Self-Evaluation Paper
NUCO-4430 Transition and Validation Seminar I
Kimberely S. Strickland
University of Virginia
December 12, 2010
The Transition and Development Seminarat the University of Virginia set seven goals for its students to complete during the semester. I believe that I have successfully completed each of these goals.
First, the class forced me to turn to microscope on myself and look at my own body of knowledge when completing the adult case study. Although the case study was a difficult task to complete, I surprised myself with the amount of nursing knowledge I discovered inside my own mind. I also began to look ahead to set goals of where I want to be in nursing in the next few years.
Second, this class has encouraged me to look at the different nursing roles in my organization when setting goals. I looked at the roles of the floor nurses, clinical shift managers, unit managers, unit clinicians, and director of medical-surgical nursing. In my unit, the higher up the corporate ladder nurses are, the less patient contact they have. The director of medical-surgical nursing sees patients only in rare cases, usually if someone complains loudly and repeatedly.
Third, I have developed the first half of a professional portfolio that my professor will use to validate my prior nursing knowledge. The second half of this portfolio will be completed during the spring semester. This portfolio has also served to increase my nursing knowledge through the examination of current nursing journals and the use of standardized nursing language. In addition, the Career Self-Assessment assignment forced me to look at my own nursing path and receive input from a peer a superior.
Fourth, when writing the Standard Nursing Language (SNL) and Adult Case Study papers, I was forced to revisit nursing diagnoses, interventions, and outcomes in a formal manner. Although I had written care plans in my associate degree program, I did not use the NIC and NOC as I did in this class. Initially, I felt much anxiety at this new language but now feel much more comfortable I as look ahead to the second half of the Transition.
Fifth, both inside and outside of class, I examined ethical issues in nursing practice. For example, each day I work, I see issues on my unit that need to be addressed. Is it ethical for management to cut staffing at the expense of patient care? Patient care quality decreases when cuts are made, so management should examine whether this can be rectified.
Sixth, when completing the assigned papers during the semester, I used the Health Sciences Library in the Claude Moore Building to complete my research. I used the library’s resources both on-line and in person when writing my papers.
Seventh, I was motivated to complete the assignments in a timely manner. I asked questions when confused and communicated with the professor as problems arose.
In conclusion, I feel as though I met all the learning objectives of the Transition and Validation Seminar I. Not only have I learned a lot about nursing, but I have also learned a lot about myself as a nursing professional. This new knowledge has given me increased confidence as a registered nurse and I look forward to the Transition and Validation Seminar II in the spring.
Tuesday, December 14, 2010
Skin Integrity
Skin Integrity: Skin Breakdown on Nine General
Immobility + Bony Prominences
—Common areas for skin ulcers are the head, shoulder blades, elbows, sacrum, and heels
—Pressure relief on these areas is crucial
Impaired Skin Integrity
—Major risk factors are decreased level of consciousness, limited mobility, impaired senses, and incontinence (Jaul, 2010)
—Edema, dehydration, poor nutrition, medications, immunosuppression, and decreased oxygenation also contribute (Jaul, 2010)
—Pressure management
Nonrestrictive clothing, monitor mobility and activity, facilitate small shifts of body weight, turn the patient every two hours, refrain from applying pressure, use toe pleats and heel protectors, monitor nutritional status (Bulechek et al., 2008, p 585)
Interventions
—Document skin status on admission
—Clean, dry linens
—Document weight
—Moisture dry, unbroken skin
—Avoid donut devices
—Use protective devices
—Keep skin dry
—Monitor for sources of friction or pressure
—Follow accepted recommendations for repositioning
—Use appropriate devices to avoid improper contact (Bulecheck et al., 2008, p. 587)
Desired Outcome: Tissue Integrity
—Skin structure is intact and function is normal (Moorhead, Johnson, Maas, & Swanson, 2008, p. 699)
—Rating Scale:
—1 Severely Compromised
—2 Substantially Compromised
—3 Moderately Compromised
—4 Mildly Compromised
—5 Not Compromised (Moorhead et al., 2008, p. 699)
References
—Bulechek, G. M., Butcher, H. K., & Dochterman, J. M. (Eds.). (2008). Nursing interventions classification (NIC) (5th ed.). St. Louis, MO: Mosby Elsevier.
—
Jaul, E. (2010). Assessment and management of pressure ulcers in the elderly: current strategies. Drugs & Aging, 27(4), 311-325.
—
—
Johnson, M., Bulechek, G., Butcher, H., Dochterman, J. M., Maas, M., Moorhead, S., & Swanson, E. (Eds.). (2006). NANDA, NOC, and NIC Linkages (2nd ed.). St. Louis, MO: Mosby Elsevier.
—
—
Moorhead, S., Johnson, M., Maas, M. L., & Swanson, E. (Eds.). (2008). Nursing outcomes classification (NOC) (4th ed.). St. Louis, MO: Mosby Elsevier.
—
Monday, December 13, 2010
Resume
Kimberely Strickland
318 Deer Ridge Lane
Ararat, Virginia 24053
276-235-0688
kss3dc@virginia.edu
Objective
Dedicated registered nurse (RN) with specialty experience in medical-surgical nursing.
Reliable, ethical healthcare provider with ability to stay calm and intervene during crises, and to collaborate on multidisciplinary teams. Proven ability to build positive relationships with patients, family members, physicians and other medical professionals.
Work Experience
Registered Nurse
11/2008 - Present Forsyth Medical Center, Winston, Salem, NC
Served as RN on 9 General, a busy medical-surgical unit. Chosen by the unit manager to serve as the unit representative on the Magnet Professional Committee and on the Safety Committee.
08/2006-10/2008 Northern Hospital of Surry County, Mount Airy, NC
Served as RN on the Step Down Unit, and was frequently pulled to the Intensive
Care Unit. Occasionally served in the Emergency Room.
Education
5/2010 – Present University of Virginia, Charlottesville, VA
Pursuing a Bachelor of Science in Nursing. Will graduate May, 2011.
5/2006 A.D.N. Surry Community College, Dobson, NC
5/1995 B.A. Communications, Salem College, Winston-Salem, NC
Departmental Honors
8/1993 A.A. Surry Community College, Dobson, NC
Honors
Skills
§ Case Management
§ Critical-Care Nursing
§ JCAHO Standards/Compliance
§ Medication Administration
§ Parent/Patient/ Family Education
§ Patient Advocacy
§ Patient Assessment
§ CVADs
§ Quality & Continuity of Care
Additional Information
Known as a patient advocate and team player; believe in empowering patients by delivering health education and nursing care that enhances wellness and quality of life.
318 Deer Ridge Lane
Ararat, Virginia 24053
276-235-0688
kss3dc@virginia.edu
Objective
Dedicated registered nurse (RN) with specialty experience in medical-surgical nursing.
Reliable, ethical healthcare provider with ability to stay calm and intervene during crises, and to collaborate on multidisciplinary teams. Proven ability to build positive relationships with patients, family members, physicians and other medical professionals.
Work Experience
Registered Nurse
11/2008 - Present Forsyth Medical Center, Winston, Salem, NC
Served as RN on 9 General, a busy medical-surgical unit. Chosen by the unit manager to serve as the unit representative on the Magnet Professional Committee and on the Safety Committee.
08/2006-10/2008 Northern Hospital of Surry County, Mount Airy, NC
Served as RN on the Step Down Unit, and was frequently pulled to the Intensive
Care Unit. Occasionally served in the Emergency Room.
Education
5/2010 – Present University of Virginia, Charlottesville, VA
Pursuing a Bachelor of Science in Nursing. Will graduate May, 2011.
5/2006 A.D.N. Surry Community College, Dobson, NC
5/1995 B.A. Communications, Salem College, Winston-Salem, NC
Departmental Honors
8/1993 A.A. Surry Community College, Dobson, NC
Honors
Skills
§ Case Management
§ Critical-Care Nursing
§ JCAHO Standards/Compliance
§ Medication Administration
§ Parent/Patient/ Family Education
§ Patient Advocacy
§ Patient Assessment
§ CVADs
§ Quality & Continuity of Care
Additional Information
Known as a patient advocate and team player; believe in empowering patients by delivering health education and nursing care that enhances wellness and quality of life.
Pain Control for a Penny
Pain Control for a Penny
Clinical Exemplar #1
Kimberely S. Strickland
September 20, 2010
Several months ago, I cared for a patient named “Penny,” a nineteen-year old[KH1] woman who was suffering with agonizing abdominal pain. Unfortunately for Penny, her doctors were unable to find the cause of her pain. Another strike against Penny’s pain battle was the jaded attitude of some of the doctors and nurses. Because of the high number of drug seekers admitted to the hospital, many staff members have developed a callous demeanor toward anyone they believe is seeking narcotics.
In nursing school, I learned that pain is subjective. I also learned that no matter what signs and symptoms the patient displays, I should ask her to rate her pain on the 1-10 pain scale. According to my professors, I should then treat this pain according to the patient’s own rating.
I first met Penny after I had received report on my patients. I entered the room and introduced myself in my usual fashion, “Hi, I’m Kimberely and I’ll be your nurse until 7:00 tonight.” What I saw disturbed me. This young woman was in tears, holding her stomach. “What’s wrong?” I asked.
She strained to get the words out, “My stomach is killing me. I asked the nurse for pain medicine but she never brought any.”
At the bedside was Penny’s mother “Pearl.” Pearl was a middle-aged woman with proof of her age clearly visible in the lines on her face and the dark circles under her eyes. Pearl had her notebook computer on her lap as she sat in her chair by the window. My gaze returned to Penny and I asked her to rate her pain on the 1-10 scale. “Ten” she replied.
I told her, “I’ll check you med list and I’ll be back as soon as I can.”
The strongest pain medicine ordered for Penny was Percocet[KH2] . I was quite annoyed that a patient in this much pain had no intravenous pain medicine ordered. So, I called her physician, “Dr. Doubting.” I gave the standard SBAR-Q report (situation, background, assessment, recommendation, questions) and emphasized that the patient needed something intravenous for her pain in addition to the Percocet. Dr. Doubting said, “Well, I think Penny is a drug seeker and she’s putting on an act.”
I met his skepticism with my own opinion, “She is writhing in pain and crying like a baby. No drug seeker that I’ve ever seen has entertained me in this fashion. None of them has shown this much acting talent.”
After taking a deep breath, Dr. Doubting reluctantly ordered morphine one milligram IV every two hours for pain. Knowing that I would be calling him back shortly, I took the order, obtained the drug, and administered it to the patient along with the Percocet. She was still crying and holding her stomach. Her mother was standing over her offering comfort. This scene reinforced my belief in the patient’s pain.
I left the room with a promise to return shortly. I checked on my other patients and completed several tasks. Twenty minutes later, I checked on Penny and found her pain no better. “Rate your pain,” I asked.
“It’s still a ten,” she cried.
I called Dr. Doubting again and explained that Penny had no relief with the morphine. He gave another order for morphine two milligrams every two hours for pain. “First dose now?” I asked.
“First dose now,” was his reply.
I obtained the drug through a narcotic administration override and went directly to Penny’s room to administer it. I found no change in her condition. So, I administered the drug and sat on the bed with her. I took her hand and told her to look at me. “Focus, Penny. Look me in the eye and think about what I’m saying to you.”
She did.
“We’re going to beat this pain and you’re going to feel better. It’s just going to take a little while. I’ve given you a total of three milligrams of Morphine and a Percocet, and I’m going to continue to give you everything I can for your pain. Do you understand?”
Still crying, she nodded.
I continued with my pain pep talk, “I am going to check on my other patients, but I’ll be back for you. While I’m gone, I want you to think about going to the beach. Do you like the beach?”
She nodded again and I continued. “Think about going to the beach with your friends. You don’t have a care in the world. Sunning for a week at Myrtle Beach will give you a great tan. You can ride the waves in the ocean and dive in the pool afterwards. When the sun goes down, you can ride the strip and meet new people. Does that sound like fun?”
With tears in her eyes, she nodded again. So I continued, “I want you to think about that while I’m gone. How would you rate your pain now?”
Still crying, she said, “It’s about an eight now.”
I stepped out of the room and called Dr. Doubting again. He and I repeated the same ritual, and I obtained an order for a one-time dose of morphine three milligrams, first dose now. I administered the dose immediately. Within fifteen minutes, Penny reported that her pain had dropped to a four. I instructed her to keep her focus on Myrtle Beach, and she agreed to do so.
Meanwhile, I checked on my other patients but kept a close watch on the clock to ensure that Penny received another dose of morphine two milligrams when the two-hour time limit had expired. When the minute arrived, I had the medicine ready to push into Penny’s IV port. Within ten minutes, she was rating her pain at a two on the pain scale. An extra-added bonus for my efforts was her droopy eyelids. I am happy to report that Penny finally drifted off to sleep.
