Mary Beavers, a 36-year-old white woman, is admitted to the emergency department complaining of diffuse abdominal pain rated as a 5 on a scale of 1 to 5. Mary is 1 week post cesarean section. She states that she is constipated and has had only one small bowel movement since discharge. She denies fever, chills, vomiting, urinary frequency or dysuria, and states vaginal discharge is normal. Vital signs on admission are: HR 114 bpm BP 110/70 mm Hg Respirations 28 breaths/min Temperature 98.7 o F orally Lab values: WBC 24,000 with 88% segs HBG 13.5 g/dl Amylase 75 U/L Lipase 302 U/L K 3.5 mmol /L Blood cultures are obtained. CT of the abdomen reveals the following: no evidence of obstruction or perforation, dermoid cyst in the right ovary with tooth embedded in area, and a markedly enlarged uterus with large amounts of fluid in the cul-de-sac. PMH includes gravida 4, para 4, three dilation and curettages (D&Cs), right knee ligament repair, and tonsillectomy. In the ED, she received D NS with 20 meq of potassium chloride at 250 cc/ hr times 1 liter, meperidine (Demerol) 100 mg IV and 5 ampicillin sodium ( Unasyn ) 3g/100 cc NS. She is admitted to the medical/surgical floor with a diagnosis of endometritis for possible D&C. Admission orders include: D NS at 125 cc/ hr , PCA morphine, and Unasyn 1.5 g IV q 6 hours. 5 Day 4 postadmission : WBCs are 20,000 and the patient has a temperature of 102oF. Mary is taken for an exploratory laparotomy that reveals diffuse peritonitis, lysed adhesions, and debrided fibrinous areas. An appendectomy is performed with placement of a Jackson-Pratt drain, nasogastric tube, and right subclavian triplelumen catheter. Mary compains of severe continuous postoperative pain, level 5 on a scale of 1 to 5 despite multiple doses of morphine sulfate. Mary is transferred to the intensive care unit. Vital sings on admission are: HR 114-145 bpm BP 80-110/35-70 mmHg Respirations 26-50 nreaths /min SaO 2 94-96% Temperature 95.7 o F - 96.7 o F Mary continues to complain of severe abdominal and back pain. The ICU nurse titrates morphine as ordered. The nurse also notes that Mary's right hand is very cold to the touch. Four hours after admission to the ICU Mary becomes unresponsive with no respirations and a code blue is called for respiratory arrest. MAry is intubated and placed on a ventilator; she is hypotensive with systolic blood pressure 50 mmHgper doppler . The midline anterior wall dressing is dry and intact. The JP drain contains 100 cc of dark blood and the right arm ermains cool to the touch with a palpable pulse. 1.What is your differential diagnosis? 2.What do you think caused this? 3.What test do you think need to be performed to confirm your diagnosis and what results would you expect? 4.What would your treatment be? 5.What would be appropriate nursing diagnoses and interventions?.

1. Mary Beavers, a 36-year-old white woman, is admitted to the emergency department complaining of diffuse abdominal pain
rated as a 5 on a scale of 1 to 5. Mary is 1 week post cesarean section. She states that she is constipated and has had only one
small bowel movement since discharge. She denies fever, chills, vomiting, urinary frequency or dysuria, and states vaginal
discharge is normal. Vital signs on admission are:
HR 114 bpm BP 110/70 mm Hg Respirations 28 breaths/min Temperature 98.7 o
F orally
Lab values: WBC 24,000 with 88% segs HBG 13.5 g/dl Amylase 75 U/L Lipase 302 U/L K 3.5 mmol /L
Blood cultures are obtained. CT of the abdomen reveals the following: no evidence of obstruction or perforation, dermoid cyst in
the right ovary with tooth embedded in area, and a markedly enlarged uterus with large amounts of fluid in the cul-de-sac.
PMH includes gravida 4, para 4, three dilation and curettages (D&Cs), right knee ligament repair, and tonsillectomy. In the ED,
she received D 5 NS with 20 meq of potassium chloride at 250 cc/ hr times 1 liter, meperidine (Demerol) 100 mg IV and
ampicillin sodium ( Unasyn ) 3g/100 cc NS. She is admitted to the medical/surgical floor with a diagnosis of endometritis for
possible D&C.
Admission orders include: D 5 NS at 125 cc/ hr , PCA morphine, and Unasyn 1.5 g IV q 6 hours.
Day 4 postadmission : WBCs are 20,000 and the patient has a temperature of 102oF. Mary is taken for an exploratory laparotomy
that reveals diffuse peritonitis, lysed adhesions, and debrided fibrinous areas. An appendectomy is performed with placement of a
Jackson-Pratt drain, nasogastric tube, and right subclavian triplelumen catheter. Mary compains of severe continuous
postoperative pain, level 5 on a scale of 1 to 5 despite multiple doses of morphine sulfate. Mary is transferred to the intensive
care unit. Vital sings on admission are:
HR 114-145 bpm BP 80-110/35-70 mmHg Respirations 26-50 nreaths /min SaO 2 94-96% Temperature 95.7 o
F - 96.7 o
F
Mary continues to complain of severe abdominal and back pain. The ICU nurse titrates morphine as ordered. The nurse also notes
that Mary's right hand is very cold to the touch. Four hours after admission to the ICU Mary becomes unresponsive with no
respirations and a code blue is called for respiratory arrest. MAry is intubated and placed on a ventilator; she is hypotensive with
systolic blood pressure 50 mmHgper doppler . The midline anterior wall dressing is dry and intact. The JP drain contains 100 cc
of dark blood and the right arm ermains cool to the touch with a palpable pulse.
1.What is your differential diagnosis?
2.What do you think caused this?
3.What test do you think need to be performed to confirm your diagnosis and what results would you expect?
4.What would your treatment be?
5.What would be appropriate nursing diagnoses and interventions?