Question

A 77-year-old man is admitted to the intensive care unit (ICU) of a university hospital from the operating room. Earlier the same day, he had presented to the emergency department with abdominal pain. His medical history included treated hypertension and hypercholesterolemia, previous heavy alcohol intake, and mild cognitive impairment. In the emergency department, he was drowsy and confused when roused and was peripherally cold with cyanosis. The systemic arterial blood pressure was 75/50 mm Hg, and the heart rate was 125 beats per minute. The abdomen was tense and distended. After the administration of 1 liter of intravenous crystalloid to restore the blood pressure, a computed tomographic scan of the abdomen showed extraluminal gas and suspected extraluminal feces consistent with a perforated sigmoid colon. He was treated with intravenous antibiotics and taken to the operating room for laparotomy. During this procedure, gross fecal peritonitis from a perforated sigmoid colon was confirmed; resection of the sigmoid colon with the closure of the rectal stump and creation of an end colostomy (Hartmann’s procedure) was performed with extensive peritoneal toilet and washout. On arrival in the ICU, he is still anesthetized and remains intubated. the arterial blood pressure is supported with a norepinephrine infusion. When the patient was in the operating room, he received a total of 4 liters of crystalloid. On his arrival in the ICU, the vital signs are a blood pressure of 88/52 mm Hg, heart rate of 120 beats per minute in sinus rhythm, central venous pressure of 6 mm Hg, and temperature of 35.6°C. An analysis of arterial blood shows a pH of 7.32, the partial pressure of carbon dioxide of 28 mm Hg, partial pressure of oxygen of 85 mm Hg, and a lactate level of 3.0 mmol per liter. Please use the following questions to help you formulate a response to this case study:

1. What is your suspected diagnosis of the patient (other than the listed surgical diagnosis)

2. What are the treatment options for this diagnosis?

3. What are the risks to the patient?

4. What nursing interventions and orders would you expect to be a part of this patient's care?

Answer 1

1. Bowel perforation is the diagnosis. It can be secondary to trauma , other medical conditions like Crohn's disease, appendicitis or malignancy in the bowel.

2 . Treatment options include surgery with infection control by antibiotics . Here , Hartmann procedure was performed which involves surgical resection of rectosigmoid colon and formation of colostomy. If abscess is present , it is drained out. Sometimes , even exploratory laprotomy is performed to identify the cause and the removal of abscesses.

3 . Risks include multi organ failure if not treated early , hypotension, shock , coma and death.

4 . Orders include - antibiotics, ionotropic drugs to increase heart rate and blood pressure, colostomy care , suctioning of endotracheal tube.

Nursing interventions :

• Monitor vital signs especially blood pressure.
• Monitor Central venous pressure.
• Administer antibiotics and ionotropic medications as ordered.
• Suctioning and assessment of breath sounds.
• Back care and frequent change of position.
• Nebulisation as ordered .
• Bed bath and application of moisturizer to prevent skin breakdown.

Thank you.