Running head: MEDICAL/ SURGICAL CASE STUDY
Medical/ Surgical Case Study
Lacey Hastings
Stenberg College
Medical/ Surgical Nursing Practice Theory
NURS 201-3
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MEDICAL/ SURGICAL CASE STUDY
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Medical/ Surgical Case Study
This case study was written to provide an in depth analysis of one of the writer’s patients
on the medical unit of Nanaimo Regional General Hospital.
Identifying Data and General Description
For confidentiality purposes the client will be referred to as only L.W. L.W. is a 31 year
old Caucasian European Canadian female, married with 1 child. She is an accountant, a nonsmoker, and non-drinker, and lives a healthy lifestyle. L.W. is fit, and takes care of her body. She
is a tall woman, with a fair complexion, and appears well put together prior to admission.
Chief Complaint/ History of Present Illness
The primary complaint that brought L.W. to the hospital was viral diarrhea, and what
appeared to be a reaction to a medication (Keflex). L.W had oral ulcers, a rash on her face, chest
and stomach, as well as an abscess on her thigh and stomach, and a fever (38). L.W. was
admitted with the diagnosis of diarrhea/SIRS (systemic inflammatory response syndrome)
(Nanaimo Regional General Hospital, 2013). L.W had nausea and vomiting upon admission to
the medical unit, and shortly began passing blood from her bowels (1-2 cups) and vomiting
blood/sputum. L.W. was in ‘agonizing’ pain, with the oral ulcers, and ‘gut wrenching’ pain in
her stomach.
At the beginning of L.W. stay, the hospitalists were unsure what was exactly going on,
was this in fact a drug reaction from the Keflex that was prescribed just before the diarrhea
started, or was it a coxsackievirus (hand foot- and- mouth disease)-which was the initial
diagnosis. However towards the end of L.W. stay she was noted to be diagnosed and treated for
inflammatory colitis or ‘inflammatory bowel disease’ (NRGH, 2013).
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Past Medical/ Surgical History and Allergies
L.W. has a history of anxiety and depression, this was noted to be ‘significant’ in her
chart (NRGH, 2013). L.W. also has asthma, however does not currently take medication or use
an inhaler, and she has no acute signs or symptoms. She has eczema, and suggests she has ‘very
sensitive skin’. L.W.’s father also has a history of depression, and irritable bowel disease; which
she claimed not to be aware of prior to her diagnosis of inflammatory bowel disease.
L.W. does not have a surgical history, however underwent procedures while on the
medical floor that I will include. She had a CT scan of her chest, abdomen, and pelvis, which
showed diffuse thickening of the colon and rectum consistent with infectious or inflammatory
colitis (NRGH, 2013). She also had a sigmoidoscopy done; a sigmoidoscopy is a procedure in
which the inner lining of the lower large intestine is examined. Flexible sigmoidoscopy is
commonly used to evaluate gastrointestinal symptoms, such as abdominal pain, rectal bleeding,
or changes in bowel habits (WebMD, 2013). During the procedure, a doctor uses a
sigmoidoscope, a long, flexible, tubular instrument about 1/2 inch in diameter, to view the lining
of the rectum and the lower third of the colon (the sigmoid colon) (WebMD, 2013). The photos
and biopsy showed query severe inflammatory bowel disease (NRGH, 2013).
L.W. allergies to medications include: Erythromycin, Cephalexin, and although not added
or clarified, potentially Keflex. There is no food allergies known at this time.
Disease Process
Please see the attached Appendix A , Table 1 and 2 for Disease Processes.
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Medications
The medications that L.W. is currently taking at home include Valcyclovir an antiviral
for the sores in her mouth; Valcyclovir decreases the severity and length of these outbreaks. It
helps the sores heal faster, keeps new sores from forming, and decreases pain (WebMD, 2013).
Tramadol, which is an opioid analgesic used to treat moderate-severe pain, and previously
Keflex which is an antibiotic used to fight bacteria and treat infection (WebMD, 2013).
The medications that L.W. received in the hospital included in the table below
Drug: Generic/ Trade Classification
Route
Ceftriaxone/rocephin
IV
Cephalosporinantibiotic
Dose &
Frequenc
y
1g- Q24
Time
0900
hr.
Fluconazole/diflucin
Azole
Antifungal
PO
200mg
0900
Benzydamine/difflamhydrochloride
Locally acting
non-steroidal
antiinflammatory
with local
anesthetic and
analgesic
properties
antifungal
PO
PRN
PRN
100,000
units
0900
Nystatin/nilstat
Rinse
PO
liquid
Major side effects
1300
1800
c-diff(diarrhea),
allergic reaction,
seizures, chest
pain, trouble
breathing
Severe
stomach/abdominal
pain,
nausea/vomiting,
fast/irregular heartbeat, fainting
Nausea or
vomiting, burning,
or numbness in
mouth, throat
irritation.
