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Faulkner State Community College; Division of Nursing

NUR 201
Clinical Paperwork Data Sheet

Student Name___________________________________ Clinical Week_______________________________

Date _____________ Client Initials__________ Age _______________ Admission Date ______________

Instructor_______________________________________ Clinical Area ________________________________

Medical Diagnosis and Pathophysiology: (Be sure to list signs and symptoms). Please indicate your
source of information.

Patient had a carcinoma of the hepatic flexure of the colon. Her physician recommended a right colectomy.
A colectomy is the surgical removal of all or part of the colon, the first part of the large intestine. Doctors
perform a colectomy to remove large Stage 1 colon cancer lesions or to cure colon cancer that: has spread
beyond the mucous membrane, has infiltrated or spread beyond the intestinal wall, or is likely to recur. The
surgery may perform the procedure to improve patients quality of life by relieving pain and preventing
bleeding and other symptoms that occur when colon cancer invades organs near the bowel, and also, when
non-surgical means are unsuccessful, to treat diverticulitis, ulcerative colitis, and benign colon polyps. A
colectomy is the preferred therapy for colon cancers that can be cured. The procedure involves removing the
cancerous part of the colon, a margin of normal bowel, any tissue or lymph nodes affected by the disease,
and reconnecting the healthy segments of the colon (anastomosis). If infection or obstruction make it
impossible to reconnect the colon, the surgeon creates an opening (stoma) in the abdominal wall (colostomy)
through which feces passes from the body into an ostomy pouch. A colostomy may be temporary, with the
ends of the intestines being reconnected at a later time, or permanent in patients whose cancer cannot be
completely removed. My patient had a tumor removed from a portion of the ascending colon from the small
intestine to the transverse colon. This procedure involves removing the cecum, descending colon, the
hepatic flexure where the ascending colon where it joins the transverse colon, and the first one-third of the
transverse colon. This procedure is considered radical because they involve removing nerves, blood vessels,
and lymph nodes near the tumor. A patient who has had an open colectomy will spend at least a week in
the hospital and experience significant postoperative pain. Side effects of colectomy surgery include:
bladder complications, diarrhea, bowel irregularities, urinary urgency, and sexual dysfunction.

http://www.healthline.com/galecontent/colectomy

List and prioritize any secondary diagnosis that has been identified for your client (Based on your patient's
problems).

1. Iron Deficiency Anemia


2. Coronary Artery Disease
3. History of Congestive Heart Failure
4. Hypertension
5. Insulin-dependent Diabetes Mellitus
6. Dyslipidema
7. Prior cholecystectomy