Student Advance Preparation for Nursing Practice: Expectations
Topic
When Started
Standard
Presenting
Health Challenge
Praxis Week 1
Clinical Week 2
Students will come to clinical having completed a standardized
template on the patient’s admitting/priority health challenge(s)
as validated by the Instructor. The template is attached.
Concurrent
Health
Challenges
Decision Making
Worksheet
Praxis week 1
Clinical Week 2
Students will come to clinical with a page on which each of the
patient’s concurrent health challenges are defined only.
Praxis Week 1
Clinical Week 2
Students will come to clinical with Anticipated Foci listed in
pencil and an assessment plan outlined within the system
assessment boxes on the back of the worksheet.
Medications:
Drug Guide
Clinical Week
4/Two weeks
prior to
medication quiz
1. For each of the medications your patient is receiving, flag
Medications:
Client Drug
Profile
Clinical Week 4
Two weeks prior
to medication
quiz.
and review the Drug guide
2. Use the Drug Guide to prepare the Client Drug Profile Card
(see the next section).
3. Bring the flagged Drug Guide to each clinical day.
4. Have the Drug Guide with you for reference as you prepare
the medications e.g. for checking safe dose and other
important details etc.
Students will come to clinical with a client specific medication
profile e.g. index card, in words understood by most clients that
identifies:
Nursing Responsibilities
(Including Major/Common Side
Drug Name Purpose/Action
Effects & Assessments)
1.
2.
3.
4.
5.
6.
Etc.
This information should be carried in the uniform pocket and
accessed as needed e.g. at the bedside.
Laboratory & Diagnostic Tests
Please note that students are NOT expected to come to clinical practice with evidence of having
researched and understood laboratory and diagnostic tests; this will be an expectation in Semester III
when pathophysiology courses have begun. In semester II, students are encouraged to be curious about
these tests and to consult with the instructor and staff about their use and the related nursing
responsibilities.
Knowledge Preparation on Presenting Health Challenges
Student:
Date
Health Challenge/Diagnosis: Small bowel obstruction (SBO)
***Please note that this research is standardized for any client with this health challenge and as such, once
completed can be re-used with any other client with this specific health challenge. In future semesters, additional
knowledge including pathophysiology and diagnostic tests will be expected.
Description/Definition
(in your own words)
-partial or complete
Clinical Manifestations
Obstruction in small
blockage preventing the intestine:
normal flow of contents -dehydration
through the intestinal
-rapid onset
tract
-frequent and copious
vomiting
-could occur in the
-pain is colicky, crampsmall or large intestine, like, intermittent
however small is most
-BM- feces for a short
common
time
-abdominal distension
-3 causes of
depends on location of
obstruction:
obstruction – the further
down the obstruction in
a) extrinsic: bowel
the intestinal tract, the
obstruction begins
greater the distension
outside of GI tract such
as adhesions (Scar
Obstruction in the large
tissue growth) or
intestine:
volvulus (closed loop)
-gradual onset
b) intrinsic: b.o. is
-late manifestation of
caused by blockages of vomiting
lumen, including
-low-grade cramping and
tumours, inflammatory abdominal pain
processes or congenital -abdominal distension is
defects
greatly increased
c) intraluminal: caused
by things that entered
but didn’t pass through
the bowel (fecal
materials, gall stones
etc)
-adhesions is the most
common cause for
bowel obstruction
Collaborative Care
(Medical, Pharmacological, Surgical etc Treatments)
Prevention: relief of the obstruction and return to
normal bowel function, minimal to no discomfort,
normal fluid and electrolyte status, maintenance of
adequate nutrition
Diagnostic:
- Thorough auscultation of bowel sounds and GI
assessment high pitched sounds in area
above obstruction, low to no sounds below
obstruction. Assessment could show
abdominal distension, pain scale, BM’s
- Abdominal X-Ray to show presence of gas and
fluid in intestines
- CT scan to show mechanical changes that are
secondary to obstruction
- MRI shows more vascular and a more detailed
picture of mechanical changes
- Barium enema: helps in locating large
intestinal obstructions
- Sigmoidoscopy or Colonoscopy: lower GI tract
study provides direct visualizations of an
obstruction in the colon (if in lower region)
Laboratory Tests:
- Elevated WBC count could mean strangulation
or peforation
- Elevated haematocrit hemoconcentration
- Serum electrolytes should be monitored
frequently essential info on clients fluid and
electrolyte balance
- Na, K, Cl levels are decreased in SOB
- BUN may be increased due to dehydration
- Stool should be checked for occult blood
Nutrition:
- Administration of IV fluids to restore proper
electrolyte balance
- Diet rich in fibre
-severity of obstruction
depends on:
a) region affected
b) degree to which
lumen is occluded
c) degree to which
vascular supply to
bowel wall is disturbed
Surgical:
- Most mechanical obstructions treated
surgically bowel resection is resecting the
obstructed segment of bowel and
anastomosing the remaining healthy bowel
- Partial or total colectomy  surgical removal
of a region of colon
- Temporary or permanent ileostomy
surgical opening in ileum, stoma created
outside of abdomen)
- -colostomy surgical opening in the colon,
stoma created in abdomen
- Laparotomy surgical incision into abdomen
(under general anesthesia) done to explore
and aid in diagnosis of abdominal pain
Drug Therapy:
- Pain control (**but most analgesics have a
tendency to slow peristalsis which may
complicate obstruction)
Nursing Management
Nursing
Assessment
-client history
-physical
examination:
abdomendistension, pain,
tenderness, skin
- determine location,
duration, intensity
and frequency of
abdominal pain
-if patient is
vomiting: onset,
frequency, colour,
odour, amount
-bowel function
-passing of flatus?
