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Clinical Case Study: Sigmoid Volvulus with Perforation
Amanda Frederick
00791934
Sentara Princess Anne Hospital
Submitted in partial fulfillment of the requirements in the course
NURS351: Clinical Management – Adult Health Nursing III
Old Dominion University
NORFOLK, VIRGINIA
Spring, 2013
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Clinical Case Study: Sigmoid Volvulus With Perforation
C.J is a 76-year-old male who was being evaluated for abdominal distention and
constipation. His family made these reports because this patient was nonverbal at baseline due to
having Progressive Supranuclear Palsy (PSP). PSP is a “neurologic disorder of unknown cause
that is characterized by paralysis of eye muscles, ataxia, neck and truck rigidity, pseudobulbar
palsy, and parkinsonian facies” (“Mosby’s dictionary,” 2009, Pg. 1522). Due to the seriousness
of this disease, he had a Percutaneous Endoscopic Gastrostomy tube (PEG tube) placed before
this admission, which allowed for feeding and medication administration.
When the doctors performed a flexible sigmoidoscopy a Sigmoid Volvulus was detected.
However, when the doctor advanced the scope it entered into the peritoneal cavity and the
procedure was ceased. C.J had a colon resection done; Hartmann’s procedure performed, and
then ended up becoming septic. He was unable to be extubated after surgery and was sent to the
intensive-care unit (ICU) on a ventilator and with a Jackson-Pratt Drain (JP drain). His past
medical history is quite extensive but the most relevant and important ones include: benign
prostatic hyperplasia (BPH) with urinary retention, altered mental status, unspecified
hypotension, leukocytosis, azotemia, hypernatremia, lactic acid acidosis, acute interstitial
pneumonia, bladder neck contracture (BNC), a neurogenic bladder which results in him having a
chronic foley, myocardial infarction, and hypercholesterolemia.
Scope of Paper
The scope of this paper is to discuss the patient’s medical diagnosis, which in turn will
allow for relevant nursing diagnoses to be made. Making nursing diagnoses is vital when
providing patient care because it also provides an opportunity to make attainable goals and
outcomes for that patient. This paper will discuss not only these aspects, but also the appropriate
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interventions to be taken with certain nursing diagnoses, which will help attain our goals set forth
for this specific patient.
Medical Diagnosis
C.J’s medical diagnosis, which was noted from the chart, was Sigmoid Volvulus with
perforation. However, his main reason for ICU admission was because he became septic from
peritonitis and went into respiratory failure and couldn’t be weaned off the ventilator after
surgery. Sigmoid Volvulus is a type of mechanical obstruction where the sigmoid colon
becomes twisted (Ignatavicius & Workman, 2012). Perforation refers to the fact that the doctor
mistakenly pierced a hole through the entire intestinal wall while observing with a scope, which
allowed the digestive tract contents to leak into the peritoneal cavity (“Mosby’s dictionary,”
2009). Signs and symptoms of bowel obstruction include abdominal distention and constipation,
both of which C.J was experiencing, but also cramping and possible slight pain (Ignatavicius &
Workman, 2012).
Peritonitis, “a life-threatening, acute inflammation of the visceral/parietal peritoneum and
endothelial lining of abdominal cavity” occurs because the peritoneal cavity is usually sterile and
when the intestinal contents leak into this space it became contaminated with bacteria, which is
what happened in C.J’s case (Ignatavicius & Workman, 2012, pg. 1268). This, in turn, caused an
infection, which triggered a whole-body inflammatory response and the bacteria entered into the
blood stream and C.J developed sepsis (Ignatavicius & Workman, 2012).
To make matters worse, after surgery to try to fix everything discussed thus far, C.J went
into respiratory failure and could not be taken off the ventilator. Respiratory failure develops
when “the pulmonary system fails to maintain adequate gas exchange” and hypoxemia occurs
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(Urden, Stacy, & Lough, 2010, pg. 602). He then was sent to the ICU where he could be
discretely watched and cared for.
