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CONCEPT MAP WORKSHEET DESCRIBE DISEASE PROCESS AFFECTING PATIENT (INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS) Chronic venous insufficiency  This is flaw of the venous valves that impair venous return from legs to the heart  This causes venous stasis and clotting Deep vein thrombosis  This occurs when blood remains static and fails to return properly and thus blood begins to build and clumps, causing thrombi Chronic Obstructive Pulmonary Disorder  A form of pulmonary disease that causes an obstruction of air, which causes difficulty breathing

DIAGNOSTIC TESTS (REASON FOR TEST AND RESULTS) CBC 

Used to assess for infection

BMP Used to measure electrolyte levels Prealbumin  Used to assess nutritional levels  Was lower than normal Albumin  Used to assess protein levels  Lower than normal

PATIENT INFORMATION

Josephine Morrow 80 Y/O Female White non-Hispanic

ANTICIPATED NURSING INTERVENTIONS Educate about wound care and cleansing of affected site Educate about venous stasis Assist with range of motion Consult therapy regarding the limited mobility problems Application of compression stocking Wound care on pressure ulcer site

ANTICIPATED PHYSICAL FINDINGS I anticipate finding no sign of infection or pain in the pressure ulcer

vSim ISBAR ACTIVITY INTRODUCTION 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

RECOMMENDATION Any orders or recommendations you may have for this patient

STUDENT WORKSHEET Student Registered Nurse Hillcrest skilled nursing facility

Josephine Morrow 80-year-old female Chronic venous insufficiency Allergic to penicillin

Primary Dx- Chronic venous insufficiency Admitted on 04/09/2020 Orders- Regular diet with protein supplements twice per day, out of bed ad libitium, keep bed elevated, CBC, BMP, Total protein, albumin, prealbumin monthly, change of dressing every 3 days with normal saline irrigation, anti-embolism stocking to left leg, and elastic bandage on right leg Medications: multivitamin 1 tablet PO per day at 0900, Zinc supplement 1 tablet PO per day at 0900, Aspirin 81mg PO per day at 0900, Albuterol inhaler 360 mcg PRN for wheezing, Acetaminophen 650 mg PO every 6 hours PRN for pain Head= all findings normal/ neuro assessment normal/ pupils dilated 4 mm Chest= all findings normal/ normal heart sounds/ normal lung sounds Abdomen= all findings normal/ normal bowel sounds Arms= all findings normal Legs= RLE has dressing site on pressure wound which was clean, intact, and dry. Edema with hyperpigmentation on both lower extremities. Wound on right medial malleolus was pink/ red, no sign of infection or necrosis Skin= all findings normal, normal turgor, normal hydration Mucosa= Dry Vitals= BP 120/80, Temp 97 F, Pulse 95 regular, RR 19, SpO2 94% on room air I would recommend continuous assessment of vitals to monitor for signs of infection Further monitoring and assessment of wound site dressing Assisting with rang of motion and elevation of legs

PHARM-4-FUN PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE

MEDICATION: Albuterol

CLASSIFICATION: Bronchodilator, Adrenergic

PROTOTYPE: Accuneb

SAFE DOSE OR DOSE RANGE, SAFE ROUTE

PO, inhaling PO= 2-4 mg x3 or x4 a day Inhaling= 2 inhalations every 6 hours PURPOSE FOR TAKING THIS MEDICATION

Treatment of COPD

PATIENT EDUCATION WHILE TAKING THIS MEDICATION

Take only as directed Do not double dose Notify HCP if you have shortness of breath, dizziness, palpitations, or chest pain Prime canister with 4 sprays prior to using and discard after 200 sprays Report to HCP if there is no sign of improvement after several days on regimen

PHARM-4-FUN PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE

MEDICATION: Aspirin

CLASSIFICATION: Anti-pyretic, Salicylates

PROTOTYPE: Ecotrin

SAFE DOSE OR DOSE RANGE, SAFE ROUTE

PO, 2.4 g-7.4 g per day PURPOSE FOR TAKING THIS MEDICATION

Reduce inflammation

PATIENT EDUCATION WHILE TAKING THIS MEDICATION

Explain purpose to client or caregiver Take as prescribed Report tinnitus, bleeding of gums, black tarry stools, or fever lasting more than 3 days to HCP Take with a full glass of water

