COVID-19 Assignment

1015 Non-COVID Virtual Clinical Assignment Summer 2020

Laboure College

Summer 2020

Non-COVID-19 Virtual Clinical Assignment Tissue Integrity

Course: NUR ____1015_____ Concept/Exemplar: ___Tissue Injury/Pressure Injury________ Hours: __6.5___

Student Learning Outcomes (SLOs): See CLM concept/exemplar for SLOs.

Scenario: Please use your Pearson Text as reference

You are a nurse working on a medical surgical unit and take the following report from the emergency department (ED) nurse. (NG NCLEX What matters most? Noticing)

Date	Scenario
	“We have a patient for you: R.L. is an 81-year-old frail woman who has been in a nursing home. Her primary admitting diagnoses are sepsis, pneumonia, and dehydration, and she has a known Stage 3 pressure injury on her right hip. Past medical history includes cerebrovascular accident (CVA) with residual right-sided weakness and paresthesia, myocardial infarction (MI), and peripheral vascular disease PVD). She is a full code. Her vital signs are 98/62, 88 and regular, 38 and labored, 100.4° F (38° C). Weight is 41 kilograms, she states never eating more than 25% of her meal. Spends a limited amount of time in a chair, possibly once a day. Lab work is pending; she has oxygen at 4 L via nasal cannula and an IV of D5.45 at 100 mL/hr. An indwelling catheter was inserted. The infectious disease healthcare provider has been notified, and respiratory therapy is with the patient—the patient should arrive shortly.”	Identify the 4 Top client findings requiring immediate follow-up (NG NCLEX What matters most? Noticing) Tanner’s Clinical Judgement model

1. What major factors increase risk for developing a pressure injury?

2. Each health care setting should have a policy that outlines how to assess patients’ at risk for developing a pressure injury. What should be included in that assessment?

3. As part of R.L.’s admission assessment, the nurse conducts a skin assessment. What areas of R.L.’s body will the nurse pay particular attention to?

4. What are the advantages of using a validated, standardized risk assessment tool to document her skin condition on admission?

5. How often should patients be reassessed for the risk of developing an injury?

6. For each client finding below, specify the finding consistent with the process of aging, wound healing and pressure injury. (NG NCLEX What could it mean? Noticing/Analyzing)

Time	Client Findings (above)	Older adult	Healing wound	Pressure injury
	Dryness Redness Warmth Edema Foul odor Pain	□ □ □ □ □ □	□ □ □ □ □ □	□ □ □ □ □ □

CASE STUDY PROGRESS

During your assessment, you note that R.L. has very dry, thin, almost transparent skin. She has limited mobility from her stroke and is currently bedridden. There are several areas of ecchymosis on her upper extremities. She is alert and oriented to person only. You review the transfer summary from the long-term care facility and note she has a history of urinary and fecal incontinence.

7. Evaluate R.L. with the Norton risk assessment scale. https://sagelink.ca/sites/default/files/clinical-resources/Norton_presure_sore_risk_assessment_scale.pdf (complete scale)

	Physical Condition	Mental Condition	Activity	Mobility	Incontinence:	Total Score
Date	Good	4	Alert	4	Ambulant	4	Full	4	Not	4
	Fair	3	Apathetic	3	Walk/help	3	Slightly limited	3	Occasional	3
	Poor	2	Confused	2	Chair bound	2	Very limited	2	Usually/urine	2
	Very bad	1	Stupor	1	Bed rest	1	Immobile	1	Urinary and fecal	1

8. How does the above scale differ from the Braden Skin Assessment Scale? https://www.in.gov/isdh/files/Braden_Scale.pdf

9. Knowing that R.L. has right-sided weakness, and a pressure injury, what consultations or referrals could the nurse initiate?

CASE STUDY PROGRESS

As the nurse completes R.L.’s assessment, the Certified Wound Care Nurse enters the room. She knows R.L. from a prior admission; as soon as she received the request for a wound care consultation, she ordered a specialty mattress. She says an air overlay should be delivered to your unit before your shift ends.

