Case Study on Principles of Nursing

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Running head: CASE STUDY
Principles of nursing
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CASE STUDY 1
Question 1
The given case study describes an 82-years old male patient named Edward Ted William,
who underwent an operation for bowel resection and development of colostomy. Edward was
a widower and lived alone as both his children stay separately. The biopsychosocial approach
states that the impression of pain is regulated by the biological, social and mental factors
(Wijma et al., 2016). The application of biopsychosocial perspective on Edward demonstrates
that the changes in the attitude, actions, social environment and thoughts are a consequence
of his pain. After his evaluation, he was recommended a surgery, to which he agreed and
displayed a positive outlook. The impact of his family was not required as they did not stay
together and he was his only family. Besides, the procedure of the surgery had no implication
from the spiritual perspective for Edward, which made him readily agree to the surgical
intervention. This also gives an idea of the educational background of Edward, which helped
him prioritize his health over spiritual reasons. The third evaluating aspect includes the
cultural perspective, which is guided by cultural beliefs and practices, society and family
(VanderWeele, Balboni & Koh, 2017). Edward’s evaluation in the context of cultural aspect
is negligible. This can be attributed to his stay at the retirement village, which allowed
minimum influence of the society and cultural beliefs on the life of Edward. Moreover, he
stayed away from his family and was abandoned by them, hence the role of his family can
also be neglected.
Question 2
The information provided in stage two of the clinical reasoning cycle consists of a collection
of cues and data for the case of Edward. An evaluation of the information presented depicts
that the information for day four of the operation was not mentioned in a detailed manner. It
is just stated that Ted was nil by mouth for the initial two days after the operation. The details
of the constituents of his diet are not mentioned. Besides, the case study stated that his diet on

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the third day comprised of liquids and was given light food later in the evening, which was
digestible by him. An assessment of his vital signs presented standard values of heart rate,
respiratory rate and percentage of oxygen saturation. However, his temperature was higher
than usual with a value of 38.10C. Moreover, his blood pressure was also high as 135/85.
Further assessment revealed that he had a moist, productive cough and coarse crackles on his
right-sided inspiration. Coarse crackles are associated with the accumulation of fluids in the
lungs, which can be indicative of pulmonary oedema and subsequent pneumonia in the
patient. In addition, the productive and moist nature of the cough is indicative of sputum or
mucous accumulation causing congestion in the chest (Ramos, Krahnke & Kim, 2014). These
symptoms may display that Ted was suffering from pneumonia. It is also observed that his
abdomen is distended. On further investigation, it was found that Ted also experienced an
abdominal pain rated between four to five out of ten, which worsens to seven on palpitation.
Abdominal enlargement can be explained by the accumulation of fluid, presenting such an
appearance. The colostomy bag placed after the surgery to collect the waste was undisturbed
the surface of the bag displayed the stoma present inside. It is a common observation after
surgeries and presented a positive indication. The texture of the stoma was moist, pink, warm
and slightly elevated from the skin of the patient. This indicates a surgical procedure and
gradually reduces with time. A significant concern in the case of Ted was the absence of any
output in the bag for four days and the presence of sluggish bowel sounds without passing
flatus. A possible explanation of this can be post-operative ileus, which is the transient delay
in the bowel movement or a disruption of the usually coordinated mobility of the
gastrointestinal tract after surgical intervention. The pathophysiology of postoperative ileus is
complex and multifactorial. However, it can be explained as complexity in the interaction of
the central nervous system with the autonomic system causing a transient paralysis in some
segments of the intestine (Venara et al., 2016). It often induces pain in the region, which can

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be attributed to the in situ administration of PCA morphine to regulate pain after the
operation added with the stress caused by pneumonia. These clinical conditions result in
persistent coughs due to fluid-filled air sacs in lungs, abdominal pain, breathing difficulties
and a mild fever.
Question 3
The next step in clinical reasoning cycle (CRC) after the successful evaluation of the patient
and identification of his problem is to formulate a set of nursing interventions addressing the
clinical issues highlighted in the patient and providing optimum care. Ted needs additional
care and careful consideration while setting up strategies for him as he lives alone and has to
take care of himself on his own. Moreover, his past medical history also displays heart
failure, type 2 diabetes, gout and obesity, which also need consideration while developing
interventions for the present postoperative condition. Thus, some useful nursing interventions
have been developed for Ted after careful consideration of his physical and social scenario as
follows:
 Strategies addressing his abdominal pain are of utmost importance to release a
significant part of his stress. The gastrointestinal matter can be suctioned out with the
help of nasogastric aids. It is a useful tool to drain the contents obstructed in the
gastrointestinal tract unable to mobilize to be expelled out of the patient’s system.
However, this approach involves the insertion of the tube via the nostrils and
gradually transported to the stomach carefully to avoid any damage. This nursing
intervention requires experience and adequate expertise of the nursing or health care
professionals. The suction is maintained with the help of water or saline administered
through the tube and also prevent electrolytic imbalance in the patients caused by
removing the liquid contents of the stomach (Yamada et al., 2018).

