Comprehensive Nursing Case Study: NRSG264 Analysis and Interventions

This assignment presents a comprehensive nursing case study centered around a patient, Ted, who underwent bowel resection surgery for colorectal cancer. The report begins by applying the Roper, Logan, and Tierney model to assess the biopsychosocial, spiritual, and cultural impacts of the surgery on Ted and his family, considering factors like mobilization, elimination, and psychological distress. The study then delves into the pathophysiology of colorectal cancer and analyzes Ted's vital signs, identifying potential patient problems such as infection, postoperative ileus, and dehydration. Following the problem identification, the assignment details specific, measurable, achievable, relevant, and time-bound (SMART) goals and corresponding nursing interventions to address issues like abdominal distension, pain management, airway clearance, and blood pressure stabilization. The interventions include dietary modifications, medication administration (simethicone, probiotics, benzphetamine, propranolol, salmeterol, morphine via PCA), and promoting deep breathing exercises. Finally, the assignment provides information on the drugs metoclopramide and erythromycin, including their mechanisms of action and side effects, relevant to postoperative care.

Running head: NURSING
NRSG264
Name of the Student
Name of the University
Author Note

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Table of Contents
Question 1........................................................................................................................................2
Question 2........................................................................................................................................3
Question 3........................................................................................................................................5
Question 4........................................................................................................................................8
References......................................................................................................................................10

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Question 1
The Roper, Logan and Tierney model of nursing takes into consideration judgment,
diagnosis, development, intervention, and evaluation. It focuses on activities of living (AL), in
order to promote independence of patients by conducting a thorough assessment that helps in
implementation of interventions, which provide support to patients in different areas, which they
might find impossible a difficult to accomplish on their own (Holland & Jenkins, 2019). The
major ALs that are associated with this model encompass breathing, communication,
maintenance of safe environment, elimination, eating and drinking, mobilization, working and
playing, controlling temperature, sleeping, expressing sexuality, death and dying. Analysis of the
case scenario suggests that the bowel resection surgery that had been performed on Ted will
create major impact on his activities of living, particularly on mobilization, elimination, sleeping,
breathing, and grooming. The surgery will create significant biopsychosocial impact by causing
psychological distress not only to Ted, but also to his children, who live far away from him.
Isolation from his children might negatively influence his recovery from bowel resection, apart
from causing financial problems (Pinto et al., 2016).
Patients who are subjected to surgery often consider the event and subsequent health
implications as having a significant or definite meaning for their lives. Thus, Ted might place his
belief on spiritual resources for responding to the difficulties and challenges, in relation to
colorectal cancer and the surgery. Spiritual commitment is expected to enhance his recovery
from the current condition (Pereira, Faria & Lopes, 2019). Although no definite information has
been provided about the cultural beliefs of Ted and his family members, the process of informed
choice can be affected by cultural practice, if the decision making authority is placed on his

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children. Poor cultural competence from the healthcare professionals can also impede the
recovery process (Fayi et al., 2018).
Question 2
Colorectal cancer has been identified as one of the most significant reason behind cancer-
associated death among males and females. However, it is preventable, owing to the fact that it
commonly generates from benign neoplasm that are referred to as serrated polyps or tubular
adenoma (IJspeert et al., 2017). It has been mentioned in the case study that Ted was suffering
from malignant colorectal cancer that required bowel resection. The development of colorectal
cancer has been found to be associated with several genetic, environmental, and diet factors. An
increase occurs in the incidence of colorectal cancer with age, particularly beginning at the age
of 40 years. However, it rapidly accelerates after 50 years of age. The prevalence has also found
to double each decade, unless a person is 80 years of age (Jeon et al., 2018).
On conducting a vital signs assessment, the patient observation at 10:00 am suggested
that he had the temperature of 38.1°C, regular heart rate 98, blood pressure of 135/85 mmHg,
and oxygen saturation of 94%. Analysis of the patient observation suggests Ted either suffers
from infection or postoperative ileus or even both. Postoperative ileus encompasses the
intolerance or obstipation of oral intake that can be accredited two factors, which bring about a
description of normal propulsive motor activity that occurs in the gastrointestinal tract, following
an abdominal surgery (Tevis & Kennedy, 2016). Postoperative ileus is typically characterised by
a body temperature of approximately 100.4°F, In addition to swelling or pain in the abdomen, it
is concomitant with vomiting and nausea. The increase in body temperature can also be cited as
a direct outcome of failed thermoregulation, thus providing an indication for bacterial or viral

