Clinical Assessment and Practice: University Healthcare Assignment

This assignment presents a detailed analysis of a clinical case study involving an 82-year-old patient, Edward (Ted) Williams, who underwent surgery for a temporary colostomy and bowel resection. The assignment explores various aspects of Ted's care, including biological, psychological, and cultural factors influencing his recovery. It utilizes the Roper-Logan-Tierney (RLT) model to assess his daily activities and strategies to improve his quality of life, addressing potential challenges such as poor self-esteem and depression related to the stoma. The assignment also examines evidence-based nursing practices, including the management of postoperative complications like ileus and pulmonary edema, considering Ted's medical history of heart failure and diabetes. It also includes a discussion of pharmacological interventions, such as methyl naltrexone and metoclopramide, for managing opioid-induced constipation and promoting gastrointestinal motility. The assignment highlights the importance of nursing interventions, including patient education, emotional support, and monitoring of vital signs, to optimize patient outcomes and facilitate a smooth transition to self-care. References from various medical journals and books are also provided in the assignment.

Running Head: CLINICAL ASSESSMENT AND PRACTICE
CLINICAL ASSESSMENT AND PRACTICE
Name of the Student:
Name of the University:
Author Note:

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CLINICAL ASSESSMENT AND PRACTICE
Answer 1:
According to the case study, Edward (Ted) Williams is an 82 year old man,
underwent a surgery regarding temporary colostomy and bowel resection. Age of Ted,
his past medical history of heart failure, type II diabetes, and obesity could be the
biological factor that impacted on his surgery. Van Greevenbroek (2013) assert that
obesity significantly increases the risk of hypertension and diabetes. Ted with all those
three factors can have high risk of mortality and complications. The RLT therapeutic
strategy reflects on the everyday activities (ADLs) and strategies to increase patient
health and quality of life. The RLT nursing model explains the potential of patients within
the context of their age, their risk factor and the key factors in the design of the care
system (Holland & Jenkins, 2019). Physiological and psychological challenges Ted can
suffer are poor self-esteem, fear, pessimistic attitude, or feeling vulnerable to stoma.
Personal problems and depression are expected to escalate (Jayarajah &
Samarasekera, 2017). It is more likely that having a stoma would encourage Ted to
seek personalized care, stoma treatment, and thus become more relaxed and reliant on
his ADLs. Ted is said to have a partner who is only a few years younger than him, but
he always seems to be depressed. The case analysis shows that Ted has a friend
called Gwen who lives in the same retirement center. He may be concerned about
being a burden on her in this state of affairs. The psychological effect of creating a
stoma is shown dramatically in different cultures (Williams, 2017. The other factors may
have an effect on the reality that Ted was a widow and that he would miss his wife and
children. On the other hand, there was not much cultural impacts on Ted and his family
as he had minimum influence of cultural belief. As Ted himself agreed for the surgery
there were no spiritual impacts.
Answer 2:
Evidence research indicates that Ted has never received operations following
abdominal resection and partial colostomy. During this part of the CRC, nurses should
closely analyze Ted's previous medical background, illness meaning, new recovery

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strategy, outcomes of tests, and vital signs (Hunter & Arthur, 2016). Examining the case
report, it was noted that Ted had symptoms of the disease when he was provided his
diabetes meds on the fourth day of his surgery. Unusually high vital signs indicate the
presence of certain type of infection. Consequently, the nurse can keep in mind the
perioperative regulation of fluids and electrolytes. It is also very essential to have
sufficient preloading of the heart to increase respiratory contractility and cardiac
efficacy, often referred to as Plasma Volume Management (EDWARDS & GROCOTT,
2015). Optimal intravascular volume is also needed for the maximum possible supply of
oxygen to the tissue. Nurses may know, as mentioned above, some of the conditions
that Ted is most likely to suffer from. It's a condition that varies between intestinal
distention and lack of digestive sounds. It is also suspected that gastrointestinal
metabolism failure might have occurred, most likely due to intestinal resection surgery,
which could also be referred to as postoperative ileus (Venara et al., 2016).. Ted has a
distensive neck, as well as sluggish intestinal effects. Hence, it is often referred to as
Plasma Volume Management (EDWARDS & GROCOTT, 2015). Optimal intravascular
volume is also needed to ensure the maximum possible supply of oxygen to the tissue.
Drugs are primarily used to relieve pain, which may also enhance the risk of post-
operative ileus. In terms of signs and symptoms, the surgical procedure stimulates the
afferent nerves due to the incision. Postoperative ileus is also characterized by
accumulation of gas in the GI tract, which results in impaired absorption and flattened
activity, as with Ted. Diarrhea and vomiting are also the main signs of the disease
(Doenges, Moorhouse & Murr, 2016). There are a broad variety of causes that can
contribute to the development of big crackles. Though, it should be noted that Ted has a
history of cardiac attacks and is still on Captopril medicine, which is also treated for
congestive heart failure. Symptoms have been shown to increase in people with CHF
after extensive surgery, such as intestinal resection. Ted's second crucial challenge
may be attributed to his strongly motivational crackling and crippling cough. CHF may
also induce pulmonary edema signaling that fluid has been accumulated in the alveolar
region (Purvey & Allen, 2017). Pathophysiology implies because, since the heart cannot
regulate properly, the blood implies contained in the veins hold the blood to the lungs.
This induces violent palpitations, cough and enthusiastic crackles, most of which are

