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Running Head: SELF CONCEPT EXAMINATION OF A PATIENT WITH APR 1
Self-Concept Examination of a Patient with Abdominoperieal ...
SELF CONCEPT EXAMINATION OF A PATIENT WITH APR 2
Abstract
This paper explores the impact of self-concept on an individual ...
SELF CONCEPT EXAMINATION OF A PATIENT WITH APR 3
Self-Concept Examination on a Patient with Abdominoperieal Resection
Self...
SELF CONCEPT EXAMINATION OF A PATIENT WITH APR 4
The patient has had a history of irregularly irregular heart rhythms, whi...
SELF CONCEPT EXAMINATION OF A PATIENT WITH APR 5
extreme pain. The patient also has a history of depression, which may hav...
SELF CONCEPT EXAMINATION OF A PATIENT WITH APR 6
Understanding of illness. The patient and her family did thorough researc...
SELF CONCEPT EXAMINATION OF A PATIENT WITH APR 7
desire to be sexually active. The patient may also be afraid to have sexu...
SELF CONCEPT EXAMINATION OF A PATIENT WITH APR 8
Expressiveness. While the patient insisted she did not want to be a burde...
SELF CONCEPT EXAMINATION OF A PATIENT WITH APR 9
family she loved them”. The patient also had insurance through Medicare, ...
SELF CONCEPT EXAMINATION OF A PATIENT WITH APR 10
over her, and did not want to bother everyone. The patient was still not...
SELF CONCEPT EXAMINATION OF A PATIENT WITH APR 11
patient, followed by the desire to end her life, demonstrates how pain c...
SELF CONCEPT EXAMINATION OF A PATIENT WITH APR 12
The third nursing intervention is to provide only information that the p...
SELF CONCEPT EXAMINATION OF A PATIENT WITH APR 13
positive signs of progress, such as reduced abdominal distention or edem...
SELF CONCEPT EXAMINATION OF A PATIENT WITH APR 14
References
Carpenito, L. (2008). Handbook of nursing diagnosis (12th ed....
SELF CONCEPT EXAMINATION OF A PATIENT WITH APR 15
lonely older people: favourable processes and mediating factors of the i...
SELF CONCEPT EXAMINATION OF A PATIENT WITH APR 16
Appendix
Cephalocaudal Note
98.2° F, 88, 20, 170/78, 99% on 2L/min O2, 8...
SELF CONCEPT EXAMINATION OF A PATIENT WITH APR 17
amount of water with her PO medications, as ordered by doctor. Pt receiv...
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SelfConcept

  1. 1. Running Head: SELF CONCEPT EXAMINATION OF A PATIENT WITH APR 1 Self-Concept Examination of a Patient with Abdominoperieal Resection Meghan Brill Binghamton University, State University of New York
  2. 2. SELF CONCEPT EXAMINATION OF A PATIENT WITH APR 2 Abstract This paper explores the impact of self-concept on an individual throughout one nursing shift. Self-concept plays a critical role in the wellbeing of a patient, and can impact their physical, emotional, psychological, and social aspects of life. Nurses are responsible for advocating for patients, and ensuring the best possible levels of satisfaction and health during the patient’s hospital stay. The patient worked with during the nursing shift experienced situational low self- esteem, demonstrated by multiple statements of wanting to die, after spreading pain following an abdominoperieal resection (APR). The patient had feelings of uselessness and felt as though they were a burden on others. It is the role of the nurse to intervene with the patient and help them in a time of crisis. Keywords: nursing, colostomy, self-concept, self-esteem
  3. 3. SELF CONCEPT EXAMINATION OF A PATIENT WITH APR 3 Self-Concept Examination on a Patient with Abdominoperieal Resection Self-concept is important to an individual’s wellbeing and health, regardless of their age, gender, sexuality, or socioeconomic status. Nurses can help to foster a positive self-concept through developing a trusting relationship with a patient, and can help to inspire a patient. Through evaluation of an individual’s self-concept, a nurse can help to expedite the healing process and encourage the patient to become their best self. Client Introduction History of Present Admission The patient being observed was a 70-80 year old female, admitted eight days ago to the telemetry floor at UHS Wilson Medical Center. The patient had a transanal excision of an anorectal lesion identified as an invasive adenocarcinoma. Based on this finding, and the positive margins found, oncology recommended an abdominoperieal resection (APR). The client agreed to this procedure, wanting to return to her life prior to the cancerous findings. After the procedure was performed, the client now has a permanent colostomy bag. However, the patient has a small bowel obstruction, and dilation of the small bowel loops. To alleviate the situation and abdominal gas and bloating, multiple doctors and nurses have attempted to insert a nasogastric tube. She had the tube successfully inserted once during her hospital stay, but found it uncomfortable and removed it shortly after. She will not let anyone insert another. Because of this situation, the patient is on a nil per os (NPO) diet, besides small amounts of water with medication. The patient’s rectal sutures are not well approximated, and the drainage is a bloody, pink liquid. The patient is not in any discomfort in the region, but the nurses on duty were concerned about infection. The abdominal incisions were clean, dry and intact.
