Question

Case Study 49 Inflammatory Bowel Disease with Peritonitis

Setting: Hospital

Index Words: inflammatory bowel disease (IBD), ileostomy, nutrition, assessment, skin care, patient education

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 post-anesthesia 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 original

surgical 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 PROGRESS

The 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 finger stick blood test every 2 hours for the first several

hours. 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 this data mean?

CASE STUDY PROGRESS

You 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 you

explain?

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?

CASE STUDY PROGRESS

C.W. successfully battled peritonitis. Gradually, tubes were removed as she grew stronger with TPN and time. C.W. learned how to change her ostomy appliance and was discharged home.

Case Study 49 Inflammatory Bowel Disease with Peritonitis

Setting: Hospital

Index Words: inflammatory bowel disease (IBD), ileostomy, nutrition, assessment, skin care, patient education

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 post-anesthesia 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 original

surgical 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 PROGRESS

The 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 finger stick blood test every 2 hours for the first several

hours. 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 this data mean?

CASE STUDY PROGRESS

You 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 you

explain?

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?

CASE STUDY PROGRESS

C.W. successfully battled peritonitis. Gradually, tubes were removed as she grew stronger with TPN and time. C.W. learned how to change her ostomy appliance and was discharged home.

Case Study 49 Inflammatory Bowel Disease with Peritonitis

Setting: Hospital

Index Words: inflammatory bowel disease (IBD), ileostomy, nutrition, assessment, skin care, patient education

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 Ja

Answer 1

Case Study:

1)  C.W. returns from post-anesthesia recovery unit (PACU) on your shift. What do you do when her bed is rolled into her room?

We must first assess her mental status and interact to find out her confidence levels and her thoughts,get all the vitals checked.Then do a thorough head to toe assessment and find out if there were any complications faced during her surgery.Check out the medications that she is on and finally assess IV infusion, assess surgical site- and find out what type of drainage and if there is any bleeding seen in her.

2) You pull the covers back to inspect the abdominal dressing and find that the original surgical dressing is saturated with fresh bloody drainage. What should you do?

If the original dressing is saturated with fresh bloody drains then follow protocol and reinforce the dressing.Immediately call the doctor. Mark the drainage on the dressing.

3) C.W. has 4 tubes in her abdomen, as well as a nasogastric tube (NGT).What information do you want to know about each?
The information that we want to know is type of tube that is placed in the abdomen,how it works and what is supposed to be draining from them and also when it was placed.Then we should also have to know where it specifically goes to in the patient. and we have to know whether the NGT is for continuous low suction or not.Tubes should have hatch marks to indicate any movement of the tube in the patient.

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.

The D5W is not an appropriate solution to infuse into this patient's peritoneum.The solution is isotonic when administered intravenously, but when instilled in the peritoneum it becomes hyper-osmolar and pulls fluid into the abdomen from the vascular system. This could cause hypovolemia.Immediately change the IV tubing and solution, monitor VS, get a fingerstick blood glucose reading, and notify the surgeon about what happened.If C.W. appears anxious or asks what is going on, explain that the wrong solution was hung but you have corrected the error.Notify the charge nurse, and complete an incident report

5) Postoperative pain will be a problem for C.W. after the anesthesia wears off. How do you plan to address this

When She is awake enough,we must ask her to rate her pain on a 1-to-10 scale and rate the amount of relief she receives from the morphine.Teach her that she needs to use the PCA pump to prevent the pain from becoming too intense. She must be taught to administer a dose to herself when the pain is starting to increase.If the prescribed medication does not work well, then she must seek the medical advise and help.

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?

Because CW is severely undernourished, she needs supplemental nutrition to encourage the healing process. The reason you would want to reduce the IV fluids is so she does not go into fluid volume overload or blow a vein.TPN will supplement CWs body with nutrients necessary for life.

7) The physician did not specifically order glucose monitoring, but you know that it should be initiated. You plan to conduct a finger stick blood test every 2 hours for the first several hours. What is your rationale

Glucose abnormalities are common with TPN and one way to avoid hyperglycemia is to monitor the blood sugar closely and giving insulin as needed. Hypoglycemia can occur when the TPN is suddenly stopped so careful monitoring is important.This patient just received multiple surgeries which causes stress on the body also causing elevated blood glucose levels for patients.

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 this data mean​?

The weight loss can be secondary to drainage tubes and location of ostomy. Additionally patient is only receiving TPN nutrients which does not carry the physical weight of a regular meal.

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 you explain?

The first phase of healing,called the proliferative phase. "Granular tissue" is the tissue that fills in the surgical wound; it is red because it contains newly formed collagen and blood vessels. The "epithelialization noted around edges" means that the epithelial cells migrate and proliferate around the edges of the granulation tissue. The epithelial tissue looks silvery.Adequate nutrition is essential to the healing process.

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

The ileum is responsible for absorbing bile salts, vitamins C and B12, and chloride. The large colon is responsible for absorbing water and electrolytes. Therefore, because C.W. lost 7 feet of ileum and 2 feet of colon, she is at risk for dehydration and electrolyte imbalance.