CRITICAL THINKING: CASE STUDY

BOWEL OBSTRUCTION

Case Scenario:
While you are working as a nurse on a gastrointestinal/genitourinary (GI/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 (N/V). 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 D5½NS with 20 mEq KCl infused at 100 mL/hr, and 3 L oxygen by nasal
cannula (O2/NC).

1. Based on the nurse's report, what signs of bowel obstruction does A.G. manifest?
- Based on the nurse’s report for the past three days, A.G. has been exhibiting signs of
bowel obstruction such as abdominal pain, abdominal bloating, and nausea and vomiting.
She has a history of colectomy surgery, so she is most likely suffering from bowel
obstruction.

2. Are there other signs and symptoms that you should observe for while A.G. is in your care?
- Other signs and symptoms to look for include number one, continuous and severe pain in
one area, as well as guarding, grimacing, and pain-related facial expressions. Second,
keep an eye out for signs of dehydration, such as thirst, drowsiness, and aching. Three,
due to her receiving IV fluids, we would also check the IV site patency and flow rate.
Fourth, we should also check her electrolyte levels to see if there is an imbalance, and
also monitor for metabolic alkalosis (high obstruction) and metabolic acidosis (low
obstruction). And lastly, assess the presence of bowel movements, bowel sounds and
observe for abdominal distension, tenderness, and rigidity.

3. While A.G. is on the way, you have secured the hospital's interpreter service on the
telephone.
- Securing the hospital’s interpreter is one of the best ways if the relative is on the way
because this will help both the nurse and the relative to communicate with each other so
that we could make immediate decisions for the client. Without the interpreter,
explaining information and instructions will be difficult, being able to communicate with
the patient and the guardian/relative is a priority to provide quality healthcare service
- I will inform and explain to the interpreter the questions that I would like to ask, so that
they have a clear idea of what they will ask the client for immediate response.
 - If A.G. arrives my priority is to build rapport so that I can introduce myself to her and her
grandson. After building rapport I would ask questions directly to A.G. so she could feel
comfortable that her nurse is listening to her which builds our therapeutic relationship.
- Then I would ask her permission about her history and explain that I would conduct a
complete physical examination focusing on her abdomen.
A.G. arrives on your unit with her grandson. You admit A.G. to her room and introduce yourself as her
nurse. As her grandson introduces her, she pats your hand. You know that you need to complete a physical
examination and take a history exam. What will you do first?

4. Before you begin your examination, you ask the grandson to excuse himself, explaining the
hospital's confidentiality policies. The grandson, an attorney, tells you that elderly Italian
women are extremely modest and might not answer questions completely. How might you
gather information, in this case?
- First, I would explain the hospital's confidentiality policy to her grandson and ask him to
excuse himself before my physical examination. Second, reassure the grandson that A.G.
will be safe and everything will be confidential. Next, while the interpreter is on the line,
I would also explain to A.G. the importance of telling the truth and including details
about her situation in order for her treatment plan to be as effective and safe as possible.
And lastly I'd like to emphasize that everything discussed is strictly confidential and will
only be shared with the health care professionals on her care team. I would also explain
that I will need to conduct a thorough physical examination in order to collect objective
assessment data.

5. What key questions must you ask this patient while you have the use of an interpreter?
- The key questions I must ask the patient while I have the use of an interpreter are: First, I
would conduct a thorough pain assessment and ask questions using the “OPQRST”
(onset, provocation, quality, radiation, severity, time, and understanding). Through pain
assessment, a nurse can get information and assess the characteristics of the patient’s
symptoms, and to learn about the patient’s complaints to understand the client’s state of
health. I would also ask for information about her recent bowel movement, including
asking about quality, quantity and effort. Ask her also about her vomiting, if it included
fecal matter, the odor, the amount, the color, and the frequency. Next, I'd ask if she's
experiencing any nausea and ask her to describe her current diet. In addition, I would ask
about her hydration status and whether she is currently dehydrated. And lastly, I would
gather information about her medical history, allergies, immunizations, and advance
directives with the help of the interpreter.