I left Penny to dream and her mother Pearl followed me out of the room. “Kimberely,” she began, “Penny has been in and out of the hospital for a lot of years but no nurse did what you did today. Most would have given up but you didn’t, and I want you to know how much I appreciate how much you helped my daughter.” She then gave me a big hug and returned to Penny’s room.
After my shift ended, I didn’t see Penny or Pearl anymore nor did I learn the source of Penny’s abdominal pain. I cared for Penny on my last day of the week and then was off for several days so I suppose I’ll never know.
As I was writing this exemplar, I realized that working with Penny taught me a lesson. For the first time in my nursing career, I did not let a doctor’s reluctance to treat a patient stop me from being an advocate for that patient. I did not care if he yelled at me or became upset. I made up my mind early in the day to keep calling Dr. Doubting until Penny’s pain was greatly relieved. I was quite proud when she fell asleep.
Although many drug seekers are admitted to our unit, this should not sway caretakers from giving patients the best pain control possible. In this situation, I utilized what I was taught in nursing school to help the patient achieve a more favorable and comfortable outcome. That teaching combined with persistence helped ensure a pain-free Penny.
Kimberely, what an exquisite exemplar. The care that you provided exemplified the standards of nursing practice. Advocacy is huge with our professional standards and with Nursing’s Social Policy Statement. I am hopeful you will look at those documents and place your exemplar into perspective using these as a framework. For writing, please review APA format for your title page: what items it should include, all 12 font, running head, page number, no bolds, and no tables. These are in the APA manual/Perrin. In our first class, I also added course title to be on the title page. Remember too that APA is left justified. Thank you for a nice paper. 14/15
[KH1]See APA format for age
[KH2]Use generic lower case
Clinical Exemplar #1
Kimberely S. Strickland
September 20, 2010
Several months ago, I cared for a patient named “Penny,” a nineteen-year old[KH1] woman who was suffering with agonizing abdominal pain. Unfortunately for Penny, her doctors were unable to find the cause of her pain. Another strike against Penny’s pain battle was the jaded attitude of some of the doctors and nurses. Because of the high number of drug seekers admitted to the hospital, many staff members have developed a callous demeanor toward anyone they believe is seeking narcotics.
In nursing school, I learned that pain is subjective. I also learned that no matter what signs and symptoms the patient displays, I should ask her to rate her pain on the 1-10 pain scale. According to my professors, I should then treat this pain according to the patient’s own rating.
I first met Penny after I had received report on my patients. I entered the room and introduced myself in my usual fashion, “Hi, I’m Kimberely and I’ll be your nurse until 7:00 tonight.” What I saw disturbed me. This young woman was in tears, holding her stomach. “What’s wrong?” I asked.
She strained to get the words out, “My stomach is killing me. I asked the nurse for pain medicine but she never brought any.”
At the bedside was Penny’s mother “Pearl.” Pearl was a middle-aged woman with proof of her age clearly visible in the lines on her face and the dark circles under her eyes. Pearl had her notebook computer on her lap as she sat in her chair by the window. My gaze returned to Penny and I asked her to rate her pain on the 1-10 scale. “Ten” she replied.
I told her, “I’ll check you med list and I’ll be back as soon as I can.”
The strongest pain medicine ordered for Penny was Percocet[KH2] . I was quite annoyed that a patient in this much pain had no intravenous pain medicine ordered. So, I called her physician, “Dr. Doubting.” I gave the standard SBAR-Q report (situation, background, assessment, recommendation, questions) and emphasized that the patient needed something intravenous for her pain in addition to the Percocet. Dr. Doubting said, “Well, I think Penny is a drug seeker and she’s putting on an act.”
I met his skepticism with my own opinion, “She is writhing in pain and crying like a baby. No drug seeker that I’ve ever seen has entertained me in this fashion. None of them has shown this much acting talent.”
After taking a deep breath, Dr. Doubting reluctantly ordered morphine one milligram IV every two hours for pain. Knowing that I would be calling him back shortly, I took the order, obtained the drug, and administered it to the patient along with the Percocet. She was still crying and holding her stomach. Her mother was standing over her offering comfort. This scene reinforced my belief in the patient’s pain.
I left the room with a promise to return shortly. I checked on my other patients and completed several tasks. Twenty minutes later, I checked on Penny and found her pain no better. “Rate your pain,” I asked.
“It’s still a ten,” she cried.
I called Dr. Doubting again and explained that Penny had no relief with the morphine. He gave another order for morphine two milligrams every two hours for pain. “First dose now?” I asked.
“First dose now,” was his reply.
I obtained the drug through a narcotic administration override and went directly to Penny’s room to administer it. I found no change in her condition. So, I administered the drug and sat on the bed with her. I took her hand and told her to look at me. “Focus, Penny. Look me in the eye and think about what I’m saying to you.”
She did.
“We’re going to beat this pain and you’re going to feel better. It’s just going to take a little while. I’ve given you a total of three milligrams of Morphine and a Percocet, and I’m going to continue to give you everything I can for your pain. Do you understand?”
Still crying, she nodded.
I continued with my pain pep talk, “I am going to check on my other patients, but I’ll be back for you. While I’m gone, I want you to think about going to the beach. Do you like the beach?”
She nodded again and I continued. “Think about going to the beach with your friends. You don’t have a care in the world. Sunning for a week at Myrtle Beach will give you a great tan. You can ride the waves in the ocean and dive in the pool afterwards. When the sun goes down, you can ride the strip and meet new people. Does that sound like fun?”
With tears in her eyes, she nodded again. So I continued, “I want you to think about that while I’m gone. How would you rate your pain now?”
Still crying, she said, “It’s about an eight now.”
I stepped out of the room and called Dr. Doubting again. He and I repeated the same ritual, and I obtained an order for a one-time dose of morphine three milligrams, first dose now. I administered the dose immediately. Within fifteen minutes, Penny reported that her pain had dropped to a four. I instructed her to keep her focus on Myrtle Beach, and she agreed to do so.
Meanwhile, I checked on my other patients but kept a close watch on the clock to ensure that Penny received another dose of morphine two milligrams when the two-hour time limit had expired. When the minute arrived, I had the medicine ready to push into Penny’s IV port. Within ten minutes, she was rating her pain at a two on the pain scale. An extra-added bonus for my efforts was her droopy eyelids. I am happy to report that Penny finally drifted off to sleep.
I left Penny to dream and her mother Pearl followed me out of the room. “Kimberely,” she began, “Penny has been in and out of the hospital for a lot of years but no nurse did what you did today. Most would have given up but you didn’t, and I want you to know how much I appreciate how much you helped my daughter.” She then gave me a big hug and returned to Penny’s room.
After my shift ended, I didn’t see Penny or Pearl anymore nor did I learn the source of Penny’s abdominal pain. I cared for Penny on my last day of the week and then was off for several days so I suppose I’ll never know.
As I was writing this exemplar, I realized that working with Penny taught me a lesson. For the first time in my nursing career, I did not let a doctor’s reluctance to treat a patient stop me from being an advocate for that patient. I did not care if he yelled at me or became upset. I made up my mind early in the day to keep calling Dr. Doubting until Penny’s pain was greatly relieved. I was quite proud when she fell asleep.
Although many drug seekers are admitted to our unit, this should not sway caretakers from giving patients the best pain control possible. In this situation, I utilized what I was taught in nursing school to help the patient achieve a more favorable and comfortable outcome. That teaching combined with persistence helped ensure a pain-free Penny.
Kimberely, what an exquisite exemplar. The care that you provided exemplified the standards of nursing practice. Advocacy is huge with our professional standards and with Nursing’s Social Policy Statement. I am hopeful you will look at those documents and place your exemplar into perspective using these as a framework. For writing, please review APA format for your title page: what items it should include, all 12 font, running head, page number, no bolds, and no tables. These are in the APA manual/Perrin. In our first class, I also added course title to be on the title page. Remember too that APA is left justified. Thank you for a nice paper. 14/15
[KH1]See APA format for age
[KH2]Use generic lower case
Career Self-Assessment
MIRROR, MIRROR
LOOKING AT ME: A SELF-ASSESSMENT
Kimberely S. Strickland
NUCO 4430 Transition / Validation Seminar I
University of Virginia School of Nursing
October 12, 2010
MIRROR, MIRROR
LOOKING AT ME: A SELF-ASSESSMENT
Values
As a nurse, I always try to act in the best interests of the patient. In order to achieve this goal, I am honest about my shortcomings. I practice with an open mind and a questioning attitude. I have seen many nurses make avoidable mistakes because they were too afraid or too proud to consult a colleague when they could have asked a few questions. Additionally, if I make a mistake, I admit it quickly so that no harm comes to the patient. Admitting mistakes increases both my knowledge and patient safety. Another important facet of nursing is teamwork. Even though each patient is assigned one nurse, we must act as a team in order to put the needs of the patient first. For example, two or more people are required to pull up a patient in bed safely, two nurses check insulin to ensure a correct dose, and two or more nurses are often needed to decipher a doctor’s handwritten orders. Without honesty, an open mind, admission of mistakes, and teamwork, patient safety is always compromised.
Knowledge
I attended nursing school at Surry Community College and graduated in May 2006. However, this is not my first degree. I earned an Associate of Arts from Surry in 1993 and a Bachelor of Arts in Communications from Salem College in 1995[KH1] . My first job out of nursing school was on a step down unit at a small community hospital. I stayed there for two years before moving onto a medical-surgical unit at a major hospital in one of the largest cities in the state. When I started this second job, I had as much confidence as a new nurse[KH2] as I did that first day on the job even though I had two years experience. Now, I have two years experience on this busy unit and have seen a range of diagnoses from anemia to zinc deficiency. Because of this experience, I now feel that I can work on any unit and be successful.
One of my greatest strengths is my ability to talk to almost anyone in any given situation. My supervisors, co-workers, and patients compliment me on my honesty and clarity when conveying important information. Many times, I must translate what the doctor told the patient into more easily understandable terms. Sometimes, I may give the newly-admitted patient a preview of what to expect when the doctor arrives. Other times, I’ll help the patient and family formulate a list of questions for the doctor so none are unanswered. This helps me to establish a rapport with my patients and their families rather quickly so that trust is not an issue. This rapport and trust serves the patients and families well because they aren’t afraid to approach me if issues or new questions arise.
Active listening is another skill that has been honed since I became a nurse. This has been one of the most difficult skills to sharpen because I have an innate ability to tune out people, even those who are in close proximity to me. I have had to learn to focus my attention on what’s being said at that moment to prevent my mind from wandering. This skill is currently serving me well in the academic world as I pursue another degree.
Interests
I have a wide variety of interests but not a lot of time to pursue them, unfortunately. One of my favorite things is writing. When I was a little girl, I had several pen pals from foreign lands and corresponded with them for many years. When I matured into adolescence, I wrote silly poems about my job or family or pets. I was in my late thirties when I realized that I had the writing skills to pen a novel. Now I have two in the works.
Another love is teaching. I have always enjoyed sharing my knowledge and skills with others. I enjoy that moment of enlightenment when the student realizes what the teacher is trying to teach. Anytime students are assigned to my unit, I make a point of introducing myself and offering my assistance, whether they are assigned to my patients or not. After I graduate with my bachelor’s degree, I may pursue graduate school and a subsequent career as a nursing instructor[KH3] .
Accomplishments
Four accomplishments rank among the largest in my nursing career to date. First, I was selected to join the Magnet Committee for our hospital. This committee helps to educate the nursing staff about what Magnet means and cement our continued commitment to maintaining Magnet status. Second, I was also chosen to join the Safety Committee. This committee reviews medication mistakes made throughout the facility and devises methods to avoid these mistakes in the future. The committee also reviews current nursing practice to determine if more safe guidelines could be implemented. Third, I was chosen by my manager to participate on the Nurses’ Week Committee. This committee implemented a week-long celebration to honor the facility’s nursing staff. Fourth, I was admitted to the University of Virginia. I was extremely excited when I received the notification and am eagerly anticipating where my degree will lead me.
Conclusion
Looking at me is something I’ve never really enjoyed although it is a task that is constructive from time to time. Completing this self-assessment has confirmed my suspicion that I want to pursue higher education beyond my current pursuit. Completing the exercises required for the self-assessment has increased my confidence as a nurse as well by demonstrating that I have more knowledge and skills than I sometimes give myself credit.
References
Waddell, J., Donner, G., & Wheeler, M. (2009). Building your nursing career (3rd ed.). Toronto: Mosby Elsevier.
Waddell, J., Donner, G. J., & Wheeler, M. M. (2009). Building your nursing career: A Guide for students (3rd ed.). Ontario, Canada: Elsevier Canada.
[KH1]This is very impressive and will truly be an asset to your career
[KH2]You are not alone. Change and being the new man on the block is always humbling
[KH3]OK…we need to talk as we are looking at a new program that may interest you!
