Nursing Assignment Analysing Medical Case with Clinical Reasoning Cycle

Question

Task

Case Study: Edward (Ted) Williams

• Edward (Ted) Williams is an 82year old male who is day 4 post-operative following a bowel resection and formation of a temporary colostomy. Ted had previously had a coloscopy and biopsy that confirmed a malignant mass. He has a past medical history of; heart failure, type II diabetes melilites, obesity and gout. (BMI 37.6m2; Height 175cm; weight 115kgs)
• Ted is a widower and lives alone. His wife died 3 years ago following a bout of pneumonia. One year ago, Ted moved into a retirement village located in a regional area two and a half hours from the city. The retirement village is near where he lived with his wife and children until they left home. Ted has 2 grown up children, a son Christopher who lives overseas with his wife and son, and a daughter Janice who lives with her husband and 3 children in the city. While Ted lives alone, he has a partner Gwen 78, who also lives in the same retirement village as Ted.
• Current medication: Metformin 500mg Mane Captopril 12.5mg mane Frusemide 40mg mane Allopurinol 100mg Daily Paracetamol 1g QID
• Ted is now day 4 post op. He was Nil By Mouth (NBM) for the first 48 hours after surgery. Yesterday he commenced on a full fluid diet and has upgraded to a light diet yesterday evening. Today, Ted was given his regular metformin and ate breakfast. Since then Ted has vomited twice and feels nauseous. He has been given ondansetron 4mg for nausea.
• Teds vital signs at 10am are as follows: T 38.1; HR 98 reg; BP 135/85; RR 26; SpO2 94% on 3L NP. He has right sided inspiratory coarse crackles and he has a moist productive cough. He has PCA morphine in situ for effective pain regulation. Ted has some abdominal pain that he says is at a scale of 4-5/10, he says the pain worsens on palpation to 7/10 and you note that his abdomen is distended. The colostomy bag is intact and the stoma can be sighted through the bag. The stoma is warm, pink, moist and slightly raised above the skin. There has been no output since his surgery. He has sluggish bowel sounds and has not passed flatus. The abdominal laparotomy has a clear occlusive dressing (opsite) and there is minimal ooze present. He has a redivac drain with 30mls of haemoserous fluid, and a urinary catheter in situ and is passing approx. 60-70mls of urine/hr.

Nursing Assignment Task:

1: Use stage one of the clinical reasoning cycle (CRC) ‘Consider the patient situation’ to identify the biopsychosocial, spiritual and cultural impacts of Ted’s surgery for him and his family

2: The information for stage two of the CRC collect cues and information has been provided for you in the case study. Use this information to provide responses to CRC stages three ‘Process the information’ and stage four ‘Identify Problems.’ Please link to pathophysiology and provide evidence from the literature to support your thinking.

3: Using stage five of the CRC Establish goals outline and justify (5) nursing care interventions/strategies the registered nurse would implement to provide care for Ted. Justify your thinking with links to current peer reviewed evidence and literature

4: Select two classes of drugs that would be used to manage Ted’s post operative condition. Please provide a rationale for why that drug class would be suitable for Ted. Provide a detailed description of the pharmaco-dynamics of each of the selected class of drug as well as the potential side effects and the nursing implications for administration

Answer

Answer 1:Application Of Rlt
In order to diagnose the patient's condition as portrayed in the given case of nursing assignment, the clinical reasoning cycle can provide appropriate detailed information. The CRC is a process by which nurses collects information, cues and processes information to understand patient problem or situation. Then according to the diagnosis of the patient's condition appropriate nursing intervention is planned. In his care plan, pharmacological intervention is seen and is vital signs are provided in the case analysis. In the current discussion, the impact of Ted's surgery for him and his family is understood. Then the link to pathophysiology from literature evidence is understood. Then the goals of nursing interventions and strategies for care planning for Ted are included. Lastly, pharmacological intervention for managing Ted's port operative condition has been included.

