Josephine Morrow v SIm PDF

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CONCEPT MAP WORKSHEET DESCRIBE DISEASE PROCESS AFFECTING PATIENT (INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS) 

Venous Stasis Ulcer = malfunctioning venous valves causing pressure in the veins to increase o Pathophysiology:  Venous (or stasis) ulceration is initiated by venous hypertension that develops because of inadequate calf muscle pump action o Risk factors:  Diabetes mellitus  Congestive heart failure  Peripheral vascular disease  DVT  Pregnancy  Obesity

PATIENT INFORMATION DIAGNOSTIC TESTS (REASON FOR TEST AND RESULTS)

Albumin level test Prealbumin test

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Josephine Morrow 80-year-old White female Venous stasis ulcer on her right medial malleolus Admitted on 04/15/2021

ANTICIPATED NURSING INTERVENTIONS  

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Apply anti-embolism/compression stockings Wound care o Apply bandages o Dress wound o Signs and symptoms of infection Monitor vital signs o Temperature, BP, skin integrity, self-care abilities, pain assessment Skin assessment o Skin turgor o Skin color, temperature, humidity, and appearance Patient education o Wound care o Preventing venous injury o Fall risk o Fluid intake Assist with all ambulation needs Ensure adequate nutrition

ANTICIPATED PHYSICAL FINDINGS

I anticipate the patient to have an impaired gait I anticipate the patient to report pain in the affected area

vSim ISBAR ACTIVITY INTRODUCTION

STUDENT WORKSHEET 

Good morning, my name is Jonelle and I am student nurse from Nova Southeastern University rotating on MedSurge unit 0800

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Josephine Morrow 80-year-old white female The patient developed a venous stasis ulcer on her right medial malleolus while still living at home. Patient was moved into a skilled nursing home care facility 3 days ago She has a history of COPD, chronic venous insufficiency, and DVT. The patient is also obese. Admission date: 04/14/2021 Admitting DX: venous stasis ulcer Orders: vital signs (once a week), wound care (change dressing every 3 days, clean and irrigate wound with normal saline), antiembolism stockings, and medications Diet: regular, with nutritional protein supplement twice daily Activity: out of bed ad libitium, keep legs elevated Labs: CBC, BMP, total protein, albumin, and prealbumin monthly Fall risk assessment ADL assessment Patient is AAOx3 to person, time, and place but sometimes forgetful of recent events. Vital signs: BP: 122/80 mmHg (RUE, sitting), RR: 20 bpm (the chest is moving equally), HR: 95 bpm (radial and pedal; pulse is regular), T: 97 F (tympanic), SpO2: 97%, capillary refill: less than 2 seconds Auscultated the lungs: breath sounds are clear and equal bilaterally Auscultated the heart: heart sounds were regular and without murmurs Skin assessment: normal elasticity of the skin, the color is normal, normal skin turgor, and she was not sweating Assessed mucous membranes: membranes were pale pink and had moisture Assessed the patient’s dressing and ulcer: ulcer is shallow, 1 inch in width, and looks mostly pink to red, with no signs of infection Patient teaching: wound care, fall risk, and what to do to increase venous return Monitor: vital signs every 4 hours, change dressing every 3 days; clean and irrigate wound with normal saline Antiembolism stockings Diet: regular, with nutritional protein supplement twice daily Activity: out of bed ad libitium, keep legs elevated Medications Social services consult: to do follow-ups at the skill nursing home care facility

Your name, position (RN), unit you are working on

SITUATION Patient’s name, age, specific reason for visit

 BACKGROUND Patient’s primary diagnosis, date of admission, current orders for patient

ASSESSMENT Current pertinent assessment data using head to toe approach, pertinent diagnostics, vital signs

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     RECOMMENDATION

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Any orders or recommendations you may have for this patient

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PHARM-4-FUN PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE MEDICATION:  Aspirin  Albuterol  Acetaminophen

CLASSIFICATION:  Aspirin: non-opioid analgesic  Albuterol: bronchodilators  Acetaminophen: non-opioid analgesic

PROTOTYPE:  Aspirin: aspirin  Albuterol: albuterol  Acetaminophen: acetaminophen SAFE DOSE OR DOSE RANGE, SAFE ROUTE   

