Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Reason for Visit:
Post-operative follow-up for ostomy surgery (colostomy, ileostomy,
urostomy)
Evaluation of ostomy site (stoma appearance, drainage)
Management of ostomy appliance leaks or skin complications
Education and support for ostomy care
History of Present Illness:
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Date of ostomy surgery and type of ostomy created (colostomy,
ileostomy, urostomy).
Underlying reason for ostomy surgery (e.g., inflammatory bowel disease,
colon cancer, bladder cancer).
Post-operative course: Any complications (e.g., bleeding, infection),
pain management, return of bowel function (if applicable).
Current ostomy management routine (frequency of appliance changes,
irrigation schedule, if applicable).
Any concerns about the stoma, drainage, or skin health around the stoma.
Physical Examination:
General examination: Assess vital signs and overall health status.
Abdominal examination: Evaluate the ostomy site for size, color,
protrusion, and any signs of infection (redness, swelling, drainage).
Skin assessment: Inspect the peristomal skin (skin surrounding the stoma)
for irritation, breakdown, or leaks.
Stoma Appearance:
Document the size, shape, and color of the stoma (typically pink
or red).
Describe the stoma’s position in relation to anatomical landmarks.
Note the presence of any granulation tissue (red, bumpy tissue)
around the stoma.
Stoma Drainage:
Characterize the output from the stoma (stool consistency, color,
volume).
Assess the frequency and amount of drainage.
If applicable, inquire about irrigation practices and effluent
characteristics.
Assessment:
Post-operative status: Evaluate the patient’s recovery following
ostomy surgery, including pain management, wound healing, and return of
bowel function (if applicable).
Stoma health: Assess the stoma’s appearance, drainage pattern, and
surrounding skin health.
Potential complications: Identify any signs of infection, leakage,
or skin breakdown around the stoma.
Plan:
Management of stoma: Provide recommendations for ongoing ostomy
care, including:
Frequency of appliance changes
Selection of appropriate ostomy supplies
Skin care routine
Irrigation technique (if applicable)
Diet and hydration recommendations
Management of complications: Address any identified issues
such as
Leakage: Adjust appliance type or technique to achieve a better
seal.
Skin breakdown: Implement proper skin care and consider protective
barriers.
Infection: Monitor for signs and symptoms and initiate antibiotics
if necessary.
Education and support: Provide ongoing education about ostomy
care and management. Address any concerns or anxieties the patient
may have about living with an ostomy.
Follow-up:
Schedule follow-up appointments to monitor stoma health,
manage any
ongoing issues, and provide ongoing support and education.
Additional Notes:
Document the specific ostomy appliance system the patient is using.
Consider including a diagram of the stoma and surrounding skin
for
reference in future encounters.
Encourage open communication and address any concerns the patient
may have about their ostomy or recovery process.