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ANATOMY 2086 Marvin Hayes CONCEPT MAP WORKSHEET LATEST
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ANATOMY 2086 Marvin Hayes. CONCEPT MAP WORKSHEETCONCEPT MAP WORKSHEET
DESCRIBE DISEASE PROCESS AFFECTING PATIENT
(INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS)
Colorectal Cancer is malignant tumor of the colon or rectum, and very slow progression. In the United
States the second most common of cancer death, which type of common in men and women. Almost
always involves adenocarcinomas, about one half are sessile lesions of rectosigmoid area, and all others are
polypoid lesion.
DIAGNOSTIC TESTS PATIENT INFORMATION ANTICIPATED PHYSICAL FINDINGS
(REASON FOR TEST AND
RESULTS)
Mr. Hayes is a 43- year-
• Fecal occult blood test may old white male who
show blood in stools, a underwent a
Abdominal
warning sign of colorectal laparoscopic abdominal
cancer. perineal resection with
• Colonoscopy permits visual a permanent sigmoid • distention or
inspection and colostomy 3 days ago visible mass
photography for rectal cancer. • Enlarged abdominal
of the colon up to the veins
ileocecal valve. • Abnormal bowel sounds
• Proctoscopy • Enlarged inguinal and
• Sigmoidoscopy supraclavicular nodes
ANTICIPATED NURSING INTERVENTIONS
• Wash hands, introduce self, and identify patient
• Obtain vital signs, including asking about allergies and assess pain
• Auscultate lung sounds
,ANATOMY 2086 Marvin Hayes. CONCEPT MAP WORKSHEET
• Check the provider’s orders in the electronic health record (EHR)
• Provide patient education about incentive spirometer
• Provide patient education about ostomy care
• Provide patient education about diet
• Assess and encourage patient used an incentive spirometer
• Assess the patient’s perineal incision
• Assess the patient’s abdominal incision
• Change the ostomy pouch
, ANATOMY 2086 Marvin Hayes. CONCEPT MAP WORKSHEET
vSim ISBAR ACTIVITY STUDENT WORKSHEET
INTRODUCTION My name is Yingyi, I am a student nurse from Nova
Southeastern University. I work at the rehabilitation unit 0800
Your name, position (RN), unit you
are working on
SITUATION Mr. Hayes is a 43-year-old white male who underwent a
laparoscopic abdominal perineal resection with a permanent sigmoid
Patient’s name, age, specific reason for visit colostomy 3 days ago for rectal cancer.
BACKGROUND Admitted on 04/12/2020. Patient experienced weight loss, increasing
fatigue, and narrowing stools with blood, which led to the diagnosis of
Patient’s primary diagnosis, date of rectal adenocarcinoma and the recent surgery. Current orders are
admission, current orders for patient Omeprazole 40 mg, Enoxaparin sodium 40 mg and
Hydrocodone/Acetaminophen 10/325 mg.
ASSESSMENT Received patient in bed alert and oriented x3. Vital signs performed:
B/P: 136/86 mm Hg, pulse is 95 per minute, breathing at 19 bpm,
Current pertinent assessment data using temperature is 99 F, SP02 is 96%. Pain level is currently 1 from scale
head to toe approach, pertinent diagnostics, 0-10. The colostomy appliance is an open-ended pouch attached to a
vital signs skin barrier. The stoma is red and moist with liquid, brown stool
output. The three small abdominal incisions are open to air. There is
a clean pad covering the perineal incision. Patient has been up and
ambulating and is taking full liquids.
RECOMMENDATION I recommended to perform morning assessment. Assess his colostomy,
and empty the pouch, if necessary. Provide colostomy care, including
Any orders or recommendations you emptying an open-ended pouch, noticing leakage, and changing the
mayhave for this patient skin barrier. Assess the stoma for complications such as retraction,
bleeding, or compromised circulation. The peristomal skin
surrounding the stoma should be kept clean, dry, and protected to
prevent irritation or breakdown. Educate the patient about self-care
and assess the patient’s acceptance of the colostomy.
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