University Nursing Case Study: Post-Operative Surgical Patient Care

This case study focuses on an 82-year-old patient, Ted, who underwent surgery involving resection and colostomy, and includes a history of obesity, heart attack, and type 2 diabetes. The case study explores the biopsychosocial impacts of Ted's surgery, considering factors like dependence, depression, and cultural sensitivities. It details Ted's post-operative complications, including coarse crackles, a productive cough, elevated temperature, abdominal pain, distension, nausea, and vomiting, along with his medication. The assignment outlines five nursing goals: reducing cough, decreasing abdominal distension and pain, managing body weight, and monitoring urine output to prevent hypovolemia. It also examines the use of expectorants and diuretics for treatment, emphasizing the importance of monitoring side effects and patient conditions. The study highlights the application of the Roper-Logan-Tierney model, emphasizing activities of daily living and the impact of health issues on the patient's well-being and care requirements.

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

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Answer 1
According to the Roper-Logan-Tierney (RTL) model, the main factors that influence
the activities of daily living are biological, psychological, socio-cultural, environmental and
polito-economical. The main activities of daily living (ADL) include maintenance of safe
environment, communicating, eating and drinking, personal hygiene, mobilizing, proper
control of body temperature, expressing sexuality, sleeping and dying. Decrease in the
execution of ADL increase the level of dependence (Holland & Jenkins, Eds, 2019).
The bio-psychological impact of Ted's surgery include increased in the level of
dependence over others in order to conduct the activities of daily living like maintenance of
personal hygiene, eating and mobilizing. This is because, Ted is 82 years old and has
undergone a surgery following resection and formation of temporary colostomy. Other
reasons include obesity (Ted is 175 cm in height and 115 kilograms in weight) and has
previous case history of heart attack along with the presence of Type 2 diabetes (T2DM).
Increase in the level of dependence over others will increase his sense of depression and at
the same time will hamper the process of health aging and thereby negatively hampering bio-
psychosocial aspect of life (Gatchel et al., 2018). With the process of aging, there occurs
difficulty to adjust with new situation leading to adverse chances on the intellectual sphere
and cognitive thinking. This in turn cast a negative impact on the cultural and spiritual aspect
in the life of the older adults and thus increasing loss of perceived sensation and involution of
perception process. Ted lives alone after the death of his wife in a retirement village,. Both
his wards stay away from him due to professional commitments and have their own family.
Ted's only partner is his friend in retirement village, Gwen, 78 years old. Gatchel et al. (2018)
stated that lack of independence among the older adults increase their spiritual dependence
over the family members and thus creating burden for Ted’s children especially his son who

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resides overseas. At this time cultural sensation becomes strong and thus Ted seek healthcare
assistance only form older adults or nurses whom are culturally competent.
Answer 2
The case study highlights that post 4 days of operation, Ted has developed right sided
inspiratory coarse crackles along with the generation of moist productive cough. Crackles
(rales) are caused by the secretion of excessive fluid in the airways. It is cause due to either
an transudate or exudates. Exudate arises due to lung infection like pneumonia and transudate
occurs due to congestive heart failure. The presence of the moist productive cough indicates
the possible signs of pneumonia and thus a health priority (Momose et al., 2018). His body
temperature is also high, indicating possible chances of microbial infections or sepsis.
Crackle mainly occurs when airways pop open during the process of inspiration in
comparison to expiration. This pop opening of the airways lead to the infiltration of the
extracellular fluids inside the pulmonary cavities and this might be a reason behind the
formation of moist cough for Ted. There are different types of crackles like fine medium and
coarse. Ted had course crackles that is louder and low itched and long lasting. They indicate
excessive fluid build-up inside the lungs cause by pulmonary oedema arising from congestive
heart’s disease or chronic bronchitis and leading to pneumonia (Valade et al., 2018). The
blood pressure of Ted is high (135/85; high systolic pressure) and Ted has previous history of
heart attack thus indicating priorities of care in the domain of congestive heart failure.
Case study indicates that he as certain degree of abdominal pain with a pain scale of
4 to 5 out of 10. However, on palpation, the pain score increase to 7/10. The abdomen is also
distended. Zhang and Xu (2017) stated that postoperative ileus (POI) is regarded as a
predictable delay in the motility of the gastro-intestinal tract. It is mainly common after the
abdominal surgery. Ted has also under-went bowel resection and was NBM for first 48 hours,

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He is in his fourth day in the post-operative care and is commenced fluid diet followed by
light diet. The probable mechanisms of disruption include tampering of the parasympathetic
or sympathetic pathways of the GI tract followed by inflammatory changes. This is the reason
of increased level of pain upon palpation. The use of opioids also increases the chance of
POI. Ted is on morphine (an opiod) (Vilz et al., 2017). Alternatively it can be said that Ted’s
regular medication include Frusemide, a diuretics drug that helps in reducing the amount of
additional fluid in blood through urine arising out of renal complications. Ted might be on
renal complications as he has T2DM the urine output is also marginally less than normal (Ted
is excreting 60-70mls of urine/hr while normal is 80 ml per hour approx). Lack of proper
management of abdominal distension might increase the chance of internal infection and thus
health priority (Meouchy, Hayek & Shan, 2018).
Ted has vomited twice during the post 4 days of the surgery and is feeling nauseous.
Shaikh et al. (2016) stated that post-operative nausea and vomiting (PONV) is one of the
complex yet significant problem under post-operative anesthetic practice. Pathophysiology of
post-operative nausea and vomiting involves several receptors and pathways. These pathways
include: (i) chemoreceptors trigger zone (CTZ); (ii) vagal mucosal pathway present in the
gastro-intestinal system; (iii) neuronal pathways present in the vestibular system; (iv) reflex
afferent pathways present in the cerebral cortex and (v) midbrain afferents. In case of Ted, it
is mucosal pathway present in the gastro-intestinal system. Alternative pathophysiology
include disturbance in the gut or oropharynx leading to pain followed by vomiting. In case of
Ted, profuse vomiting might lead to the generation dehydration followed by hypovolemia
and hypo-tension. The present heath condition of Ted indicates high systolic present and
standard diastolic pressure. The blood loss during the surgery and further dehydration arising
from vomiting might led to hypovolemia leading to decrease in the level of oxygen saturation

