Comprehensive Nursing Case Study: Ted Williams, Post-Operative Care

This case study focuses on the nursing care of Edward (Ted) Williams, an 82-year-old male who is four days post-operative following a bowel resection and temporary colostomy due to a malignant mass in his colon. The case study utilizes the Roper-Logan-Tierney (RLT) model to assess Ted's psychological and social deficits, altered body image, pain, and nutritional challenges. It examines his medical history, current medications, and vital signs, identifying potential nursing problems such as pain, body image disturbance, self-care deficit, and risk of infection. The case study proposes nursing goals, including pain management, positive body image, self-care independence, and infection prevention, and outlines appropriate interventions. Furthermore, it suggests pharmacological interventions like Metoclopramide and Amoxicillin to address post-operative complications and potential infections, along with the nurse's role in patient education and monitoring. The study emphasizes the importance of a holistic approach to patient care, considering both physical and psychological aspects of recovery.

Nursing
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Case Study
Question 1
Edward (Ted) Williams, an 82-year-old male, is now 4-day post-operative having undergone
a bowel resection and formation of a temporary colostomy. He underwent surgery after being
diagnosed with a malignant mass in his colon according to his coloscopy and biopsy tests.
Ted lives alone since his wife died three years ago due to a bout of pneumonia. He moved to
a retirement village one year ago and has a partner Gwen, aged 78, living in the same
retirement village. Ted has two children, a son and a daughter. The son, Christopher, lives
overseas with his wife and son while his daughter, Janice, lives with her family (husband and
three children) in the city. Applying the RLT Model for assessment of the patient, it is
evident that he suffers from psychological and social deficits which must be addressed during
his nursing care. He has to adapt to acquiring skills to live with his altered body and go
through a psychological transition. He may require assistance for cleaning and emptying of
his stoma from a healthcare professional. Studies show self-deprecating experiences inpatient
with a stoma due to feeling of mutilation, fear of social rejection, reduced self-esteem and a
sense of incapacitation (Song at al., 2020). Ted is also experiencing diet restriction due to
surgery. He was Nil By Mouth 48 hours post-surgery and a full fluid diet and the light meal
was commenced yesterday. Therefore, according to Roper-Logan-Tierney's model, Teds
achieves the activities of daily living such as a safe environment, sleeping, breathing and
communication. However, he is yet to effectively meet others like elimination, working and
playing, washing and dressing, and eating and drinking

Question 2
Ted has a past medical history type II diabetes mellitus, heart failure, obesity and gout. His
weight and height are 115kgs and 175cms, respectively, with a BMI of 37.6m2. Breakfast
was served today he vomited twice and feels nauseated. This was managed by 4mg
ondansetron for nausea. Vomiting is one of the common problems after a colostomy due to
poor digestion and absorption of the nutrients from his intestine (Silva et al., 2018). At 10 am
His vital signs are; T 38.1°C, BP 135/85 mmHg, HR 98 b/min, RR 26 and SpO2 94% on 3L
NP. Ted is also experiencing right-sided inspiratory coarse crackles and has a moist
productive cough. These are an indication that the patient might be suffering from aspiration
and chronic bronchitis (Studer et al., 2016). Coarse crackles are also one of the primary
symptoms of aspiration after abdominal surgery (Cheng, 2010). He reported an abdominal
pain of 4-5/10 scale which increased to 7/10 on palpation; however, he is under patient-
controlled analgesia (PCA) morphine for effective pain relief. His abdomen is also distended.
The stoma was pink, moist, and warm and slightly raised from the skin and visible through
the colostomy bag. The abdominal laparotomy performed has clear occlusive dressing with a
minimal ooze present. He has a redivac drain with 30 ml of haemoserous fluid and urine
output via the urinary catheter in situ with an output of approximately 60-70 ml per hour,
which is within the normal range (Yue et al., 2015). Ted current medication includes
Metformin 500mg Mane, Captopril 12.3mg mane, Allopurinol 100mg Daily and paracetamol
1 g QID.
Ted’s temperature of 38.1 degree Celsius is higher and may indicate infection. Fever is one of
the four cardinal signs of infection. Paracetamol, being an antipyretic and analgesic, is,
therefore, being administered to reduce fever and pain. Ted heart rate is more than the
average (75 b/mins) in adults which may be due to heart failure. His respiratory rate is also a
bit higher. He is also obese (BMI) of 37.6. Captopril is being administered in order to manage

