Documentation Assignments

Documentation Assignments 1. Document your findings related to the focused assessment regarding Mr. Hayes's stoma status, peristomal skin, abdominal and perineal incisions. The focused abdominal assessment revealed. The colostomy was deep pink, moist and protruding 1”. The pouch/bag was 1/2 full, which indicates time for a change. There was minor leakage on the peristomal skin, which indicates a need for thorough cleaning with soap and water. The abdominal incision has no sign of infection or bleeding, dehiscence, and evisceration. The perineal incision with no sign of infection. The dressing is clean and dry. Pt skin is pink, no excessive moister noted. Patient reports pain of 2 out of 10. No sign of tenderness, guarding or distention. 2. Document assessment findings related to gastrointestinal function, output from colostomy, and ability to advance current diet post surgery. Assessment findings r/t GI function revealed normal bowel sounds present in all four quadrants, which indicates optimal function. Output from colostomy revealed loose brown stools that showed no sign of hemorrhage. This is expected because patient has a full liquid diet. First 6 weeks should avoid foods that are: high in fiber; cause flatus and diarrhea, simple carbohydrates. Introduce foods gradually. 3. Identify and document key nursing diagnoses for Mr. Hayes regarding his current condition. Risk for situational low self-esteem r/t disturbed body image AEB pt statement “I'm a little embarrassed by the smell.” Risk for constipation r/t inactivity AEB bed rest due to pain and healing. 4. Referring to your feedback log, document all nursing care provided and Mr. Hayes's response to this care. Placed patient in a semi Fowlers position RESPONSE: the patient was comfortable, and position helped with respirations. Vitals were recorded RESPONSE: The pt was cooperative. Vital signs were within normal limit; minor pain present, 1 out of 10. Positioned patient to lying flat RESPONSE: Patient was cooperative with no complaints. Inspected and Auscultation abdomen RESPONSE: the patient showed no sign of discomfort at looking at the colostomy and showed no sign of abdominal pain Assessed and changed colostomy site and pouch RESPONSE: Pt was educated on changing the pouch and caring for site. Pt participated during the teaching and was encouraged to get accustomed with new colostomy site. PT was educated on incentive spirometer to help with his breathing RESPONSE: Patient used the incentive spirometer 10 times per hour with proper technique Educated pt on diet RESPONSE: Patient understood and engaged in teaching by asking questions and raising important concerns. 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 education includes techniques to empty and change the pouch, measure and size replacement pouches. Emphasis on pouch removal that does not cause skin stripping and pain. Technique to properly size and fit the new appliance was demonstrated. The pt was informed the colostomy should be bright pink-red and moist. The skin around the site was kept clean and dry. Regarding the diet, pt was informed that for 6-8 weeks he should avoid high fiber, product that cause diarrhea, and excessive flatus. 2 quarts of water were recommended. Pt understood the information and was participating during the education. 6. Document your handoff report in the situation-background-assessment-recommendation (SBAR) format to communicate Mr. Hayes's future needs. Situation- the patient recently was dx with rectal cancer and has a new colostomy (3 days ago). Background: Mr. Haye’s has been leaning and practicing care of his new colostomy and breathing exercises. He has been on a full liquid diet for 3 days. I&O was rescinded every 4 hours Assessment: Vitals have been stable with minor pain present (1 out of 10). No sign of infection at stoma and incision sites. No sign of distension or obstruction. Normal bowel sounds present in all four quadrants. Stool output was liquid and brown. Recommendation: Pt is almost due for his medications before breakfast. ‘He should also progress to a solid food diet gradually. Adequate amount of water is recommended (2 quartz per day).