kept low, as well as volume on TV.
Vital Signs: Time Temp HR RR BP P02 Pain 0700 98.0 40 22 164/74 97 RA 1 1100 97.2 56 20 148/76 95 RA 2 1500 97.5 68 16 162/92 95 RA 0 1900 97.7 60 16 161/87 97 RA 0
Diagnostic Tests Completed with Results: Zachary Kelley Concept Map 4/21/15
Labs:
Lab Admit (4/10/15) Current (4/1415) WBC 10.0 9.6 RBC 5.21 4.39 L Hgb 15.5 12.9 L Hct 45.3 38.7 L MCV 86.9 88.2 MCH 29.8 29.3 MCHC 34.2 33.3 RDW 12.6 12.7 Plt 332 262 MPV 9.6 10.2 Immature Gran% 0.2 0.2 Neutrophils 78.3 H 82.1 H Lymphocytes 14.3 L 9.3 L Monocytes 6.9 8.3 Eosniphils 0.1 0.0 Basophils 0.2 0.1 Immature Gran # 0.0 0.0 Neutrophils 7.8 H 7.9 H Lymphocytes 1.4 0.9 L Monocytes 0.7 0.8 Eosphils 0.0 0.0 Basophils 0.0 0.0 Total Counted 100 Neutrophils 71.0 H Band Neutrophils 11.0 H Lymphocytes 9.0 L Monocytes 9.0 H Sodium 132 L 138 Potassium 4.6 3.7 Chloride 90.9 L 102.7 CO2 24 18 L BUN 17 15 Creatinine 1.6 H 1.4 H GFR 47 L 54 L Glucose 203 H 60 Calcium 9.3 8.0 L Total Bilirubin 1.9 H 0.9 AST 14 11 ALT 22 10 Alkaline Phosphate 85 59 CRP 170.6 H Zachary Kelley Concept Map 4/21/15
Total Protein 8.2 6.5 Albumin 3.9 2.9 L Globulin 4.3 H 3.6 H A/G Ratio 0.9 L 0.8 L Amylase 36 Lipase 40 Urinalysis: Clean void, yellow, slightly cloudy, pH (6.0), Specific Gravity (1.005), Protein (2+ - High), no glucose or ketones, urobilinogen (0.2), RBC (rare), squamous epithelial cells (rare) Negative for clostridium difficile, no growth on peripheral blood draw culture Imaging: 4/10/15 CT Abdomen and Pelvis without contrast: 5.5 cm abcess adjacent to sigmoid colon, several diverticula, moderately atrophic L kidney with 3 mm stone, degree of function questioned, 2 mm nonobstructing stone in L kidney, 2mm nonobstructing stone in R kidney, sludge in gallbladder, possible history of pancreatitis 4/12/15 Abdomen/KUB: Essentially negative exam withouth significant change from previous on 10/2/13 4/13/15 CT of Abdomen and Pelvis: stable pelvic abcess, atrophy of L kidney with 2-3 mm proximal left ureteral calculus, punctate nonobstructive nephrolithiasis bilaterally, diverticulosis of descending and sigmoid colon 4/14/15 Sent for further abdominal imaging, results not received in time
Medications:
Medication Class Reason Unasyn Inj 3 Gm in normal Broad-spectrum Intraabdominal infections saline minibag plus 100 mL antiinfective Q6H Mylicon PO 80 mg Tab Antiflatulent Flatulence, unlabeled for QIDPCHS dyspepsia Flagyl 500mg/NS 100 mL Antiinfective Intestinal amebiasis, amebic 100 mL/hr IV Q8H abcess Normal Saline 1000 mL 100 Used to supply fluid to the body, mL/hr IV Q10H prevent dehydration Tenormin 50 mg Tab Q6H Antihypertensive Mild to moderate hypertension Amaryl 2 mg Tab Daily Antidiabetic Type 2 diabetes mellitus Paxil 20 mg Tab Daily Antidepressant General anxiety disorder Zestril 20 mg PO Daily Antihypertensive (ACE Mild to moderate hypertension inhibitor) Lovenox Inj SQ 40 mg Daily Anticoagulant Prevention of DVT, abdominal surgery at risk for thrombosis Protonix Inj 40 mg IVP AC Proton pump inhibitor Gastroesophageal reflux disease, Lunch maintenance Dilaudid Inj 1 mg IVP Q2- Opioid analgesic Treatment of moderate to severe Zachary Kelley Concept Map 4/21/15
4H/PRN pain Zofran Inj 4 mg IVP Antiemetic Prevent nausea and vomiting Q6H/PRN Tylenol 650 mg PO Q4H/PRN NSAID Pain or Fever
Actual/Potential Complications and Reasons they occur:
1. Bowel Perforation – may form due to irritation of the colon and bowels a. Interventions/Rationales/Evaluation i. Considered a medical emergency and surgery is needed 1. Apply SCD’s to prevent deep vein thrombosis 2. No formation of DVT, signs and symptoms 3. Client is free from signs and symptoms of DVT ii. Incentive Spirometry for prevention of hospital acquired pneumonia 1. Use of IS 10x per hour while awake 2. Prevent fluid retention in the lungs and development of pneumonia 3. Lungs are free from fluid and signs of infection 2. Peritonitis – inflammation of the abdominal cavity or lining, often caused by bacteria from inside the GI tract a. Interventions/Rationales/Evaluation i. Monitor urine output 1. Oliguria may develop due to decreased renal perfusion, and circulating of the toxins 2. Urinary output returns to adequate levels 3. Urinary output of 30 mL or more per hour ii. Observe skin and mucous membranes for dryness 1. May result in hypovolemia and nutrition deficits due to vomiting 2. Maintain fluid volume and hydration status 3. Urination and skin turgor return to normal limits iii. Change position frequently and provide skin care as needed 1. Prevent skin breakdown due to edema and possible incontinence of urine and bowel 2. No skin breakdown 3. Client is free from skin breakdown and risk is reduced 3. Obstruction – result from inadequate hydration status, low-fiber consumption, inactivity, and immobility a. Interventions/Rationales/Evaluation i. Encourage daily fluid intake of 2000 to 3000 mL 1. Increased fluids to help soften stool formation 2. Client has formed, soft stool 3. Client passes soft, formed stool Zachary Kelley Concept Map 4/21/15
ii. Encourage physical activity and exercise 1. Movement causes the gases to move through the body, helping to pass formed stool through the colon 2. Help pass obstruction and prevent reformation 3. Client is able to pas stool freely iii. Encourage increased fiber diet 1. Help soften formed stool, allowing for easier passage 2. Formed, soft, stool, decrease in pain 3. Client passes soft, formed stool, with no reports of pain
Desired Outcomes:
1. Client’s urination and skin turgor return to normal limits a. Urination is greater than or equal to 30 mL/hr and skin turgor is elastic b. Body is free from retaining excess fluid 2. Client passes soft, formed stool a. Client is able to have bowel movement without issue b. Obstruction is not present due to presence of stool 3. Client is free from signs of DVT a. Client’s legs are not red and hot to the touch, nor tender b. Holman’s sign is negative