Question

Marvin Hayes Documentation Assignments- Document in DocuCare Document your findings related to the focused assessment regarding Mr. Hayes's stoma status, peristomal skin, abdominal and perineal incisions. Document assessment findings related to gastrointestinal function, output from colostomy, and ability to advance current diet post surgery. Identify and document key nursing diagnoses for Mr. Hayes regarding his current condition. Referring to your feedback log, document all nursing care provided and Mr. Hayes's response to this care. Document all patient education regarding colostomy care, diet, and safety issues provided to Mr. Hayes, as well as his response to the teaching. Document your handoff report in the situation-background-assessment-recommendation (SBAR) format to communicate Mr. Hayes's future needs.

Answer 1

1. a.) Stoma status – the stoma appears to look pink, moist, and rounded
b.)Periostomal skin – there is some stool leaking between the skin and the skin barrier
c.) Abdominal Skin – the skin lesion showed no signs of infection or bleeding
d.) Perineal Incision – there is a perineal pad and there are no signs of infection or draining

2. 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. 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. 0:05 – Wash Hands

1:19 – Introduce self

1:34 – Identify patient

1:43 – Asked patient about allergies, he responded, “No, I am not allergic to anything”
2:07 – Pulse oximeter was attached, SpO2 95%
2:11 – Respirations were assessed, 19 breaths per minute
2:34 – Radial pulse assessed, pulse was strong, regular and 95/minute
2:56 – Temperature was taken 99F (37C)
3:18 – Blood Pressure was measured, 140/85 mmHg
4:12 – Assesed patient’s IV, the site had no redness, swelling, infiltration, bleeding or draining, and the dressing was dry and intact
4:52 – Auscultated patient’s lung fields, breath sounds are clear and equal bilaterally
5:10 – Auscultated patient’s abdomen, normal bowel sounds were heard
5:29 – I educated the patient about the use of the incentince spirometer, indicated by order
6:20 – Patient used the incentice spirometer as indicated by order
7:38 – Asked if the patient had any pain, he replied “Yes, I have some pain”
7:45 – On a scale from 0-10, patient stated “Not too bad, it’s about a 1”
7:59 – Asked patient if anything made the pain better, he stated “No, not really”
8:06 – Asked patient if anything made the pain worse, he stated “No, not really”
8:34 – Patient was educated on ostomy care
9:17 – Abdominal incision was assessed, it shows no signs of infection or bleeding
9:23 – Asked the patient if there has been any leakage from the pouch, he responded “There might be, I am embarrassed about the smell”
9:35 – Ostomy was assessed, pouch was half full with brown liquid stool, there was some stool leaking between the skin and the skin barrier
10:11 – The ostomy pouch was changed
12:04 – The patient’s perineal incision was assessed, there was a perineal pad and no signs of infection or drainage
15:53 – Patient was educated about diet.

5. 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.