Reason for
medication
Suspected
infectionthis was d/c
shortly after
starting
Treat fungal
and yeast
infections.
Sores in
mouth
relieves pain
and
inflammation
associated
with a sore
throat or
mouth sores
Diarrhea, nausea or Used to treat
vomiting
fungus
infection of
the mouth
MEDICAL/ SURGICAL CASE STUDY
Morphine
5
Opioid/narcotic PO
PRN
PRNq4
hours
Acetaminophen/Tylen
ol
Antipyretic/
analgesic
PO
Dalteparin/fragmin
type of heparin
Anticoagulant
‘blood thinner’
injection 5000 IU
Once
daily
1600
IV
PRN
PRN
PO
5mg
HS
Dimenhydrinate/gravol antiemetic
PRN
zoplicone
PRN
2100
Sedative
hypnotic
Allergic reaction,
slowed heartbeat,
shortness of breath,
severe vomiting,
decreased
awareness or
responsiveness,
fever
To treat
Moderatesevere Pain
Stomach and
mouth sores
fever
Too much
acetaminophen
may cause serious
(possibly fatal)
liver disease and
liver problems.
Persistent nausea/
vomiting.
Unusual or
prolonged
bleeding, unusual
or easy bruising,
unusual pain or
swelling, allergic
reaction, fainting,
seizures.
Constipation,
dizziness, allergic
reaction,
confusion, blurred
vision, difficulty
passing urine
Behavior changes,
confusion, anxiety,
wheezing, tightness
in chest
(Vallerand & Sanoski, 2013)
Nursing Physical Assessment
While competing a head-to-toe assessment, L.W. temperature was 38, radial pulse was
80, strong and regular, Respirations were easy at 16 per minute. BP was 108/71. Neck veins flat
Treat/prevent
blood clots
Nausea and
vomiting
short-term
and
symptomatic
relief of sleep
disturbances
Lab Test
MEDICAL/ SURGICAL CASE STUDY
at 45 degree angle. Apical pulse S1, S2 clear without rubs or murmurs. Radial and pedial pulses
strong and regular. L.W. was alert and oriented x4, she was pleasant and calm. Her hand and leg
strength was strong bilaterally. Capillary refill to hands and toes returns 2 sec. bilaterally. Skin
turgor returns less than 1 second, skin is warm, but very pale, rash on face, abscess on buttocks
and thigh. Lung sounds clear bilaterally, good air entry, oxygenation- 97 on room air. Pt. c/o not
being able to void this a.m. Bowel sounds present and active x 4 quadrant; pt. having diarrhea,
with blood approx. 1-2 cups, frank red. Nausea and vomiting present. No peripheral edema. L.W.
c/o pain in mouth (sores), 8/10, throbbing pain, worse when eating and drinking; also c/o pain in
stomach, 7/10, ‘gut wrenching’ pain, worse with diarrhea and vomiting.
Lab Results
The out of range significant lab results from L.W stay at the hospital are provided in the
table below
Normal Range
Hemoglobin
Clients’ results
Purpose of the test
Indications about the client
105
To assess overall health.
Usually done as part of
complete blood count
(MayoClinic, 2013)
Could indicate anemia. L.W.
Was losing blood due to
Inflammatory bowel disease.
120 to 155
grams per
liter)
RBC’s
WBC’s
6
3.90-5.03
trillion cells/L
3.34
3.5-10.5
billion cells/L
11.5
(MayoClinic, 2013).
