| Course | NR 570 Common Diagnosis and Management in Acute Care Practicum |
|---|---|
| Week | 2 |
| Paper type | Case paper |
| Length | About 1,290 words, 5 pages |
| Format | APA 7 student paper |
| School | Chamberlain University |
| Program | MSN, Adult-Gerontology Acute Care NP (AGACNP) |
| Updated | October 2026 |
Free sample paper for NR 570 Week 2
Adhesive Small Bowel Obstruction Thirty-Five Years After a Hysterectomy: A Case Paper on Nonoperative Management in a 74-Year-Old Who Walked a Mile Each Morning
Student Name
College of Nursing, Chamberlain University
NR 570: Common Diagnosis and Management in Acute Care Practicum
Instructor Name
Month Day, Year
Adhesive Small Bowel Obstruction Thirty-Five Years After a Hysterectomy: A Case Paper on Nonoperative Management in a 74-Year-Old Who Walked a Mile Each Morning
The Person Before the Condition
This case describes a composite patient, assembled from admissions I took part in on the hospital medicine service this term. The patient is 74, a retired postal carrier who lives alone in a second-floor apartment. Two weeks before this illness the patient walked about a mile most mornings, drove to church and the grocery store and filled a weekly pillbox without help. A neighbor checks in most evenings.
The medical history includes hypertension treated with lisinopril 20 mg daily, type 2 diabetes on metformin 500 mg twice a day with a last A1c of 7.1%, and osteoarthritis of both knees, for which the patient takes ibuprofen 400 mg on most days. Surgical history matters more than usual here: an appendectomy at 19 and an open hysterectomy through a lower midline incision at 39, thirty-five years ago. There has been no abdominal surgery since.
What Brought the Patient In
Crampy pain around the navel began about 30 hours before arrival and came in waves every few minutes. Vomiting started that evening, six times overnight, green by morning. The patient last passed stool 36 hours before arrival and had not passed gas for about 20 hours. There was no blood in the vomit, no fever at home and no new medicine.
Findings as They Were Found
In the emergency department the temperature was 37.4 C, pulse 104, pressure 148/86, respirations 18 and saturation 96% on room air. The abdomen was distended and drum-like to tapping, with high-pitched rushes on listening. Tenderness was mild and spread across the middle of the abdomen, without guarding, rebound or rigidity. The lower midline scar was healed. I looked for a hernia at the navel and both groins and in the scar itself and found none, which mattered because a trapped hernia would change the plan. A rectal examination found an empty vault without blood.
Blood work showed a white count of 11.2, hemoglobin 14.6, sodium 134, potassium 3.3, chloride 94 and bicarbonate 29, a pattern fitting fluid and acid lost through vomiting. Urea nitrogen was 31 and creatinine 1.6, against a baseline of 1.0 from a clinic visit in the spring. Glucose was 188. Lactate was not drawn in the emergency department; I added it at 22:00, five hours after arrival, and it was 1.4.
CT of the abdomen and pelvis was done with intravenous contrast after the radiologist and the emergency physician weighed the creatinine against the need to see the bowel wall. It showed dilated small bowel loops up to 3.6 cm, a transition point in the right lower abdomen near the old appendectomy site, collapsed bowel beyond it and normal enhancement of the bowel wall. A small amount of fluid lay between loops. There was no free air and no gas in the bowel wall. At the lung bases, a 7 mm solid nodule sat in the right lower lobe.
Assessment
This is an adhesive small bowel obstruction, most likely from bands related to the old appendectomy or hysterectomy, without signs of strangulation at presentation. Alongside it sit an acute kidney injury from volume loss, compounded by daily ibuprofen and lisinopril, low potassium and a contraction alkalosis from vomiting, and diabetes that will need a new plan while the patient cannot eat. The lung nodule is incidental and not part of this admission's problem, but it needs an owner.
Management
Management is where most of this paper's length belongs, and each element is written with the reason it fits this patient.
1. Nothing by mouth and decompression through a nasogastric tube to low intermittent suction. The guideline for adhesive obstruction names these, with intravenous fluids and electrolytes, as the principles of nonoperative care, and states that most patients improve without an operation (ten Broek et al., 2018). The tube drained 1,100 mL in the first six hours, which confirmed that the stomach and upper bowel were holding a large volume.