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apparent in the case of Ted, such as hypertension. Purvey & Allen (2017) has
mentioned that, pulmonary edema is the main cause of serious cracking in the body.
While blood pressure is elevated, the fluid may be forced into alveolar space, causing
pulmonary edema. This can still be due to influenza, but Ted still has a long experience
of heart failure, which is assumed to be the key cause in his condition.
Answer 3:
Regulation and preparation of health facilities for people with ileostomy or
colostomy includes avoiding accidents, assisting individuals and/or communities
through transition, sharing details of procedures / prognosis, medical
problems, promoting self-care, and future concerns (Ambe et al., 2018). Nursing staff
will set targets for the delivery of appropriate treatments to Ted in accordance with the
next phase of the CRC. The goal of geriatric and palliative care is to take care of his
postoperative ileus and pulmonary edema.
 Nurses are also called to inform him of his postoperative condition. Although the
integration of the stoma into the outward image may take months or even years,
looking at the stoma and making observations may help the patient to identify the
stoma (Aktas & Gocman, 2015). Motivating Ted to express his emotions about
ostomy, as well as to recognize the normality of feelings of embarrassment and
sorrow, would be assured. This makes it possible for a person to realize that
feelings are not rare and that it is not necessary or helpful to feel bad about them.
 Intravascular volume is often required to provide adequate oxygen to all tissues
(EDWARDS & GROCOTT, 2015). The increased amount of interstitial fluid can
also have a negative impact on the supply of tissue oxygen, since this can lead
to edema, reduced oxygen diffusion duration and micro vascular stress.
 Disrupted frequency or shortage of effluent associated with auscultated bowel
sounds is often detected. Postoperative ileus may be controlled by determining
dietary regimen and volume, the amount of fluid intake needs to be assessed for
sufficient fiber intake, and the roughage produces a bulk of the fluid, and the
quality of the stool needs to be calculated (Zhang & Xu, 2017).

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CLINICAL ASSESSMENT AND PRACTICE
 Nursing staff may be able to well advise Ted to sit up straight with an elevated
head to prevent excessive sitting because this will help to facilitate the drainage
of perineal wounds / drains and improve the chance of pooling (Doenges,
Moorhouse and Murr, 2016). The illness could also contribute to prolonged
hospital visits and increased expenses that could contribute to pain for the
patient. Nurses are vitally important at all rates to motivate and sustain them
through their treatment. Recurrent sessions are said to cause perineal
discomfort, reduce wound bleeding and enhance sluggish healing.
 Evaluating the daily regimen and volume, the amount of nutrient consumption
needs to be calculated for sufficient fiber intake, and the roughage produces a
bulk of the fluid, so the strength of the stool needs to be established (Wu et al.,
2015). Disrupted frequency or absence of effluent associated with auscultated
bowel sounds is often detected.
Answer 4:
Methyl naltrexone, which is branded as Relistor in the market can be
administered to Ted in this case study (Schwenk et al., 2017). Methyl naltrexone is in a
family of medicines termed peripheral mu-opioid receptor antagonists. It functions by
shielding the intestine from the impact of opioid (narcotic) medications. As observed in
the case study, Ted improves from pain and constipation; this medication can be
administrated for the management of opioid-induced constipation (OIC) in patients with
advanced illness (Nair, 2019). They require palliative care where there has been
inadequate reaction to laxative therapy (Janku et al., 2016). The utilization of drugs
allows it possible to slow down gastrointestinal motility and breathing. Adverse effects
can include the patient feeling dizzy and nauseated. Abdominal discomfort and
flatulence are often found in the patient in severe circumstances.
Metoclopramide is widely used as an opioid antagonist and as a way of
supporting the nasoduodenal feeding tube. Metoclopramide acts by facilitating gastric
emptying and by causing gastric, pyloric and small-bowl muscle motions that have little
to no impact on the colon (Agah et al., 2015). It is known to be a prokinetic agent that
may theoretically be used to monitor POIs (Acosta & Camilleri, 2015). A retrospective,

