A patient with a history of diverticulosis presents with obstipation and abdominal distention. Diagnostic results show significant fecal loading and mild bowel wall thickening. What is the most appropriate initial nursing intervention to help alleviate the patient's symptoms and prevent complications?

A) Administer a fleet enema as prescribed to relieve fecal impaction.

B) Encourage the patient to increase oral fluid intake immediately.

C) Position the patient upright to promote comfort and gas expulsion.

D) Consult with the dietitian to increase dietary fiber intake.

A patient has been diagnosed with significant fecal impaction in the sigmoid colon, accompanied by mild thickening of the bowel wall, and elevated white blood cell count. What is the most appropriate initial nursing intervention to address the patient's condition and prevent complications?

D) Administer prescribed stool softeners and monitor for bowel movement.

A) Administer a high-fiber diet to promote bowel movements.

B) Encourage ambulation to stimulate gastrointestinal motility.

C) Prepare the patient for a possible surgical consultation.

D) Administer prescribed stool softeners and monitor for bowel movement.

A patient with a history of fecal impaction is experiencing increasing lethargy, mild confusion, tachycardia, hypotension, and a low-grade fever. Which nursing action is most appropriate to prioritize at this time?

B) Initiate intravenous fluid resuscitation to manage potential hypovolemia.

A) Administer prescribed broad-spectrum antibiotics immediately.

B) Initiate intravenous fluid resuscitation to manage potential hypovolemia.

C) Contact the surgical team for urgent evaluation for potential decompression.

D) Educate the patient's family about signs of dehydration and infection.

A patient with a history of fecal impaction and bowel wall thickening is showing signs of lethargy, confusion, increased heart rate, decreased blood pressure, and a low-grade fever. Based on this clinical presentation, what is the most appropriate nursing intervention to prioritize at this time?

C) Initiate intravenous fluids to support hemodynamic status.

A) Administer antipyretics to reduce the fever.

B) Increase oral fluid intake to address potential dehydration.

C) Initiate intravenous fluids to support hemodynamic status.

D) Perform a digital rectal examination to assess the fecal impaction.

A patient with suspected bowel ischemia presents with increased lactate levels and signs of hemodynamic instability. Which nursing intervention is the highest priority to prevent further complications?

B) Prepare the patient for immediate surgery to address bowel ischemia.

A) Administer prescribed vasopressors to stabilize blood pressure.

B) Prepare the patient for immediate surgery to address bowel ischemia.

C) Increase the rate of intravenous fluids to improve perfusion.

D) Monitor urine output to assess renal perfusion.

A patient is experiencing significant bowel distension with pneumatosis intestinalis and elevated lactate levels. Vital signs indicate tachycardia and hypotension, and the patient is confused. What is the priority nursing action at this time?

D) Prepare the patient for possible immediate surgical intervention.

A) Administer additional broad-spectrum antibiotics.

B) Increase the rate of intravenous fluid infusion.

C) Monitor vital signs every 4 hours.

D) Prepare the patient for possible immediate surgical intervention.

A patient undergoing an exploratory laparotomy develops respiratory distress with a respiratory rate of 28 breaths per minute and an oxygen saturation of 88% on room air. Arterial blood gas analysis indicates mixed respiratory and metabolic acidosis. Which initial nursing intervention is most appropriate to address the patient's respiratory status?

B) Initiate high-flow oxygen therapy to improve oxygenation

A) Administer bronchodilators to open the airways

B) Initiate high-flow oxygen therapy to improve oxygenation

C) Encourage deep breathing exercises to increase ventilation

D) Prepare for immediate intubation and mechanical ventilation

A patient undergoing exploratory laparotomy is experiencing respiratory distress and renal impairment. The arterial blood gas shows a pH of 7.32, PaCO2 of 50 mmHg, and HCO3- of 20 mEq/L. Which of the following interventions should the nurse prioritize to address the patient's current condition?

B) Initiate high-flow oxygen therapy to improve oxygen saturation.

A) Administer sodium bicarbonate to correct metabolic acidosis.

B) Initiate high-flow oxygen therapy to improve oxygen saturation.

C) Administer diuretics to increase urine output and reduce fluid overload.

D) Prepare for emergent dialysis to address renal impairment.

A patient with suspected severe sepsis has been intubated and placed on mechanical ventilation due to respiratory failure. The nurse notes the patient has persistent hypotension despite fluid resuscitation and is now on norepinephrine. Which priority nursing intervention should the nurse implement to ensure effective patient management?

B) Monitor urine output closely to assess kidney perfusion.

A) Increase the rate of intravenous fluids to improve blood pressure.

B) Monitor urine output closely to assess kidney perfusion.

C) Elevate the head of the bed to 45 degrees to enhance ventilation.

D) Administer a sedative to reduce patient agitation and oxygen demand.

