Name:
NGN Case Study
Title: Colon resection: Diverticulitis Pre-op and Post-op Care
Scenario: An otherwise healthy 60-year-old male, with diverticulosis that was diagnosed during a colonoscopy 5 years ago, was admitted into the hospital today with complaints of extreme left lower abdominal pain, bloating, nausea, and vomiting. A CT scan done in the emergency department confirmed his diagnosis to be diverticulitis. The nurse documents the following assessment findings:
• Reports abdominal pain of 9/10 on a 0-10 pain intensity scale
• Blood pressure 142/70
• Heart rate 115 bpm
• Temperature 101.3
• Absent bowel sounds in left lower quadrant
• Reports he has had no food in the past 12 hours
• Reports a history of excess flatulence
• Drowsy but arouses easily with verbal stimuli
1. NGN Item Type: Enhanced Hot Spot
Highlight the assessment findings that require follow-up by the nurse.
Rationale for your choices above:
Cognitive Skill: Recognize Cues
2. NGN Item Type: Cloze
Choose the most likely options for the information missing from the statement, below, by selecting from the list of options provided.
The nurse recognizes that, based on the assessment data and patient’s history, the patient is currently at risk for complications, including ______, ______, and ______.
Options
• Abscess
• Skin breakdown
• Peritonitis
• Constipation
• Malnutrition
• Gastrointestinal bleeding
• Urinary retention
Rationale for choices above:
Cognitive Skill: Analyze Cues
Scenario: A bowel resection was done 3 days ago to treat an abscess caused by diverticulitis. The patient now has a temporary colostomy to divert stool from the inflamed bowel and allow it to rest and heal. The patient is drowsy but awakens easily with verbal stimuli. Vital signs are all stable. He states he is maintaining his pain at 3/10 without activity (on a 0-10 pain intensity scale), which he says is a manageable level, by using his patient-controlled analgesia (PCA) pump sparingly. He reports that as long as he does not move his pain is manageable. He is hesitant to do anything that causes increased pain and does not like to use his PCA due to his fear of addiction. His stoma is located on his left lower quadrant and is rosy red. There is a scant amount of drainage in his colostomy pouch. His abdominal dressing is clean and dry. He is voiding adequate amounts of urine and is NPO. He has a nasogastric tube to low intermittent suction. He is receiving Lactated Ringer’s solution via a peripheral IV.
Vital indicators are all stable. He claims that he is able to keep his pain at a bearable level by making infrequent use of his patient-controlled analgesia (PCA) pump, which allows him to keep his pain at a level of 3/10 even when he is not active (on a scale of 0-10 for the intensity of the pain). According to him, the discomfort is bearable so long as he stays still and doesn’t move around. He avoids using his PCA because he is afraid of becoming addicted to it, and he avoids doing anything that would worsen the amount of pain he is in. His stoma is bright pink in color and may be found in the lower left quadrant of his body. His colostomy pouch only contains a minute bit of discharge at this point. His abdomen bandage is spotless and devoid of moisture. He is passing an adequate amount of urine and is not receiving any nutrition or fluids. He is being given mild intermittent suction through a nasogastric tube. A Lactated Ringer’s solution is being administered to him through a peripheral IV.
1. NGN Item Type: Extended Multiple Response
When planning care for this patient, for which priority potential complications will the nurse monitor? Select all that apply.
a. Deep vein thrombosis
b. Panic attack
c. Atelectasis
d. Electrolyte imbalance
e. Chronic pain
f. Bowel obstruction
g. Sepsis
h. Urinary tract infection
Rationale for your choices above:
Cognitive Skill: Prioritize Hypotheses
2. NGN Item Type: Matrix
Use an X for the nursing actions listed below that are Indicated (appropriate or necessary), Contraindicated (could be harmful), or Nonessential (makes no difference or not necessary) for the client’s care at this time. Only one selection can be made for each nursing action.
Nursing Action Indicated Contraindicated Nonessential
Encourage patient to stay in bed and lie still.
Instruct patient to use PCA before activity.
Assess the skin surrounding the stoma for breakdown.
Implement nonpharmacologic pain control methods.
Check back with the patient the next day when he may be more comfortable with increasing his activity.
Consider collaborating with the surgeon to provide multimodal analgesia.
Rationale for your choices above:
Cognitive Skill: Generate Solutions
Scenario: A 60-year-old male had a bowel resection 4 days ago to treat an abscess caused by diverticulitis. He has a temporary colostomy to divert stool from the inflamed bowel and allow it to rest and heal. Since his surgery, the patient’s postoperative recovery has been uneventful. His nasogastric tube was discontinued today, and he will be started on a clear liquid diet this afternoon and advanced to solids as tolerated. His pain is managed by administration of a nonsteroidal anti-inflammatory drug every 6 hours and using his patient-controlled analgesia (PCA) pump before activity. His stoma is located on his left lower quadrant and is rosy red. There is a small amount of liquid brown stool in his colostomy pouch. His abdominal dressing remains clean and dry. He is voiding adequate amounts of urine and is receiving Lactated Ringer’s solution via a peripheral IV.
NGN Item Type: Extended Drag and Drop
Use an X (or drag and drop) to indicate which actions listed in the left column would be included in the plan of care for this patient.
Nursing Actions Implementation
Monitor for signs and symptoms of nausea.
Encourage use of incentive spirometry.
Help patient to ambulate.
Change the colostomy pouch every 8 hours.
Monitor complete blood count.
Educate patient on a low-fat diet.
Notify the surgeon about the patient’s stoma color.
Rationale for your choices above:
Cognitive Skill: Take Action
Scenario: A 60-year-old male had a colon resection and colostomy 2 weeks ago. He was discharged home 7 days after surgery and received discharge instructions and teaching before leaving the hospital. He is now at the clinic for a follow-up visit. The nurse evaluates the effectiveness of actions.
NGN Item Type: Extended Multiple Response
Which of the following findings indicate effectiveness? Select all that apply.
____1. The patient has not taken prescribed pain medication due to fear of “addiction.”
____2. The stoma is rosy red.
____3. The patient changes the colostomy drainable pouch every 5 days unless it is leaking, and then changes it at that time.
____4. The patient empties the colostomy drainable pouch when it becomes 75% full.
____5. The patient reports 7/10 pain (using a 0-10 pain intensity scale) during activity.
____6. The patient eats three regular meals a day with no restrictions.
____7. The patient sits in his recliner most of the day and ambulates to the bathroom three to four times a day.
____8. The skin surrounding the stoma is slightly reddened.
Rationale for your choices above:
Cognitive Skill: Evaluate Outcomes