Career Self Assessment Paper
Name: Kimberely Strickland
Points
Total
Introduction
0.5
0.25
Vision - Description of your vision or picture of your future career
2
.5
Self-Assessment (33-40) – Values
1
1
Self-Assessment (33-40) - Knowledge and Skills
1
1
Self-Assessment (33-40) – Interests
1
1
Self-Assessment (33-40) – Accomplishments
1
1
Scanning the Environment (23)
2
0
Reality Check (from professional colleague)
2
0
Conclusion
0.5
0.5
APA: Paper, font, spacing, margins, indentations, seriation, paging, running heads, headings (not for introduction), title page (course title included), quotations, citations, reference page.
First person OK this paper; no bullets this paper
2
1
Grammar: periods, commas, semicolons, colons, dashes, hyphens, quotation marks, parentheses, slashes, capitalization, italics, numbers, verb tense, jargon, bias, pronouns, prepositions, spelling
2
2
Total
15
8.25=9.25
Comments:
Your values are unique. They will help you wherever you practice. Your self-assessment of your knowledge and skills was superb - honest, complete, and very well written. I am not surprised at all about your two novels. You write well, with good grammar, appropriate word choice, and an easy style. I do hope to read those novels soon. Your accomplishments are also commendable! You did a fantastic job with the pieces that you wrote, but you did not complete the assignment. I would have loved to read about your vision of being a nursing instructor under the heading ‘Vision.’ A scan of school and national trends would help to inform you about that vision – is it realistic? Does the ‘environment’ support teaching as a goal – faculty shortage, etc? In addition, a reality check from those you respect is critical in your assessment to confirm your strengths and point our areas for improvement. The content of your paper was wonderful; you simply needed more.
Kimberely, I can’t emphasize enough that APA is boring. It has no borders, it is ONLY 12 font, spacing is double always (not 1.5), and everything about it is prescribed. There is no creativity involved - no borders, no boxes, no large fonts, just plain formatting. When you write your papers, you need to have Perrin right beside you and do not stray from the examples given. Review the format for the running head. It is different between the title page and the remaining pages. The title on page 2 is simple 12 font centered. You were correct to cite Waddell on the reference page, but it must also be in your paper. A good place for this would be in the introduction. I noticed you did not include an introduction. In an introduction, you could state that you are using their model to complete your self-assessment. The reference page is also to be double-spaced. You did a great job with the headers. Again, your writing itself is outstanding!
LOOKING AT ME: A SELF-ASSESSMENT
Kimberely S. Strickland
NUCO 4430 Transition / Validation Seminar I
University of Virginia School of Nursing
October 12, 2010
MIRROR, MIRROR
LOOKING AT ME: A SELF-ASSESSMENT
Values
As a nurse, I always try to act in the best interests of the patient. In order to achieve this goal, I am honest about my shortcomings. I practice with an open mind and a questioning attitude. I have seen many nurses make avoidable mistakes because they were too afraid or too proud to consult a colleague when they could have asked a few questions. Additionally, if I make a mistake, I admit it quickly so that no harm comes to the patient. Admitting mistakes increases both my knowledge and patient safety. Another important facet of nursing is teamwork. Even though each patient is assigned one nurse, we must act as a team in order to put the needs of the patient first. For example, two or more people are required to pull up a patient in bed safely, two nurses check insulin to ensure a correct dose, and two or more nurses are often needed to decipher a doctor’s handwritten orders. Without honesty, an open mind, admission of mistakes, and teamwork, patient safety is always compromised.
Knowledge
I attended nursing school at Surry Community College and graduated in May 2006. However, this is not my first degree. I earned an Associate of Arts from Surry in 1993 and a Bachelor of Arts in Communications from Salem College in 1995[KH1] . My first job out of nursing school was on a step down unit at a small community hospital. I stayed there for two years before moving onto a medical-surgical unit at a major hospital in one of the largest cities in the state. When I started this second job, I had as much confidence as a new nurse[KH2] as I did that first day on the job even though I had two years experience. Now, I have two years experience on this busy unit and have seen a range of diagnoses from anemia to zinc deficiency. Because of this experience, I now feel that I can work on any unit and be successful.
One of my greatest strengths is my ability to talk to almost anyone in any given situation. My supervisors, co-workers, and patients compliment me on my honesty and clarity when conveying important information. Many times, I must translate what the doctor told the patient into more easily understandable terms. Sometimes, I may give the newly-admitted patient a preview of what to expect when the doctor arrives. Other times, I’ll help the patient and family formulate a list of questions for the doctor so none are unanswered. This helps me to establish a rapport with my patients and their families rather quickly so that trust is not an issue. This rapport and trust serves the patients and families well because they aren’t afraid to approach me if issues or new questions arise.
Active listening is another skill that has been honed since I became a nurse. This has been one of the most difficult skills to sharpen because I have an innate ability to tune out people, even those who are in close proximity to me. I have had to learn to focus my attention on what’s being said at that moment to prevent my mind from wandering. This skill is currently serving me well in the academic world as I pursue another degree.
Interests
I have a wide variety of interests but not a lot of time to pursue them, unfortunately. One of my favorite things is writing. When I was a little girl, I had several pen pals from foreign lands and corresponded with them for many years. When I matured into adolescence, I wrote silly poems about my job or family or pets. I was in my late thirties when I realized that I had the writing skills to pen a novel. Now I have two in the works.
Another love is teaching. I have always enjoyed sharing my knowledge and skills with others. I enjoy that moment of enlightenment when the student realizes what the teacher is trying to teach. Anytime students are assigned to my unit, I make a point of introducing myself and offering my assistance, whether they are assigned to my patients or not. After I graduate with my bachelor’s degree, I may pursue graduate school and a subsequent career as a nursing instructor[KH3] .
Accomplishments
Four accomplishments rank among the largest in my nursing career to date. First, I was selected to join the Magnet Committee for our hospital. This committee helps to educate the nursing staff about what Magnet means and cement our continued commitment to maintaining Magnet status. Second, I was also chosen to join the Safety Committee. This committee reviews medication mistakes made throughout the facility and devises methods to avoid these mistakes in the future. The committee also reviews current nursing practice to determine if more safe guidelines could be implemented. Third, I was chosen by my manager to participate on the Nurses’ Week Committee. This committee implemented a week-long celebration to honor the facility’s nursing staff. Fourth, I was admitted to the University of Virginia. I was extremely excited when I received the notification and am eagerly anticipating where my degree will lead me.
Conclusion
Looking at me is something I’ve never really enjoyed although it is a task that is constructive from time to time. Completing this self-assessment has confirmed my suspicion that I want to pursue higher education beyond my current pursuit. Completing the exercises required for the self-assessment has increased my confidence as a nurse as well by demonstrating that I have more knowledge and skills than I sometimes give myself credit.
References
Waddell, J., Donner, G., & Wheeler, M. (2009). Building your nursing career (3rd ed.). Toronto: Mosby Elsevier.
Waddell, J., Donner, G. J., & Wheeler, M. M. (2009). Building your nursing career: A Guide for students (3rd ed.). Ontario, Canada: Elsevier Canada.
[KH1]This is very impressive and will truly be an asset to your career
[KH2]You are not alone. Change and being the new man on the block is always humbling
[KH3]OK…we need to talk as we are looking at a new program that may interest you!
Career Self Assessment Paper
Name: Kimberely Strickland
Points
Total
Introduction
0.5
0.25
Vision - Description of your vision or picture of your future career
2
.5
Self-Assessment (33-40) – Values
1
1
Self-Assessment (33-40) - Knowledge and Skills
1
1
Self-Assessment (33-40) – Interests
1
1
Self-Assessment (33-40) – Accomplishments
1
1
Scanning the Environment (23)
2
0
Reality Check (from professional colleague)
2
0
Conclusion
0.5
0.5
APA: Paper, font, spacing, margins, indentations, seriation, paging, running heads, headings (not for introduction), title page (course title included), quotations, citations, reference page.
First person OK this paper; no bullets this paper
2
1
Grammar: periods, commas, semicolons, colons, dashes, hyphens, quotation marks, parentheses, slashes, capitalization, italics, numbers, verb tense, jargon, bias, pronouns, prepositions, spelling
2
2
Total
15
8.25=9.25
Comments:
Your values are unique. They will help you wherever you practice. Your self-assessment of your knowledge and skills was superb - honest, complete, and very well written. I am not surprised at all about your two novels. You write well, with good grammar, appropriate word choice, and an easy style. I do hope to read those novels soon. Your accomplishments are also commendable! You did a fantastic job with the pieces that you wrote, but you did not complete the assignment. I would have loved to read about your vision of being a nursing instructor under the heading ‘Vision.’ A scan of school and national trends would help to inform you about that vision – is it realistic? Does the ‘environment’ support teaching as a goal – faculty shortage, etc? In addition, a reality check from those you respect is critical in your assessment to confirm your strengths and point our areas for improvement. The content of your paper was wonderful; you simply needed more.
Kimberely, I can’t emphasize enough that APA is boring. It has no borders, it is ONLY 12 font, spacing is double always (not 1.5), and everything about it is prescribed. There is no creativity involved - no borders, no boxes, no large fonts, just plain formatting. When you write your papers, you need to have Perrin right beside you and do not stray from the examples given. Review the format for the running head. It is different between the title page and the remaining pages. The title on page 2 is simple 12 font centered. You were correct to cite Waddell on the reference page, but it must also be in your paper. A good place for this would be in the introduction. I noticed you did not include an introduction. In an introduction, you could state that you are using their model to complete your self-assessment. The reference page is also to be double-spaced. You did a great job with the headers. Again, your writing itself is outstanding!
Standardized Nursing Language
Skin Integrity: Skin Breakdown on Nine General
Kimberely S. Strickland
University of Virginia
NUCO-4430
November 16, 2010
Skin Integrity: Skin Breakdown on Nine General
Immobility, even for short periods, can lead to impaired skin integrity. Bony prominences place pressure on the skin, cutting off the circulation. With no blood flow to the area, the skin will eventually die. The most common areas [KH1] on the body for impaired skin integrity related to immobility are the head, shoulder blades, elbows, sacrum, and heels. The area between the knees is also prone to breakdown. Relieving pressure on these areas is crucial.
Skin integrity, impaired,Impaired Skin Integrity [KH2] is a common nursing diagnosis seen on Nine General, a busy medical-surgical nursing unit at Forsyth Medical Center (FMC) in Winston-Salem, North Carolina. This unit receives scores of patients from skilled nursing facilities weekly, and a majority of these patients have some degree of impaired skin integrity. Patients that arrive from home can also have impaired skin integrity. Almost all of the patients with impaired skin integrity have decreased mobility. Because of limited mobility, these patients are unable to reposition themselves properly and at regular intervals to allow blood to flow to the common areas cited above.
Learning more about how to help these patients will improve their quality of life. Educating nurses about impaired skin integrity will enable them to decrease the prevalence of this nursing diagnosis.
Skin integrity, impaired,Impaired Skin Integrity may be defined as “altered epidermis and/or dermis” (Johnson et al., 2006, p. 401). This definition may apply to redness, burns, ulcers, wounds, cuts, or scrapes. A variety of health issues affect how quickly skin integrity can become impaired. Cardiovascular issues, neurological disorders, hepatic and renal disease, diabetes mellitus, and malnutrition all have an effect on how quickly the skin’s integrity can deteriorate (Jaul, 2010). However, for the purposes of this paper, the nursing diagnosis skin integrity, impaired,Impaired Skin Integrity will relate to issues of immobility.
Perhaps the best way to define this diagnosis is to describe some of its many manifestations. The mildest form of skin integrity, impaired,Impaired Skin Integrity related to immobility may be evidenced by redness on a patient’s sacrum because he the patient has notn’t been turned in four hours, for example. A more severe form would be the peeling epidermis of the sacral area after a week of neglect. In another week, the area deepens and forms a small crater. Continued neglect would lead to an ulcer that would allow anyone to see the patient’s raw sacral bone.
Wound assessment is described by several parameters:
· Site
· Staging (Depth)
· Surface Appearance (Color)
· Infection
· Odor
· Exudate
· Pain
· Undermining of the soft tissue
· Condition of the surrounding skin (Jaul, 2010)
The major risk factors for the nursing diagnosis skin integrity, impairedImpaired Skin Integrity, related to immobility are decreased level of consciousness, limited mobility, impaired senses, and incontinence (Jaul, 2010). Other factors also put the patient at risk: edema, dehydration, poor nutrition, certain medications, immunosuppression, and decreased oxygenation (Jaul, 2010). The identification of a patient’s risk factors on admission is crucial to ensuring the best outcome (Senturan et al., 2009). The Norton and Braden scales are two devices used to assess this risk but neither account for oxygenation or perfusion (Senturan et al., 2009). The Braden scale is used daily in shift assessments on Nine General and when transferring patients between units or to a skilled nursing facility.