Stage one of the clinical reasoning cycle (CRC)includes considering facts from the patient or situation for the purpose of understanding biopsychosocial, spiritual and cultural impacts from the surgery that Ted had on him and his family (Levett-Jones et al, 2019). As the case of Ted is presented after bowel resection surgery where he was formed a temporary colostomy, and he is seen to have various associated comorbidities. The Roper-Logan-Tierney (RLT) Model for Nursing can enable identifying the biopsychosocial, cultural and spiritual impacts of Ted’s surgery (Williams, 2015). The biopsychosocial impact of Ted's surgery on him is significant. Ted is living alone and his daughter resides in the city nearby. Ted requires continued pharmacological interventions along with nursing care for managing his current condition. His partner Gwen is also considerably aged to take care of Ted and resides in the same retirement however away from him. Considering his current condition and history of heart failure, having malignant mass being detected in his coloscopy. These vital signs reveal that he requires considerable nursing care and attention from healthcare professionals to manage his situation. His family members will be worried due to his biopsychosocial impacts and considering ways to manage his condition.

The surgery's impact on the spiritual and cultural aspects of Ted might be considerable in nature. Ted will require spiritual as well as cultural support for dealing with such a situation. This will enable him to deal with his situation well. As he is quite aged and facing such a complex situation, spiritual and cultural support for him and his family members might enable dealing with this situation.

Answer 2: Problem Identification
Collecting relevant information from stage two of the CRC, cues will be collected from the case study to respond to stage three. At stage three this information will be used in processing information and then identify the pathophysiological problems to Ted's condition. In the current case Edward (Ted) Williams is an 82-year-old patient who had the formation of temporary colostomy after 4 days of bowel resection operation. His comorbidities include malignant mass detected by coloscopy, heart failure, obesity, gout, and type II diabetes melilites. He is a widower and lives alone. He is nauseous, and he has vomited twice. His vital signs reveal he has a fever with T 38.1. His blood pressure remains high at 135/85. His HR is regular at 98 while his RR is slightly high at 26. His SpO2 is at 94% on 3L NP. He has slightly high pain when he is palpitating 7/10. Initially, he was on liquid and then given a light solid diet. After having his breakfast, he feels nauseous and has vomited.He is seen to have moist productive cough with right sided inspiratory coarse crackles.

Post collecting these cues related to the surgery, the pathophysiological condition of Ted can be understood. He will need to stay back in the hospital for as long as two weeks post the surgery or until all his symptoms subside (such as his fever, palpitation and high blood pressure). He might not be able to pass stool till a long time period which will need to be reinstated such that he can manage his condition back at home (Kupelian, &Cutner, 2016). He is seen to have sluggish bowel sounds but has not passed flatus, hence passing of stool needs to be normalized before his discharge. The healing of his colon and rectum need to be checked for healing such that there is no risk posed post his surgery. Though there are minimal ooze present and the abdominal laparotomy has cleared occlusive dressing. The risk of infection has to be monitored to check as he has diabetes such that it can be reduced before he is discharged. As he has redivac draining with 30mls of haemoserous fluid and he is passing urine in catheter 60-70 ml/hour. This draining has to be reduced and checked for any signs of infections. Any possible scarring of tissue has to be checked and leaks between the joined sections of the colon have o be noticed (DiBaise, &Motil, 2016). The patient's pain which is sometimes high has to be monitored for checking any injury to the bladder, blood vessels or ureters. Though this operation does not cause many problems even in older people, as Ted has a temporal colostomy, care about the collection bag is essential.

This leads to stage 4 of the CRC where the problem needs to be identified. The problems are;

• Problem 1:The main cause of the problem that can arise for Ted is the presence of abdominal pain which is rated at 7/10 during palpitation. The pathophysiology of this condition is the presence of scar tissue or leak between the joined section of the colon or presence of injury to the bladder. The presence of injury to the bladder can also be supported by his redivac drain of haemoserous fluid. His time to heal his condition might be significantly higher as he has associated comorbidities like diabetes (Darwish, & Roman, 2016). The pathophysiology of this condition reflected in his fever reveals that he might have an underlying infection which is another sign identified post-analysis of information. His blood pressure needs to be stabilized before he can be discharged from the hospital.
• Problem 2:He has right sided inspiratory coarse crackles and he is seen to have moist productive cough. The pathophysiology of crackles is caused due to excessive fluid in the airways. The primary pathophysiological reason behind this is mainly transudate or exudate. This problem needs further examination, such as exudate might be due to lung infection such as pneumonia and transudate might be from congestive heart failure. These crackles pathophysiology occurs when a small airway open with a pop during inspiration and collapses due to loos esecretions or from the lack of aeration while expiration.