A patient in the ICU is exhibiting signs of respiratory distress and sepsis, with an oxygen saturation of 89-90%, a GCS score of 13, and persistent hypotension. The interprofessional team has initiated intubation, mechanical ventilation, broad-spectrum antibiotics, and norepinephrine. As the ICU nurse, what is the priority intervention to address the patient's hemodynamic instability?

B) Administer a bolus of intravenous fluids for additional volume support

A) Increase the rate of norepinephrine infusion to improve blood pressure

B) Administer a bolus of intravenous fluids for additional volume support

C) Monitor urine output closely to assess renal perfusion

D) Adjust ventilator settings to increase oxygen delivery

Obstipation - Nursing Case Study

Pathophysiology

• Primary mechanism: Obstipation is primarily caused by severe constipation due to prolonged colonic transit time, where decreased peristalsis leads to hardened stool that obstructs the bowel, often due to dietary, metabolic, or neurological factors.

• Secondary mechanism: Impaired neuromuscular function of the colon, such as in conditions like Hirschsprung's disease or chronic use of medications affecting bowel motility, exacerbates the inability to pass stool, contributing to bowel obstruction.

• Key complication: Prolonged obstipation can lead to fecal impaction, increased risk of bowel perforation, and subsequent peritonitis, requiring urgent medical intervention to prevent systemic complications.

Patient Profile

Demographics:

52-year-old male, accountant

History:

• Key past medical history: Chronic constipation, hypertension, history of diverticulosis

• Current medications: Lisinopril 10 mg daily, polyethylene glycol as needed, multivitamin

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Severe abdominal pain and bloating

• Key symptoms: Abdominal distension, nausea, decreased appetite, infrequent bowel movements for 5 days

• Vital signs: Blood pressure 145/90 mmHg, heart rate 105 bpm, respiratory rate 22 breaths per minute, temperature 99.1°F, oxygen saturation 95% on room air

Section 1

New Diagnostic Results:

Following the initial assessment, a series of diagnostic tests were ordered to further investigate the underlying causes of the patient's obstipation and abdominal symptoms. An abdominal X-ray was performed, revealing significant fecal loading throughout the colon, with a notable distension of the transverse and descending colon, suggestive of a possible fecal impaction. Additionally, there was no evidence of free air under the diaphragm, which somewhat reassured against bowel perforation at this point. Laboratory tests showed elevated white blood cell count at 13,000/mm³, indicating a possible inflammatory response, and mildly elevated C-reactive protein levels, which could suggest an early inflammatory process or potential risk for infection.

A CT scan of the abdomen and pelvis without contrast was subsequently conducted to provide a more detailed view of the gastrointestinal tract. The scan confirmed the presence of substantial fecal impaction in the sigmoid colon and revealed mild thickening of the bowel wall, which raised concerns for potential complications such as diverticulitis or early ischemic changes due to increased intraluminal pressure. Given the patient's history of diverticulosis, there was an increased risk for these complications. No definitive signs of perforation were observed, but the findings underscored the urgency of addressing the obstruction to prevent further deterioration.

These diagnostic results prompted the healthcare team to consider more aggressive interventions to relieve the obstruction and prevent complications. The patient's clinical picture necessitated a multidisciplinary approach, including potential surgical consultation, to determine the most appropriate and timely management strategy. These findings also highlighted the need for careful monitoring of the patient's condition, anticipating that any delay in resolution could escalate the risk of systemic complications such as sepsis or bowel ischemia.

Section 2

As the healthcare team deliberated on the next steps, the patient's condition began to exhibit subtle yet concerning changes. Over the past few hours, the nursing staff noted that the patient became increasingly lethargic, with a new onset of mild confusion. Vital signs were carefully monitored, revealing a slight increase in heart rate from 88 to 110 beats per minute and a mild decrease in blood pressure to 100/60 mmHg, suggestive of early hemodynamic instability. The patient also developed a low-grade fever of 100.8°F, consistent with the inflammatory markers noted earlier.

These changes prompted the healthcare team to reconsider the possibility of evolving complications, such as a developing infection or early ischemia due to the unresolved fecal impaction and the noted bowel wall thickening. The elevated white blood cell count and C-reactive protein levels from previous lab results reinforced the suspicion of an inflammatory or infectious process. Given the patient's lethargy and altered mental status, there was also a concern for possible systemic involvement, potentially signaling the onset of sepsis.

In response, the team initiated a more aggressive management approach, including intravenous fluids to address potential hypovolemia and to support hemodynamic status. They also started broad-spectrum antibiotics to preemptively target any incipient infection. A surgical consult was urgently requested to assess the need for potential intervention, such as decompression or, if necessary, surgical removal of the impaction. The patient's family was informed of the developments and the critical nature of the situation, ensuring they understood the importance of swift intervention to prevent further deterioration. As the patient was closely monitored, the team remained vigilant for any further changes that might necessitate additional interventions or adjustments in the treatment plan.

