Students should complete the Data Collection Assignment independently and submit as a Word document attachment on the Assignments link in Sakai by the deadline stated in the course schedule found in the syllabus.  Specific grading criteria are outlined below. Do not include any patient identifiers to maintain confidentiality for the patient.
Grading Criteria:
CONTENT    Maximum Points    Points Awarded    Comments
Data Collection (Assessment)     (44 total for this section)    34.5
Chief Complaint (signs/symptoms,
medical diagnosis)    4    2    See comments below
Patient Demographics    4    4

Patient Medical History     4    3    See comments below
Patient Surgical History     4    3    See comments below
Significant Family History    4    4
Diagnostics (lab, x-ray, etc.)    4    2.5    See comments below
Current Medications    4    3    See comments below
Pathophysiology    4    4
Developmental Considerations    4    2    See comments below
Nursing Considerations    4    4
Patient Education Needs    4    1    See comments below
Nursing Process    (56 total for this section)    35
Nursing Diagnosis – high priority
according to patient presentation
and assessment data provided    10    2    See comments below
Planning – Patient Goals: measurable
& realistic    10    3
Planning – Nursing Interventions    10    4
Implementation (selected
intervention)    10    10
Evaluation    10    10
Format [name included, correct grammar/spelling/punctuation, include  references (APA format), submitted as Word document attachment via Assignments link]
NOTE: 10 points per day will be deducted if submitted late; assignment will not be accepted if submitted more than 3 days late and assigned grade will be 0 (zero).     6    6
TOTAL    100    69.5
10/1/2013
DATA COLLECTION ASSIGNMENT
CHIEF COMPLAINT
Focused assessment findings related to medical and/or nursing diagnosis, including vital signs:
Vital signs: blood pressure 157/71, pulse rate 62, oxygen saturation 99% how how much oxygen and by what modality, temperature 97.6, respiration rate 18. Any pain?
General: She is awake, alert, no apparent distress. States that she feels better
Chest: clear chest is clear of what?
Missing lung sounds
Heart: No murmur, rub, or gallop This is what you didn’t hear, but what about what you did hear?
Abdomen: The colostomy looks good, both the mucous fistula and the end stoma. There is a solid soft stool in the ostomy bag. The abdomen is just slightly distended and non-tender. The tumor nodule which is the nodule on the midline wound in the upper part of the incision which is most likely a cancer nodule is very hard and non-tender. Hyperactive bowel sounds are present in which quadrants?. No peristaltic rushes or high pitched audible sounds.
Pulse: Radial pulses, pedal pulses, posterior tibial (RP, DP, PT) +2 bilaterally with capillary refill < 3 sec
Extremities: Edematous edema is reported using a numerical value. She has chronic lymphedema
Pulses?
IV access?
Turgor?
Reason for Seeking Care, Admitting Diagnosis and/or Rationale for Transfer to Current Level of Acuity :
She’s been having nausea, vomiting and bilious emesis for the past 4 days.  Also intermittent abdominal cramps and she has not had any colostomy output for 4 days you report above she has stool in the bag, confused!.  Admitting diagnosis is small bowel obstruction.
PATIENT DEMOGRAPHICS
Age/Birthdate: 60
Gender: Female
Marital Status: Single
Race/Ethnicity:Caucasian
Height/Weight: 5 ft 9.5 inches/ 171 lbs
Occupation: Teacher
Support System: Mother
PATIENT MEDICAL HISTORY
(Childhood illnesses, accidents or injuries, immunizations, allergies, prior diagnoses, etc.)
Positive for chronic narcotic use for chronic pain syndrome related to previous coccygectomy years ago after she had fractured her tailbone. Her immunizations are up to date and she recently got a flu shot here at the hospital. She is allergic to erythromycin and tetracycline. Prior diagnoses include unresectable distal rectal cancer with left ureter involvement leading to obstruction of the left ureter.
Pneumonia shot?
Shingles vaccine?
Is this patient diabetic? Insulin is in her med list?
PATIENT SURGICAL HISTORY
(Previous hospitalizations, operations, procedures, etc. and dates)
Left ureteral stent, diverting transverse loop colostomy converted to end-colostomy with mucous fistula in February Date?
SIGNIFICANT FAMILY HISTORY
(Positive or negative family history of disorders including but not limited to diabetes, hypertension, cardiac, cancer, endocrine, psychiatric. Also include what family member was affected.)
Her mum is also diabetic and has high blood pressure. Her dad has high blood pressure and passed away few years ago after being diagnosed with rectal cancer.

