Surgical Case Study | Answers

Surgical Case Study
Name of the Student
Name of the University
Author Note

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Answer 1
According to the clinical reasoning cycle, Ted’s situation must be evaluated
first(Utas.edu.au., 2020). Ted is currently postoperative and has a temporary colostomy.
Having a stoma often impacts certain aspects of a person’s life. According to the R-L-T
model of nursing, the assessment of a patient is based on the activities of living, and factors
influencing those(Williams, 2017). The major psychosocial issues that are faced by patients
are usually related to body image issues, negative perception of the stoma, or lack of self-
confidence. It is possible that Ted may have been feeling insecure about his stoma. Patients
also tend to suffer from depression and sexual problems(Ayaz‐Alkaya, 2019). Ted has a
partner named Gwen, who lives in the same community like him, and he may also be worried
about how she might view him. This sort of psychological issue is common and may
influence the activities of the daily life of the patient. Having a stoma may also lead to Ted
requiring help and thus become less independent in accordance with the R-L-T
model(Williams, 2017). Ted may also feel apprehensive about going outside and interacting
in professional environments(Campos et al., 2017). There has been a steady report of
colostomy patients feeling a decrease in spiritual wellbeing, which may occur to Ted as
well(Repić et al., 2018). The concept of the stoma may be perceived differently in many
cultures. Ted may find it humiliating, and there are reports of patients feeling ashamed
enough to avoid going to churches (Campos et al., 2017). This way, Ted’s daily life may be
heavily impacted.
Answer 2
According to the Clinical Reasoning Cycle(Utas.edu.au., 2020), the second step is to
collect the cues from the patients. Ted is currently post-operative and recently switched from
nothing by mouth to a fluid diet and then a light diet, which resulted in him nauseous and

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vomiting. He is suffering from inspiratory coarse crackles on the right side of his chest as
well as a productive cough. He has some abdominal pain that is managed by morphine. His
abdomen is distended, and there has been no output for four days. There are sluggish bowel
sounds present, as well. These are the cues that have been presented. As for his history, he
has a history of Type II Diabetes, Heart failure, gout, and obesity. So, following the next
steps of the Clinical Reasoning Cycle, which is processing information and identifying the
problems, these cues need to be assessed.
From the above cues, the nurses can identify some possible conditions that Ted is
most likely suffering from. Ted is four days postoperative and has not had any output since
after the surgery. So, it can be understood that impairment of gastrointestinal motility may
have occurred, most likely due to the bowel resection surgery. This is known as Postoperative
ileus. This is a condition that is characterized by bowel distention as well as a lack of bowel
sounds. Ted is suffering from a distended bowel as well as sluggish bowel sounds.
Postoperative ileus is also characterised by the accumulation of gas in the GI tract, which
results in delayed passage of stool and flatus, as happening with Ted. Vomiting and nausea is
also an important characteristic of the condition. It has been seen that the patients are unable
to tolerate a liquid or semi-liquid diet. The morphine used for pain relief may also be a factor
that increased his risk for post-operative ileus(Venara et al., 2016). In terms of
pathophysiology, the surgical procedure stimulates the afferent nerves due to the incision
caused.The disruption of sympathetic/parasympathetic nerves in the gastrointestinal tract
leads to a later prolonged inflammatory phase. The manipulation of the macrophages by the
surgery leads to the entry of inflammatory elements like neutrophils and monocytes in the
muscle(Stakenborg, Gomez-Pinilla &Boeckxstaens, 2016). The majority of this mechanism,
however, still remains unclear.