  4. 4. SELF CONCEPT EXAMINATION OF A PATIENT WITH APR 4 The patient has had a history of irregularly irregular heart rhythms, which led to her placement on a telemetry floor. Family Situation The patient lives alone, but has strong familial support. She is widowed, but has a significant other that came to visit her in the hospital. She has three children, two daughters and a son, whom have been visiting and checking up on her. Her eldest daughter is particularly concerned with her health, and has been visiting daily for several hours. She has strong relationships with all three children, and talks positively about them. The other two children live outside of the surrounding area, but telephone frequently. The patient also speaks fondly about her grandchildren, and enjoys spoiling them when they come to visit. The patient’s parents passed away over ten years ago. The patient stated that she misses them, but knows that they’re looking down on her. The patient also has a sister, whom she talks to weekly on the telephone. Rationale for Client Selection This patient was selected for a variety of reasons. Although the patient is a senior, she is very active, and is able to provide for herself. Ostomies have been found to have a significant negative impact on individuals’ sexual relationships, physical appearance, and travel (Popek et al., 2010). The colostomy can impact her daily life, and will change the way that she functions daily. The patient was also selected based on her drastic mood shift during the shift. Initially, the patient was very friendly, talkative, and positive. As the shift progressed, the patient’s attitude quickly turned negative and she became very depressed, stating that she “wanted to die”. The patient also was worried about being a burden and bothering everyone, even as she was in
  5. 5. SELF CONCEPT EXAMINATION OF A PATIENT WITH APR 5 extreme pain. The patient also has a history of depression, which may have had an impact on her mood changes. The patient was very open to conversations about her life, and was willing to share her story. She was happy to have someone to talk with, and express her concerns to. The patient was interested in exploring her self-concept and learning more about herself to grow. Self-Concept Assessment Intellectual Self Cognitive ability. The patient is of normal cognitive ability. Her short and long term memory were normal, as evidenced by her ability to recall visitors from the past few days, as well as her birthday and other important events. The patient is able to tell stories well and recollect past events. The patient had a willingness to learn about her colostomy bag and its management, and was able to repeat information back and ask follow up questions. The patient was able to focus her attention on me throughout my visit, without becoming distracted. Education level. The patient graduated high school, but did not continue to college. She was a stay at home mother, and did not have an interest in returning to school. Creative/artistic abilities and hobbies. The patient is active in her church, and is a United Methodist. She occasionally volunteers for various activities related to her church, such as soup kitchens and food drives. In her spare time, she enjoys crocheting and writing poetry. She has created various items and has sold them at craft fairs. She also likes spending time with her family and keeping up with them on the telephone. She does not watch that much television, but does enjoy reading the newspaper. She is uncomfortable with computers, and prefers to pay bills by paper.
