University Surgical Nursing Case Study: Principles and Practice

This case study analyzes the nursing care of an 82-year-old patient, Edward William (Ted), who underwent bowel resection and colostomy. The assignment covers the patient's medical history, including conditions like heart failure, diabetes, and obesity, along with his family and social context. It details the collection of cues and information, including vital signs, symptoms of pneumonia (coarse crackles, productive cough), and potential postoperative ileus. The study progresses through the Clinical Reasoning Cycle, identifying goals like addressing pneumonia and postoperative ileus. It outlines nursing interventions, such as assessing respiratory status, maintaining hydration, nasogastric suctioning, and early mobilization. Furthermore, it discusses pharmacological interventions, including macrolide antibiotics for pneumonia and alvimopan for postoperative ileus, highlighting their mechanisms and potential side effects. The case study emphasizes evidence-based practices and the application of the Clinical Reasoning Cycle in surgical nursing.

Running head: PRINCIPLES OF NURSING: SURGICAL
PRINCIPLES OF NURSING: SURGICAL
Name of the Student:
Name of the University:
Author’s Note:

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Answer 1
From the review of the case study, it was known that Edward William or Ted is an 82
year old man who had bowel resection and formation of temporary colostomy; thus, was
operated. Previously, colposcopy and biopsy were conducted upon him that clearly confirmed
that there was a presence of a malignant mass in his colon. From the past medical history, it
was known that he had suffered from heart failure, type II diabetes mellitus, gout and obesity
where his BMI was 37.6m2. From his familial background, Ted is a widower and lived alone
after his wife died due to a bout of pneumonia three years ago. About a year ago, he had
moved to a retirement village that is approximately two and a half hours away from the city
and was near to where he used to live with his wife and children. His children, a son, named
Christopher lives overseas with his family comprising of his wife and son and his daughter
Janice who lived in the city with her husband and three children. Ted has a partner, Gwen,
who was 78 years old and lived in the same retired village. From bio psychological
assessment, it can be stated that Ted was responding in a positive manner to the operation;
the evaluation was done after four days. Instead of an issue of abdominal pain, it was no such
serious complication found. As it was found that he does not have an immediate family and
the only one who was with was an older woman thus, it can be stated both Ted and Gwen had
an accepting attitude toward the surgery. The emotional and cultural impact of the surgery on
Ted and his family was no significant in nature (Williams, 2017). It can be seen that the age
is one of the most significant factors that affected his life and daily processes over the time
and since the mass found to be malignant, thus, Ted had agreed to the surgery in no time.
This is because delaying it may increase the possibility of its growing its size and pose a
threat to life (Wilson et al., 2018). From the spiritual aspects, it can be stated that Ted had
prioritised medical services more than spiritual or religious belief or value; as a result, he was
willing to conduct the colposcopy as soon as the malignant mass identified in his colon.

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Answer 2
From stages two and three of Clinical Reasoning Cycle, collection of cues and
information, the case study had been able to present all the details. After four days of
operation, he had not eaten anything in the first 48 hours of the surgery and on day 3, he was
given a fluid diet and light diet in the evening. On assessing his vital signs, he had a slightly
high temperature (38.1), normal heart rate, and elevated somewhat bp (135/85). He had a
right-sided inspiratory coarse crackle and moist product cough. As per the opinion of García
et al. (2019), coarse crackle is found to be louder, long-lasting and low pitched thus, it
indicates that there is excessive fluid in the lungs and may be caused due to aspiration,
pulmonary edma, pneumonia that require thorough investigation. On the other hand, the
productive and moist cough stated that it produces mucous or sputum and thus there is
congestion in the chest. This may indicate to the fact that he might be suffering from
pneumonia-like symptoms (Li et al., 2020). According to the study by Zhu et al. (2020),
pneumonia is an infection that causes inflammation of the air sacs in one or both the lungs.
The air sacs are filled with fluid and cause coughing, fever, abdominal pain and difficulty in
breathing. In addition to this, he had compliant of abdominal pain which was in the scale of 4
to 5 out of 10 however, on palpitation worsen and increase to 7 out of 10 and it was observed
that his abdomen was distended. This indicates that there is swelling in the abdominal area
due to accumulation of fluid in the activity, which gives the swelling appearance (Mesquita &
Rosas, 2017). The colostomy bag was intact and the stoma can be seen through the bag. The
physical feature of stoma includes warm, moist, pink and raised above the skin. This is one of
the indications that occur after surgery and is a common aspect that reduces in size with time.
The concerning factor was no output after the surgery, sluggish bowel sound and did not pass
flatus. This indicates that he a temporary delay in the gastrointestinal mobility after surgery
or postoperative ileus. According to Katayama et al. (2016), the probable reason of this is the

