Sherman “Red” Yoder – Part A
Part 1: Plan of Care Concept Map (adapted from vSim template)
Simulation Patient Overview
• Client summary:
... [Show More] presentation, medical history and background, physical assessment findings, medications, diagnostics
• brief summary of pathophysiology and rationale for clinical manifestations
Red is an 80-year-old male who lives alone, 20 miles from the nearest city. The patient has previously been diagnosed with type 2 diabetes (six months ago) and has recently began taking insulin. The nurse came to Reds’ house to assess and evaluate a wound that was caused by wearing shoes that were too tight. The toe was injured about three weeks ago. It is plausible that Red has developed peripheral neuropathy which is typically caused by diabetes. This causes loss of sensation and numbness to the extremities. In Reds’ case, he might have not felt in the injury on his toe and that is why he did not address it immediately. Red also lives alone so there was no was else in the household to bring his attention to the injured toe.
The Assessment
Anticipated Physical Assessment Findings
• additional focused assessment
• relevant cues (S&S)
• cues indicating need for immediate
concern and rationale Anticipated Diagnostic Tests
• relevant cues (abnormal findings)
• additional tests to consider
Peripheral neuropathy – numbness and loss of Abnormal Values
sensation in the feet Part A: No diagnostic tests
Right toe wound
Additional tests to consider – monitoring of blood
glucose x 4 times a day.
Plan
Anticipated Care Priorities Anticipated Nursing Interventions
Monitor blood glucose levels and adhere to medication.
Wound dressing.
Educate patient on: the importance of monitoring his blood glucose after meals, and adhering to the sliding scale dosage, daily inspection of feet with help of mirrors and family, how to apply wound dressings on his right toe to prevent further complications, information on diet and nutrition.
Feet inspection.
Great importance must be placed on footcare.
Diet and nutrition information. Sleep education.
Assess independence in ADLs.
ISBAR Worksheet (adapted from vSim)
ISBAR Student Notes
Introduction
• Your name, position (Nursing student), unit you are working on
• What is the purpose of this communication? Hello, my name is Ronit Patel. I am student RN with a home health agency. I will be giving you a report on Red Yoder.
Situation
• What is happening at the moment?
• Patient’s name, age, specific reason for visit/admission Red Yoder is an 80-year-old male that is being seen at home for a right toe wound.
Background
• What are the issues that led up to this situation?
• Patient’s primary diagnosis, date of admission, current orders The patient was diagnosed with type two diabetes six months ago. He has recently began taking insulin. Red suffered an injury to his toe three weeks ago. Up till now, he has been wearing tight shoes which progressively made his injury worse. No current orders.
Assessment
• What do you believe the problem is?
• Current pertinent assessment data using head to toe or focused assessment approach,
• Pertinent diagnostics
• Vital signs The issue with the patient is the lack of knowledge regarding the disease, as well as non- adherence to treatment.
Recommendation
• What should be done to correct this situation?
• Any orders or recommendations you have for this patient I would recommend that the patient be connected with a diabetes education, a dietician, and be a participant for a sleep study. The patient also might need assistance with ADLs so an OT/PT assessment might also benefit the patient.
Guided Reflection Questions
1. How did the simulated experience of Red Yoder’s case make you feel?
I felt comfortable in this simulation because it felt like a very real scenario that could take place in the community. I have also had patients with peripheral neuropathy in the past so I was able to draw from that experience to help me in this simulation.
2. What nursing actions did you feel were appropriate within this scenario?
The nursing actions that I felt were appropriate in this scenario was the evaluation of Red’s knowledge about diabetes, and how much he adheres to checking his blood sugar and taking medications. Another important nursing action was providing the patient with education regarding diabetes, wound and foot care, medication, sleep, etc.
3. EBP What are the priority nursing actions for Red Yoder based on physical findings and social and family interaction?
Based on physical findings and social and family interaction, the priority nursing actions for Red Yoder would be patient education. I believe that the foundation of the problems that Red experienced are based on not having enough information about the disease process, and being unable/not willing to take care of himself. If we prioritize teaching and educating the patient and provide guidance on how can he better take care of himself and his disease, then he is more likely to succeed and less likely to be re-admitted for diabetes related issues.
