Journal of Visceral Surgery

Running head: SURGICAL CASE STUDY
SURGICAL CASE STUDY
Name of the Student:
Name of the University:
Author Note:

1SURGICAL CASE STUDY
Answer 1.
Edward (Ted) Williams was an eighty-two-year-old male patient who had gone
through a bowel resection surgery, which was followed by a temporary colostomy. After four
days from the completion of his operation, he was provided with a light breakfast and his
regular dose of metformin as he had a history of type 2 diabetes mellitus. However, after
breakfast, Ted vomited twice and also feeling nausea continuously. He also reported
experiencing an abdominal pain, which gets worsened on palpation. When his vital signs
were measured, it was found that he had slightly higher blood pressure and respiratory rate
along with a lower oxygen saturation than usual. There was also right-sided coarse crackles
could be detected along with the fact that the patient was experiencing a moist and productive
cough.
Ted is a widower, having lost his wife three years ago. He has a daughter, named
Janice, who lives two and a half hours away from him with her family. He also has a son,
named Cristopher who lives overseas with his family. The patient currently lives in a
retirement village alone.
The spiritual impact of Ted’s surgery might be resulting from his old age, pain and
discomfort resulting from his surgery and difficulty in the management of his other medical
conditions. His family lives far away from him, and thus they might not be able to help him
with his day to day activity, which can be listed under the biopsychosocial issue affecting his
health. Ted has a helpful neighbour named Gwen, who is also an older adult individual. Thus
her help will also be limited due to both her advanced age and cultural limitations.
Answer 2.
Ted had been gone through a colostomy even before this operation. There was also a
biopsy done on him, which confirmed the presence of malignant mass. He also had a medical

2SURGICAL CASE STUDY
history of type 2 diabetes mellitus, obesity, heart failure and gout. His BMI was 37.6. Ted
was prescribed with metformin, captopril, frusemide, allopurinol and paracetamol. The
paracetamol drug was prescribed for helping him with the pain management; allopurinol was
for his gout and metformin was for controlling his type 2 diabetes mellitus condition. The
captopril drug was prescribed for the heart failure condition in him and the use of frusemide
drug was for encouraging an appropriate urine output after the colostomy. He was also on
morphine therapy for the surgical pain management. Ted was nil by mouth for 48 hours post
his surgery. He was only provided with liquid diet on the morning of the third day. There was
no adverse clinical manifestation in him when he was put on a light but solid diet from the
evening of the third day. It was only after he had his breakfast on the next day morning, he
started feeling nauseous and vomited for two times. Upon nursing examination, his stoma
appeared to be pink, moist, and warm and also to be slightly raised above the skin. Even
though his colostomy bag was intact, there was no output post his surgery. The dressings at
the site of the laparotomy was clear and occlusive, with the presence of minimal ooze. He had
two intubation attached to his body, a redivac drain and a urinary catheter.
The patient was on morphine therapy, yet he reported a severe pain in his abdomen,
that increases in intensity on palpation (Gan, 2017). The appearance of his stoma was normal
and thus the possibility of an inflammation at the stoma can be nullified (Steinhagen, Colwell
& Cannon, 2017). His bandage at the site of surgery was also tight and intact without
displaying any signs for an infection at the area. However, no bowel output including the
passage of flatus through three entire day was abnormal. The noticeable distension of his
abdomen suggests a possibility of gas accumulation inside the bowel. He was kept nil by
mouth for 48 hours post his surgery, which is a usual practice but also increases the risk of
post-operative ileus in the patients (Volpi et al., 2016). He was experiencing a constant
feeling nausea along with frequent vomiting. Both of those clinical manifestations along with

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the abdominal pain and restricted bowel activity can be associated with the post-operative
ileus condition (Liu, Tang, Gong & Chan, 2017). Ted also had a medical history of type 2
diabetes. It has been found from the studies that the patients with diabetes mellitus conditions
are at a higher risk of developing post-operative ileus compared to the non-DM patients
(Ozdemir et al., 2014).
Upon medical examination, there was a right sided inspiratory coarse cackle can be
detected, which was paired with moist and productive cough in the patient. The patient had a
low oxygen saturation along with a slightly higher respiratory rate. All of these symptoms
can be associated with another post-operative condition, named pulmonary edema, which is
also a rare occurrence (Tebay, Bouti & Tebay, 2017).
Thus it can be decided that Ted had developed two main medical condition post his
surgery, which were a post-operative ileus condition and a pulmonary ileus condition. The
post-operative ileus is a common complication associated with the gastrointestinal surgery.
The pulmonary edema on the other hand, is a rare post-operative condition. The post-
operative ileus results from an inhibition of the gastrointestinal (GI) motility. There are
various factors responsible for this inhibitory effect. The opioid therapy, sympathetic and
parasympathetic nervous system activity, the activity of various hormones, neurotransmitters
and also some local inflammatory mediators in the post-operative condition promotes the
inhibition of the GI motility. The phenomenon results into gaseous accumulation within the
bowel along with a delayed bowel output (Venara et al., 2016).
The post-operative non-cardiogenic pulmonary edema is also known as negative
pressure pulmonary edema (NPPE). NPPE is a rare condition that can be associated with the
general anaesthesia. A high negative intrathoracic pressure disrupts the alveolar-capillary

