NURS 3000

NURS 121L-A Rev. 2-20

Cultural considerations, ethnicity, occupation, religion,

family support, insurance. (1) (14)

-Patient is Caucasian -Patient is a retired lawyer

-Patient is a Christian

-Patient does not have much family support in regards to stoma care

History of Present Illness (HPI), Pathophysiology of Admitting Dx

(Cite References) Medical, Surgical, Social History (1).

R.S. is a 69 year old Caucasian female admitted for acute cholecystitis

exacerbated by cholelithiasis. The patient came in complaining of intense pain in the abdominal area. Patient received a laparscopic

cholecystectomy, however, intra-op complications occurred and a

bowel resection occurred. The surgeon placed a temporary ileostomy on

the patient. After 3 days post op, the patient apperead depressed when

speaking with the nursing staff while providing stoma care. Post discharge, the patient called the hospital requesting a wound care nurse

give stoma care. This is because the patient, nor the husband were

willing to provide care, so they asked neighbor (who is a nurse) to

provide it for them.

Medical History

Acute Cholecystitis

Acute Cholecystitis is an acute inflammation of the gallbladder wall.

90% of patients who experience this have had a previous diagnosis of

cholelithiasis. In almost all patients, this inflammation is from an obstruiction of the cystic duct (Copstead & Banasikm 2013). Most

patients have sign and symptoms of severe right upper abdominal pain

that radiates to the back, abdominal tenderness, and fever. The main

treatment to reduce this inflammation is a cholecystectomy. This is

considered the mainstay treatment of this condition because reoccurance of the stones and inflammation is likely (Copstead &

Banasikm 2013). If untreated, this can lead to gangrene due to ischemic

conditions to the surrounding tissue of the inflamed area, as well as a

rupture of the gall bladder.

Chronic Cholithiasis

Chronic Cholilithiasis is the longterm presence of gallstones within the

gallbladder. This condition mostly occurs due to high LDL levels

within the body (high cholesterol) (Copstead & Banasikm 2013). It occurs more in women than men, and age also is considered a risk

factor in the development of this disease. There are 3 phases in which a

gallstone will form. The first is the supersaturation of bile with

cholesterol (Copstead & Banasikm 2013). Meaning that the gallbladder

is filling up with too much bile that shouldn’t be there. The second phase is the nucleation of crystals (Copstead & Banasikm 2013). This is

where cells will form in a pattern creating crystals in the gallbladder.

Nad lastly, hypomotility leads to stone growth (Copstead & Banasikm

2013). This means that stagnant crsytallized bile within the gall bladder

will continue to grow more and more due to the lack of movement that they have within the gallbladder.

Surgical History

There is no past surgical history that played into the development of

Cholelithiasis and the acute cholysystitis.

Social History

-No smoking

-Not ETOH

Chief Complaint

-Severe RUQ pain that radiates to the back

Admitting Diagnosis

Acute Cholysistitus related to chronic

Cholelithiasis.

Patient Information (1)

Name: Ramona Stokes

Age: 69 years old Gender: Female

Code Status: Full code

DPOA: Yes

Living Will: No

Patient Education (In Pt.) & Discharge Planning (home needs)

-Patient has an increased acuity in regarding to education for stoma care

post ileostomy placement

-The patient should be provided with proper supplies needed for

independent stoma care at home.

-Patient and family should be educated and taught how to provide stoma care at home. This includes teaching in the affective domain of learning

that tackles emotions. The patient as well as the husband have been

disregarding the fact that they must provide stoma care, and have instead

asked a neighbor to provide it instead. Further teaching that tackles the

rationale to why providing independent stoma care is essential will allow the patient and family to feel more open to living with the presence of

the stoma.

