V Sims DA- Marvin Hayes

Marvin Hayes Documentation Assignments 1. Document your findings related to the focused assessment regarding Mr. Hayes's stoma status, peristomal skin, abdominal and perineal incisions. Stoma status – the stoma appears to look pink, moist, and rounded Periostomal skin – there is some stool leaking between the skin and the skin barrier Abdominal Incision – the skin lesion showed no signs of infection or bleeding Perineal Incision – there is a perineal pad and there are no signs of infection or draining 2. Document assessment findings related to gastrointestinal function, output from colostomy, and ability to advance current diet post surgery. GI function – Upon auscultation of abdomen, normal bowel sounds were heard Colostomy output – brown, liquid stool The patient is able to advance current diet post surgery. 3. Identify and document key nursing diagnoses for Mr. Hayes regarding his current condition. Risk of disturbed body image r/t recent placement of sigmoid colostomy AEB patient stating that he is “embarrassed by the smell” Risk of impaired skin integrity r/t recent placement of sigmoid colostomy AEB stool leakage between skin and skin barrier and embarrassment of the smell of the stoma. 4. Referring to your feedback log, document all nursing care provided and Mr. Hayes's response to this care. 0:00 You arrived at the patient side. 0:00 You reviewed the patient information. 0:00 You reviewed the patient log. 0:00 You reviewed the diagnostics. 0:00 You reviewed the clinical observations. 0:00 You reviewed the MAR. 0:00 You reviewed the orders. 0:00 You reviewed the intake and output. 0:07 You washed your hands. To maintain patient safety, it is important to wash your hands as soon as you enter the room. 1:08 You put on gloves. 1:21 You introduced yourself. This was reasonable. 1:36 You identified the patient. To maintain patient safety, it is important that you quickly identify the patient. 1:45 You asked if the patient was allergic to anything. He replied:No, I am not allergic to anything 2:07 You assisted the patient into a sitting position. 2:24 You educated the patient about activities, safety, and fall risk. 3:52 You educated the patient about diagnostics. 4:12 You educated the patient about diet. This was reasonable. 5:50 You educated the patient about ostomy care. 7:09 You educated the patient about use of incentive spirometer. This was indicated by order. 7:29 You asked the patient: Has there been any leakage from or around the pouch? He replied: There might be; I am embarrassed about the smell. 7:39 You asked the patient if he was a smoker. He replied: 'No, I don’t smoke 7:54 You asked the patient what medication he was taking, if any. He replied: No, I don’t take any medication. 9:22 You examined the patient chest. He is breathing at 18 breaths per minute. The chest is moving equally. There is normal elasticity of the skin. His color is normal, and he 10:49 You examined the patient abdomen and pelvis. The skin lesion on the abdomen shows no signs of infection or bleeding. The ostomy pouch is half full with brown liquid stool. There is some stool leaking between the skin and the skin barrier. There is normal elasticity of the skin. His color is normal, and he is not sweating. There is nothing else to find on examination of the abdomen and pelvis. 12:25 You listened to the lungs of the patient. The breath sounds are clear and equal bilaterally. 12:52 You listened to the abdomen of the patient. Normal bowel sounds were heard. 14:11 You measured the Blood pressure 128/84 mm Hg. It is appropriate to monitor the patient by measuring the blood pressure. 15:47 You attached the Pulse oximeter; It is a good idea to monitor the saturation and pulse here. This will allow you to reassess the patient continuously. 17:00 You checked the radial pulse. The pulse is strong, 95 per minute, and regular. It is correct to assess the patient vital signs. 17:10 Patient status - ECG: Sinus rhythm. Heart rate: 94. Pulse: Present. Blood pressure: 130/84 mm Hg. Respiration: 18. Conscious state: Appropriate. SpO2: 95%. Temp: 99 F (37 C) 18:23 You checked the Temperature at the ear. The temperature was 99 F (37 C). 19:38 You examined the patient skin. There is normal elasticity of the skin. His color is normal, and he is not sweating. The skin lesion on the pelvis shows no signs of infection or bleeding. The skin lesion on the abdomen shows no signs of infection or bleeding. 20:10 Patient status - ECG: Sinus rhythm. Heart rate: 94. Pulse: Present. Blood pressure: 131/85 mm Hg. Respiration: 18. Conscious state: Appropriate. SpO2: 95%. Temp: 99 F (37 C) 20:41 You looked for normal breathing. He is breathing at 18 breaths per minute. The chest is moving equally. 20:55 You asked the patient if he had any pain. He replied: Yes, I have some pain. 20:58 You asked the patient if he could describe his pain. He replied: No, not really 21:00 You asked: How would you rate your pain? He replied:Not too bad; it about a 1. 21:05 You asked the patient if he needed anything for the pain. He replied: No. I’m okay 21:24 You assessed the patient IV. The site had no redness, swelling, infiltration, bleeding, or drainage. The dressing was dry and intact. This is correct. Assessing any IVs the patient has is always important. 21:54 You assessed the patient neurological status. This is reasonable. 24:50 You assessed the patient’s abdominal incision. This was reasonable. 26:04 You assessed the patient’s ostomy. This was reasonable. 27:21 You assessed the patient perineal incision. This was reasonable. 28:57 The patient used an incentive spirometer. This was indicated by order. 30:14 You changed the ostomy pouch. This was reasonable. 32:10 Patient status - ECG: Sinus rhythm. Heart rate: 93. Pulse: Present. Blood pressure: 132/85 mm Hg. Respiration: 18. Conscious state: Appropriate. SpO2: 95%. Temp: 99 F (37 C) 32:16 A patient handoff was performed 5. Document all patient education regarding colostomy care, diet, and safety issues provided to Mr. Hayes, as well as his response to the teaching. Colostomy care– When introducing the topic of colostomy care Mr. Hayes states “I want to know what to think when changing the pouch, and about stoma and skin care” The bag should be emptied when it is one third to one half full. The stoma should be bright red, moist, and rounded. The skin barrier prevents the stool from coming into contact with the skin and should be adjusted to fit around the stoma. Remember that the skin always has to be completely dry before applying new appliances. Diet– When talking about diet Mr. Hayes states, “What should I think of when I am having an ostomy” Most patients return to a fairly normal diet. Avoid swallowing larger pieces of leafy vegetables or food in general to prevent any blockages at the stoma opening. To reduce gas, don’t eat fast or use straws. Any foods that you know increase gas should be avoided. Asparagus, fish and spiced food can increase odor. Yogurt can help reduce odor. Safety issues– Infection, impaired skin integrity, risk of disturbed body image 6. Document your handoff report in the situation-background-assessmentrecommendation (SBAR) format to communicate Mr. Hayes's future needs. Situation: Marvin Hayes is a 43 year old male who underwent a laparoscopic abdominal perineal resection with permanent sigmoid colostomy 3 days ago for rectal cancer. Background: Mr. Hayes experienced weight loss, increased fatigue and narrowing stools with blood which led to the diagnosis of rectal adenocarcinoma and the recent laparoscopic perineal resection with sigmoid colostomy. Assessment: Vital signs are stable with a saturation of 95%. Mr Hayes pain level is at a 1. The stoma is pink, moist, and rounded and the incisions show no signs of infection or bleeding. There is a clean perineal pad covering the perineal incision. The pouch was half full with brown liquid stool, there was some stool leaking between the skin and the skin barrier so it was changed. Mr. Hayes used the incentive spirometer as indicated by order and was also education on colostomy care and diet. Recommendation: Assess colostomy and empty the pouch as necessary, continue with use of the incentice spirometer and continue education to prepare for discharge. Also continue to encourage ambulation.