Brief Description Client Explained for Students (Easy Guide)
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This question relates to brief description client and requires a structured academic response.
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Original Question
Brief Description of Client Name: Marvin Hayes Gender: M Age: 43 Race: Caucasian Weight: 165 lbs (75 kg) Height: 70 in (178 cm) Religion: Protestant Major support: Wife, Caroline Hayes Allergies: No Known Allergies Immunizations: Up to date Primary Care Provider/Team: Dr. Ellen Ryder Past Medical History: No remarkable past medical history, family history of colorectal cancer History of present illness: Weight loss, fatigue, occult stools; Rectal adenocarcinoma status post abdominoperineal resection of rectum with a permanent sigmoid colostomy 3 days ago Social history: Lives with wife of 15 years; no children; Employment – Owns a restaurant; Drinks socially; No history of smoking or drugs Surgeries/Procedures & Dates: status post abdominoperineal resection of rectum with a permanent sigmoid colostomy 3 days ago Complete the following data for colon cancer: What is it? Signs and symptoms Common causes and risk factors What is an abdominoperineal resection of the rectum with a permanent sigmoid colostomy? Complete the following related to medications: Medication Drug Classification Mechanism of Action (How does it work in the body?) Side Effects Why would this medication be ordered for this patient? Patient education needed (in Layman’s terms) Omeprazole Enoxaparin Acetaminophen What orders for lab and/or diagnostic testing should the nurse anticipate for this patient? What is included in a surgical incision assessment? What is included in a colostomy assessment? How should the ostomy site look? Describe the procedure for changing an ostomy bag. What education would you anticipate providing to this patient regarding colostomy care and diet? Potential Problems: Identify 3 potential problems that the patient is at risk for. What objective or subjective data might your assessment reveal to support each problem? How would you manage each of these problems (interventions)? Problem List Supportive data Interventions 1. 2. 3.
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