NURS 121L-A Concept Map

Student Name: Andrew Tayag

Instructor: Professor Pa Chi Moua

Diagnostic Test/ Lab Results with dates

and Normal Ranges (3)

Test Norms Date

Current

Value

Ultrasound Intact

gallbladd

er

Inflamed

gallblad

der

CBC

(WBC)

5,000-

10,000

12,000

AST 5-40 50

ALT 7-56 60

BUN 7-20 15

Creatinine 1.2- 2.1 1.3

Medical Management/ Orders/ Medications & Allergies (2)

Please refer to MAR

Erickson’s Developmental Stage Related to pt. & Cite

References (1) The patient is in the Ego Integrity vs. Despair phase at the age of 69. This

is a phase that starts at 65 and ends at death (Cherry, 2020). Individuals

during this stage reflect on their lives thus far and either regret not

achieving their goals or contemplate our accomplishments to thus

develop integrity regarding our life’s journey. Most who reflect on their

life and develop a sense of not being productive may feel guilty that they

did not accomplish their life goals, leading to feelings depression or

sadness. With the patient, if she were to feel depressed and sad post op due to the presence of an ileostomy, then she may be feeling as if she

does not have independence anymore, and that her life has lead all the

way up to the point in which she does not have control. This can cause

feelings of guilt and despair due to the fact that she may not feel as if her

life has been fulfilling, and the presence of the ileostomy may further the

notion that she may believe that her life is unfulfilled.

https://www.coursehero.com/file/76624843/Concept-Map-2-Draft-NURS-121-Apdf/

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Priority nursing diagnosis #1

Disturbed body image related to

the presence of a stoma

secoondary to ileostomy bag placemennt as evidenced by

patient stating she feels sad and

depressed to the PACU nurse.

Vital Signs (4)

BP: 114/62 Pulse: 100

RR: 20

PaO2: 96%

Temp: 98.7

Height: 5’4 Weight: 175

Pain: 6/10

Neurological (5)

-Alert and Oriented x4

-Clear speech

-No signs of hearing loss

-Depressed when

speaking with nursing staff (post bowel

resection)

Respiratory (7) -Patient is utilizing incentive

spirometer

-900ml on day 1 post op

-1250ml day 3 post op

-Must be reminded to use the

incentive spirometer -No crackles or wheezing

upon auscultation

-Breath sounds are clear

Priority nursing diagnosis #2

Deficient knowledge related to

stoma care secondary to

ileostomy bag placement as

evidenced by family members refusing to provide stoma care

and requesting information for a

home health wound care nurse

while at home.

Outcome/Goal #2

Patient will correctly preform necessary procedures, while

explaining the reasons for each

action by the next follow up

appointment.

Outcome/Goal #1

Patient will verbalize feelings about the presence of the stoma

in order to deal with the

situation in a contstruictive

way before the ileostomy bag

is removed.

Interventions #1 -The first intervention would be to encourage the patient to

verbalize their feelings of depression and sadness related

to their grief. By allowing verbalization with reassurance

that the patient is not alone in their feelings will help the

patient understand that they should not feel guily to

isolated in expressing their feelings.

-Providing opportunities for the patient to view and touch

their stoma will akllow the patient to confront their fears

regarding its presence. This allows the patient to normalize

its presence in order to feel more accepting for

independent care.

-Teaching the patient what a normal stoma looks like as

well as educating them on the positive sings of healing

will allow the patient to feel a sense of encouragement

regarding its presence. It will allow the patient to

understand that she does not have to feel disabled, and to

hopefully have her go back to her daily ativites with the

stoma present.

(Vera, 2019b)

Interventions # 2 -Including written, electronic, and visual

learning resources will provide a reference in

stoma care while at home. Doing so will promote independence so that professional

care will not be as needed, and independent care can be initialized.

-Alloting time after education for the patient to

provide demonstrations on stoma care, while giving positive feedback for their efforts will

reduce the risk of imporper management and care. Additionally, it can allow them to feel a

sense of responsibility knowing that they have

to fully understand the procedure and show it to a professional.

-Teaching the patient proper diet and consumption technieuqes such as taking time

to chew food will reduce the risk for the

patient to experience a bowel obnstruction, which can lead to compllications.

(Vera, 2019a).

Assessment/ Evaluation #1

The patient only partially met the goal of verbalizing her

feelings regarding the stobecausease she and her family

requested a wound care nurse to provide stoma care instead of

maintiangin care independatly. Further teaching regarding independent stoma care should be provided to her and her

busdband to allow further acceptance of its presence within her

life.

