NRSG258: Surgical Nursing Case Study - Analysis of Ted Williams' Care

This report presents a comprehensive analysis of a surgical nursing case study involving an 82-year-old male, Ted Williams, who is four days post-operative following a bowel resection and colostomy. The report addresses the biopsychosocial, spiritual, and cultural impacts of the surgery on Ted and his family, identifying key patient problems such as abdominal pain, distension, and coarse crackles. It outlines a detailed nursing care plan with specific, measurable, achievable, realistic, and time-bound (SMART) goals, including breathing exercises, posture changes, pain management through music therapy, and diabetes management. The report also includes a review of medications, Guaifenesin and Furesemide, and their implications for Ted's care. The case study emphasizes evidence-based practice, incorporating relevant literature to support the nursing interventions and management strategies, demonstrating a holistic approach to patient care within the context of a surgical setting.

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 Activities of Daily Living (ADL) is
influenced by psychological, environmental, biological, political, economic and socio-
cultural factors. The main ADL include tasks that are important in order to execute on a daily
basis like maintenance of personal hygiene, eating, sleeping, mobilizing, drinking and
expressing libido. Decrease in the capacity to conduct ADL increase dependence over others
and thus hampering the overall quality of life (Rwakonda, 2017). In case of Ted, ADL is
going to get hampered due to his post surgical condition and thus hampering his overall
quality of life, both physical and psychological. The main bio-psychological impact of Ted’s
surgery for him will include increase in the level of mental health depression as he might
require manual assistance to conduct ADL for a certain period of time. If the family members
of Ted are required to provide manual assistance to Ted, in this case it would be Ted’s
daughter who lives in the same city then her carer stress might get increase leading to the
development of compassion fatigue. Under the spiritual and cultural context, it can be stated
that Ted’s spiritual and cultural inclination might get increases leading to increase in the level
of dependence over others. Rwakonda (2017) stated that with the process of gaining and
physical alignment, the level of inclination towards the culturally competent care along and
this increase in the need for developing person-centred care plan.
Answer 2
Formation of coarse crackles in airways
According to the case study Ted has developed right sided inspiratory coarse crackles along
with the development of moist productive cough in post operative care. Crackles mainly
develop due to the secretion of the pulmonary fluid inside the pulmonary cavities. The

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accumulation of fluid in the airways might give indication to lung infection (exudates
secretion in the lungs common during the condition of pneumonia) or might give indication
to the congestive heart failure (transudate accumulation in the lungs) (). In case of Ted, it
might be an indication of pneumonia and is further highlighted by the increase in the body
temperature (38.1 T). Douros, Grammeniatis and Loukou (2018) stated that nosocomial or
hospital acquired pneumonia are common among the older adults and the chances increase
among the in-patients during the post surgical condition. Crackles mainly occurs when the
pulmonary airways pop-open during the process of inspiration under the disease condition in
order to increase the surface area of the lungs. Crackles mainly occur due to blockage of the
pulmonary airways due to fluid accumulation. Such opening of airways leads to the influx of
the extra cellular fluid into the pulmonary cavities and thus increasing the thickness of the
moist cough and creating shortness of breath. Coarse crackles produce louder sounds and are
long lasting and thus further increasing the severity of the breathing problems and indicating
increase in the severity of pneumonia (Douros, Grammeniatis & Loukou, 2018).
Abdominal pain
Ted is passing through abdominal pain with a pain score of 4 to 5 out of 10. However,
the severity of the pain increases upon the palpation (7 out of 10). Pain in the abdomen in Td
might be due to the post-operative pain. Though he is on PCA morphine in-situ for effective
pain regulation, the sightly raised stoma that is warm and pink in nature might is increasing
the level of pain upon palpation. Strong (2016) stated that creating stoma among the obese
patient might give rise of several challenges. Obesity predominantly localized to the
subcutaneous tissue and thus it becomes difficult to pass stoma through the tick abdominal
wall or the overall distance the bowel needs to travel can dramatically increase when the
panniculus settles under more dependent position with ambulation. The thickening of the