his heart failure. Metformin improves the sensitivity of insulin by increasing the uptake of
glucose and peripheral utilization (Dumitrescu et al. 2015), hence is being given to Ted to
manage type II diabetes mellitus. Allopurinol has also been prescribed to manage his gout.
Some of the nursing problems that have been identified for Ted are as follows. Pain-related to
post-operative pain, as evidenced by ted verbalizing a pain scale of 4-5/10. Ted reports that
he has an abdominal pain of scale 4-5/10 which worsen to a scale of 7/10 on palpation. Body
image disturbance (Gordon, 2014) related to bowel resection and the formation of temporary
colostomy as evidenced by the presence of colostomy bag and altered body part. Body image
disturbance can have a profound impact on how a patient perceives his overall self. Also,
self-care deficit related to an energy deficit as evidenced by the patient inability to bathe,
groom and perform toileting task. Altered nutrition less than body requirements (Gordon,
2014) is also another problem for Ted. This is related to the fact that he is not able to retain
food which evidenced by the fact that he vomited after being introduced to a light meal.
There is also a risk of infection related to the presence of a catheter in-situ and a broken skin
resulting from surgery. These nursing problems for Ted should, therefore, be addressed while
providing nursing care for him. Proper goals and interventions have to be established in order
to meet the needs intended.
Question 3
The nursing goals that will be appropriate for ted include the following:
 The patient should report a pain scale of 2/10 by the end of four hours or be able to
cope up with the pain.
 The patient should also be able to portray a positive perception, self-esteem and an
enhanced body image. This may be evidenced by the patient's ability to freely talk or

provide actual care to the altered body parts—for example, the colostomy bag in Ted's
case.
 The patient should also be able to carry out self-care activities is a safe way and to the
maximum capability.
 Ted should also remain free of infection, and this will be portrayed by normal vital
signs and the absence of the symptoms of infections (fever, pain, swelling, purulent
discharge.
 Infection should also be recognized early so that prompt treatment can be initiated.
The interventions/strategies that will be taken to achieve the goals stated will include the
following.
 Assess the characteristics of pain, including the quality, severity, location, onset,
duration and factors that aggravate or relieve it. The prescribed analgesics
(Paracetamol) will also be administered as indicated. Since the patient is on PCA, the
iv line will also be used only for PCA (Butcher, Bulechek, Dochterman, & Wagner,
2018) and the nurse should watch out for possible PCA complications such as
excessive sedation, nausea, vomiting and IV site infection.
 Ted's knowledge of other pain-relieving strategies that are non-pharmacological will
be assessed. Furthermore, proper education about such strategies will be taught. This
includes the cognitive-behavioural strategies like imagery, relaxation exercises and
distraction techniques (Agoston, & Sieberg, 2016).
 Assess the perception of the patient toward the altered changes in his body image.
Acknowledge that it normal to have the emotional response to the changes in body
functions or structure and help the client to note the real changes. Teach him about the
normalcy and the grief process and moreover the adaptive mechanisms that will help
to manage the problem.

 Assess the level of ability that the patient meets while carrying out the self-care
activities of daily living such as feeding, bathing, eating, dressing, toileting and
ambulation. Encourage the patient to be independent as much as possible and help
where he is not able to perform the intended task (Entwistle, & Watt, 2013).
Moreover, it will be helpful to assess the need for assistive devices and make
arrangements for the patients. This is to ensure that the patient is able to perform the
activities of daily living without straining.
 Assess the risk factors for infections. Ted has open wounds, and a catheter in situ will
are risk factors for infection. Being in the hospital may also expose him to hospital-
acquired infections. Monitor for the signs of infection, which includes swelling,
redness, fever, pain and purulent discharge at injured sites or exit sites of the tubes.
Asepsis should also be maintained while dressing the wound. Encourage proper
handwashing among the healthcare staffs, the patient and even any visitor. This is to
minimize the spread of pathogens by contact hence reducing the risk of infection.
Therefore, Ted will be educated on proper handwashing technique.
 Moreover, the patient should be well informed about his condition and the
management (Perry, Potter, & Ostendorf, 2015). He should be educated concerning
his medication and the progress of the condition. This includes the use of medication,
dosage, and side effects. The patient should be informed when to report to the nurses
about the changes experienced. This will promote patient cooperation throughout care
and hence better healthcare outcomes.
Question 4
As the patient has no output for the past four days after undergoing colostomy, the possibility
of post-operative abdominal obstruction is apparent. Metoclopramide belongs to drug class

antidopaminergics which can be used to manage Ted’s case. Metoclopramide is a drug that is
used to increase the peristaltic movement of the stomach and the intestines (Sanger, 2017). It
is used for fasted stomach emptying in patients with diabetes. It is also used in patients with
gastroesophageal reflux disease. Symptoms of nausea, vomiting, and heartburn can be treated
with the drug. It can be prescribed twice daily to be taken in an empty stomach orally.
Alternatively, a liquid solution of the drug can also be prescribed. Before prescribing the
medication, any allergic history of the patient to the drug must be checked. Side effects of the
drug include dizziness, tiredness, headache, frequent urination, diarrhea, to name a few.
Therefore, Metoclopramide can be beneficial in Ted's case as he is suffering from nausea and
vomiting and has a PO abdominal BO too.
As the patient is at risk of getting infections, and antibiotic administration is highly
recommended. Amoxicillin (drug class: Penicillin) is a broad-spectrum drug that can be
effective against a wide range of gram-positive and some gram-negative bacteria (Kaur et al.
2014). 500mg can be prescribed to be taken orally every 8 hours for a period of three days.
Nausea and vomiting are some common symptoms of the drug, and if persistent doctor's
advice must be taken. The nurse role will include patient education and monitoring for the
side effects of the medication given

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