Applying the Clinical Reasoning Cycle to Edward Williams' Post-Op

This case study demonstrates the application of the Clinical Reasoning Cycle (CRC) to the care of Edward (Ted) Williams, an 82-year-old male recovering from bowel resection and colostomy formation. The analysis considers Ted's medical history, including heart failure, diabetes, obesity, and gout, alongside psychosocial factors like living in a retirement village away from family. Key health problems identified include potential stoma wound infection, constipation, and psychological distress. The study outlines nursing goals focused on medication adherence, stoma care, constipation prevention, patient education, and psychosocial support. Treatment options such as polyethylene glycol (PEG) 3350 for constipation and cefoxitin for infection prophylaxis are discussed, emphasizing the importance of holistic patient care and addressing both physical and psychological needs to improve post-operative outcomes. The importance of stoma management and patient education for a smooth recovery is highlighted.

Running head: CLINICAL REASONING CYCLE 1
Clinical Reasoning Cycle
Name
Institutional Affiliation

CLINICAL REASONING CYCLE 2
Introduction
Nurses have a role to ensure make accurate clinical judgements while using their
critical thinking skills. Critical thinking helps nurses to make life-saving decisions that are
fair, precise and accurate. The clinical reasoning cycle (CRC) is an appropriate tool for
clinical decision-making that was developed to help nurses collect data and make informed
decisions through the process of considering various factors (Levett-Jones et al. 2010). This
paper aims to demonstrate the use of CRC in clinical judgement. The study involves the use
of a case study of Edward (Ted) Williams an 82 year old male who underwent a bowel
resection and formation of temporary colostomy four days ago. The paper entails the use of
Ted’s case study to provide insights on the appropriate treatment for Ted.
Question 1
The first stage of the CRC is the consideration of patient situation. (Blakey, Guinea,
& Saghafi, 2017). The the Roper Logan-Tierney (R-L-T) Model is a practice-centred
theoretical nursing that is founded in accessibility and realism. The model is essential for use
in nursing academic and clinical settings the RLT model of nursing is applicable in the
nursing process using five important concepts (Williams 2015). According to Elsherif, and
Noble (2011) the RLT model can be used in conjunction with the nursing process to identify
the priorities of nursing care.
Twelve activities of living are the normal activities that a person performs, and can be
altered as a result of different health conditions (Stonehouse 2017). Factors influencing
activities of living include biological, psychological, sociocultural, and environmental and
politico economic factors are essential in the assessment of Ted’s healthcare condition
(Stonehouse 2017). The biological factors affecting Ted’s post-operative outcomes include a
history of heart failure, obesity, gout and diabetes mellitus. The Sociocultural factors are that
Ted is a widower and his wife dies three years ago as a result of pneumonia. However, he has

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a partner at the retirement home where he lives. Ted lives in a retirement village that is two
and a half hours from the city. He lives away from his three children who are grownup and
married.
The activities pf living are also affected in the case of Ted. Ted is on a full fluid diet
and can only take a light diet. However, he feels nauseous and is vomiting. He also has
challenge breathing as he is experiencing inspiratory coarse crackles and a moist productive
cough. Ted also has an abdominal pain and the pain worsens following palpation. Ted also
has a stolen stomach. He also has slow bowel sounds and has not egested since operations.
Question 2:
The information obtained from Ted’s health assessment is vital in the identification of
the patient’s problems. Ted has malignant mass that was treated using an operation involving
bowel resection and formation of a temporary colostomy. Additionally, Ted has other
comorbidities that may affect his health outcomes. He has diabetes, gout, obesity and heart
failure. He is under metmorphin to control the sugar levels as a result if type 2 diabetes. He
is also taking captopril dose, an ACE inhibitor to ensure proper flow of blood through the
body, and frusemide to control heart failure. Other medications include allopurinol for gout
treatment and paracetamol, a pain killer. With the chronic conditions managed appropriately
using the medication, Ted may not experience adverse symptoms. However, it is important to
ensure that the patient has appropriate.
The patient may experience various psychosocial challenges such as living away from
the family, as his family lives away from him. He also lost his wife three years ago. He lives
in an elderly village. The environment and circumstances in which he lives in may have a
detrimental effect on his health. Additionally, Ted has previously undergone biopsy and
colposcopy, which may affect his treatment outcomes.

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Wound infection of the stoma is a possible health problem that Ted may experience
following an operation. There is evidence of an infection as Ted’s stoma is warm, pink, moist
and slightly raised above the skin. Li et al. (2014) explained that surgical site infections are
the main risk for patients with stoma reversal. According to Hu, Lee, Tsai, and Chen (2018),
obesity and high BMI are important risk factors for wound infection, and has a reported range
of 2 to 41 percent of occurrence. The most common morbidities arising from the stoma
infection include incisional hernia, and poor wound healing, the surgical site infections may
have significant negative effects of the patient (Hu et al. 2018). The outcomes may include
prolongs in-patient stay, high rates of outpatient hospital visits and an increased utilization of
home-based care. The post-operative surgical site infection also poses a major health burden
for the patient. Tsujinaka et al. (2020) explained that stoma creation particularly in the
intestines is an important treatment condition for enhancing bowel continuity. Stoma
creation aims to improve the quality of life of the patients. However, if the stoma are not
managed appropriately post operation, they may have significant adverse effects on the
patient including reduced quality of life, increase medical costs, and increased medical
interventions.
The second health problems is that Ted may have constipation associated with
swollen stomach, and slow bowel movements. Edward may be experiencing constipation.
Bari, Fakheri, and Sardarian (2015) explained that small intestinal obstruction after
colonoscopy is common for patients with a prior history of small intestinal surgery. In the
case, Edward, Williams, the patient, has a history of coloscopy and biopsy, which may
predisposes him to the bowel problems he is experiencing. Edward Williams has an empty
colostomy bag, four days after the procedure. According to Finlay, Sexton, and McDonald
(2018), empty colostomy bag a few days after the procedures is an indication of stromal