Section 3

As the healthcare team continued their vigilant monitoring of the patient, new diagnostic results began to shed light on the evolving clinical picture. An abdominal CT scan revealed significant distension of the bowel with evidence of pneumatosis intestinalis, raising concerns about possible bowel wall ischemia. This finding was corroborated by a marked increase in lactate levels, now at 3.8 mmol/L, suggesting tissue hypoperfusion and anaerobic metabolism. The surgical team, upon reviewing the imaging and laboratory data, noted the risk of progressing to bowel necrosis if the obstruction and potential ischemia were not promptly addressed.

In response to these alarming indicators, the team intensified their intervention strategy. The patient was rapidly prepared for potential surgical intervention, with informed consent obtained from the family for possible exploratory laparotomy. Meanwhile, the nursing staff increased the frequency of vital sign monitoring, as the patient's heart rate had escalated to 120 beats per minute, and blood pressure continued to trend downward, now at 94/58 mmHg. The low-grade fever persisted, and the patient's mental status showed no improvement, maintaining a concerning level of confusion.

Despite the initial administration of broad-spectrum antibiotics and intravenous fluids, the patient showed minimal response, indicating that the underlying issue might require more definitive surgical intervention. The team recognized the urgency of the situation, as the risk of sepsis and further hemodynamic instability loomed. This critical juncture underscored the importance of rapid decision-making and interprofessional collaboration to optimize patient outcomes and prevent further complications. As preparations for surgery were underway, the healthcare team remained poised to adapt their plan based on the patient's evolving needs, fully aware of the gravity of the situation and the potential for rapid deterioration.

Section 4

As the surgical team prepared the patient for an exploratory laparotomy, new complications emerged that added complexity to the clinical picture. The patient's respiratory status began to deteriorate, evidenced by an increase in respiratory rate to 28 breaths per minute and decreasing oxygen saturation, now at 88% on room air. Arterial blood gas analysis revealed a pH of 7.32, PaCO2 of 50 mmHg, and HCO3- of 20 mEq/L, indicating a mixed respiratory and metabolic acidosis, likely secondary to hypoventilation and ongoing tissue hypoperfusion.

Simultaneously, the patient's renal function showed signs of compromise, with serum creatinine levels rising to 2.1 mg/dL from a baseline of 1.0 mg/dL, suggesting acute kidney injury potentially due to hypovolemia and decreased perfusion. Urine output decreased to less than 20 mL/hour, raising concerns about oliguria and further renal impairment. The combination of these factors pointed towards a worsening systemic inflammatory response, with the risk of multi-organ dysfunction if not addressed swiftly.

In response to these developments, the healthcare team adjusted the intervention plan. High-flow oxygen therapy was initiated to support respiratory function, while diuretics were withheld to focus on optimizing fluid resuscitation. The possibility of intubation and mechanical ventilation was discussed as a contingency plan should the patient's respiratory status continue to decline. The nephrology team was consulted to evaluate the need for renal support, and vasopressors were prepared to stabilize blood pressure as the patient's hemodynamic status remained fragile. This escalation in care highlighted the critical need for ongoing reassessment and interprofessional coordination to navigate the patient's precarious condition and prevent further deterioration.

Section 5

As efforts continued to stabilize the patient, a change in status was observed that necessitated immediate attention. Despite high-flow oxygen therapy, the patient's respiratory status showed little improvement, with oxygen saturation persistently hovering around 89-90%. The patient became increasingly lethargic, with a Glasgow Coma Scale (GCS) score dropping to 13. Auscultation of the lungs revealed diminished breath sounds bilaterally, suggesting potential atelectasis or fluid accumulation. The surgical team, now increasingly concerned about impending respiratory failure, opted to proceed with intubation and mechanical ventilation to ensure adequate oxygenation and ventilation.

Simultaneously, new diagnostic results revealed an elevated white blood cell count of 16,000/mm³, alongside a significant increase in lactate levels to 4.5 mmol/L, indicative of severe sepsis and tissue hypoxia. Blood cultures were drawn, and broad-spectrum antibiotics were initiated to address the suspected underlying infection, which was likely exacerbating the patient's systemic inflammatory response. Continuous monitoring of vital signs showed persistent hypotension with blood pressure readings around 88/52 mmHg, despite fluid resuscitation efforts, prompting the initiation of vasopressor support with norepinephrine to maintain adequate organ perfusion.

These developments highlighted the critical importance of vigilant monitoring and dynamic adaptation of the treatment plan. The interprofessional team was tasked with balancing respiratory support, hemodynamic stabilization, and renal protection while addressing the underlying infectious process. The focus shifted to anticipating potential complications and ensuring the patient remained on a trajectory towards stabilization, with a keen eye on laboratory markers and clinical manifestations to guide further interventions. The pathway forward would depend heavily on the patient's response to these aggressive therapies and the timely identification of any additional complications.