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infection. Respiratory rate between 12-25 breaths/minute at the time of resting is generally
considered normal (NSW Health, 2010). An increase in the respiratory rate of the patient
suggested compensation of decreased saturation, which might have occurred when the oxygen
levels in the blood were less than normal (Lewis et al., 2017). This can be accredited to general
anaesthesia, which often impairs pulmonary function and decreases oxygenation during post-
anaesthesia period. The blood pressure and heart rate of the patient were within normal
limits. Additionally, assessment of stoma and redivac drain was normal as well. However, the
colostomy bag was found to be empty for 3-4 days, in addition to distended abdomen. This
provides an indication for probable obstruction in the intestine. Ted reported poor urine output,
thus providing an indication for dehydration. This in turn is associated to post-operative ileus,
since the wall of the gut might have become obstructed and congested, following which a
significant quantity of fluid might have been secreted in the lumen of the bowel, thereby causing
electrolyte imbalance and dehydration (Tevis & Kennedy, 2016).
Distended abdomen has also been reported in cases of intestinal obstruction that results in
manifestation of signs of nausea vomiting and pain. Bowel resection performed on the patient
might have resulted in abdominal distension due to postoperative ileus, which if not treated
appropriately can also subject the abdomen to an increase pressure, beyond the intra-abdominal
hypertension (IAH), thus causing organ failure dysfunction (Cheatham & Safcsak, 2017). Signs
of inspiratory crackles must also be taken into consideration, since they hint at the accumulation
of excess fluid in the lungs that might have occurred due to previous history of heart failure, or
pneumonia, which was also reported by Ted’s wife (Aviles-Solis et al., 2019). This suggests the
presence of excess secretions in the airways that leads to bronchoconstriction.

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Additionally, postoperative pain is a common phenomenon reported by majority of the
patients, and it might have occurred due to obstruction in the bowel that made him manifest signs
of nausea and vomiting (Gan, 2017). Postoperative pain is correlated with susceptibility to deep
vein thrombosis (Yüceer, 2011). Hence, it is necessary to take immediate steps for postoperative
pain management, in order to facilitate early mobilization of the patient with easy recovery,
besides decreasing the risk of suffering from cardiac and pulmonary complications.
Question 3
The SMART goals and interventions provided below address the problems identified in the
previous section:
 Ted will show adherence to dietary modification and appropriate health behaviour that
will gradually help in decreasing body weight, with approximately 1 kg weight loss
within 10 days.
Efforts will be taken to help the patient identify the components that need to be eliminated
from his diet, which result in metabolic imbalance such as, fats or carbohydrates that lead to
metabolic acidosis, instability, weakness, fatigue, and headache. Besides motivating the patient
for accomplishing a reasonable loss of body weight and identification of realistic
goals, information will also be shared on the benefits of dietary modification. The diet
ecommended will contain high amount of dietary fibre, vegetables, whole grains, legumes, nuts
and seeds (Mancini et al., 2016). In addition, the amount of sweetened beverage and unsaturated
fats from the diet shall be removed. Ted will also be administered an appetite suppressant drug,
such as, benzphetamine, together with dietary modification that will help to reduce weight (Brett,
2019).

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 Ted will not display any signs of abdominal distension, vomiting, or nausea, within 30
hours.
In order to address the issue of abdominal distension, Ted will be administered the drug
simethicone that has been found effective in decreasing discomfort, bloating, or pain in the
abdomen (Springer et al., 2018). This shall be followed by administration of probiotics for
enhancing his gut flora, which in turn will improve digestion (O’Toole, Marchesi & Hill,
2017). Efforts will also be taken to eliminate excess food components from his diet that have
been found to worsen abdominal distension such as, vegetables that contain high amount of
raffinose like broccoli or cabbage.
 Ted will report a pain score less than 3 on using the numeric pain rating scale on normal
instances, and even when palpation is performed, within 30 hours.
Postoperative pain management makes it necessary to assess vital signs such as, heart rate,
blood pressure, and body temperature, which are often concomitant with acute pain. Ted will
also be evaluated for his suitability as a PCA candidate. PCA refers to the intravenous infusion
of demerol or morphine, with the use of an infusion pump for pain management. The evaluation
will focus on determining allergy to opioid analgesics, clear sensorium, and history of substance
abuse, renal, hepatic, or respiratory disease, psychiatric disorder, manual dexterity and
cooperation. Following this assessment, morphine will be administered in the form of patient-
controlled analgesia (PCA) that will provide Ted the authority to effectively manage his pain
symptoms (Firouzian et al., 2018). A computerized pump, also referred to as patient controlled
analgesia pump, comprising of a syringe with the medication, will be connected directly to
his intravenous line.