Aspirin: 325-1000 mg every 4 -6hr (not to exceed 4g/day) Albuterol: 2-4 mg 3-4 times daily (not to exceed 32 mg/day) or 4-8 mg of extended-release tablets twice daily Acetaminophen: 325-650 mg every 6hr or 1 g 3-4 times daily or 1300 mg every 8hr (not to exceed 3 g or 2g/24hr in patients with hepatic/renal impairment)

PURPOSE FOR TAKING THIS MEDICATION   

Aspirin: inflammatory disorders, mild to moderate pain, fever, prophylaxis of TIAs and MI Albuterol: treatment or prevention of bronchospasm in asthma or COPD Acetaminophen: treatment of mild pain, fever

PATIENT EDUCATION WHILE TAKING THIS MEDICATION   

Aspirin: caution patient to avoid concurrent use of alcohol to reduce gastric irritations Albuterol: take as directed, take missed dose as soon as remembered, contact HCP immediately if shortness of breath is not relieved by medication Acetaminophen: take medication exactly as directed and not to take more than recommended amount, avoid alcohol, discontinue and notify HCP if rash occurs.

Clinical Worksheet Date: 04/15/2021 Initial: JM

Student Name: Jonelle Wray Diagnosis: venous stasis ulcer on right medial malleolus

Isolation: standard

Assigned vSim: Josephine Morrow IV Type: Other Services: Critical Labs: Location CBC, BMP, total protein, : N/A albumin and prealbumin

Fall

Age: 80

HCP:

Length of

Consults: cardiology, wound care

Consults Needed: Fluid/Rate: Risk:

M/F: F Code Status: Full code

Stay: 2.5 days

high

Allergies:

Transfer

penicillin

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Why is your patient in the hospital (Answer in your own words and include the History of present Illness)?:  Josephine Morrow is an obese, 80-year-old white female who developed a venous stasis ulcer on her right medial malleolus while still living at home. She was moved into a nursing home 3 days ago. Her daughter admitted her due to concerns for her safety with impaired mobility, an unhealthy diet, and inability to adequately care for herself at home. Mrs. Morrow has a past medical history of COPD, chronic venous insufficiency, and DVT. Health History/Comorbities (that relate to this hospitalization):  She has a history of DVT, chronic venous stasis, and COPD

Shift Goals/ Patient Education Needs: 1. Client will be able to express knowledge in venous return 2.

Client will improve knowledge on mobility exercises

3.

Client will be able to ingest an adequate amount of her meals

4.

Client will be able to understand her need to improve BMI

Path to Discharge:  Client will have improved range of motion on affected extremity, demonstrate no signs of infections or complications on the wound site

Path to Death or Injury:  Client will neglect wound site and fail to improve venous return. This will likely cause further clotting or DVT

Alerts: What are you on alert for with this patient? (Signs & Symptoms)

Management of Care: What needs to be done for this Patient

1.

Elevated temperature (fever)

Today?

2.

Severe pain

1.

This patient needs to have wound site assessed

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Purulent drainage

2.

Repositioning as appropriate

3.

Assist with motion exercises to improve venous return

4.

Elevate legs to improve circulation

5.

Administration of prescribed medications to avoid blood clotting

6.

Receive hydration and proper nutrition as prescribed

What Assessments will focus on for this patient? (How will I identify the above signs &Symptoms?) 1.

Continuous assessment of dressing and wound

2.

Assessment of lower extremities

3.

Vital signs

Priorities for Managing the Patient’s Care Today 1. Continuous assessment of edema and circulation 2.

Assessment of wound healing

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Ensure prescribed medications are administered

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Range of motion exercises

List Complications that may occur related to dx, procedure, comorbidities: 1.

Infection on wound site

2.

Falling due to mobility limitations

3.

Cardiac/clotting complications related to impaired venous return

What nursing or medical interventions may prevent the above Alert or complications?

1.

Continuous changing or dressing and assessment of wound site

2.

Educating client on exercises to improve venous return

3.

Encourage client to reposition and move extremities

4.