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 Another useful nursing intervention is the use of airway exchange catheters (AEC)
for relieving the airway obstruction in Ted. AEC is a tool available in varying sizes
that need to be placed into the trachea of the patient through the tracheal tube, which
can then be removed leaving the AEC in the mid-trachea level. It can be tolerated for
72 hours and provides extubation of the airway congestion (Batuwitage & Charters,
2017).
 Regular monitoring of the hydration level of the patient can be a useful nursing
intervention. This is because airway obstruction is commonly associated with
inadequate hydration resulting in the accumulation of mucus in the respiratory tract.
Routine surveillance of the hydration status of Ted by administering 3-3.5L of liquid,
preferably warm each day can be a useful strategy (Moore, 2016).
 Another nursing intervention targeted towards addressing the issue of postoperative
ileus is chewing gums. Some studies have demonstrated that chewing gums thrice
daily resulted in an earlier passage of flatus and stimulates motility of bowel (Topcu
et al., 2016).
 Management of the productive cough of the patient is vital. It can be achieved by
monitoring the breathing pattern and sounds to understand the nature of the coughs. It
may require a change in the breathing strategy to include the use of accessory
muscles in breathing or relevant breathing exercises (Hill et al., 2017)
 The effectiveness of all the interventions mentioned above largely depends on the
psychological state of Ted as well. A surgery followed by these complications leads
to anxiety and distress among the patients. Moreover, Ted might feel the absence of
family even more during these circumstances. Thus, nursing interventions to provide
mental support to the patient is essential for faster recovery. The anxiety of the
patient can be reduced by effectively communicating with the patient and providing

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reassurance regarding their concerns (Le et al., 2014). Relaxing music or other
related activities can also help in reducing the patient’s distress and improving patient
recovery.
Question 4
Nursing interventions need to be incorporated with pharmacological treatment to obtain the
best results. Ted presents two primary complications, which require medications. The first
condition is pneumonia and the use of medications such as glycopeptide antibiotics are the
most effective pharmacological treatment options against it. These drugs are of microbial
origin and comprise of polycyclic peptides or glycosylated cyclic non-ribosomal peptides
inhibiting cell wall formation. Oral administration of this drug reduces infections in the body
by inhibiting the formation of the cell walls of the infection-causing microbes (Ni et al.,
2015). These drugs are often accompanied by side-effects such as taste disturbances and
diarrhoea. The condition of post-operative ileus can be managed by non-steroidal anti-
inflammatory drugs. It also helps in reducing the dosage of opioids administered by 10%. The
anti-inflammatory properties of the drug increase bowel motility. It also includes added
benefits of decreasing vomiting and nausea with enhanced gastrointestinal transit. However,
it is often associated with side-effects such as rashes, throat swelling or wheezes. In some
cases, adverse effects such as stomach ulcers are also observed (Gero et al., 2017 ).

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References
Batuwitage, B., & Charters, P. (2017). Postoperative management of the difficult airway. Bja
Education. https://doi.org/10.1093/bjaed/mkw077
Gero, D., Gié, O., Hübner, M., Demartines, N., & Hahnloser, D. (2017). Postoperative ileus:
in search of an international consensus on definition, diagnosis, and
treatment. Langenbeck's archives of surgery, 402(1), 149-158.
https://doi.org/10.1007/s00423-016-1485-1
Hill, C. J., Lazzeri, M., & D’Abrosca, F. (2018). Breathing Exercises and Mucus Clearance
Techniques in Pulmonary Rehabilitation. In Textbook of Pulmonary
Rehabilitation (pp. 205-216). Springer, Cham. https://doi.org/10.1007/978-3-319-
65888-9_1
Le, H., Khankhanian, P., Joshi, N., Maa, J., & Crevensten, H. (2014). Patients recovering
from abdominal surgery who walked with volunteers had improved postoperative
recovery profiles during their hospitalization. World journal of surgery, 38(8), 1961-
1965. https://doi.org/10.1007/s00268-014-2491-5
Moore, T. (2016). Tracheostomy care. Clinical Skills for Nursing Practice, 419.
Ni, W., Shao, X., Cai, X., Wei, C., Cui, J., Wang, R., & Liu, Y. (2015). Prophylactic use of
macrolide antibiotics for the prevention of chronic obstructive pulmonary disease
exacerbation: a meta-analysis. PloS one, 10(3). 10.1371/journal.pone.0121257
Ramos, F. L., Krahnke, J. S., & Kim, V. (2014). Clinical issues of mucus accumulation in
COPD. International journal of chronic obstructive pulmonary disease, 9, 139.
10.2147/COPD.S38938

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Topcu, S. Y., & Oztekin, S. D. (2016). Effect of gum chewing on reducing postoperative
ileus and recovery after colorectal surgery: A randomised controlled
trial. Complementary therapies in clinical practice, 23, 21-25.
https://doi.org/10.1016/j.ctcp.2016.02.001
VanderWeele, T. J., Balboni, T. A., & Koh, H. K. (2017). Health and
spirituality. Jama, 318(6), 519-520. 10.1001/jama.2017.8136
Venara, A., Neunlist, M., Slim, K., Barbieux, J., Colas, P. A., Hamy, A., & Meurette, G.
(2016). Postoperative ileus: pathophysiology, incidence, and prevention. Journal of
visceral surgery, 153(6), 439-446. https://doi.org/10.1016/j.jviscsurg.2016.08.010
Wijma, A. J., van Wilgen, C. P., Meeus, M., & Nijs, J. (2016). Clinical biopsychosocial
physiotherapy assessment of patients with chronic pain: The first step in pain
neuroscience education. Physiotherapy theory and practice, 32(5), 368-384.
https://doi.org/10.1080/09593985.2016.1194651
Yamada, T., Yokoyama, Y., Takeda, K., Takahashi, G., Iwai, T., Koizumi, M., ... & Ohta, K.
(2018). Negative Effects of Mechanical Bowel Preparation on the Postoperative
Intestinal Motility of Patients with Colorectal Cancer. In Enhanced Recovery after
Surgery (pp. 101-107). Springer, Singapore.