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thus it is a health priority (Shaikh et al.,2016). At present the oxygen saturation is SpO2 94%
on 3L NP.
Nursing Goals
Goal 1: Reduction in the level of moist productive cough
Parisien-La Salle et al. (2019) stated that older adults at a high risk of airway
clearance and it increases the risk of emphysema along with higher risk of sputum
production. One of the effective nursing intervention for the removal of the moist cough from
the chest include breathing exercise. The breathing exercise must be initiated through deep
breathing, followed by slow breathing through nose. This helps in expansion of the lower rib
cage and helping the diaphragm to move forward. This exercise must be continued for three
to five times. This would be followed by pursed lip-breathing at first slowly and then rapidly.
Breath must never be forced out. Pursed lip-breathing helps to excrete out the moist cough
entangled in the chest through mouth and thus promoting airway clearance (Parisien-La Salle
et al., 2019).
Goal 2: Decrease in the level of the abdominal distention
Case study indicates that Ted has sluggish bowel sounds and has not passed flatus.
Moreover, he has renal complications leading to the fluid retention in abdomen. Regulation
of fluid intake in the diet along with the regulation of the urine output will be regarded as the
one of the promising non-pharmacological intervention for abdominal distention. Along with
the regulation of fluid intake, the dietary intake must be controlled strictly and this includes
restricted intake of fermentable disaccharides, oligosaccharides, monosaccharides, and
polyols (Foley et al., 2014).

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Goal 3: Decrease in the level of abdominal pain
Reduction in the level of the abdominal pain can be done by proper repositioning of
the patient. Re-positioning of the patient or change in the sitting of sleeping posture of the
patient in periodic interval might help to reduce the severity of the pain. Changing the
position Ted, depending on the location of the stoma might help to reduce the pain severity.
Change in positioning of Ted will help in the re-distribution of the water throughout the
abdomen along with increasing the probability of passing flatus and thus reducing pain
sensation (He, Li & Liu, 2017).
Goal 4: Decrease in unregulated body weight
Decrease in the unregulated body weight can be done by the proper regulation of the
diet plan once Ted is been asked to commenced oral food intake. The diet chart of Ted must
include restricted intake of sugar, carbohydrate and fat in diet. Physical exercise will not be
an option for Ted, taking his age and operational status in mind. The dietary intake must be
regulated under the supervision of trained yet professional dietician by taking the age, weight
and gender of the patient into consideration. The decrease in the level of body weight will be
indicated through decrease in the level of body mass index (BMI) (Barnes & Cassidy, 2018).
Goal 5: Monitoring urine output and managing hypovolemia
Vomiting in Ted might give rise of hypovolemia and this is the reason why he is
experiencing nausea. Thus in order to reduce the chances of developing hypovolemia, the
strict regulation of the fluid intake (in the form of intravenous medication and oral intake)
must be monitored in comparison to the fluid output (through urine as collected in the in-situ
catheter and redivac drain with 30mls of haemoserous fluid). Proper regulation of the input
and output and fluid will help to reduce the chances of dehydration and faster recovery from
post-operative condition. Increase in the level of urine output or fluid output through redivac

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drain must be compensated through increase in the level of the fluid intake and vice-versa
(Egal, 2018).
Question 4
Expectorants: Expectorants like Guaifenesin are drugs that increase overall airway
secretions. They conduct this by increasing the overall water content of the secretions, which
promote the overall decrease in the tickiness of the mucus, and making it easier to cough up.
Thus, the use of this drug will help To excrete the most cough from the chest. Side-effects of
expectorants include development of fatigue, confusion, excess salivation, irregular heartbeat,
skin sores and severe headache. It would be the duty of nurse to monitor the heart rate of Ted
as Ted has already encountered heart failure previously. It is administered in the form of
syrup or liquid (McFadden, 2019).
Frusemide can be used for the effective reduction of the abdominal distention of Ted.
Frusemide falls under the category of diuretics. This medication helps in inhibiting the
luminal Na-K-Cl co-transporter in the Henle’s Loop (ascending loop) by bonding to chloride
and thus helping to promote loss of sodium, potassium and chloride through urine and
reducing extra fluid content in the body. The main side effects of this medication include
dehydration and thus the urine output must be monitored strictly based on the intake of the
fluid. This medication is injected intravenously or orally (McFadden, 2019).

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References
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Egal, M. (2018). Urine Output Based Fluid Management in the Critically Ill: assessing
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Foley, A., Burgell, R., Barrett, J. S., & Gibson, P. R. (2014). Management strategies for
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