Identify and document key nursing diagnoses for Mr. Hayes regarding his current Preview text. When will the nure administer the medication? What question(s) would be appropriate for the nurse to include in the nursing health history? This is a non-returnable/non-refundable item. (Select all that apply. Which statements best support the nurse's evaluation that a patient who recenty experienced a sigmoid colostomy has begun to accept the body change? than 0 cm. (Select all that apply.) EducatedptondietRESPONSE:Patientunderstoodandengagedinteachingbyasking Received patient in bed alert and oriented x3. Manage classes and monitor student results by viewing pre-simulation and post-simulation . What is the appropriate response by the nurse? The perineal incision with no sign of infection. The downstroke adiabatically compresses the air, which reaches a gauge pressure of 8.00105Pa8.00 \times 10^5 \mathrm{~Pa}8.00105Pa before entering the tire. Which statement by the nurse indicates a thorough understanding of the purpose of postoperative nursing care? Marvin Hayes, 43 year old male diagnosed with rectal cancer. c. Leakage around the colostomy bag Recommendation:Ptisalmostdueforhismedicationsbeforebreakfast. What instructions should the nurse provide to a patient concerning how often the colostomy pouch should be emptied? Course Hero is not sponsored or endorsed by any college or university. The skin b. Assess the abdomen for signs of distention and ability to pass flatus. Pt participated during Privacy Statement, Stuvia is not sponsored or endorsed by any college or university, Also available in package deal from $35.49, Pennsylvania State University - All Campuses, Rutgers University - New Brunswick/Piscataway, University Of Illinois - Urbana-Champaign, Essential Environment: The Science Behind the Stories, Everything's an Argument with 2016 MLA Update, Managerial Economics and Business Strategy, Primates of the World: An Illustrated Guide, The State of Texas: Government, Politics, and Policy, IELTS - International English Language Testing System, TOEFL - Test of English as a Foreign Language, USMLE - United States Medical Licensing Examination. Documentation Assignments. The nurse is completing an abdominal assessment and observes a pulsating midline mass. - Condition of the skin around the stoma ago). A postoperative patient is receiving enoxaparin sodium therapy. colostomy, and ability to advance current diet post surgery. informed that for 6-8 weeks he should avoid high fiber, product that cause One hour before breakfast. Answer: First patient was aducated and asked if he was okay with myself proceding with the focused diet. Document Mr. Hayes reaction to his altered body image. Assist with developing positive coping strategies. Patient was educated on recommended foods to consume and foods Pt d. Moderate output liquid brown stool proper technique - Incision is slightly edematous. The pouch/bag was 1/2 full, which indicates No signs of drainage, infection. C. 83.0A The dressing is clean and dry, skin is pink, no excessive moister noted. removal that does not cause skin stripping and pain. teaching by asking questions and raising important concerns. 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EBP/PCC Describe the components of a focused abdominal assessment. image and condition. Patientreportspainof2outof10. After a few months, most patients can predict the best emptying time, which may r may not be after each meal. Assess for knowledge of stoma care, signs of body Pre-Simulation Quiz. Additionally, she has. Answer: Patient was educated on current clear liquid diet, which will be changed to full liquids The nurse is assessing the muscle strength in Mr.Russell's left hand and notes active motion against some resistance. Foods that increase odor being asparagus, fish, spicy foods. Hayes had a sigmoid colostomy procedure done. (Select all that apply.). Which statement made by the patient indicates an understanding of diet progression after surgery? a. Stoma that is dark purple status, peristomal skin, abdominal and perineal incisions. Identify and document key nursing diagnoses for Mr. Hayes regarding his current Hehasbeenonafullliquiddietfor3days. skinispink,noexcessivemoisternoted. quiz data and student feedback logs. Lab Report #11 - I earned an A in this lab class. Patient may advance to full liquid diet and then to Situation: Marvin Hayes is a 43-year-old White male who underwent a laparoscopic abdominal perineal resection with a permanent sigmoid colostomy yesterday for rectal cancer. Document assessment findings related to gastrointestinal function, output from colostomy, and ability to advance current diet post surgery. a) The goal is to prevent infection. In what order should the nurse complete the assessment? Theabdominalincisionhasnosignofinfectionorbleeding,dehiscence,andevisceration. 2quartsofwaterwere c. Scissors c. Providing client teaching (SBAR) format to communicate Mr. Hayes's future needs. Which statement made by the patient indicates an understanding of diet progression after surgery? Riskforsituationallowself-esteemr/tdisturbedbodyimageAEBptstatementI'ma vSim for Nursing allows each student to have a different experience with the patient. Post-Simulation. comfortablewiththemselves. (Select all that apply.). The need for a sigmoid colostomy is generally a result of cancer at what point in the intestinal tract? In the United, States the second most common of cancer death, which type of common in men and women. 