NRSG258 Principles of Nursing: Mr. Ted’s Case | Assignment

Hi, according to the rubric is essential ,I have attached question and rubric in same page. We can't assume thing therefore, it's basically on what case study is and only about information given there. Hypertension is also Ted past history that's missing there Due date on 20th April Monday at 2pm. Thankyou

Running head: PRINCIPLES OF NURSING 1
NRSG258; Principles of Nursing: Mr. Ted’s Case
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PRINCIPLES OF NURSING 2
Question 1
According to the RLT model of nursing, the activities of living carried out by Mr. Ted are
suggestive and could potentially affect the outcome of any surgical procedure performed on him.
This model specifies how bio psychosocial, cultural and spiritual factors can have impacts on
someone’s health (Cao, White & Ma, 2017). Below is an overview of how the RLT model of
nursing care was applied in the clinical assessment of Mr. Ted.
The first element of the RLT model is maintaining a safe environment. Mr. Ted was an
obese patient who had a urinary catheter in situ. After his surgical procedure to remove the mass
in his colon, he had a surgical wound that was infected. He also had a colostomy bag in place
and had no output since the procedure. Effective communication is also an RLT model (Cao,
White & Ma, 2017). He was communicating with the nurses. He gave them information of the
morning day of his surgery on how he was faring on. His breathing had also been affected by the
surgery. The respiratory rate had increased to 26 breaths per minute. The bold oxygen saturation
level was 90%.
Another element of the RLT model is eating and drinking (Du, Li, Qu, Li & Bao, 2019). This
was an obese patient who also had gout. He had his bowel prepared for the effectiveness of the
surgery. He remained nil by mouth for the first two days after the surgery. He started ordinary
diet on a full fluid diet and on their day post-operative; he was given his regular metformin and
breakfast. Proper nursing care had been considered in order to make him eliminate his urine and
fecal contents. It is reported that he voided 60 to 70 mls of urine per hour. A colostomy bag was
also in place. In terms of personal cleansing, it is not told whether Mr. Ted had the ability to
clean himself. His body temperature was 38.1 degrees Celsius. In terms of mobilization, he could

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move and turn in his bed. Working and playing are the RLT elements that had been affected by
his condition (Du, Li, Qu, Li & Bao, 2019). His wife had died three years ago from pneumonia.
Expressing sexuality; Mr. Ted’s wife had died and had a friend, Gwen, who was living nearby. It
is however not known whether his sleep had been affected.
Question 2
The two identified problems during the assessment of Mr. Ted were abdominal distention
& obstruction and post-operative pain with nausea & vomiting. These were in the post-operative
period on the fourth day. It should be remembered that he had a bowel resection procedure done
on him to remove the large mass in his descending colon. The evidence form the case study to
support the problem of intestinal obstruction is that he had started eating on the third day post-
surgery but had not voided anything into the colostomy bag connected to his stoma. Another
pathophysiology linked to this problem is that he exhibited a clinical symptom of vomiting (Du,
Li, Qu, Li & Bao, 2019). This is suggestive of an obstruction. He also complained of abdominal
pain that could be as a result of the obstruction. The intestinal contents could have exerted
pressure on nearby organs hence the pain, considering that he had had a bowel resection
(Shoqirat, Mahasneh, Dardas, Singh & Khresheh, 2019).
Mr. Ted did not eat anything first 48 hours post-surgery. On the 3rd day, he had a meal
made up of only fluids in the morning and a light meal in the evening. He was given his regular
metformin and breakfast on this 4th day. However, he feels nauseated and has vomited twice.
This raises a red flag for the care givers. The collected information also narrows down to the
possibility of having an infection due to the fever (Feng-Juan, Yu, Hua, Jin-Zhuo & Zhen-
Zhong, 2019).

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He had post-operative pain which he rated it at 4-5/10 and increased in its severity to 7/10
on palpation. He was given morphine as an analgesic to help counteract the pain. This was
somehow helpful. However, morphine leads to a reduced respiratory rate and also slows down
intestinal movements (Feng-Juan, Yu, Hua, Jin-Zhuo & Zhen-Zhong, 2019). These side effects
are potentially life threatening considering the fact that he had been given a general anesthesia
during his surgery that could as well be having the same side effects (Hesketh et al., 2017).
Therefore, the observed slowed bowel movements and his intestinal obstruction could be as a
result of the morphine given (Roshanov et al., 2017). He was also given ondansetron to relieve
his nausea and vomiting. This drug has similar side effects, and hence could have exaggerated
his condition (Feng-Juan, Yu, Hua, Jin-Zhuo & Zhen-Zhong, 2019).
He also had an abdominal laparotomy which had clear occlusive dressing with minimal
ooze. The stoma margins were slightly raised above the skin, warm, pink ad moist. There was
no output into the colostomy bag since the surgery had been performed. A urinary catheter was
in place, draining about 60 to 70 mls of urine per hour. This shows that his kidneys were
functioning normally (Manworren, Gordon & Montgomery, 2018).
The nurse took his vital signs in the morning and found out that his temperature was 38.1
degrees Celsius, a heart rate of 98 beats per minute, a blood pressure of 135/85, a respiratory rate
of 26 and an oxygen saturation level of 90%. The raised temperature could indicate that he had
fever that could have been caused by a possible infection (Manworren, Gordon & Montgomery,
2018). He had right sided inspiratory course crackles with a moist productive cough. All these
observations should have been carefully taken into consideration as they are normally the
indicators of health (Shoqirat, Mahasneh, Dardas, Singh & Khresheh, 2019).