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DIAGNOSTICS
(Include labs, x-rays, special tests, etc. related to medical and/or nursing diagnosis and values: normal vs. abnormal)
WBC -10.8 (normal 3.4-10)
hemoglobin 13 mg/dL, (normal 12-16)
platelets were 269,000/mm3 (normal 140000-440000)
CBC-
serum creatinine- 1.2 (normal 0.7-1.5)
amylase, value?
triglycerides, values?
CMP,
magnesium  value?
BUN levels- 15(normal 8 to 20)
Sodium?
Potassium?
Procalcitonin?

CT of the abdomen results?
CT of the pelvis results?

DATA COLLECTION ASSIGNMENT
CURRENT MEDICATIONS
(Include Dose/Route, Times-scheduled vs PRN)
Enoxaparin 40mg SQ once daily
Pantoprazole IV 40mg q 12 h
Hydromophone 3.5mg IVP q 2 h prn
Ondansetron IVP 8mg q 4 h prn
Alprazolam 0.25mg po qhs
Oxycontin 240mg tid
Oxycodone 30mg po q 3 h prn
Lactinex 2 tabs po bid
Simethicone 80mg po with meals
NaCl flush 0.9% 10ml  q 12 h
Capsicum oleoresin cream 0.25%. apply qid apply where?
Regular insulin sliding scale b range
Heparin lock flush 30 units prn
5% dextrose 0.9 NS 1000ml At what rate?
Antibiotics?

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PATHOPHYSIOLOGY
(Include etiology & progression of disease, as well as scholarly reference to support)
Bowel obstruction can be caused by tumors, scar tissue (post surgical adhesions), or twisting or narrowing of the intestines. These are called mechanical obstruction.
Small-bowel obstruction results to proximal dilatation of the intestine due to accumulation of GI secretions and swallowed air. This bowel dilatation stimulates cell secretory activity, resulting in more fluid accumulation. This leads to increased peristalsis above and below the obstruction, with frequent loose stools and flatus early in its course.
“Bowel Obstruction Symptoms, Treatment, and Causes.” WebMD. WebMD, 3 Jan. 2000. Web. 15 Nov. 2013. <http://www.webmd.com/digestive-disorders/tc/bowel-obstruction-topic-overview>.
Nobie, Brian. “Small-Bowel Obstruction .” Small-Bowel Obstruction. N.p., 28 Oct. 1994. Web. 15 Nov. 2013. <http://emedicine.medscape.com/article/774140-overview#aw2aab6b2b3>.

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DEVELOPMENTAL CONSIDERATIONS
(based on developmental theory, i.e. Erik Erikson,
with supporting rationale from patient data; also include scholarly reference to support)
The patient was satisfied with the life she lived. She interpreted her life as meaning because she achieved a lot of her goals. She also feels valued and appreciated. She was given 6 months to live and she has lived over a year now. She believed she is still alive because God has a purpose for her and she is still needed by her family. She also said she does not fear death because she lived most of her life the godly way.
Per the above directions, you were to choose a development theory by Erik Erickson and identify which stage your patient was in and provide supporting data.
Potter, Patricia Ann, Anne Perry, Patricia Stockert, and Amy Hall. “Caring Throughout the Life Span.”Fundamentals of nursing. 8th ed. St. Louis, Mo.: Mosby, 2013. 132-133.
NURSING CONSIDERATIONS
(what should the nurse take into consideration when planning/providing care)
Make sure the colostomy bag is clean and emptied at every shift
Monitor the output
Make sure the patient knows how to take care of their colostomy bag This is education
The nurse also need to take into consideration that this patient is in pain so she will be calling you often for pain medication
The patient has been given few months to live so the nurse has to use calm, reassuring approach in discussions