6. For each characteristic listed, specify whether it is a characteristic of small-bowel

obstruction (SBO), large-bowel obstruction (LBO), or both (B).
a. LBO - Intermittent lower abdominal cramping
b. SBO - Abdominal discomfort or pain accompanied by visible peristaltic waves in the
upper and middle abdomen
c. SBO - Upper or epigastric abdominal distention
d. LBO - Distention in the lower abdomen
 e. B - Obstipation
f. LBO - Ribbon-like stools
g. SBO - Nausea and early, profuse vomiting, which may contain fecal material
h. LBO - Minimal or no vomiting
i. SBO - Severe fluid and electrolyte imbalances
7. What is obstipation?
- Obstipation is when a person cannot pass stool or gas, usually due to an obstruction or
blockage of hard, difficult-to-pass stool or flatus for over 8 hours despite having the urge.
It is the inability of a client to pass stool or to defecate. Obstipation is a signal that
constipation is chronic and a more severe problem that could lead to serious health side
effects if left untreated.

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?
- There are a number of ways to check for the proper placement of the tube besides the
gold standard of X-ray confirmation. One way is to aspirate some of the stomach contents
from the patient. If the content that has been aspirated has a pH level of less than 4 and
the color is cloudy and green, it is in the stomach. Another is if you inject 10 cc of air in
the tube while auscultating the epigastric area of the patient, you will hear a whooshing
sound which also indicates placement. Another way to check the proper placement of the
NGT is through assessing the patient’s airway and respirations. This can be done through
observing the patient’s breathing, because when they are having difficulty in breathing, it
may indicate that the NGT is not properly inserted, because it might be at the lungs,
instead of the stomach, which poses serious danger if not correctly placed.

9. List, in order, the structures through which the NGT must pass as it is inserted.
- The NGT will be inserted into the patient in the following. First, it will be inserted
through the nostrils of the patient, it will then pass into the nasopharynx, oropharynx,
pharynx, then to the esophagus, and lastly, into the stomach.

10. 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?
- I will tell A.G.’s grandson that the blue thing at the end of the tube is the vent and it
shouldn’t be connected to something else because it is always open to the air to provide
continuous atmospheric air irrigation. It can also be opened to allow free continuous
drainage of gastric contents if needed. I will also emphasize to A.C.’s grandson that it
should never be blocked, clamped, connected to anything, or used for irrigation purposes
for this matter.

11. What comfort measures are important for A.G. while she has an NGT?
- While the client has an NGT, it is important to provide comfort measures by securing the
proper positioning and placement of the NGT tube as well as frequent oral and tube care.
To ensure the position and placement of the NGT, the nurse should check if the nose tape
is effectively securing the tube to her nose and gown at all times. Change the nose tape
 every other day or as needed. If the tube falls out, the nurse should not reinsert by
himself, instead, seek medical assistance. On one hand, to provide oral hygiene, cleanse
the nostrils and tube with warm water using a moistened cotton bud and clean the client’s
mouth at least daily using a moist towel to clean the tongue, toothbrush and floss to clean
the teeth.
12. You note that A.G.'s NGT has not drained in the last 3 hours. What can you do to facilitate
drainage?
- The nurse can facilitate drainage by doing the following measures: The nurse should
ensure that the tube is not kinked or folded or clamped as it will inhibit drainage.
Draining NGT is important as it enables the healthcare provider to drain gastric contents
and to obtain specimens for tests. The nurse could also verify the NGT placement and
positioning as well as adjust as needed. The nurse could also ambulate, specifically, turn
the client from side to side in bed to observe and facilitate drainage. More so, positioning
the client in a semi-fowler’s position could also facilitate drainage and minimize risk for
aspiration. Lastly, if not contraindicated and ordered by the doctor, the nurse would
perform irrigation of the NGT tube using a normal saline. Afterwards, the nurse could
note and observe the characteristics of the client’s drainage.

