Nursing Case Study: Impact of Surgery and Care Plan for Patient Ted

This case study focuses on an 82-year-old patient named Ted, who underwent a bowel resection and temporary colostomy. It utilizes the Roper Logan Tierney (RLT) model to assess the biopsychosocial and cultural impacts of the surgery, including potential social isolation and physiological restr...Read More

Running Head: NURSING CASE STUDY
NURSING CASE STUDY
Name of the student
Name of the University
Author Note

NURSING CASE STUDY
Question 1
Ted is an 82-year-old man who has undergone a bowel resection and creation of a
temporary colostomy via surgical procedures. The patient is a widower and lives alone in a
retirement village, which is far from the city. He has two grown-up children, a son and a
daughter, both of whom live away. However, he has a partner, Gwen, in the village where he
lives. Using the Roper Logan Tierney (RLT) Model, the biopsychosocial, and cultural effects
of the patient’s surgery can be ascertained. By analyzing these impacts, it will be easier to lay
down a tailored nursing care plan with appropriate interventions. There are a total of 12
activities included in the RLT model with the help of which nursing aid and assistance can be
provided to the patient. The social aspects include maintaining a safe environment in the
postoperative state and even after recovery when he is released from the hospital. A safe
patient care intervention is vital for Ted as he will remain susceptible to develop
complications from the surgery. Due to the surgery, he might also suffer a drop in his quality
of life and become unable to perform activities of daily life. The cultural impact of the
surgery will include social solation due to less mobility and physiological restrictions. Since
it can be assumed that he has a partner in his residential area, any chances of sexual
expression and activities may also be hampered as a consequence.
Question 2
The case scenario indicates that the patient has been previously diagnosed with a
malignant mass upon examinations via colonoscopy and biopsy. Therefore, the underlying
pathophysiology for his cancer diagnosis includes two distinct pathways of formation of the
precursor polyps that give rise to the cancerous tumours. The malignant mass could be a
conventional adenoma developed by the action of conventional adenoma-to-carcinoma
sequence, or it could be a serrated adenoma that is formed via genetic predispositions as per

NURSING CASE STUDY
the serrated adenoma-to-carcinoma theory. The progression of colon cancer is believed to be
a multistage process that entails mutation of the APC gene induced by multiple triggers such
as environmental risk, old age and unknown genetic defects. Bowel resection surgery
followed by a temporary colostomy involves the removal of a part of the bowel to provide
relief from an obstruction in the large intestine. The presence of malignancy, in this case,
could be the primary reason for the surgeon to perform a bowel resection and opening of a
stoma. The malignancy found from colonoscopy indicates the presence of colorectal cancer
which requires the deceased part to be removed. This requires the surgical intervention also
called as partial colostomy through which the identified malignant mass is eliminated by the
operation of resection. When the parts of colon or rectum opened by the surgery cannot be
stitched back together, the surgeon creates a stoma or opening through the abdominal wall
outside the body, and administers a colostomy bag through which the bowel and faeces can
pass through until the colon is healed and fully functional. Evidence suggests that the best
possible treatment for invasive colon or related cancer is performing a bowel resection to
successfully remove malignant tumours that are obstructing the intestines or leading to
bleeding. For the patient, a temporary colostomy is performed as his condition is reversible
and does not require permanent removal of the colon. With the help of the colostomy bag, he
will be able to egest conveniently and in comfort.
There are a few problems that manifest in the patient post-surgery, which can be
identified from the postoperative vital signs of the patient and by assessing physical
examinations of the signs and symptoms exhibited by him. These problems could be an
outcome of surgery complications or ineffectiveness, as well as medication side effects. One
of the most marked problems in the patient is postoperative pulmonary complications
supported by the presence of right-sided inspiratory coarse crackles and production of a moist
cough. Coarse crackles are caused whenever there is an excess of fluid secretion in the

NURSING CASE STUDY
airways typically detected by wet lung sounds that are low pitched. This can be related to the
wet cough that produces sputum and indicates the presence of an infection as the underlying
mechanism. The patient also complains of abdominal pain that increases on palpation. The
pain assessment levels indicate that his abdomen is swollen, although the colostomy bag is
positioned correctly. Literature suggests that after surgeries such as bowel resection, and
colostomy, there is a high risk of developing postoperative ileus (POI) which is described as
impaired gastric motility caused by acute delay in gastric secretions resulting in symptoms of
oliguria and high airway pressure. The clinical finding of the patient includes a delay in
outputs via the stoma opening, which could be an outcome of the POI. The repeated
vomiting, sluggish bowel sounds and feeling of nausea observed in the patient are clinical
symptoms frequently manifested in POI. The underlying cause of POI, in this case, could be
linked to the use of opioid pain relievers such as morphine which has been administered to
the patient. The mode of action of these opioid analgesics includes binding to the mu
receptors of the central nervous system, as an effect of which there are incidences of slow
intestinal motility.
Question 3
Patient care goals (SMART framework)
With the help of individualized goal setting, the nurse can facilitate targeted ad
measurable outcomes for the patient and further nursing interventions can be implemented
based on the customized goals. The SMART goals are based on one specific goal, which is
measurable, achievable, realistic, and time appropriate.
 Specific- The patient will be relieved of delayed gastric symptoms which increase the
abdominal pain and distention