10. Why is a specialty mattress used for immobile or compromised patients?

11. Why are patients placed on specialty mattresses who are at risk for skin breakdown?

12. Why do the heels have the greatest incidence of breakdown, even when the patient is on a specialty mattress?

13. What intervention can the nurse initiate to protect R.L.’s heels?

14. Compare friction and shear and provide an example of each.

15. What risk factor does using a draw sheet prevent or minimize?

16. Describe 6 interventions aimed at minimizing friction and shear.

17. Elevated skin temperature and perspiration increase risk for pressure injury. Write 4 specific measures to manage the client’s skin change.

18. Which instructions will the nurse delegate to the UAP when caring for R.L.? Select all that apply.

a. Assess R.L.’s skin status every shift.

b. Develop an every-2-hour turn schedule.

c. Use the appropriate sheets on the airflow bed.

d. Keep R.L.’s head of bed below a 30-degree angle.

e. Assist with hygiene measures when R.L. is incontinent.

f. Empty and measure output in the urine collection device.

19. Write an outcome related to R.L.’s skin integrity. The client/patient will ________________________

CASE STUDY PROGRESS

The Certified Wound Care Nurse needs to evaluate the preexisting pressure injury. She gently removes the old dressing, using the push-pull method and adhesive remover wipes. After taking off the outside dressing, or the secondary dressing, she pulls out the primary dressing and states that R.L. has a tunneled wound that was “packed too hard.”

20. What problems can be created by packing a wound too full?

21. The nurse systematically assesses the injury and confirms the presence of a stage 3 pressure injury with moderate yellow drainage. There is no tissue necrosis or debris. What does it mean to “stage” a wound? Define the type of wound drainage.

22. What does the nurse expect a stage 3 pressure injury to look like?

23. What is a tunneling wound? What risk factors are associated with tunneling?

24. What are the dimensions of R.L.’s wound? ____________________________(need to know what position patient is in to measure- ex. Left lateral; head is 12:00 feet is 6, etc..) Wounds are measured and documented by 3 dimensions, LxWxD (length x width x depth).

CASE STUDY PROGRESS

After Certified Wound Care Nurse obtains a set of wound cultures, you watch as she packs the wound with gauze. The wound nurse charts the findings and makes formal recommendations for management of the wound to the primary care provider.

25. A nurse is collecting an ordered wound culture with a swab. What location is the culture taken from?

a. Wound drainage

b. Healthy-appearing granulating tissue

c. Most necrotic-appearing tissue

d. Very outer edges of the wound

26. Describe the technique for packing a tunneled wound.

27. What factors influence the choice of a wound dressing?

28. What is the best choice for dressing R.L.’s wound?

29. What wound documentation is necessary at this time?

30. Complete an example of a documentation entry for R.L.’s wound care. Include below descriptors.

Wound Location Pressure Injury Stage Wound Dimensions Undermining Tissue Type Drainage Periwound Condition Cleansing Agents Dressing Type Applied

CASE STUDY OUTCOME

After 3 weeks of intensive treatment, R.L.’s sepsis and pneumonia subside, she is transferred o a local subacute facility for further healing.

31. Complete a concept map on R.L.’s priority problems prior to discharge. (Deliverable)

Harding (2020) CS 119

“Think like a Nurse” questions

· What concepts are best defined by this assignment? Why?

· What did you learn from this assignment?

· What do you know now that you did not know prior to this assignment?

· If you had to care for patient with a pressure injury, what information would be helpful to know in advance?

Submit Assignment: Upload deliverables to eLearning under the Coursework tab, labeled Non-COVID Clinical Assignment. · Assignment/scenario · ALT medication template · Concept map · Reflective journal

Rubric Criteria		Pass		Not Pass
Case assignment		Student demonstrates an understanding of the concept through complete and thoughtful answers to scenario questions and to the content within the deliverables..		Student does not demonstrate completion of scenario questions and deliverables.
Professionalism		Student completes and uploads virtual case assignments and deliverables in a timely manner.		Student does not complete and or uploads the virtual case assignment.
Comments, Signatures and Dates		Student		Faculty

Developed 6-2020 1