Nursing Case Study Question 2022

Running Head: Nursing
Case study
Name of the Student
Name of the University
Authors Note

1CASE STUDY
Response to Question 1
Ted William, an 82-year-old patient, was admitted to the hospital for the colostomy.
His biopsy report showed the presence of a malignant mass in his gastrointestinal system.
The patient had undergone through the surgery four days ago for removal of the malignant
mass.
According to the Roper- Logan-Tierney Model of Nursing, the daily activities of
living will be used for the planning of care for patients’ to assess the biopsychosocial,
spiritual and cultural impact of surgery on them (Holland & Jenkins, 2019). Here the
following analysis is given on Ted William as per RLT model.
Maintaining a safe environment
Sign of disorientation is absent in Ted as he was able to answer the questions. He had a pre-
medical history of cardiac failure. He is diabetic and obese.
Communicating
He has no problem with communication. His family members (his children and their family)
live away from him, and he lives with his partner Gwen in the retirement village.
Breathing
His respiratory rate is higher than normal. Coarse crackle sound is present during
inspiration. He has a moist and productive cough.
Eating and Drinking
Initially, Liquid (or fluid) diet was given to him, and later it was upgraded to a light diet.
Eliminating

2CASE STUDY
He has a bowel problem, and sluggish bowel sound is present in him. He has not passed
flatus. No output has been observed after since. However, after his breakfast, he vomited
twice on 4th operative day.
Personal Cleansing and dressing
The patient is unable to help in wound dressing. Additionally, he has occlusive dressing in
the abdominal wound.
Mobilising
He has a pre-medical history of gout. Moreover, he is an older adult so he might have some
ambulatory issues after the surgery. He has pain in the abdominal wound so that he could
not move quickly without the help of the nurses.
Working and playing
One year ago, he retired from his job. He lived in a retirement village.
Sleeping
The case study has no evidence of a poor sleeping pattern of the patient.
Death and Dying
He had not expressed any fear or the worry about death and dying. He faced the grief of his
wife's death three months ago.
Response to Question 2
The person is having chest congestion, and his respiratory rate is high (respiratory rate
=26 bpm). He is already a survivor of cardiac failure. The accumulation of fluid in the small
airways and alveoli due to heart failure can result in the crackling sound during the
inspiration of air (Assaad et al., 2018). The intermittent and non-muscular sound might

3CASE STUDY
represent pulmonary oedema in the patient. However, the signs are indicating clinical
respiratory distress due to ARDS and pre-medical condition of congestive heart failure. The
patient is suffering from ARDS and hyperventilation. 3L Nasal Pronge was administered to
him, and SPO2 was recorded as 94% which is at the borderline of the normal range.
The release of vasoactive substances (like serotonin, histamine and bradykinin) causes
vascular narrowing and obstruction in the Airways. Release of these substances increases or
decreases the blood pressure in a patient. In acute respiratory distress, disruption of the
alveolar capillary membrane can be observed. Non-cardiogenic pulmonary oedema can be
occurred due to an increase in capillary permeability and pressure gradient in the pulmonary
capillaries (Clark & Soos, 2019). Vasoactive substances can increase alveolar-capillary
membrane permeability (Doursout, Deshpande & Williams, 2016). The increased
permeability will outward the migration of the blood cells and fluid from capillaries. As a
result, pulmonary oedema can be observed, which leads to the impairment of gas exchange
and hypoxia will occur (Bhatnagar et al., 2018). The vascular narrowing is directly related to
the cause of pulmonary hypertension.
In this case study, the patient is a survivor of heart failure. Heart failure is not directly
related to acute respiratory disorder but may increase the risk of development of this disease
(Richards & Ho, 2020). Pre-medical history of cardiac failure and hypertension are the two
most prominent risk factor in this case. According to the pathogenesis of respiratory disorder
syndrome, bilateral infiltrates diffused in the body of alveolar and destroyed epithelial cells.
Destruction of epithelial cells accumulates fibroblast (Aranda-Valderrama, & Kaynar, 2018).
Acute respiratory disorder syndrome leads to ventilation-perfusion mismatch. With the
progression of the disease, lung damage can be caused by fibrosis formation (in the hyaline
membrane) which declines the compliance (of the lung) and leads to impairment of gas

4CASE STUDY
exchange (Pourfathi et al., 2018). The vascular narrowing is also the cause of impairment of
gas exchange.
He has a history of heart failure and is overweight (BMI= 37.6 m2 and weight=115
kg) person. He takes Captopril which is an ACE inhibitor to reduce hypertension (Masjoan-
Juncos et al. , 2017). Heart rate was regular, and the blood pressure is 135/85 mm Hg.
Therefore, it might be evident that respiratory distress and vomiting are the reasons for his
present elevated blood pressure rate (Elliott & Lawton, 2018). His body temperature is 38.1
C. Blood pressure is elevated as per the repercussion of vomiting and nausea. He was
suffering from respiratory congestion following that the BP can be raised. The increased rate
of blood pressure can be caused due to moderate to severe pain and hypertensive crisis. The
patient has colorectal or gastrointestinal cancer, for which the colostomy was done. As an
effect of colostomy, the body of the patient might show elevated BP along with headache and
vomiting as withdrawal syndrome (Fernandez-Robles et al., 2017). There are different causes
of hypertensive crisis such as withdrawal of antihypertensive medication and the medication
related to the oncological purposes.
Due to the post-operative condition, the person is undergoing the wound-healing
procedure. The pain worsens on palpation for the post-operative wound. The patient has
gastrointestinal cancer and bowel problem. His abdomen is distended. Therefore, distension
and wound might increase the pain of the patient (Tsze et al. , 2018). The pain score is 4-5
out of 10, which is moderate in nature. The pain increased in the severe range, which his 7
out of 10. The abdomen is distended as gas and fluid might be accumulated in the abdomen.
The person is elderly, and his stoma bag was intact, which means no excretory products.
Therefore, it can be said that the person is suffering from bowel problems.

