Case Study: Nursing Interventions for Ted's Post-Surgical Recovery

This case study analyzes the post-surgical care of an 82-year-old patient named Ted, who underwent a bowel resection and colostomy. It explores the biopsychosocial impacts of the surgery, including the use of the Roper-Logan-Tierney (RTL) model to assess activities of daily living (ADL) and psy...Read More

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

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Answer 1
Roper-Logan-Tierney (RTL) model states that the activities of daily living (ADL) is
influenced by psychological, biological, environmental, socio-cultural and polito-economic
factors. The ADL that are important in order to execute proper lifestyle include eating,
drinking, maintenance of personal hygiene like bathing, sleeping, mobilizing, control of the
body temperature and expressing sexuality. Decrease in the capacity to execute ADL increase
the degree of dependence over others and thus hampering overall quality of life (Mac Neela,
Butler & Drennan, 2005).
The bio-psychological impact in Ted’s life during the post-surgical condition includes
increase in dependence of others for execution of ADL like maintenance of proper hygiene
and mobilizing and eating. Ted is 82-years old and is under post-surgical condition following
resection and formation of the temporary colostomy. Ted’s post surgical condition might
create biological barrier towards execution of ADL independently. Ted is also over-weight
(height 175 cm and weight 115 Kg) and this weight issue during his post surgical condition
might create barrier in execution of ADL. Steptoe, Deaton and Stone (2015) stated that after
major surgery, older adults develop long-term decline in their psychological health. Decline
in the psychological health is expressed in the domain of decrease in the level of life
satisfaction (Evaluative well-being), lack of meaning in life (Eudemonic well-being) and a
constant feeling of sadness or happiness (hedonic well-being). Ted being 82 years old might
suffer from poor psychological well-being post surgery and thus casting negative bio-
psychological impact. Lane and Smith (2018) stated that during the process of ageing, the
people strong cultural insecurities and increase in the spiritual thoughts. This strong cultural
sense increase when the older adults live alone, away from the family. Ted lives alone and
thus post surgical condition might increase his cultural and spiritual insecurities.

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Answer 2
Formation of coarse crackles in airways
According to the case study Ted has developed right sided inspiratory coarse crackles
along with moist productive cough during the post surgical condition. Crackles develop due
to the secretion of unwanted fluid in the airways. The unwanted fluid accumulation in the
airways can be either transudate or exudates. Exudate accumulate arise during lung infection
like pneumonia and transudate accumulation occurs during congestive heart failure. The
presence of moist productive cough indicates the possible signs of pneumonia (might be
hospital acquired) and this is further confirmed by slightly elevated body temperature (38.1
degree T) (Douros, Grammeniatis & Loukou, 2018). Crackles mainly occurs when the
pulmonary airways pop-open during the proper of inspiration under diseased condition in
order to increase the surface areas of the lungs that is blocked by fluid. Such opening of the
airways leads to the infiltration of the extracellular fluids inside the pulmonary air sacks and
thus increasing the severity of moist cough for Ted. Crackles can be different types like fine,
medium and coarse. Ted is expressing coarse crackles. Coarse crackles are characterised by
louder sound which is low-itched and at the same time long-lasting. Coarse crackle promotes
excessive fluid build up and thus increasing the chance of developing pulmonary oedema and
this might further promote development of the congestive heart failure and chronic bronchitis
(Dünser, Dankl, Petros & Mer, 2018). The signs of congestive heart failure is indicated high
blood pressure (high systolic pressure), Ted’s previous medical history of heart failure along
with the presence signs of coarse crackles and high blood pressure is making this pathological
condition a healthy priority.
Abdominal pain
Ted is experiencing abdominal pain (pain scale measurement of 4/5 out of 10).
However, upon palpation, the pain score increase to 7/10. Ted’s abdomen also looks

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distended. Ted has post operative ileus (POI). Adiamah and Lobo (2020) states that post-
operative ileus (POI) is a predictable delay in the motility of the gastro-intestinal tract and is
common during post surgical condition. After bowel resection, Ted is nil by mouth (NBM)
for the first 48 hours. He is on this fourth day of surgery and has commended on light diet
after initiating oral intake through fluid diet. The underlying pathological condition includes
disruption of the sympathetic and parasympathetic pathways of the gastro-intestinal (GI) tract
leading to inflammatory reactions. Pronounced inflammatory reactions in the GI tract and
release of the inflammatory mediators might be a reason behind high abdominal pain scale of
Ted. Ted is also on opioids (morphine) in order to manage pain in the post operative
condition and this might also be a reason for his increased severity of POI (Gero et al., 2017).
Abdominal distension of Ted might be due to fluid retention. Ted has prolong case history of
Type 2 Diabetes Mellitus (T2DM) and he is also on diuretics or water pill (Frusemide). Both
this condition indicates renal complications. Lack of proper passage of urine through the
renal ducts (Ted is excreting 60 to 70 mls of urine / hour; normal parameters : 80 mls per
hour approximately) along with possible indications toward renal complications might also
be a reason for abdominal distension (Gero et al., 2017).
Post-operative Nausea and Vomiting (PONV)
Ted has vomited twice during his post surgical condition and is feeling nauseous.
PONV is a complex problem that is mediated by (i) vagal mucosal pathway in the GI tract;
(ii) chemo-receptors trigger zone (CTZ), (iii) neuronal pathways in the vestibular system; (iv)
reflex afferent pathways present in the cerebral cortex and (v) midbrain afferents (Halliday et
al., 2017). GI patways and vagal mucosal pathway might be reason behind in profuse
vomiting and nausea. PONV give rise of dehydration followed by electrolyte imbalance and
hypovolemia and thus a health priority (Halliday et al., 2017).

