Department 14 · 25 scenarios

Gastroenterology & Hepatology

See the risk. Understand the response.
Practise the reasoning you will carry to the bedside.

Plain English Primary sources Students & tutors

From routine safety to critical change

Learn the reasoning. Follow your local clinical pathway. These are fictional teaching cases, not patient-specific treatment instructions. Adult, pregnancy, pediatric and neonatal responses differ. Use the population-specific pathway and verified weight where required. Use current facility protocols, authorized orders and your scope of practice. Students work under supervision. In a real emergency, activate clinical help rather than consult this page.

How to use these cases Read the cues before opening the actions. Name your first priority, then compare your reasoning. The difficulty describes learning complexity; even an introductory case can involve a serious risk.

5 introductory5 intermediate5 difficult10 extremely difficult

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Learning complexity

25 of 25 scenarios

Open a scenario to explore its actions25 original cases

Stoma & hydration

The new stoma appliance leaks onto skin

Introductory

The situation

A patient with a new stoma has repeated appliance leakage and sore surrounding skin. They think soreness is unavoidable.

What should catch your attention

Leakage
Skin injury
New self-care skill

Your immediate priority

Arrange stoma-nurse review of fit and teach the approved skin/appliance routine.

01Leakage
02Arrange stoma-nurse review of fit and teach the approved skin/appliance routine.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Arrange stoma-nurse review of fit and teach the approved skin/appliance routine. [1]
Why it matters Output or colour changes can indicate skin, fluid or surgical problems.
2
Examine the change
Assess output amount and character, stoma appearance, surrounding skin, pain, intake and urine. [1]
Why it matters Output or colour changes can indicate skin, fluid or surgical problems.
3
Use specialist support
Involve the stoma nurse or surgical team for concerning tissue, obstruction symptoms, leakage or high output. [1]
Why it matters Different stomas and complications require different management.
4
Review the response
Deliver the prescribed appliance, hydration and medicine plan and teach the patient how to recognize warning changes. [1]
Why it matters Effective self-care requires understanding both routine care and when to seek help.

What to look for next

Track skin healing and leakage. Track output, urine, skin and clinical response, and escalate worsening pain, ischemic appearance or dehydration.

Avoid this shortcut

Do not normalize preventable ongoing skin damage. Do not irrigate a stoma, insert an object or give antidiarrheals independently in a possible obstruction.

A clear way to hand it over

“I am calling about this new concern: the new stoma appliance leaks onto skin. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English A stoma is a surgically created opening; an ileostomy drains small-bowel contents and can cause substantial fluid loss.

Sources behind the actions 2 primary references

NIDDK · Complications of ostomy surgery
Skin, tissue, obstruction and dehydration concerns requiring clinical review.
NICE · CG174: Intravenous fluid therapy in adults
Individual fluid assessment and repeated review of response and comorbid risks.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

© 2026 RN Clarity · Lumiere Labs. All rights reserved. Original scenarios and diagrams are for personal learning. Do not copy, screenshot, print, repost, sell or reproduce them without written permission, except where applicable law permits. Cited guidance belongs to its respective owners.

Stoma & hydration

An output chart omits overnight stoma losses

Introductory

The situation

A patient with an ileostomy has large overnight output that was not measured. They are thirsty and urine is darker.

What should catch your attention

Incomplete output
Possible fluid loss
Hydration cues

Your immediate priority

Measure ongoing output and request review of hydration and the individual replacement plan.

01Incomplete output
02Measure ongoing output and request review of hydration and the individual replacement plan.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Measure ongoing output and request review of hydration and the individual replacement plan. [1]
Why it matters Output or colour changes can indicate skin, fluid or surgical problems.
2
Examine the change
Assess output amount and character, stoma appearance, surrounding skin, pain, intake and urine. [1]
Why it matters Output or colour changes can indicate skin, fluid or surgical problems.
3
Use specialist support
Involve the stoma nurse or surgical team for concerning tissue, obstruction symptoms, leakage or high output. [1]
Why it matters Different stomas and complications require different management.
4
Review the response
Deliver the prescribed appliance, hydration and medicine plan and teach the patient how to recognize warning changes. [1]
Why it matters Effective self-care requires understanding both routine care and when to seek help.

What to look for next

Track urine and prescribed electrolytes. Track output, urine, skin and clinical response, and escalate worsening pain, ischemic appearance or dehydration.

Avoid this shortcut

Do not equate an incomplete chart with low output. Do not irrigate a stoma, insert an object or give antidiarrheals independently in a possible obstruction.

A clear way to hand it over

“I am calling about this new concern: an output chart omits overnight stoma losses. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English A stoma is a surgically created opening; an ileostomy drains small-bowel contents and can cause substantial fluid loss.

Sources behind the actions 2 primary references

NIDDK · Complications of ostomy surgery
Skin, tissue, obstruction and dehydration concerns requiring clinical review.
NICE · CG174: Intravenous fluid therapy in adults
Individual fluid assessment and repeated review of response and comorbid risks.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Enteral tube safety

The feeding-tube mark has changed

Introductory

The situation

Before a planned feed, the RN sees a different external tube length after vomiting. The previous placement check does not verify the current position.

What should catch your attention

Possible tube migration
Vomiting
Feed pending

Your immediate priority

Hold unsafe tube use and arrange approved placement reassessment.

01Possible tube migration
02Hold unsafe tube use and arrange approved placement reassessment.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Hold unsafe tube use and arrange approved placement reassessment. [1]
Why it matters A feeding tube can be misplaced or migrate, and symptoms may be subtle.
2
Pause uncertain use
Stop use when placement or tolerance is in doubt; assess respiratory and abdominal symptoms. [1]
Why it matters A feeding tube can be misplaced or migrate, and symptoms may be subtle.
3
Verify by the approved method
Use the facility’s validated placement-confirmation pathway, trained interpretation and documentation; obtain specialist review if uncertain. [1]
Why it matters Air-injection sounds and tube appearance cannot reliably prove safe gastric placement.
4
Follow the nutrition plan
Restart only after confirmation and an authorized feeding or medication plan; check positioning, interactions and monitoring. [1]
Why it matters Correct placement does not remove aspiration, blockage or formulation risks.

What to look for next

Document verified clearance before use. Recheck after relevant displacement events and monitor tolerance, hydration and respiratory changes according to policy.

Avoid this shortcut

Do not confirm location by a whoosh test. Do not use a whoosh test as confirmation, give crushed modified-release medicines or force a blocked tube.

A clear way to hand it over

“I am calling about this new concern: the feeding-tube mark has changed. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Enteral means nutrition or medicine is delivered into the gastrointestinal tract.

Sources behind the actions 2 primary references

NHS England · Enduring nasogastric-tube placement safety standards
Validated placement checks; no whoosh test or unverified feeding/medicine delivery.
NICE · CG32: Nutrition support for adults
Nutrition assessment, refeeding risk, individualized support and monitoring.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Communication & discharge

The patient misunderstands a bowel-preparation instruction

Introductory

The situation

A patient uses much less prescribed bowel preparation because the instructions were not understood in their preferred language.

