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Running Head: SELF CONCEPT EXAMINATION OF A PATIENT WITH APR 1
Self-Concept Examination of a Patient with Abdominoperieal Resection
Binghamton University, State University of New York
SELF CONCEPT EXAMINATION OF A PATIENT WITH APR 2
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
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.
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.
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.
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
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
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.
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.
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.
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
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.
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.
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
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
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
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.
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
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.
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
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
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
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
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
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.
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.
SELF CONCEPT EXAMINATION OF A PATIENT WITH APR 14
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),
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),
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
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-
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.
SELF CONCEPT EXAMINATION OF A PATIENT WITH APR 16
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
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.