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Therefore, the problem linked to Mr. Ted is abdominal obstruction with distension and
nausea & vomiting. The margins of his stoma on which the colostomy bag was connected were
raised and swollen. The high fever could possibly indicate potential infection at the wound
site .This problem should therefore be well taken care of with proper care plan goals and
interventions (Hesketh et al., 2017).
Question 3
 The first identified problem is abdominal distention with obstruction. His surgical
procedure involved bowel resection to remove the mass in his descending colon. Mr. Ted
had eaten yet there was no output since surgery. His bowel sounds were sluggish and he
had not passed flatus.
 The goal to address his abdominal distension should be to assess and palpate his abdomen
in order to find out the exact location of the obstruction. This helps to find out whether
the obstruction is directly related to his previous surgical procedure (Assis et al., 2018).
Another goal in regards to his abdominal obstruction would be to give medication or stop
the administration of existing drugs in order to normalize bowel movements (Shoqirat,
Mahasneh, Dardas, Singh & Khresheh, 2019).
 The nursing intervention to handle this would therefore be regular assessments and
frequent taking of his vital signs (Jeppesen, Tolstrup, & Gögenur, 2016). This abdomen
needs to be auscultated in order to identify whether the bowel movements are
normalizing. The second and most important intervention is to stop the administration of
morphine (Manworren, Gordon & Montgomery, 2018). This is because morphine causes
slowed bowel movements with potential constipation. Nabilone, an opioid receptor

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antagonist, can also be given to counteract the slowed bowel movements (Jeppesen,
Tolstrup, & Gögenur, 2016).
 The second problem in regards to Mr. Ted is his pain coupled with nausea and vomiting.
He already had morphine is situ that had been intended to take care of his pain. However,
morphine is an opioid analgesic that has side effects of slowing down the bowel
movements and increasing the level of fecal continence. This is through its action on the
acetylcholine receptors in the small intestines (Jeppesen, Tolstrup, & Gögenur, 2016).
This increases the pressure on the blockage and hence exaggerating the pain The goal as
far as this problem is concerned would be to alleviate the abdominal pain and relieve the
pressure exerted on the abdominal contents due to the blockage The goal as far as this
problem is concerned would be to alleviate the abdominal pain and relieve the pressure
exerted on the abdominal contents due to the blockage (Jeppesen, Tolstrup, & Gögenur,
2016). The food eaten is thus voided through vomiting.
 The goal as far as this problem is concerned would be to alleviate the abdominal pain and
relieve the pressure exerted on the abdominal contents due to the blockage. This is a very
significant target as pain free patients in the surgical recovery ward have been shown to
improve and heal faster because they are stress free (Assis et al., 2018).
 The nursing intervention that should be conducted in order to achieve this goal would be
stopping the delivery of morphine as an analgesic. Probably, an opioid receptor
antagonist like nabilone might be considered. This helps relieve the pressure in his
abdomen (Shoqirat, Mahasneh, Dardas, Singh & Khresheh, 2019). It is also beneficial to
this patient as he had complained of nausea and vomiting. Nabilone has also been

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approved by the food and drug administration for the treatment of nausea and vomiting
(Shoqirat, Mahasneh, Dardas, Singh & Khresheh, 2019).
 Another nursing intervention in regards to Mr. Ted would be to carry out a proper wound
assessment and cleaning. This is because his temperature was 38.1 degrees Celsius
meaning that he had fever. This could be due to an infection of his surgical wound.
Question 4
Pain and nausea & vomiting were his major complains. He rated the pain at 4-5/10 when
relaxed and 7/10 when his abdomen was palpated. The pain should therefore be controlled
adequately by the use of analgesics. Patient controlled analgesia has proved to be efficient for the
management of post-operative pain. Nausea and vomiting could be controlled by use of
antiemetics like ondansetron which prevent postoperative nausea and vomiting (Assis et al.,
2018).
The rationale for use of PCA is because Mr. Ted’s pain increased on palpation.
Movement was an exaggerating factor and so he could press the button in anticipation of
movement. Most PCA contain morphine, which works by blocking some receptors used in pain
perception. The potential side effects include nausea, vomiting, reduced cognition and itching.
However, he had already been given morphine which causes constipation and worsens intestinal
obstruction. Therefore, this should be replaced with paracetamol (Assis et al., 2018).
Ondansetron is effective for the treatment of post-operative nausea and vomiting. It is
implicated for this because it inhibits the serotonin 5 HT3 receptors, and thus blocking the
chemicals that are involved in the generation of nausea and vomiting (Grant, Yang, Wu, Makary
& Wick, 2017). Its potential side effects include blurred vision, slowed heart rate, breathing