  6. 6. SELF CONCEPT EXAMINATION OF A PATIENT WITH APR 6 Understanding of illness. The patient and her family did thorough research on adenocarcinoma and decided that an APR was her best option. She reviewed other choices with her doctor, but determined this method was the best to enable return to regular activities most quickly. The patient’s daughter had printed out articles about the cancer and treatment methods from the internet, and the patient reviewed the information for several days before coming to a decision. The patient asks questions when she does not understand something, allowing her to understand her illness better. She understood what a colostomy bag was, and the general methods to maintain it. Physical Self Effects of illness on appearance, function, and control. Since the patient had her adenocarcinoma treated, she now has a colostomy bag. While the bag has enabled her to get rid of her cancer, it will impact her activities of daily living. The quality of life of those with permanent colostomies has been found to be poor in approximately half of those studied, and nearly 80% of patients report negative feelings, such as depression. Colostomy patients are also concerned about physical activities that may place them in an embarrassing situation, such as the bag being seen, leaking, or rupturing (Fortes, Monteiro, & Kimura, 2012). While the patient was not shy about the colostomy bag in the hospital (encouraging nursing students to look at it), this may change once she is discharged from the hospital. The patient felt more in control of her body after the surgery, as she was able to make a choice and stop the cancer from spreading further. The patient understands that colostomy care will need to be part of her daily routine, but was willing to make the sacrifice to return to her regular life. Threats to sexual identity. The patient’s significant other was supportive of her desire to have a colostomy. However, the patient’s body image may suffer, and she may not have a
  7. 7. SELF CONCEPT EXAMINATION OF A PATIENT WITH APR 7 desire to be sexually active. The patient may also be afraid to have sexual relations with the bag attached, for fear of damaging it. Additionally, the patient’s rectal sutures are not well approximated, and the open wound extends to near her vagina. The patient will want to refrain from sexual activity until it is healed. The wound was very deep (approximately 8 centimeters), and may take a significant amount of time to heal. The patient should be cautioned against sexual relations until it is better approximated, and the area should be avoided from contact. The patient stated that her sexual desire was not as high as it had been in the past, so there was not a great deal of concern. Review of Systems. Please refer to the Appendix. Moral/Ethical Self Belief system. As mentioned earlier, the patient is active in her United Methodist Church. She believes in giving back to the community and volunteers. The patient believes that family is very important and stated that “she would do anything” for them. The patient also is very independent and does not like to be obtrusive or a burden on anyone. The patient values hard work, but believes that people can come onto hard times. The patient stated that she does not like President Obama, indicating that she is a republican. Cultural influences. The patient is a white female who grew up in the greater Binghamton area. Her parents were also from the area, but her grandparents were from Italy. Prior to her surgery, she enjoyed Italian food, such as pasta and meatballs. The patient did not have any particular healthcare requirements, and wanted to be a full code. The patient was looking forward to celebrating the holidays, and has enjoyed hosting family meals in the past. Emotional Self
  8. 8. SELF CONCEPT EXAMINATION OF A PATIENT WITH APR 8 Expressiveness. While the patient insisted she did not want to be a burden on anyone, when pressed, she would state her needs. The patient was open to answering questions presented to her, and was open in her feelings. The patient initially had some minor pain in her legs, which, throughout the shift, progressed up and down her legs, and into her abdomen. When the pain spread, the patient indicated the extreme discomfort she was in, and stated that she “couldn’t go on like this”. Prior to the spreading of the pain, the patient expressed discomfort in the one location, but said there was none elsewhere. Needs and drives. The patient was motivated to return to her previous state of health by her family and her desire to return to her normal way of life. She was very anxious to return to her church, and was anxious to be back in her house. The patient wanted to be well in order to spend more time with her family, and to be with them over the holidays. Although she was very pleasant, she expressed her desire to get out of the hospital quickly and to return to her home. Mood and affect. Initially, the patient was in a very easygoing, pleasant mood. However, as her pain spread throughout her legs and abdomen, she became increasingly irritable and expressed a desire to die. The patient did not want to become a burden on her family or on the hospital staff, and would rather “not go on like this”. The patient had a very broad affect and was very expressive with her feelings. It was easy to infer the patient’s mood without verbal cues, as she was very expressive. The patient was much more concerned with her pain than her colostomy bag, as that did not bother her much. The patient was excited about removing the cancer. Support systems. As mentioned earlier, the patient has a strong support system in her children. Her eldest daughter lives nearby and frequently came to the hospital to visit her mother. When in extreme pain and wanting to die, the patient wanted the nurse to “tell her
