Marvin Hayes Documentation Assignment PDF

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Jessica Bridges NUR104 Clinicals

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. Upon assessment of the patient’s stoma it appears to be pink, moist, and rounded. There was some leaking between the skin and skin barrier. There is a perineal pad and there are no signs of infection or drainage at the perineal incision. There are no signs of infection or bleeding at the abdominal incision. 2. Document assessment findings related to gastrointestinal function, output from colostomy, and ability to advance current diet post surgery. Upon auscultation of the abdomen the bowel sounds were normal. Assessment of the colostomy appliance showed that the ostomy pouch was half full of brown liquid stool. Per the physicians orders the patient can advance to a regular diet as tolerated, avoiding foods that cause gas, avoiding larger pieces of leafy green vegetables and food in general to prevent blockages at the stoma opening. 3. Identify and document key nursing diagnoses for Mr. Hayes regarding his current condition. Risk for impaired skin integrity related to excretions as evidenced by leakage between the skin and skin barrier. Disturbed body image related to presence of stoma, daily care of fecal matter. Readiness for enhanced knowledge related to expresses an interest in learning as evidenced by the patient wanting to know what to think of when changing the pouch, and about stoma and skin care. 4. Referring to your feedback log, document all nursing care provided and Mr. Hayes's response to this care. 

Performed hand hygiene.

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Introduced self.

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Identified patient. From vSim for Nursing | Fundamentals. © Wolters Kluwer

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Assessed pain:  Asked patient if he had any pain? He replied, “Yes, I have some pain.”  Asked patient how would you rate your pain on a scale of 0-10? He replied, “Not too bad; it’s about a 1.”  Asked patient if anything made the pain feel better? He replied, “No, not really.”  Asked patient if anything made the pain feel worse? He replied, “No, not really.”  Asked patient if he could describe the pain? He replied, “No, not really.”  Asked the patient where does it hurt? He replied, “It is mostly in the wound around my butt that hurts.”

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Asked the patient if he was allergic to anything? He replied, “No, I am not allergic to anything.”

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Assessed vital signs.

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Assessed skin integrity.

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Assessed pedal pulses.

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Assesses capillary refill.

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Auscultated lung sounds.

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Auscultated heart sounds.

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Auscultated bowel sounds.

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Educated the patient on activities, safety, and fall risk, diet, ostomy care, coughing, incentive spirometer, wound care.

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Performed hand hygiene and applied gloves.

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Assessed IV site.

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Assessed abdominal incision.

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Assessed ostomy.

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Assessed perineal incision.

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Removed gloves, performed hand hygiene, and applied new gloves.

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Encouraged coughing.

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Patient used incentive spirometer.

From vSim for Nursing | Fundamentals. © Wolters Kluwer

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Changed ostomy pouch.

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Removed gloves, performed hand hygiene.

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Patient tolerated assessment and ostomy change well.

5. Document all patient education regarding colostomy care, diet, and safety issues provided to Mr. Hayes, as well as his response to the teaching.

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Activities, safety, and fall risk; instructed the patient when we are not in the room, we will lower the bed with 2 rails up and will leave the call light in reach to ensure safety.

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Coughing: informed the patient that it is important to take a few breaths and deep cough every hour to prevent any breathing problems.

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Diet: patient asked, “What should I think of when I am having an ostomy?” Explained to the patient that most patient’s return to a fairly normal diet. Avoid swallowing larger pieces of leafy green vegetables and food in general to prevent any blockages at the stoma opening. To reduce gas, do not eat fast or use a straw. Any foods that you know increase gas should be avoided. Foods such as, asparagus, fish, and spiced foods can increase odor. Eating yogurt can help reduce odor.

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Ostomy care: patient replied, “Yes, I want to know what to think of when changing the pouch, and about the stoma and skin care.” Explained to the patient that the bag should be emptied when it is 1/3-1/2 full. The stoma should be bright red, moist, and rounded. The skin barrier prevents the stool from coming into contact with your skin and it should be adjusted so it fits around the stoma. Remember that the skin always has to be completely dry before applying new appliances.

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Incentive spirometer: Explained that the spirometer can help with deep breathing exercises and increase ventilation to all areas of the lung. It also helps to loosen and mobilize secretions.

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Wound care: patient replied, “I think the ones on my stomach are healing well, but I don’t know about the one below.” Explained that the incision should be checked regularly for signs of infection.

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Patient verbalized understanding of patient education.

6. Document your handoff report in the situation-background-assessment-recommendation (SBAR) format to communicate Mr. Hayes's future needs. S- Mr. Hayes is a 43-year-old white male who underwent a laparoscopic abdominal perineal resection with a permanent sigmoid colostomy 3 days ago for rectal cancer. -----From vSim for Nursing | Fundamentals. © Wolters Kluwer

B- Mr. Hayes experienced weight loss, increasing fatigue, and narrowing stools with blood, which led to the diagnosis of rectal adenocarcinoma and the recent surgery. -------A- Mr. Hayes vitals are stable, and he has a pain level of 1/10. He has NKA. Skin color is normal for ethnicity, elasticity is normal, and he is not sweating. Pedal pulses are 95, strong and regular. Capillary refill is less than 2 seconds. Breath sounds are clear and bilaterally equal. Heart rate and rhythm are regular without murmurs. Bowel sounds are normal. Abdominal incision has no signs of infection or bleeding. Perineal incision has a perineal pad and there are no signs of infection or drainage. Ostomy pouch is half full of brown liquid stool. There is some stool leaking between the skin and skin barrier. Ostomy pouch was emptied, skin barrier removed, and the area around the stoma was cleaned. Allowed for area to completely dry and a new appliance applied. IV site shows no signs of redness, swelling, bleeding, or drainage. The dressing is dry, clean, and intact. Incentive spirometer was used per order. Patient was educated on activities, safety, and fall risk, coughing, incentive spirometer, diet, ostomy care, and wound care. --------------R- Continue to monitor Mr. Hayes vital signs and pain level. Administer regular medications and PRN medications per physician’s orders. Continue to assess IV site, abdominal incision, perineal incisions, and dressings for infection and drainage. Continue to assess ostomy pouch, once it becomes one third to half full empty the pouch and change the appliance if necessary. Encourage continuous use of incentive spirometer and ambulation. Monitor abnormal lab results and keep the physician updated on them. Have the patient use teach-back on the areas that he was educated on. Monitor patients I&O since he is advancing to a regular diet as tolerated. ------------ J. Bridges, Nursing Student

From vSim for Nursing | Fundamentals. © Wolters Kluwer...