Concept Care Map

Student: Cynthia Leon Date of admission: 10/25/2011 Occupation: N/A Religion: Catholic Diet: __SOFT, ENSURE BID________ Culture: _African American Med-Surg history: Liver CA/Colon CA Allergies: ______NKA___________

Clients initials, age, gender: K.D 41 years old MALE_______

Vital Signs B/P: 127/80 HR: 100 Temp: 98.3 02 Sat: 99 RR: 20
Knowledgeable deficit related to care of colostomy as evidenced by lack of exposure and unfamiliarity with resourced regarding colostomy devices. -description of steps in the procedure -description of proper care of equipment -description of appriate action to take for complications -states and performs proper colostomy care procedure

Pain Level:
0/10

No Facial grimacing, guarding Medications: Rocephin 1000mg IVPB daily ran at 100ml/hr Pepcid 10 mg/ml, 20 mg IV push twice a day Feosol oral 324 mg oral twice a day Diflucan 100mg IVPB 100ml/hr

Reason for seeking healthcare

Current Treatments: -CT Guided biopsy: results showed metastatic adenocarcinoma of the liver. -Colonoscopy: showed large adenocarcinoma in the descending colon. -Exploratory laparotomy/transverse colostomy: colonic ca which spread to the liver causing obstruction. -removal of retention sutures/colostomy bag change and stoma care: removed by RN. No drainage, edema.
Lab Results
Hgb 10.4 Hct 32 WBC 11 Na-131 Cl- 92 K-3.2

Abdominal Pain (Liver &Colon cancer)

Evaluation: -no signs of infection noted -no redness, skin breakdown noted near stoma or other parts of the body. -proper size fitting accomplished and patient taught how to measure stoma fitting -colostomy care done and teaching demonstration was given to patient. Patient able to participate and showed knowledge of colostomy removal an care. -patient expressed feelings of anger and depression -patient given time to share his feelings.

Disturbed body image related to recent colostomy placement as evidenced by verbalization of feelings that reflect an altered view of ones body in appearance. -states or demonstrates acceptance of change or loss and an ability to adjust to lifestyle change. -looks at and touches changed or missing body part.

Patient quit smoking and drinking alcohol 6 months ago. Lives with brother and mother.