PHARM-4-FUN PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE

MEDICATION: Acetaminophen

CLASSIFICATION: Antipyretic, Non opioid analgesic

PROTOTYPE: Tylenol

SAFE DOSE OR DOSE RANGE, SAFE ROUTE

PO, Rectal, IV 325- 650 mg every 6 hours PURPOSE FOR TAKING THIS MEDICATION

Treatment of mild pain Treatment of fever

PATIENT EDUCATION WHILE TAKING THIS MEDICATION

Take only as indicated, not more or less Avoid alcohol while using due to an increase risk of liver damage Discontinue if rash occurs and notify HCP Label this product correctly to avoid mix-up

PHARM-4-FUN PATIENT EDUCATION WORKSHEET NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE

MEDICATION: Zinc Supplement

CLASSIFICATION: Micronutrient/ dietary supplement

PROTOTYPE: Zinc Sulfate

SAFE DOSE OR DOSE RANGE, SAFE ROUTE

PO 15 mg- 40 mg every day PURPOSE FOR TAKING THIS MEDICATION

Improve cardiac health and blood flow PATIENT EDUCATION WHILE TAKING THIS MEDICATION

Take only the amount prescribed by HCP Advise patient to report any symptoms of bleeding, bruising, dizziness, itching, rash, fever, swelling, or difficulty breathing

Clinical Worksheet Date: 04/11/2020 Initials: JM

Josephine Morrow Assigned vSim:

Student Name:

Diagnosis: Chronic Venous Insufficiency

Age: 80

HCP: Dr. Alvin Hernandez

Consults:

Isolation: No

IV Type: N/A Location: N/A

3 days

Code Status: Full Code

Allergies:

Albumin Prealbumin Consults Needed:

Cardiology Wound care

Female

Other Services: Wound care

Fall Risk:

Length of Stay: M/F:

Critical Labs:

Fluid/Rate: Yes

Transfer:

Occupational/ physical therapy N/A

N/A Penicillin

Why is your patient in the hospital (Answer in your own words and include the History of present Illness)?: My patient is in the nursing facility due to a complication of venous insufficiency in her lower extremity, causing the facilitation and formation of a pressure ulcer which she is unable to care for independently. Health History/Comorbidities (that relate to this hospitalization): She has a history of Deep Vein Thrombosis, 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 sign of infection of complication 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 Today?

1.

Elevated temperature (fever)

1. This patient needs to have wound site assessed

2.

Severe pain

2. Repositioning as appropriate

3.

Purulent drainage on wound site

3. Assist with motion exercises to improve venous return 4. Elevate legs to improve circulation

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

5.

Administration of prescribed medications to avoid blood clotting

1.

Continuous assessment of dressing and wound

6.

Receive hydration and proper nutrition as prescribed

2.

Assessment of lower extremities

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

3.

Vital signs 2.

Assessment of wound dressing

3.

Ensure prescribed medications are administered

4.

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 of 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 stocking

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

Josephine Morrow 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 problems 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/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.



 The Scenario Analysis Questions are correlated to the Quality and Safety Education for Nurses (QSEN) competencies: Patient-Centered Care (PCC), Teamwork and Collaboration (T&C), Evidence-Based Practice (EBP), Quality Improvement (QI), Safety (S), and Informatics (I). Find more information at: http://qsen.org/

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

EAD B

Score: vSim 1  A  A  E

EAD B EAD B

Total for category:

10

Interpreting: Prioritizing Data: Making Sense of Data:

 

E E

   

A E E A

 

E E

EAD B EAD B

Total for category: 8 Responding: Calm, Confident Manner: EAD B Clear Communication: EAD B Well-Planned Intervention/Flexibility: EAD B Being Skillful EAD B Total for category: 14 Reflecting: Evaluation/Self-Analysis: EAD B Commitment to Improvement: E A D B Total for category: 8

Score: vSim 2

Score: vSim 2...