Nursing Diagnoses
Impaired Spontaneous Ventilation
The priority nursing diagnosis for C.J would be Impaired Spontaneous Ventilation related
to acute respiratory failure. Evidence of respiratory failure, such as that of respiratory acidosis
and arterial blood gases (ABGs) were not noted since I cared for C.J weeks into his admission,
where he was then respiratory alkalotic. However, according to Maslow’s Hierarchy of Needs
priority must be given to those things that must be met in order to sustain life, in other words
physiologic and survival needs (Johnson & Webber, 2010). Maintaining adequate airway is the
most vital intervention nurses must implement regardless of the circumstances.
This nursing diagnosis coincides with Dorothea E. Orem’s Theory of Self-Care Deficit.
Orem explains that when patients are unable to care for themselves, even with the assistance of
family members, nurses can meet that self-care demand (Johnson & Webber, 2010). One of the
five methods that nurse’s use to help meet self-care needs of a patient is acting for or doing for
another, which is what we did when supplying him the ventilation he was unable to provide for
himself after coming out of surgery (Johnson & Webber, 2010).
Imbalanced Nutrition: Less Than Body Requirements
The second most important nursing diagnosis for C.J is imbalanced nutrition: less than
body requirements related to an increased metabolic need caused by his disease process. C.J had
a PEG tube and was receiving tube feedings. However he was “nothing by mouth” (NPO) status
for the two days that I cared for him because he was waiting for an ultrasound to be done.
Adequate nutrition is essential for the body to heal, as we have learned in other classes, as well
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as an essential part of sustaining life according to Maslow’s Hierarchy of Needs (Johnson &
Webber, 2010). Coinciding with interventions for respiratory failure, “the goals of nutrition
support are to meet the overall nutritional needs of the patient while avoiding overfeeding, to
prevent nutrition delayed-related complications, and to improve patient outcomes” (Urden et al.,
2010, pg. 605). As Orem signifies, we must be able to provide this self-care requisite to this
patient, as he is unable to make sure he gets proper nutrition on his own (Johnson & Webber,
2010).
Infection
After airway is maintained and nutrition is adequate, allowing for the healing process to
occur, we can then worry about our third nursing diagnosis, which is infection. As previously
mentioned, C.J developed peritonitis and went into septic shock, but he also had a urinary tract
infection (UTI) containing Klebsiella. This nursing diagnosis is also ranked third because these
infections were being well controlled and not as much of a concern as they once were. Health
deviation requisites are another universal requisite that Orem discusses in her theory (Johnson &
Webber, 2010). C.J is no longer able to assist in fighting off infection and caring for his health,
so we must provide that physical support and maintain an environment that supports his personal
development (Johnson & Webber, 2010).
Ineffective Coping (denial)
Another diagnosis that seems fit for this patient is ineffective coping (denial) of his
family. The daughters of C.J were very uptight during the days I cared for him. They were very
“jumpy” per say about everything that was being done to the patient and asked an abundance of
questions. They got very mad and upset when things were changed without their knowing or
approval. They did not seem to accept the seriousness and extent of C.J’s illness. They kept
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pushing out comfort care measures in hopes that things would miraculously make a turn for the
better. Dorothea Orem discusses that we need to be able to provide psychological support, be
able to guide and direct, and teach our patients and family when need be (Johnson & Webber,
2010). Though this nursing diagnosis is not directly associated with the patient, it does revolve
around him and will have an affect on him in the long run.
Impaired Physical Mobility
The last diagnosis for C.J is impaired physical mobility. This is not as much of a priority
as the others because this is something that we cannot fix due to his debilitating disease state of
Progressive Supranuclear Palsy. However, it is something that we need to consider when caring
for him. He is unable to provide for himself in any shape or form because his whole body is
contracted. Again coinciding with Dorothea Orem’s theory, this is termed a “wholly
compensatory system” meaning the patient has no active role in his care and the nurse provides
total nursing care to meet self-care needs (Johnson & Webber, 2010).
Outcomes and Interventions For Top 2 Diagnoses
Impaired Spontaneous Ventilation
Outcomes.
