Copyright © 2020 Keith Rischer, d/b/a KeithRN. All Rights reserved.

Part II: Perforated Bowel/Sepsis/ICU NextGen Unfolding Reasoning

Mary O’Reilly, 55 years old

Primary Concept Infection/Inflammation

Interrelated Concepts (In order of emphasis)  Gas Exchange

 Perfusion

 Clinical judgment

NCLEX Client Need Categories Covered in

Case Study

NCSBN Clinical

Judgment Model

Covered in

Case Study Safe and Effective Care Environment Step 1: Recognize Cues 

 Management of Care  Step 2: Analyze Cues 

 Safety and Infection Control Step 3: Prioritize Hypotheses 

Health Promotion and Maintenance  Step 4: Generate Solutions 

Psychosocial Integrity  Step 5: Take Action 

Physiological Integrity Step 6: Evaluate Outcomes 

 Basic Care and Comfort 

 Pharmacological and Parenteral

Therapies



 Reduction of Risk Potential 

 Physiological Adaptation 

Copyright © 2020 Keith Rischer, d/b/a KeithRN. All Rights reserved.

Part I: Initial Nursing Assessment

History of Present Illness: Mary O’Reilly is a 55-year-old female with a prior history of partial colectomy w/colostomy who was admitted to the

medical/surgical unit for small bowel obstruction. Yesterday she developed severe RLQ abdominal pain and CT revealed

a perforated small bowel with free intraperitoneal air. Before she was brought to the operating room (OR) for an

exploratory laparotomy, her lactate was 4.9, WBC 18.9, and her systolic BP began to drop to 65-75, with a mean arterial

pressure (MAP) of 50-55. She received a total of 2500 mL of 0.9% NS preop and piperacillin-tazobactam 4.5 g. IVPB.

Her last BP before she went to the OR was 94/52 w/MAP 65.

What data is RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential)

RELEVANT Data: Clinical Significance:

Present Problem: Mary had an exploratory laparotomy that required extensive lysis of adhesions and was found to have a perforated

jejunum with fecal peritonitis. Mary has a 7.0 mm endotracheal tube (ET) that is well secured, 23 cm at the lips. Current

vent settings are: CMV/AC rate 12, TV 500 mL, PEEP +5, FiO2 35%. She has an arterial line placed in the right radial

artery and a central line was placed in the right internal jugular (RIJ). Placement was confirmed by chest x-ray. Mary

received 2.5 liters of LR during the case and had an estimated blood loss (EBL) of 375 mL. To maintain adequate

perfusion during surgery, she required norepinephrine IV gtt, currently at 10 mcg. Her SBP was consistently in the 90-

100s during surgery with a mean arterial pressure (MAP) of 65-70 and CVP: 12. She has a wound VAC applied to her

open abdominal incision with an intact dressing at 125 mm suction with no drainage and a 14 Fr. Salem Sump NG, 68 cm

in the left nare.

What data is RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential)

RELEVANT Data: Clinical Significance:

Mary is coming to ICU after surgery and the OR

nurse provides you with the following report:

Copyright © 2020 Keith Rischer, d/b/a KeithRN. All Rights reserved.

Patient Care Begins: Cardiac Telemetry Strip (6 seconds):

Regular/Irregular: P wave present? PR: QRS: QT:

Interpretation:

Clinical Significance:

Current VS: T: 99.4 F/37.4 C (oral)

P: 94 (regular)

R: 20 (AC: 12)

Arterial BP: 92/55 MAP: 67

O2 sat: 96% w/FiO2 35% ventilator

What VS data are RELEVANT and must be NOTICED as clinically significant by the nurse? (NCSBN: Step 1 Recognize cues/NCLEX Reduction of Risk Potential Reduction of Risk Potential/Health Promotion and Maintenance)

RELEVANT VS Data: Clinical Significance:

Current Head to Toe Nursing Assessment:

GENERAL SURVEY: Body relaxed, no grimacing, appears to be resting comfortably with no restlessness noted. Peripheral IV and central line well secured w/dressings intact, no redness or signs of

infection present, LIS suction w/NGT, ET 23 cm at lip, NGT 68 cm, tape secure on nasal

bridge and NG tube.

NEUROLOGICAL: PERRLA-3 mm, opens eyes briefly when name called, but then goes back to sleep, limited

spontaneous movements of all extremities noted

HEENT: Head normocephalic with symmetry of all facial features, sclera white bilaterally,

conjunctival sac pink bilaterally. Lips, tongue, and oral mucosa pink and moist. Biteblock for

ET properly placed.