Chief Complaint CC/History of Present Illness:
Mrs. Morris is a 66-year-old woman who has been complaining of nausea, vomiting, weakness, abdominal pain and abdominal fullness for the past 3 days. She has had a fever for the last 24 hours and reports that her mid-abdominal pain is colicky and “crampy”. She states her “Crohn’s” has been acting up for the past 4 weeks with diarrhea, anorexia, extreme fatigue and weight loss. She is 65 inches tall and weighs 65 kg with a usual weight of 75 kg. Mrs. Morris was admitted to the Med/Surg unit with a complete small bowel obstruction, multiple adhesions, and exacerbation of Crohn’s disease. She is NPO and an exploratory lap is scheduled with lysis of adhesions and small bowel resection to remove diseased bowel. Mrs. Morris will be NPO postoperatively and it is expected that her GI tract will not be accessible for at least 10-14 days.

Social and Past Medical History:
Mrs. Morris currently lives alone in a senior living apartment. Her husband died of pancreatic cancer 2 months ago and they had no children. She has had Crohn’s disease since she was 37 years old and was diagnosed with diabetes type 2, five years ago.

Your Initial Nursing Assessment:
GENERAL APPEARANCE: anxious, appears weak and pale
SKIN/INTEG: skin dry, tenting noted, eyes sunken
RESP: breath sounds clear with equal aeration bilaterally, non-labored
CARDIAC: skin pale, warm & dry, S1S2, no edema, pulses 2+ in all extremities
NEURO: alert & oriented x4,
GI/GU: abdomen firm and distended. Absent bowel sounds, has not voided yet
MISC: complains of crampy, colicky abdominal pain in RLQ, 8/10, nausea and vomiting

Initial Vital Signs:
T: 100.8 F
P: 110
R: 22
BP: 100/60
O2 sats: 98%

Lab/diagnostic Results:
CBC Current High/Low/WNL?
WBC 15000
HGB 9 g/dL
Basic Metabolic panel Current High/Low/ WNL?
Sodium 146
Potassium 3.3
Glucose 165
Albumin 2.9 g/dL
Prealbumin 5 mg
Transferrin 104 mg/dL
BUN 7
Creatinine 1.2

1. What data is RELEVANT and must be recognized by the nurse as clinically significant to the need for nutritional support in Mrs. Morris?
2. Describe the difference between Peripheral Parenteral Nutrition and Total Parenteral Nutrition.
3. Describe the types of parenteral nutrition solutions.
4. Describe the purpose of the components of Parenteral Nutrition.
5. Calculate the total 24 hour caloric content of the Dextrose, Amino Acids and IVFE (Lipids) for Mrs. Morris.
6. Define central venous catheter therapy
7. Is a PICC line a central venous catheter? And if so, why?
8. List the 5 key components of the Institute for Healthcare Improvement (IHI) central line bundle that must be implemented regarding the central venous catheter (CVC).
9. Related to Mrs. Morris’s TPN and CVC therapy, what nursing priority (s) will guide your plan of care? (these nursing priorities may or may not be written as NANDA diagnostic statements)
10. What interventions will you initiate based on the nursing priority (s) identified in # 9?
11. What body systems will you focus on based on Mrs. Morris’s TPN therapy and your nursing priority (s)?12. Mrs. Morris is at risk for complications due to the administration of TPN.
a. What are the worst possible complications to anticipate with TPN administration and CVC management?
b. What signs/symptoms should the nurse anticipate to identify the development of this complication? What relevant nursing action will need to be implemented for this complication?
13. What is Mrs. Morris likely experiencing or feeling right now in her situation?
14. What can you do to engage yourself with Mrs. Morris’s experience and show her that she matters to you as a person?