Clinical Assessment Case Study: Patient with Postoperative Ileus

This case study delves into the clinical assessment of an 82-year-old patient, Edward Williams, who underwent a bowel resection with temporary colostomy and is experiencing postoperative complications. The assessment utilizes the Clinical Reasoning Cycle to analyze the patient's psychosocial challenges, including concerns about body image and potential marital issues, along with physical symptoms like nausea, vomiting, fever, and respiratory distress. The study identifies potential diagnoses such as postoperative ileus and pulmonary edema, considering the patient's medical history of heart disease and diabetes. The case examines the nursing interventions, including nasogastric suction, intravenous hydration, and medication management, with a focus on supporting the patient and preventing complications. The study also explores pharmacological interventions, such as opioid antagonists and prokinetic agents like metoclopramide, to manage postoperative ileus. The case highlights the importance of comprehensive patient care, including psychological support and continuous monitoring, to improve outcomes and reduce hospital stays. The study references multiple sources to support the analysis and recommendations.

Running Head: CASE STUDY: CLINICAL ASSESSMENT
CASE STUDY: CLINICAL ASSESSMENT
Name of the Student:
Name of the University:
Author Note:

1CASE STUDY: CLINICAL ASSESSMENT
Assessment Task 1:
Question 1)
The case study can be clarified by formulating the Clinical reasoning cycle (Hunter & Arthur,
2016) and with the information, that Edward (Ted) Williams, an 82-year- individual, is the patient of
interest and that he has just come out of an operation that involved the development of temporary
colostomy and is the fourth day of postoperative bowel resection. Ted is now postoperative and is
colostomically reversible. Getting a stoma often influences certain facets of a person's existence.
According to the nursing model R-L-T, a patient's appraisal is focused on living habits, and variables that
affect certain behaviors (Williams, 2017). The main psychosocial challenges patients experience are
typically linked to concerns with body identity, poor stoma interpretation, or loss of self-confidence. It's
likely Ted may have felt worried regarding his stoma. Patients also continue to suffer stress and marital
problems (Ayaz‐Alkaya, 2019). Ted has a partner named Gwen, who works in the same neighborhood as
him, so he may even be worried with how she may see him. This sort of psychological problem is that
and may influence the patient's day-to-day activities. Using a stoma will often result in Ted needing
support and thus being less autonomous according to the R-L-T model (Williams, 2017). Ted can also
feel apprehensive about being out of work settings and engaging (Campos et al., 2017). There has been a
consistent study of patients with colostomy experiencing a decline in moral well-being, which may also
relate to Ted. In certain societies the stoma definition can be interpreted differently. Ted can consider it
embarrassing, and patients are recorded embarrassed enough to stop going to places or chruces. Ted's
everyday life may be significantly influenced this way.
Question 2)
At this phase in the Clinical Thinking Process (Hunter & Arthur, 2016), nurses will carefully
examine Ted's past medical history, history in disease, current treatment plan, study results and vital signs

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present. The case report notes that following a resection of the intestines and a partial colostomy, Ted has
recently undergone surgery. In fact, a malignant mass post had already been found during a colonoscopy
and a biopsy. He also recorded becoming a chronic patient with severe heart disease, type II diabetes
mellitus, the medical records said. This was also discovered that after the medical details and measuring
the BMI Ted was obese and had gout. Observing the case study it was discovered that when treated with
his diabetes medication on his fourth day postoperative operation, Ted displayed symptoms of nausea. He
was seen vomiting twice and it felt dizzy. The critical data we recorded at 10 a.m. This expected elevated
body temperature values of 38.1 ° and respiratory rate of 26. The jump in the post of body temperature
during an procedure suggests the existence of some form of infection. The measured blood pressure has
already been observed to be high.
Similar to the above symptoms, the nurses can identify certain possible diseases where Ted most
certainly suffers. Ted is postoperative for four days as per the case report, and has had no success since
the surgery. Therefore, it should be understood that gastrointestinal motility disorder may have occurred,
most definitely due to the bowel resection procedure. This is called the Ileus Postoperative (Venara et al.,
2016). It is a condition characterized by both gastrointestinal distention and a lack of vocal sounds. Ted
has a distended throat, with sluggish impact on the colon. Postoperative ileus is sometimes characterized
by gas accumulation in the GI tract, resulting in compromised storage and flatus function, much as with
Ted. This was demonstrated to the doctors that they could not tolerate a liquid or semi-liquid diet. The
medicine used to relieve discomfort will also improve his risk of post-operative ileus. The surgical
procedure, thanks to the incision made, stimulates the afferent nerves in terms of pathophysiology (Bragg
et al., 2015). Breakdown of sympathetic / parasympathetic nerves in the gastrointestinal tract leads to a
prolonged period of inflammation that is normal. Macrophage surgical stimulation draws attention to the
infectious agents such as neutrophils and monocytes entering the body. Most of this mechanism continues
to remain however as an open question. Ted can encounter the second critical difficulty related to his
coarsely inspiring crackles and painful cough. There is a large variety of factors that may lead to
producing motivating coarse crackles. But it's important to remember that Ted has a history of heart