  9. 9. SELF CONCEPT EXAMINATION OF A PATIENT WITH APR 9 family she loved them”. The patient also had insurance through Medicare, and said that she was very secure financially. She stated that her husband had done a very good job saving money for retirement, and that finances were not a concern for her. The patient also has a strong support system through her church. Psychological status. The patient has a history of depression, which she states is well managed. However, the patient’s reaction to the pain indicates that improvements still need to be made psychologically, and should return to her psychologist. The patient stated that she writes poetry when stressed, and had a notebook on her table in the hospital. She also said she talked with others about her stressors, specifically her daughter. Self-Concept Nursing Diagnosis Major Diagnosis Situational low self-esteem related to patient stating she is a “burden”, that she “wanted to die”, that she “can’t go on like this”, not being able to take care of herself, secondary to pain and recent surgery. Explanation Situational low self-esteem was given as the diagnosis due to the patient expressing a desire to die. Prior to the onset of pain, the patient was in good spirits, stating she wanted to be a full code and resuscitated if there was an emergency. Once the pain was affecting her, the patient stated that she wanted the doctor to just give her something to let her die. This is in line with the definition of situational low self-esteem, in which an individual who previously had positive self-esteem experiences negative feelings about self in response to an event (Carpenito, 2008). The extremes in the patients mood indicates that this was due to the pain occurrence, and was not present prior to the discomfort. The patient indicated she felt guilty having everyone fuss
  10. 10. SELF CONCEPT EXAMINATION OF A PATIENT WITH APR 10 over her, and did not want to bother everyone. The patient was still not open to insertion of inserting a nasogastric tube, even with this pain, stating that it “would not make a difference”. Effects of Situational Low Self-Esteem on Appearance, Function, and Control When the patient was experiencing low self-esteem, she no longer felt in control of her life and felt as though there was no point in going on. The patient stated that she could not “go on like this”, and did not want to try anything to improve her situation. The patient was encouraged to use her Fentanyl patient controlled analgesia (PCA), but because of her distress, it was not having an impact. The patient could not do any tasks beyond focus on the pain, and was frozen in bed, unable to talk about anything else. With the situational low self-esteem, the patient is uninterested in the care of her colostomy bag, and would not be able to care for it on her own. Life Impact Situational low self-esteem has an obvious negative effect on the patient’s life. The patient does not want her life to continue, and wanted everything to end. The patient did not want to try anything to improve her situation, and believed it would be easier to end everything. The ultimate negative impact on an individual’s life is to end it, which is exactly what the client was proposing. Specific Clinical Example While a colostomy is frequently a source of depression in itself, the patient was not as concerned about the physical appearance as much as the pain experienced in the legs and abdomen. The pain may have been as a result of the dehisced rectal wound, and the nerves impacted that may be located nearby. “Pain can affect individuals physically, emotionally, psychologically, and socially” (Roden & Sturman, 2009). The severe pain experienced by the
  11. 11. SELF CONCEPT EXAMINATION OF A PATIENT WITH APR 11 patient, followed by the desire to end her life, demonstrates how pain can have an emotion and psychological impact. The patient may have also had more a psychological effect from the colostomy than verbalized, which may have also led to the situational low self-esteem. The psychological impact is sometimes greater from colostomies than the physical impact (Youngberg, 2010). Plan of Care Intervention and Implementation One The first nursing intervention is to develop a trusting working relationship with the patient by the end of the shift. Trust is regarded as the foundation of a therapeutic relationship, and is essential to the nurse-patient relationship. A trusting relationship with the nurse and patient is important because it helps to shape their illness experience, and fosters satisfaction from patients, helping to promote patient competence (Dinc & Gastmans, 2013). A trusting relationship was formed with the patient through listening to what the patient was saying, and asking relevant questions. Additionally, the patient developed trust in this student nurse through just sitting with her, holding hands. Intervention and Implementation Two The second nursing intervention is to encourage creative problem solving through writing exercises throughout the shift, when the patient is distressed. Creative activities, such as art and writing, help individuals overcome self-imposed limits, and encourages patients to have a stronger sense of empowerment, self-esteem, and mastery over their lives (Savikko, Routasalo, Tilvis, & Pitkal, 2010). This intervention can be implemented for this patient by encouraging the use of poetry to express feelings and to work through times of stress. Intervention and Implementation Three