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The second critical problem that Ted may be facing is related to his inspiratory coarse
crackles and productive cough. There is a vast array of conditions that may result in the
production of inspiratory coarse crackles. However, it is vital to remember Ted has a history
of heart failure, and he is currently taking Captopril medication, often prescribed for
Congestive Heart Failure(Pubchem.ncbi.nlm.nih.gov., 2020). It has been seen that in patients
of CHF, the symptoms may increase after major surgery, such as bowel resection. CHF may
sometimes cause pulmonary edema, which means fluid has accumulated in the alveolar
space.This leads to productive cough, palpitations, and inspiratory crackles, which are all
apparent in Ted’s case, including high blood pressure. As for pathophysiology, this often
occurs when the heart is unable to pump the efficiently, and the blood backs up into the veins
that carry the blood through the lungs. When the pressure in the blood vessels becomes high,
the fluid may be pushed into the alveolar space, causing pulmonary edema(King & Goldstein,
2020). Pulmonary edema is the major cause of the patient having inspiratory coarse crackles.
This may be dangerous for the patient. This may also be caused by pneumonia, but since Ted
has a history of heart failure, it is the most likely cause in his case.
Answer 3
In accordance to the next step of the Clinical Reasoning Cycle(Utas.edu.au., 2020),
the nurses must set goals and provide proper interventions to Ted. The primary nursing care
goals should include taking care of his Postoperative Ileus as well as pulmonary oedema. The
interventions that should be administered are as follows.
 In most cases, postoperative ileus can be controlled with supportive treatment and
watching the patient. Since the patient already has many comorbidities, his vitals
should be kept continuously checked, and he should be kept under close observation.

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The patient’s vitals should be checked continuously, and the tests must be conducted
as well.
 The medications should be checked. It has been seen that Morphine often increases
the severity of the condition. Here, Ted has been on morphine to reduce his surgical
pain. He should be taken off morphine and suggested something else for his pain. This
may also include ways to manage pain without medication after surgery. Examples of
such interventions may include- slowly increasing physical exercise, which has often
proven to be helpful in the management of pain or controlling the stress level of the
patient by being supportive and encouraging him. It is also possible to administer pain
medication intravenously(Nair, 2019).
 The major nursing support that is required here is support and education. The patient
just went through a major operation, and they are suffering from postoperative
conditions that may be causing him distress. At this point, it is extremely important
that the nurses encourage and support him throughout the treatment. The nurses must
also educate him on his postoperative condition. Postoperative ileus often causes
longer hospital stays and higher bills, which may be distressing to the patient. The
prolonged hospital stay may be causing stress to Ted. So the nurses must be
supportive and provide Ted with encouragement. In terms of patient education, he
must be explained what procedures are being done to him and why it is necessary.
This will enable him to feel more in control and may reduce his stress. This is
important for any patient who has undergone surgery (Arvelos Mendes et al., 2018).
 According to the Parisien-La Salle et al. (2019), older adults are vulnerable to airway
clearance and this increase the risk of developing emphysema along with higher risk
of sputum production. Thus nursing intervention for the removal of the moist cough
from chest includes breathing exercise. The initiation of breathing exercise must be

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initiated through deep breathing through mouse followed by slow breathing with the
help of nose. This helps in expansion of the diaphragm and thus helping in the
removal of the thick moist cough from the chest. The exercise must be practiced three
to five times of day. Deep and slow breathing exercises must be followed by pursed
lip-breathing first slowly and then rapidly and this will further help in increasing the
chances of removal of the thick cough from the chest and thereby helping to ease the
process of breathing and airway clearance. Proper regulation of the breathing exercise
will help in reducing the chances of developing course crackles.
 Case study highlights that the Ted has unregulated body weight. Decrease in the level
of unregulated body weight in case of Ted can be done through the proper regulation
of the diet plan. Ted is over-weight as highlighted in the case study and thus dietary
intake will involve restriction of the carbohydrate and fat and sweet intake in the diet.
Proper nutritional planning must be done under the guidance of the trained dietician.
Physical exercise might not be an option for Ted keeping his age into consideration
and this post surgical condition (Ríos-Hoyo & Gutiérrez-Salmeán, 2016).
Answer 4
It is known that opioids such as morphine often stimulate and enhance postoperative
ileus. So, one of the possible treatments of this condition is known to be opioid antagonists.
Opioids antagonists act on one or more opioid receptors to block off the effects of opioids.
Thus the opioids cannot impact the system. Naloxone is a possible option that can be used on
Ted for treating his postoperative ileus. This medication should be administered
intravenously for Ted as he is mostly unable to keep anything down when taken orally. Since
this medication reduces the effect of opioids, it will reduce the effect of morphine-induced
postoperative ileus(Schwenk et al., 2017). Thus this will enable the treatment of Ted. It is
used for the reversal of opioid dosage, so it will decrease the effect of opioids that Ted has