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mesentery and largeness of the omentum increase the level of pain after the stoma creation.
Ted is obese as indicated by his BMI: 37.6 m2 (basal metabolic index), height (175 cm) and
weight (115 kilograms). Based on the age of Ted and his height, his ideal weight must be 55
to 65 kilograms. Obesity in case of ted is increasing the level of abdominal pain. Ted has
Type II diabetes mellitus (T2DM) and this T2DM is creating a problem towards successful
wounding wound management and thus increasing the pain further (Mohan et al., 2018).
Abdominal distension
Ted’s abdomen looks distended. According to the case study, Ted was Nil by Mouth
(NBM) for the first 48 hours of surgery. Yesterday he has commenced on full fluid diet and
the same has been upgraded to light diet at yesterday evening. There has been no output post
the surgery. He also has sluggish bowel sounds and has not passed flatus. Thus it can be
stated that abdominal distension for Ted might have developed due to bloating or
accumulation of wind inside the stomach resulting from two days NBM. Bloating is defined
as a sense of gassiness or a sense of distension (Mari et al., 2019). The overall
pathophysiology of gas bloating is complicated. In case of Ted, bloating or wind formation
might be common has be has undergone bowel resection and formation of a temporary
colostomy for the removal of the malignant mass. The tampering of the intestine results in the
formation of the colonic gas prediction arising from the empty stomach and accumulation of
the carbon dioxide and thus increasing the chance of developing bloating (Mari et al., 2019).

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Figure: Pathophysiology of abdominal bloating resulting from Co2 accumulation in the
intestine
(Source: Mari et al., 2019)
Answer 3
Goal 1: Breathing exercise for the removal of moist cough
Specific (S) Breathing exercise through pursed lip breathing
Measurable (M) The breathing will help in the removal of the moist cough from the chest

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Achievable (A) Simple breathing exercise two to three times a day under nursing supervision in
upright position
Realistic (R) Breathing is achievable under the in-patient settings and does not require my use
of equipments
Time (T) 1 week for the removal of moist cough under nursing supervision
Pursed lip breathing is a simple technique that is used for slowing the person’s breathing and
thus helping to get more air into their lungs. Under regular practice, it helps in strengthening
the lungs and thus helping in the removal of the moist cough from the chest. The technique
involved breathing through pursed lip at first slowly and then faster. This help in the
promotion pulmonary rehabilitation program. The removal of cough will be initiated post 3
days of breathing exercise (Rudi, Soedarsono & Makhfudli, 2018).
Goal 2: Change in posture for the abdominal distension
Specific (S) Change in body posture
Measurable (M) Decrease in the bloating of the abdomen
Achievable (A) Under the controlled supervision of the nursing professionals
Realistic (R) Non-pharmacological interventions requires and can be regulated over the
bed
Time (T) 2 to 3 days in order to provide relief
Wilkinson, Cozine and Loftus (2019) stated that patients who are suffering from
bloating physical exercise (stationary bike) might help in the removal of the intestinal gas
clearance and thus reducing the bloating symptoms. However, stationary cycling might not be
suitable of Ted, keeping his age and post surgical wound into consideration. Thus for Ted, the

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best suitable intervention will be change in posture, change from the supine position to the
upright position might help in release of gas.
Goal 3: Pain management
Specific (S) Application of music therapy based on patients preference
Measurable (M) Reduction in the intensity of pain as measured by the pain scale
Achievable (A) Proper application of music therapy helps in the reduction of the pain intensity by
10%
Realistic (R) The application of music therapy is realistic as
Time (T) 20 minutes per day for 1 week
The proper management of pain can be done with the help of the music therapy.
Radcliffe and Porterfield (2018) stated that the proper application of music therapy helps in
reducing the sensation of pain. This is regarded as one of the most utilized non-
pharmacological nursing interventions for pain management. The selection of the music must
be done based on the preference of the patients. The music therapy will be given in periodic
manner. Application of the music therapy among the older adults in the post –operative care
helps in reducing the severity of the pain by 10% and improvement in the patient satisfaction
by 30%. Radcliffe and Porterfield (2018) stated that music therapy can be considered as an
adjunctive therapy to the traditional nursing care.
Goal 4: Diabetes Management
Specific (S) Management of diabetes by the use of proper diet management
Measurable (M) Reduction in the level of glucose concentration in blood (hyperglycemia)
Achievable (A) Target achievable as proper regulation of diet will help in the reduction of the
BMI and thus helping to severity of diabetes