Answer 3:Nursing Intervention/ strategies
Analyzing the five stages of CRC, the goal outline for nursing care intervention/ strategies using SMART goals includes;

SMART Objective 1: To reduce risk of infection post-surgery. This outcome will be measured by the draining from redivac drain has to be stop. It is an attainable objective and relevant to the case. This can be achieved within a week by measuring ESR post-surgery everyday.

SMART Objective 2:To check signs of pneumonia/ heart failure and treat it. This outcome will be directly be measured by conducting tests for heart failure (ECG) and for pneumonia (testing).

Keeping in mind the above goals for the patient, the following will be the nursing care intervention/ strategies.

1. For SMART Goal 1:
• Wound Dressing: Ted will be provided with routine care procedures post-surgery, which includes dressing of wounds. Monitoring of bowel for signs of discharge or blood in the stool. Any signs of pain or site infection will need to be closely monitored for understanding any additional infection taking place or scars present. He will need to be guided through the entire procedure of wound care. His wound care will need to be conducted keeping him informed. Ted will need to monitor his bowel sounds in a close manner and understand the degree of abdominal distention (Shah et al, 2016). Due to surgical procedure, there might be disruption of bowel peristalsis, leading to an initial ileus. Once Ted is able to pass flatus and have regular bowel sounds, it indicates the returning of peristalsis. Ted will need to be monitored for bowel sounds and for abdominal distension frequently during this period.
• Monitoring Activities: Ted will be also be asked to restrict certain activities that he usually undertakes (Richards et al, 2018). Ted's movement will be monitored in a close manner which minimizes risk to his site of injury and displacement of his catheter or other tubes. The color, amount and odor of the drainage from surgical drains will be monitored for checking any signs of clots o bright bleeding. A change in color, amount or odor reflects complications such as infection, hemorrhage or intestinal obstruction.
• Patient education: Ted will need to be maintained provided proper education such that he is able to manage his condition well (Clayton et al, 2015). Ted will be told regarding the significant consequences of his surgery and ways he could overcome them. He will be guided with proper education such that he is able to take care of his surgery post returning home. Oral feeding is gradually introduced to reduce abdominal distention and trauma to the suture lines. A proper nutrition plan will enable Ted to maintain his regular diet and recover fast. Ted will be monitored for signs of nausea or bloating or gas after his feedings to understand his suitability to liquid or solid foods.
2. For SMART Goal 2:
• Monitoring: Continuous monitoring of his vital signs and checking for signs of improvisation. Monitoring his breathing for checking any signs of abnormalities.
• Oxygen Supplementation: Providing additional supply of oxygen to ease his breathing and reducing his crackling sounds from his lungs.

Answer 4: Managing the post-operative condition
Managing the post-operative condition of Ted is important through pharmacological intervention strategy. The two-class of drugs that can assist in managing Ted's post-operative condition are histamine2-receptor antagonists and antibiotic therapy. Histamine2-receptor antagonist's pharmaco-dynamics include reducing the number of acids that are made by the stomach. This reduction in acid reduces acid reflux which prevents the formation of ulcers and prevents irritation of the oesophagus (Drake, & Ward, 2016). It helps by regulating the amount of acid is present in the stomach and aids in digesting the meals eaten. The potential side-effect of this drug is the impaired functionality of the stomach in controlling acid reflux. The nursing implication for this drug includes enabling the digestion of food given to the patient and enabling the patient to pass bowel or flatus.

Antibiotic therapy pharmaco-dynamics includes killing organisms such as B-lactams, Fluoroquinolones, Daptomycin, metronidazole, and so on- Bactericidal (Brady et al, 2015). Another aspect is bacteriostatic- which inhibits the growth of harmful infection-causing bacteria. This therapy can reduce the site of infection. This is suitable for Ted to control his infections. Potential side effects of antibiotics are destruction if useful bacteria that aid in digesting food. The nursing implication for this therapy is providing the capability for the management of the disease.