  12. 12. SELF CONCEPT EXAMINATION OF A PATIENT WITH APR 12 The third nursing intervention is to provide only information that the patient wants and needs, as their ability to assimilate information is decreased throughout the shift. Perceived information overload significantly increases rates of self-reported greater stress, poorer health, and less time devoted to contemplative activities (Misra & Stokols, 2012). Providing information that the client asks about can be implemented through encouraging the patient to ask questions, as she has in the past, and answering with succinct, clear information. If there is anything additional the patient does not ask about, information should be provided to her daughter, her health care proxy, as well as written material the patient can refer to at her leisure. Intervention and Implementation Four The fourth intervention is to encourage the patient to set two realistic goals by the end of the shift. Setting realistic goals help a patient to feel in control of a situation, and help to build self-esteem. Guiding the patient through the situation, separating it into smaller pieces, can help an individual to cope (Krouse et al., 2009). This intervention could be accomplished through discussion with the patient in the outcomes they would like to see, then working together to figure out what goals are achievable, both short and long term. The nurse could help the patient to work towards them. Intervention and Implementation Five The final intervention that should be used is to point out signs of positive progress or change throughout the shift. Individuals that are facing low self-esteem may not be able to identify movement towards goals, and need nurses to help point them out. Through providing frequent feedback, the patient is less likely to display depressive symptoms (Newnham, Hooke, & Page, 2010). The nurse can implement this through assessing the patient’s pain, and working with other healthcare providers to assess the patient’s level of health. The nurse can provide
  13. 13. SELF CONCEPT EXAMINATION OF A PATIENT WITH APR 13 positive signs of progress, such as reduced abdominal distention or edema. This can help to provide the patient with small victories that can help improve the patient’s low self-esteem. Conclusion Working with a patient with situational low self-esteem was difficult initially, but has helped this author to grow professionally. It was upsetting to hear a patient’s self-concept change drastically throughout a shift, and to hear someone with many loved ones and a good support system want to end their life. In working with a patient with a drastic shift of feelings like this, it is important to be a support system for the patient, and advocate for them and their life. It is critical to listen to the patient’s needs and wants, and help them in any ways needed. The nurses’ role also includes expressing the patient’s feelings to the doctor, and making sure that all healthcare providers are on the same page. The impact of this patient on this author’s self-concept makes the author aware that even though an individual may typically have a positive outlook, it can quickly change. Individuals cannot predict how they will react in a situation, and cannot be judgmental of others. A positive self-concept is important for the nurse and other healthcare providers to keep in mind, as it impacts the patient not only psychologically, but also physically. The nurse needs to continually advocate for the patient, and to assist the patient with their return to wellbeing. Self-concept is an important component of full person care of individuals in the hospital, and nurses should be mindful of this whenever providing care.
  14. 14. SELF CONCEPT EXAMINATION OF A PATIENT WITH APR 14 References Carpenito, L. (2008). Handbook of nursing diagnosis (12th ed.). Philadelphia, PA.: Lippincott Williams & Wilkins. Dinc, L., & Gastmans, C. (2013). Trust in nurse-patient relationships: A literature review. Nursing Ethics, 20(5), 501-516. Fortes, R., Monteiro, T., & Kimura, C. (2012). Quality of life from oncological patients with definitive and temporary colostomy. Journal of Coloproctology (Rio De Janeiro), 32(3), 253-259. Krouse, R., Grant, M., Rawl, S., Mohler, M., Baldwin, C., Coons, S., ... Ko, C. (2009). Coping and acceptance: The greatest challenge for veterans with intestinal stomas. Journal of Psychosomatic Research, 66(3), 227-233. Misra, S., & Stokols, D. (2012). Psychological and Health Outcomes of Perceived Information Overload. Environment and Behavior, 44(6), 737-759. Newnham, E., Hooke, G., & Page, A. (2010). Progress monitoring and feedback in psychiatric care reduces depressive symptoms. Journal of Affective Disorders, 127(1), 139-146. Popek, S., Grant, M., Gemmill, R., Wendel, C., Mohler, M., Rawl, S., ... Krouse, R. (2010). Overcoming challenges: Life with an ostomy. The American Journal of Surgery, 200(5), 640-645. Roden, A., & Sturman, E. (2009). Assessment and management of patients with wound-related pain. Nursing Standard, 23(45), 53-62. Savikko, N., Routasalo, P., Tilvis, R., & Pitkäl, K. (2010). Psychosocial group rehabilitation for
  15. 15. SELF CONCEPT EXAMINATION OF A PATIENT WITH APR 15 lonely older people: favourable processes and mediating factors of the intervention leading to alleviated loneliness. International Journal Of Older People Nursing, 5(1), 16- 24. Youngberg, D. (2010). Individuals with a permanent ostomy: quality of life, preoperative stoma site marking by an ostomy nurse, six peristomal complications, and out-out pocket financial costs for ostomy management. Ph.D. Columbia University.