What should catch your attention

Language barrier
Preparation altered
Procedure pending

Your immediate priority

Use language assistance to clarify what was actually taken and notify the endoscopy team for a safe revised plan.

01Language barrier
02Use language assistance to clarify what was actually taken and notify the endoscopy team for a safe revised plan.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Use language assistance to clarify what was actually taken and notify the endoscopy team for a safe revised plan. [1]
Why it matters Agreement or a smile does not demonstrate understanding of a treatment plan.
2
Make the explanation accessible
Ask the person’s preferred language and communication needs. Use a qualified interpreter for clinical decisions when needed. [1]
Why it matters Agreement or a smile does not demonstrate understanding of a treatment plan.
3
Use a small teach-back
Explain one important step in plain language and ask the person to show or describe it in their own words. [1]
Why it matters This tests how clearly we explained the task without making the person feel examined.
4
Repair the gap
Rephrase, demonstrate and repeat the check. Provide an accessible written plan and a named contact for problems. [1]
Why it matters A usable plan supports safer decisions after the nurse is no longer beside the patient.

What to look for next

Confirm the new instructions by teach-back. Confirm the person can identify the next step and warning signs. Resolve missing equipment, support or follow-up before an unsafe discharge proceeds.

Avoid this shortcut

Do not independently repeat the full preparation. Do not rely on children to interpret or label a person noncompliant because of a language barrier.

A clear way to hand it over

“I am calling about this new concern: the patient misunderstands a bowel-preparation instruction. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Teach-back asks the person to explain the plan so staff can check their explanation.

Sources behind the actions 2 primary references

AHRQ · Teach-back: patient and family engagement
Check the clarity of an explanation by asking patients to describe the plan in their own words.
US HHS Office of Minority Health · National CLAS Standards: communication and language assistance
Competent language assistance; avoid using untrained people or children as interpreters.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Bowel function & comfort

Abdominal discomfort after opioid treatment

Introductory

The situation

A patient on opioids has new hard stools and discomfort. Their bowel history, intake and prevention plan are incomplete.

What should catch your attention

Medication factor
New constipation
Assessment needed

Your immediate priority

Review the prescribed bowel plan while checking for vomiting, inability to pass gas or severe continuous pain.

01Medication factor
02Review the prescribed bowel plan while checking for vomiting, inability to pass gas or severe continuous pain.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Review the prescribed bowel plan while checking for vomiting, inability to pass gas or severe continuous pain. [1]
Why it matters Overflow stool can coexist with impaction, and a changed pattern needs assessment.
2
Check the pattern
Review stool frequency and consistency, pain, intake, mobility and medicines; assess abdomen and observations within competence. [1]
Why it matters Overflow stool can coexist with impaction, and a changed pattern needs assessment.
3
Identify urgent concerns
Escalate severe pain, vomiting, distension, blood or physiological decline before routine bowel treatment. [1]
Why it matters Obstruction or serious illness needs a different plan from uncomplicated constipation.
4
Follow the bowel plan
Use prescribed bowel measures, appropriate hydration and supported toileting; document response and request review if ineffective. [1]
Why it matters An individualized routine and medication review address contributing causes.

What to look for next

Track response and warning changes. Review stool, comfort and abdominal change. Persistent symptoms or new red flags need prompt reassessment.

Avoid this shortcut

Do not blindly escalate laxatives. Do not repeatedly give laxatives or enemas when obstruction is suspected.

A clear way to hand it over

“I am calling about this new concern: abdominal discomfort after opioid treatment. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Impaction is a large retained stool mass; overflow is liquid stool leaking around it.

Sources behind the actions 2 primary references

NIDDK · Constipation: symptoms and causes
Constipation history and warning symptoms requiring prompt assessment.
NICE · CG50: Recognising and responding to inpatient deterioration
Escalate using both physiological changes and clinical concern; emergencies bypass a routine graded response.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Stoma & hydration

High ileostomy output causes dizziness

Intermediate

The situation

A patient has increased watery ileostomy output, dizziness and reduced urine. The apparent improvement in abdominal pain masks increasing fluid loss.

What should catch your attention

High output
Postural symptoms
Low urine

Your immediate priority

Seek prompt hydration, electrolyte and stoma/surgical review with the measured output.

01High output
02Seek prompt hydration, electrolyte and stoma/surgical review with the measured output.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Seek prompt hydration, electrolyte and stoma/surgical review with the measured output. [1]
Why it matters Output or colour changes can indicate skin, fluid or surgical problems.
2
Examine the change
Assess output amount and character, stoma appearance, surrounding skin, pain, intake and urine. [1]
Why it matters Output or colour changes can indicate skin, fluid or surgical problems.
3
Use specialist support
Involve the stoma nurse or surgical team for concerning tissue, obstruction symptoms, leakage or high output. [1]
Why it matters Different stomas and complications require different management.
4
Review the response
Deliver the prescribed appliance, hydration and medicine plan and teach the patient how to recognize warning changes. [1]
Why it matters Effective self-care requires understanding both routine care and when to seek help.

What to look for next

Track perfusion and renal trends. Track output, urine, skin and clinical response, and escalate worsening pain, ischemic appearance or dehydration.

Avoid this shortcut

Do not recommend unlimited plain water as a universal replacement plan. Do not irrigate a stoma, insert an object or give antidiarrheals independently in a possible obstruction.

A clear way to hand it over

“I am calling about this new concern: high ileostomy output causes dizziness. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English A stoma is a surgically created opening; an ileostomy drains small-bowel contents and can cause substantial fluid loss.

Sources behind the actions 2 primary references

NIDDK · Complications of ostomy surgery
Skin, tissue, obstruction and dehydration concerns requiring clinical review.
NICE · CG174: Intravenous fluid therapy in adults
Individual fluid assessment and repeated review of response and comorbid risks.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Upper gastrointestinal bleeding

Black stool is new after an admission

Intermediate

The situation

A patient passes new black sticky stool and feels weak. They have antithrombotic exposure; prescribed iron could also alter stool colour.

What should catch your attention

New stool pattern
Weakness
Bleeding risk

Your immediate priority

Report promptly, assess circulation and prepare the ordered bleeding evaluation.

01New stool pattern
02Report promptly, assess circulation and prepare the ordered bleeding evaluation.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Report promptly, assess circulation and prepare the ordered bleeding evaluation. [1]
Why it matters Visible signs and physiological trends help identify potentially serious loss.
2
Recognize and assess
Report hematemesis, new black sticky stool, weakness and perfusion changes with medicine and liver history. [1]
Why it matters Visible signs and physiological trends help identify potentially serious loss.
3
Activate the appropriate response
Call urgent GI/medical review and emergency bleeding support for instability; protect the airway when alertness falls. [1]
Why it matters Significant loss can threaten circulation and airway before a later blood count returns.
4
Prepare prescribed definitive care
Assist ordered blood tests, products, specialist reversal decisions and endoscopic assessment after appropriate stabilization. [1]
Why it matters Resuscitation and control of the bleeding source must be coordinated.

What to look for next

Track stool and physiological trends. Track bleeding, consciousness, circulation and response to treatment and promptly escalate ongoing loss.

