Detailed Case Study: Post-Operative Care and Clinical Reasoning

This case study focuses on an elderly patient post-surgery with a colostomy, a history of malignancy, and multiple comorbidities including obesity, heart failure, and diabetes. The case study utilizes the Roper Logan Tierney model to assess the patient's psychosocial issues, particularly social isolation and spiritual distress. The clinical reasoning process is applied to identify key problems: pain, infection risk, and anxiety. Nursing interventions are proposed, including pain management strategies (non-pharmacological and PCA), infection prevention (hygiene, antibiotics), and management of pulmonary edema (oxygen and vasodilator therapy). Cognitive behavioral therapy is suggested to manage anxiety. The case study also explores suitable medications like cyclooxygenase 2-inhibitors, methylnaltrexone, alvimopan, and opioid antagonists to address post-operative ileus and pain. The study emphasizes the importance of comprehensive care and clinical judgment in managing complex patient cases.

Running head: CASE STUDY
Case Study
Name of the Student
Name of the University
Author Note

1CASE STUDY
ANSWER NO.1
The patient in the case had is an older adult who underwent surgery and is in the
postoperative period and also has a condition of temporary colostomy. The patient also had a
history of a malignant mass in the body, which also affects the condition. The patient is
grasped with other symptoms as well, which also deteriorated the state, such as obesity, heart
failure, and, most importantly, diabetes mellitus. The Roper Logan Tierney model is a
nursing care planning model that is based upon the activities and identification of factors that
affect the life and activity of any individuals (Williams, 2015). The issues mainly
psychosocial that are usually faced by the patients are undesirable discernment of stoma,
feeling of loneliness, and also the age factor. A patient is an older person who survives alone
and is grasped with many diseases. It is also referred to as social isolation, which leads to the
development of many diseases like anxiety, depression, and also post-traumatic disorder (Ge
et al., 2017). According to this model, the daily activities of Ted will be affected due to his
psychosocial issues. The continuum of dependence and independence shows that he will have
complete dependence on others because he will not be able to fulfil his daily activity as he
had a complicated medical history. His lifestyle will also get affected because he is in the
post-operative stage, so he needs help from his family for his mobility. The patient also lived
in a remote village alone, which can be considered as the main reason of being socially
isolated. The spiritual distress that is present in the patient is also because of the lifestyle that
the patient was having, which integrated with the psychological nature resulting in a
deterioration in health condition. The patient had many challenges in life, such as dealing
with chronic diseases such as heart disease, obesity, trauma, diabetes mellitus (Xia & Li,
2018). The patient moved away from the city due to a feeling of shame and avoidance by
society due to the development of malignant. All these factors affected the patient's life
terribly.

2CASE STUDY
Answer No. 2
The clinical reasoning process helps in planning the treatment of the patient. It
involves problem-solving and clinical judgment after collecting information about the
patients. The 3 priority goals that will be focused on will be controlling his pain that is rated
4-5/10, decrease his risk of infections because he has a weak immunity due to his old age,
and reduce his anxiety so that he can have a positive mental health. The patient was in a state
of the post-operative period. The patient had a history of diabetes mellitus, obesity, gout, and
heart failure. The patient also has cancer, which was confirmed after the biopsy test. The
patient's current medication was metformin for controlling the diabetes mellitus and captopril
for controlling and preventing the heart problem (Wang et al., 2017). The patient developed
this state due to bowel syndrome; as a result, the consumption of allopurinol, which produces
an allergic reaction in the body such as rashes and intestinal upset (Stamp, Day & Yun,
2016). Bowel syndrome is prevalent after any surgery. It is common when the small intestine
is removed from the body (Moayyedi et al., 2017). The patient was an elderly one with a low
immune system and also suffering from many chronic diseases (Pinti et al., 2016). The lower
immune function must have resulted in the development of infection in the lungs, which can
be hospital-acquired as well. The patient also had abdominal pain with a pain score of 4 to 5
out of 10. The pain rises after palpitation, which indicates which was identified after
observation. The palpitation is caused due to stress in the body as well as the mind, which
results in an increase in heart rate and can even cause a heart attack (Alijaniha et al., 2016).
He also had a symptom of abdominal distention. It was also observed that the opening of the
organ where the colostomy bag was injected was slightly pinkish, moist, and warm. It did not
pass any output after surgery but has a sluggish bowel sound. The pus output with the help of
the medivac drain is also minimum. The vital signs of the patient indicate that he was
suffering from fever, and the temperature was 38.1-degree centigrade. The heart rate was also