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membrane, which results in a leakage of fluid and blood inside the lungs. The condition
might lead to respiratory failure if not addressed in time (Lemyze & Mallat, 2014).
Answer 3.
The NPPE condition in Ted can be considered as the priority condition compared to
his post-operative ileus condition. Thus the first nursing goal will be focused on this NPPE
condition in Ted. There must be successful management of the NPPE condition in him,
within 24 hours of time. The nursing intervention for the achievement of this goal is the
application of the oxygen therapy by using a Continuous Positive Airway Pressure (CPAP)
machine. The rationale for this intervention is that the application of the positive pressure
help in the neutralisation of the build-up of negative pressure on the respiratory system. The
body gradually heals the disrupted alveolar-capillary membrane if the pressure is no-longer
contributing in the process of disruption, which restores the normal activity of the respiratory
system (Liu, Wang, Zhao & Su, 2019). Thus the intervention will be lowering the risk of
complete respiratory failure in the patient considerably. The success of the intervention can
be determined by monitoring the oxygen saturation in the patient along with observing him
for the possible respiratory distress symptoms in him.
The second nursing goal will be focusing on the post-operative edema condition in
Ted. The nursing goal focusing on this condition will be a successful management of the
post-operative ileus condition in Ted along with lowering the risk of intestinal trauma within
three days of time. There are about three nursing interventions, which can be considered
useful for the achievement of this goal.
1. The post-operative ileus condition creates electrolyte imbalance in the body. There is
also a high risk of malnutrition as the patient’s body rejects any form of nutrition
taken by mouth. Thus the first nursing intervention for the management of this

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condition should be an administration of necessary nutrients and electrolytes through
intravenous route. The fluid also supply the necessary water for maintaining an
appropriate homeostasis in the body (VandeHei, Papageorge, Murphy & Kennedy,
2017). This intervention will prevent the risk of dehydration in the patient and the
evaluation of this intervention can be achieved by monitoring the patient for the signs
and symptoms of dehydration.
2. The patient was experiencing severe pain in his abdomen due to the gaseous
accumulation. Thus the second intervention should focus on lowering this pain in the
patient along with improving the bowel activity in him. The nasogastric
decompression is the application of a nasogastric tube for the releasing the gaseous
contents of the stomach (Vilz et al., 2017). The tube is generally inserted through the
nose of an individual for releasing the accumulated gas resulted from the inhibition of
the GI motility. The success of the intervention can be evaluated by monitoring the
distention of the patient’s abdomen and interviewing him about the severity of his
pain.
3. The third intervention should be based on the pharmacology. The contributing factors
for the inhibition of GI motility in the patients include the activity of sympathetic and
parasympathetic nervous system and the local inflammatory agents. It has been found
from the studies that the activation of sympathetic nervous system inhibits the
parasympathetic nervous system activity of promoting the inhibition of GI motility
(Peters et al., 2015). Thus the drugs, such as the beta receptor agonists will be
effective in promoting the GI motility by the activation of the sympathetic nervous
system. The drugs, such as NSAIDs are the anti-inflammatory agents, who inhibits
the inflammatory mediators and thus the application of these drugs will also be
effective for inviting a positive response in the patient (Milne, Jaung, O'Grady &

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Bissett, 2018). The evaluation can be achieved my monitoring the symptoms of
vomiting and nausea in the patient.
The last nursing goal will be focused on preventing the possible nosocomial infection in
the patient during the period of his stay at the healthcare facility. The nursing intervention for
the achievement of this goal will be maintaining an appropriate sanitized environment around
Ted (Haque et al., 2018). The evaluation of this intervention can be achieved by monitoring
him continuously for any signs or symptoms of microbial infection.
Answer 4.
The Non-Steroidal Anti-Inflammatory drugs or NSAIDs are also known as the anti-
inflammatory drugs. The drugs are involved in the inhibition of inflammation event inside the
body. There are various mechanisms by which the activity of the inflammatory mediators are
prevented. As it was previously discussed, the activity of the inflammatory mediators are
responsible for mediating the inhibition of the GI motility in the patients. Hence, the
administration of NSAID drugs will aid in a successful management of the post-operative
ileus condition in the patient. The side effects of the drug include apnoea, headache, nausea,
respiratory distress, hyperkalemia and various others (Ghlichloo & Gerriets, 2019).
The beta receptor agonist drugs mimic the ligands for the beta receptors, which are
the epinephrine and the norepinephrine. The binding of those drugs to the beta receptor sends
a stimulation signal for the sympathetic nervous system activity (Alhayek & Preuss, 2018).
There is a lower activity of the sympathetic nervous system in the post-operative condition,
which acts as a stimulatory factor for the GI motility inhibition. Thus the activity of these
drugs will also be able to improve the GI motility in the patients, promoting a successful
management of the post-operative ileus condition in Ted. The side effects of this drug

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includes hypertension, insomnia, tachycardia, tremors and various others (Alhayek & Preuss,
2018).

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Alhayek, S., & Preuss, C. V. (2018). Beta 1 Receptors. In StatPearls [Internet]. StatPearls
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Ghlichloo, I., & Gerriets, V. (2019). Nonsteroidal Anti-inflammatory Drugs (NSAIDs).
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inflammatory drugs reduce the time to recovery of gut function after elective

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