2. Intravenous fluid as lactated Ringer's, a liter over an hour and then a maintenance rate adjusted to the tube output. I chose a balanced solution over saline because the patient already had a chloride-losing alkalosis and kidney injury; in a large trial in adults outside intensive care, balanced fluids led to fewer major kidney events than saline (Self et al., 2018), although the patients in that trial were mostly not vomiting and the difference was small.
3. Potassium replacement through the vein, with a recheck six hours later, because a low potassium slows the bowel further and the tube was removing more.
4. Lisinopril, metformin and ibuprofen held. The first and third were contributing to the kidney injury; metformin was held because the kidney was struggling, the patient had received contrast and would not be eating.
5. Glucose checked every six hours with a correction scale of short-acting insulin, because the patient's usual drug was held and the stress of illness had raised the glucose to 188.
6. A water-soluble contrast challenge: 100 mL of diatrizoate through the tube after two hours of decompression, with the tube clamped for an hour and a plain film at eight hours. A meta-analysis found that contrast reaching the colon predicted resolution without surgery with 92% sensitivity and 93% specificity, and that giving it reduced both the need for an operation and the length of stay (Ceresoli et al., 2016).
7. A surgical consultation on the night of admission, so the surgeon knew the patient before any decision had to be made and could examine the abdomen alongside us.
8. Heparin under the skin for clot prevention, since the patient would be in bed with dehydration and had no bleeding risk on the blood work.
9. Pain relief with small doses of intravenous hydromorphone, kept to the lowest effective amount because opioids slow an already stalled bowel.
10. Walking the hallway three times a day with the tube clamped for the walk, and a physical therapy referral, because a patient who walked a mile a day should not leave the hospital needing a walker. Covinsky et al. (2003) found that about one in three older adults admitted to medical services left with less daily function than they had two weeks before admission.
The Course
At 02:10 on the first night the pressure rose to 194/100 with worsening pain; the tube had stopped draining, and flushing it brought out 400 mL with relief. On day 2 the contrast challenge was given at 06:00, and the eight-hour film showed contrast in the right colon. The patient passed gas that evening. The tube came out on the morning of day 3, clear liquids were tolerated and a soft diet followed on day 4. Creatinine fell from 1.6 to 1.3 and then to 1.1. The patient walked the full hallway without help on day 4 and went home that afternoon.
What Was Still Open
Three things were unresolved at discharge. The lung nodule needed a follow-up CT on a schedule matched to the patient's former smoking, and someone had to own it. The kidney value needed a recheck before metformin and lisinopril returned at full doses. And the patient's knee pain needed a plan that did not involve daily ibuprofen. The paper does not claim that this obstruction will not return; adhesions remain, and the patient was told which symptoms should bring a call.
References
Ceresoli, M., Coccolini, F., Catena, F., Montori, G., Di Saverio, S., Sartelli, M., & Ansaloni, L. (2016). Water-soluble contrast agent in adhesive small bowel obstruction: A systematic review and meta-analysis of diagnostic and therapeutic value. American Journal of Surgery, 211(6), 1114-1125. https://doi.org/10.1016/j.amjsurg.2015.06.012
Covinsky, K. E., Palmer, R. M., Fortinsky, R. H., Counsell, S. R., Stewart, A. L., Kresevic, D., Burant, C. J., & Landefeld, C. S. (2003). Loss of independence in activities of daily living in older adults hospitalized with medical illnesses: Increased vulnerability with age. Journal of the American Geriatrics Society, 51(4), 451-458. https://doi.org/10.1046/j.1532-5415.2003.51152.x
Self, W. H., Semler, M. W., Wanderer, J. P., Wang, L., Byrne, D. W., Collins, S. P., Slovis, C. M., Lindsell, C. J., Ehrenfeld, J. M., Siew, E. D., Shaw, A. D., Bernard, G. R., & Rice, T. W. (2018). Balanced crystalloids versus saline in noncritically ill adults. New England Journal of Medicine, 378(9), 819-828. https://doi.org/10.1056/NEJMoa1711586
ten Broek, R. P. G., Krielen, P., Di Saverio, S., Coccolini, F., Biffl, W. L., Ansaloni, L., Velmahos, G. C., Sartelli, M., Fraga, G. P., Kelly, M. D., Moore, F. A., Peitzman, A. B., Leppaniemi, A., Moore, E. E., Jeekel, J., Kluger, Y., Sugrue, M., Balogh, Z. J., Bendinelli, C., . . . van Goor, H. (2018). Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2017 update of the evidence-based guidelines from the World Society of Emergency Surgery ASBO working group. World Journal of Emergency Surgery, 13, Article 24. https://doi.org/10.1186/s13017-018-0185-2
The Chamberlain NR 570 Week 2 instructions
The Week 2 case paper usually asks you to present one patient with a common acute care condition and to show how management was tailored to that person. Expect a long paper in many sections, written as prose under headings rather than as a chart note. The opening should establish who the patient was before the illness, including age, baseline function and existing treatment. Findings follow in the order they were found. Management carries most of the length, and each element needs a reason tied to this patient rather than to the condition in general. Most prompts end by asking what remained unresolved at discharge, and nearly all expect current published sources.