4. EBP What potential problems can you identify for Red Yoder?
The potential problems that I can identify with Red Yoder relate to his non-adherence to self-care and medications. If Red continues to neglect his health then potential problems could be worsening of his wound, and maybe even an infection. The patient also has problems with sleep so without the proper rest, the patient’s body can breakdown, and be prone to other infections.
5. S/QI For the following Safety/Quality Improvement measures, what nursing actions should be taken during Red Yoder’s case?
Safety/Quality Improvement Measures Nursing Actions
Assessment of patient’s ability to self-administer his insulin Ask the patient if he knows how to self- administer insulin. If he states yes, ask him to
demonstrate how he would self-administer insulin.
Assessment of patient’s ability to monitor blood glucose Ask the patient if he knows how check his blood sugar. If he states yes, ask him to demonstrate how he checks his blood sugar as well as how
often and at what times.
Safety issues related to needle disposal Provide patient with a sharps container and instruct the patient on how to properly dispose of
his used needles.
6. PCC/I What appropriate assessments were made to help you decide what interventions Red Yoder needed?
The assessments that helped in determining the appropriate interventions was evaluating Reds’ ability to take care of himself as well the family’s input on Red’s habits and behaviours.
Assessment of the wound also helped in determining the type of care Red will need in order to prevent infection and promote healing.
7. T&C Why is it important to include Red Yoder’s family as members of his health care team?
The inclusion of Red’s family is vital to this simulation because they are able to provide more information on Red’s eating and drinking habits. The family is also extremely supportive of Red and they want to see him get better, therefore, we should involve them in his care because they will provide him with emotional support and encouragement.
8. Reflecting on Red Yoder’s case, were there any actions you would do differently? If so, what were these actions, and why would you do them differently?
If I had a change to repeat this simulation, I would focus more on speaking to the family members as well as they might have been able to provide additional information.
9. How would you apply the knowledge and skills that you obtained in Red Yoder’s case to an actual patient care situation?
I would apply the knowledge and skills I gained from this simulation by conducting thorough and detailed assessments that include both the patient and the family member. It is important to look at the patient as a whole and see if they have any support systems that we can involve in the care of the patient. I also learned that education is extremely important as many patients will not have sufficient information about the disease and will not be able to take care of themselves.
Sherman “Red” Yoder – Part B
Part 1: Plan of Care Concept Map (adapted from vSim template)
• brief summary of pathophysiology and rationale for clinical manifestations
Red is being seen for a pressure ulcer on his right toe that developed around five weeks ago. It is likely that the patient continued to not adhere to his medication routine as well as his foot care routine. The patient is being treated at home with the use of an oral antibiotic and a wet to damp saline dressing daily. Red is being admitted due to a possible wound infection. The ER orders for this patient are an IV bolus of normal saline 500ml, a lab order for the following blood work: CBC, electrolytes, BUN and creatinine, blood culture x 2, and serum lactate. The
patient’s oxygen levels are to stay above 94%, if they drop below that, administer oxygen via nasal canula. If the patient is retaining fluid and is unable to void, insert urinary catheter to continuous drainage. Patient requires continuous ECG and SpO2 monitoring, as well as capillary blood glucose monitoring in order to give insulin on a sliding scale. The patient is placed on IV antibiotic Ceftazidime 1 gram IV every 8 hours.
The Assessment
Anticipated Physical Assessment Findings
• additional focused assessment
• relevant cues (S&S)
• cues indicating need for immediate
concern and rationale Anticipated Diagnostic Tests
• relevant cues (abnormal findings)
• additional tests to consider
Abnormal Values
Right toe ulcer
Distended bladder (need for urinary catheter)
Potential polyuria, polydipsia, and polyphagia due to increased glucose levels.
Blood Glucose: 210
Serum Lactate: >4 White blood cells: 12000 Red blood cells: 4.2 Hemoglobin: 10.5
Would culture: Staphylococcus positive
Additional tests to consider – monitoring of blood glucose x 4 times a day.
Plan
Anticipated Care Priorities Anticipated Nursing Interventions
Monitor blood glucose levels and adhere to medication.
Wound dressing. Feet inspection.
Diet and nutrition information. Intake/output monitoring Educate patient on: the importance of monitoring his blood glucose after meals, and adhering to the sliding scale dosage, daily inspection of feet with help of mirrors and family, how to apply wound dressings on his right toe to prevent further complications, information on diet and nutrition.