Pressure management, “minimizing pressure to body parts”, is an important intervention whichintervention, which can be utilized by the nurse to preserve a patient’s skin integrity (Bulechek, Butcher, & Dochterman, 2008, p. 585[KH3] ). To be successful, the nurse should do the following:
· Dress patient in nonrestrictive clothing
· Place on appropriate therapeutic mattress / bed
· Refrain from applying pressure to the affected body part
· Turn the immobilized patient at least every 2 hours, according to a specific schedule
· Facilitate small shifts of body weight
· Monitor patient’s mobility and activity
· Use an established risk assessment tool to monitor patient’s risk factors (e.g., Braden scale)
· Make bed with toe pleats
· Apply heel protectors, as appropriate
· Monitor the patient’s nutritional status
· Monitor for sources of pressure and friction (Bulechek et al., 2008, p. 585)
All of the above are utilized on Nine General to increase improve patient outcomes[KH4] .
A closely-relatedclosely related intervention that can be utilized by the nurse is pressure ulcer prevention (Bulechek et al., 2008). This intervention is preventative and lists steps to maintain skin integrity. For example, the nurse should:
· Document skin status on admission and daily
· Document weight and shifts in weight
· Monitor any reddened areas closely
· Remove excessive moisture on the skin resulting from perspiration, wound drainage, and fecal or urinary incontinence
· Keep bed linens clean, dry, and wrinkle-free
· Moisturize dry, unbroken skin
· Monitor for sources of pressure and friction
· Avoid “donut” devices to sacral area
· Use devices on the bed to protect the individual (Bulechek et al., 2008, p. 587)., Butcher, & Dochterman, 2008)
Again, all[KH5] of the above are utilized on Nine General as preventative methods. Pressure management and pressure ulcer prevention are two closely-relatedclosely related interventions that are used concurrently to prevent impaired skin integrity. Many of the steps found listed with one intervention are also found onlisted with the other.
FMC[KH6] also provides a skin care kit that can be utilized by the nurses at their discretion. The three-part kit must be obtained on a medication override.[KH7] It contains a skin cleanser, a moisturizer, and a protective gel. This kit is used many times daily on this unit. Any time a certified nursing assistant (CNA) or nurse views an appropriate skin impairment on a patient, the nurse will obtain the kit.
Immobility also affects a patient’s ability to eliminate wastes. If a patient is incontinent, prevention of skin breakdown becomes more difficult. Urinary and fecal incontinence both put moisture and bacteria against the skin (Beldon, 2008). This creates the perfect environment for compromising skin integrity. The moisture combines with the bacteria and enzymes in the excrement to strip away the epidermis, thus leaving a distinctive lesion that appears raw and reddened around the peri-anal area (Beldon, 2008).
Nurses at FMC have a great deal of autonomy where skin care is concerned. Part of FMC’s standards of care and practice plan for the prevention of skin impairment and altered skin integrity includes routine skin care orders. At her the nurse’s discretion, the nurse may order the care that she/he believes the patient needs without the physician’s approval. She The nurse completes the pre-printed order sheet provided by the facility and scans it to the pharmacy.[KH8] The order sheet addresses issues such as incontinence care, skin tears, redness, partial thickness ulcers, and deep wounds (Forsyth Medical Center, 2008).
Jaul proposes that decreased mobility leads to many complications and treatment should be started early and quickly to prevent problems (2010). Guidelines for repositioning are:
· Recumbent patients should be repositioned a minimum of every two hours
· Seated patients should be repositioned every fifteen to thirty minutes (Jaul, 2010, p. ?)
Frequent repositioning is the primary means of avoiding impaired skin integrity (Jaul, 2010). This relieves the pressure on bony prominences and allows blood to flow to the area. Pressure-reduction products, such as heel and elbow protectors, are also effective methods of maintaining skin integrity and relieving pressure (Walsh & Plonczynski, 2007). However, the nurse must remember that these devices alone are not sufficient to maintain skin integrity and must be used as part of a plan of care (Padula, Osbourne, & Williams, 2008).
At FMC, all patients are screened on admission using the Braden scale. At-risk patients are identified. Mobility issues are considered and proper measures are implemented to decrease the risk of skin impairment. These patients are repositioned frequently. FMC policy follows Jaul’s recommendations of every two hours for recumbent patients and every fifteen to thirty minutes for seated patients (Jaul, 2010).[KH9] Nurses and CNAs also make frequent use of the skin care kits. Generally, heel and elbow protectors are not used. Instead, arms and legs are propped with pillows and rolled towels in such a way to avoid pressure to those areas. AlsoIn addition, a pillow is placed between the patient’s knees to avoid pressure in this area.
The use of pillows and linens to relieve pressure is very effective. Many patients are able to move to some degree so these the patient much be checked frequently to ensure that the props remainy are in place. The skin care kits are very effective at protecting the patients’ skin integrity. The cleanser is very gentle and rarely causes any irritation. The moisturizer and protective gel are often mixed and massaged into the patients’ skin to stimulate blood flow while moisturizing and protecting the patients’ largest organs. Not only do the patients enjoy these mini massages, but they also comment on how much better the area feels after the application[KH10] .
FMC policy is conducive to excellent patient skin care. Because every patient receives a skin assessment by a registered nurse on admission, no issues of impaired skin integrity go unnoticed. Because of the autonomy the facility grants to the nurses, they can order what is needed without having to wait on for the physician’s specific order to do so. The nurse’s orders are quickly and aggressively implemented, as recommended by Padula et al , Osbourne, and Williams (2008).
The only outcome relevant [KH11] [KH12] to the selected nursing diagnosis as it relates to mobility issues is Tissue Integrity: Skin and Mucous Membranes (1101). The definition is “structural intactness and normal physiological function of skin” (Moorhead, Johnson, Maas, & Swanson, 2008, p. 699). The rating scale for the indicators is below[KH13] :
· 1 Severely Compromised / severe
· 2 Substantially Compromised / substantial
· 3 Moderately Compromised / Moderate
· 4 Mildly Compromised / Mild
· 5 Not Compromised / None (Moorhead et al., 2008, p. 699)
The outcome indicators and definitions are listed below:
· Skin temperature (110101): The skin should feel lukewarm to the touch. Skin that is too hot is abnormal.
· Sensation (110102): The patient should feel your touch on his skin.
· Elasticity (110103): When pulled away from the body, skin should return to its normal position. Skin elasticity decreases as people age.
· Hydration (110104): Moisturize the skin with appropriate lotions and skin care products.
· Perspiration (110104): Wetness helps to create an ideal environment for impairing skin integrity. If the patient is perspiring, adjust the room temperature or the number of blankets until the environment is comfortable and perspiration is no longer a problem.
· Texture (110108): The texture of the patient’s skin is noted on the initial assessment. Is the skin thin, dry, peeling, or red? These factors can contribute to impaired skin integrity.
· Tissue perfusion (110111): Ensure that the peripheral pulses are strong and equal. Assess the capillary refill.
· Skin integrity (110113): Assess the patient for any open areas.
· Erythema (110121): Skin redness may be an early indicator of pressure issues.
· Necrosis (110123): Premature skin death occurs when pressure has eliminated the blood supply to an area for an extended length of time (Moorhead et al., 2008, p. 699).
The above indicators are utilized daily on Nine General as a means of measuring how the patients are responding to the nursing interventions. They are included in the plan of care by the initiating nurse as a means of communicating with subsequent nurses. This will ensure continuity of care for the patient and increase the chance for a better outcome. All of the outcomes are not placed on one care plan at one time but are chosen for each patient based on his assessment and situation. Individualizing the plan of care also ensures that the patient will receive the most appropriate care possible.
With an aging population suffering from health issues that deteriorate mobility, the nursing diagnosis of Impaired Skin Integrity deserves much attention. Impaired skin integrity can lead to complications of ulcers, infection, sepsis, and ultimately death[KH14] . By using simple devices and linens on the unit, pressure can be decreased or eliminated on bony prominences and blood flow to high-risk areas can be maintained in a manner that does not put the patients’ skin integrity at risk.
Staff[KH15] on Nine General will receive education and in-service training about how to care for patients with impaired skin integrity. The education will include photos and explanations about interventions that can be implemented to improve outcomes for their patients. Staff will also be reminded about the facility’s policy regarding repositioning. Currently, a patient care representative is[KH16] making rounds on the unit to ensure that staff members perform their duties in a manner that is satisfying to the patient while complying with facility policy. During this re-training, repositioning and skin care will be added to this check listchecklist to ensure that patient care standards are being maintained. Staff will be encouraged to ask questions or offer suggestions to improve care. Patients who are capable will also be made active participants. They will be educated about maintaining skin integrity and repositioning guidelines. They will be instructed to call for help when turning or repositioning. Additionally, staff will be encouraged to remain alert to new situations that may be used to help staff better understandbetter understand how to improve current methods to maintain and/or improve their patients’ skin integrity. These situations will then be used in ongoing education for stafffor staff so that they may deliver the best possible care for their patients.
References
Beldon, P. (2008). Problems encountered managing pressure ulceration of the sacrum. British Journal of Community Nursing, 13(12), 6-12.
Bulechek, G. M., Butcher, H. K., & Dochterman, J. M. (Eds.). (2008). Nursing interventions classification (NIC) (5th ed.). St. Louis, MO: Mosby Elsevier.
Forsyth Medical Center (2008, May). Standards of care and practice: Prevention of skin impairment/altered skin integrity. Retrieved November 1, 2010, from employee intranet[KH17]
Jaul, E. (2010). Assessment and management of pressure ulcers in the elderly: current strategies. Drugs & Aging, 27(4), 311-325.
Johnson, M., Bulechek, G., Butcher, H., Dochterman, J. M., Maas, M., Moorhead, S., & Swanson, E. (Eds.). (2006). NANDA, NOC, and NIC Linkages (2nd ed.). St. Louis, MO: Mosby Elsevier.
Moorhead, S., Johnson, M., Maas, M. L., & Swanson, E. (Eds.). (2008). Nursing outcomes classification (NOC) (4th ed.). St. Louis, MO: Mosby Elsevier.
Padula, C. A., Osbourne, E., & Williams, J. (2008). Prevention and early detection of pressure ulcers in hospitalized patients. Journal of Wound, Ostomy and Continence Nursing, 35(1), 66-75.
Senturan, L., Karabacak, U., Ozdilek, S., Alpar, S. E., Bayrak, S., Yuceer, S., & Yoldz, N. (2009). The relationship among pressure ulcers, oxygenation, and perfusion in mechanically ventilated patients in an intensive care unit. Journal of Wound and Ostomy Care, 35(5), 503-508.
Walsh, J. S., & Plonczynski, D. J. (2007). Evaluation of a protocol for prevention of facility-acquired heel pressure ulcers. Journal of Wound, Ostomy, & Continence Nursing, 34(2), 178-183.
Criteria for Grading Formal Paper on Standardized Nursing Language
25/25 Descriptions of diagnosis (definition, characteristics, etc). Description of intervention and analysis of nursing activities listed in the text
Dx is from NANDA list and defined. For defining characteristics you shared two extremes of mild and that associated with severe neglect. You nicely described how the dx applies to your population. You defined the nursing intervention and included a second intervention. And yes, while they are similar, your focus would have been better on one to allow you the depth to then analyze the literature. You share well your reasons for selecting this intervention. You also described, defined and summarized the activities listed in the intervention (NIC text) that were specific to your patients.
22/25 Use of & analysis of current literature about intervention
Your intervention was Pressure Management. Your paper and your analysis should be entirely focused on this, pressure management. From your review of the literature, are there new activities that need to be evaluated for inclusion in Bulechek? Are there activities that should be eliminated? What is the current literature on the beds that are being used? What you did with Braden was perfect … you critiqued it for what was missing. That’s the analysis that you want!! Are there better scales? This skin care kit, you need to ask yourself, is this evidence based? If not, that may be in your conclusion as to what you could do; can you do a research study to prove that the gel is effective? You did do a nice job of relating what you read to your practice. You brought it in throughout. You did a good job of noting how your policy is consistent with Bulechek and implying that your policy makes the nurses stay on top of the quality of care. What I want you to work toward is that focused analysis to bring it altogether for your reader. You don’t want the reader to have to work.
25 / 25 Description & analysis of outcome(s)
You did a better job of getting the ONE outcome you wanted and your explanation of why you chose only one was perfect. Careful with not using the scales verbatim per the authors. Semantics is the issue here and the reason why they used two scales.
9 /10 Summary and Conclusions
You spoke well about what is going on with your unit specific to this intervention. Is there more that can be done beyond your unit that you can work toward? My concern was more with the writing. See below.
12 /15 Quality of writing, use of correct format (APA).
APA basics well done! You really got that down pat, except for one very important piece. You are quoting from these sources and you need page numbers associated with the definition and the lists that you include. Think of your lists as those long quotes that are indented. Writing … I believe it can be cleaner and stronger. You used your journals to discuss the activities, but you need to tie it all together. You need to keep the focus entirely on the one intervention you chose, the focus of your paper. Doing so, you need to refer to it often. Also, try to branch out to more journals. There were times that you needed supportive citations and they weren’t there.