Avoid this shortcut

Do not dismiss possible bleeding solely because iron is prescribed. Do not assume iron explains every black stool or independently select antithrombotic reversal.

A clear way to hand it over

“I am calling about this new concern: black stool is new after an admission. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Hematemesis means vomiting blood; melena describes black tarry stool from digested blood.

Sources behind the actions 2 primary references

NICE · CG141: Acute upper gastrointestinal bleeding—recommendations
Resuscitation, appropriate blood products, specialist reversal decisions and endoscopy after resuscitation in severe unstable bleeding.
NICE · NG24: Blood transfusion (updated February 2026)
General blood-product decisions, compatibility and patient monitoring; major bleeding follows a separate emergency pathway.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Acute abdominal deterioration

Vomiting and abdominal distension with little output

Intermediate

The situation

A postoperative patient has increasing distension, vomiting and little bowel or stoma output. They request a laxative.

What should catch your attention

Obstruction/ileus concern
Vomiting
Reduced output

Your immediate priority

Seek surgical review and clarify safe intake and decompression/medicine orders.

01Obstruction/ileus concern
02Seek surgical review and clarify safe intake and decompression/medicine orders.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Seek surgical review and clarify safe intake and decompression/medicine orders. [1]
Why it matters New patterns can signal obstruction, infection, ischemia or a postoperative complication.
2
Check the pattern
Assess pain onset and change, distension, vomiting, bowel output, wound/drain findings and vital signs. [1]
Why it matters New patterns can signal obstruction, infection, ischemia or a postoperative complication.
3
Escalate the warning cues
Seek urgent surgical or medical review for severe progressive pain, shock, persistent vomiting or peritoneal concerns. [1]
Why it matters Some abdominal emergencies need time-sensitive definitive treatment.
4
Support the prescribed plan
Prepare ordered imaging, tests, fluid and symptom management; clarify safe oral intake and medicine routes. [1]
Why it matters Treatment and intake depend on the suspected cause and aspiration or procedure risk.

What to look for next

Monitor pain, hydration and perfusion. Track pain, perfusion, urine, vomiting and abdominal findings during treatment and diagnostic waits.

Avoid this shortcut

Do not give a laxative or enema automatically. Do not give an enema, laxative or oral load automatically in a suspected obstruction or dismiss severe pain because an earlier test was normal.

A clear way to hand it over

“I am calling about this new concern: vomiting and abdominal distension with little output. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Ischemia means inadequate blood flow; a peritoneal concern involves irritation of the lining inside the abdomen.

Sources behind the actions 2 primary references

NIDDK · Abdominal adhesions and obstruction
Obstruction symptoms, severe complications and urgent clinical assessment.
NICE · CG50: Recognising and responding to inpatient deterioration
Escalate using both physiological changes and clinical concern; emergencies bypass a routine graded response.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Cirrhosis & acute change

Confusion in a patient with cirrhosis

Intermediate

The situation

A usually orientated patient with cirrhosis becomes confused. They recently had constipation, a medicine change and poor intake.

What should catch your attention

Acute mental change
Several precipitants
Liver disease

Your immediate priority

Assess competing causes and request medical review rather than assuming one explanation.

01Acute mental change
02Assess competing causes and request medical review rather than assuming one explanation.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Assess competing causes and request medical review rather than assuming one explanation. [1]
Why it matters Infection, bleeding, kidney injury and medicine effects can precipitate serious deterioration.
2
Identify the change
Compare consciousness, abdominal symptoms, bleeding, intake, medicines, circulation and urine with baseline. [1]
Why it matters Infection, bleeding, kidney injury and medicine effects can precipitate serious deterioration.
3
Seek prompt review
Escalate confusion, shock, new abdominal pain or worsening renal findings and prepare prescribed assessment. [1]
Why it matters A known liver diagnosis does not safely explain every new symptom.
4
Monitor the ordered treatment
Deliver the authorized cause-specific plan and track fluid, neurological and laboratory response. [1]
Why it matters Treatment needs reassessment because both illness and therapy can change organ function.

What to look for next

Track cognition and the cause-specific response. Track consciousness, perfusion, urine and the response to the identified precipitant and escalate worsening findings.

Avoid this shortcut

Do not label all confusion hepatic encephalopathy. Do not label confusion as hepatic encephalopathy before evaluating competing causes or give extra fluid solely because urine is low.

A clear way to hand it over

“I am calling about this new concern: confusion in a patient with cirrhosis. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Hepatic encephalopathy is brain dysfunction associated with liver disease; other causes of confusion still need assessment.

Sources behind the actions 3 primary references

NICE · NG50: Cirrhosis assessment and management
Cirrhosis complications and assessment of encephalopathy precipitants and renal concerns.
NICE · NG148: Acute kidney injury—recommendations
Recognize low urine output, compare creatinine with baseline, investigate causes and do not routinely treat AKI with loop diuretics.
NICE · CG141: Acute upper gastrointestinal bleeding—recommendations
Resuscitation, appropriate blood products, specialist reversal decisions and endoscopy after resuscitation in severe unstable bleeding.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Infection control

A drain site is red and newly painful

Intermediate

The situation

After abdominal surgery, a drain site becomes red and painful with changed discharge. The patient feels unwell.

What should catch your attention

Local change
Device exposure
Systemic symptoms

Your immediate priority

Report to the surgical team and use the ordered site/specimen assessment pathway.

01Local change
02Report to the surgical team and use the ordered site/specimen assessment pathway.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Report to the surgical team and use the ordered site/specimen assessment pathway. [1]
Why it matters Different infections spread in different ways; one isolation label does not fit all illnesses.
2
Apply the right precautions
Use standard precautions plus the indicated contact, droplet or airborne precautions; follow the facility’s placement and PPE pathway. [1]
Why it matters Different infections spread in different ways; one isolation label does not fit all illnesses.
3
Assess clinical severity
Check breathing, alertness, vital signs and hydration, and request diagnostic review when indicated. [1]
Why it matters Infection control cannot replace clinical treatment of a deteriorating patient.
4
Protect shared care
Use dedicated or cleaned equipment, appropriate hand hygiene and environmental cleaning; communicate precautions during transfer. [1]
Why it matters Organisms can spread through staff hands, equipment and unclear handovers.

What to look for next

Track systemic deterioration. Watch for new cases, ongoing symptoms and deterioration. Recheck that precautions remain appropriate as the diagnosis or test results change.

Avoid this shortcut

Do not independently flush or remove the drain. Do not delay emergency care while seeking a perfect room or assume gloves replace hand hygiene.

A clear way to hand it over

“I am calling about this new concern: a drain site is red and newly painful. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Transmission-based precautions add measures to routine infection prevention.

Sources behind the actions 2 primary references

CDC · Clinical safety: hand hygiene for healthcare workers
Gown/gloves and hand hygiene; soap and water when visibly soiled and as an additional precaution in C. diff outbreaks. Alcohol rub access should remain available.
CDC · Transmission-based precautions
Organism-specific isolation, respiratory protection and safe transport precautions.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Acute abdominal deterioration

Abdominal pain increases after endoscopy

Difficult

The situation

Following endoscopy, a patient develops increasing abdominal pain and rigidity with tachycardia. Their earlier recovery assessment was satisfactory.

