CONCEPT MAP WORKSHEET

DESCRIBE DISEASE PROCESS AFFECTING PATIENT

(INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS)

Bowel Obstruction: Page 10

Dehydration: Page 11

Serum Potassium Level: Page 12

Serum Chloride Level: Page 13

Nasogastric tube to low intermittentsuction: Page 14

DIAGNOSTIC TESTS (REASON FOR

TEST AND RESULTS)

Abdominal x-ray to rule out bowel obstruction

WBC

ABG

CT with contrast

Colonoscopy/Sigmoidoscopy

Barium enema

Electrolyte panel

PATIENT INFORMATION

52 year old male

Distended abdomen

C/O abdominal pain with N/V

“dizzy and weak”

Poor skin turgor

Dry mucous membranes

No urine outputsince yesterday

Allergy: Demeral

Height: 160cm

Weight: 76kg

ANTICIPATED PHYSICAL

FINDINGS

Fever >100*F

Abdominal pain

Hyperactive bowelsounds

Vomiting

Diarrhea followed by constipation

Absence of flatulence

Tachycardia

Abdominal distention

Poor skin turgor

Weakness

Dry mucous membranes

ANTICIPATED NURSING INTERVENTIONS

Nutrition monitoring

Frequent positioning 30-45 degrees;semi-fowlers position

Respiratory monitoring

Splinting when coughing

Decompression of gastric via Nasogastric Tube with suction

Fluid management and maintenance

Wound Care/Incision care ifsurgery is needed

Monitor for hypovolemic shock

ECG monitoring

Continuous pulse oximetry

Abdominal x-ray to check placement of nasogastric tube

Administration of fluids via IV

Administration of medications per physician order

Obtain IV access if not available

Prepare patient for surgery if needed

 1 / 3

Rebekah Taylor VSIM Stan Checketts NSG 270 Page 2

vSim ISBAR ACTIVITY STUDENT WORKSHEET

INTRODUCTION Rebekah Taylor, SN calling from the ED reporting on Stan Checketts.

Your name, position (RN), unit you are

working on

SITUATION Stan Checketts is a 52 year old male who came to the ED today with

complaints of severe abdominal pain as well as nausea and vomiting

that has lasted several days. Allergic to Demerol due to skin reaction.

Full Code. Past medical history of hernia repair and appendectomy.

Denies smoking, medications and any current illness.

Patient’s name, age,specific reason for visit

BACKGROUND Mr. Checketts admitted on January 14, 2021 due to the above concerns

for a suspected small bowel obstruction. Abdominal x-ray was ordered

and perfomed. Current Orders are: Start IV with NS Bolus 500mL over

30 minutes; Apply O2 to maintain SpO2 of >92%; Diet: NPO; Insert

Nasogastric tube to intermittent suction; Labs: CBC, Chemistry

Profile, Abdominal X-ray; Medications: Buprenorphine 0.3mg slow IV

push Q6H PRN for pain, Ondansetron 4-8mg IV push Q6H PRN for

nausea; ECG monitoring.

Patient’s primary diagnosis, date of

admission, current orders for patient

ASSESSMENT Vitals upon arrival: T 99*F, P 128 left radial 3+ regular, R 29 deep and

even, BP 109/78mmHg left arm sitting, SpO2 90% room air. Abnormal

lab values: Hb 20, Hct 60, WBC 17, Na+ 150, Cl- 108, BUN 42,

Creatinine 1.9. Radiology report confirmed small bowel obstruction.

Alert and oriented X4. States feeling dizzy, weak, been sick to his

stomach and mouth is dry. States stomach pain started 2 days ago and

has now been vomiting. Capillary refill >8seconds. Decreased skin

tugor. Skin pale, cold to the touch bilaterally. Lungs clear bilaterally

A&P. S1, S2 heart sounds heard on ausculatation; no extra sounds or

murmurs heard. Hyperactive bowel sounds heard in all 4 quadrants.

Abdomen is distended, tender to the touch. Education provided on

results of radiology report as well as physician orders. Patient

acknowledged understanding. 3-lead ECG attached and obtained.

Result was Sinus Tachycardia. 18G IV obtained in right antecubital

space, flushed with 10mL NS. Tolerated well. 500mL IV Bolus

initiated over 30minutes to gravity. Patient stated a feeling of nausea.

Administered 6mg Ondansetron IV push and flushed with 10mL of

NS. Stated stomach pain that felt crampy of 4/10 on scale of 0-10.

Administered 0.3 Buprenorphine IV push over 2 minutes and flushed

with 10mL of NS. Blood sample obtain via venipuncture and sent to

lab for analysis. Education provided about nasogastric tube procedure.

Patient acknowledged understanding. Consent obtained. Nasogastric

tube inserted via left nare and secured. Intermittent suction attached.

Tolerated well. Abdominal x-ray requested and performed by

radiology and confirmed placement of NG tube. Reassess pain level.

Stated feeling better with a pain level of 1/10 on pain scale 0-10. Vitals

reassess: T99*F, P 117 left radial 2+ regular, R 29 deep and even, BP

105/75mmHg left arm sitting, SpO2 94% 4L/min via NC. ECG sinus

tachycardia. Physician notified of findings.

Current pertinent assessment data using head

to toe approach, pertinent diagnostics, vital

signs

RECOMMENDATION Continue to monitor vitals