PATIENT EDUCATION NEEDS IDENTIFIED

Teaching colostomy care
Teach progressive relaxation
Medications
Nutrition
Eating habits
Chemo options
Diabetic management    OTHER PERTINENT INFORMATION
(such as risk factors, psychosocial risk factors; examples include smoking, limited access to care, etc.; can be left blank if no other pertinent information is identified)

DATA COLLECTION – NURSING PROCESS COMPONENT
(Refer to Ackley & Ladwig text)
NURSING DIAGNOSIS (Dx)
Include one three part NANDA approved nursing diagnostic statement (include problem, etiology, symptoms). Example:  Activity intolerance related to imbalance between oxygen supply and demand as evidenced by verbal reports of weakness and abnormal blood pressure response to activity.  NOTE: The diagnosis should be a high priority diagnosis for the patient. Include rationale and scholarly reference for why this is a high priority diagnosis.
Constipation related to decreased motility and intestinal obstruction defined by decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool.  Patient has colostomy bag and she has not had an output in 4 days. She has hyperactive bowel sound, abdominal distention, firm and non tender.
Your patient is not constipated she has a bowel obstruction. Not the same thing at all.
Intestinal obstruction does not create constipation.
A better diagnosis would have been acute pain, or Risk for Impaired Skin Integrity due to having a fecal diversion.
Also you were to provide rationale for this being a high priority diagnosis along with a scholarly reference.

PLANNING: PATIENT GOALS
Identify two patient-oriented goals and include outcome criteria that are measurable and realistic.  Example: The client will ambulate 25 feet by the end of the 12 hour shift.
•    Goal 1:   Patient will maintain passage of soft stool everyday everyday for how long? This was to be timed.
•    Goal 2:   Patient will state relief from discomfort of constipation by the end of the shift This patient is not constipated, she has an obstruction, therefore this goal is not appropriate.
PLANNING: NURSING INTERVENTIONS
List 2 nursing interventions for each goal. Example: Monitor cardiorespiratory response to activity.  The interventions should be realistic, individualized and include both rationale and scholarly reference for each.
•    Goal 1 Interventions (Include two interventions for this goal):
1.  Nurse will: Assess usual pattern of defecation including  time of day, amount, frequency and consistency of stool No rationale, no reference
2.  Nurse will: Encourage fluid intake of  1.5 to 2 L/per (6 to 8 glasses of liquids per day) No rationale, no reference
•    Goal 2 Interventions (Include two interventions for this goal):
1.  Nurse will: Assess abdominal discomfort every hour. No rationale, no reference.
2.  Nurse will: Encourage patient to resume walking and activities of daily living. No rationale, no reference.
IMPLEMENTATION
Describe one intervention that was implemented.  What did you do and how did the patient respond?  This should be in narrative documentation format.
Patient was given prune juice as a snack and also helped the patient walk down the hall to get her bowel moving.  Contacted the Dr to see if she can get a daily stool softener and she was prescribed colace. She was cooperative and participating in the care by trying to get her bowel stimulated.
EVALUATION (Outcome Criteria from Planning Section Above)
Describe if the outcome criteria were achieved (could be completely or partially) for both patient goals.  Also identify what changes should be made in the plan and include a new target date if appropriate.
•    Goal 1: goal is in progress until discharged
•    Goal 2: She had a copious amounts of soft stool output per her colostomy before the end of the shift

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