Grade: 93 Overall, a very good paper. Well done.
[KH1]Source is important – you need a citation.
[KH2]Remember from class, when you use it as the nursing diagnosis, each word is capitalized (see SNL PowerPoint on Collab)
[KH3]You must use quotes and give the page numbers, otherwise, it’s plagiarism.
[KH4]Somehow you need to acknowledge that these are 11 of the 18 activities presented by Bulechek et al.
[KH5]See comment above.
[KH6]APA – do not begin sentences with abbreviations.
[KH7]Important?
[KH8]Importance?
[KH9]Good!
[KH10]Is this measure evidence based practice?
[KH11]Excellent – you explained well why you chose the outcome you did and you explained it in one sentence!!
[KH12]Did you use Johnson to decide which outcome to use?
[KH13]There are two scales used for these indicators, not just this one. While they are very much alike, both need to be included.
[KH14]You again need a source
[KH15]Need a transition sentence to this. It’s exactly what you need to be writing, but you need to transition your reader to this change in thought. The change to “will” and future tense needs to be revisited with this transition.
[KH16]Currently is vs. will make the paragraph confusing.
[KH17]Check Perrin
Kimberely S. Strickland
University of Virginia
NUCO-4430
November 16, 2010
Skin Integrity: Skin Breakdown on Nine General
Immobility, even for short periods, can lead to impaired skin integrity. Bony prominences place pressure on the skin, cutting off the circulation. With no blood flow to the area, the skin will eventually die. The most common areas [KH1] on the body for impaired skin integrity related to immobility are the head, shoulder blades, elbows, sacrum, and heels. The area between the knees is also prone to breakdown. Relieving pressure on these areas is crucial.
Skin integrity, impaired,Impaired Skin Integrity [KH2] is a common nursing diagnosis seen on Nine General, a busy medical-surgical nursing unit at Forsyth Medical Center (FMC) in Winston-Salem, North Carolina. This unit receives scores of patients from skilled nursing facilities weekly, and a majority of these patients have some degree of impaired skin integrity. Patients that arrive from home can also have impaired skin integrity. Almost all of the patients with impaired skin integrity have decreased mobility. Because of limited mobility, these patients are unable to reposition themselves properly and at regular intervals to allow blood to flow to the common areas cited above.
Learning more about how to help these patients will improve their quality of life. Educating nurses about impaired skin integrity will enable them to decrease the prevalence of this nursing diagnosis.
Skin integrity, impaired,Impaired Skin Integrity may be defined as “altered epidermis and/or dermis” (Johnson et al., 2006, p. 401). This definition may apply to redness, burns, ulcers, wounds, cuts, or scrapes. A variety of health issues affect how quickly skin integrity can become impaired. Cardiovascular issues, neurological disorders, hepatic and renal disease, diabetes mellitus, and malnutrition all have an effect on how quickly the skin’s integrity can deteriorate (Jaul, 2010). However, for the purposes of this paper, the nursing diagnosis skin integrity, impaired,Impaired Skin Integrity will relate to issues of immobility.
Perhaps the best way to define this diagnosis is to describe some of its many manifestations. The mildest form of skin integrity, impaired,Impaired Skin Integrity related to immobility may be evidenced by redness on a patient’s sacrum because he the patient has notn’t been turned in four hours, for example. A more severe form would be the peeling epidermis of the sacral area after a week of neglect. In another week, the area deepens and forms a small crater. Continued neglect would lead to an ulcer that would allow anyone to see the patient’s raw sacral bone.
Wound assessment is described by several parameters:
· Site
· Staging (Depth)
· Surface Appearance (Color)
· Infection
· Odor
· Exudate
· Pain
· Undermining of the soft tissue
· Condition of the surrounding skin (Jaul, 2010)
The major risk factors for the nursing diagnosis skin integrity, impairedImpaired Skin Integrity, related to immobility are decreased level of consciousness, limited mobility, impaired senses, and incontinence (Jaul, 2010). Other factors also put the patient at risk: edema, dehydration, poor nutrition, certain medications, immunosuppression, and decreased oxygenation (Jaul, 2010). The identification of a patient’s risk factors on admission is crucial to ensuring the best outcome (Senturan et al., 2009). The Norton and Braden scales are two devices used to assess this risk but neither account for oxygenation or perfusion (Senturan et al., 2009). The Braden scale is used daily in shift assessments on Nine General and when transferring patients between units or to a skilled nursing facility.
Pressure management, “minimizing pressure to body parts”, is an important intervention whichintervention, which can be utilized by the nurse to preserve a patient’s skin integrity (Bulechek, Butcher, & Dochterman, 2008, p. 585[KH3] ). To be successful, the nurse should do the following:
· Dress patient in nonrestrictive clothing
· Place on appropriate therapeutic mattress / bed
· Refrain from applying pressure to the affected body part
· Turn the immobilized patient at least every 2 hours, according to a specific schedule
· Facilitate small shifts of body weight
· Monitor patient’s mobility and activity
· Use an established risk assessment tool to monitor patient’s risk factors (e.g., Braden scale)
· Make bed with toe pleats
· Apply heel protectors, as appropriate
· Monitor the patient’s nutritional status
· Monitor for sources of pressure and friction (Bulechek et al., 2008, p. 585)
All of the above are utilized on Nine General to increase improve patient outcomes[KH4] .
A closely-relatedclosely related intervention that can be utilized by the nurse is pressure ulcer prevention (Bulechek et al., 2008). This intervention is preventative and lists steps to maintain skin integrity. For example, the nurse should:
· Document skin status on admission and daily
· Document weight and shifts in weight
· Monitor any reddened areas closely
· Remove excessive moisture on the skin resulting from perspiration, wound drainage, and fecal or urinary incontinence
· Keep bed linens clean, dry, and wrinkle-free
· Moisturize dry, unbroken skin
· Monitor for sources of pressure and friction
· Avoid “donut” devices to sacral area
· Use devices on the bed to protect the individual (Bulechek et al., 2008, p. 587)., Butcher, & Dochterman, 2008)
Again, all[KH5] of the above are utilized on Nine General as preventative methods. Pressure management and pressure ulcer prevention are two closely-relatedclosely related interventions that are used concurrently to prevent impaired skin integrity. Many of the steps found listed with one intervention are also found onlisted with the other.
FMC[KH6] also provides a skin care kit that can be utilized by the nurses at their discretion. The three-part kit must be obtained on a medication override.[KH7] It contains a skin cleanser, a moisturizer, and a protective gel. This kit is used many times daily on this unit. Any time a certified nursing assistant (CNA) or nurse views an appropriate skin impairment on a patient, the nurse will obtain the kit.
Immobility also affects a patient’s ability to eliminate wastes. If a patient is incontinent, prevention of skin breakdown becomes more difficult. Urinary and fecal incontinence both put moisture and bacteria against the skin (Beldon, 2008). This creates the perfect environment for compromising skin integrity. The moisture combines with the bacteria and enzymes in the excrement to strip away the epidermis, thus leaving a distinctive lesion that appears raw and reddened around the peri-anal area (Beldon, 2008).
Nurses at FMC have a great deal of autonomy where skin care is concerned. Part of FMC’s standards of care and practice plan for the prevention of skin impairment and altered skin integrity includes routine skin care orders. At her the nurse’s discretion, the nurse may order the care that she/he believes the patient needs without the physician’s approval. She The nurse completes the pre-printed order sheet provided by the facility and scans it to the pharmacy.[KH8] The order sheet addresses issues such as incontinence care, skin tears, redness, partial thickness ulcers, and deep wounds (Forsyth Medical Center, 2008).
Jaul proposes that decreased mobility leads to many complications and treatment should be started early and quickly to prevent problems (2010). Guidelines for repositioning are:
· Recumbent patients should be repositioned a minimum of every two hours
· Seated patients should be repositioned every fifteen to thirty minutes (Jaul, 2010, p. ?)
Frequent repositioning is the primary means of avoiding impaired skin integrity (Jaul, 2010). This relieves the pressure on bony prominences and allows blood to flow to the area. Pressure-reduction products, such as heel and elbow protectors, are also effective methods of maintaining skin integrity and relieving pressure (Walsh & Plonczynski, 2007). However, the nurse must remember that these devices alone are not sufficient to maintain skin integrity and must be used as part of a plan of care (Padula, Osbourne, & Williams, 2008).
At FMC, all patients are screened on admission using the Braden scale. At-risk patients are identified. Mobility issues are considered and proper measures are implemented to decrease the risk of skin impairment. These patients are repositioned frequently. FMC policy follows Jaul’s recommendations of every two hours for recumbent patients and every fifteen to thirty minutes for seated patients (Jaul, 2010).[KH9] Nurses and CNAs also make frequent use of the skin care kits. Generally, heel and elbow protectors are not used. Instead, arms and legs are propped with pillows and rolled towels in such a way to avoid pressure to those areas. AlsoIn addition, a pillow is placed between the patient’s knees to avoid pressure in this area.
The use of pillows and linens to relieve pressure is very effective. Many patients are able to move to some degree so these the patient much be checked frequently to ensure that the props remainy are in place. The skin care kits are very effective at protecting the patients’ skin integrity. The cleanser is very gentle and rarely causes any irritation. The moisturizer and protective gel are often mixed and massaged into the patients’ skin to stimulate blood flow while moisturizing and protecting the patients’ largest organs. Not only do the patients enjoy these mini massages, but they also comment on how much better the area feels after the application[KH10] .
FMC policy is conducive to excellent patient skin care. Because every patient receives a skin assessment by a registered nurse on admission, no issues of impaired skin integrity go unnoticed. Because of the autonomy the facility grants to the nurses, they can order what is needed without having to wait on for the physician’s specific order to do so. The nurse’s orders are quickly and aggressively implemented, as recommended by Padula et al , Osbourne, and Williams (2008).
The only outcome relevant [KH11] [KH12] to the selected nursing diagnosis as it relates to mobility issues is Tissue Integrity: Skin and Mucous Membranes (1101). The definition is “structural intactness and normal physiological function of skin” (Moorhead, Johnson, Maas, & Swanson, 2008, p. 699). The rating scale for the indicators is below[KH13] :
· 1 Severely Compromised / severe
· 2 Substantially Compromised / substantial
· 3 Moderately Compromised / Moderate
· 4 Mildly Compromised / Mild
· 5 Not Compromised / None (Moorhead et al., 2008, p. 699)
The outcome indicators and definitions are listed below:
· Skin temperature (110101): The skin should feel lukewarm to the touch. Skin that is too hot is abnormal.
· Sensation (110102): The patient should feel your touch on his skin.
· Elasticity (110103): When pulled away from the body, skin should return to its normal position. Skin elasticity decreases as people age.
· Hydration (110104): Moisturize the skin with appropriate lotions and skin care products.
· Perspiration (110104): Wetness helps to create an ideal environment for impairing skin integrity. If the patient is perspiring, adjust the room temperature or the number of blankets until the environment is comfortable and perspiration is no longer a problem.
· Texture (110108): The texture of the patient’s skin is noted on the initial assessment. Is the skin thin, dry, peeling, or red? These factors can contribute to impaired skin integrity.
· Tissue perfusion (110111): Ensure that the peripheral pulses are strong and equal. Assess the capillary refill.
· Skin integrity (110113): Assess the patient for any open areas.
· Erythema (110121): Skin redness may be an early indicator of pressure issues.
· Necrosis (110123): Premature skin death occurs when pressure has eliminated the blood supply to an area for an extended length of time (Moorhead et al., 2008, p. 699).
The above indicators are utilized daily on Nine General as a means of measuring how the patients are responding to the nursing interventions. They are included in the plan of care by the initiating nurse as a means of communicating with subsequent nurses. This will ensure continuity of care for the patient and increase the chance for a better outcome. All of the outcomes are not placed on one care plan at one time but are chosen for each patient based on his assessment and situation. Individualizing the plan of care also ensures that the patient will receive the most appropriate care possible.
With an aging population suffering from health issues that deteriorate mobility, the nursing diagnosis of Impaired Skin Integrity deserves much attention. Impaired skin integrity can lead to complications of ulcers, infection, sepsis, and ultimately death[KH14] . By using simple devices and linens on the unit, pressure can be decreased or eliminated on bony prominences and blood flow to high-risk areas can be maintained in a manner that does not put the patients’ skin integrity at risk.