5CASE STUDY
Response to Question 3
The registered nurse should implement the intervention to reduce three major issues in the
patient:
1. ARDS
2. Pain
3. Bowl movement or gastric disorders
As a Registered nurse, chest congestion, pain and problem related to gastric disorders.
The goals will be explained in the following paragraphs.
The nurse will try to reduce the crackling sounds in the chest and increase the oxygen
flow in the lungs. The nurse will try to normalise the respiratory rate (within 22bpm) and will
look after that no ventilator-associated infection.
To manage pain after the operation, the nurse should intervene in a way so that the pain
score will be reduced to 0/10. Interrelating causes or risk factors for pain should be managed
by pharmacological and non-pharmacological intervention. Therefore no related factors
(distension, infection, trauma, poor circulation and poor dressing of wound) will bother the
patient's condition.
The distension in abdomen should be reduced and assessed. The colostomy bag should be
assessed, and the wound should be managed. Therefore, the chances of infection will be
reduced. Patient's bowel movement should be regularised. The bowel sound should be
assessed by the nurses, and the expected complication should be resolved.
Related interventions which will help to establish the above-discussed goals:

6CASE STUDY
1. The lab report should be assessed, and P/F ratio should be detected. Blood gas levels
should be checked (pH, PaCO2, PaO2 and HCO3). Complete respiratory assessment
(inspection, palpation, percussion and auscultation) should be performed with the
evaluation of respiratory distress (Staines, Sheridan & Pickering, 2019). Suctioning,
repositioning, and potential fluid restriction might be required. Sputum specimen
should be collected and is checked by laboratory experts. Nurses should help Ted in
sitting for lung expansion for better inspiration and expiration with proper gas
exchange. Deep breathing and coughing can help in preventing injuries in the lungs.
Nurses help Ted to sit in High-Fowler's Position, and they should help the patient in
turning (Abd Elbaky, 2019).
2. Nurses should give him oxygen supplements with the suggestion of the physician.
The nurses should educate the patient on how to take a deep breath and how to cough.
Deep breathing techniques will help the patient to manage the situation before and
after the nasotracheal suctioning (Meads et al. ,2017). The suctioning will be
administered if coughing and breathing failed. Hydration facilitation and
collaboration with the respiratory therapist for nebuliser management. The prescribed
medications should be given the patient over the clock.
3. Pain should be assessed in both resting and during movement. The quality, severity,
location, onset, duration, and precipitating or relieving factors of pain should be noted
(Nesbit, Browner & Grossman, 2020). Evaluation of the signs and symptoms related
to the pain. As the patient is on PCA, the amount of the medication should be
weighed. The causes related to urinary retention or constipation must be analysed.
4. The occlusive dressing should be changed between 3 to 5 days (Catapano et al.,
2019). Therefore tissue disposition and injury will not happen. The wound should be
checked while changing the dressing. Thus infection or necrosis and hair growth

7CASE STUDY
should be prevented. The catheter, colostomy bag and the transfusion tube should be
checked. The patient had a malignant tumour; therefore, the blood vessels should be
inspected. Obstacles in the blood vessel might be responsible for pain.
5. Nurses need to collect subjective data, such as fatigue, abdominal or rectal pain, and
elimination patterns and check the body weight. The nurse should help the patient by
auscultation and palpation to understand the distention. Hyper and hypoactive bowel
sounds should be analysed care plan will be formed as per the findings (Close, 2019).
6. Proper nutritional habits will be implemented for the patient. The nurses will help the
patient in accepting the distortion of the body. The patient should be encouraged to
take care of the colostomy bag and infection in the stoma (Burch, 2017). Hydration
should be supported by the nurses by the increased rate of fluid intake.
Response to the Q4
Two drugs which are appropriate for the patient are Odansetron and Furosemide.
Furosemide is diuretics by drug class, and continuous dosage of the drug will help in
reducing ARDS (Acute respiratory distress syndrome) by its therapeutic effectiveness
(Hanidziar & Bittner, 2017). The drug will encourage urine output and promotes diuresis by
obstructive tubular reabsorption and acts as the vasodilator by reducing the responsiveness of
vasoconstrictor. Chest pain, chill, cough, sore throat, pain in limbs and muscles are the
results of vasocnstriction. Overdose of the drug will lead to dehydration, renal failure,
seizures and drowsiness. Ondansetron belongs to 5 HT3 antagonists and used for managing
vomiting and nausea as the repercussion of chemotherapy and radiotherapy (Simino et al.,
2016). Ondansetron blocks the actions of chemicals in the body that can trigger nausea and
vomiting. This drug will react with the serotonin receptors in CTZ (Chemotherapy Triggred

8CASE STUDY
Zone) (Navari & Aapro, M. 2016). The reaction will reduce communication to the vomiting
centre of the brain. Anti-emetic actions of the drug will influence antagonise retching in CTZ.
Muscle spasm, diarrhoea, weakness, confusion are side effects of this medicine.

9CASE STUDY
References
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10CASE STUDY
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11CASE STUDY
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