Great importance must be placed on footcare. Assess independence in ADLs.
Insert urinary catheter if patient is retaining fluid
Part 1: Medication Worksheet (one per medication) (adapted from vSim template)
Medication Classification
cefTAZidime Antibiotic
Dose - PO, IV, IM.SC or most common route
Adults and children age 12 and older: 1 to 2 g IV or IM every 8 to 12 hours. Route and dosage are determined by susceptibility of the organism, severity of infection, and condition of patient. Give up to 6 g daily in life-threatening infections.
Drug calculations: how supplied, how to reconstitute, volume for required dose, drip rate N/A
Purpose/Main Drug Actions
Inhibits cell-wall synthesis, promoting osmotic instability; usually bactericidal.
Nursing Considerations/Actions
• If large doses are given, therapy is prolonged, or patient is at high risk, monitor patient for superinfection.
• Monitor patient for diarrhea and treat appropriately.
• Look alike-sound alike: Don’t confuse drug with other cephalosporins that sound alike.
ISBAR Worksheet (adapted from vSim)
ISBAR Student Notes
Introduction
• Your name, position (Nursing student), unit you are working on
• What is the purpose of this communication? Hello, my name is Ronit Patel. I am student RN with a home health agency. I will be giving you a report on Red Yoder.
Situation
• What is happening at the moment?
• Patient’s name, age, specific reason for visit/admission Red Yoder is an 80-year-old male that is being seen for a pressure ulcer on his right toe.
Background
• What are the issues that led up to this situation?
• Patient’s primary diagnosis, date of admission, current orders The patient has uncontrolled diabetes and was admitted due to the concerns of a pressure ulcer that has been forming over the past five weeks. The ER orders for this patient are an IV bolus of normal saline 500ml, a lab order for the following blood work: CBC, electrolytes, BUN and creatinine, blood culture x 2, and serum lactate.
The patient’s oxygen levels are to stay above 94%, if they drop below that, administer oxygen via nasal canula. If the patient is retaining fluid and is unable to void, insert urinary catheter to continuous drainage. Patient requires continuous ECG and SpO2 monitoring, as well as capillary blood glucose monitoring in order to give insulin on a sliding scale. The patient is placed on IV antibiotic Ceftazidime 1 gram IV every 8 hours.
Assessment
• What do you believe the problem is?
• Current pertinent assessment data using head to toe or focused assessment
approach,
• Pertinent diagnostics
• Vital signs The problem might be patients elevated blood glucose level, and his WBC count which indicate an infection. The patient is presenting with an atypical presentation of sepsis. IV antibiotics have been started; the patient is reporting 3/10 pain. Patient is unsure when he last voided. Family reports that the patient is “different right now” from his baseline.
Recommendation
• What should be done to correct this
situation? The patient should get blood work daily to
monitor the sepsis. Continue to do dressing changes daily. Recommendations would be to
• Any orders or recommendations you have for this patient conduct a CAM assessment and a SPICES assessment.
Guided Reflection Questions
1. How did the simulated experience of Red Yoder’s case make you feel?
I felt more involved in this simulation because the patient developed an infection, and there were a lot of new orders from anti biotics to collecting of pertinent lab values. I enjoyed this simulation because I was able to conduct a lot of assessments and gather valuable information from the patient.
2. What nursing actions did you feel were appropriate within this scenario?
Speaking to the family to gather information regarding the patients baseline and how he is presenting now. Administration of IV antibiotics to combat sepsis. All assessments and patient education were very appropriate for this scenario.
3. PCC What is the correlation between Red Yoder’s open foot wound, the diagnostic findings, and treatment modalities including fluid bolus, insulin, and antibiotic therapy?
Due to the patient’s uncontrolled type 2 diabetes (glucose level of 210), he developed peripheral neuropathy. Red requires insulin therapy because his diabetes is not controlled. This means that the patient has decreased sensation and numbness in his extremities. Red injured his toe, but most likely did not feel it and therefore did not notice the wound initially, and it got worse from wearing tight shoes. Red Yoder’s open foot wound left his body susceptible to a bacterial invasion due to a break in the skin. This bacterial invasion led to an infection in his toe, and later sepsis (WBC: 12000). For this infection, the patient was ordered an antibiotic. The patient is also not consuming enough fluids due to fear of retention and incontinent, therefore a fluid bolus is required and it must be followed up by keeping track of intake and output.