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Realistic (R) Diet and physical exercise along with other lifestyle interventions help in the
reduction of type 2 diabetes mellitus
Time (T) One month
Arnold et al. (2018) stated that proper maintenance of diet like decrease in the intake
of the carbohydrate, fat and lipid content along with the reduction of sugar intake will help in
the reduction of the overall BMI and thereby helping to reduce the high glucose concentration
in the blood and thereby helping in the reduction of severity T2DM. The regulation of the
dietary plan must be done under active supervision of dietician by taking into consideration
of the height, weight and gender of Ted.
Goal 5: Education of patient and family members
Specific (S) Educating family members and patient in geriatric care will help in therapy
adherence
Measurable (M) Helping to increase the level of therapy adherence post discharge and thus
helping to fasten the process of recovery during the post surgical condition
Achievable (A) The plan is achievable because use of the effective communication will help
in promoting patient awareness
Realistic (R) The goal is realistic because proper education will help to improve the
therapy outcome
Time (T) 1 to 3 days
Gellis et al. (2019) stated that for caring geriatric patient, it is important to educate the
family members in order to increase the therapy adherence and thus helping to improve
patients’ outcome. Education will be important for Ted as post release he might need
assistance from his family members in order to conduct activities of daily living.

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Answer 4
Medication 1: Guaifenesin: It is expectorant that it will be used for increasing the
pulmonary secretion and thus helping to reducing the viscocity of moist cough and thereby
helping to reduce the coarse crackles. The main side-effects of this medication include
fatigue, nausea and confusion. Thus muse must monitor the patient condition while giving
this medication in order to avoid the chances of the post operative nausea and vomiting. The
medication is given orally in the form of liquid (McCuistion et al., 2020).
Medication 2: Furesemide: It is a water pill that helps in the clearance of the
accumulated water in the body. The medication reduces the reabsorption of the electrolytes
from the Henle’s loop and thereby promoting excess water output from the urine. Ted’s urine
putput is low as indicated from the in-situ catheter and thus proper excretion of urine will
help to maintain the body fluid balance. The nurse must monitor urine input and output in
order to avoid dehydration. The medication is available in the form of tablets and at times
might give rise to headache (Lilley, Collins & Snyder, 2019).

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References
Arnold, S. V., Lipska, K. J., Wang, J., Seman, L., Mehta, S. N., & Kosiborod, M. (2018). Use
of intensive glycemic management in older adults with diabetes mellitus. Journal of
the American Geriatrics Society, 66(6), 1190-1194.
Douros, K., Grammeniatis, V., & Loukou, I. (2018). Crackles and Other Lung Sounds.
In Breath Sounds (pp. 225-236). Springer, Cham.
Gellis, Z. D., Kim, E., Hadley, D., Packel, L., Poon, C., Forciea, M. A., ... & Johnson, J.
(2019). Evaluation of interprofessional health care team communication simulation in
geriatric palliative care. Gerontology & geriatrics education, 40(1), 30-42.
Lilley, L. L., Collins, S. R., & Snyder, J. S. (2019). Pharmacology and the Nursing Process
E-Book. Elsevier Health Sciences.
Mari, A., Backer, F. A., Mahamid, M., Amara, H., Carter, D., Boltin, D., & Dickman, R.
(2019). Bloating and Abdominal Distension: Clinical Approach and
Management. Advances in therapy, 36(5), 1075-1084.
McCuistion, L. E., Yeager, J. J., Winton, M. B., & DiMaggio, K. V. (2020). Pharmacology-
E-Book: A Patient-Centered Nursing Process Approach. Elsevier Health Sciences.
Mohan, P. B., Chittoria, R. K., Aggarwa, A., Gupta, S., Reddy, C. L., & Pathan, I. (2018).
ABCDE approach to wound management: Case Study. Journal of Society for Wound
Care & Research, 11(1).
Radcliffe, J. A., & Porterfield, S. (2018). Music Therapy and Post-Operative Pain. DigiNole.
2018-04-23

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Rudi, H., Soedarsono, S., & Makhfudli, M. (2018). Effect Of Pursed Lips Breathing for Peak
Expiratory Flow Rate, Oxygen Saturation, Dynamic Hyperinflation: Systematic
Review.
Rwakonda, M. E. (2017). Lived Experiences of Individuals Quality of Life on Prolonged
Home Mechanical Ventilation.
Strong, S. A. (2016). The difficult stoma: challenges and strategies. Clinics in colon and
rectal surgery, 29(02), 152-159.
Wilkinson, J. M., Cozine, E. W., & Loftus, C. G. (2019). Gas, Bloating, and Belching:
Approach to Evaluation and Management. American family physician, 99(5), 301-
309.