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. [Show More]

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