Typically ordered as part of a
complete blood count (CBC)
and may be used as part of a
health checkup to screen for a
variety of conditions
(Mayoclinic, 2013)
Anemia- Blood loss
Complete Blood Count
Inflammation- Inflammatory
Bowel disease
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Treatment
While L.W. was in the hospital she was receiving antifungals, antibiotics, antiemetics,
pain control and towards the end when finding out she had inflammatory bowel disease she was
started on a steroid for inflammation (NRGH, 2013). She was on continuous IV D5NS w 40 meq
KCL @ 125 ml which is used for fluid and electrolyte replenishment and caloric supply (RxList,
2013). She was given a regular diet and then switched to a small pureed diet which was easier on
her mouth and her stomach, and she was seeing a dietician while on the floor (NRGH, 2013). We
were taking L.W. vitals BID and temp QID, and continuously monitoring her nausea, vomiting,
diarrhea, and pain. We were monitoring her hemoglobin and RBC’s, as she was losing blood
through her bowels and vomiting. L.W. was mainly on bed rest , with activity as tolerated
(AAT). We assisted her with ADL’s, however she is a young woman and independent so we set
up her hygiene supplies and she did this on her own. L.W. would get very anxious about being in
the hospital and not knowing what was wrong, and her heart would start “racing”, so we spent
some time teaching her about deep breathing, and relaxation techniques. L.W. was involved in
her care; she wanted to know what she was taking, and why she was taking it. She would involve
in her care and treatment, she wanted to know everything that was going on, what her tests
results were, what her vitals were, etc. She would notify us of any changes that she noticed or
felt, and would let us know what PRN’s were working for her and which weren’t, what we could
do to make her comfortable, etc. There was good communication with L.W. and a definite ‘team’
approach.
Teaching, and Discharge Planning
Upon finding out that L.W. in fact has inflammatory bowel disease, which was inflamed,
L.W. was discharged to Victoria General and referred for tertiary care to see a gastroenterologist
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(NRGH, 2013). Thus the discharge instructions will come from the specialist at Victoria
General, she would follow up with her GP. Just prior to her discharge from NRGH L.W. was
started on hydrocortisone IV, a steroid for inflammation (NRGH, 2013).
Writer’s Reflection
This was a very interesting case, and I learnt a lot while caring for this patient, and while
reflecting and analyzing through this case study. This case was so interesting because it was a
mystery at the beginning, what was happening to this poor lady? When she came to the hospital
she was sure it was a reaction to an antibiotic, she had a rash, fever, nausea, vomiting, diarrhea,
and thus this seemed to be the first consensus. However after being on the floor, the consensus
changed to the thought of her having hand-foot-and-mouth disease or ‘coxsackie’ virus. It
seemed as though this ladies whole body was under attack, she was placed on contact precaution,
as they weren’t sure whether this was a contagious virus. When L.W. started passing a lot of
blood through her bowels, and then vomiting with blood, the consensus again shifted. I quickly
noticed it is like putting pieces together in a puzzle. You have to look at the whole picture, piece
by piece to get a good idea of what is going on.
With vitals, assessments, lab values, tests, and procedures (Ct scan, sigmoidoscopy), the
pieces start to come together. Thus L.W. was diagnosed with inflammatory bowel disease. What
I did learn was that with inflammatory bowel disease, the digestive system becomes scarred due
to excessive inflammation, and ulcers can develop (NHS, 2013). Over time these ulcers develop
into tunnels, or passageways, that run from one part of your digestive system to another or, in
some cases, to the bladder, vagina, anus or skin- these passageways are known as fistulas (NHS,
2013). Larger fistulas can become infected and cause symptoms such as: a constant, throbbing
pain , a high temperature (fever) of 38°C (100°F) or above , and blood or pus in your faeces
MEDICAL/ SURGICAL CASE STUDY
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(stools) (NHS, 2013). Fistula can also develop on your skin, as well as skin lumps or soreswhich could be the explanation for the abscesses present on her buttocks and thigh. (NHS, 2013).
With this inflammation or obstruction from inflammatory bowel disease, one can also feel
nausea/vomiting, and have abdominal pain and cramping (NHS, 2013). Although the exact cause
of her mouth ulcers were not determined I did find some resources that note mouth ulcers can be
symptoms associated with inflammatory bowel disease (Medline Plus, 2013; Mayo Clinic,
2013).
Thus I was able to see the connections of some of the complications of inflammatory
bowel disease, and some of L.W. signs and symptoms. Finally the puzzle came together, and she
was able to get the treatment she needed.
Priority Nursing Diagnosis and Goals
Please see attached the attached Appendix B for a short term nursing diagnosis and goal,
Appendix C for a long-term nursing goal, and Appendix D for a community focused nursing
goal.
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References
Lewis, S. L., Heitkemper, M. M., Dirkson, S. R., Butcher, L., & O’Brian, P. G. (2010). Medicalsurgical nursing in Canada assessment and management of clinical problems (2nd ed.).
Toronto, Canada: Mosby Elsevier.
