NR 442 ELO Experience
NR 442 ELO
NR 442
NR 442 ELO Experience
This ELO must be submitted to the Dropbox at the end of week 3, Sunday, March 19th, no
... [Show More] later than 1159.
NO POINTS ARE AWARDED BUT PARTICIPATION IN THIS ELO AND THIS ASSIGNMENT ARE CONSIDERED INTO THE OVERALL CLINICAL EXPERIENCE AND ARE “PASS/FAIL”.
A “Passing” score for this assignment requires a thorough and specific completion of the questions below.
ANSWERS
Unfolding Case Study: Seymour Jones
Mr. Jones is a 69-year-old who was discharged from the hospital yesterday following a short hospitalization to treat a leg ulcer that became increasingly worse (increased pain and inflammation) over a two-week period prior to admission. In addition, he has a diagnosis of congestive heart failure (CHF) and diabetes. Mr. Jones lives alone in a senior citizens’ high-rise.
Donna Atkins, BSN, RN is the home care nurse assigned to visit Mr. Jones. She prepares to make his initial home visit.
What steps should Donna take to prepare for the initial home visit?
Remind herself of all things regarding diabetes, CHF and leg ulcers in order to teach her patient about how to care for himself. She can research the area he lives of healthy food options, transportation options, exercise options. She should also review his charts and when she sets his appointment find out if he needs her to bring anything to the visit.
As Donna reviews the “Continuing Patient Care Form” received from the discharge planner at the hospital, she notes the following:
• 67-year-old male
• admitted to hospital with two-week history of infection; right leg ulcer with progressive pain
• treatment with intravenous antibiotics
• history of CHF with shortness of breath for 10 years
• history of diabetes for 10 years
• home oxygen
What is the top priority for the home care nurse during this initial home visit?
The top priority in the first visit is to establish a good relationship with Mr. Jones. It is very important he feels he can trust her and feel he can speak to her and share his issues. Education will be a top priority on the first visit as well.
An important role for the home care nurse is that of patient or family education. Review the “Continuing Patient Care Referral Form” (below).
What patient education materials should Donna consider bringing with her for this initial home visit?
Heart and diabetic healthy diet Information on wound care Information on diabetes and CHF
Continuing Patient Care Form
Patient Name: Jones, Seymour
Address for Care: 700 Shadyside Manor Dr., Apt. 804, Somerville, MN
Sex: male Marital status: widow
Report by physician:
• Diagnosis: right leg ulcer, CHF X 10 years, diabetes X 10 years
• Complications: none
• Rehabilitation or treatment goal: wound healing, stable CHF and diabetes
• Prognosis: good
• Patient informed of diagnosis: yes
• Family informed of diagnosis: yes
• Brief medical history: admitted to hospital with two-week history of infection; right leg ulcer with progressive pain; treatment with IV antibiotics; history of CHF and history of diabetes
• Date and place of physicians next visit: visit in office in two weeks
Medical Orders and Plan of Treatment:
• Diet: 1800 ADA
• Dressing or treatment: drive dressing right leg ulcer BID, clean technique
• Medications:
Prandin 3.5 mg PO before meals
Lasix 40 mg every day: new medication
Keflex 500 mg two tabs PO Q6 hours for seven days
• Activity: as tolerated
• Patient uses: Walker
• Physical Therapy and Occupational Therapy Consult for home therapy
Hospital Nurses Assessment
• TPR: 99.8-90-28
• BP 136/90
• Blood Sugar: 100
• Weight: 165 ibs.