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 Ted will report signs of clear and open airway that will be measured by normal breathing
sound, appropriate rate and depth of respiration and no inspiratory course crackles, within
30 hours.
It is necessary to conduct auscultation the lungs, in order to identify adventitious breathing
sounds such as, rhonchi or wheezing that will provide an indication for partial resistance or
obstruction, or retained secretions inside the airways. Besides assessing the colour, odour,
viscosity and amount of secretion, the patient will be subjected to laboratory test of white blood
cell count, which would provide an indication for infection. Interventions would focus on
encouraging coughing exercise and deep breathing exercise that will facilitate loosening of
excess secretion, inside the lungs, thereby effectively clearing out the mucus (Yokogawa et al.,
2018). Apart from encouraging the consumption of fluid up to 3000 ml/day, salmeterol drug will
also be administered for effectively clearing the airways.
 Ted will demonstrate blood pressure near 120/80 mmHg, in addition to stable cardiac
rhythm, and a normal heart rate within 24 hours.
Ted will be administered propranolol for management of elevated blood pressure. In
addition, he would also be advised to maintain activity restrictions, in order to decrease physical
stress that might create an impact on blood pressure. Non-therapeutic techniques would involve
guided imagery and instructions that would not only produce a calming effect, but also decrease
stressful stimuli, thus lowering blood pressure (dos Santos Felix et al., 2019).
Question 4
Metoclopramide drug is predominantly used for the treatment of oesophagus and stomach
problems, in addition to the management of vomiting and nausea. The drug is also administered

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for facilitating emptying of the bowel, in addition to treating gastroesophageal reflux disease
(Cuesta & Bonjer, 2014). The drug forms an association with the dopamine D2 receptors, with a
nanomolar affinity of approximately Ki = 28.8 nM. The drug is a receptor antagonist. Its
antagonist activity on the D2 receptors that are located in chemoreceptor trigger zone,
predominantly in the central nervous system prevents vomitting and nausea (Sise & Erowele,
2010). Muscarinic activity of the drug mediates its gastroprokinetic activity that directly leads to
the antiemetic effect. Side effects include restlessness, focal dystonia, hyperprolactinaemia,
extrapyramidal effects, and hypertension. Its blockade activity on 5-HT3 and 5-HT4 also creates
an impact on mood.
Erythromycin belongs to the category of macrolide antibiotic. The antibiotic is commonly
used for the management of bacterial infections such as, chlamydia infection, respiratory tract
infection, skin infection, and pelvic inflammatory disease. It is also administered for improving a
delay in emptying of the stomach. The drug manifests bacteriostatic activity and directly inhibits
bacterial growth, when administered at high concentration. It forms a bond with the bacterial
rRNA complex 50s subunit, following which it inhibits protein synthesis and other functional
and structural processes, which are required for bacterial replication (Sise & Erowele, 2010). It
directly affects the process of aminoacyl translocation, thereby preventing tRNA transfer that is
attached to the A site, to the P site of the rRNA complex. Some common side effects of this drug
are nausea, diarrhoea, abdominal pain, vomiting, and arrhythmia.
Implications of the aforementioned interventions in postoperative pain management can
be accredited to the fact that all registered nurses work towards ensuring enhanced health
outcomes, and preventing any complications amongst patients, who have been subjected to a

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surgery. It is their primary responsibility to ensure appropriate pain management that would
facilitate patient recovery.

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Melbye, H. (2019). Prevalence and clinical associations of wheezes and crackles in the
general population: the Tromsø study. BMC pulmonary medicine, 19(1), 173.
Brett, E. M. (2019). Pharmacotherapy for Weight Management. In Bariatric Endocrinology (pp.
395-411). Springer, Cham.
Cheatham, M. L., & Safcsak, K. (2017). Intra-abdominal Hypertension and Abdominal
Compartment Syndrome in Acute Care Surgery. In Complications in Acute Care
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Cuesta, M. A., & Bonjer, H. J. (Eds.). (2014). Treatment of postoperative complications after
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Firouzian, A., Gholipour Baradari, A., Alipour, A., Emami Zeydi, A., Zamani Kiasari, A.,
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