3CASE STUDY
high in this patient which was 98beat per minute; the patient had a high blood level of 135/85
mmHg and also with the high respiratory rate, which is 26 beats per minute and spo2 of 94%.
The collective clues indicate that the patient is suffering from intense pain due to
palpitations and abdominal distention. He is in a post-operative stage and the constant pain
indicates that his wounds are not healing. His pain has to be reduced with the help of nursing
priorities. Similarly, he also needs to be protected from any type of infection because he has
low immunity due to his age and also due to his health condition. He has a history of diabetes
with obesity, and his temperature his slightly higher than the normal range, which is 38.1.
Ted’s mental condition is vulnerable at this stage because he is dependent on other for his
daily activities, he had a medical history of chronic diseases and he is currently in a hospital
after his operation. He could be suffering from anxiety due to social reasons as he lives alone
and he will be needing someone to look after him (Ramírez & Palacios‐Espinosa, 2016). The
inflammatory state of the body is due to the defective function of both sympathetic and
parasympathetic nerves. The inflammation is mainly caused due to any injury in the body,
which results in the chemicals leaking into the tissue resulting in swelling (Chen et al., 2017).
Answer 3.
The next step in the clinical reasoning cycle is to establish goals and interventions
according to the identified problems and according to taking actions to resolve the problem.
The main problems that the patient is having are postoperative ileus due to surgery, the
occurrence of pulmonary oedema, and stress and anxiety due to this chronic condition. The
anxiety also results in palpitation and thereby increasing pain. The five nursing plan that can
be adapted for addressing the patients problem is to reduce his pain to 2/10, prevent infection
in his wounds, treat the pulmonary oedema by providing vasodilator therapy and pulmonary

4CASE STUDY
rest through oxygen therapy. The anxiety can be managed by providing the patient with
cognitive behavioural therapy or counselling.
I. The first and foremost and foremost intervention is to reduce his pain and it will be
done with the help of some non-pharmacological methods such as using comfortable
positions. His current rating of pain is 4-5/10 and it has to be decreased to 2/10. Ted is
an old man so his bones are weak, which makes it important that he condition should
be considered so that he does not suffer from pain anymore. The nurses should make
him sleep on the back with his knee support, and few other techniques are useful such
as sleeping on the side with a pillow between the knees, sleeping in foetal position
and sleeping with the pillow on the front (Reid, Eccleston & Pillemer, 2015).
II. Preventing of infection in his wounds as it is an essential protocol during the post-
operative stage. Hygiene needs to be maintained and that includes sponging him every
day, cleaning his wounds using anti-septic fluids and changing his dressing in every
short intervals. These methods will reduce the chances of his wound infection and he
will be able to recover soon without the risk of getting any infection. Hand hygiene
will be maintained and the protocols that are needed for a safe wound management
will be followed so that the nurses could improve their professional practice as well
(Ding et al., 2017).
III. The pulmonary state can be managed by providing the patient with oxygen therapy. It
is a supplemental oxygen therapy that is given to the patient with pulmonary edema. It
is used in the maintenance of low blood oxygen in the blood, removal of carbon
monoxide and to maintain an adequate amount of oxygen. Long-term oxygen can be
used for treating chronic pulmonary disorders. This therapy also enhances the state of
the body by improving sleep, along with providing stamina in the body (Brill,
Wedzicha, 2014).