What should catch your attention

Post-procedure change
Rigidity
Physiological response

Your immediate priority

Activate urgent procedural/surgical review and prepare ordered investigations.

01Post-procedure change
02Activate urgent procedural/surgical review and prepare ordered investigations.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Activate urgent procedural/surgical review and prepare ordered investigations. [1]
Why it matters New patterns can signal obstruction, infection, ischemia or a postoperative complication.
2
Check the pattern
Assess pain onset and change, distension, vomiting, bowel output, wound/drain findings and vital signs. [1]
Why it matters New patterns can signal obstruction, infection, ischemia or a postoperative complication.
3
Escalate the warning cues
Seek urgent surgical or medical review for severe progressive pain, shock, persistent vomiting or peritoneal concerns. [1]
Why it matters Some abdominal emergencies need time-sensitive definitive treatment.
4
Support the prescribed plan
Prepare ordered imaging, tests, fluid and symptom management; clarify safe oral intake and medicine routes. [1]
Why it matters Treatment and intake depend on the suspected cause and aspiration or procedure risk.

What to look for next

Trend perfusion and abdominal findings. Track pain, perfusion, urine, vomiting and abdominal findings during treatment and diagnostic waits.

Avoid this shortcut

Do not assume all post-procedure discomfort is trapped gas. Do not give an enema, laxative or oral load automatically in a suspected obstruction or dismiss severe pain because an earlier test was normal.

A clear way to hand it over

“I am calling about this new concern: abdominal pain increases after endoscopy. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Ischemia means inadequate blood flow; a peritoneal concern involves irritation of the lining inside the abdomen.

Sources behind the actions 2 primary references

NIDDK · Abdominal adhesions and obstruction
Obstruction symptoms, severe complications and urgent clinical assessment.
NICE · CG50: Recognising and responding to inpatient deterioration
Escalate using both physiological changes and clinical concern; emergencies bypass a routine graded response.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Acute abdominal deterioration

Pancreatitis with worsening breathing and urine

Difficult

The situation

A patient with pancreatitis develops rising oxygen needs and reduced urine. Their abdominal pain is somewhat better.

What should catch your attention

Possible organ dysfunction
Pain improvement misleading
Fluid balance complex

Your immediate priority

Seek urgent review of respiratory, renal and perfusion findings with pancreatitis-specific management.

01Possible organ dysfunction
02Seek urgent review of respiratory, renal and perfusion findings with pancreatitis-specific management.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Seek urgent review of respiratory, renal and perfusion findings with pancreatitis-specific management. [1]
Why it matters New patterns can signal obstruction, infection, ischemia or a postoperative complication.
2
Check the pattern
Assess pain onset and change, distension, vomiting, bowel output, wound/drain findings and vital signs. [1]
Why it matters New patterns can signal obstruction, infection, ischemia or a postoperative complication.
3
Escalate the warning cues
Seek urgent surgical or medical review for severe progressive pain, shock, persistent vomiting or peritoneal concerns. [1]
Why it matters Some abdominal emergencies need time-sensitive definitive treatment.
4
Support the prescribed plan
Prepare ordered imaging, tests, fluid and symptom management; clarify safe oral intake and medicine routes. [1]
Why it matters Treatment and intake depend on the suspected cause and aspiration or procedure risk.

What to look for next

Monitor response to individualized support. Track pain, perfusion, urine, vomiting and abdominal findings during treatment and diagnostic waits.

Avoid this shortcut

Do not infer overall recovery from pain alone. Do not give an enema, laxative or oral load automatically in a suspected obstruction or dismiss severe pain because an earlier test was normal.

A clear way to hand it over

“I am calling about this new concern: pancreatitis with worsening breathing and urine. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Ischemia means inadequate blood flow; a peritoneal concern involves irritation of the lining inside the abdomen.

Sources behind the actions 2 primary references

NICE · NG104: Pancreatitis
Pancreatitis complications, nutrition and organ-function assessment.
NICE · CG50: Recognising and responding to inpatient deterioration
Escalate using both physiological changes and clinical concern; emergencies bypass a routine graded response.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Cirrhosis & acute change

New fever and pain with ascites

Difficult

The situation

A patient with cirrhosis and ascites develops new abdominal tenderness, fever and reduced urine.

What should catch your attention

Possible infection
Ascites
Kidney change

Your immediate priority

Arrange urgent medical assessment and prescribed ascitic sampling and treatment.

01Possible infection
02Arrange urgent medical assessment and prescribed ascitic sampling and treatment.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Arrange urgent medical assessment and prescribed ascitic sampling and treatment. [1]
Why it matters Infection, bleeding, kidney injury and medicine effects can precipitate serious deterioration.
2
Identify the change
Compare consciousness, abdominal symptoms, bleeding, intake, medicines, circulation and urine with baseline. [1]
Why it matters Infection, bleeding, kidney injury and medicine effects can precipitate serious deterioration.
3
Seek prompt review
Escalate confusion, shock, new abdominal pain or worsening renal findings and prepare prescribed assessment. [1]
Why it matters A known liver diagnosis does not safely explain every new symptom.
4
Monitor the ordered treatment
Deliver the authorized cause-specific plan and track fluid, neurological and laboratory response. [1]
Why it matters Treatment needs reassessment because both illness and therapy can change organ function.

What to look for next

Track circulation and renal findings. Track consciousness, perfusion, urine and the response to the identified precipitant and escalate worsening findings.

Avoid this shortcut

Do not attribute new pain to stable chronic swelling. Do not label confusion as hepatic encephalopathy before evaluating competing causes or give extra fluid solely because urine is low.

A clear way to hand it over

“I am calling about this new concern: new fever and pain with ascites. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Hepatic encephalopathy is brain dysfunction associated with liver disease; other causes of confusion still need assessment.

Sources behind the actions 3 primary references

NICE · NG50: Cirrhosis assessment and management
Cirrhosis complications and assessment of encephalopathy precipitants and renal concerns.
NICE · NG148: Acute kidney injury—recommendations
Recognize low urine output, compare creatinine with baseline, investigate causes and do not routinely treat AKI with loop diuretics.
NICE · CG141: Acute upper gastrointestinal bleeding—recommendations
Resuscitation, appropriate blood products, specialist reversal decisions and endoscopy after resuscitation in severe unstable bleeding.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Acute abdominal deterioration

Large-volume vomiting with aspiration risk

Difficult

The situation

A patient with suspected obstruction repeatedly vomits and becomes drowsier after analgesia. Their airway protection is deteriorating.

What should catch your attention

Vomiting
Reduced alertness
Aspiration risk

Your immediate priority

Call urgent assessment and protect airway while preparing authorized decompression and treatment.