Appropriate expected outcomes for this nursing diagnosis that is relevant to C.J include:
patient will maintain spontaneous gas exchange resulting in normal arterial blood gases (ABGs)
within patient parameters during the two days I am caring for him; Patient will demonstrate no
complications from the ventilator, such as ventilator associate pneumonia (VAP), during the two
days that I am caring for him; and patient will be able to wean off the ventilator during the two
days that I am caring for him.
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Interventions.
In hopes to meet the outcomes discussed above, certain interventions needed to be
implemented along the way. Aseptic suctioning was done, which was “based on a need basis
rather than on a preset time interval, which reduced risk for infection and airway trauma”
(Gulanick & Myers, 2011, pg. 421). Soft wrist restraints were used to prevent self-extubation,
however most likely not needed because this patient was severely contracted in his upper
extremities (Gulanick & Myers, 2011). Ventilator alarms were checked whenever they went off,
which made sure that problems were taken care of if need be, and made sure that adequate
ventilation was being supplied to the patient (Gulanick & Myers, 2011). Ventilator settings were
also checked often to ensure that the patient was not fighting the ventilator, meaning receiving
more than he needed (Gulanick & Myers, 2011). Spontaneous Breathing Trials (SBTs) were
also performed, which tested to see if C.J was able to come off the ventilator and breath on his
own.
“Ventilator-associated pneumonia (VAP) accounts for the majority of nosocomial
pneumonias (90%), which may increase intensive care and prolonged hospital stays” (Speroni et
al., 2011, pg 15). So according to the Clinical Practice Guidelines for Mechanical Ventilation
and Discontinuation from Mechanical Ventilation, there are many things that can be
implemented to prevent VAP that were incorporated in C.J’s care as well. These included: using
continuous aspiration of subglottic secretions (CASS tube) and doing oral hygiene with
cholhexidine every 4 hours to prevent entry of bacteria into the lower airway; keeping the head
of the bed at a 30-40 degree angle at all times to prevent aspiration; and using preventative
measures like promoting rest and providing nutrition. Sedwick, M. B., Smith, M. L., Reeder, S.
J., & Nardi, J. (2012) also spoke to these same care practices as part of the VAP bundle.
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However, they also incorporated peptic ulcer disease (PUD) and deep-vein thrombosis (DVT)
prophylaxis and daily interruption of sedation. They monitored nurses incorporating these
interventions using a feedback tool and were able to conclude “that strict adherence to a VAP
bundle improved morbidity, mortality, and health care costs” (Sedwick, M. B., Smith, M. L.,
Reeder, S. J., & Nardi, J., 2012, pg. 49). C.J was on DVT and PUD prophylaxis, which included
aspirin and prevacid respectively, but was not under any sedation.
Teaching is directed toward the family in this situation because the patient is not able to
physically learn and incorporate what was taught. However when teaching does occur it should
be in front of the patient because he is most likely still able to understand what is going on
around him. The nurse needs to make sure the family understands the reasoning for intubation
and ventilation and the significance of the alarms (CPG: Mechanical Vent., 2010). For this
specific case the family needs more teaching about what to expect when doing spontaneous
breathing trials and a better understanding of the severity of his condition.
Critically thinking I do not see a good prognosis for C.J and it is going to take a lot to
even try to get him weaned off the ventilator. When performing the SBT he failed with a rapid
shallow breathing index (RSBI) of 300, which is relatively high. You cannot even be considered
for weaning until your RSBI is under 105 (Urden et al., 2010, pg. 659). All of his body systems
are working against him right now and his body is overly stressed.
Imbalanced Nutrition: Less Than Body Requirements
Outcomes.
Appropriate expected outcomes for this nursing diagnosis that is relevant to C.J include:
Patient will maintain normal hemodynamic state during the two days that I am caring for him;
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Patient will have normal electrolyte balances by the end of the two days that I am caring for him;
Patient will not lose any weight during the two days that I am caring for him.
Interventions.