2. PCC/T&C Discuss the education you would provide to Marvin Hayes and his family. - I've gotten accustomed to drinking at least two quarts of water a day. him. Request more information Overview Images Specifications Vitalsignswerewithin condition. Risk for impaired skin integrity related to excretions as evidenced by leakage betwee, Disturbed body image related to presence of stoma, daily care of fecal matte, Readiness for enhanced knowledge related to expresses an interest in learning as, evidenced by the patient wanting to know what to think of when changing the pouch, and, Psychology (David G. Myers; C. Nathan DeWall), The Methodology of the Social Sciences (Max Weber), Principles of Environmental Science (William P. Cunningham; Mary Ann Cunningham), Give Me Liberty! diarrhea, and excessive flatus. Ptunderstoodtheinformationandwasparticipatingduringtheeducation. Marvin Hayes Bowel Elimination Colostomy Care_6 items (concept map worksheet, documentation assignments, pre sim assignments, post sim assignment, vsim, guided reflection questions) Marvin Hayes VSIM/Marvin Hayes VSIM/Marvin Hayes VSIM/Marvin Hayes VSIM/Marvin Hayes VSIM/Marvin Hayes VSIM/Marvin Hayes VSIM/Marvin Hayes VSIM/Marvin Hayes VSIM/Marvin Hayes VSIM/Marvin Hayes VSIM/Ma. c. Characteristics of drainage Assess vital signs, adbomen, stoma, and bowel sounds Name: NUR : Pre-Sim Assignment - Marvin Hayes Scenario Background Situation: Mr. Hayes is a 43-year-old white male who underwent a laparoscopic abdominal perineal resection with a permanent sigmoid colostomy 3 days ago for rectal cancer. Upon The nurse recognizes the need for further education or support when Mr. Hayes's wife states which of the following? a. Sterile gloves Pt In what order should the nurse complete the assessment? Emphasis on pouch Referring to your feedback log, document all nursing care provided and Mr. Hayes's This is We're available through e-mail, live chat and Facebook. virtual simulation documentation assignment for Marvin Haynes. (Select all that apply.). 3. vSim. symmetry of the abdomen. The most likely cause of Jeremy's disease is: Vitamin D deficiency Thiamine, A pregnant women who has gestational diabetes mellitus (GDM) in the second trimester has which type of diabetes? vSim for Mental Health (released in 2017), in the pre-populated case library on the My Case Library tab: . Answer: Patients stoma was red and shiny, moist. Other meals for Marvin Hayes that may be beneficial include: water. encouragedtogetaccustomedwithnewcolostomysite. - It is time for his morning assessment. Become Premium to read the whole document. A. - A 50-year-old whose diet includes red meat daily Surrounding skin - Encourage the patient to take part in the care process. Colostomy care education includes techniques to empty and change the This is a battle stoma. abdomen where to start in an assessment. abdominal assessment. What information will the nurse include when providing education for a patient who is scheduled for a sigmoid colostomy? What information should the nurse include in the documentation associated with the changing of a patient's colostomy pouch? Thefocusedabdominalassessmentrevealed. Find the average binding energy per nucleon of. Describe how you would apply the knowledge and skills that you acquired in Marvin Hayess case to Become Premium to read the whole document. Itmakesthisacceptanceprocesseasierwithpeers. Risk for situational low self-esteem r/t disturbed body image AEB pt statement "I'm a little embarrassed by the smell." Risk for constipation r/t inactivity AEB bed rest due to pain and healing. How many bowel sounds per minute would the nurse expect to hear in a healthy patient? (Select all that apply.) Inspected and Auscultation abdomen RESPONSE: the patient showed no status, peristomal skin, abdominal and perineal incisions. Moderate bleeding from the stoma within normal limit; minor pain present, 1 out of 10. Answer: The specificity of the Vsim assignment being a focused abdominal assessment allowed me to Exam (elaborations) - Marvin hayes guided reflection questions _fundamentals case 2. Inspection, auscultation, percussion, palpation. Retrieved from Concluding Questions Describe how you would apply the knowledge and skills that you acquired in Marvin Hayes's case to future cases. From vSim for Nursing | Health Assessment. Unique, Personalized Learning. A patient is placed on omeprazole 20 mg daily. Theptwas Which question should the nurse ask the patient prior to conducting the assessment? sign of discomfort at looking at the colostomy and showed no sign of Describe the role of fungi in lichens and mycorrhizae. In which quadrant should the nurse begin the assessment? diet. (Select all that apply.) Request more information Real-World, Evidence-Based Scenarios (Select all that apply.) new colostomy (3 days ago). Audrey Blake SN, Surgical UnitMarvin Hayes, 43-year-old. breathingexercises. Document assessment findings related to gastrointestinal function, output from colostomy, Marvin Hayes reflection W VSIM University California State University Bakersfield Course Nursing (202) Uploaded by Whitney hersley Academic year2020/2021 Helpful? Theskinaroundthesitewas b. leaf veins parallelnet veined vSim: Fundamentals Scenario Marvin Hayes Flashcards | Quizlet vSim: Fundamentals Scenario Marvin Hayes Term 1 / 20 Which nursing interventions are implemented primarily to prevent respiratory complications in a patient after abdominal surgery? time for a change. ), -avoid high fiber foods for 8 weeks after the surgery, Which of the following should the nurse do when preparing to educate a patient whose condition requires a permanent colostomy? What A: Vitals Stable (P:82 bpm, R:16/min, BP:118/76 mmHg, T:99F, O2Sat: 95% Pain Level: 1/10) Contour of Situation- the patient recently was dx with rectal cancer and has a The many other situations this may not be the case. (Select all that apply.). condition. Nosignof Referring to your feedback log, document all nursing care provided and Mr. Hayes's The nurse is assessing bowel sounds. As well as education for support groups or external physocolgical groups that can make the Prepare him for discharge in 1-2 days. Wolters Kluwer. Assess the abdomen for signs of distention. patientappropriately. I noticed that my ankles and, Ann is a primigravida in her 35th week of pregnancy and presents to the clinic with severe recurrent headaches, blurred vision, pitting edema, and right upper quadrant pain. Body change proceding with the patient to take part in the intestinal tract in. Is pink, no excessive moister noted that apply. skin b. Assess abdomen. 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