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randomized analysis of metoclopramide studied in 100 patients undergoing elective
abdominal colorectal surgery to reduce the duration of the ileus after colorectal surgery
(Thiele et al., 2015). The medication is delivered by an intravenous route every 8 hours
from the completion of the operation before and until a healthy diet is prescribed.
Metoclopramide has been shown not to substantially change the POI pathway (Liu &
Abell, 2017). This should be borne in mind that metoclopramide may induce intubation,
signs of motor disturbance and other autonomic impairment reactions.

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References:
Acosta, A., & Camilleri, M. (2015). Prokinetics in gastroparesis. Gastroenterology
Clinics, 44(1), 97-111.
Agah, J., Baghani, R., Rakhshani, M.H. and Rad, A., 2015. Metoclopramide role in
preventing ileus after cesarean, a clinical trial. European journal of clinical
pharmacology, 71(6), pp.657-662.
Agass, R. F., Brennan, M., & Rendle, D. I. (2017). Extrapyramidal side effects following
subcutaneous metoclopramide injection for the treatment of post-operative
ileus. Equine Veterinary Education, 29(10), 564-568.
Aktas, D., & Gocman, Z. B. (2015). Body Image Perceptions of Persons With a Stoma
and Their Partners: A Descriptive, Cross-sectional Study. Ostomy/wound
management, 61(5), 26-40.
Ambe, P. C., Kurz, N. R., Nitschke, C., Odeh, S. F., Möslein, G., & Zirngibl, H. (2018).
Intestinal ostomy: classification, indications, ostomy care and complication
management. Deutsches Ärzteblatt International, 115(11), 182.
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2016). Nursing diagnosis manual:
Planning, individualizing, and documenting client care. FA Davis.
EDWARDS, M. R., & GROCOTT, M. P. (2015). Perioperative fluid and electrolyte
therapy. Young, 60(22), 7.
Hunter, S., & Arthur, C. (2016). Clinical reasoning of nursing students on clinical
placement: Clinical educators' perceptions. Nurse education in practice, 18, 73-
79.

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Holland, K., & Jenkins, J. (Eds.). (2019). Applying the Roper-Logan-Tierney Model in
Practice-E-Book. Elsevier Health Sciences.
Janku, F., Johnson, L. K., Karp, D. D., Atkins, J. T., Singleton, P. A., & Moss, J. (2016).
Treatment with methylnaltrexone is associated with increased survival in patients
with advanced cancer. Annals of Oncology, 27(11), 2032-2038.
Jayarajah, U., & Samarasekera, D. N. (2017). Psychological adaptation to alteration of
body image among stoma patients: a descriptive study. Indian journal of
psychological medicine, 39(1), 63.
Morgan, A. (2016). Development of a learning resource manual for nurses on caring for
patient's post-stoma surgery.
Nair, A. S. (2019). Management of opioid induced postoperative ileus: the current
scenario. Anaesthesia, Pain & Intensive Care, 380-382.
Purvey, M., & Allen, G. (2017). Managing acute pulmonary oedema. Australian
prescriber, 40(2), 59–63.
Schwenk, E. S., Grant, A. E., Torjman, M. C., McNulty, S. E., Baratta, J. L., & Viscusi,
E. R. (2017). The efficacy of peripheral opioid antagonists in opioid-induced
constipation and postoperative ileus: a systematic review of the literature. Reg
Anesth Pain Med, 42(6), 767-777.
Thiele, R. H., Rea, K. M., Turrentine, F. E., Friel, C. M., Hassinger, T. E., Goudreau, B.
J., ... & McMurry, T. L. (2015). Standardization of care: impact of an enhanced
recovery protocol on length of stay, complications, and direct costs after
colorectal surgery. Journal of the American College of Surgeons, 220(4), 430-
443.

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Venara, A., Neunlist, M., Slim, K., Barbieux, J., Colas, P. A., Hamy, A., & Meurette, G.
(2016). Postoperative ileus: pathophysiology, incidence, and prevention. Journal
of visceral surgery, 153(6), 439-446.
Williams, B. C. (2017). The Roper-Logan-Tierney model of nursing. Nursing2019 Critical
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Wu, Z., Boersema, G. S., Dereci, A., Menon, A. G., Jeekel, J., & Lange, J. F. (2015).
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Translational Surgery, 2(2), 50.