C.W., a 36-year-old woman, was admitted several days ago with adiagnosis of recurrent inflammatory bowel disease (IBD) andpossible small bowel obstruction (SBO). C.W. is married, and herhusband and 11-year-old son are supportive, but she has no extendedfamily in the state. She has had IBD for 15 years and has beentaking mesalamine (Asacol) for 15 years and prednisone 40 mg/dayfor the past 5 years. She is very thin; at 5 feet 2 inches (157cm), she weighs 86 lbs (39 kg) and has lost 40 lbs (18 kg) over thepast 10 years. She averages 5 to 10
loose stools per day. C.W.’s life has gradually become dominated byher disease, with anorexia, lactase deficiency, profound fatigue,frequent nausea and diarrhea, frequent hospitalizations fordehydration, and recurring, crippling abdominal pain that oftenstrikes unexpectedly. The pain is incapacitating and relieved onlyby a small dose of diazepam (Valium), oral electrolyte solution(Pedialyte), and total bed rest. She confides in you that sexualactivity is difficult: “It always causes diarrhea, nausea, and lotsof pain. It’s difficult for both of us.” She is so weak she cannotstand without help. You indicate complete bed rest on the nursingcare plan.
1. Identify 6 priority problems for C.W.
2. Considering C.W.’s weakness, chronic diarrhea, and lower than-desired body weight, what nursing interventions need to
be implemented to minimize skin breakdown? Name at least 6.
3. What is the mechanism of action of the mesalamine (Asacol) inrelation to the IBD?
a. It increases bulk and moisture content in the stool.
b. It relaxes the smooth muscle of the intestines, thus reducingmotility.
c. It slows intestinal motility, prolonging transit time ofintestinal contents.
d. It blocks prostaglandin production, thus diminishinginflammation in the colon.
Case study progress
C.W.’s condition deteriorates. On the third day after admission sheexperiences intractable abdominal pain and unrelenting nausea andvomiting. C.W. is taken to the operating room because of probableSBO and is readmitted to your unit from the post anesthesia careunit. During surgery, 38 inches (96 cm) of her small bowel wasfound to be severely stenosed, with 2 areas of visible perforation.Much of the remaining bowel is severely inflamed and friable. Atotal of 5 feet (152 cm) of distal ileum and 2 feet (61 cm) ofcolon have been removed,and a temporary ileostomy was established.She has a Jackson-Pratt (JP) drain to bulb suction in her rightlower quadrant (RLQ), and her wound was packed and left open. Shehas 2 peripheral IV lines, a Salem Sump nasogastric tube (NGT), anda Foley catheter. Her vital signs (VS) are 112/72, 86, 24, 100.8° F(38.2° C) (tympanic). You attach her NGT to low-continuous wallsuction per the postoperative orders.
4. You begin a thorough postoperative assessment of C.W.’s abdomen.What does your assessment include? List the steps in the order inwhich the assessment should be completed.
5. A nursing student enters C.W.’s room and auscultates herabdomen. She looks at you and excitedly announces that she hearsgood bowel sounds. You take the opportunity to teach
her the proper method of auscultating bowel sounds on a patient whohas NGT to low-continuous wall suction. How would you correct hererror?
6. Four hours later, you measure the drainage from the JP tube.Look at the following figure and state how much drainage youobtained.
7. What else will you note about the drainage?
8. Describe the proper method for reestablishing suction on the JPdrain after you have emptied the bulb container.
9. C.W. asks you, “I know why I have the pouch. Why do I have tohave this other little tube?” How will you explain the purpose ofthe JP drain?