• Activity limitations: ambulatory with assistance
• Mental state: alert and oriented, Patient states, “I really feel down about my leg”
• Disabilities and impairments: wears glasses, decreased sensation to lower extremities (diabetes)
• Allergies: NKA
• Oxygen: 2 L per minute per nasal cannula
• Activities of daily living: needs assistance
• In Hospital Teaching: copy of diet to patient
• Weight daily; Call Dr. Smith if weight gain over 2 lbs. in 24 hours or over 5 pounds in 7 days
Donna arrives at Mr. Jones apartment at 10:30 AM. She introduces herself and explains the purpose of this home visit. “Mr. Jones, your doctor has made this referral to provide you some additional support and care during the transition from the hospital to the home. He has given specific instructions for your care so that you can recover.” Mr. Jones expresses concern regarding the cost of the service. “I am on a fixed income, you know, and I can’t afford to pay for any service.” Donna reviews the continuing patient care referral form again before responding.
To provide additional information regarding home care benefits under Medicare, Donna provides Mr. Jones with the following pamphlet, “Medicare and Home Healthcare”.
Find this pamphlet on the Internet. Review the pamphlet, and paste the web address below. What two things did you learn about Medicare and home health coverage?
http://www.medicare.gov/publications/pubs/pdf/10969.pdf. Medicare covers skilled nursing visits, PT, OT, speech therapy & medical supplies. A patient has to be homebound in order to qualify
Question: Select All that Apply Related to Home Health.
A. “Home healthcare services are provided free to all seniors living in the community.”
B. “You will have to pay a small amount of money for this service. Medicare requires a you are charged $5 dollars co-pay for each home visit.”
C. “You won’t need to pay anything out of pocket because you need intermittent skilled nursing care.”
D. “You won’t need to pay anything out of pocket because you meet the criterion of being homebound.”
E. “You are eligible to receive home healthcare services because you have an order for occupational therapy.”
After washing her hands, Donna begins the initial assessment, taking vital signs and reviewing the discharge materials provided to the patient upon discharge from the hospital. Mr. Jones vital signs are: BP: 140/88, Tim: 99 2°, heart rate: 90 bpm, respiratory rate 32.
He has a soiled dressing on his right lower leg. Bilateral edema present: worse on right leg than left; right leg is 3+ pitting; left leg is 2+ pitting.
Mr. Jones denies any chest pain but does report being short of breath more than before the hospitalization. He complains that he tires more easily than before. He uses two pillows in order to sleep comfortably. Mr. Jones reports an occasional cough that sometimes raises some frothy white sputum.
Donna notices the chart for recording daily weights and asked the patient has he weighed himself today. He replies, “No, I figured you would do it when you came.”
Donna looks around the room and notices that Mr. Jones Walker is across the room. She brings the walker within his reach and observes his ability to get up and ambulate. Donna observes that Mr. Jones is able to ambulate slowly using a walker but appears to get short of breath with minimal exertion. Mr. Jones expresses frustration regarding his decreased ability to ambulate. She provides encouragement.
What additional instruction is warranted for Mr. Jones regarding safe ambulation in managing activities with CHF?
He needs to be educated more on CHF, weighing himself daily at the same time every day, on the importance of using a walker for ambulation, keeping his legs raised when sitting or laying down. Also, he should be reminded of signs and symptoms of CHF worsening .
Mr. Jones ambulates to the bathroom where the digital scale is located. Donna makes sure that the scale is functioning properly and stands close to Mr. Jones as he stands on the scale. Mr. Jones weight is 166.1 lbs. Donna documents the weight on the chart and compares it with the weight recorded on the Continuing Patient Care Form.
Weight Chart
Date Weight
3/16 165.0
3/17 166.1
3/18
3/19
3/20
3/21
Multiple-choice Question
Donna notices that Mr. Jones weight is higher than it was in the hospital yesterday. Mr. Jones asks, “Is that a bad thing?” What is the best response for Donna to give?
A. This is nothing to worry about, but it is something we should monitor.
B. We need to call your doctor. He will want to adjust your medication
C. This is something that we need to monitor closely because weight gain can be an early signal that you are retaining fluid.
D. Have you been eating foods high in salt? That can be the cause of your weight gain.
What specific instructions should Donna provide to Mr. Jones about weight, signs and symptoms, follow-up and other information related to managing his CHF?