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problems, and he's already on Captopril medication, which is often prescribed for congestive heart failure.
Symptoms have been seen to increase in patients with CHF following significant surgery, such as
intestinal resection. Often, CHF can cause pulmonary edema (Purvey & Allen, 2017), meaning that fluid
in the alveolar area has accumulated. These result in aggressive palpitations, cough and inspiratory
crackles, each of which, are evident in Ted's case. The pathophysiology is addressed as well, is where the
heart can not properly control, therefore the blood corroborates through the veins, which brings the blood
into the lungs. If the strain of the blood vessels is raised, the fluid can be squeezed into alveolar space,
creating pulmonary edema. Pulmonary edema (Purvey & Allen, 2017) is the patient's primary source of
inspiring coarse crackles. This to the individual is extremely risky. It could all be attributed to influenza,
but because Ted has a previous record with heart disease, that is probably the most possible cause in his
situation. This neuromuscular bowel pattern (Nieto & Rakestraw, 2017) is defined as the Migrating Motor
Complex (MMC) that arises throughout a starving state every 1 to 2 hours. The stomach consists of
muscles that act to perform electrophysiological actions.
Question 3)
In compliance with the next step of the Clinical Reasoning Cycle, the nurses will establish goals
and provide Ted with appropriate therapies. The primary priorities in clinical services would include
support both for his Postoperative Ileus and the pulmonary edema. The treatment to undergo is as follows.
Ted reports problems in separating stools, didn't have their bowels stretched post op or are already on
drugs, according to the patient's case report. Managing and planning health programs for people with
ileostomy or colostomy (Ambe et al., 2018) includes: helping persons and/or SOs during adjustment,
preventing complications, encouraging self-care freedom, offering information on procedure / prognosis,
medical conditions and potential issues.
 Investigate the presence or lack of abnormal effluents, as well as the auscultation of bowel
symptoms. Postoperative paralytic and/or adynamic ileus will usually heal within 48–72 hours, so
Postoperative Ileus will be the main challenge confronting Ted. The therapies seek to put back

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natural gastrointestinal activity. They require nasogastric suction. Nasogastric suctioning applies
to pushing out some barrier in the intestine and has often proved effective in postoperative ileus
(Venara et al., 2016). It can be used by the doctors along with other clinical strategies that mostly
needs intravenous hydration. As the individual cannot handle a fluid diet or a moderate diet,
nutrition and hydration must be intravenously delivered. But Ted will be issued intravenous shots
and he has his correct meals.
 For the majority of situations, postoperative ileus (Zhang & Xu, 2017) may be managed with
assistance and medical treatment. Since the individual already has many comorbidities, the vital
elements will be checked periodically and held under close surveillance. The patient's vitalities
will be checked periodically, and the checks will be performed as well.
 Periodically check the medications. Morphine was also used to enhance sickness frequency. Ted
was on drugs here to popular his medical suffering. He was supposed to have got medicine cut off
and prescribed something positive about his pain. This can also provide methods (Nair, 2019) to
alleviate discomfort after surgery without taking the prescription
 Pleural effusion is often associated for pulmonary oedema. Here a pin is put into the thorax, and
it pulls out the extra blood. However, provided that Ted has not recorded respiratory issues, that
might not be appropriate. In case the condition gets worse it may be relevant. It will be taken care
of quickly and if left unchecked it might create further complications including a respiratory
failure.
 Aid and awareness are the key nursing assistance needed here. The patient has recently
experienced a big surgery and has postoperative problems which may give him distress. At this
point, it is vitally crucial that the nurses help and assist him throughout the treatment. The nurses
are often required to keep him aware of his postoperative state. Postoperative ileus (Zhang & Xu,
2017) also contributes to prolonged hospital stays and higher expenses and may contribute to pain
for patients. Ted could be impacted by prolonged hospital stay, which ensures that the nurses will
remain supportive to encourage Ted. In respect to psychological knowledge, it needs to be

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explained what interventions are being provided to Ted and whether they should be required. This
would make him feel more comfortable and alleviate the tension. It is important about everyone
has an action (Arvelos Mendes et al., 2018).
Question 4)
Opioids such as morphine are considered to regularly induce and improve postoperative ileus.
Therefore, Opioid antagonists are considered to be one of the potential therapies for this disease.
Antagonists to opioids function on one or more opioid receptors to inhibit the opioid damage. Therefore
the drugs are unable to reach the body. Naloxone is a potential choice on Ted for the care of his
postoperative ileus. This drug will be given intravenously for Ted, since when administered orally, he is
still unable to hold it down. Because this drug decreases the impact of drugs it should mitigate the risk of
postoperative ileus caused by morphine (Schwenk et al., 2017). This is used for opioid dose reduction,
and the impact of drugs Ted has already taken should reduce. It has small risk of damaging a patient and
may also be an good medication to use. Peripherally specific opioid antagonists including
methylnaltrexone and alvimopan can also be used.
Metoclopramide is a prokinetic agent that can potentially be used to control POIs (Agah et al.,
2015). It is commonly used as an antiemetic and as a method of nasoduodenal feeding-tube development.
Metoclopramide works by promoting gastric emptying and stimulates muscle contraction in the bladder,
pyloric, and small bowel, but has minimal or no effect on the colon. A longitudinal, randomized study
measured metoclopramide in 100 patients who underwent elective abdominal colorectal surgical
procedures to the the length of the ileus during colorectal surgery. The drug was delivered to Intraven
every 8 hours before toleration with a solid-food diet from completion of the procedure. Metoclopramide
has been developed to not significantly alter the direction of POI. A double-blind, 60-patient managed
study showed metoclopramide has a negative impact on POI resolution. It should be borne in mind that
metoclopramide will cause sedation, signs of motor agitation and other autonomic dysfunction reactions

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