In effort to meet the outcomes discussed above certain interventions needed to be
implemented. These included giving medications as needed for low blood pressure such as
Midodrine (proamatine), giving replacement therapy fluids to help correct electrolyte imbalances
like magnesium sulfate and potassium chloride, doing daily weights, and giving the patient his
Jevity at 30ml/hr as directed. Maintaining adequate nutrition can also help with getting the
patient off his ventilator because “malnutrition decreases the patients ventilatory drive and
muscle strength” (Urden et al., 2010, pg. 605). Other interventions related to Enteral tube
feedings include: assessing for patency and free flow of Enteral feeding, which will assure
nutrients is delivered; assessing weight every other day or as ordered, which can help determine
an improved nutritional status but also fluid retention; and flushing the tube with 20mL of water
after medication administration or anytime the flow of solution is interrupted, which will also
make sure no disruption of nutrient intake occurs (Gulanick & Myers, 2011).
According to the Clinical Practice Guidelines for Enteral nutrition, some indications of
malabsorption/maldigestion are: abdominal pain, cramping, loose and frequent stools, electrolyte
imbalances, vitamin/mineral deficiencies, unintentional weight loss, and bleeding. So as nurses
we can monitor their stool patterns, advocate for diagnostic studies, review medications that may
impair absorption and make adjustments, and evaluate the need for total parenteral nutrition
(TPN) (CPG: Enteral Nutrition, 2010).
Kim et al. (2012) conducted a prospective, cohort study, which evaluated the adequacy of
energy and protein intake of patients in an ICU in the first four days after initiation of enteral
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feeding and investigated the factors that had impact on adequate intake. This study showed that
most of the patients (62%) received insufficient energy and 52% had insufficient protein intake
(Kim et al., 2012). They also were able to determine that the reasoning for underfeeding of
energy were due to not initiating nutrition early enough, not giving enough nutrition, and because
of prolonged interruption of enteral feeding (Kim et al., 2012). Through this study we are able to
see that there is a trend of reasons people in the ICU are malnourished. With insight to these
results we can look at these factors and make adjustments to the interventions we are doing. For
instance, C.J being NPO status for the two days was potentially too long and can hinder our
clinical outcomes set forth for him. So we could have waited until we knew exactly when he was
going for his ultrasound and stopped his feedings then, while still allowing for accurate results
from the ultrasound. Being NPO for over 36 hours was most definitely not needed.
Since this patient has had his PEG tube since before his admission, one would hope his
family has already learned how to care for it. However assessing for understanding and
knowledge should be incorporated. We would want to make sure they know the importance of
enteral nutrition and at what rate it should be administered. We would also want to make sure
they knew how to maintain good skin integrity, such as applying skin barriers and moisturizers,
and being able to detect infection, like the occurrence of swelling, tenderness, or drainage (CPG:
Enteral Nutrition., 2010).
Critically thinking I think this patient will have a hard time becoming nutritionally sound.
With enteral feedings you are always at risk for imbalanced nutrition and with the high demands
his body needs right now it will be hard to catch up since he is already behind. However, in order
to fix his fluid overload problem, we could give him albumin, which was at a low of 1.7, which
will help diuresis to occur more efficiently.
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Cultural Considerations
Culturally speaking we have to look at the patient’s state of well being and quality of life.
C.J has become very ill and his quality of life has decreased dramatically. Though we don’t
want to just simply give up on him, we need to look at the overall picture. Having Progressive
Supranuclear Palsy has already taken so much from him, that at this state, with all the new health
problems, it needs to be considered if were actually prolonging his life or just prolonging his
death. C.J is also a DNR/DNI with limits. So this also needs to be taken into consideration.
Obviously he didn’t want to live his life the way he is, stuck on a ventilator, so it really is a
matter of getting the family to accept what all is going on and getting them to understand what is
morally right for the patient.