Weighing himself everyday, at the same time, wearing the same clothes. Weight gain can be a sign of retaining fluid and CHF acting up. He needs to watch for fatigue, shortness of breath, palpitations, dizziness, edema, weight gain, coughing, wheezing, bloating, nausea, coughing up pink foaming mucus.
Donna asks Mr. Jones about his diabetes and how he has been managing it. He shows her his blood sugar record. “I’ve been a diabetic for more than 10 years now and have been managing that pretty well. This leg pain is what messed me up. I just don’t understand why. I have been doing everything the same as always and taking my sugar pill.”
Blood Sugar Chart
Date Morning BS Evening BS
3/15 100 140
3/16 110 160
3/17 98 134
3/18 120
3/19
3/20
3/21
Multiple Choice Question
What would be the best response for Donna to give to Mr. Jones?
A. “You must have eaten something that you shouldn’t have and that’s what has thrown off your blood sugar levels.”
B. “Diabetes affects how your body responds to infection. It was good that you went to the doctor when you started having problems with your leg.”
C. “When your body is fighting an infection, it is important to increase your dietary calories to provide nutrients for healing.”
D. “When your body has an infection, it really doesn’t matter what you do, you just have to let it run its course.”
Donna reviews the blood sugar record and asks Mr. Jones to show her how he checks his blood sugar. He pulls out his glucometer and very proficiently demonstrates how he performs a blood sugar test. Donna asks Mr. Jones about his diabetes medication. He reports that he takes his as directed without fail.
Donna refers to the drug guide, Epocrates, to review the common side effects and potential adverse reactions to his diabetes medication: Go to the site below and list the top three side effects and potential adverse effects.
https://online.epocrates.com
Top three side effects are: hypoglycemia, URI sx, and headache
Top three adverse effects are: Stevens-Johnson syndrome, anaphylactoid rxn, any myocardial ischemia
Donna asks Mr. Jones about his diet. “Well, I was always on a 1800 cal diet, from the beginning when I was first diagnosed. I know that I am supposed to use a different method for my diet but I am a little fuzzy on that new method.” Donna tells Mr. Jones, “The new method focuses on portion sizes so it makes it easier to eat healthy.”
Mr. Jones uses his new tablet that his son gave him for Christmas, so Donna reinforces the instruction she provided, by showing Mr. Jones the website:
http://www.diabetes.org/food-and-fitness/food/planning-meals/create-your-plate/
Go to this site and “make” your plate for dinner. List the foods you put on your plate:
8oz. steak, roasted brussel sprouts, roasted red potatoes, and sugar free tea
Donna asks Mr. Jones to do a 24-hour dietary recall:
Breakfast yesterday at the hospital: two scrambled eggs, two slices of toast with butter and jelly, coffee, orange juice
Lunch, at home: cans tomato soup with crackers and grilled cheese sandwich
Dinner, Stouffers chicken pot-pie, coleslaw, and a glass of 2% milk
Breakfast today: oatmeal, coffee, and a banana
What additional dietary teaching should Donna provide to Mr. Jones?
Cut back on foods high in sodium and should also eat more foods high in protein to promote healing of his wounds.
Mr. Jones reports that he tests his blood sugar twice a day. He denies being excessively thirsty. “I think it seems like I am going to the bathroom more than before I was in the hospital, maybe it just seems that way because I get tired so easily.”
Donna reviews the medications on the “Continuing Patient Care Form” and verifies the labels on the prescriptions bottles.
Mr. Jones medications are:
• Prandin 3.5 mg orally before meals
• Lasix 40 mg orally every day (new medication)
• Keflex 500 mg, two tabs orally every six hours for seven days
What additional teaching does Mr. Jones need about his medications at this time?