01Vomiting
02Call urgent assessment and protect airway while preparing authorized decompression and treatment.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Call urgent assessment and protect airway while preparing authorized decompression and treatment. [1]
Why it matters New patterns can signal obstruction, infection, ischemia or a postoperative complication.
2
Check the pattern
Assess pain onset and change, distension, vomiting, bowel output, wound/drain findings and vital signs. [1]
Why it matters New patterns can signal obstruction, infection, ischemia or a postoperative complication.
3
Escalate the warning cues
Seek urgent surgical or medical review for severe progressive pain, shock, persistent vomiting or peritoneal concerns. [1]
Why it matters Some abdominal emergencies need time-sensitive definitive treatment.
4
Support the prescribed plan
Prepare ordered imaging, tests, fluid and symptom management; clarify safe oral intake and medicine routes. [1]
Why it matters Treatment and intake depend on the suspected cause and aspiration or procedure risk.

What to look for next

Track breathing and perfusion. Track pain, perfusion, urine, vomiting and abdominal findings during treatment and diagnostic waits.

Avoid this shortcut

Do not leave the drowsy patient supine and unattended. Do not give an enema, laxative or oral load automatically in a suspected obstruction or dismiss severe pain because an earlier test was normal.

A clear way to hand it over

“I am calling about this new concern: large-volume vomiting with aspiration risk. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Ischemia means inadequate blood flow; a peritoneal concern involves irritation of the lining inside the abdomen.

Sources behind the actions 2 primary references

NIDDK · Abdominal adhesions and obstruction
Obstruction symptoms, severe complications and urgent clinical assessment.
NICE · CG50: Recognising and responding to inpatient deterioration
Escalate using both physiological changes and clinical concern; emergencies bypass a routine graded response.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Nutrition & electrolyte shifts

Feeding starts after prolonged poor intake

Difficult

The situation

A severely undernourished patient is beginning nutrition after many days of minimal intake. Baseline electrolytes and the refeeding-risk plan are missing.

What should catch your attention

Prolonged low intake
Nutrition restart
Electrolyte risk

Your immediate priority

Pause unplanned escalation and obtain the prescribed risk assessment, monitoring and supplementation plan.

01Prolonged low intake
02Pause unplanned escalation and obtain the prescribed risk assessment, monitoring and supplementation plan.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Pause unplanned escalation and obtain the prescribed risk assessment, monitoring and supplementation plan. [1]
Why it matters Restarting nutrition after depletion can produce dangerous electrolyte and fluid shifts.
2
Identify risk before feeding
Review poor intake, weight loss, illness and baseline potassium, phosphate and magnesium as ordered. [1]
Why it matters Restarting nutrition after depletion can produce dangerous electrolyte and fluid shifts.
3
Use the specialist prescription
Obtain dietetic and medical review for gradual feeding, vitamin support and electrolyte replacement; follow the prescribed rate. [1]
Why it matters A full calorie target immediately may be unsafe for a high-risk person.
4
Watch the response
Monitor ordered electrolytes, glucose, balance and cardiorespiratory signs, and report new weakness or edema. [1]
Why it matters The complications may appear after feeding starts rather than at the initial assessment.

What to look for next

Follow phosphate, potassium, magnesium and clinical response as ordered. Escalate arrhythmia, worsening breathing, marked weakness or a rapid biochemical change; confirm the revised feed and replacement plan.

Avoid this shortcut

Do not assume rapid full feeding is harmless. Do not increase feeding to catch up or treat a normal initial electrolyte result as permanent reassurance.

A clear way to hand it over

“I am calling about this new concern: feeding starts after prolonged poor intake. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Refeeding syndrome is a harmful metabolic response when nutrition restarts after significant depletion.

Sources behind the actions 1 primary references

NICE · CG32: Nutrition support for adults
Nutrition assessment, refeeding risk, individualized support and monitoring.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Upper gastrointestinal bleeding

Massive hematemesis with shock

Extremely difficult

The situation

A patient vomits substantial fresh blood, becomes hypotensive and struggles to stay alert. Anticoagulant use is confirmed.

What should catch your attention

Major upper-GI bleeding
Shock
Airway and reversal concerns

Your immediate priority

Activate major-bleeding/airway response and urgent GI assessment, communicating anticoagulant timing.

01Major upper-GI bleeding
02Activate major-bleeding/airway response and urgent GI assessment, communicating anticoagulant timing.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Activate major-bleeding/airway response and urgent GI assessment, communicating anticoagulant timing. [1]
Why it matters Visible signs and physiological trends help identify potentially serious loss.
2
Recognize and assess
Report hematemesis, new black sticky stool, weakness and perfusion changes with medicine and liver history. [1]
Why it matters Visible signs and physiological trends help identify potentially serious loss.
3
Activate the appropriate response
Call urgent GI/medical review and emergency bleeding support for instability; protect the airway when alertness falls. [1]
Why it matters Significant loss can threaten circulation and airway before a later blood count returns.
4
Prepare prescribed definitive care
Assist ordered blood tests, products, specialist reversal decisions and endoscopic assessment after appropriate stabilization. [1]
Why it matters Resuscitation and control of the bleeding source must be coordinated.

What to look for next

Track resuscitation and prepare prescribed definitive treatment. Track bleeding, consciousness, circulation and response to treatment and promptly escalate ongoing loss.

Avoid this shortcut

Do not wait for a later hemoglobin result. Do not assume iron explains every black stool or independently select antithrombotic reversal.

A clear way to hand it over

“I am calling about this new concern: massive hematemesis with shock. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Hematemesis means vomiting blood; melena describes black tarry stool from digested blood.

Sources behind the actions 2 primary references

NICE · CG141: Acute upper gastrointestinal bleeding—recommendations
Resuscitation, appropriate blood products, specialist reversal decisions and endoscopy after resuscitation in severe unstable bleeding.
NICE · NG24: Blood transfusion (updated February 2026)
General blood-product decisions, compatibility and patient monitoring; major bleeding follows a separate emergency pathway.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Acute abdominal deterioration

Severe abdominal pain with little early examination change

Extremely difficult

The situation

A patient with vascular disease develops sudden severe abdominal pain. Early examination findings are modest, but perfusion is worsening.

What should catch your attention

Pain disproportionate to early findings
Vascular risk
Deterioration

Your immediate priority

Request immediate emergency/surgical assessment for a time-sensitive abdominal cause.

01Pain disproportionate to early findings
02Request immediate emergency/surgical assessment for a time-sensitive abdominal cause.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Request immediate emergency/surgical assessment for a time-sensitive abdominal cause. [1]
Why it matters New patterns can signal obstruction, infection, ischemia or a postoperative complication.
2
Check the pattern
Assess pain onset and change, distension, vomiting, bowel output, wound/drain findings and vital signs. [1]
Why it matters New patterns can signal obstruction, infection, ischemia or a postoperative complication.
3
Escalate the warning cues
Seek urgent surgical or medical review for severe progressive pain, shock, persistent vomiting or peritoneal concerns. [1]
Why it matters Some abdominal emergencies need time-sensitive definitive treatment.
4
Support the prescribed plan
Prepare ordered imaging, tests, fluid and symptom management; clarify safe oral intake and medicine routes. [1]
Why it matters Treatment and intake depend on the suspected cause and aspiration or procedure risk.