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Answer 3
Goal 1: Reduction in the level of moist productive cough
Older adult are pulmonary congestion due to accumulation of moist productive cough.
The formation of the moist productive cough increases the risk of sputum formation in the
pulmonary airways. Effective nursing intervention for fighting against moist productive
cough includes practice of breathing exercise (Gopalakaje, Sahama & Chang, 2018). The
initiation of exercise must be done with fast breathing (inhale and exhale) through mouth
followed by slow breathing through nostrils. This rhythmic breathing exercise helps in the
expansion of the lower rib cage and thus assisting the diaphragm to move forward and
assisting in removal of the sputum through mouth. This rhythmic breathing must be
conducted three to five times a day followed by pursed lip-breathing. Pused lip breathing
must be initiated slowly followed by faster inhaling and exhaling. Breathing (exhaling) must
never be forced under any circumstances. Pursed lip breathing further aids in removal of the
moist cough and thus promotion clearance of the airways (Michaudet & Malaty, 2017).
Breathing exercise must b done while sitting up-right (Michaudet & Malaty, 2017).
Goal 2: Decrease in abdominal pain
Decrease in the abdominal pain can be down via reducing the abdominal distension.
Intake of fluid must be regulated strictly depending on the urine output in order to reduce the
abdominal distension. Decreasing the fluid accumulation in the abdomen will help to reduce
abdominal distension and subsequent decrease in the high pains score upon palpation
(Camilleri & Boeckxstaens, 2017). Another measure for the regulation of the abdominal pain
might include repositioning of the Ted. Repositioning of change in the sitting posture or
sleeping posture might help in the redistribution of the accumulate fluid inside the abdominal
cavity and thus helping to reduce the severity of the pain. Change in the body posture will

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assist Ted to pass flatus and further helping to reduce distension and abdominal (Camilleri &
Boeckxstaens, 2017).
Goal 3: Decrease in the unregulated body weight
The case study of Ted highlights that Ted is over-weight (BMI: 37.6 m2; Height: 175
cm; weight: 115 Kilograms). Ted also been asked to commence oral food intake. In order to
reduce weight, the diet chart of Ted must be regulated strictly (Gousios, Thompson & Marra,
2017). This must be done under the constant supervision of trained dietician. The intake of
sugar, lipids and carbohydrate must be restricted in order to promote faster weight loss.
Weight loss will aid Ted to promote faster post-surgical recovery followed by decrease in the
severity of the T2DM. Decrease in the severity of the T2DM will help to improve his renal
proficiency. Physical activity for weight loss is not recommended for Ted taking into
consideration his age and nature of the surgery conducted and his past medical history
(Gousios, Thompson & Marra, 2017).
Goal 4: Monitoring the electrolyte balance
PONV might give rise of electrolyte imbalance followed by dehydration and this
might be a reason why he is suffering from nausea. Proper regulation of the fluid intake must
be done by the nursing professional by taking into consideration the urine output (urine
collected in the in-situ catheter and redivac drain include 30 mls haemoserous), fluid intake
(both oral and intravenous intake) and nature of the abdominal distension (the pain scale upon
palpation) (Mansour, 2019). The intake of fluid must be determined under the active
supervision of physicians and fluid output (vomiting and urine) must be monitored strictly by
the nurse (Mansour, 2019).

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Goal 5: Patient education
Gordon and Hornbrook (2018) stated that proper patient education is an important
aspect of nursing intervention as will help in increasing the disease self-management skills,
and at the same time will help to increase the level of participation of the patient in the care
plan. Ted is an older adult who lives alone and thus post hospital discharge, he is require to
manage with health on his own. Proper disease education, therapy planning and expected
outcome will help Ted to increase his level of health literacy and thus promoting disease self-
management. Education about the health prognosis and disease outcome must be done by the
nursing professional by the use of the effective communication skills. Proper use of the
effective communication skills will help in the development of the therapeutic relationship
with the patient and thus helping to increase in the outcome of care. The patient education for
Ted must be done under the presence of his wards and this will help in increasing the
family’s participation in the care plan, an important aspect of older adult care.
Question 4
The first medication will include Guaifenesin, an expectorant that will help in
increasing the pulmonary airway secretion. The mode of action of guaifenesin include
increase in the water content of the pulmonary secretion that will help in decreasing the
viscosity of the mucous and thus helping the congested cough to ooze out through nose and
mouth while coughing. Side-effects of Guaifenesin include fatigue, confusion, headache and
excess salivation. Nurse must keep Ted under active observation to denote any signs of
alarming fatigue and withdrawing the medication if needed. The medication is given in its
liquid form, orally (McCuistion et al., 2020).
Fursemide is another medication of Ted. It is an water pill and is diuretic in nature.
This will help in the reduction of the abdominal distension by removing excess accumulated

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water. The medication inhibits Na-K-Cl co transporters present in the Henle’s loop of the
nephrons by binding with the chloride ions. This inhibiting electrolyte re-absorption excretion
of sodium, potassium and chloride through urine and decreasing the unwanted water content
of the body. The side-effects include hypovolemia or dehydration. Thus the fluid volume of
the body must be maintained strictly. The medication is given orally in the form of tablets
(McCuistion et al., 2020).

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References
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https://doi.org/10.1007/978-3-030-33443-7_27
Camilleri, M., & Boeckxstaens, G. (2017). Dietary and pharmacological treatment of
abdominal pain in IBS. Gut, 66(5), 966-974. Camilleri, M., & Boeckxstaens, G.
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