The body temperature was higher with systolic hypertension

Running head: NURSING
Nursing-Medical Surgical
Name of the Student
Name of the University
Author Note

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Table of Contents
Question 1........................................................................................................................................2
Question 2........................................................................................................................................3
Question 3........................................................................................................................................5
Question 4........................................................................................................................................7
References........................................................................................................................................9

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Question 1
The patient Ted Williams, an octogenarian is currently in post-operative care, after being
subjected to a bowel resection surgery and temporary colostomy. In the words of the Roper,
Logan and Tierney model of nursing appropriate clinical judgment, disease diagnosis,
development of care plan, implementation of intervention, and evaluation of health outcomes
form core aspects of nursing (Holland & Jenkins, 2019). The bowel resection surgery will
significantly affect activities of living of Ted, principally on movement, excretion, breathing,
sleeping, and self-care. On assessing the patient, inspiratory crackles and moist productive cough
were observed and the assessment confirmed slightly higher respiration rate (26 bpm). The body
temperature was higher (38.1°C), with systolic hypertension (135/85) and normal oxygen
saturation levels (94%). Additionally, Ted reported a pain score of 4-5/10 that increased on
palpation.
The surgery is expectedly to result in substantial biopsychosocial impact by subjecting
the patient to psychological anguish and agony, in addition to causing apprehensions and worry
amongst his family members, who do not live with him. Not only will the surgery cause major
monetary distress, but isolation from family would also prevent easy recovery from the condition
(Hallowell et al., 2017). Surgical patients have often been found to seek solace in spiritual
activities and teachings. Thus, Ted might show an interest in obtaining assistance from a spiritual
leader for coping with the surgery. It is anticipated to improve his recovery from the current state
(Tajbakhsh, Hosseini & Rahgozar, 2016). Despite lack of information on his cultural viewpoint,
if the health professionals are not culturally competent, Ted will demonstrate a poor health
outcome (Fayi et al., 2018).

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Question 2
Analysis of the case scenario suggests that the patient Ted had been suffering from malignant
colorectal cancer. Colorectal cancer typically originates from the lining of the epithelial cells
near the rectum or colon, of the gastrointestinal tract. The condition frequently occurs due to
mutations in the Wnt signalling pathway that results in upregulated signalling activity (Schatoff,
Leach & Dow, 2017). Pathophysiology of his condition can be accredited to mutation in APC
gene that is responsible for the production of APC protein. This protein inhibits β-catenin
accumulation. Therefore, in absence of this protein, there was a build-up of β-catenin that got
translocated to the nucleus, following which it formed a bond with the DNA, and resulted in the
activation of proto-oncogene transcription (Han et al., 2017).
In addition colorectal cancer, as reported by the patient can also be attributed to the activation of
mother proteins like DCC (Deleted in Colorectal Cancer) and TGF-β. Additionally, there is a
growing body of evidence for the overexpression of particular oncogenes in colorectal cancer
such as, those responsible for encoding the protein PI3K, RAF, and KRAS, all of which under
normal circumstances, stimulate division of a particular cell, in relation to growth factors (Filbin-
Wong, Gonen & Kieft, 2018). The aforementioned proteins acquired mutations that are
responsible for cell proliferation. The patient Ted reported signs and symptoms of several risk
factors that increased his likelihood of suffering from colorectal cancer, due to which he was
subjected to a temporary colostomy.
From the case scenario it was found that he had a history of type 2 diabetes mellitus, gout
and obesity, in addition to having suffered from heart failure. Research evidences elaborate that
T2D is correlated with the higher risk of suffering from colorectal cancer, in both males and
females, particularly during the initial months after diagnosis of diabetes, and the risk is greater

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in the proximal colon (De Kort et al., 2017). The patient was 82 years old, which also acted as a
significant risk factor for his condition. This can be accredited to the fact that T2D has been
correlated with a sub-site specific and time varying increased risk of colorectal cancer, which in
turn is particularly greater in males, who are aged more than 65 years (Jeon et al., 2018).
Epidemiological research studies have consistently elucidated a positive correlation between
colorectal cancer and obesity (Jochem & Leitzmann, 2016). The relative risk that is allied with
obesity as measured in terms BMI is found to be greater among males, in comparison to their
female counterparts for cancer of the colon, rather than cancer that affect the rectum. In addition,
the fact that individuals who demonstrate an increased likelihood of being affected with
colorectal cancer, in comparison to normal weight individuals provides an explanation for Ted
acquiring the condition that required bowel resection. Hence, obesity and uncontrolled T2D are
two significant problems that need to be addressed.
Ted also reported pain score of 4-5/10 that worsened during palpation, hence, this was another
significant problem. Signs of pain, following surgery provide an indication of surgical
complications such as, any obstruction in the normal functioning of the bowel that also leads to
vomiting and nausea. In addition, intestinal obstruction have also been found to result in
approximately 65-70% small bowel obstruction, concomitant with pain, vomiting, nausea, and
bowel function alterations (Riiskjær et al., 2018). Presence of a distended abdomen was another
significant problem that required immediate treatment. Abdominal distension typically occurs
due to accumulation of fluid or gas, following a surgery, and often results in an increased airway
pressure or oliguria. The bowel resection might have resulted in postoperative ileus that
eventually caused an impairment of gastrointestinal motility (Adiamah & Lobo, 2020). If left
untreated, the condition can also lead to abdominal compartment syndrome. Another problem