What to look for next

Trend perfusion while preparing urgent investigations. Track pain, perfusion, urine, vomiting and abdominal findings during treatment and diagnostic waits.

Avoid this shortcut

Do not use a mild early examination to dismiss severe new pain. Do not give an enema, laxative or oral load automatically in a suspected obstruction or dismiss severe pain because an earlier test was normal.

A clear way to hand it over

“I am calling about this new concern: severe abdominal pain with little early examination change. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Ischemia means inadequate blood flow; a peritoneal concern involves irritation of the lining inside the abdomen.

Sources behind the actions 2 primary references

NIDDK · Abdominal adhesions and obstruction
Obstruction symptoms, severe complications and urgent clinical assessment.
NICE · CG50: Recognising and responding to inpatient deterioration
Escalate using both physiological changes and clinical concern; emergencies bypass a routine graded response.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Infection & shock

Postoperative leak concern progresses to sepsis

Extremely difficult

The situation

After bowel surgery, a patient develops worsening pain, fever, tachypnea and hypotension. Drain output has changed.

What should catch your attention

Surgical source concern
Shock
Changed drainage

Your immediate priority

Activate sepsis and urgent surgical source-control assessment.

01Surgical source concern
02Activate sepsis and urgent surgical source-control assessment.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Activate sepsis and urgent surgical source-control assessment. [1]
Why it matters Delay can allow poor organ perfusion to worsen before the diagnosis is fully confirmed.
2
Escalate early
Assess airway, breathing, circulation and mental state; activate the local emergency or sepsis response for shock or rapid decline. [1]
Why it matters Delay can allow poor organ perfusion to worsen before the diagnosis is fully confirmed.
3
Support the prescribed bundle
Prepare cultures and lactate testing, urgent antimicrobials and individualized fluid or vasopressor treatment as ordered; do not delay urgent therapy for a difficult sample. [1]
Why it matters Identifying infection and supporting circulation address different parts of the same emergency.
4
Reassess after each step
Trend blood pressure, breathing, alertness, urine and response to treatment; report overload or persistent poor perfusion. [1]
Why it matters Fluids and medicines must be adjusted to response and comorbidity, rather than repeated automatically.

What to look for next

Track respiratory/circulatory response. Continue close observations through transfer and handover. Persistent shock, rising support needs or reduced consciousness requires further immediate escalation.

Avoid this shortcut

Do not manage fever alone while ignoring source control. Do not wait for fever, laboratory confirmation or a score threshold when clinical shock is evident.

A clear way to hand it over

“I am calling about this new concern: postoperative leak concern progresses to sepsis. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Perfusion means blood flow delivering oxygen to organs.

Sources behind the actions 2 primary references

SCCM / ESICM · Surviving Sepsis Campaign adult guidelines—2026
Immediate emergency response, cultures/lactate, prompt antimicrobials in shock and individualized resuscitation with reassessment.
NICE · CG50: Recognising and responding to inpatient deterioration
Escalate using both physiological changes and clinical concern; emergencies bypass a routine graded response.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Stoma & hydration

An ileostomy becomes dark and painful

Extremely difficult

The situation

A new stoma becomes unusually dark with increasing pain and reduced function. The earlier colour was healthy.

What should catch your attention

Possible ischemia
New tissue change
Reduced function

Your immediate priority

Seek immediate surgical assessment and document the actual appearance and time of change.

01Possible ischemia
02Seek immediate surgical assessment and document the actual appearance and time of change.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Seek immediate surgical assessment and document the actual appearance and time of change. [1]
Why it matters Output or colour changes can indicate skin, fluid or surgical problems.
2
Examine the change
Assess output amount and character, stoma appearance, surrounding skin, pain, intake and urine. [1]
Why it matters Output or colour changes can indicate skin, fluid or surgical problems.
3
Use specialist support
Involve the stoma nurse or surgical team for concerning tissue, obstruction symptoms, leakage or high output. [1]
Why it matters Different stomas and complications require different management.
4
Review the response
Deliver the prescribed appliance, hydration and medicine plan and teach the patient how to recognize warning changes. [1]
Why it matters Effective self-care requires understanding both routine care and when to seek help.

What to look for next

Track systemic and stoma findings. Track output, urine, skin and clinical response, and escalate worsening pain, ischemic appearance or dehydration.

Avoid this shortcut

Do not insert instruments or irrigate to test the stoma. Do not irrigate a stoma, insert an object or give antidiarrheals independently in a possible obstruction.

A clear way to hand it over

“I am calling about this new concern: an ileostomy becomes dark and painful. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English A stoma is a surgically created opening; an ileostomy drains small-bowel contents and can cause substantial fluid loss.

Sources behind the actions 2 primary references

NIDDK · Complications of ostomy surgery
Skin, tissue, obstruction and dehydration concerns requiring clinical review.
NICE · CG174: Intravenous fluid therapy in adults
Individual fluid assessment and repeated review of response and comorbid risks.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Alcohol withdrawal & neurological risk

Severe withdrawal causes confusion and autonomic instability

Extremely difficult

The situation

A patient hospitalized for liver disease develops tremor, agitation, hallucinations and unstable vital signs after alcohol cessation.

What should catch your attention

Withdrawal timeline
Autonomic change
Seizure risk

Your immediate priority

Activate urgent withdrawal assessment and authorized treatment/observation with attention to nutrition and competing causes.

01Withdrawal timeline
02Activate urgent withdrawal assessment and authorized treatment/observation with attention to nutrition and competing causes.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Activate urgent withdrawal assessment and authorized treatment/observation with attention to nutrition and competing causes. [1]
Why it matters Withdrawal can coexist with infection, poisoning or head injury.
2
Check timing and competing causes
Assess recent alcohol use, withdrawal history, symptoms, glucose, injury and other illness. [1]
Why it matters Withdrawal can coexist with infection, poisoning or head injury.
3
Escalate severe symptoms
Seek urgent medical review for seizure, confusion, hallucinations or marked autonomic instability and prepare the prescribed withdrawal pathway. [1]
Why it matters Severe withdrawal can be life-threatening and needs monitored treatment.
4
Monitor treatment and nutrition
Follow ordered medicine, thiamine and fluid/electrolyte care with sedation and respiratory observation. [1]
Why it matters Treatment can impair breathing, while nutritional deficiencies also need attention.

What to look for next

Track sedation, breathing and withdrawal response. Track consciousness, breathing, circulation and symptom response and escalate worsening immediately.

Avoid this shortcut

Do not assume every confused liver patient has only encephalopathy. Do not delay life-saving glucose for hypoglycemia while arranging thiamine, or give unprescribed sedatives.

A clear way to hand it over

“I am calling about this new concern: severe withdrawal causes confusion and autonomic instability. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Autonomic instability includes marked changes in pulse, pressure, temperature or sweating.

Sources behind the actions 1 primary references

NICE · CG100: Alcohol-related physical complications
Monitored withdrawal care, severe complications and thiamine/nutritional assessment.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Upper gastrointestinal bleeding

Bleeding and encephalopathy threaten the airway together

Extremely difficult

The situation

A patient with advanced liver disease has recurrent hematemesis and decreasing consciousness. Both blood and reduced alertness threaten airway protection.