-auscultation of
bowel sounds
-palpation (masses,
distension)
Foci: Nursing
Diagnosis
Nursing Implementation
Nursing Interventions & Rationales
1. Acute pain related to
abdominal distension/
discomfort
1.1 Administer pain medications on time to relieve pain and
discomfort, keeping in mind adverse reactions, side effects (some
medications slow peristalsis)
1.2 Evaluate the patient's response to pain and medications or
therapeutics aimed at abolishing or relieving pain.
It is important to help patients express as factually as possible (i.e.,
without the effect of mood, emotion, or anxiety) the effect of pain
relief measures. Discrepancies between behavior or appearance and
what the patient says about pain relief (or lack of it) may be more a
reflection of other methods that the patient is using to cope with
than pain relief itself.
1.3 Respond immediately to complaint of pain.
In the midst of painful experiences, a patient's perception of time
may become distorted. Anxiety and fear about delayed pain relief
can exacerbate the pain experience. Prompt responses to
complaints may result in decreased anxiety in the patient.
Demonstrated concern for the patient's welfare and comfort fosters
the development of a trusting relationship.
2. deficient fluid volume
2.1 Administer parenteral fluids as ordered. Anticipate the need for
an IV fluid challenge with immediate infusion of fluids for patients
with abnormal vital signs.
Fluids are needed to maintain hydration states. Determination of
the type and amount of fluid to be replaced and infusion rates will
vary depending on clinical status.
2.2Monitor serum electrolytes and urine osmolality, and report
abnormal values.
Elevated blood urea nitrogen suggests fluid deficit. Urine specific
gravity is likewise increased.
2.3Assess skin turgor and mucous membranes for signs of
dehydration.
Loss of interstitial fluid causes loss of skin turgor. Assessment of skin
turgor in older adults is less accurate because the skin normally loses
its elasticity. Therefore skin turgor assessed over the sternum or the
forehead is best. Several longitudinal furrows and coating may be
noted along the tongue.
3. imbalanced nutrition
3.1 Encourage intake of high fibre fruits and vegetables to
encourage production of bowel
3.2 Consult dietitian for further assessment and recommendations
regarding food preferences and nutritional support.
Dietitians have a greater understanding of the nutritional value of
foods and may be helpful in assessing specific ethnic or cultural
foods
3.3Monitor laboratory values that indicate nutritional well-being or
deterioration:
Serum albumin
This test indicates degree of protein depletion (2.5 g/dL indicates
severe depletion; 3.8 to 4.5 g/dL is normal).
4.risk for skin breakdown
4.1Assess the patient's nutritional status, including weight, weight
loss, and serum albumin levels.
An albumin level less than 2.5 g/dL is a grave sign, indicating severe
protein depletion. Research has shown that patients whose serum
albumin level is less than 2.5 g/dL are at high risk for skin
breakdown, all other factors being equal.
4.2Encourage ambulation if the patient is able.
Ambulation reduces pressure on the skin from immobility.
4.3 Reassess skin often and whenever the patient's condition or
treatment plan results in an increased number of risk factors.
The incidence and onset of skin breakdown is directly related to the
number of risk factors present.
5. risk for respiratory
impairment
5.1 Monitor 02 sats, should remain >94% on room air, if not, 02
therapy might need to be supplemented
5.2Assess lung sounds, noting areas of decreased ventilation and the
presence of adventitious sounds.
Changes in lung sounds may reveal the etiology of impaired gas
exchange.
5.3Provide reassurance, and allay anxiety.
Anxiety increases dyspnea, respiratory rate, and work of breathing.
References: It is anticipated that the required textbook Medical-Surgical Nursing in Canada (Lewis et.al.,
2010) is used for this research. If other sources are used, please provide a brief list here.