Marvin Hayes
Documentation Assignments
1. Document your findings related to the focused assessment of Mr. Hayes's stoma status,
peristomal skin, and abdominal and perineal incisions.
The pouch was emptied. Stoma is pink, moist, and rounded. No leakage.
2. Document assessment findings related to gastrointestinal function, output from
colostomy, and ability to advance current diet post surgery.
Bowel sounds present and normal/active. May advance from full liquid diet to regular diet as
tolerated
3. Identify, prioritize, and document key nursing diagnoses for Mr. Hayes regarding his
current condition.
Risk for constipation R/T placement of ostomy in sigmoid colon
Desired Outcome:
Client will establish an elimination pattern suitable to physical needs and lifestyle with the
effluent of appropriate amount and consistency.
Interventions:
 Instruct patient in the use of closed-end pouch when irrigation is successful and the
sigmoid colostomy effluent becomes more manageable, with stool expelled every 24 hr.

Demonstrate use of irrigation equipment per institution policy or under the guidance of a
physician or certified wound, ostomy, continence nurse.

Involve patient in the care of the ostomy on an increasing basis.
4. Referring to your feedback log, document all nursing care provided and Mr. Hayes's
response to this care.
Arrived at patient’s bedside. Reviewed patient’s information, patient log and diagnostics.
Reviewed clinical observations, MAR and Radiology information. Reviewed orders, inatake and
output. Introduced myself, washed my hands, put on gloves, identified the patient, asked about
allergies. Patient stated he was not allergic to anything. Started a head – to – toe assessment
beginning with assessing mucous membranes, examined the skin, head, arms and chest. Patient
is breathing at 19 BPM and the chest is moving equally. Should have assessed the ostomy ouch
at this time. I examined the patient’s abdomen and pelvis. The skin lesion on the abdomen shows
From vSim for Nursing | Fundamentals. © Wolters Kluwer
no sign of infection or bleeding. The ostomy pouch is half full with brown liquid stool. There is
some leaking between the skin and the skin barrier. There is nothing else to find on examination
of the abdomen and pelvis. I removed my gloves, washed my hands and put on new gloves. I
changed the ostomy pouch and assessed the patient’s perineal incision. I assessed the patient’s
ostomy and should have removed my gloves. I tried to assess a dressing but there was no
dressing. I removed my gloves, washed my hands and put new gloves on. I educated my patient
on ostomy care and diet, along with incentive spirometer use and wound care to which the
patient seemed to be receptive and understanding. I examined the patient’s legs. There is normal
elasticity of the skin. Skin is dry with normal temperature and color. I assisted the patient to a
sitting position and examined his back and spine. I assessed the patient’s IV, the site had no
redness, swelling, infiltration, bleeding or drainage. The dressing was dry and intact. I listened to
the patient’s lungs, heart and abdomen. Removed my gloves, ashed my hands and put on new
gloves. Looked for normal breathing. Patient is breathing 18 BPM, chest moving equally. I
checked the patient’s vital signs. Should have assessed pain and use of incentive spirometer. I
gave the patient his 0900 meds with water. The patient tolerated well. Removed my gloves,
washed my hands and gave hand off report.
5. Document all patient education regarding colostomy care, diet, and safety issues provided
to Mr. Hayes, as well as his response to the teaching.
Ostomy care includes emptying the pouch at 1/3 – half full. Skin barrier can be adjusted
according to size. Assesss for leakage and make sure the skin around stays dry and intact. The
stoma should be moist, red and rounded. Educate patient about diet. Most patients can return to a
fairly normal diet. Avoid large pieces of food and leafy green vegetables to avoid blockage.
Asparagus, fish or spicy foods increase odor. Yogurt decreases odor. Don’t eat fast or use straws
to reduce gas.
6. Document your handoff report in the situation-background-assessment-recommendation
(SBAR) format to communicate Mr. Hayes's future needs.
Situation: He was admitted after surgery
Background: He has no known allergies
Assessment: O2 saturations 94-97% on room air, abdomen is soft and there are normal vowel
sounds, the colostomy appliance is an open-ended pouch attached to a skin barrier, he rates his
pain level as 1/10
Recommendation: Continue to monitor vital signs every 4 hours, he can advance to a regular
diet as tolerated, please assess his colostomy and appliance.
From vSim for Nursing | Fundamentals. © Wolters Kluwer