What should catch your attention

Active bleeding
Reduced consciousness
Airway risk

Your immediate priority

Activate urgent airway and major-bleeding support with GI/critical-care teams.

01Active bleeding
02Activate urgent airway and major-bleeding support with GI/critical-care teams.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Activate urgent airway and major-bleeding support with GI/critical-care teams. [1]
Why it matters Visible signs and physiological trends help identify potentially serious loss.
2
Recognize and assess
Report hematemesis, new black sticky stool, weakness and perfusion changes with medicine and liver history. [1]
Why it matters Visible signs and physiological trends help identify potentially serious loss.
3
Activate the appropriate response
Call urgent GI/medical review and emergency bleeding support for instability; protect the airway when alertness falls. [1]
Why it matters Significant loss can threaten circulation and airway before a later blood count returns.
4
Prepare prescribed definitive care
Assist ordered blood tests, products, specialist reversal decisions and endoscopic assessment after appropriate stabilization. [1]
Why it matters Resuscitation and control of the bleeding source must be coordinated.

What to look for next

Track ventilation and perfusion through definitive care. Track bleeding, consciousness, circulation and response to treatment and promptly escalate ongoing loss.

Avoid this shortcut

Do not give oral medicines to an unsafe-swallowing patient. Do not assume iron explains every black stool or independently select antithrombotic reversal.

A clear way to hand it over

“I am calling about this new concern: bleeding and encephalopathy threaten the airway together. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Hematemesis means vomiting blood; melena describes black tarry stool from digested blood.

Sources behind the actions 2 primary references

NICE · CG141: Acute upper gastrointestinal bleeding—recommendations
Resuscitation, appropriate blood products, specialist reversal decisions and endoscopy after resuscitation in severe unstable bleeding.
NICE · NG24: Blood transfusion (updated February 2026)
General blood-product decisions, compatibility and patient monitoring; major bleeding follows a separate emergency pathway.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Nutrition & electrolyte shifts

Severe refeeding complications after nutrition escalation

Extremely difficult

The situation

After nutrition increases, an undernourished patient develops weakness, edema and arrhythmia with major electrolyte changes.

What should catch your attention

Temporal feeding change
Electrolyte depletion
Cardiac instability

Your immediate priority

Call urgent medical/nutrition review and apply the authorized refeeding-complication and rhythm pathways.

01Temporal feeding change
02Call urgent medical/nutrition review and apply the authorized refeeding-complication and rhythm pathways.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Call urgent medical/nutrition review and apply the authorized refeeding-complication and rhythm pathways. [1]
Why it matters Restarting nutrition after depletion can produce dangerous electrolyte and fluid shifts.
2
Identify risk before feeding
Review poor intake, weight loss, illness and baseline potassium, phosphate and magnesium as ordered. [1]
Why it matters Restarting nutrition after depletion can produce dangerous electrolyte and fluid shifts.
3
Use the specialist prescription
Obtain dietetic and medical review for gradual feeding, vitamin support and electrolyte replacement; follow the prescribed rate. [1]
Why it matters A full calorie target immediately may be unsafe for a high-risk person.
4
Watch the response
Monitor ordered electrolytes, glucose, balance and cardiorespiratory signs, and report new weakness or edema. [1]
Why it matters The complications may appear after feeding starts rather than at the initial assessment.

What to look for next

Monitor ECG, fluid status and repeat electrolytes. Escalate arrhythmia, worsening breathing, marked weakness or a rapid biochemical change; confirm the revised feed and replacement plan.

Avoid this shortcut

Do not continue escalation unchanged or replace electrolytes independently. Do not increase feeding to catch up or treat a normal initial electrolyte result as permanent reassurance.

A clear way to hand it over

“I am calling about this new concern: severe refeeding complications after nutrition escalation. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Refeeding syndrome is a harmful metabolic response when nutrition restarts after significant depletion.

Sources behind the actions 1 primary references

NICE · CG32: Nutrition support for adults
Nutrition assessment, refeeding risk, individualized support and monitoring.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Infection & shock

Cholangitis concern with shock and confusion

Extremely difficult

The situation

A patient with biliary symptoms develops fever, jaundice, confusion and hypotension. A procedure-related source-control plan may be needed.

What should catch your attention

Biliary source concern
Shock
Definitive intervention possible

Your immediate priority

Activate urgent sepsis and GI/surgical assessment and prepare ordered treatment and source evaluation.

01Biliary source concern
02Activate urgent sepsis and GI/surgical assessment and prepare ordered treatment and source evaluation.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Activate urgent sepsis and GI/surgical assessment and prepare ordered treatment and source evaluation. [1]
Why it matters Delay can allow poor organ perfusion to worsen before the diagnosis is fully confirmed.
2
Escalate early
Assess airway, breathing, circulation and mental state; activate the local emergency or sepsis response for shock or rapid decline. [1]
Why it matters Delay can allow poor organ perfusion to worsen before the diagnosis is fully confirmed.
3
Support the prescribed bundle
Prepare cultures and lactate testing, urgent antimicrobials and individualized fluid or vasopressor treatment as ordered; do not delay urgent therapy for a difficult sample. [1]
Why it matters Identifying infection and supporting circulation address different parts of the same emergency.
4
Reassess after each step
Trend blood pressure, breathing, alertness, urine and response to treatment; report overload or persistent poor perfusion. [1]
Why it matters Fluids and medicines must be adjusted to response and comorbidity, rather than repeated automatically.

What to look for next

Track perfusion and neurological response. Continue close observations through transfer and handover. Persistent shock, rising support needs or reduced consciousness requires further immediate escalation.

Avoid this shortcut

Do not wait for every classic symptom before escalating. Do not wait for fever, laboratory confirmation or a score threshold when clinical shock is evident.

A clear way to hand it over

“I am calling about this new concern: cholangitis concern with shock and confusion. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Perfusion means blood flow delivering oxygen to organs.

Sources behind the actions 2 primary references

SCCM / ESICM · Surviving Sepsis Campaign adult guidelines—2026
Immediate emergency response, cultures/lactate, prompt antimicrobials in shock and individualized resuscitation with reassessment.
NICE · CG50: Recognising and responding to inpatient deterioration
Escalate using both physiological changes and clinical concern; emergencies bypass a routine graded response.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Bleeding & circulation

Bleeding after a liver procedure is largely concealed

Extremely difficult

The situation

After a liver procedure, a patient has new abdominal pain, pallor and falling pressure. The puncture dressing remains dry.

What should catch your attention

Recent procedure
Shock
Concealed loss possible

Your immediate priority

Activate urgent procedural/major-bleeding assessment and communicate the timeline.