Evaluation
C.J did not progress in the two days that I was with him in the ICU. If anything, things
may have taken a turn for the worse. Although he did not develop ventilator associated
pneumonia, his ABGs did not remain within normal parameters: pH – 7.506 (high), PCO2 – 30.0
(low), PO2 – 77 (low), HCO3 – 23.8, which is indicative of respiratory alkalosis, and he was
unable to be extubated after failing two spontaneous breathing trials. Alternatively, the next time
that an SBT is done, maybe we could make sure the family is present. This might give C.J some
encouragement and he may try harder. We could also ensure that he is sleeping at night that way
he has enough energy to perform better on the SBT. Also, as previously mentioned, maintaining
adequate nutrition could also be of benefit to him, while trying to wean off the ventilator (CPG:
Mechanical Vent., 2010).
His nutritional status did not improve either in the two days that I was there. As
mentioned, he was placed NPO status for a pending ultrasound, in which they held his tube
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feedings, and he was not fed anything for over 36 hours. His blood pressure remained low:
95/46, and electrolytes were still out of normal limits: Phosphorus - 1.5 (low), calcium - 7.2
(low), potassium – 3.4 (low). He was +18 liters and his albumin level was low: 1.7.
Alternatively, as spoken to before, we could give him some albumin to help with the diuresis
process, which in turn would help with his electrolyte imbalances, which are low from dilution.
Conclusion
During this two-day assignment with C.J I learned a lot. His health status allowed me to
connect the different body systems and understand how they all affect each other. For instance,
since he was 18 liters positive in fluid, this affected his respiratory status as well as his
cardiovascular system, making his electrolytes low from dilution. I also saw how important the
quality of life of a patient is and how much it really does matter when speaking to life or death
issues. It made me realize what “being alive” actually means. Sadly, C.J was not progressing.
He was having a hard time trying to compensate for all the bullets he was struck by. Going from
a simple bowel obstruction, to developing an infection and becoming septic, to going into
respiratory failure and being stuck on a ventilator is a lot of stress on the body at one time,
especially for a 76 year old. Comfort measures would be highly considered if it were my
decision but its not. But, it is my obligation as a soon to be nurse, to advocate for C.J and make
sure the right decisions are made, while respecting what he would have wanted.
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References
(2009). Mosby’s dictionary of medicine, nursing & health professions. (8th ed., p. 1522). St.
Louis, MO: Mosby Elsevier.
(2010). Clinical practice guidelines: Enteral nutrition. CPM Resource Center: an Elsevier
Business
(2010). Clinical practice guidelines: Mechanical ventilation and discontinuation from
mechanical ventilation. CPM Resource Center: an Elsevier Business
Gulanick, M., & Myers, J. L. (2011). Nursing care plans: Diagnoses, interventions, and
outcomes. (7 ed.,). St. Louis, MO: ELSEVIER.
Ignatavicius, D. D., & Workman, M. L. (2012). Medical-surgical nursing: Patient-centered
collaborative care. (7 ed., Vol. 1, p. 1254). St Louis, MO: ELSEVIER.
Johnson, B. M., & Webber, P. B. (2010). An introduction to theory and reasoning in nursing.
(3rd ed.). Lippinocott Williams & Wilkins
Kim, H., Stotts, N., Froelicher, E., Engler, M., Porter, C., & Kwak, H. (2012). Adequacy of early
enteral nutrition in adult patients in the intensive care unit. Journal Of Clinical Nursing,
21(19/20), 2860-2869. doi:10.1111/j.1365-2702.2012.04218.x
Sedwick, M., Lance-Smith, M., Reeder, S. J., & Nardi, J. (2012). Using Evidence-Based Practice
to Prevent Ventilator-Associated Pneumonia. Critical Care Nurse, 32(4), 41-51.
doi:10.4037/ccn2012964
Speroni, K., Lucas, J., Dugan, L., O'Meara-Lett, M., Putman, M., Daniel, M., & Atherton, M.
(2011). Comparative Effectiveness of Standard Endotracheal Tubes vs. Endotracheal
Tubes With Continuous Subglottic Suctioning On Ventilator-Associated Pneumonia
Rates. Nursing Economic$, 29(1), 15-37.
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Urden, L. D., & Stacy, K. M., & Lough, M. E. (2010). Critical care nursing: Diagnosis and
management. (6th ed.).