4. PCC What potential problems can you identify for Red Yoder if his symptoms are not managed in a timely manner?
Potential problems for Red Yoder would be worsening of the pressure ulcer, worsening of the symptoms associated with sepsis such as: fever, increased heart rate, trouble breathing, confusion, decreased urination, and other problems with the heart, kidneys, or brain.
5. S/QI For the following Safety/Quality Improvement measures, what nursing actions should be taken during Red Yoder’s case?
Safety/Quality Improvement
Measures Nursing Action
Medication administration Assess patient’s knowledge of medication administered and provide patient with the correct information on how he can self-
administer medications.
Supportive care Assess patient’s level of support from his family. Determine which care patient will need additional
supportive care with.
Safety issues related to infection control Assess patient’s knowledge of infection prevention related to his toe. Education patient on the steps he can take to be safer, and to
prevent infection.
6. PCC/I What appropriate assessments were made to help you decide what interventions Red Yoder needed?
The assessments that helped in determining the appropriate interventions was gathering information from Red’s family regarding his baseline and if there are any changes in his baseline. Assessment of the wound also helped in determining the type of dressings Red will need in order to prevent infection and promote healing. Blood work was able to inform the team about the sepsis, and antibiotics were administered on time.
7. QI/EBP In your situation-background-assessment-recommendation (SBAR) report to the provider, what would you request?
I would request information such as primary diagnosis, date of admission, the issues that lead up to the event, current orders, vital signs, pertinent diagnostic and lab results.
8. T&C In addition to the health care team, who should be involved in discussions about Red Yoder's treatment?
The family. Gathering information from Red’s family regarding his baseline and if there are any changes in his baseline. The family can also provide information on the patient’s ADL, and daily
routines and habits.
9. Reflecting on Red Yoder’s case, were there any actions you would do differently? If so, what were these actions, and why would you do them differently?
No, I would not do anything differently in this scenario.
10. How would you apply the knowledge and skills that you obtained in Red Yoder’s case to an actual patient care situation?
I would apply the knowledge and skills I gained from this simulation by conducting thorough and detailed assessments that include both the patient and the family member. It is important to look at the patient as a whole and see if they have any support systems that we can involve in the care of the patient. I also learned that education is extremely important as many patients will not have sufficient information about the disease and will not be able to take care of themselves.
Part C
Part 1: Plan of Care Concept Map (adapted from vSim template)
Simulation Patient Overview
• Client summary: presentation, medical history and background, physical assessment findings, medications, diagnostics
• brief summary of pathophysiology and rationale for clinical manifestations
Red was admitted five days ago with sepsis that was caused by an infected wound on his right toe. The wound was previously being treated by oral antibiotics but the patient does have an issue with nonadherence. Due to the non-adherence, the bacteria from the wound was most
likely able to enter the patient’s blood stream which later led to sepsis. A urinary catheter was removed, and currently the patient is presenting with urge incontinence. There is an order for the
patient to be discharged today. Daily wound dressing change and applying of topical antibiotic is ordered.
The Assessment
Anticipated Physical Assessment Findings
• additional focused assessment
• relevant cues (S&S)
• cues indicating need for immediate
concern and rationale Anticipated Diagnostic Tests
• relevant cues (abnormal findings)
• additional tests to consider
Right toe ulcer
Urge incontinence post catheter removal Decrease muscle tone Abnormal Values
Glucose: 118
Red blood cells: 4.4 Hemoglobin: 11
Additional tests to consider – monitoring of blood glucose x 4 times a day.
Plan
Anticipated Care Priorities Anticipated Nursing Interventions
Monitor blood glucose levels and adhere to medication.
Wound dressing. Feet inspection.
Diet and nutrition information.
Determine patient’s support and social system Educate patient on: the importance of monitoring his blood glucose after meals, and adhering to the sliding scale dosage, daily inspection of feet with help of mirrors and family, how to apply wound dressings on his right toe to prevent further complications, information on diet and nutrition.
Great importance must be placed on footcare.
Assess independence in ADLs., diabetes self-
care, wound self-care, and medication self- administration.
