Student

Elisia Silva Goncalves

Date

03/09/2020

Instructor

Molina

Course

NURS 101L

Patient Initial

SC

Unit/ Room#

303

DOB

03/09/1968

Code Status

Full Code

Height/Weight

4’11”, 190 lbs

Allergies

Demerol (rash)

Temp (C/F Site)

Pulse (Site)

Respiration

Pulse Ox (O2 Sat)

Blood Pressure

Pain Scale 1-10

98.6°F (axillary)

75 bpm (not noted)

20 bpm

100% (room air)

125/96 (supine)

(no non-pharmacologic interventions noted)

History of Present Illness including Admission Diagnosis &

Chief Complaint (normal & abnormal) supported with Evidence Based Citations

Physical Assessment Findings including presenting signs and symptoms supported with Evidence Based Citations

Chief Complaint: abdominal pain

Patient complained of generalized abdominal pain that was constant, sharp, cramping, and tender when palpated. Patient was observed to be crying, and rated pain 10/10 upon admission. Patient had performed a self-enema to relieve constipation and reported experiencing pain 15 minutes prior to going to the Emergency Department via ambulance.

Admission Diagnosis: bowel perforation

· colostomy performed in LUQ, 2.8 cm stoma

Bowel perforations may occur as a result of damage or breakdown to the mucosal layers of the gastrointestinal tract. This develops an opening along the organ, leading to leakage of digestive contents (e.g. stomach acid or fecal matter) into the peritoneum. Can result from inflammation/infection, obstruction, invasive surgeries/procedures, or trauma (Jones & Zabbo, 2019).

A colostomy is a surgically created opening (stoma), diverting bowel elimination from the colon through the abdominal wall, and into an external pouching system for collection. This surgery can be temporary or permanent. Can be located in the ascending, transverse, descending, or sigmoid portion of the colon. Performed when elimination of stool through the rectum is prevented due to disease, or obstruction/damage to the colon (Johns Hopkins Medicine, n.d.-b).

CNS: Patient fully conscious, oriented x4. Head normocephalic, with full range of motion. Deep tendon reflexes +2/normal. EENT: Face, eyes, ears symmetrical. Pupil size 4mm each, bilaterally reactive.

Oral

mucosa moist and intact. SKIN: intact, color appropriate for ethnicity, skin turgor – recoils immediately MS: upper and lower extremities full ROM, vascular perfusion WNL CV: heart rhythm and sound WNL, no signs of cardiac symptoms RESP: pattern/effort WNL, no cough, patient currently on room air GI: abdomen soft, bowel sound present x4, passing flatus. Colostomy bag LUQ, semi-formed stool; stoma intact, red, moist
GU: urine yellow, no odor, symptoms WNL

(Taylor et al., 2018)

Pain Assessment: 3 – mild; abdomen – LUQ (Taylor et al., 2018)

Glasgow Coma Scale: eye response – 4/spontaneous eye opening; motor response – 6/obeys commands fully; verbal response – 5/alert and oriented

· total score – 15/15

· patient fully awake, alert, and oriented (Taylor et al., 2018)

Braden Scale for Predicting Pressure Sore Risk: sensory perception – 4/no impairment; moisture – 4/rarely; activity – 4/walks frequently; mobility – 4/no limitation; nutrition – 4/excellent; friction and shear – 3/no apparent problem

· total score – 23/23

· not at risk for developing pressure injuries (Taylor et al., 2018)

Morse Fall Scale: no history of falling – 0; no secondary diagnosis – 0;

IV

access – 20; normal gait, bedrest, wheelchair – 0; orientated to own ability – 0

· MFS score – 20

· no risk, no fall interventions needed (Morse Fall Scale, n.d.)

Erikson’s Developmental Stage with Rationale

And supported by Evidence Based Citations

Socioeconomic/Cultural/Spiritual Orientation

& Psychosocial Considerations/Concerns (3) supported with Evidence Based Citations

Generativity vs. Stagnation

Occurs during middle adulthood, ages 40-65 years. Developmental stage with focused on care and the sense of productively contributing to the continuity of society (generatively) vs. the trivialization of one’s activities (stagnation). Is the person making their life meaningful by guiding future generations? Activities include working, teaching/mentoring others, volunteering in the community, and raising children (Feldman, 2016).