Ted will need to be provided medication such that he is able to pass his bowels properly, hence he will be provided with antacids, histamine2- receptor antagonists, and antibiotics as given by the surgeon. Antibiotic therapy is a common measure to prevent infection that might lead to preventing infection as a result of contamination of the abdominal cavity with gastric contents. Antibiotics from the same group will be given to treat pneumonia, in case diagnosed. Ted will need to be handed over a medication discharge plan that he needs to be followed post his discharge. The pharmacological intervention plan will include medication to manage his condition post-operation and also which will cater to his other medical conditions. There will be SOS medication suggested that the patient will need to take in the absence of healthcare professionals and in case of pain intensifies. Ted is experiencing a significant condition. Ted requires proper pharmacological with nursing intervention. The post-discharge plan of Ted will need to be provided such that he can heal faster. Moreover, there needs to be health intervention for Ted which allows for close monitoring of his condition.

Reference
Brady, J. T., Dosokey, E. M., Crawshaw, B. P., Steele, S. R., & Delaney, C. P. (2015). The use of alvimopan for postoperative ileus in small and large bowel resections. Expert review of gastroenterology & hepatology, 9(11), 1351-1358. DOI: 10.1586/17474124.2015.1095637.

Clayton, J. T., Reisch, J. S., Sanchez, P. J., Fickes, J. L., Portillo, C. M., & Chen, L. E. (2015). Postoperative regimentation of treatment optimizes care and optimizes length of stay (PROTOCOL) after pyloromyotomy. Journal of pediatric surgery, 50(9), 1540-1543. DOI: 10.1016/j.jpedsurg.2014.12.019.

Darwish, B., & Roman, H. (2016). Surgical treatment of deep infiltrating rectal endometriosis: in favor of less aggressive surgery. American journal of obstetrics and gynecology, 215(2), 195-200. DOI: 10.1016/j.ajog.2016.01.189.

DiBaise, J. K., &Motil, K. J. (2016). Pathophysiology of short bowel syndrome.

Drake, T. M., & Ward, A. E. (2016). Pharmacological management to prevent ileus in major abdominal surgery: a systematic review and meta-analysis. Journal of Gastrointestinal Surgery, 20(6), 1253-1264. DOI: 10.1007/s11605-016-3140-0.

Kupelian, A. S., &Cutner, A. (2016). Segmental bowel resection for deep infiltrating endometriosis. Nursing assignment BJOG: An International Journal of Obstetrics & Gynaecology, 123(8), 1368-1368. DX.DOI: 10.1111/1471-0528.13975.

Levett-Jones, T., Courtney-Pratt, H., & Govind, N. (2019). Implementation and Evaluation of the Post-Practicum Oral Clinical Reasoning Exam. In Augmenting Health and Social Care Students’ Clinical Learning Experiences (pp. 57-72). Springer, Cham. DOI: 10.1007/978-3-030-05560-8_3.

Richards, D. A., Hilli, A., Pentecost, C., Goodwin, V. A., & Frost, J. (2018). Fundamental nursing care: A systematic review of the evidence on the effect of nursing care interventions for nutrition, elimination, mobility and hygiene. Journal of clinical nursing, 27(11-12), 2179-2188. DOI: 10.1111/jocn.14150.

Shah, M., Ellis, C.T., Phillips, M.R., Marzinsky, A., Adamson, W., Weiner, T., Erickson, K., Lee, S., Lange, P.A. and McLean, S.E. (2016). Preoperative bowel preparation before elective bowel resection or ostomy closure in the pediatric patient population has no impact on outcomes: A Prospective Randomized Study. The American surgeon, 82(9), 801-806.

Williams, B. C. (2015). The Roper-Logan-Tierney model of nursing: A framework to complement the nursing process. Nursing2019, 45(3), 24-26. DOI: 10.1097/01.NURSE.0000460730.79859.d4.