Case Study 2: Ted Williams - Clinical Reasoning Cycle and Nursing Care

This case study analyzes the case of Ted Williams, an 82-year-old man who underwent bowel resection surgery. The analysis applies the Clinical Reasoning Cycle (CRC) to understand the patient's situation, considering biopsychosocial, spiritual, and cultural factors. The study identifies key problems such as post-operative ileus, pain, and the management of pre-existing conditions like diabetes and heart failure. It proposes interventions including patient education, non-pharmacological treatments, family involvement, and the use of medications like alvimopan and beano. The document also recommends specific drug classes and discusses the implications of each, emphasizing the importance of considering side effects and patient-specific needs. The analysis highlights the importance of a holistic approach to patient care, focusing on improving health outcomes and patient satisfaction.

Running head: CASE STUDY 2: TED WILLIAMS
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Case Study 2: Ted Williams
Student’s Name
Institutional Affiliation
Case Study 2: Ted Williams

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Clinical Reasoning Cycle (CRC) is one of the effective reasoning processes used by
nurses to understand patients’ situations before coming up with plans and conclusions about
patients. CRC has significant advantages in the sense that it improves the quality of health
outcomes in patients while increasing the learning experiences for healthcare providers. This
paper applies the CRC model to Ted William’s case study.
Question 1. The Patient’s Situation and Biopsychosocial, Spiritual, and Cultural Impacts
The first step in CRC is the patient situation. According to the case study, Ted has
undergone a bowel resection surgery which has attracted biopsychosocial, spiritual, and cultural
effects that he did not anticipate. According to Gruppen (2017), surgical operations interfere
with activities of living (ALs) that are defined by the Roper-Logan-Tierney (RLT) model. The
surgery has interfered with his biopsychosocial life such as distress and discomfort that he may
encounter after surgery. The pain emanating from the affected area and inability to move and
carry out daily activities such as eating or bathing can also attract psychological distress as
explained in Williams (2016). During the recovery process, Ted will be unable to move and
socialize with his friends and close relatives. Psychologically, Ted may be depressed because of
losing his freedom of movement and relying on drugs and medications. Ted may also feel
embarrassed, considering that he cannot pass urine or due to the use of colostomy because he has
lost his natural ability to use organs. Spiritually, Ted needs spiritual motivation considering that
he is eighty-two years and may be thinking about his death Kusnanto, Agustian, & Hilmanto
(2018). There is also a need to consider cultural implications of Ted’s surgery. For instance, Ted
may find it difficult being attended to by young doctors. Additionally, the Ted’s culture may
make him to refuse conversations about his health issues or family background. When nurses

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notice that he is not willing to share his history, they should avoid pressing him to open up about
his preferences.
Question II. Processing Information and identifying the problem
The third step in the CRC framework is the processing of the information and cues
provided in the given case study. It is evident from the case study that Ted is an eighty-two year-
old man. A person who has advanced in age is expected to experience chronic diseases such as
diabetes and heart problems due to the aging of the organs. Ted has a history of diabetes
mellitus, heart failure, obesity, and gout, which is expected for his age (Engel, Just, Bleckwenn,
& Weckbecker, 2017). Obesity can be linked to lifestyle factors as discussed in Fields and
Batterman (2018), while diabetes mellitus and heart failure could be linked to his advance in age
as conditions that are expected when people advance in age.
The registered nurse taking care of Ted will have to take into consideration the health
history of Ted and consider his recent surgery. The medical history creates room for one to
understand and interlink the present interventions with the past medical data for desired
outcomes in the patient. Ted’s temperature is at 38.1 and has developed abdominal pain and
vomited after being given a dose of his regular metformin. Metformin is used in the management
of type II diabetes, and vomiting is one of its side effects (Nair, 2016). The registered nurse
should also consider current post-operational ileus from Ted’s surgery. It is evident that Ted is
suffering from post-surgery ileus, which is expected due to contraction or paralyzing of the
intestines after surgery. According to the case study, the symptoms of post-op ileus evident in
Ted include pain in lower abdomen, absence of flatus, and sluggish bowel sounds. These are the
new problems that will need to be addressed in addition to the medical history of heart failure,
gout, and diabetes mellitus.