Religion/Spirituality: Catholic

Economic Background: bank teller with a bachelor’s degree

Social Background: white male, primary language English; widowed, father of three (3) adult children (one son and daughter listed as emergency contacts), lives alone

· potential for low self-esteem and social isolation

· anxiety or fear of asking children for help

· failure to thrive from loss of spouse, or living alone

Safety Screening: patient did not mention concern for personal safety; no physical signs of abuse or neglect

Substance use: patient consumes alcoholic drinks twice (2) a week

No advanced directives listed

(Taylor et al., 2018)

Priority Nursing Diagnosis

(at least 2)

Written in three-part statement

Planning

(outcome/goal)

Measurable goal during your shift

(at least 1 per Nursing diagnosis)

Prioritized Independent and collaborative nursing interventions; include further assessment, intervention and teaching

(at least 4 per goal)

Rationale Each must be

supported with Evidence Based Citations

Evaluation

Goal Met, Partially Met,

or Not Met

& Explanation

Disturbed body image related to daily care of fecal material, as evidenced by verbalization of negative opinions of having a “poop bag” attached to person.

(Ladwig et al., 2020)

Patient will demonstrate social involvement and begin to accept situation by observing care of, or touching colostomy bag.

Ask patient psychosocial questions related to medical situation during nursing assessment.

Consideration of providing counseling.

Review the medical necessity behind surgical procedure, maintain positive approach during care.

Assess patient’s level of social support.

Verbalization of patient’s feelings can help identify the patient’s progress and risk for body image disturbance.

Can assist patient with acceptance of a temporary medical situation and promote will to thrive.

Supporting patient can help develop strategies to cope with the emotional stress.

A determent of patient’s speed of recovery and emotional health.

Goal not met:

· patient refused to open eyes or listen to any positive outlooks on situation. Patient used vulgar language about their perception of themselves. Patient asked to be left alone.

Deficient knowledge related to lack of exposure to new ostomy, as evidenced by lack of participation.

(Ladwig et al., 2020)

Patient able to explain the purpose of the colostomy procedure.

Patient able to explain and perform colostomy care on self satisfactorily.

Assess and evaluate patient’s emotional/cognitive/physical wellbeing.

Use client-centered approach. Have patient participate during ostomy care.

Consider use of printed material (e.g. brochures) and electronic methods (e.g. videos, images, diagrams) during teaching.

Repeat education and practice frequently.

Patient must be willing to cooperate in order to learn effectively.

Engages with client as an active learner. Promotes sense of control.

Serves as additional sources of information. Alternative formats of patient education may resonate with patient better.

Reinforces learning.

Goal partially met

· patient was able to verbally explain why they received a colostomy and its purpose. Patient acknowledge that they knew the colostomy bag is a temporary procedure, however expressed that they felt cursed by this event. Patient consequently was unwilling to participate during care and wished for the nurse to leave as soon as possible.

Medications (with APA citations

Class/Purpose

Route

Frequency

Dose (& range)

If out of range, why?

Mechanism of action

Onset of action

Common side effects

Nursing considerations

specific to this patient

docusate

(Jones & Bartlett Learning, 2020)

Pharmacologic class: stool softener, surfactant

Therapeutic class: laxative

Daily

50 mg capsule

1) acts as surfactant that softens stool by decreasing surface tension between oil and water in feces

2) increases electrolyte and water secretion into colon, forming a softer fecal mass

syncope, abdominal cramps, distension, nausea/vomiting, diarrhea, perianal irritation

increase fiber intake, hydration

ketorolac tromethamine

(Jones & Bartlett Learning, 2020)

Pharmacologic class: NSAID

Therapeutic class: analgesic

Every 8 hours, PRN

30 mg

blocks cyclooxygenase and inhibits prostaglandin synthesis, thus reducing inflammation and relieves pain

GI bleeding, prolonged bleeding time, hepatic failure, renal failure, exfoliative dermatitis

1) take with food, remain upright for 30 minutes to decrease irritation of lower esophagus

2) avoid alcohol, increases stomach irritation

ondansetron hydrochloride

(Jones & Bartlett Learning, 2020)

Pharmacologic class: selective serotonin (5-HT3) receptor antagonist

Therapeutic class: antiemetic

Every 6 hours, PRN

4 mg tablet

blocks serotonin receptors in the chemoreceptor trigger zone (CTZ) in the CNS and peripherally at vagal nerve terminals in the intestine, thus reducing nausea and vomiting

headache, fatigue, diarrhea/constipation, abdominal pain, arrhythmias

monitor nausea, bowel sounds/activity, gastric distention