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already taken. It has low chances of harming a patient, so it can be an ideal drug to use.
Peripherally selective opioid antagonists such as Methylnaltrexone and alvimopan can be
used as well. However, alvimopanis often associated with an increased risk of heart attack,
and since Ted has a history of heart failure, this medication should be avoided (Zhang & Xu,
2017).
The other class of drugs that may be used are Cyclooxygenase-2 inhibitors. These are
non-steroidal anti-inflammatory drugs that are often observed to be useful in treating
postoperative ileus. These drugs (NSAIDs) stop the conversion of arachidonic acid to
prostaglandin. Prostaglandins have been proven to enhance gastrointestinal motility after
bowel surgery. So, this will be useful in treating postoperative ileus for Ted (Zhang & Xu,
2017). Patient may experience nausea, insomnia, and flatulence etc. Zhang and Xu (2017)
stated that the lining of the gastro-intestinal tract (GI) are exposed to damage leads to the
generation of the post-operative ileus. Prostoglandins (PG) mainly PGE2 and PGI2 play an
important role in modulating the GI tract followed by promotion of the defence mechanism.
COX-2 inhibitors inhibit the PG synthesis and this helps in the reduction of the inflammation
in the GI tract and in the intestine and thus helping in decrease the disease severity. Another
explanation states that NSIADs help in reducing the mucus and other bicarbonate secretion in
the small intestine and stomach and thereby helping to reduce the damage of the GI walls.
However, this category of drug also triggers the adhesion of the leucocytes to the GI tract
and thus increase the chance of NSAID-indiced mucosal ulberation and thus while
prescribing the medication, proper efforts must be undertaken by the doctors (in the domain
of dosage determination).

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Reference
Arvelos Mendes, D. I., de Almeida Clemente Ferrito, C. R., & Rodrigues Goncalves, M. I.
(2018). Nursing Interventions in the Enhanced Recovery After Surgery (R): Scoping
Review. REVISTA BRASILEIRA DE ENFERMAGEM, 71, 2824-2832.
Ayaz‐Alkaya, S. (2019). Overview of psychosocial problems in individuals with stoma: A
review of literature. International wound journal, 16(1), 243-249.
Campos, K. D., Bot, L. H. B., Petroianu, A., Rebelo, P. A., Souza, A. A. C. D., &Panhoca, I.
(2017). The impact of colostomy on the patient's life. Journal of Coloproctology (Rio
de Janeiro), 37(3), 205-210.
King, K. C., & Goldstein, S. (2020). Congestive Heart Failure And Pulmonary Edema.
In StatPearls [Internet]. StatPearls Publishing.
Nair, A. S. (2019). Management of opioid induced postoperative ileus: the current
scenario. Anaesthesia, Pain & Intensive Care, 380-382.
Pubchem.ncbi.nlm.nih.gov. (2020). Captopril. Retrieved 2 April 2020, from
https://pubchem.ncbi.nlm.nih.gov/compound/Captopril.
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prescriber, 40(2), 59–63.
Repić, G., Ivanović, S., Stanojević, Č., &Trgovčević, S. (2018). Psychological and spiritual
well-being aspects of the quality of life in colostomy
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Ríos-Hoyo, A., & Gutiérrez-Salmeán, G. (2016). New dietary supplements for obesity: What
we currently know. Current obesity reports, 5(2), 262-270.

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Schwenk, E. S., Grant, A. E., Torjman, M. C., McNulty, S. E., Baratta, J. L., &Viscusi, E. R.
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Zhang, L., & Xu, X. (2017). Therapeutic management of postoperative ileus. Translational
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