MayoClinic. (2013). Inflammatory bowel disease (IBD). Health Information. Retrieved from:
http://www.mayoclinic.com/health/inflammatory-bowel-disease/DS01195
MedlinePlus.(2013). Crohn's disease. National Insititute of Health. Retrieved from:
http://www.nlm.nih.gov/medlineplus/ency/article/000249.htm
National Health Service. (2013). Crohn's disease – Complications. Retrieved from:
http://www.nhs.uk/Conditions/Crohns-disease/Pages/Complications.aspx
Stuart, G. (2009). Principles and Practice of Psychiatric Nursing. (9th ed). St.Louis, Missouri:
Mosby Elesvier.
Vallerand, A.H., Sanoski, C.A. (2013). Davis’s Drug Guide for Nurses. (13th ed). Philadelphia,
PA: F.A. Davis Company
WebMD. (2013). Inflammatory Bowel Disease Health Center. Retrieved from:
http://www.webmd.com/ibd-crohns-disease/
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Appendix A
Table 1- Disease Processes
TEXTBOOK DESCRIPTION OF
DISEASE PROCESS
Diagnosis-
CLIENTS PRESENTATION OF DISEASE
PROCESS
Diagnosis-
Inflammatory Bowel Disease
Inflammatory bowel disease
Etiology/ PathophysiologyDisorder of the gastrointestinal tract,
characterized by idiopathic inflammation and
ulceration (Lewis et al, 2010).Causes remain
unknown, potential causes are infectious
agents, autoimmune responses, environmental
influences, or genetics (Lewis et al, 2010)
Clinical Signs and symptomsBloody, diarrhea and abdominal pain are the
major symptoms; other symptoms include
fever, fatigue, weight loss, anemia, and
dehydration.
EtiologyDad has irritable bowel syndrome
Clinical Signs and symptomsBloody diarrhea, abdominal pain, fever,
vomiting, mouth ulcers, abscesses, fatigue,
dehydration
Depression
Etiology/ Pathophysiology
EtiologyPsychiatric and medical illness. Significant
abnormalities can be seen in many body
Again, father had depression. Possible life
systems, including electrolyte imbalances,
events- this was not clarified
neuropsychological alterations, dysfunction or
faulty regulation of ANS activity,
adrenocortical, and thyroid changes, and
neurochemical alterations in neurotransmitters
(Stuart, 2009). Causes are unknown, can be life
events, genetics,, medical comorbidity etc.
MEDICAL/ SURGICAL CASE STUDY
Clinical signs and symptomsFeelings of sadness or unhappiness, feelings of
helplessness or worthlessness. Irritability,
anxiety, agitation, trouble thinking or slowed
thinking, indecisiveness, change in appetite,
etc. (Stuart, 2009).
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Clinical signs and symptomsAnxiety, fatigue and change in appetitealthough this was due to her medical condition.
Unhappiness and sadness, was partly due to
hospitalization and being sick, however could
be partly due to depression.
Table 2- Disease Processes continued
TEXTBOOK DESCRIPTION OF
DISEASE PROCESS
Diagnosis- Anxiety (Generalized)
CLIENTS PRESENTATION OF DISEASE
PROCESS
Diagnosis- Anxiety
Etiology/ PathophysiologyPsychiatric disorder involves excessive,
unrealistic worry and tension (Stuart, 2009).
May be caused by environmental factors,
medical factors, genetics, brain chemistry,
substance abuse or a combination of these
(Web MD, 2013).
EtiologyUnknown.
Clinical Signs and symptomsRestlessness, on edge, fatigue, difficulty
concentrating-mind going blank, ongoing
worry, muscle tension, irritability (Stuart,
2009).
Clinical Signs and symptomsWorry, restlessness, heart racing, trouble
breathing.
Could be from depression, could be genetics.
Seems to be worse while in hospital, could be
related to medical factors.
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Appendix B
Table 3- Short term care plan for L.W.
Nursing
Diagnosis
Diarrhea
Related To:
Etiology/Risk
Factors
Inflammation,
irritationInflammatory
Bowel Disease.
Defining (S/S)
Characteristics
Frequent and
persistent
watery stools.
Blood mixed
with diarrhea.
Abdominal
pain-urgency
and cramping
Desired Outcomes
(Goals)
L.W. will report
reduction in
frequency of stools,
return to more
normal stool
consistency.
Identify/avoid
contributing factors.
Interventions
1.Observe and
record stool
frequency,
characteristics,
amount, and
precipitating factors
Rationale for
Interventions
1.Helps differentiate
individual disease and
assesses severity
of episode.