Staff[KH15] on Nine General will receive education and in-service training about how to care for patients with impaired skin integrity. The education will include photos and explanations about interventions that can be implemented to improve outcomes for their patients. Staff will also be reminded about the facility’s policy regarding repositioning. Currently, a patient care representative is[KH16] making rounds on the unit to ensure that staff members perform their duties in a manner that is satisfying to the patient while complying with facility policy. During this re-training, repositioning and skin care will be added to this check listchecklist to ensure that patient care standards are being maintained. Staff will be encouraged to ask questions or offer suggestions to improve care. Patients who are capable will also be made active participants. They will be educated about maintaining skin integrity and repositioning guidelines. They will be instructed to call for help when turning or repositioning. Additionally, staff will be encouraged to remain alert to new situations that may be used to help staff better understandbetter understand how to improve current methods to maintain and/or improve their patients’ skin integrity. These situations will then be used in ongoing education for stafffor staff so that they may deliver the best possible care for their patients.
References
Beldon, P. (2008). Problems encountered managing pressure ulceration of the sacrum. British Journal of Community Nursing, 13(12), 6-12.
Bulechek, G. M., Butcher, H. K., & Dochterman, J. M. (Eds.). (2008). Nursing interventions classification (NIC) (5th ed.). St. Louis, MO: Mosby Elsevier.
Forsyth Medical Center (2008, May). Standards of care and practice: Prevention of skin impairment/altered skin integrity. Retrieved November 1, 2010, from employee intranet[KH17]
Jaul, E. (2010). Assessment and management of pressure ulcers in the elderly: current strategies. Drugs & Aging, 27(4), 311-325.
Johnson, M., Bulechek, G., Butcher, H., Dochterman, J. M., Maas, M., Moorhead, S., & Swanson, E. (Eds.). (2006). NANDA, NOC, and NIC Linkages (2nd ed.). St. Louis, MO: Mosby Elsevier.
Moorhead, S., Johnson, M., Maas, M. L., & Swanson, E. (Eds.). (2008). Nursing outcomes classification (NOC) (4th ed.). St. Louis, MO: Mosby Elsevier.
Padula, C. A., Osbourne, E., & Williams, J. (2008). Prevention and early detection of pressure ulcers in hospitalized patients. Journal of Wound, Ostomy and Continence Nursing, 35(1), 66-75.
Senturan, L., Karabacak, U., Ozdilek, S., Alpar, S. E., Bayrak, S., Yuceer, S., & Yoldz, N. (2009). The relationship among pressure ulcers, oxygenation, and perfusion in mechanically ventilated patients in an intensive care unit. Journal of Wound and Ostomy Care, 35(5), 503-508.
Walsh, J. S., & Plonczynski, D. J. (2007). Evaluation of a protocol for prevention of facility-acquired heel pressure ulcers. Journal of Wound, Ostomy, & Continence Nursing, 34(2), 178-183.
Criteria for Grading Formal Paper on Standardized Nursing Language
25/25 Descriptions of diagnosis (definition, characteristics, etc). Description of intervention and analysis of nursing activities listed in the text
Dx is from NANDA list and defined. For defining characteristics you shared two extremes of mild and that associated with severe neglect. You nicely described how the dx applies to your population. You defined the nursing intervention and included a second intervention. And yes, while they are similar, your focus would have been better on one to allow you the depth to then analyze the literature. You share well your reasons for selecting this intervention. You also described, defined and summarized the activities listed in the intervention (NIC text) that were specific to your patients.
22/25 Use of & analysis of current literature about intervention
Your intervention was Pressure Management. Your paper and your analysis should be entirely focused on this, pressure management. From your review of the literature, are there new activities that need to be evaluated for inclusion in Bulechek? Are there activities that should be eliminated? What is the current literature on the beds that are being used? What you did with Braden was perfect … you critiqued it for what was missing. That’s the analysis that you want!! Are there better scales? This skin care kit, you need to ask yourself, is this evidence based? If not, that may be in your conclusion as to what you could do; can you do a research study to prove that the gel is effective? You did do a nice job of relating what you read to your practice. You brought it in throughout. You did a good job of noting how your policy is consistent with Bulechek and implying that your policy makes the nurses stay on top of the quality of care. What I want you to work toward is that focused analysis to bring it altogether for your reader. You don’t want the reader to have to work.
25 / 25 Description & analysis of outcome(s)
You did a better job of getting the ONE outcome you wanted and your explanation of why you chose only one was perfect. Careful with not using the scales verbatim per the authors. Semantics is the issue here and the reason why they used two scales.
9 /10 Summary and Conclusions
You spoke well about what is going on with your unit specific to this intervention. Is there more that can be done beyond your unit that you can work toward? My concern was more with the writing. See below.
12 /15 Quality of writing, use of correct format (APA).
APA basics well done! You really got that down pat, except for one very important piece. You are quoting from these sources and you need page numbers associated with the definition and the lists that you include. Think of your lists as those long quotes that are indented. Writing … I believe it can be cleaner and stronger. You used your journals to discuss the activities, but you need to tie it all together. You need to keep the focus entirely on the one intervention you chose, the focus of your paper. Doing so, you need to refer to it often. Also, try to branch out to more journals. There were times that you needed supportive citations and they weren’t there.
Grade: 93 Overall, a very good paper. Well done.
[KH1]Source is important – you need a citation.
[KH2]Remember from class, when you use it as the nursing diagnosis, each word is capitalized (see SNL PowerPoint on Collab)
[KH3]You must use quotes and give the page numbers, otherwise, it’s plagiarism.
[KH4]Somehow you need to acknowledge that these are 11 of the 18 activities presented by Bulechek et al.
[KH5]See comment above.
[KH6]APA – do not begin sentences with abbreviations.
[KH7]Important?
[KH8]Importance?
[KH9]Good!
[KH10]Is this measure evidence based practice?
[KH11]Excellent – you explained well why you chose the outcome you did and you explained it in one sentence!!
[KH12]Did you use Johnson to decide which outcome to use?
[KH13]There are two scales used for these indicators, not just this one. While they are very much alike, both need to be included.
[KH14]You again need a source
[KH15]Need a transition sentence to this. It’s exactly what you need to be writing, but you need to transition your reader to this change in thought. The change to “will” and future tense needs to be revisited with this transition.
[KH16]Currently is vs. will make the paragraph confusing.
[KH17]Check Perrin
Adult Case Study
Validation Case Study I
NUCO 4430: Transition and Validation Seminar I
October 26, 2010
Kimberely S. Strickland
University of Virginia
One: The most obvious symptom of a compound fracture is the bone protruding through the patient’s skin. Other indications of this type of fracture are edema at the site, pain and tenderness, false motion, and extremity deformity (Nettina, 2006). Another sign is bleeding at the site. Because the bone has burst through muscle, blood vessels, subcutaneous tissue, and skin to make contact with the outside world, these would be damaged as well. Nerve damage is also certain and the clinician can expect to see parasthesia as a result.
As swelling continues, the nurse should look for the classic signs of ischemia: pain, pallor, pulselessness, paralysis, parasthesia, and poikilothermia (Acute limb ischemia, 2006). After only six hours, irreversible changes can occur if ischemia is left untreated (2006). The nurse should also be on alert for signs of shock. Bones are extremely vascular and an injury such as this can lead to loss of large amounts of blood both outside and inside the body. Anxiety, vertigo, shallow breathing, increasing heart rate, clammy skin, unconsciousness, and decreased urine output are all signs of shock.
Because Mr. Vasquez is a smoker, his risk of infection is more than twice that of a non –smoker (Castillo, Bosse, MacKenzie, & Patterson, 2005). His rib fractures will discourage him from deep breathing and could lead to pneumonia. Another serious complication of a fracture is an embolism and the nurse should be alert at all times for respiratory distress, mental status changes, and fever (Nettina, 2006). Decreased mobility is also a potential complication with any fracture of the lower extremities.
To diagnose a compound fracture, the physician would certainly order an X-ray and CT scan of the left leg and ribs. The nurse should also expect a complete blood count, basic metabolic panel, PT/INR, arterial blood gas, cardiac enzyme series, serum albumin, liver function tests, BUN, creatinine and a urine analysis and culture. The patient will also be typed and cross-matched for a possible blood transfusion. The physician would likely order an angiography to assess the extent of blood vessel damage. Because of the soft tissue injuries associated with this fracture, an MRI would probably be ordered as well. She should also expect telemetry and pulse oximetry monitoring. Because Mr. Vasquez has a dry, hacking cough, night sweats, and fatigue, the nurse should expect the chest X-ray to indicate tuberculosis. If this is the case, the patient shall be placed on airborne isolation.
Prior to surgery, the nurse wants to ensure that the patient understands his N.P.O. status to prevent any risk of aspiration during surgery. She should also view all the lab results and alert the doctor to any abnormalities. If her facility requires a pre-operative checklist for the patient, this should be completed and vital signs should be obtained. The patient should be frequently assessed for any signs of complications or change in condition. Urine output should be monitored for any change in color that might indicate hematuria. Pain should be monitored and treated as ordered by the physician. The nurse should also continue to monitor for any blood loss. If a bandage was applied in the emergency department, she must check it frequently for shadowing or saturation.
Also, the nurse needs to talk to the patient and his family and ensure that all their questions have been answered. If the nurse can answer any lingering questions, she must do so. However, if the patient or his family has questions outside her scope of practice, she should alert the physician so that these can be addressed prior to surgery.
After the patient returns from surgery, the nurse should obtain a set of vital signs and perform an assessment immediately. Respiratory function should be closely monitored for any changes, and the patient’s pain must be kept under control. Compartment syndrome and thromboembolism are two serious complications that can develop from this type of injury, and the nurse should be alert to any signs of either condition. Neurological changes such as poor capillary refill, paralysis, pain, tightness, and pulselessness can signal impending compartment syndrome (Nettina, 2006). The physician will likely order anticoagulants to decrease the risk of thromboembolism, but the nurse should monitor the patient closely for calf pain or tenderness, unilateral leg edema, skin warmth and redness, and a fever greater than 100.4 degrees Fahrenheit (Collins, 2009). The area around the fracture area should be monitored for any changes.
Two: Mr. Vasquez is an underweight male with body mass index of 19.9 (Centers for Disease Control, n.d.). His family doesn’t eat a lot of meat and relies on beans for most of their protein. The family eats a variety of vegetables and Mrs. Vasquez bakes fresh bread daily. Mr. Vasquez also drinks three beers every day.
Part of any nutritional history includes diet information which is stated above. During the diet history, the nurse should also ask if the patient has any financial difficulty obtaining food. Mr. Vasquez had stated that the family can’t afford a lot of meat and that the family’s primary source of protein is beans. This is a concern because Mr. Vasquez may not be getting enough protein as well as the recommended daily allowance of vitamins and minerals. Other[KH1] s subjects the interviewer would include are the number of restaurant meals in a given period (including fast food); likes, dislikes, and cravings; food storage and preparation; and diet choices. During this part of the assessment, the nurse should also ask about any gastrointestinal-related health changes in the past year (Forsyth, 2005). For example, questions about nausea, vomiting, and diarrhea; weight loss and gain; swallowing difficulties; and appetite changes would be asked during this part of the patient interview (2005).
The physical assessment is a head-to-toe account of a patient’s nutritional status. This process relies on both subjective data from the patient and objective data from the nurse (Lutz & Przytulski, 2006). She should begin with his overall general appearance. Is he sluggish or peppy? Does he appear obese or thin? Are his hair and nails brittle and thin or healthy and thick? Has he had any vision changes? Do his corneas appear hardened or do his conjunctiva appear pink? Does his mouth appear dry and cracked? Are sores inside? Does the tongue appear normal or swollen? Are all the patient’s teeth intact? Are any caries visible? Does the patient have headaches? Do any areas of his head and neck appear swollen? Is the patient having heart palpitations or problems with the peripheral vasculature (Estes, 2006)? Is his abdomen tender? Has he had any nausea, vomiting, or diarrhea? Have his bowel habits changed (Forsyth, 2005)? Does she detect any ascites? Has the patient had any musculoskeletal issues (2005)? How is his muscle tone? Is he agitated or irritable? Has he experienced any numbness? Is his speech slurred? How are his coordination and gait? When the nurse answers all of the above questions, she will have a good idea of the patient’s physical status. As an example of the worst case scenario, the nurse has assessed the patient and found him to have brittle hair and nails. This could be due to a lack of vitamins and minerals or something as serious as kidney disease. Vision changes could be attributed to age or to diabetes. Mouth sores may be caused by a broken tooth. Dental caries may be the result of too little calcium or too many sweets. Headaches may be the result of too many diet sodas sweetened with aspartame. Swollen cheeks might be due to enlarged glands or goiter. Heart palpitations could be caused by too much caffeine. Changes in appetite may be caused by depression. Changes in bowel habits might be a warning sign of malnutrition. Musculoskeletal changes may be solved by correcting vitamin and mineral deficiencies. Agitation and irritability could be caused by one of hundreds of ailments.
