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NUR 3180 vSim6 Marvin Hayes Nova Southeastern University /UPDATED 2022
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NUR 3180 vSim6 Marvin Hayes Nova Southeastern University /UPDATED 2022
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CONCEPT MAP WORKSHEETDESCRIBE DISEASE PROCESS AFFECTING PATIENT
(INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS)
Colorectal Cancer
A premalignant lesion (adenoma) progresses to invasive adenocarcinoma via a complex unknown mechanism
that most often involves genetic alterations. Most lesions of the large bowel are moderately differentiated
adenocarcinomas. Tumors tend to grow slowly and remain asymptomatic for a long time. Tumors in the
sigmoid and descending colon undergo circumferential growth and constrict the intestinal lumen. Tumors in
the ascending colon are usually large at diagnosis and are palpable on physical examination.
DIAGNOSTIC TESTS PATIENT INFORMATION ANTICIPATED PHYSICAL FINDINGS
(REASON FOR TEST AND RESULTS)
Imaging: computed tomography scanning Marvin Hayes is a 43-year-
Abdominal distention or visible mass,
determines stage. Transrectal old white male who enlarged abdominal veins, enlarged
ultrasonography determines extent of underwent a laparoscopic inguinal and supraclavicular nodes,
rectal lesions. abdominal perineal abnormal bowel sounds, abdominal
Diagnostic procedures: Proctoscopy or mass, generalized abdominal
resection with a
sigmoidoscopy permits visualization of tenderness, right color cancers tend to
the lower GI tract and can detect up to permanent sigmoid
be asymptomatic until palpable mass
66% of colorectal cancers. Colonoscopy colostomy 3 days ago for in LRQ and blood mixed with stool
permits visual inspection and rectal cancer. He has lost becomes visible, and left colon tumors
photography of the colon up to the weight, experiencing produce pencil-shaped stool.
ileocecal valve and provides access for
polypectomies and biopsies of suspected fatigue and narrowing
lesions. stools with blood.
ANTICIPATED NURSING INTERVENTIONS
Provide support and encourage verbalization of fears and concerns; assist in providing the patient and
family with information related to the treatment plan; allow the patient and family time for questions;
answer questions honestly.
Assist with developing positive coping strategies. Arrange for the patient to speak with someone who has
had a similar experience, if appropriate, to reduce fears and to mitigate feelings of being alone.
Give prescribed drugs. Provide information to the patient about prescribed chemotherapy, including
possible adverse effects. Premedicate with antiemetics about 30 minutes before administration, as
ordered.
Prepare the patient physically and psychologically for surgery.
Administer laxatives, enemas, and antibiotics preoperatively, as ordered.
Arrange for a preoperative visit by a wound, ostomy, and continence nurse if an ostomy is planned.
Apply antiembolism stockings or sequential compression stockings to prevent VTE.
Provide postoperative care. Assess cardiopulmonary status. Encourage coughing and diaphragmatic
breathing exercises, and incentive spirometry. Advise the patient to splint the incisional area to decrease
pain and facilitate coughing. Encourage early ambulation.
Assess the surgical site and perform site care, as ordered; auscultate bowel sounds; inspect the ostomy, if
present; note the integrity of the surrounding skin and check for passage of stool, noting amount, color,
and consistency.
, vSim ISBAR ACTIVITY STUDENT WORKSHEET
INTRODUCTION Hello, my name is Paola I am the nurse taking care of Mr. Hayes in the
Surgical Unit 0800. Am I speaking to ____?
Your name, position (RN), unit you are
working on
SITUATION Marvin Hayes is 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 Patient was admitted on 4/15/2020 and diagnosed with rectal
adenocarcinoma. Current orders include: diet full liquids, advance to
Patient’s primary diagnosis, date of regular diet as tolerated, CBC and BMP every 24 hours, vitals signs
admission, current orders for patient every 4 hours, get out of bed and ambulate in hallway, colostomy care,
IV saline lock, administer scheduled medication and as needed meds,
and the use of incentive spirometer 10x every hour while awake.
ASSESSMENT Vital signs have been stable with a saturation of 94%-97%. Pain level
is currently 1 after pain medication was administered an hour ago. The
Current pertinent assessment data using head colostomy appliance is an open-ended pouch attached to a skin barrier.
to toe approach, pertinent diagnostics, vital 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
signs
covering the perineal incision. Mr. Hayes has been up and ambulating
and is taking full liquids.
RECOMMENDATION My recommendation for this patient is to do a morning assessment,
assess his colostomy, and empty the pouch if necessary. He can
Any orders or recommendations you may have advance to a regular diet as tolerated and I will provide patient
for this patient education to prepare him for discharge in 2-3 days.
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