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difficulties, anxiety and shivering. Nabilone is an opioid receptor antagonist. It could be also
used to offset the reduced bowel movement. It is also meaningful since it can help reduce the
side effects of ondansetron such as breathing difficulties and the intestinal obstruction which
could have been caused by morphine (Jeppesen, Tolstrup, & Gögenur, 2016).

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References
Assis, G. L. C., Sousa, C. S., Turrini, R. N. T., Poveda, V. B., & Silva, R. C. G. E. (2018).
Proposal of nursing diagnoses, outcomes and interventions for postoperative patients of
orthognathic surgery. Revista da Escola de Enfermagem da USP, 52, e03321-e03321.
Cao, X., White, P. F., & Ma, H. (2017). An update on the management of postoperative nausea
and vomiting. Journal of anesthesia, 31(4), 617-626.
Du, C., Li, H., Qu, L., Li, Y., & Bao, X. (2019). Personalized nursing care improves
psychological health, quality of life, and postoperative recovery of patients in the general
surgery department. Int J Clin Exp Med, 12(7), 9090-9096.
Feng-Juan, W., Yu, Y., Hua, Y., Jin-Zhuo, W., & Zhen-Zhong, W. (2019). Effect of three kinds
of anaesthetic drugs on postoperative recovery, regulatory T cells and T lymphoid cells in
elderly patients. Tropical Journal of Pharmaceutical Research, 18(2), 391-395.
Goyal, K., Davin, S., & Rispinto, S. (2019). 271. A biopsychosocial approach in the management
of chronic low back pain: 2-year outcomes. The Spine Journal, 19(9), S132.
Grant, M., Yang, D., Wu, C., Makary, M., & Wick, E. (2017). Impact of Enhanced Recovery
After Surgery and Fast Track Surgery Pathways on Healthcare-associated
Infections. Annals Of Surgery, 265(1), 68-79.

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Hesketh, P., Kris, M., Basch, E., Bohlke, K., Barbour, S., & Clark-Snow, R. et al. (2017).
Antiemetics: American Society of Clinical Oncology Clinical Practice Guideline
Update. Journal Of Clinical Oncology, 35(28), 3240-3261
Jeppesen, M., Tolstrup, M., & Gögenur, I. (2016). Chronic Pain, Quality of Life, and Functional
Impairment After Surgery Due to Small Bowel Obstruction. World Journal Of
Surgery, 40(9), 2091-2097.
Kang, D., Kim, I., Choi, E., Yoon, J., Lee, S., & Lee, J. et al. (2017). Who are happy survivors?
Physical, psychosocial, and spiritual factors associated with happiness of breast cancer
survivors during the transition from cancer patient to survivor. Psycho-Oncology, 26(11),
1922-1928.
Keeley, P. (2020). Nausea and vomiting in palliative care. Medicine, 48(1), 14-17.
Kreijtz, J., Fouchier, R., & Rimmelzwaan, G. (2011). Immune responses to influenza
virus infection. Virus Research, 162(1-2), 19-30.
Lee, L., & Feldman, L. (2017). Improving Surgical Value and Culture Through Enhanced
Recovery Programs. JAMA Surgery, 152(3), 299.
Ljungqvist, O., Scott, M., & Fearon, K. (2017). Enhanced Recovery After Surgery. JAMA
Surgery, 152(3), 292.
Manworren, R. C., Gordon, D. B., & Montgomery, R. (2018). CE: managing postoperative pain.
AJN The American Journal of Nursing, 118(1), 36-43.

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Roshanov, P., Rochwerg, B., Patel, A., Salehian, O., Duceppe, E., & Belley-Côté, E. et al.
(2017). Withholding versus Continuing Angiotensin-converting Enzyme Inhibitors or
Angiotensin II Receptor Blockers before Noncardiac Surgery. Anesthesiology, 126(1),
16-27.
Shoqirat, N., Mahasneh, D., Dardas, L., Singh, C., & Khresheh, R. (2019). Nursing
Documentation of Postoperative Pain Management: A Documentary Analysis. Journal
of nursing care quality, 34(3), 279-284.