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disruption in the sympathetic or parasympathetic pathway in the gastrointestinal tract and
thus, the inflammatory change that has been responsible for mediating a number of pathways
as well as opioid usage for management of pain in this case as noted in the case study that the
use of PCA morphine in situ was given to the patient for pain regulation. After the processing
of information and identification of the problem, it can be stated that Ted may have
developed pneumonia and he was surely suffering post-operative ileus.
Answer 3
The fifth stage of CRC is to Establish goals for the patient in order to address all the health
conditions that have been identified in the previous step. From the assessment of the health
condition of Ted, it was stated that he might be suffering from post-operative pneumonia that
has affected his breathing, he had a high temperature and the abdominal pain that increase
with palpitation. Another condition that was critical in this case was post-operative ileus,
which is a common post-operation symptom that has an impact on the gastrointestinal system
of the patient. Therefore, it is necessary to strategize nursing care intervention or strategies
that would help in treating the patient from the above stated health condition. The nursing
care interventions for pneumonia are:
 To assess the rate, depth of respiration and rhythm as well as the movement of the
chest and usage of the accessory muscles. This will allow in assessing the
effectiveness and productivity of coughing. As stated in the case that Ted had a moist
and productive cough, which in addition to other symptoms indicated pneumonia. As
per the opinion of Shuang (2017), tachypnea, asymmetric chest movement and
shallow respiration are presented in such cases that demonstrate that there is a
discomfort in moving the wall of the chest and the fluid in the lung. This is because of
the compensatory response that occurs due to airway obstruction. Thus, the nurse

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needs to help the patient with altered breathing strategies that will help in the effective
use of accessory muscles and increase the chest excursion that allowing effective
breathing.
 The assessment of patient hydration status needs to be done. As per the study of
Zhang (2019), airway clearance is most hindered due to inadequate hydration in the
body and the thickening of mucus deposition. The hydration needs to be maintained
by forcing fluid at 3000 ml/day and offering warm fluid rather than col. The warm
fluid will aid in expectoration and mobilisation of the secretion. It will maintain the
hydration level in the body and increase the ciliary action that will help in the
elimination of secretion.
 Observation of sputum colour, odour and viscosity need to be done as it may indicate
infection and increase in airway resistance that requiring more strict intervention.
The nursing care intervention for postoperative ileus are:
 Nasogastric suctioning or nasogastric aspiration, which is a process of draining the
content of the stomach through a tube that can be done. This is mainly conducted
upon patient for removing gastrointestinal secretions and air who are suffering from
GI obstruction. The nurse needs to pass the plastic or rubber tube through the nose to
the esophagus and in the stomach (Adiamah & Lobo, 2020). The nursing intervention
is critical and thus, an experienced registered nurse needs to conduct the procedure
for a temporary basis. The nurse needs to spray water or saline solution through the
tube prior to the application of suction. This will help in protecting the patient from
electrolyte imbalance that may occur during the removal of fluid from the stomach.
 Another intervention that will help Mr Ted to recover from postoperative ileus is
early mobilisation. According to Wolthuis et al. (2017), the patient does not move
after major surgery; as a result, the action of muscle in the GI tract is limited and

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thus, after a prolonged period of time, it does not act on its own. Another factor that
may cause this condition is a disruption in the pathway of GI, which may occur due
to the surgery. Therefore, the best strategy is to mobilise at an early period which will
help in fixing the issue. As per the case study, the age factor of the patient is a critical
factor that may affect the application of the intervention; however, the nurse needs to
motivate the patient and communicate in such a way that the patient is able to move
for few minutes that will help in reducing the impact of the ileus in the body.
Answer 4
It is evident that drugs need to be administered to Ted in addition to the nursing
interventions in order to treat the health condition. For treating pneumonia, the class of drug
that can be used is macrolide is an antibiotic that helps in treating bacterial infections. It
offers effective coverage for various kinds of bacteria. Dinos (2017) opined that it is a protein
synthesis inhibitor that inhibits the biosynthesis of protein produced by the bacteria and thus,
prevents peptidyl transferase from ding peptide in the tRNA to the amino acid. Thus, it
inhibits the process of ribosomal translation. Another mechanism of this drug is the
premature dissociation of the peptidyl-tRNA from the ribosomes (Murray et al., 2017). The
side-effect of this drug is it causes myopathy, cholestasis and gastrointestinal symptoms that
can be adverse in nature. It can be administered orally or intravenous to the patient.
The drug that can be used for treating preoperative ileus is alvimopan which acts as a
peripheral acting μ-opioid receptor antagonist. The drug is responsible for accelerating the
recovery period of the GI system as defined by the time and thus, the first bowel movement
or flatus can be obtained (Kehlet, 2017). There are side effects of the drugs that include:
 Dyspepsia
 Back pain

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 Hypokalemia
 Delayed micturition
The drug can be administered orally to the patient and it has an ability of 80% of protein
binding ability

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