NURSING CASE STUDY
 Measurable- abdominal pain will be significantly lowered, and there would be no
swelling on palpation
 Achievable- the pain assessment scale would be below 3
 Realistic- audible bowel sounds should help to determine the feeding patterns which
is a risk factor for developing ileus induced pain
 Timely- interventions will be frequently administered based on regular monitoring of
the pain assessments
Nursing care strategies
Successfully identifying the areas of care priority and determining the process of
accomplishing that helps the nurse to develop the care plans targeted for significant patient
outcomes. Five nursing care interventions for the patient are the following:
 Relief from pain- Assessment of the pain (0-10 scale) along with proper
documentation that identifies the pain location, intensity, and characteristics must be
performed. This helps to ascertain the degree of discomfort, prevent any developing
complications, and the efficacy of ongoing treatments to relieve the pain. The nurse
should encourage the patient to voice his concerns and pain tolerance accurately.
Comfort can be provided with the help of measures such as back rubs, and a change
of position that does not affect the stoma. Aiding the patient with a range of motion
(ROM) exercises also helps to decrease muscle stiffness, and encouraging early
ambulation facilitates the resumption of normal functioning by reducing perineal
pressure. It is also vital for the nurse to investigate any rigidity of the abdominal
muscle to avoid complications related to peritoneal inflammation.
 Prevention of postoperative constipation or diarrhoea – the nurse, must be able to
identify the risk factors that can give rise to defecation problems. The primary

NURSING CASE STUDY
intervention should be to detect any delayed onset or absence of effluent in the post-
surgery period via auscultation of the bowel sounds. A delay will suggest that
persistent ileus has developed or there is a stomal barrier caused by various
underlying complications. In this context, the nurse must also review the pattern of
diet, amounts of food being given, and examine the fluid intake. This helps in ample
provision of fibre rich diet, which helps in producing roughage for the body. Fluid
measurements help to prevent complications and determine the stool consistency.
 Preventing impairment of skin integrity- the nurse must identify the complications
which could manifest as alterations of dermis or epidermis. Inspection of the stoma
and peristomal skin area after changing the colostomy bag should be ensured to
prevent the risk of infection. Wounds and drainage characteristic must be accounted
for to administer necessary management. Monitoring in this way accelerates the
healing process and ascertains the effectiveness of appliances and identifies the need
for further evaluation and intervention. Detecting stomal necrosis or ischemia or
fungal infection in advance helps to mediate timely interventions. Appropriate
irrigation management of the ostomy bag must also be maintained routinely to avert
infection risks.
 Adequate nutritional intake – an imbalance of nutrition puts the patient at risk of
complications when his metabolic needs are not fulfilled due to insufficient nutrient
intake. A thorough nutritional screening must be performed by the nurse, along with
the designated dietitian to identify the deficient areas and establish a proper dietary
pattern. The postoperative diet should be gradually transitioned from a liquid diet to a
solid food diet to avoid repeated vomiting, abdominal cramps and feeling of nausea.
 Deficient patient knowledge- the nurse plays a pivotal role in providing patient
information and increasing health literacy of the patient, specific to his care needs.

NURSING CASE STUDY
Evaluation of the patient’s emotional, cognitive, and physical capabilities should be
conducted as these factors affect the patient’s ability to master care-tasks and
willingness to assume responsibility for ostomy care. The nurse should also instruct
the patient about stomal care via demonstrations and encourage positive feedback
from the patient. Improved patient knowledge in postoperative setup encourages
progressive management and moderates the chances of risk and complications arising
from improper ostomy care.
Question 4
Two class of medicines that can be administered for the patient are - Movicol™ and
Microlax™. Both of these drugs are laxatives that are used in the treatment of chronic
constipation and will assist the patient in smooth bowel movement by resolving the faecal
impaction. A laxative effect is exhibited by Movicol by its osmotic action in the gut. By this
activity, stool volume is increased that in turn prompts motility of thee colon via
neuromuscular pathways. As a result, transportation of the softened stools within the colon is
improved, which supports defecation. Electrolytes that are combined with Movicol gets
exchanged with serum electrolytes across the intestinal mucosa, and are emitted through
faecal water. On the other hand, Microlax is a micro-enema that acts rapidly to soften stool
and improve passing of bowels promptly. By administering this, rectal constipation can be
relieved. It should be used under the supervision or guidance of a physician.

NURSING CASE STUDY
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