Case Study 49 Inflammatory Bowel Disease withPeritonitis
Setting: Hospital
Index Words: inflammatory bowel disease (IBD),ileostomy, nutrition, assessment, skin care, patient education
C.W. is a 36-year-old woman admitted 7 days ago forinflammatory bowel disease (IBD) with small bowel obstruction(SBO). She underwent surgery 3 days after admission for a colectomyand ileostomy. She developed peritonitis and 4 days later returnedto the operating room (OR) for an exploratory laparotomy, whichrevealed another area of perforated bowel, generalized peritonitis,and a fistula tract to the abdominal surface. Another 12 inches ofileum were resected (total of 7 feet of ileum and 2 feet of colon).The peritoneal cavity was irrigated with normal saline (NS), and 3drainage tubes were placed: a Jackson-Pratt (JP) drain to bulbsuction, a rubber catheter to irrigate the wound bed with NS, and asump drain to remove the irrigation. The initial JP drain remainsin place. A right subclavian triple-lumen catheter wasinserted.
1. C.W. returns from post-anesthesia recovery unit(PACU) on your shift. What do you do when her bed is rolled intoher room?
2. You pull the covers back to inspect the abdominaldressing and find that the original
surgical dressing is saturated with fresh bloodydrainage. What should you do?
3. C.W. has a total of 4 tubes in her abdomen, as wellas a nasogastric tube (NGT). What
information do you want to know about each tube?
4. The sump irrigation fluid bag is nearly empty. Youclose the roller clamp, thread the IV
tubing through the infusion pump, check the irrigationcatheter connection site to make
certain it is snug, and then discover that the nearlyempty liter bag infusing into C.W.’s
abdomen is D5W, not NS. Does this require any action?If so, give rationale for actions,
and explain the overall situation.
CASE STUDY PROGRESS
The physician arrives on the unit and removes C.W.’ssurgical dressing. There is a small “bleeder†at the edge of theincision, so the physician calls for a suture and ties off thebleeder. You take the opportunity to ask her about a morphinepatient-controlled analgesia (PCA) pump for C.W., and the physiciansays she will write the orders right away.
5. Postoperative pain will be a problem for C.W. afterthe anesthesia wears off. How do you
plan to address this?
6. Pharmacy delivers C.W.’s first bag of totalparenteral nutrition (TPN). The physician has
instructed you to start the TPN at a rate of 60 ml/hrand decrease the maintenance IV rate
by the same amount. What is the purpose of thisorder?
7. The physician did not specifically order glucosemonitoring, but you know that it should
be initiated. You plan to conduct a finger stick bloodtest every 2 hours for the first several
hours. What is your rationale?
8. C.W.’s blood glucose increased temporarily, but bythe next day it dropped to an average of 70 to 80 mg/dl and hasremained there for 2 days. Her VS are stable, but her abdominalwound shows no signs of healing. She has lost 1 kg over the past 3days. What do this data mean?
CASE STUDY PROGRESS
You discuss your concerns with C.W.’s physician, andshe agrees to request a consult from a registered dietitian (RD).After gathering data and making several calculations, the RD makesrecommendations to the attending physician. The TPN orders areadjusted, C.W. begins to gain weight slowly, and her wound showssigns of healing. Nutritional problems in clinical populations canbe complex and often
require special attention.
9. You and a co-worker read the following in C.W.’sprogress notes: “Wound healing by
secondary closure. Formation of granular tissue withepithelialization noted around edges.
Have requested dietitian to consult on ongoing basis.Will continue to follow.†Your
co-worker turns to you and asks whether you know whatthat means. How would you
explain?
10. Both of you start to discuss what specificdigestive difficulties C.W. is likely to face in the
future. What problems might C.W. be prone to developafter having so much of her
bowel removed?
11. The RD consults with C.W. about dietary needs. Youattend the session so that you will
be able to reinforce the information. What basicinformation is the RD likely to discuss
with C.W.?
12. After 3 days of dressing changes, C.W.’s skin isirritated, and a small skin tear has appeared
where tape was removed. How can you minimize this typeof skin breakdown and help
this area heal?
13. What specifics of ostomy teaching do you plan todo?
CASE STUDY PROGRESS
C.W. successfully battled peritonitis. Gradually,tubes were removed as she grew stronger with TPN and time. C.W.learned how to change her ostomy appliance and was dischargedhome.