01Recent procedure
02Activate urgent procedural/major-bleeding assessment and communicate the timeline.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Activate urgent procedural/major-bleeding assessment and communicate the timeline. [1]
Why it matters External loss can underestimate bleeding, and a normal early blood count cannot rule out shock.
2
Call and assess
Activate the local bleeding response for instability; assess airway, breathing, pulse, pressure, alertness and visible loss. [1]
Why it matters External loss can underestimate bleeding, and a normal early blood count cannot rule out shock.
3
Prepare safe resuscitation
Maintain or obtain suitable access within competence; prepare ordered fluids, blood tests and blood products using identification and compatibility checks. [1]
Why it matters Resuscitation supports circulation while the team seeks the bleeding source.
4
Track treatment and source control
Report procedure history, anticoagulants and last doses; help arrange urgent specialist review and prescribed monitoring. [1]
Why it matters Replacement alone cannot stop every source of bleeding or resolve medication-related risk.

What to look for next

Monitor circulation and ordered investigations. Trend observations and loss after interventions. Escalate ongoing shock, respiratory change or a suspected transfusion reaction immediately.

Avoid this shortcut

Do not exclude bleeding from the skin dressing alone. Do not wait for a laboratory result before responding to shock or independently select reversal drugs.

A clear way to hand it over

“I am calling about this new concern: bleeding after a liver procedure is largely concealed. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Hemodynamic instability means circulation is not adequately supporting the body.

Sources behind the actions 2 primary references

NICE · NG24: Blood transfusion (updated February 2026)
General blood-product decisions, compatibility and patient monitoring; major bleeding follows a separate emergency pathway.
NICE · CG50: Recognising and responding to inpatient deterioration
Escalate using both physiological changes and clinical concern; emergencies bypass a routine graded response.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

Acute abdominal deterioration

Fulminant abdominal illness with multiple competing causes

Extremely difficult

The situation

An immunosuppressed patient develops severe abdominal pain, bloody stool and shock. Infection, bleeding and ischemia all require rapid assessment.

What should catch your attention

Immunosuppression
Bleeding
Shock

Your immediate priority

Activate emergency resuscitation and urgent surgical/medical investigation without assuming a single cause.

01Immunosuppression
02Activate emergency resuscitation and urgent surgical/medical investigation without assuming a single cause.
03Check response + communicate

Decision pathway · a learning summary, not a substitute for the full clinical plan

What the RN should do—and why

1
Respond to the situation first
Activate emergency resuscitation and urgent surgical/medical investigation without assuming a single cause. [1]
Why it matters New patterns can signal obstruction, infection, ischemia or a postoperative complication.
2
Check the pattern
Assess pain onset and change, distension, vomiting, bowel output, wound/drain findings and vital signs. [1]
Why it matters New patterns can signal obstruction, infection, ischemia or a postoperative complication.
3
Escalate the warning cues
Seek urgent surgical or medical review for severe progressive pain, shock, persistent vomiting or peritoneal concerns. [1]
Why it matters Some abdominal emergencies need time-sensitive definitive treatment.
4
Support the prescribed plan
Prepare ordered imaging, tests, fluid and symptom management; clarify safe oral intake and medicine routes. [1]
Why it matters Treatment and intake depend on the suspected cause and aspiration or procedure risk.

What to look for next

Track organ function and treatment response. Track pain, perfusion, urine, vomiting and abdominal findings during treatment and diagnostic waits.

Avoid this shortcut

Do not use one plausible diagnosis to stop evaluating the others. Do not give an enema, laxative or oral load automatically in a suspected obstruction or dismiss severe pain because an earlier test was normal.

A clear way to hand it over

“I am calling about this new concern: fulminant abdominal illness with multiple competing causes. The key findings are __, starting at __. Baseline and relevant medicines/procedures are __. I have __. My assessment is __, and I need __ by __. Current response and outstanding actions are __.”

Use your facility's handover format; fill in the actual findings and times.

In plain English Ischemia means inadequate blood flow; a peritoneal concern involves irritation of the lining inside the abdomen.

Sources behind the actions 2 primary references

NIDDK · Abdominal adhesions and obstruction
Obstruction symptoms, severe complications and urgent clinical assessment.
NICE · CG50: Recognising and responding to inpatient deterioration
Escalate using both physiological changes and clinical concern; emergencies bypass a routine graded response.

Links and relevant guidance checked October 7, 2026. Publication dates differ; local requirements may differ. These original cases do not imply endorsement by the source organizations.

Now connect the cues to clinical judgment.
Practise an NGN case · Access depends on your plan.

CONNECT UNDERSTANDING TO EXAM PRACTICE

The explanation is clear.
The exam asks you to choose.

Here, we explain the nursing response directly. In an NCLEX®-style question, several options may sound reasonable. You must weigh the cues, priority, timing and safety—not just recognize a familiar phrase.

Practise applying the reasoning, read why alternatives are less appropriate and review your decisions before exam day.

Build question-bank judgmentStudy by topic or system; review the rationale

Work through NGN casesConnect changing cues across a case

Explore standalone NGN itemsPractise decisions in different item formats

Rehearse a full mockPractise pacing and review your decisions

Try adaptive practiceA CAT-style learning simulator

For tutors & preceptors

Turn a scenario into a conversation.

Pause at the cues. Ask learners to identify the change from baseline and the immediate risk.
Explain the action. Ask what is independent nursing care and what requires a protocol or order.
Change one detail. Explore how unsafe swallowing, low pressure or kidney disease alters the plan.
Rehearse the handover. Compare with local policy, check the source and name what must be reassessed.

Explore the free teaching toolkit

Gastroenterology & Hepatology

The new stoma appliance leaks onto skin

What should catch your attention

What the RN should do—and why

Respond to the situation first

Examine the change

Use specialist support

Review the response

What to look for next

Avoid this shortcut

A clear way to hand it over

An output chart omits overnight stoma losses

What should catch your attention

What the RN should do—and why

Respond to the situation first

Examine the change

Use specialist support

Review the response

What to look for next

Avoid this shortcut

A clear way to hand it over

The feeding-tube mark has changed

What should catch your attention

What the RN should do—and why

Respond to the situation first

Pause uncertain use

Verify by the approved method

Follow the nutrition plan

What to look for next

Avoid this shortcut

A clear way to hand it over

The patient misunderstands a bowel-preparation instruction

What should catch your attention

What the RN should do—and why

Respond to the situation first

Make the explanation accessible

Use a small teach-back

Repair the gap

What to look for next

Avoid this shortcut

A clear way to hand it over

Abdominal discomfort after opioid treatment

What should catch your attention

What the RN should do—and why

Respond to the situation first

Check the pattern

Identify urgent concerns

Follow the bowel plan

What to look for next

Avoid this shortcut

A clear way to hand it over

High ileostomy output causes dizziness

What should catch your attention

What the RN should do—and why

Respond to the situation first

Examine the change

Use specialist support

Review the response

What to look for next

Avoid this shortcut

A clear way to hand it over

Black stool is new after an admission

What should catch your attention

What the RN should do—and why

Respond to the situation first

Recognize and assess

Activate the appropriate response

Prepare prescribed definitive care

What to look for next

Avoid this shortcut

A clear way to hand it over

Vomiting and abdominal distension with little output

What should catch your attention

What the RN should do—and why

Respond to the situation first

Check the pattern

Escalate the warning cues

Support the prescribed plan

What to look for next

Avoid this shortcut