How the NR 570 Week 2 example is put together
This sample starts with a retired postal carrier who lived alone, walked daily and filled a pillbox, then lists the conditions, medicines and decades-old operations that explain the diagnosis. The presentation comes next, followed by examination and results in the order they arrived, including a hernia search and a late lactate. A short assessment groups the obstruction with kidney injury, low potassium and diabetes. Management runs to ten numbered items, from decompression and a balanced fluid to a contrast challenge, an early surgical consult and hallway walking, each with a clause explaining why. The course covers an overnight pressure rise and recovery. The final section names three open items.
Reading the NR 570 Week 2 grading rubric
The heaviest marks in this paper go to management that fits the person, so the sample attaches a reason to every element. A paper that could describe anyone with this diagnosis loses ground early, because the person has no age, baseline or home; this one establishes all three in the first section. Findings reported as they were found, with the negatives that were sought, satisfy the findings criterion. Sources need to do work, as when the meta-analysis on contrast changes the plan rather than decorating it. The closing criterion rewards an honest account of what was unresolved. References count for less individually but add up across the paper. Margin notes on the sample show where each of these rows is earned.
NR 570 Week 2 help from the desk
The weakest NR 570 Week 2 papers describe the textbook condition with a generic patient attached. Others list correct management steps with no reason for any of them, which scores as knowledge rather than practice. Findings are often summarized as normal without saying what was examined. Many papers stop at the point the patient improved and never mention what was left open. Long background sections on pathophysiology crowd out management. If your rotation case is a different condition, send the history, findings and plan you have; a case paper can be built around your patient, giving each management element a reason that belongs to that person. Keep the history to what the plan needs.
Get a NR 570 Week 2 example written to your instructions
Give the desk the assignment, the rubric rows, the page count and your reference style, plus a couple of sentences sketching the case. A custom case paper built around a constructed patient who matches that shape comes back inside 24-48h, free the first time, revisions included.
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NR 570 Week 2 questions, answered
My case is completely routine. Is that a problem?
It is the assignment. This week wants a presentation your service meets constantly, and the marks come from how completely an unremarkable episode is documented rather than from how unusual it was. A rare case often scores worse here, because the rubric rows are written for something with an accepted management pattern behind it and a rarity has none.
How long should the paper be?
Sections differ, and ten to fifteen pages is common for a full case paper at this level, with management taking the largest share. Send the page or word count with your request. Length decides proportion here, so an example written long turns into a different document: the history swells and the management block, which carries the rows, gets squeezed.
Do I have to name a published source in Week 2?
Most sections expect them well before the concordance assignment arrives, so a finished example cites current recommendations for the condition and gives the issuing body with the year. If your classroom specifies a source, that one leads and the others sit around it. Nothing in a sample is clinical advice or written for use with a patient.
Where can I find a free NR 570 Week 2 sample paper?
This page carries the full case paper on adhesive small bowel obstruction, with ten management elements and the reasons attached to each, plus margin notes.
Why does the NR 570 Week 2 case paper use a contrast challenge?
A meta-analysis found that water-soluble contrast reaching the colon predicts resolution without surgery and shortens the stay, so it serves as both a test and a treatment.