Anthropometrics are the measurements of the human body. These measurements include height, weight, and body proportions (Lutz & Przytulski, 2006). The nurse would begin by taking the patient’s height and weight. She would then calculate the body mass index and assess whether the patient’s measurements are normal. Next, she would calculate the waist/hip ratio. This is obtained by measuring the narrowest point of the waist and the widest point of the hips. The number is calculated by dividing the waist by the hip (2006). Abnormal measurements are linked to obesity (2006). The skinfold thickness test determines body fat reserves and nutrition status (Estes, 2006). Using calipers, the nurse measures the subcutaneous fat between the patient’s acromion process and the olecranon process on his tricep (2006). Since most of the body’s fat is in the subcutaneous tissue, this is a very reliable indicator of body fat (Lutz & Przytulski, 2006). Last, the mid-arm circumference is used to obtain information on skeletal muscle mass. The patient flexes his arm at the elbow and the nurse measures the circumference halfway between the two processes mentioned above (2006). The number is then put into a mathematical formula to determine the range into which the patient falls. Abnormal results may be indicative of kwashikor (protein malnutrition) or marasmus (protein-calorie malnutrition) or a mixture of the two (Estes, 2006).
Mr. Vasquez should complete a three-day diet history (2006). The nurse should obtain the times of his meals and snacks as well as the content to establish a clear picture of his eating habits. Portion size information would also be helpful since he is underweight.
Labs ordered in conjunction with the nutritional assessment and diet history would be:
· White blood count (5,000-10,000 / mm3)
· Glucose (70-100 mg / dL)
· BUN (Blood urea nitrogen) (7-20 mg / dL)
· Creatinine (0.6-1.2 mg / dL)
· Sodium (135-145 mEq / L)
· Potassium (3.5 – 5.0 mEq / L)
· Phosphate (2.4-4.1 mg / dL)
· Magnesium (1.7-2.2 mg / dL)
· Calcium (8.5-10.2 mg / dL)
· Chloride (98-106 mEq / L)
· Albumin (3.4-5.4 g / dL)
· Prealbumin (15-35 mg / dL)
· Folic Acid (2.7-17.0 ng / mL)
· Vitamin B12 (200-900 pg / mL)
· Vitamin D (30.0-74.0 ng / mL)
The values listed are the desired level for each blood test (Forsyth, 2005). The physician might also order a twenty-four hour urine test.
Three: Mr. Vasquez has four nursing diagnoses:
· Pain, Acute, related to leg wound and recent surgery;
· Nutrition: Imbalanced, Less than Body Requirements related to inadequate caloric and protein intake;
· Risk for Constipation, related to immobility, diet changes, and pain medication administration; and
· Risk for Falls, related to leg injury, pain medication administration, and unfamiliar environment.
These four diagnoses will be discussed below.
Nursing Diagnosis: Pain, Acute, related to leg wound and recent surgery
Major Suggested Optional
Nursing Outcomes Interventions Interventions Interventions
Pain Control-1605 Medication Simple Guided Surveillance
Management Imagery -monitor patient
-administer -assist patient to for signs of pain
Uses analgesics as pain medicines use his imagination
recommended as ordered to redirect his attention -Monitor behavior
160505 away from his pain patterns
-Monitor for signs -Plan with patient an -Monitor vital signs,
and symptoms of appropriate time to do as appropriate
drug toxicity guided imagery
-Determine the
patient’s know-
ledge about
medication
Patient-Controlled Teaching: Individual Animal-Assisted
Reports uncon- Anesthesia (PCA) -teach patient about Therapy
trolled symptoms Assistance pharmacological -contact volunteer
to health pro- -teach patient how methods of pain services about
fessional to use the PCA relief putting patient on
160507 their rounds
Rating:
1 Never demonstrated
2 Rarely demonstrated
3 Sometimes demonstrated
4 Often demonstrated
5 Consistently demonstrated
Pain Level-2102 Analgesic Admini- Positioning Music Therapy
stration -Premedicate patient -Determine the
-Determine pain before moving as patient’s interest
location, charac- appropriate in music
teristics, quality,
Length of pain and severity before -Position in proper -Inform the patient
episodes 210204 medicating patient body alignment as to the purpose of
the music
Restlessness 210208 -Check history for -Immobilize or support experience
drug allergies the affected body part, as
appropriate -Assist the patient
Agitation 210222 -Determine analgesic in assuming a
selection based on comfortable
type and severity of position
pain
Rating:
1 Severe
2 Substantial
3 Moderate
4 Mild
5 None
Nursing Diagnosis: Nutrition: Imbalanced, Less than Body Requirements related to inadequate caloric and protein intake
Major Suggested Optional
Nursing Outcomes Interventions Interventions Interventions
Appetite-1014 Nutrition Therapy Nutrition Management Weight Gain Assistance
-select nutritional -encourage calorie intake -discuss possible causes
Desire to eat 101401 supplements, as appropriate for body type of low body weight
appropriate and lifestyle
-Monitor food -Inquire if patient has any -Provide a variety of
Food intake 101406 ingested and cal- food allergies high-calorie nutritious
culate daily caloric foods from which to
intake, as appro- choose
priate
Rating:
1 Severely
Compromised
2 Substantially
Compromised
3 Moderately
Compromised
4 Mildly
Compromised
5 Not Compromised
Nutrient intake 101407
Nutritional Status: Nutritional Monitoring Teaching: Prescribed Diet Sustenance Support
Nutrient Intake-1009 -Monitor skin turgor, -Explain the purpose of -Determine adequacy
as appropriate the diet of patient’s financial situation
Caloric Intake -Weigh patient at -Appraise patient’s
100901 specified intervals current knowledge about -Determine adequacy
prescribed diet of food supplies in
Protein Intake -Monitor albumin, home
100902 total protein, hemo- -Provide written meal
globin, and hemato- plans, as appropriate -Discuss financial aid
crit levels support with the patient
Rating:
1 Not Adequate
2 Slightly Adequate
3 Moderately
Adequate
4 Substantially Adequate
5 Totally Adequate
Nursing Diagnosis: Risk for Constipation, related to immobility, diet changes, and pain medication administration
Major Suggested Optional
Nursing Outcomes Interventions Interventions Interventions
Bowel Elimination- Constipation / Nutritional Medication Adminis-
0501 Impaction Manage- Monitoring tration: Oral
ment
-Monitor for signs -Monitor energy -Follow the five rights of
Elimination and symptoms of level, malaise, medication administration
pattern 050101 constipation fatigue, and
weakness -Note patient’s medical
-Monitor bowel history and history of
sounds -Monitor for allergies
Passage of stool nausea and
without aids -Monitor bowel move- vomiting
050121 ments, including
frequency, consistency,
shape, volume, and
color, as appropriate
Rating:
1 Severely
2 Substantially
Compromised
3 Moderately
Compromised
4 Mildly
Compromised
5 Not Compromised
Self-Care: Toileting Self-Care Assistance: Exercise Therapy: Anxiety Reduction
0310 Toileting Ambulation
-Consider the culture -Dress patient in non- -Use a calm,
of the patient when restrictive clothing reassuring approach
Positions self on promoting self-care
toilet or commode activities -Provide low-height bed, -Clearly state
031005 as appropriate expectations for
-Provide privacy patient’s behavior
during elimination -Consult physical therapist
Gets to toilet between about ambulation plan, as -Explain all
urge and passage of -Remove essential needed procedures,
urine 031014 clothing to allow for including sensations
elimination -Assist patient to transfer, likely to be
Gets to toilet between if needed experienced during
urge and evacuation of the procedure
stool 031015
Rating:
1 Severely
Compromised
2 Substantially
Compromised
3 Moderately
Compromised
4 Mildly
Compromised
5 Not Compromised
Nursing Diagnosis: Risk for Falls, related to leg injury, pain medication administration, and unfamiliar environment
Major Suggested Optional
Nursing Outcomes Interventions Interventions Interventions
Balance-0202 Fall Prevention Environmental Vital Signs Monitoring
Management: Safety
Maintains balance -Identify behaviors -Identify safety needs -Monitor blood pressure,
while standing on and factors that of the patient, based pulse, temperature, and
one foot 020209 affect risk of falls on level of physical respiratory status, as
and cognitive function appropriate
-Monitor gait, and past history of
balance, and behavior -Note trends and wide
Maintains balance fatigue level fluctuations in blood
while walking with ambulation -Modify the environment pressure
020203 to minimize hazards
-Assist unsteady and risk -Monitor lung sounds
Rating: individual with
1 Severely ambulation -Provide adaptive devices -Monitor pulse oximetry
Compromised to increase the safety of
2 Substantially -Place mechanical the environment
Compromised bed in lowest
3 Moderately position
Compromised
4 Mildly
Compromised
5 Not Compromised
Coordinated Body Mechanics Self-Care Assistance Medication Management
Movement Promotion
0212 -Determine patient’s -Assist patient in -Facilitate changes in
commitment to accepting dependency medication with physician,
learning and using needs as appropriate
correct posture
Control of -Instruct patient -Provide desired -Monitor for non-
movement about need for personal articles therapeutic drug
021205 correct posture (e.g., deodorant, reactions
to prevent fatigue, toothbrush, and
strain,or injury bath soap)
-Assist to avoid -Encourage -Determine the patient’s sitting in the same independence but knowledge about
position for intervene when patient medication
prolonged periods is unable to perform
Rating:
1 Severely
Compromised
2 Substantially
Compromised
3 Moderately
Compromised
4 Mildly
Compromised
5 Not Compromised
Four: The Hemovac drainage system is a type of closed drainage system in which blood and exudate are gently sucked out of the patient’s wound and into the reservoir. Removing the exudates serves several purposes. Edema is reduced as are the risk for infection and skin breakdown (Wolters Kluwer / Lippincott Williams & Wilkins, n.d.). Emptying the reservoir every four to six hours ensures optimum suction and reduces strain on the sutures (n.d.). When emptying the drain, the nurse should maintain clean technique and be sure to compress the device fully when she is finished. This will ensure that the system remains closed and continues the gentle suction on the wound. This type of system is commonly seen with orthopedic and abdominal surgeries (n.d.).
Five: The purpose of a blood transfusion is to replenish blood products that a patient has lost through hemorrhage or is lacking because of an illness. For example, a patient involved in a life-threatening car accident has lost a lot of blood and is rushed to the hospital. Lab tests reveal that his hemoglobin is 7.5 gm / dL. The physician would most likely order at least one unit of packed red blood cells to replace some of what the patient has lost. In other cases, illness keeps the hemoglobin level low enough to warrant a unit of packed red blood cells, usually below 8.0 gm / dL. Patients with anemia sometimes find themselves on the receiving end of a bag of blood. Red blood cells carry oxygen in the blood. Anemic patients with low hemoglobin don’t have enough red blood cells to carry the oxygen to their tissues and may need a transfusion to help their blood do its job. Other patients with thrombocytopenia may receive platelets. The normal platelet count is 150,000-450,000 per deciliter. Patients with this disorder have less than 150,000 platelets per deciliter.
Fresh frozen plasma is administered when the patient’s stable plasma coagulation factors are decreased (Forsyth, 2008). The patient may have an allergic reaction with this type of transfusion. Albumin is also administered to patients occasionally to treat shock, trauma, infection, electrolyte imbalances, and hypoproteinamia (2008).
Another less common types of blood transfusion is granulocytes (white blood cells) which is given to patients with very low white blood counts to help them fight infection. Some donors prefer to bank their own blood and this is called an autologous blood transfusion.
Before any patient gets the first drop of blood, a physician’s order must be on the chart and the patient will sign a blood consent form. Then the lab will type and cross-match his blood for compatibility. This usually takes approximately one to two hours. Before the patient’s nurse initiates the transfusion, two nurses must verify the patient’s name, his date of birth, his corporate identification number, and his blood bank number. Four identifiers are always checked at the bedside for patient safety. If any identifier does not match, the blood is returned to the lab immediately.
Although most blood in the United States is safe for transfusions, reactions do occur. If a reaction occurs, the nurse should immediately stop the transfusion and obtain a set of vital signs before notifying the patient’s physician. Depending on the type of reaction, the physician may elect to stop the transfusion or continue. If the transfusion if halted, the blood, saline bag, and all tubing is then hand delivered to the lab along with the slip that accompanied the blood. The nurse should complete the reaction portion of the slip and place one copy on the chart (one copy goes to the lab).
One reaction that can occur is an acute lung injury. The patient will suddenly become short of breath, have chills, decreased blood pressure, and increased temperature (Novant, 2010). Hypoxia results and oxygen should be titrated to keep saturation greater than ninety-two percent (2010). Another type of reaction is an acute hemolytic or febrile non-hemolytic reaction. In this reaction, the blood pressure drops, but the heart rate and respirations increase (2010). The patient’s immune system is attacking the transfused cells. The patient may experience “severe flank or back pain”, hemoglobin in the urine, “shock, nausea, chills, (and) burning at the infusion site” (2010). Other times, a patient may experience increased temperature, chills, increased heart rate and systolic blood pressure changes which are indicative of bacterial contamination (2010). If a patient is having an allergic reaction, he is likely flushed, itching, and breaking out in hives (2010). In all the above reactions, the physician should be notified at once.