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The issue of family support and involvement of Ted in making decisions regarding his
health has to be addressed for effective treatment and management of Ted. According to the case
scenario, Ted lives in a retirement village alone, even though he has a partner living in the same
retirement village. The nurse taking care of Ted will need to consider the extended family
support in terms of making decisions regarding Ted’s health. His children could be contacted
and informed of the current health status of their father and the contribution they can make to
improve his health.
The fourth step in the CRC problem is the problem identification after processing the
information and cues provided in the case study. The main problem is to help Ted manage his
health after the surgery and improve health outcomes within the shortest time possible and at the
affordable costs. The nurse taking care of Ted will, for instance, need to ask Ted if it is possible
to involve his children or his grandchildren in his health. This is a crucial aspect of managing the
patient’s condition because it is a respect of their autonomy and it shows that they still have
control over what happens to them. It also triggers patient satisfaction with the quality of care
they receive. The second problem with Ted is the management of his previous chronic illnesses
which are still present even after the bowel resection. Some drugs such as metformin could
increase the risks associated with post-op recovery and increase the length of stay in hospital.
Ted may also find it difficult to manage his condition alone, considering that he is aging and the
complications of chronic diseases are increasing. The nurse should consider the best
pharmacological interventions that will not increase the side effects while at the same time
helping Ted to recover from post-op ileus.
Question 3: Goals and Possible intervention strategies for Ted
 To improve his health and make sure that he leaves the hospital as soon as possible

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 To resolve the pain his lower abdomen in the next five days
 To make sure that Ted attains full recovery from post op ileus before leaving the hospital
 To equip Ted with knowledge on self-management so that he can participate in his own
care
 To minimize the side effects that affect Ted when he use drugs to manage type 2 diabetes
One of the possible interventions to help Ted involves the use of patient education
approach. A study carried out by Adekhera (2016) found that patient education improves the
quality of recovery and satisfaction in healthcare setting for patients suffering from post-surgery
ileus. The nurse could educate Ted on managing his post-op ileus and his previous medical
conditions by encouraging him to identify possible complications that may arise. The RN should
also teach the patient on therapeutic management of gout and how to respond to the problem as
he recovers from the operation. Vilz, Stoffels, Strassburg, Schild, and Kalff (2017) found that
post-surgery ileus are prevalent in most surgeries, but they often go away in two to three days in
most patients. The nurse will need to explain to Ted that the complications he is feeling are part
of the healing process.
The second possible intervention could involve non-pharmacological management of
gout, type II diabetes, and the post op ileus. A study conducted by Jaensson, Dahlberg, and
Nilsson (2019) found that different factors affect the recovery time from ileus. Non-
pharmacological interventions include the use of therapy and physical exercises to reduce
overreliance on drugs, considering that the patient is taking a lot of drugs. If possible, the RN
could encourage or find a person that could encourage Ted to participate in his favorite physical
activities that relieve emotional and physical distress that could arise due to complications
associated with his health.

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Ted may also need someone to talk to and listen to as an intervention to save him from
emotional and physical distress associated with his condition. This makes it necessary for
involving the family members or Ted’s family in his care to improve his recovery. A study by
Meissner and Huygen, (2018) found that involvement of families in the care of the patients
increased patient satisfaction and the speed of recovery. The RN should consider asking Ted’s
children to find time to visit their ailing father or moving in with one of them to help him during
the recovery period.
It is also for the RN to consider alternative medications in treating Ted’s chronic
diseases. The chosen medications should have minimal side effects and positive outcome
compared to the current ones. Furosemide could be used to treat type II diabetes in place of
metformin to reduce the side effects of metformin (Drugs.com, n.d.). The use of alternative
medications should only be introduced once it is evident that Ted is not responding well to the
current medications that help in managing his current condition. Simethicone should be used to
help Ted in passing flatus, and beano could be used to prevent formation of gas and possible
flatulence in the patient after surgery (Meissner & Huygen, 2018). Beano helps in relieving
bloating, which can be a persistent problem in Ted due to the paralysis of intestines and other
internal organs after the surgery (Burta, Iacobescu, Mateescu, Nicolaie, Tiuca, & Pop, 2018).
Alvimopan is another medical intervention that can be used in the treatment of Ted’s post op
ileus. According to Nair (2016), alvimopan accelerates ileus recovery after bowel resection and
it has minimal side effects.
Question 4: Recommended classes of drugs
The RN should recommend both alvimopan (mu-opioid) receptor and beano (class of
digestive enzymes) to help Ted in the management of post op ileus. Each of these medications