5CASE STUDY
IV. The vasodilator therapy can be given to the patient for reducing the condition of the
high blood pressure along with reducing pulmonary edema. It mainly includes the
drug hydralazine for the treatment. It lowers the blood pressure by reducing the
relaxing the smooth muscle with the help of the peripheral vasodilation effect. These
are medicines that are useful in the opening of blood vessels. It also prevents the
narrowing of the veins and arteries, thus preventing the tightness of the muscles and
also the walls. It enhances the blood flow from throughout the body (Harir & Patel,
2020).
V. The anxiety condition can be reduced by providing support to the patient as he is an
older patient with a lack of social interaction. It person-centred care can include
cognitive-behavioural therapy. It is mainly a talking therapy that includes
understanding the patient's condition and providing positive beliefs, which can, in
turn, help in contributing painless feeling. The condition can be helpful in reducing
the distortion along with lowering of blood pressure and heart rate. It is also known as
relaxation therapy (Chand, Kuckel & Huecker, 2019).
Answer 4.
The patient, in this case, has a symptom of postoperative ileus. Opioids drugs can not
be provided in this case as opioid drugs enhance the constipation condition of the body,
which is not beneficial for this patient as he was not passing any kind of output due to the
side effects of opioids. In this case, opioid antagonist drugs can be provided in reducing or
binding the opioid receptors to block its effect. The class of drugs that can be given to this
patient is cyclooxygenase 2-inhibitors and methylnaltrexone and alvimopan. The
cyclooxygenase 2-inhibitors belongs to the group of non-steroidal anti-inflammatory drug
and is used in the treatment of postoperative ileus. These drugs reduce the activity and

6CASE STUDY
production of prostaglandins, which are chemicals that promote inflammation, fever, and
pain. The patient had a fever as well, so this drug will be helpful in reducing the current
condition by inhibiting the enzyme cyclooxygenase. The drug can be administered orally, and
it quickly gets absorbed and distributed after 4 hours of consumption (Qureshi & Dua, 2019).
Patient controlled analgesic (PCA) is also a required intervention because it acts as a
painkiller, which will help in reducing the pain of the patient. These medications can relieve
pain by blocking the pain signals to the brain or changing the brain’s interpretation of the
signals. PCA is easy to use for the patient as it is a computerized pumping machine with
automatic buttons and it pumps the drug when it is pressed. Most of the times these pumps
have opioid pain controlling drugs such as hydromorphone, morphine and fentanyl (McNicol,
Ferguson & Hudcova, 2015). Antibiotics are also useful to protect from infections as it helps
in killing pathogens that can infect the wound, which is detrimental for a post-operative
patient (Aabenhus et al., 2014).
The next class of drugs is receptor antagonist, and these are methylnaltrexone and
alvimopan. They have a restricted capability to pass the blood-brain barrier and obstructing
the receptors of the gut. The drug is absorbed into the gut with the help of microbial flora. It
is readily scattered and absorbed in the blood plasma. The methylnaltrexone bears a
quaternary amine for its selectivity. This methylnaltrexone blocks the effect of analgesics and
reduces the constipating action upon the gastrointestinal drug (Pergolizzi et al., 2017).

7CASE STUDY
References
Aabenhus, R., Jensen, J. U. S., Jørgensen, K. J., Hróbjartsson, A., & Bjerrum, L. (2014).
Biomarkers as point‐of‐care tests to guide prescription of antibiotics in patients with
acute respiratory infections in primary care. Cochrane Database of Systematic
Reviews, (11). https://doi.org/10.1002/14651858.CD010130.pub2
Alijaniha, F., Noorbala, A., Afsharypuor, S., Naseri, M., Fallahi, F., Mosaddegh, M., Faghih
Zadeh, S., & Sadrai, S. (2016). Relationship Between Palpitation and Mental
Health. Iranian Red Crescent medical journal, 18(3), e22615.
https://doi.org/10.5812/ircmj.22615
Brill, S. E., & Wedzicha, J. A. (2014). Oxygen therapy in acute exacerbations of chronic
obstructive pulmonary disease. International journal of chronic obstructive
pulmonary disease, 9, 1241–1252. https://doi.org/10.2147/COPD.S41476
Chand, S. P., Kuckel, D. P., & Huecker, M. R. (2019). Cognitive behavior therapy (CBT).
In StatPearls [Internet]. StatPearls Publishing.
Chen, L., Deng, H., Cui, H., Fang, J., Zuo, Z., Deng, J., Li, Y., Wang, X., & Zhao, L. (2017).
Inflammatory responses and inflammation-associated diseases in
organs. Oncotarget, 9(6), 7204–7218. https://doi.org/10.18632/oncotarget.23208
Ding, S., Lin, F., Marshall, A. P., & Gillespie, B. M. (2017). Nurses' practice in preventing
postoperative wound infections: an observational study. Journal of Wound
Care, 26(1), 28-37. https://doi.org/10.12968/jowc.2017.26.1.28
Hariri, Lana, and Jayesh Patel. "Vasodilators." In StatPearls [Internet]. StatPearls Publishing,
2020.