Apply compression stockings

What aspects of the patient care can be Delegated and who can do it?  The range of motion and certain skin and hygiene care for this client can be delegated to a UAP or PCA

Clinical Worksheet

Reflection Questions Paste your reflection questions in the box below

Guided Reflection Questions Opening Questions How did the simulated experience of Josephine Morrow’s case make you feel? During this simulation, I was able to apply the use of the Braden scale and wound care assessment. For clients like Josephine, it is important to understand their risk for wounds and how to prevent complications from such wounds. This is especially true of Josephine as she has many underlying medical conditions including venous stasis in the legs, DVT, and obesity among other things Talk about what went well in the scenario. In this simulation I was able to assess the wound and intervene as requested by irrigating and changing the dressing. Doing so, allows the nurse to proactively prevent complications and worsening of the wound.

Reflecting on Josephine Morrow’s case, were there any actions you would do differently if you were to repeat this scenario? If so, how would your patient care change? For the most part, I was satisfied with the care provided to Josephine. However, I would look for more mechanisms of assessing her risk for falls as this would be crucial to understanding how much assistance is required and if therapy may be needed for her mobility problems. Scenario Analysis Questions S : What priority problem(s) did you identify for Josephine Morrow? o The main problem is that I was able to identify for Josephine was her issues with venous return and her problems with mobility. In terms of her problems with venous return, Josephine risks cardiac and perfusion complications, as well as fluid accumulation. In regard to impaired mobility, this poses a concern as her inability to properly move independently may cause her to remain in the same position in bed for an extended period of time. This may cause pressure ulcers. PCC: Identify in Josephine Morrow’s health history any factors that predisposed her to having chronic venous insufficiency. o In Josephine’s case, we may understand that her history of limited mobility, smoking for several years, and obesity may have led to her current venous insufficiency PCC o In Josephine’s case, we may understand that her history of limited mobility, smoking for several years, and obesity may have led to her current venous insufficiency. PCC: PCC/S Discuss the assessment findings and diagnostic studies that correlate with chronic venous insufficiency and venous stasis ulceration. Provide the reasons behind PCC/S Discuss the assessment findings and diagnostic studies that correlate with chronic venous insufficiency and venous stasis ulceration. Provide the reasons behind

PCC/S Discuss the assessment findings and diagnostic studies that correlate with chronic venous insufficiency and venous stasis ulceration. Provide the reasons behind

PCC/S: Discuss the assessment findings and diagnostic studies that correlate with chronic venous insufficiency and venous stasis ulceration. Provide the reasons behind these findings. o During the assessment, I noted that Josephine has edema and hyperpigmentation of the lower extremities. This is indicative that there is an inadequate movement of blood and toxins out of the area and thus causing a buildup. S: What is the rationale for the daily dose of ASA? o The Aspirin dose is likely indicated to function as a blood thinner and thus alleviate some of the clotting and stasis of the blood in the extremities. EBP/I: What is the rationale for compression therapy? o This form of therapy supports the veins and assists with flow of blood in those who may be immobile. EBP/I: What is the rationale for performing a Braden scale assessment on Josephine Morrow? o Due to her history of venous stasis and immobility, it is important to assess the risk for the formation of pressure ulcers and skin wounds to determine the necessary interventions to prevent them. T&C: What other interprofessional team members should be involved in Josephine Morrow’s care? o In Josephine’s case, consulting occupational and physical therapy experts would allow the rest of the interprofessional team to better understand her mobility better. Therapists of the aforementioned specialty would also prepare Josephine to better perform her ADL’s on her own and mobilize more efficiently.

Concluding Questions Describe how you would apply the knowledge and skills that you acquired in Josephine Morrow’s case to an actual patient care situation.  Given the knowledge I have obtained from this simulation, I would learn to apply the Braden scale and an assessment of any extremity with edema in clients with a history of venous stasis and DVT as those types of client face the risk of pressure ulcer formation, especially if immobile.

Clinical Judgement Components Scoring: Exemplary = 4 point Accomplished = 3 points Developing = 2 points Beginning = 1 point Noticing:

Score: vSim 1

Focused Observation: Recognizing Deviations from Expected Patterns: Information Seeking:

EADB EAD B EAD B

Total for category: Interpreting: Prioritizing Data: Making Sense of Data:

EADB EAD B

Total for category: Responding: Calm, Confident Manner: EAD B Clear Communication: EAD B Well-Planned Intervention/Flexibility: EAD B Being Skillful EADB Total for category: Reflecting: Evaluation/Self-Analysis: EAD B Commitment to Improvement: E A D B

Total for category:

Score: vSim 2

Score: vSim 2...