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has significant advantages and side effects, but the RN should make sure that the benefits
outweigh the side effects. The primary benefit of alvimopan is that it accelerates recovery from
post-surgery ileus, making sure that the patient spends the least number of days under the
observation of the caregiver (Nair, 2016). According to Drugs.com (n.d.), some of the side
effects of alvimopan include nausea, vomiting, headache, and sneezing. The patient may also
diarrhea depending on the dosage.
Beano is an oral form of digestive enzymes and could help Ted in passing gases from the
bowel. The drug works by accelerating digestion and reducing the formation of gas bubbles in
the intestines, hence making sure that Ted passes flatus easily. This could eventually help in
alleviating pain in lower abdomen. The side effects include allergic reactions such as rashes,
swelling of the mouth and throat, and difficulties in breathing.
The implication of each of the two drugs depends on their side effects. The Registered
Nurse prescribing them should inform Ted of the anticipated side effects. Ted should be advised
to report any side effects immediately he notices them to the nurse and the nurse should
discontinue the medications or change them if the side effects become severe. Additionally, the
medications should only be prescribed if their potential health benefits outweigh their side
effects.

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References
Adekhera E. (2016). Routine postoperative nursing management. Community Eye Health,
29(94), 24. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5100467/
Burta, O., Iacobescu, C., Mateescu, R. B., Nicolaie, T., Tiuca, N., & Pop, C. S. (2018). Efficacy
and safety of APT036 versus simethicone in the treatment of functional bloating: a
multicenter, randomized, double-blind, parallel group, clinical study. Translational
Gastroenterology and Hematology, 3(72). Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6256934/
Drugs.com (n.d.). Furosemide. Retrieved from https://www.drugs.com/furosemide.html
Engel, B., Just, J., Bleckwenn, M., & Weckbecker, K. (2017). Treatment options for gout.
Deutsches Arzteblatt International, 114(13), 215–222. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5624445/
Ferry, B. (2020). Medical benefits of Beano. Verywell Mind. Retrieved from
https://www.verywellhealth.com/beano-4767029
Fields, T. R., & Batterman, A. (2018). How can we improve disease education in people with
gout? Current Rheumatology Reports, 20(3), 12. Retrieved from
https://link.springer.com/article/10.1007/s11926-018-0720-x
Gruppen L. D. (2017). Clinical reasoning: defining it, teaching it, assessing it, and studying it.
The Western Journal of Emergency Medicine, 18(1), 4–7. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5226761/
Jaensson, M., Dahlberg, K. & Nilsson, U. (2019). Factors influencing day surgery patients’
quality of postoperative recovery and satisfaction with recovery: a narrative review.
Perioper Med, 8(3). Retrieved from

CASE STUDY 2: TED WILLIAMS
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https://perioperativemedicinejournal.biomedcentral.com/articles/10.1186/s13741-019-
0115-1
Kusnanto, H., Agustian, D., & Hilmanto, D. (2018). Biopsychosocial model of illnesses in
primary care: A hermeneutic literature review. Journal of Family Medicine And Primary
Care, 7(3), 497–500. https://doi.org/10.4103/jfmpc.jfmpc_145_17. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6069638/
Meissner, W. & Huygen, F. (2018). Management of acute pain in the postoperative setting: the
importance of quality indicators. Current Medical Research and Opinion, 34(1), 187-
196. Retrieved from
https://www.tandfonline.com/doi/full/10.1080/03007995.2017.1391081
Moreno, M., J. (2016). The influence of perceived family support on post-surgery recovery.
Psychology, Health, & Medicine, 22(1). Retrieved from
https://www.ncbi.nlm.nih.gov/pubmed/26899740
Nair, A. (2016). Alvimopan for post-operative ileus: What we should know?
Acta
Anaesthelogica, 2(3). Retrieved from
http://dl219.zlibcdn.com/dtoken/971aad2293107dd22f830add2460b875
Vilz, T. O., Stoffels, B., Strassburg, C., Schild, H. H., & Kalff, J. C. (2017). Ileus in adults.
Deutsches Arzteblatt International, 114(30), 508–518. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5569564/
Williams, B., C. (2016). The Roper-Logan-Tierney model of nursing: A framework to
complement the nursing process. Research Corner, 2(6). Retrieved from
https://www.ncbi.nlm.nih.gov/pubmed/25689705