2.Rest decreases
intestinal motility and
2.Promote bed rest,
reduces the metabolic
provide bedside
rate when infection or
commode.
hemorrhage is a
complication. Urge to
3.Identify foods and defecate may occur
fluids that precipitate without warning and
diarrhea, e.g., raw
be uncontrollable,
vegetables and fruits, increasing risk of
whole-grain cereals, incontinence/falls if
condiments,
facilities are not close
carbonated drinks,
at hand.
milk products
3.Avoiding intestinal
4.Restart oral fluid
irritants promotes
intake gradually.
intestinal rest.
Offer clear liquids
hourly; avoid cold
4. Provides colon rest
fluids.
by omitting or
decreasing the stimulus
5.Observe for fever, foods/fluids. Gradual
tachycardia,
resumption of liquids
lethargy,
may prevent cramping
leukocytosis,
and recurrence of
decreased serum
diarrhea; however,
protein, anxiety, and cold fluids can
prostration.
increase intestinal
motility.
5. identify toxic
Megacolon or
Perforation/peritonitis
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Appendix C
Table 4-Long term care plan for L.W
Nursing
Diagnosis
Pain- Acute
Related To:
Etiology/Risk
Factors
Hyperperistalsis
prolonged
diarrhea
skin/tissue
irritation,
perirectal
excoriation,
fissures and
fistulas
Mouth sores
(Inflammatory
Bowel disease)
Defining (S/S)
Characteristics
Colicky/cramping
- abdominal pain
Pt. states ‘gutwrenching pain’
8/10
Stinging, burning
pain in mouth
(sores), unable to
eat. 8/10
Desired
Outcomes
(Goals)
L.W. will report
pain is relieved
and controlled.
She will appear
relaxed and able
to sleep/rest
appropriately
Rationale for Interven
Interventions
1-Encourage L.W. to
report pain.
2. Utilize PRN’smorphine, Tylenol,
and antifungal mouth
rinses
3. Review factors that
aggravate or alleviate
pain.
Restlessness
Facial grimacingnon- verbal
expressions of
pain
4. Note nonverbal
cues, e.g., restlessness,
reluctance to move,
abdominal guarding,
withdrawal, and
depression.
Investigate
discrepancies between
verbal and nonverbal
cues
5. Provide comfort
measures (e.g., back
rub, reposition) and
diversional activities
6. Implement
prescribed dietary
modifications, e.g.,
commence with
liquids and increase to
solid foods as
tolerated.
1 she may try to tolerate
Pain, rather than request
Analgesics.
2.Control, relieve pain
3. May pinpoint
precipitating or
aggravating factors
(such as stressful events
,food intolerance) or
identify developing
complications.
4. Body language &
nonverbal cues
may be both
physiological and
psychological and
may be used in
conjunction with verbal
cues to determine
extent/severity
of the problem
5. Promotes relaxation,
refocuses attention, and
may enhance coping
abilities.
6. Complete bowel rest
can reduce pain and
cramping.
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Appendix D
Table 5- Community care plan for L.W.
Nursing
Diagnosis
Anxiety
Related To:
Etiology/Risk
Factors
Threat to selfconcept
(perceived or
actual)
Defining (S/S)
Characteristics
Desired Outcomes
(Goals)
Interventions
Exacerbation of
acute stage of
disease
L.W. will appear
relaxed and report
anxiety reduced to
a manageable
level.
1.Note behavioral clues,
e.g., restlessness,
irritability, withdrawal,
lack of eye contact,
demanding behavior.
L.W. will
verbalize
awareness of
feelings of anxiety
and healthy ways
to deal with them.
2.Encourage
verbalization of
feelings. Provide
feedback.
Increased
Threat to/change tension and
in health status, distress
socioeconomic
status, role
Heart racingfunctioning,
expressed
interaction
concerns about
patterns (new
her health and
diagnosis)
being in the
hospital/
Pain- abdominal changes (new
diagnosis)
History of
anxiety and
Increased pulse
depression
rate
Obsessing over
signs and
symptoms
3.Acknowledge that the
anxiety and problems
are similar to those
expressed by others.
Actively-Listen to L.W.
concerns.
4. Help L.W.
identify/initiate positive
coping behaviors used
in the past
5. Assist L.W. to learn
new coping
mechanisms, e.g., stress
management techniques
(deep breathing,
imagery, etc.).
Rationale for
Interventions
1.Indicators of degree
of anxiety/stress
2.Establishes a
therapeutic relationship
Assists L.W. in
identifying problems
causing stress.
3. Validation that
feelings are normal
can help reduce
stress/isolation
4. Successful
behaviors can be
fostered in dealing
with current problems/
enhancing L.W.’s
sense of self-control.
5.Learning new ways
To cope can be
helpful in reducing
stress and anxiety- and
enhancing
disease control; when
in the community
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