NCM 106 RLE MIDTERMS LONG QUIZ MURILOO,ALEXANDRA NICOLE

CASE STUDY

You are a student nurse assigned on a surgical unit and handling a newly admitted client
with a diagnosis of rule out small bowel obstruction (R/O SBO) and/or food blockage. R.D.
is a 78-year-old obese man with complaints of sudden onset of severe abdominal
cramping, distention, and nausea and vomiting; he denies passing of flatus or stool
within the past 12 hours. Past medical history includes heart failure, hypertension, colon
cancer, and ulcerative colitis. He underwent a total colectomy 16 years ago and had an
enterocutaneous fistula 12 years ago. Lab samples have been drawn, and the results will
be sent to your floor. The doctor started an IV and placed a Salem Sump nasogastric
tube (NGT). His vital signs are 140/75, 82, respirations 26 and slightly labored, and
101.1° F (38.4° C).

You begin your admission assessment. His abdomen is extremely large, firm to touch,
with multiple scars and an ostomy pouching system in his RLQ. You note that the ostomy
pouch has liquid brown effluent along the lateral edge of the wafer. You check to see
that the pouch is properly attached to the wafer and discover that stool is indeed leaking
from under the barrier.

The next day, R.D.'s vital signs return to normal, and his abdomen is less distended. The
ostomy is steadily draining greenish-brown liquid stool. The NGT is removed, and R.D. is
started on sips of clear liquids. When you go to check his ostomy pouch, R.D. tells you, “I
know I've had this a long time, but I still can't stand to look at this thing. My wife usually
helps me with it, and I hate that.”

1. Which areas of nursing assessment should you perform on admission? (5pts)

A. Get the vital signs of the patient.

b. inspect the contour of the abdomen of the patient.

c. ausculatate the abdomen ofor bowel sounds and begin in the RLQ .

d. percussion of the abdomen

e. palpation of the abdomen

2. Given that R.D. had a total colectomy, would he have a colostomy or an ileostomy?
Explain your answer. (5pts)
- In this situation ,it is given that RD had a total colectomy, he would have an ileotomy. An ileostomy
is the only option because in a colostomy, the large intestine is required and the large intestine
is removed in a total colectomy. In an ileostomy, the small intestine is put through an opening in
the belly, and the large intestine is not necessary for the procedure.

3. What would you expect to see if R.D.'s ostomy has normal function? (5pts)

- If R.D’s ostomy has normal function we would expect to see regular passing of stool or
gas, perhaps 3-5 bowel movement per day. In this case the patient will not be able to
control the movements, but the pouch over the colostomy collects the output.
NCM 106 RLE MIDTERMS LONG QUIZ MURILOO,ALEXANDRA NICOLE

4. As you assess the stoma, you look for signs that it is healthy. Which of these
assessment findings are the characteristics of a healthy stoma? (Select all that apply.)
(5pts)

a. The stoma is cherry-red, dark pink in color.

c. The stoma is moist.

5. What stoma changes would you report immediately to the physician? (5pts)

- if you would see a major color changes in a stoma, with the stoma becoming pale or dark, are a
sign that the tissue is not receiving the blood supply that it should. This type of change should be
immediately reported to your surgeon, whether the surgery was recent or in the past or you can
also report immediately if you saw these following changes:

 An abnormal bulge is visible near or underneath the stoma

 The effluent (output) drains from anywhere other than the stoma

 The length of the stoma increases noticeably

 All or part of the stoma is below skin level. It may visually appear to be concave on the
abdomen

 Separation between the stoma and peristomal skin is visible

 The diameter of output decreases along with cramps and excessive gas

 The stoma has a deep red, yellow or white partial discoloration (usually linear)

6. As a student nurse, how will you determine the correct pouching size and system?
(5pts)

- For you to determine the correct size for a pouch and system, measure the size of the
stoma and add 1⁄8 to 1⁄16 of an inch. If the stoma is oval, measure the greatest width. A
pattern can be made of the stoma on paper then traced on to the wafer, then cut to that
size.

7. List down your identified problems for R.D. with appropriate nursing diagnosis. (10pts)

 Disturbed Body Image

 Impaired skin integrity

 Impaired tissue perfusion risk for infection

8. Based on your prioritized problem, create a Nursing Care Plan for patient R.D. (10pts)
NCM 106 RLE MIDTERMS LONG QUIZ MURILOO,ALEXANDRA NICOLE

ASSESSMENT DIAGNOSI PLANNING INTERVENTION RATIONALE EVALUATION

S

SUBJECTIVE: Disturbed Short-term: Independent: After 2 hours

body of nursing
image After 2 hours - Establish rapport -To reduce intervention
related to hour of patient’s anxiety patient
“I know I've had visible nursing gradually
this a long time, intervention - to obtain
presence - Monitor and record baseline data verbalized
but I still can't Patient will
of drainage vital signs acceptance in
stand to look at gradually
this thing. My changes of his
verbalize self and about
wife usually changes in - to determine
helps me with it, - Assess general the situation.
acceptance of interventions
and I hate that.” condition
his self in the needed by the
As verbalized by
situation client.
patient
- Assess perceived - to determine
impact of change on how the patient
activities of daily will act to the
OBJECTIVE: changes.
living social
-Presence of behaviour and
ostomy personal
pouching responsibilities. -it may indicate
system on acceptance or
patient’s - Evaluate level of non- acceptance
abdomen at pt’s knowledge of of situation.
right lower and anxiety r/t
quadrant situation; observe - to provides
emotional changes. opportunities for
listening to
- Establish concerns and
therapeutic nurse- questions.
client relationship
conveying an
attitude of caring
NCM 106 RLE MIDTERMS LONG QUIZ MURILOO,ALEXANDRA NICOLE
and developing trust
acknowledge the
individual as -Because changes
someone worthwhile. in body image
can cause the
- Acknowledge patient to have
patient’s denial or anxiety.
depression as normal
feelings when
adjusting to changes
in body.