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that was identified from the case scenario was inspiratory coarse crackles that provide an
indication of excessive fluid accumulation that could have been a direct consequence of
pneumonia, chronic bronchitis, pulmonary oedema due to history of heart failure, or aspiration
(García et al., 2019).
Question 3
Below given are the five goals and their nursing interventions for the problems identified:
1. To obtain blood glucose reading not more than 180 mg/dL with fasting blood glucose
level below 140 mg/dL, within 24 hours.
The nursing intervention would focus on assessing blood glucose of the patient at bedtime and
before meals, in addition to monitoring the patient for neuropathy and peripheral perfusion. The
patient would be administered rapid acting insulin such as, lispro at the time of eating. The
effects of this insulin would typically last for approximately 5 hours. Lispro will be administered
for managing his blood glucose levels, since the final proline and lysine residues that are present
at the end of the B-chain on the C-terminal get reversed, which directly leads to inhibition of
insulin hexamer and dimer formation (Melo et al., 2019). This in turn would facilitate immediate
availability of active monomeric insulin for postprandial injection.
2. The patient will be able to recognise inappropriate healthy behaviour that is correlated
with weight gain, and will also demonstrate a modified eating pattern, and 1-2 lb loss of
body weight within one week.
In order to address the problem of obesity, it is necessary to create an opportunity for the patient
to emphasize on a realistic interpretation of the quantity of food that he consumes, in addition to

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corresponding eating behaviour and habits. The intervention would focus on motivating the
patient to show adherence to a diet pattern that comprises of low fat and sugar intake, in addition
to high content of fibres, whole grains, vegetables and fruits. If necessary, Ted will also be
administered a lipase inhibitor such as, orlistat that would facilitate loss of excess body fat,
besides decreasing a regain in body weight (Choi et al., 2017).
3. The patient would report a satisfactory pain control with a score less than 3, under normal
circumstances, and even on palpation, within 48 hours.
It is first necessary to acknowledge the patient’s reports related to pain, since it gets aggravated
with fear and anxiety, particularly when the treatment is delayed. Demonstrating concern for
comfort and welfare of the patient would play an important role in helping him tolerate the
painful stimuli. The intervention would focus on administration of ibuprofen, a nonsteroidal anti-
inflammatory drug that has been found effective in the management of mild to moderate pain,
after surgery (Ferguson et al., 2019).
4. The patient would no longer demonstrate signs of distended abdomen, nausea or
vomiting within 24 hours.
One non pharmacological method that will prove beneficial for pain management is providing
heat or cold compress. While heat would reduce pain by improving the flow of blood to the
affected area (abdomen), cold compress would lead to lessening of inflammation pain and
muscle spasticity, by inhibiting the synthesis of pain in using chemicals, in addition to
controlling pain impulse conduction (Sansone & Sansone, 2016). In addition, the over the
counter medication bismuth subsalicylate will also be administered for decreasing abdominal
distension (Bowen et al., 2019).

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5. The patient will be able to maintain open and clear ways, as reported by normal depth
and rate of respiration, normal breathing sound, and absence of any coarse crackles
within 48 hours.
It is necessary to assess the patient for airway patency since abnormal breathing sounds and
crackles provide an indication for mucus or fluid accumulation, thus suggesting presence of
secretions in the large airways of the lungs. After determining the depth and rate of
respiration, the patient will be subjected to a measurement of the blood gas values. The
intervention would focus on appropriate positioning of the patient, in order to increase abdominal
pressure and diaphragmatic movement. A bronchodilator such as, salbutamol will also be
administered for bringing about an opening and relaxation of the airways, thereby eliminating the
secretion (Gaugg et al., 2017).
Question 4
Ibuprofen administered for postoperative pain management belongs to the class of NSAID. The
drug would inhibit cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2) isoenzymes,
which are responsible for the formation of thromboxane and prostataglandin from arachidonic
acid. In addition, it would also form an interaction with the endocannabinoid system, thereby
proving beneficial in the management of acute pain, as reported by the patient (Drug Bank,
2020). However, its side effects comprise of irritation of gastrointestinal tract, diarrhoea, renal
disease, photosensitivity, and hypersensitivity reactions. It might also lead to dizziness,
headache, and confusion.
Salbutamol that will be administered for management of crackles belongs to the class of short-
acting, selective β2 agonist that activates the beta 2-adrenergic receptors present in the smooth

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muscles, thereby leading to adenyl cyclase activation. This eventually causes an upregulation in
the concentration of cyclic AMP. This subsequently triggers protein kinase A activation that
brings about an inhibition of myosin phosphorylation, thus decreasing the intracellular
concentration of calcium, and relaxing the smooth muscles of the airways, by this means leading
to bronchodilation. It also acts as a functional antagonist for triggering relaxation of the airways,
and an increase in concentration of AMP has also been associated with mediator release
inhibition from the mast cells (Drug Bank, 2020). Common side effects of this include headache,
anxiety, and dry mouth, and muscle cramp, tachycardia, flushing of skin, arrhythmia and
palpitation. It might also result in sleep disturbance, hypertension, urticaria, and angioedema.
Implication of the aforementioned two drugs can be associated to the fact that the primary goal
of a registered nurse is to ensure that all patients have optimal health outcomes, after they have
been subjected to a surgical procedure. Successful post operative care encompasses recovery of
patient, without any major health complications, in addition to appropriate pain management.
Therefore, implementation of the aforementioned intervention would help in ensuring that all
needs of the patient have been addressed, after his bowel resection.

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B. A. (2018). Male medical students’ perception of plastic surgery and its relationship
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