He needs to know he will urinate more from the Lasix. The purpose of the drug is to prevent retaining of water by preventing the body from absorbing too much salt. He may experience polyuria, tinnitus , and drowziness
To reinforce medication teaching she has done with additional patient education materials, Donna refers to the drug guide, Epocrates.
Go to https://online.epocrates.com
List the four most important pieces of information the patient should know about furosemide.
Avoid “mycin” antibiotics
if he is being treated for high blood pressure to continue using even if he feels fine
avoid using if he is unable to urinate do not take more than what is prescribed.
Donna continues the home visit and learns the following about Mr. Jones
• He has been widowed for the past 15 years.
• He has several friends in the building who became call and ask for help.
• He is highly motivated to resume his independent life, but seems afraid it will not be possible.
• His hobbies included cooking for friends, playing poker with friends.
When Donna learned that Mr. Jones enjoys cooking, she shows him the American Diabetes Association’s website where there are some good recipes that he can try out.
To provide additional dietary and diet management support, including access to recipes, meal plans, tips, and other tools, she helps him sign up for the ADA’s “My Food Advisor Program”.
http://www.diabetes.org/mfa-recipes/log-in/recipes-for-healthy-living.html?loc=ff-diabetesmealplans
Sign-up for this site and choose a recipe from the “Budget-Friendly Recipes.” Fill in the information below:
Name of the recipe: Budget-Friendly Cilantro Lime Roasted Chicken
Calories 130
Carbohydrate: 4 g
Protein: 18 g
Fat 4.5 g
Saturated Fat: 1.2 g
Sugars: 3 g
Dietary Fiber: 0 g
Cholesterol: 55 mg
Sodium: 55 mg
Potassium: 165 mg
Search for a free mobile app that Mr. Jones could use to track his diabetes. Write the name of the app below with a brief description.
BG Monitor Diabetes: Free, for Android users, easy interface to navigate, tracks everything, can calculate how much insulin is needed, sets reminders, creates spreadsheets and graphs of patient’s data, organizes all entries with tags. Can photo log all of meals in case patient is out and about.
Donna turns her attention to assess the leg wound. She washes her hands again and sets up her workspace. She positions Mr. Jones leg so that he is comfortable and she is able to safely provide care.
She verifies the order on the Continuing Patient Care Form.
When providing wound care, what characteristics of the wound must be assessed?
The wounds size and depth and extent of undermining need to be documented, as well as the appearance of the surface (necrosis, viability, etc), amount and characteristics of exudate, and the status of the periwound tissues (pigmented, scarring, and cellulite.
Find a resource guide for wound care that Donna might use in the home setting for additional information on wound assessment.
What is the name of the resource that you found? How would this resource be useful for Donna as a home health nurse?
I thought Medscape was quick and easy to find and navigate. It can be easily accessed by phone and breaks things down easy to read.
Mr. Jones looks at his wound and asks Donna how the wound looks to her. She responds that the wound is still in the inflammatory phase of wound healing. He is puzzled and asks more questions.
To help Mr. Jones understand the basis of wound healing, locate a brief video on the phases of wound healing that Donna might use. Copy the web address below. Briefly describe what you learned about the stages of wound healing.
https://www.youtube.com/watch?v=f9kQ4MQNMy0 This video does a great job at explaining the different stages of a wound and how the cells are involved.
Donna completes the wound care and provides verbal and written instruction regarding caring and monitoring the wound.
What additional instructions should Donna provide to Mr. Jones concerning his wound?
It is important to keep it clean and dry. He needs to take showers and not baths. He needs to avoid scratching it if it itches and to keep his leg elevated if he is sitting.
Donna completes her initial home visit. She summarizes all the information she has shared and provide specific instructions in writing, being mindful that patient safety is a priority concern, she reviews the signs and symptoms of complications that warrant immediate action and when to call the nurse or doctor Donna provides a list of emergency phone numbers. Finally, she makes arrangements for a follow-up home visit in two days. [Show Less]