Case no 45

While you are working as a nurse on a

gastrointestinal/genitourinary (Gl/GU) unit, you receive a
call from your affiliate outpatient clinic notifying you of a
direct admission, with an estimated time of arrival of 60
minutes. She gives you the following information: A.G. is
an 87-year-old woman with a 3-day history of
intermittent abdominal pain, abdominal bloating, and
nausea and vomiting (NV). A.G. moved from Italy to join
her grandson and his family only 2 months ago, and she
speaks very little English. All information was obtained
through her grandson. Past medical history includes
colectomy for colon cancer 6 years ago and ventral hernia
repair 2 years ago. She has no history of coronary artery disease,
diabetes mellitus, or pulmonary disease. She takes only ibuprofen
(Motrin) occasionally for mild arthritis. Allergies include sulfa drugs
and meperidine. A.G.s tentative diagnosis is small bowel obstruction
(SBO) secondary to adhesions. A.G. is being admitted to your floor
for diagnostic workup. Her vital signs (VS) are stable, she has an IV of
D5%NS with 20 mEq KCl infusing at 100mL/hr, and 3 L oxygen by
nasal cannula
A.G. is manifesting signs of bowel obstruction such as
abdominal pain, abdominal bloating, and nausea and
vomiting for 3 days now. She has a history of colectomy
surgery as well, so it is likely she is experiencing bowel
obstruction.
Other signs and symptoms I should observe includes
continuous and severe pain in one area that can be
observed with guarding, grimacing and facial
expressions of pain. Because she is on IV fluids, I would
also check IV site patency and verify the flow rate. I
would also assess the presence of bowel movements,
bowel sounds, and observe for abdominal distension,
tenderness and rigidity.
I would explain the situation to the interpreter first and tell them
the things I would like to ask A.G. so that they have an idea of
what is going on. I will also introduce myself to A.G. and her
grandson.
I will explain to A.G. the importance of telling the truth and including details about her
situation so that the treatment plan could be as effective and safe as possible. I will also
explain that everything is confidential and will only be shared with health care
professionals on her care team.
5. What key questions must you ask this
patient while you have the use of an
interpreter?

I will ask questions about her recent bowel movement

also her vomiting, the color and frequency of it. I will
also ask her current diet and her hydration status, if
she is drinking enough fluids. I will also collect
information about her medical history, allergies, and
immunizations.
6. What is obstipation?
Obstipation is having severe or complete
constipation. It is the inability to pass a stool or
flatus for over 8 hours despite having the urge.

7. List, in order, the structures through

which the NGT must pass as it is
inserted.
Nostrils – Nasopharynx – Oropharynx –
Pharynx – Esophagus – Stomach
8. With some difficulty, you insert
a Salem Sump nasogastric tube
(NGT) into A.G. and connect it to
intermittent low wall suction.
How will you check for placement
of the NGT?

The standard for checking the placement of an NG tube is by X-ray verification.

Other ways include respiratory status/response of the patient. Once the NGT is
placed, aspiration of stomach contents would indicate placement in the
stomach and also by measuring the length of tubing when it is inserted.
9. A.G.s grandson asks you.
"What is that blue thing at the end
of the tube? Shouldn’t it be
connected to something?" How do
you answer?
The blue thing that the grandson is referring to is the
vent. This vent is always open to air providing
continuous atmospheric air irrigation. It can be opened
to allow for free continuous drainage of gastric
contents. It should never be blocked, clamped,
connected to anything or used for irrigation.
10.What comfort measures
areEnsuring
important
properfor A.G. and
positioning while
shefrequent
has anoralNGT?
hygiene are important
comfort measures. Cleaning the nostrils
and tube with moistened cotton and
securing the tubing to her gown are
also ways to maintain comfort and
ensure that the NGT stays in place.
11.You note that A.G.s NGT
has not drained in the last 3
hours. What can you do to
facilitate drainage?
• Make sure that the tube is not kinked, change the patient’s
position to see whether this allows the tube to drain freely. If
there is a physician’s order and depending on the facility policy,
irrigate or flush normal saline. Check the placement of the tube,
change the position of the tube if needed and re-tape.
12.The NGT suddenly drains 575
mL; then it slows down to about
250 mL over 2 hours. Is this an
expected amount?
This is not an expected amount, but it is also not an emergency. It
is important to determine the cause of the sudden change. The
nurse should note that the sudden decrease in fluid may affect the
patient’s electrolytes, hydration status, and acid-base balance.
13. You enter A.G.'s room to
initiate your shift assessment.
A.G.'s abdomen seems to be
more distended than yesterday.
How would you determine
whether A.G.'s abdominal
distention has changed?

I will measure a baseline distension and measure it periodically to see how it has
changed. I will also measure the same spot of the abdomen each day with land
marking such as measuring around umbilicus.
What measures do you anticipate to
correct in each of the imbalances
described in Question 15?
.
To correct the imbalances described in question
13, after contacting the health care provider about
imbalances, I will anticipate IV fluid to provide
hydration and electrolyte replacement. I will also
give something to help her reverse her
hypoglycemia such as orange juice.