Case Study 49 Inflammatory Bowel Disease withPeritonitis
Setting: Hospital
Index Words: inflammatory bowel disease (IBD),ileostomy, nutrition, assessment, skin care, patient education
C.W. is a 36-year-old woman admitted 7 days ago forinflammatory bowel disease (IBD) with small bowel obstruction(SBO). She underwent surgery 3 days after admission for a colectomyand ileostomy. She developed peritonitis and 4 days later returnedto the operating room (OR) for an exploratory laparotomy, whichrevealed another area of perforated bowel, generalized peritonitis,and a fistula tract to the abdominal surface. Another 12 inches ofileum were resected (total of 7 feet of ileum and 2 feet of colon).The peritoneal cavity was irrigated with normal saline (NS), and 3drainage tubes were placed: a Jackson-Pratt (JP) drain to bulbsuction, a rubber catheter to irrigate the wound bed with NS, and asump drain to remove the irrigation. The initial JP drain remainsin place. A right subclavian triple-lumen catheter wasinserted.
1. C.W. returns from post-anesthesia recovery unit(PACU) on your shift. What do you do when her bed is rolled intoher room?
2. You pull the covers back to inspect the abdominaldressing and find that the original
surgical dressing is saturated with fresh bloodydrainage. What should you do?
3. C.W. has a total of 4 tubes in her abdomen, as wellas a nasogastric tube (NGT). What
information do you want to know about each tube?
4. The sump irrigation fluid bag is nearly empty. Youclose the roller clamp, thread the IV
tubing through the infusion pump, check the irrigationcatheter connection site to make
certain it is snug, and then discover that the nearlyempty liter bag infusing into C.W.’s
abdomen is D5W, not NS. Does this require any action?If so, give rationale for actions,
and explain the overall situation.
CASE STUDY PROGRESS
The physician arrives on the unit and removes C.W.’ssurgical dressing. There is a small “bleeder†at the edge of theincision, so the physician calls for a suture and ties off thebleeder. You take the opportunity to ask her about a morphinepatient-controlled analgesia (PCA) pump for C.W., and the physiciansays she will write the orders right away.
5. Postoperative pain will be a problem for C.W. afterthe anesthesia wears off. How do you
plan to address this?
6. Pharmacy delivers C.W.’s first bag of totalparenteral nutrition (TPN). The physician has
instructed you to start the TPN at a rate of 60 ml/hrand decrease the maintenance IV rate
by the same amount. What is the purpose of thisorder?
7. The physician did not specifically order glucosemonitoring, but you know that it should
be initiated. You plan to conduct a finger stick bloodtest every 2 hours for the first several
hours. What is your rationale?
8. C.W.’s blood glucose increased temporarily, but bythe next day it dropped to an average of 70 to 80 mg/dl and hasremained there for 2 days. Her VS are stable, but her abdominalwound shows no signs of healing. She has lost 1 kg over the past 3days. What do this data mean?
CASE STUDY PROGRESS
You discuss your concerns with C.W.’s physician, andshe agrees to request a consult from a registered dietitian (RD).After gathering data and making several calculations, the RD makesrecommendations to the attending physician. The TPN orders areadjusted, C.W. begins to gain weight slowly, and her wound showssigns of healing. Nutritional problems in clinical populations canbe complex and often
require special attention.
9. You and a co-worker read the following in C.W.’sprogress notes: “Wound healing by
secondary closure. Formation of granular tissue withepithelialization noted around edges.
Have requested dietitian to consult on ongoing basis.Will continue to follow.†Your
co-worker turns to you and asks whether you know whatthat means. How would you
explain?
10. Both of you start to discuss what specificdigestive difficulties C.W. is likely to face in the
future. What problems might C.W. be prone to developafter having so much of her
bowel removed?
11. The RD consults with C.W. about dietary needs. Youattend the session so that you will
be able to reinforce the information. What basicinformation is the RD likely to discuss
with C.W.?
12. After 3 days of dressing changes, C.W.’s skin isirritated, and a small skin tear has appeared
where tape was removed. How can you minimize this typeof skin breakdown and help
this area heal?
13. What specifics of ostomy teaching do you plan todo?
CASE STUDY PROGRESS
C.W. successfully battled peritonitis. Gradually,tubes were removed as she grew stronger with TPN and time. C.W.learned how to change her ostomy appliance and was dischargedhome.
Case Study 49 Inflammatory Bowel Disease withPeritonitis
Setting: Hospital
Index Words: inflammatory bowel disease (IBD),ileostomy, nutrition, assessment, skin care, patient education
C.W. is a 36-year-old woman admitted 7 days ago forinflammatory bowel disease (IBD) with small bowel obstruction(SBO). She underwent surgery 3 days after admission for a colectomyand ileostomy. She developed peritonitis and 4 days later returnedto the operating room (OR) for an exploratory laparotomy, whichrevealed another area of perforated bowel, generalized peritonitis,and a fistula tract to the abdominal surface. Another 12 inches ofileum were resected (total of 7 feet of ileum and 2 feet of colon).The peritoneal cavity was irrigated with normal saline (NS), and 3drainage tubes were placed: a Ja