CLINICAL REASONING CYCLE 5
output. Edwards is at a higher risk of constipation as he has previously undergone coloscopy
and biopsy.
The health problem that Ted may demonstrate is stress, anxiety and psychological
problems. Surgical complications pose a significant challenge for patients therefore, patients
may experience psychological distress such as anxiety and depression following the
challenges associated with hospitalisation. Some causes of distress may include severe
postoperative pain and permanent disfigurement. Psychological distress following surgery
may pose a delay in patient recovery from the surgery, compromise the patient immunity and
affect wound healing (Pinto, Faiz, Davis, Almoudaris, & Vincent, 2016). Edward is at a risk
of developing psychological health problems due to his living environment and his post-
operative outcomes.
Question 3
Post-operative patient care should focus on addressing holistic issues affecting the
patient such as comorbidities, age, health status, type of surgery, and mental health status
(Jaensson, Dahlberg, & Nilsson, 2019). The two main nursing goals in Ted’s case include:
 To ensure that Ted is adherent to his prescription medications to ensure high level control
of existing infections. High levels of medication adherence particularly for patients with
comorbidities helps to improve their quality of life, and patient outcomes. Patients with
comorbidities such as hypertension and diabetes have demonstrated better outcomes even
when under other acute conditions (Drzayich et al. 2018). For instance Drzayich et al.
(2018) explained that older patients with high levels of adherence to comorbidity
medications, care coordination and medication management therapy have improved
health-related quality of life. Therefore, a nurse should assist Ted to remain adherent to
the treatment throughout his recovery as a way of improving his quality of life.

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 To cleaning, disinfect and provide prophylaxis of the stoma wound to avoid infection
within 2 days. Kwiatt and Kawata, (2013) cited that the warm, dark and moist peristome
skin environment is a high risk of infections. Therefore, preventing infection should be a
treatment priority to ensure adequate recovery. Surgical site infections that occur after
operation can be lethal and cause high levels of mortality and morbidity. They increase
healthcare costs, lengthen the hospital length of stay and reduce the patient’s quality of
life. Surgical site infections are common for patients above the age of 60 years.
Therefore, old age is associated with delayed healing, chronic conditions and reduced
health outcomes (Sattar et al. 2019). Proper care of the surgical site will help to prevent
infections and subsequent deterioration of Edward’s health conditions.
 To prevent constipation within 24 hours. Intestinal stomas cause a disruption in the
digestive system. Therefore, an inpatient with bowel stoma need a specific diet instruction
to maintain the balance between water and salt and to facilitate the slow movement of
food boluses through the intestinal track (Steinhagen, Colwell, & Cannon, 2017). Edward
is experiencing pain on the abdomen after palpation which causes discomfort for the
patient. Therefore, it is important to smoothen the bowel movements and enhance better
clinical outcomes.
 To provide patient and caregiver education to ted and his caregiver during and after
hospital admission. Patient education is important after operations as it facilitates the
independence of the patient and appropriate care to avoid infections, and faster
resumption into normal activities (Tsujinaka et al. 2020). Patients who undergo the stoma
surgery need to develop new skills that can be used for the adjustment of physical
changes and help them adapt to the new circumstances. Post-operative education helps
the patient to acquire self-care skills.

CLINICAL REASONING CYCLE 7
 To provide counselling to promote psychosocial support for Ted while in hospital and
during follow-up. According to Ang, Chen, Siah, He, & Klainin-Yobas (2013) most of
the postoperative education neglects the psychological aspect arising from pre- and post-
operative experiences. Patients with stomas have a high risk of stress following
hospitalization and discharge. Nurses need to provide long-term ongoing support and
counselling, and help the patients to build social networks. Stress can be referred to as a
multidimensional concept consisting of psychologic, social and physiologic concepts.
Stress can significantly affect stoma patients and result in poor adjustment to new
circumstances and poor health outcomes. The stresses that may arise from stoma
treatment include loss of body function, altered body image, and difficulties associated
with self-care.
Question 4
The two main treatments that the nurse should consider for treating Edward Williams
to alleviate surgical site infections and facilitate bowel movement. They include:
 Polyethylene Glycol (PEG) 3350. The PEG is an isosmotic laxative that acts by inserting
the metabolism that binds to the water and promoted water retention inside the lumen.
The PEG is used as a solution for colon cleansing and has electrolytes to prevent
dehydration and electrolyte disturbances. Polyethylene glycol has been shown to be safe
in for patients with colonoscopy and colon surgery (Portalatin & Winstead, 2012).
McGraw (2016) confirmed that doses of PEG 3350 ASC, when ingested as undiluted is a
safe and well tolerated treatment for patients with chronic constipation and is a favourable
option for long- and short-term treatment and it acts by increasing osmotic pressure.
There is no evidence of contraindication for PEG, making it suitable of Edward.
 Cefoxitin. The nurse should also treat Edward Williams with a cefoxitin as prophylaxis
for surgical site infections. Cefoxitin has particularly recommended for abdominal

CLINICAL REASONING CYCLE 8
surgeries. Cefoxitin provides better treatment outcomes for surgical site infections and is
regarded as a high rate of health outcomes (Dellinger 2020). The cefoxin injection is
indicated for the treatment of abdominal conditions and is in a class of medications called
cephalosporin antibiotics. The drug acts by killing bacteria (Leekha, Terrell, & Edson,
2011). Cefoxitin is effective for preventing surgical site infections for Edward. Edward’s
stoma is already showing signs of infection as it is warm, moist and protrudes on the skin.

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