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.
Abdominal incision is open to air, dry and intact. No signs or symptoms of infection.
Wound dressing was applied. Ostomy pouch is half full with brown liquid stool and there
was leakage between the skin and barrier. Stoma appears to have no abnormalities with
normal color and shape. Perineal incision is covered with the dressing dry and intact.
2. Document assessment findings related to gastrointestinal function, output from
colostomy, and ability to advance current diet post surgery.
Patient had active bowel sounds, Ostomy pouch is half full which indicates good motility,
patient can now advance to normal diet.
3. Identify, prioritize, and document key nursing diagnoses for Mr. Hayes regarding his
current condition.
Distorted body image related to newly placed Ostomy bag.
Risk for impaired skin integrity related to colostomy bag as evidenced by stool leaking
between the skin and barrier.
Readiness for enhanced knowledge related to interest for further education as evidenced
by the patients willingness to learn.
4. Referring to your feedback log, document all nursing care provided and Mr. Hayes's
response to this care.
Vital signs were assessed , no problems were noted.
Performed thorough physical assessment with no problems noted. Patients skin was
assessed, skin has normal elasticity, dry with normal temperature and color. Incisions
were dry and skin intact.
Pain level was assessed and reported 1 out of 10.
Assesesed abdomen and Ostomy site.
IV site was assessed with no abnormal findings.
Patient was educated about incentive spirometer, Ostomy care and diet changes.
From vSim for Nursing | Fundamentals. © Wolters Kluwer
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 included techniques to empty pouch and change appliance.
Emphasis on pouch removal so that that surrounding skin remains intact.
Diet was communicated that patient should avoid high fiber diet. Recommended 2 quarts
of water.
6. Document your handoff report in the situation-background-assessment-recommendation
(SBAR) format to communicate Mr. Hayes's future needs.
Marvin Hayes is a 43 year old male patient diagnosed with rectal cancer. Patient
underwent abdominal perineal resection with a permanent colostomy 3 days prior. Patient
reports no noon allergies, has experience weight loss, increasing fatigue, and narrowing
stools with blood, which led to the diagnosis or rectal adenocarcinoma. Vital signs are
stable, patient has reported pain level of 1 out of 19. Abdominal incision was open to air,
dressing was applied. Ostomy pouch was half full and changed. Stoma has no
complications. Pt educated on Ostomy care, diet changes and use of incentive spirometer.
Pts ability to provided self care and acceptance of colostomy was assessed. It is
recommended that vital signs are monitored as well as stoma, output and reinforcement
of patient education.
From vSim for Nursing | Fundamentals. © Wolters Kluwer