ISBAR Worksheet (adapted from vSim)
ISBAR Student Notes
Introduction
• Your name, position (Nursing student), unit you are working on
• What is the purpose of this communication? Hello, my name is Ronit Patel. I am student RN with on the medical ICU unit. I will be giving you a report on Red Yoder
Situation
• What is happening at the moment?
• Patient’s name, age, specific reason for visit/admission Red Yoder is an 80-year-old male that is being seen for a pressure ulcer on his right toe. He has spent the past five days in the ICU unit and is now ready for discharge.
Background
• What are the issues that led up to this situation?
• Patient’s primary diagnosis, date of admission, current orders Red was admitted five days ago with sepsis that was caused by an infected wound on his right toe. The wound was previously being treated by oral antibiotics but the patient did not adhere to his medication routine. The wound eventually got worse and the patient
developed an infection which later lead to sepsis.
Assessment
• What do you believe the problem is?
• Current pertinent assessment data using head to toe or focused assessment
approach,
• Pertinent diagnostics
• Vital signs The initial problem was the lack of compliance with self-care, and non-adherence to medication routine. The patient has now been educated on: diabetic foot sores, wound care, medications, as well as a discharge plan. The following assessment tools were used to determine the assistance the patient will require post discharge: Katz index of independence in ADL, the Lawton Instrumental ADLs, and the Transitional Care Model.
Recommendation
• What should be done to correct this situation?
• Any orders or recommendations you have I believe the patient now understands how to manage his own health. I recommend that the
patient still receive home health care to ensure compliance and to prevent further
for this patient complications.
Guided Reflection Questions
1. How did the simulated experience of Red Yoder's case make you feel?
I felt like I experienced something new in the scenario because all of the previous simulations had to do with medical orders and medical interventions for the patient. In this scenario, we were able to explore the needs the patient will have post-discharge.
2. What nursing actions did you feel were appropriate within this scenario?
A major nursing action that was appropriate in this scenario was patient education, and patient assessment using the Katz, Lawton, and TCL models. With these assessment tools, we can attempt to provide the patient with the right support to ensure we decrease the chances of re- admission or further complications.
3. PCC/ What information should be included in the hand-off communication to the home health nurse about Red Yoder and his family for a successful transition from acute care to the home environment?
The patient’s background information should be included in the hand-off communication so that the home health nurse can gauge the type of care to provide to the patient. With this information, the nurse ensure that she continues to educate the patient on looking after himself properly. In addition, the home health nurse should also be informed about the orders on the dressing change so that she can assist the patient and prevent further infection. It is also vital to ensure that the family is involved in the care of Red as they as extremely supportive and are able to assist him with his ADLs and management of his diabetes. Involving the family into the care of the patient can be beneficial for the patient. If the family notices that there is a change in the baseline, they can report it to their healthcare provider to make sure that Red is taken care of.
5. S/QI For the following Safety/Quality Improvement measures, what nursing actions should be taken during Red Yoder's case?
Safety/Quality Improvement
Measures Nursing Action
Medication administration Assess patient’s knowledge of medication administered and provide patient with the correct information on how he can self-
administer medications.
Coordination of care transition to Assess patient’s level of support
home environment from his family. Determine which care patient will need additional supportive care with to effectively
transition to the home environment.
Home safety Consult with an occupational therapist to assess the patient’s home to ensure that it is free of clutter and other barriers than might cause injury to the patient.
Removing clutter and barriers can help with home safety.
6. PCC/I What appropriate assessments were made to help you decide what interventions Red Yoder needed for transitioning home?
Katz, Lawton, and TCL models, with these assessment tools, we can attempt to provide the patient with the right support so that he can begin transitioning from the hospital to the home setting.
7. Reflecting on Red Yoder's case, were there any actions you would do differently? If so, what were these actions, and why would you do them differently?
I would not do anything differently.
8. How would you apply the knowledge and skills that you obtained in Red Yoder's case to an actual patient care situation?
I would apply the knowledge and skills I gained from this simulation by conducting thorough and detailed assessments that include both the patient and the family member. It is important to look at the patient as a whole and see if they have any support systems that we can involve in the care of the patient. I also learned that education is extremely important as many patients will not have sufficient information about the disease and will not be able to take care of themselves. [Show Less]