Assessment/ Evaluation #2

Patient met the goal of correctly preforming the

necessary procedures while explaining the rationale per action. After multiple teaching sessions and follow ups,

the patient was more willing to provide independent

stoma care after being educated.

PC Interventions -Patient should clean the stoma and peristomal area after each pouch

change, indicating if there is any irritation, brusing, or rashes apparent.

Doing this will allow the patient to monitor the healing process, as well as

if there are any complications occurring.

-Patient should clean the stoma with warm water and pat it dry. If any area

is covered in stool, soap is allowed in the cleaining process. Doing so will

decrease the occurance of skin breakdown through keeping the area clean

and dry.

-Consutling a wound care nurse will allow the patient to learn more about

appropriate products that can be used for the patient’s ileostomy. Also, it will allow individualized care that centers around the patient’s ability to

handle self care, financial resources, and the type of ostomy she has.

(Vera, 2019c)

PC Evaluation Plan

Patient has partially met the goal of maintaining skin

integrity by the end of ileostomy care. This is due to the

fact that the patient still has the ileostomy in place. Since

the patient is still currently undergoing the placement, there should be follow ups and consistent monitoring regarding

the skin of the patient in order to maintain the skin being

intact.

PC Outcomes/Goal

Client will maintain skin integrity

around the stoma through the entire

duration of the ileostomy

Potential Complications/ at

risk for

Risk for impaired skin integrity related to absence of sphinter

at the stoma (Vera, 2019c)

Nutrition/Hydration

(8)

-Pt was on NPO status

-Now is able to eat

small amounts of ice chips

-Excessivly requests ice

chips

Rest/ Exercise (11)

-Patient does not exercise regularly

-Feels the decreased

need to ambulate with

assistance from nurses

and wants to stay in bed

GI (9) -T-tube without drainage

-NG set to low suction -Temporary ileostomy

bag (post bowel resection)

-Auscultation of the 4 quadrents indicates

normal bowel sounds

GU (10)

-Patient is utilizing an

ileostomy bag

-Requires assistance in

order to urinate -Ileostomy and perineal

care given 2-3 times

per shift

Musculoskeletal

-Patient is unable to

ambulate without

assistance from nurses

-Patient is on fall risk

precautions

Endocrine (13)

-Blood sugar: 90

-No hx of diabetes of

hyper/hypothyroidism

Cardiovascular (6)

-S1 and S2 present with

auscultation at the

apical point

-Pulse on bilateral

upper extremities (radial pulse) is

100bpm

-BP reads 114/62

Psychosocial (14)

-Pt is in need of a

better support group -Family is unwilling to

learn how to and

provide ileostomy and

stoma care

Integumentary (12)

-Skin is warm and dry -Dressing changes daily

-Braden scale: low risk

for skin breakdown

NURS 121L-A Rev. 2-20 https://www.coursehero.com/file/76624843/Concept-Map-2-Draft-NURS-121-Apdf/

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References

Cherry, K. (2020, August 25). Intimacy vs. Isolation: Forming Intimate Relationships With Others. Verywell Mind.

https://www.verywellmind.com/intimacy-versus-isolation-2795739

Copstead, L. E., & Banasik, J. L. (2013). Pathophysiology. St. Louis, MO: Elsevier.

Vera, M. B. (2019a, June 1). 10 Ileostomy and Colostomy Nursing Care Plans. Nurseslabs. https://nurseslabs.com/10-ileostomy-

colostomy-nursing-care-plans/10/

Vera, M. B. (2019b, June 1). 10 Ileostomy and Colostomy Nursing Care Plans. Nurseslabs. https://nurseslabs.com/10-ileostomy-

colostomy-nursing-care-plans/2/

Vera, M. B. (2019c, June 1). 10 Ileostomy and Colostomy Nursing Care Plans. Nurseslabs. https://nurseslabs.com/10-ileostomy-

colostomy-nursing-care-plans/

https://www.coursehero.com/file/76624843/Concept-Map-2-Draft-NURS-121-Apdf/

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