8CASE STUDY
McNicol, E. D., Ferguson, M. C., & Hudcova, J. (2015). Patient controlled opioid analgesia
versus non‐patient controlled opioid analgesia for postoperative pain. Cochrane
Database of Systematic Reviews, (6).
https://doi.org/10.1002/14651858.CD003348.pub3
Moayyedi, P., Mearin, F., Azpiroz, F., Andresen, V., Barbara, G., Corsetti, M., Emmanuel,
A., Hungin, A., Layer, P., Stanghellini, V., Whorwell, P., Zerbib, F., & Tack, J.
(2017). Irritable bowel syndrome diagnosis and management: A simplified algorithm
for clinical practice. United European gastroenterology journal, 5(6), 773–788.
https://doi.org/10.1177/2050640617731968
Pergolizzi, J. V., Jr, Raffa, R. B., Pappagallo, M., Fleischer, C., Pergolizzi, J., 3rd,
Zampogna, G., Duval, E., Hishmeh, J., LeQuang, J. A., & Taylor, R., Jr (2017).
Peripherally acting μ-opioid receptor antagonists as treatment options for constipation
in noncancer pain patients on chronic opioid therapy. Patient preference and
adherence, 11, 107–119. https://doi.org/10.2147/PPA.S78042
Pinti, M., Appay, V., Campisi, J., Frasca, D., Fülöp, T., Sauce, D., Larbi, A., Weinberger, B.,
& Cossarizza, A. (2016). Aging of the immune system: Focus on inflammation and
vaccination. European journal of immunology, 46(10), 2286–2301.
https://doi.org/10.1002/eji.201546178
Qureshi, O., & Dua, A. (2019). COX Inhibitors. In StatPearls [Internet]. StatPearls
Publishing.
Ramírez, L., & Palacios‐Espinosa, X. (2016). Stereotypes about old age, social support, aging
anxiety and evaluations of one's own health. Journal of Social Issues, 72(1), 47-68.
https://doi.org/10.1111/josi.12155

9CASE STUDY
Reid, M. C., Eccleston, C., & Pillemer, K. (2015). Management of chronic pain in older
adults. Bmj, 350, h532. https://doi.org/10.1136/bmj.h532
Stamp, L. K., Day, R. O., & Yun, J. (2016). Allopurinol hypersensitivity: investigating the
cause and minimizing the risk. Nature Reviews Rheumatology, 12(4), 235.
Wang, Y. W., He, S. J., Feng, X., Cheng, J., Luo, Y. T., Tian, L., & Huang, Q. (2017).
Metformin: a review of its potential indications. Drug design, development and
therapy, 11, 2421–2429. https://doi.org/10.2147/DDDT.S141675
Williams, B. C. (2015). The Roper-Logan-Tierney model of nursing: A framework to
complement the nursing process. Nursing2019, 45(3), 24-26.
Xia, N., & Li, H. (2018). Loneliness, Social Isolation, and Cardiovascular
Health. Antioxidants & redox signaling, 28(9), 837–851.
https://doi.org/10.1089/ars.2017.7312