13. The NGT suddenly drains 575 mL; then it slows down to about 250 mL over 2 hours. Is this
an expected amount?
- The decreased drainage value is not an expected amount as it should be consistent. If the
client’s drainage suddenly decreases like that then the client should look for possible
reasons for the decrease and then contact the doctor. It is important to determine the cause
of the sudden change by checking the placement, positioning, if it is kinked or not and
other measures mentioned above. Although this is not considered a medical emergency,
the nurse should still note that the sudden decrease in fluid because it may affect the
patient’s electrolytes that could cause cardiac dysrhythmias and life threatening problems,
hydration status that could cause shock in severe cases, and acid-base balance. After
determining the cause of this decrease in drainage, adjustments should be made as needed
to correct it until the drainage is in an expected amount.

14. You enter A.G.'s room to initiate your shift assessment. A.G. has been hospitalized for 3
days, and her abdomen seems to be more distended than yesterday. How would you
determine whether A.G.'s abdominal distention has changed?
- Abdominal distention is generally caused by flatus, fluid, feces, fetus, and fat. Now, to
determine if the patient's abdominal distention is changing over time, the nurse would
perform inspection, measuring, and palpation. Sometimes, abdominal distention is so
severe that it could be noted by looking. However, there are times that abdominal
distention is subtle. That's why, It is important to have a pre-measurement or baseline
measurement of the abdomen specifically measuring around the umbilicus, then measure
periodically to see the succeeding changes. Then, if not contraindicated and tolerated, the
nurse may also palpate and feel it. In advanced cases, the abdominal wall is tensed due to
contained fluid.
After 3 days of NGT suction, A.G.'s symptoms are unrelieved. She reports continued nausea, cramps, and
sometimes strong abdominal pain; her hand grips are weaker; and she seems to be increasingly lethargic.
You look up her latest laboratory values and compare them with the admission data.

15. Which lab values are of concern to you? Why?

a. Lab values that are a concerning include:
● Elevated levels of Carbon dioxide indicating that there is an metabolic imbalance
(acidosis)
● Elevated BUN and Creatinine levels may indicate that she is dehydrated
● Decreased Sodium levels
● Decreased Potassium levels
● Decreased Chloride levels
○ Decreased potassium, sodium and chloride indicate that there is an
electrolyte imbalance
● Low glucose level indicates hypoglycemia

16. What measures do you anticipate to correct in each of the imbalances described in the
question?
a. After contacting the health care provider about the imbalances, I would anticipate IV
fluid to provide hydration and electrolyte replacement.
● For decreased sodium level: The goal is to elevate the serum sodium level
enough to decrease neurological manifestations associated with hyponatremia
such as lethargy, confusion, and seizures. Encourage foods and fluids high in
sodium (beef broth, tomato juice).
● For decreased potassium level: encourage foods high in potassium - avocados,
broccoli, dairy products, dried fruit, cantaloupe, bananas, juices, melon, milk,
whole grains, and citrus fruits. Provide oral potassium supplementation
depending on doctor’s order.
● For low glucose level, possible intervention could be giving orange juice or a 15
to 20 grams of fast-acting carbohydrate, and recheck the blood sugar level again
in 15 minutes.

In view of A.G.'s continued slow deterioration, the surgeon met with the patient and her family, and they
agreed to surgery. The surgeon released an 18-inch section of proximal ileum that had been constricted by
adhesions. Several areas looked ischemic, so these were excised, and an end-to-end anastomosis was
done. A.G. tolerated the procedure well. Her recovery was slow but steady. A.G. went home in the care of
her grandson and his wife on the seventh postop day. Discharge plans included a home health nurse,
home health aide, in-home physical therapy, and dietitian consult. The grandson was included in the
plans.