[Answered]: Mary Cole, a 50-year-old female with a known…

Mary Cole, a 50-year-old female with a known history of ulcerative colitis (UC) and anemia, was driven to the emergency department (ED) by her daughter, Cindy just after 1000. The reason for her visit was due to complaints of severe abdominal pain/swelling and bloody diarrhea over the past four days. Vital signs were taken in the ED showing a BP of 96/50, HR 113 bpm, Respiration of 29, tympanic temperature of 38.9°C, O2 sat. of 97% on room air, and a pain of 9/10 (using the verbal numeric pain scale) located in her left lower abdominal quadrant that is sharp, constant, and aggravated by movement. Mary states, “my stomach hurts so much I can barely take the pain”. She claims that she has been taking extra-strength Advil (ibuprofen 400mg) for the pain. Her vitals were reassessed after 20 minutes showing a decrease in BP to 85/47, HR 130, RR 29, tympanic temperature of 38.9°C, O2 sat. 96%, and pain still at 9/10. Upon further assessment, Mrs. Cole appeared uncomfortable and was quietly crying and lying on her left side with her knees flexed and arms holding her abdomen. She was alert and oriented to person, place, time, and situation and was demonstrating appropriate responses and PERRLA. Her face was flushed, and her skin felt warm and dry to touch. There was slight skin tenting at her clavicle and she admitted to not being able to “eat or drink very much over the past few days” due to her abdominal pain and discomfort. She claims to have been having diarrhea that “looks kind of bloody” and hasn’t been voiding as often as she “normally does”, approximately twice a day over these past few days. Her abdomen is visibly distended and tender/firm upon palpation. Upon auscultation, she has hypoactive bowel sounds in all four quadrants and her pain is noted to be in the left lower quadrant. She is tachycardic and has a clear S1S2 heartbeat with diminished pedal pulses; tachypnea is noted, lung sounds are clear in all lobes. Her strengths in both upper and lower extremities are slightly weak and her daughter states that her mother has been “dizzy when getting up and has difficulty walking at times”. Mary’s labs revealed the following: elevated C-reactive protein of 16, positive antineutrophil cytoplasmic antibodies (ANCA), Hgb: 7.8, Hct: 23%, Platelets: 100,000, WBC: 13000, potassium: 3.3, sodium: 128, pH: 7.26, HCO3: 18, CO2: 31, lactic acid of 3.8, and the stool showed presence of blood and WBCs. Mary’s abdominal CT revealed colonic dilation of more than 6 cm in the transverse colon. Once results were in from the labs, x-ray, and CT scan, Mary was diagnosed with toxic megacolon resulting from a flare-up of UC and sent to the intensive care unit (ICU) for close observation and monitoring. Using the assessment information, identify the additional medical diagnoses (besides toxic megacolon) for this client. What is the significance of the lactic acid elevation in the labs? What signs and symptoms would the nurse be monitoring for shock? What are the priority nursing diagnoses for this client? What are three independent nursing interventions that you will implement for this client based on the nursing diagnoses. How will you evaluate whether desired outcomes are achieved?