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. I completed a focused assessment on Mr. Hayes. The stoma was a dark red, moist and protroding 1 inch. The skin around the stoma showed no signs of infection. The pouch was half full, indicating it was time to change the bag- should be changed around 1/3 full. There was also slight leakage around the peristomal area, which can mean that the bag was. Not properly fitted, or that it is overly full and leaking. I cleaned the area well with soap and water, and dried it well, before refitting a clean pouch. The abdominal incision was intact, with no signs of infection. The dressing was clean and dry. The perineal incision was covered with a clean, dry pad. There were no signs of infection. There were no signs of swelling, heat, tenderness or other indicators of infection. The edges of both surgical sites were approximated and healing well. 2. Document assessment findings related to gastrointestinal function, output from colostomy, and ability to advance current diet post-surgery. Normal bowel sounds were auscultated in all four quadrants. The colostomy bag was half full with loose brown stool. There was no blood or mucus present. Patient has been on a full liquid diet. He is tolerating it well, with no nausea or vomiting, and no adverse bowel disturbances (diarrhea, abdominal pain, flatulence, constipation) He can progress to soft solids, introducing new fewest gradually. For the first 6 weeeks after surgery, patient should avoid high fiber foods and simple carbs like excessive sugar. These can cause diarrhea and excessive gas. 3. Identify, prioritize, and document key nursing diagnoses for Mr. Hayes regarding his current condition. Risk for disturbed body image related to Ostomy. Risk for constipation related to surgical procedure & inactivity Risk for depression/ anxiety related to major life change and loss of bodily function. 4. Referring to your feedback log, document all nursing care provided and Mr. Hayes's response to this care. From vSim for Nursing | Fundamentals. © Wolters Kluwer I began by introducing myself, washing my hands and identifying the patient with two identifiers ( Name, DOB). I assesssed his pain level. I Should have asked about allergies here. Then, I completed vital signs, and a head to toe assessment. Auscultated heart, lungs, and bowel sounds. I assessed his perineal and abdominal dressings. I assessed and changed his Ostomy bag. I provided education on diet, colostomy care, incentive spirometer, and wound care. Mr. Hayes was cooperative during assessments and listened to education, asked appropriate questions and demonstrated that he understood the information. 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 hand hygiene, explained that the stoma should be deep pink to beefy red, and moist. The peristomal skin should be kept clean and dry. , how to fit the stoma properly (opening about an 8th of an inch all the way around the stoma) when to empty the bag ( 1/3 full) I educated him on the signs of infection and tissue death, as well as prevention of irritation around the stoma site. Encouraged Mr. Hayes to get used to looking at and handling the Ostomy appliance. Listened to his thoughts and feelings , and provided emotional support. 6. Document your handoff report in the situation-background-assessment-recommendation (SBAR) format to communicate Mr. Hayes's future needs. Situation- Mr. Hayes was treated for rectal cancer. As a result, just underwent surgery . He has a laparoscopic perineal resection with a permentant sigmoid colostomy. Background- Mr. Hayes is a 43-year-old businessman. 3 days ago , he had surgery – a laparoscopic abdominal perineal resection with a permenant sigmoid colostomy- due to rectal cancer. He experienced weight loss, fatigue, narrowed stool with blood present. He has no known allergies, and no previous surgical or medical complaints. He lives with his Spouse. Assessment- Vital signs are stable- 02 sat 94-97% on room air. Patient is alert and oriented. Pain level of 1 out of 10 , after receiving pain medication 1 hour ago. Incentive spirometer used; education provided. Abdomen is soft, normal bowel sounds. Colostomy appliance is an open-ended pouch attached to the skin barrier pad. There was a small amount of leakage, which was resolved after changing the bag. The bag was ½ full. The stool was brown and liquid. There are 3 small abdominal incisions, left open to air. From vSim for Nursing | Fundamentals. © Wolters Kluwer There is a pad covering the perineal incision. Mr. Hayes has been up to ambulate, on a soft diet. Education provided on diet, wound care, and colostomy care. Recommendation- Continue to monitor vital signs every 4 hours, continue to use incentive spirometer. Assess colostomy site. Assess appliance for leakage, fullness. Provide follow up education regarding diet, colostomy care, and wound care. Marvin Hayes Guided Reflection Questions Opening Questions How did the simulated experience of Marvin Hayes’s case make you feel? I felt empathy for my patient, knowing that he was going to have a long road ahead, and he has already overcome cancer. I felt that it is important for me to provide the best possible care for him, and to educate him well for the journey ahead. Talk about what went well in the scenario. I felt that I did a thorough assessment. I am becoming more confident in my choices. Reflecting on Marvin Hayes’ case, were there any actions you performed differently when repeating the scenario or that you would do differently if you were to repeat it? If so, how did/would your client care change, and what differences, if any, did you or would you expect in Marvin’s outcomes? I would be sure to ask him about his allergies, as well as remembering when to use / change gloves, and to wash hands before and after. Scenario Analysis Questions PCC When analyzing the relevant initial cues, what priority problem(s) did you identify for Marvin Hayes? Patient education on his new Stoma and appliance, and his social emotional needs. This is a life changing event, and he is at risk for self esteem issues, depression and anxiety. He also needs proper education to be able to take care of his stoma / colostomy safely and effectively at home. The Scenario Analysis Questions are correlated to the Quality and Safety Education for Nurses (QSEN) competencies: Patient-Centered Care (PCC), Teamwork and Collaboration (T&C), Evidence-Based Practice (EBP), Quality Improvement (QI), Safety (S), and Informatics (I). Find more information at: http://qsen.org/ From vSim for Nursing | Fundamentals. © Wolters Kluwer PCC What potential problems could arise due to the newly placed colostomy? A new Stoma site can delvelop infection, irritation, and necrosis. PCC Discuss what type of diet would be appropriate for Marvin Hayes. Mr. Hayes should avoid high fiber foods for 6 weeks. He should avoid foods that produce excessive gas and flatulence. PCC/T&C Discuss the importance of peer support groups in the ongoing management of Marvin’s diagnosis and colostomy. Peer Support will help Mr. Hayes to learn new strategies and coping strategies from peers who are going through a similar experience. It will help him to not feel so isolated, as well as providing socialization and emotional support. EBP Explain why it is important to measure the stoma at least once a week for the first 6-8 weeks after surgery. It is important to measure the stoma weekly, because it shrinks in size as the weeks pass after surgury. This allows a proper fit, and reduces skin breakdown and leakage. T&C What other interprofessional team members should be involved in Marvin Hayes’s care? Nutritionist, and social work , as well as a GI specialist would all be appropriate. I Cite one source that you could give to Marvin Hayes that would provide more information on colostomy care and resources. www.cancer.com Concluding Questions Describe how you would apply the knowledge and skills that you obtained in Marvin Hayes’s case to an actual patient care situation. From vSim for Nursing | Fundamentals. © Wolters Kluwer
