Marvin Hayes Documentation Assignments. NURS 200 VSIM for Nursing Fundamentals. (Download Now)

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1. Document your findings related to the focused assessment regarding Mr. Hayes's stoma status, peristomal skin, abdominal and perineal incisions. Mr. Hayes's stoma appears pink, moist, and rounded. ... There was some leakage from the ostomy pouch around the stoma. The abdominal and perineal incisions had no signs of infection or drainage. 2. Document assessment findings related to gastrointestinal function, output from colostomy, and ability to advance current diet post surgery. Mr. Hayes’ colostomy bag was half full of brown liquid. He presented with normal bowel sounds and can advance to his regular diet as tolerated. 3. Identify and document key nursing diagnoses for Mr. Hayes regarding his current condition. a. The risk for infection related to sigmoid colostomy. b. Risk of impaired skin integrity related to sigmoid colostomy as evidenced by stool leakage between the skin and skin barrier. c. Abdominal pain related to surgical incision. d. Risk of disturbed body image related to sigmoid colostomy as evidenced by patient stating that he is “embarrassed by the smell”. e. Risk of weight loss related to a selected diet. 4. Referring to your feedback log, document all nursing care provided and Mr. Hayes's response to this care. Assessed the patient's vital signs. All vitals were within normal limits. Assessed the patient's ostomy, changed the pouch due to it being over 1/3 full, and ensured the area surrounding the stoma was properly cleaned. Assessed the patient's abdominal and perineal incisions to check for signs of infection or drainage. No infection or drainage present. Checked that the patient had a manageable pain level. Pain level at 1 on a scale of 1-10. Auscultated the lungs and abdomen to ensure normal sounds were present and encouraged coughing. The patient was cooperative. 5. Document all patient education regarding colostomy care, diet, and safety issues provided to Mr. Hayes, as well as his response to the teaching. Educated patient on proper ostomy care as follows: 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 your skin and should be adjusted so it fits around the stoma. He was also advised to remember that the skin always has to [Show More]

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