  16. 16. SELF CONCEPT EXAMINATION OF A PATIENT WITH APR 16 Appendix Cephalocaudal Note 98.2° F, 88, 20, 170/78, 99% on 2L/min O2, 8/10 pain radiating/aching in back and ribs. Encouraged pt to use Fentanyl button drip. Neuro: Patient is alert and orientated to name, time, place, but can get confused occasionally; reoriented easily, clear verbal response, appropriate conversation, grips are strong equally, pupils are equally round and reach to light and accommodate, 2-3 mm. Integumentary: Skin is pink and dry in most of the body. PICC line is inserted in her left upper arm. Nitroglycerin patch is above the PICC line. EKG 5 lead is in place for constant monitoring. Pt has one small dressing on right abdomen at umbilicus line, it was clean dry and intact. Pt had larger dressing central, on umbilicus, clean dry and intact. Pt has colostomy bag on left side of abdomen; stoma is raised above skin level and red. Rectum has dehisced and is not well approximated, reaching from normal anal area to vagina. Large amounts of serosanguinous drainage with small clots. Cleaned wound with sterile water, advised not to pack by wound nurse. Wound nurse also stated that opening was deeper than 6 cm. Cardiovascular: Apical pulse was 92. Rate was irregularly irregular. S1 and S2 present. Radial pulses present equally bilaterally, +2. Pitting edema noted in both feet and ankles, +1. Peripheral pulses present, +2. Elevated pts legs while lying in bed with pillow. Capillary refill is <3 seconds. Respiratory: dyspnea with exertion. Diminished lung sounds in all lobes of both lungs. Encouraged use of incentives spirometer. Chest excursion was symmetrical. Encouraged pt to cough and deep breathe. GI: Abdomen was distended, but not sensitive to touch. Normal bowel sounds in RUQ and RLQ, but hypoactive in LUQ and LLQ. Pt had colostomy bag in place on left side, drainage was a thick brown liquid. GU: Pt had Foley catheter secured to thigh, and voided 1150 cc’s during shift. Bladder was not distended. Pt is NPO and only had a small
  17. 17. SELF CONCEPT EXAMINATION OF A PATIENT WITH APR 17 amount of water with her PO medications, as ordered by doctor. Pt receiving 100cc/hr D5W IV. Musculoskeletal: Pt had good range of motion and strength in upper extremities, as evidenced by ability to roll herself over by grabbing the railing. Pt has generalized weakness and discomfort in her lower extremities. Pt stated that her “legs were just so uncomfortable”. Encouraged use of Fentanyl drip button, and encouraged pt to flex toes and legs. Elevated feet with pillow and applied heating pad after dr approved and put in orders, as pain was lessened with a warm wash cloth during the bed bath. Called doctor about new leg pain after completion of bed bath. Pt can wiggle toes, can flex feet, but does not have good sensation and feeling in feet. Turned and positioned patient approximately every hour throughout shift. Psychosocial: Pt is a very nice woman who enjoys conversation. Pt given bed bath, which she really enjoyed. Pt is concerned about being a “burden”. Pt was in good spirits at beginning of shift, then as pain increased throughout the shift, stated that she “wanted to die”, that she “can’t go on like this”, and to “tell her family she loves them”. Alerted primary nurse, alerted doctor about this increased pain- Dr. ordered Doppler of lower extremities to access for vein blockages.

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