Six: The first priority is to apply oxygen at two liters nasal cannula and bring the saturation above ninety-two percent. After assessing the patient’s heart and lung sounds, the nurse should immediately administer nitroglycerin and morphine for the chest pain while notifying her charge nurse to order the following stat: an ABG (arterial blood gas), twelve-lead EKG, and a cardiac enzyme series. Most units have standing protocols for chest pain and enlisting the help of the charge nurse will increase the efficiency of care as well as improving the odds of a better outcome for the patient.
The doctor should also be notified, and the charge nurse can assist by paging him to the nurse’s phone. The nurse should expect a diagnosis of a pulmonary embolism (PE). Mr. Vasquez had two classic signs of a PE: unexplained shortness of breath and chest pain.
Most of the time, a PE begins as a blood clot deep in the leg veins. This is a condition known as deep vein thrombosis (DVT) (NIH, n.d.). The clot then breaks off from the vein and travels to the lungs where it blocks an artery (n.d.). A PE is not uncommon after orthopedic surgery and can be fatal if left untreated.
The patient’s doctor will most likely order an ultrasound of the left leg. He may also order a CT scan. An angiogram, D-dimer, and chest X-ray are also likely (NIH, n.d.).
The physician will probably order a regimen of heparin and Coumadin. The patient will most likely be placed on a heparin drip. The physician can choose either low-dose protocol or high-dose protocol for the drip. In either case, an unfractionated heparin blood test is drawn every six hours until the patient’s result is therapeutic. After two consecutive therapeutic results, the lab is checked every morning per protocol. The other medication, Coumadin, is given orally in conjunction with heparin. A daily PT / INR lab test is checked while the patient is on Coumadin. The physician decides whether to continue or stop the Coumadin based on the daily results.
Seven: Heparin is administered intravenously (IV) for Mr. Vasquez. This drug may be administered IV or subcutaneously (SC). Heparin has three uses. First, it is used to prevent and treat a PE (Weinstock et al, 2006). Second, heparin is used on surgery patients post-operatively to prevent clot formation(2006). Third, heparin is also used to diagnose disseminated intravascular coagulation (DIC) which is a disorder that leads to small clot formation within the vessels (2006). Fourth, heparin is also used as a flush to maintain patency of heparin locks (2006).
The most important nursing consideration when administering heparin is to ensure that the patient does not have an allergy to the drug. The nurse should also check the patient’s lab work, particularly the partial thromboplastin time (aPTT) (2006). If the patient is on IV heparin, the physician will also be checking his unfractionated heparin level every six hours until two therapeutic results are achieved. According to Weinstock et al (2006), heparin is incompatible with many drugs and the nurse should check with the pharmacy to ensure that no compatibility issues exist. Heparin can also cause many allergic reactions, ranging from alopecia to uticaria (2006). The nurse should not give heparin intramuscularly (IM) because doing so can cause “hematoma, irritation, and pain” (2006). For safety purposes, the nurse should keep a drug book close because of all the contraindications, adverse reactions, and nursing considerations associated with this drug.
Coumadin is administered orally and IV but not SC. This drug is used to prevent and treat PE, recurrent myocardial infarction, patients with heart valve replacements, and venous thrombosis (Weinstock et al, 2006). In the simplest explanation possible, Coumadin works by inhibiting the vitamin-K dependent clotting factors produced by the liver. This explains why part of the patient teaching includes no green leafy vegetables because they are loaded with vitamin K. This would serve as an antidote to the drug.
Coumadin has more drug interactions listed than heparin (Weinstock et al, 2006). Any patient with bleeding tendencies should not take Coumadin. The patient should not smoke or drink alcohol with this drug because they will alter the affects (2006).
Like heparin, the nurse should avoid IM injections because they produce the same side effects (Weinstock et al, 2006). Since this drug has as many safety considerations as heparin if not more, the nurse should keep the drug book close and pharmacy on speed dial.
Heparin
Coumadin
Routes
IV or SC
IV or Oral
Uses
Prevent / treat PE; prevent clot formation on post-op patients; diagnose DIC; heparin lock flush
Prevent / treat PE, MI; heart valve replacement, venous thrombosis
Mechanism of Action
Prevents the conversion of prothrombin to thrombin which is needed for the conversion of fibrinogen to fibrin; without fibrin, clots are unable to form (Weinstock et al, 2006)
Inhibits vitamin-K dependent clotting factors from forming in the liver
Contraindications
Heparin hypersensitivity; uncon-
trolled bleeding; severe thrombo-
cytopenia
Bleeding or bleeding tendencies; cerebral aneurysm; severe hepatic or renal disease
Drug Interactions
(see drug book for full details)
Antihistamines, digoxin, NSAIDS, platelet aggregation inhibitors, nitroglycerin (IV), thrombolytics
Acetaminophen, beta blockers, corticosteroids, barbiturates, vitamin C, vitamin K
Adverse Reactions
(see drug book for full details)
Fever, angina, hematuria, dyspnea, anaphylaxis, pain, nausea, vomiting
Intracranial hemorrhage, weakness, epistaxis, hepatitis, nausea, vomiting
Nursing Considerations
(see drug book for full details)
Use cautiously in alcoholics; avoid IM route; keep protamine sulfate on hand to use as an antidote
Monitor INR (daily in acute setting); avoid IM injections
Patient Teaching
(see drug book for full details)
Explain that heparin can’t be taken orally; advise patients to avoid NSAIDS and carry appropriate medical identification
Avoid green leafy vegetable; patient should avoid activities that could lead to trauma
(Weinstock et al, 2006)
Eight: In Winston-Salem, North Carolina, Mr. Vasquez has many resources available to him. The first of these begins before he is ever released from the hospital. The case worker, “Alice,” works tirelessly to ensure that each patient receives any resources for which they qualify. Alice would use the monies available in the social worker fund to help Mr. Vasquez obtain a month’s supply of his medicines to take home with him when he is discharged from the hospital. She would also set up home health services, home physical therapy, occupational therapy in the home, and oxygen therapy as prescribed by the patient’s physician. These services are available to everyone, not just immigrants and non-citizens. All of the above would be set up prior to discharge.
Many organizations offer services for Hispanics only but most have their doors open to all. The Hispanic League of the Triad is a non-profit organization that promotes awareness of Hispanic culture but also offers translation services at health clinics (First Line, 2008). The Second Harvest Food Bank of Northwest NC aims to decrease hunger and contributes food to 350 agencies across the region (2008). Although the agency does not provide direct service to individuals, it may be a starting point for Mr. Vasquez and his family to enrich their pantry. The nurse should also refer the family to the Forsyth County Department of Social Services for family and children’s Medicaid as well as food and nutrition services. The agency also has a Low Income Energy Assistance Program to help with heating bills. The Experiment in Self-Reliance provides financial services and counseling to low-income families who want to improve their living conditions and station in life.
Crisis Control Ministry is an excellent resource for low-income families. They provide emergency assistance with “rent/mortgage, utilities and fuel, food, and prescription medications” (First Line, 2008). The agency charges no fees and only requires that the recipients be residents of Forsyth County (2008).
Upon discharge, the patient will receive information about the above agencies. If he does not receive a flyer about each agency, he will at least receive a phone number. He will also receive three sheets minimum per policy:
· Physician’s Medical Patient Discharge Instructions
o Contains patient’s diagnosis, diet, activity level, referrals, wound management instructions, follow-up appointments and tests
· Nurse’s Medical Patient Discharge Instructions
o States that patient received information on the physician’s form as well as drug teaching (below); information regarding vaccinations, personal belongings, patient teaching, tobacco cessation, discharge destination and medications can be found on this sheet
· Patient Discharge Medication List
o Gives the patient a complete list of medications, including his home and hospital medications; which ones to stop and which ones to continue; new medications are also included on this sheet as are the times for the next dose of each medication
In addition to the information about the agencies and the facility’s three discharge sheets, the nurse should also individualize the discharge package for this patient a bit more. He will be discharged on crutches so that information needs to go home with him. Splint care will be sent as well. Wound care will be performed by the home health nurse, at least for a while. She will then determine what type of teaching is necessary after her work comes to an end.
Coumadin teaching is necessary. The patient will most likely be discharged on Lovenox, another anticoagulant, and the manufacturer provides a teaching kit with a DVD, booklet, and a needle box. Teaching will be completed before the patient is discharged. Optimally, the patient will be able to self-administer the SC Lovenox injections prior to discharge. Materials will be provided in Spanish whenever possible.
References
In Mostafa, G., Cathey, L., & Greene, F.L. (Eds.), Review of surgery: Basic science and clinical topics for ABSITE (pp. 300-301). Charlotte, NC: Springer Science +[KH2] Business Media, LLC.
Bagaria, V[KH3] ., Modi, N., Panghate, A., & Vaidya, S. (2006). Incidence and risk factors for development of venous thromboembolism in Indian patients undergoing major orthopaedic surgery: Results of a prospective study. Postgraduate Medical Journal, 82(964), 136-139.
Bulechek, G., Butcher, H.K., & Dochterman, J.M., (Eds.). (2008). Nursing interventions classification (NIC) (5th ed.). St. Louis, MO: Mosby Elsevier.
Castillo, R., Bosse, M., MacKenzie, E., & Patterson, B. (2005). Impact of smoking on fracture healing and risk of complications in limb-threatening open tibia fractures. Journal of Orthopaedic Trauma, 19(3), 151-157.
Cawley, Y.[KH4] (June, 2008)[KH5] . Mechanical thromboprophylaxis in the perioperative setting. MEDSURG Nursing, 17(3), 177-182.
Centers for Disease Control (n.d.). Healthy living: It’s not a diet, it’s a lifestyle! Retrieved October 24, 2010 from http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/english_bmi_calculator/bmi_calculator.html
Collins, S. (May 8, 2009).[KH6] Deep vein thrombosis -- an overview. Practice Nurse[KH7] , 37(9).
Coumadin (n.d.). Retrieved October 21, 2010 from http://allnurses.com/nursing-articles/patient-teaching-guide-262172.htm[KH8]
Estes, M. E. Z. (2006), Health assessment & physical examination (3rd ed.). Clifton Park, NY: Thomson Delmar Learning.
First Line (2008). Directory of community resources for Forsyth County. Winston-Salem, NC: Forsyth County Public Library.
Forsyth Medical Center (2005). Patient admission history. Retrieved October 2, 2010 from employee intranet.
Forsyth Medical Center (2005). Laboratory data. Retrieved October 2, 2010 from employee intranet.[KH9]
Lutz, C. & Przytulski, K (2006). Nutrition & diet therapy: Evidence-based applications (4th ed.). Philadelphia, PA: F.A. Davis Company.
Johnson, M., Bulechek, G., Butcher, H., Dochterman, J. M., Maas, M., Moorhead, S., & Swanson, E. (Eds.). (2006). NANDA, NOC, and NIC linkages (2nd ed.). St. Louis, MO: Mosby Elsevier.
Moorhead, S., Johnson, M., Maas, M.L., & Swanson, E. (2008). Nursing outcomes classification (NOC) (4th ed.). St. Louis, MO: Mosby Elsevier.
Nettina, S. M. (2006). Lippincott manual of nursing practice (8th ed.). Ambler, PA: Lippincott Williams & Wilkins.
Novant Health (2010). Blood and blood product administration. Retrived October 2, 2010 from employee intranet.
National Institute of Health (NIH) (n.d.). Pulmonary embolism. Retrieved October 21, 2010 from [KH10] http://www.nhlbi.nih.gov/health/dci/Diseases/pe/pe_causes.html
Weinstock, D., Bryant, J., Cray, J., Dodds, K.D., Harold, C.E., Lyons, D. Priff, N., & Shaw, M. (2006). Nurse’s drug handbook (5th ed.). Hicksville, NY: Blanchard & Loeb.
Wolters Kluwer / Lippincott Williams & Wilkins (n.d.).[KH11]
Closed wound drain management (JP or Hemovac). Retrieved October 21, 2010 from http://procedures.lww.com/lnp/view.do?pId=39341&s=p&fromSearch=true&searchQuery=hemovac
Pass
Kimberely, your case study was well written, complete and accurate! you Passed!!! thanks, carollynn
APA / Writing – This was more of a content paper, with writing reviewed mainly for basics and less focus to grammar/style. Overall, your paper was very good and I did like that table on nursing dxes. The SNL paper will be reviewed more for formal writing and APA and the following will need to be done correctly in your SNL paper in order to pass the SNL paper.
· Margins, spacing, font – margins on all sides must be 1 inch.
· Quality of references – not great. You need to use more credible nursing journals. See the reference page for comments.
· Reference list and citations – several minor errors, but you need to fine-tune these for the SNL paper.
I was impressed with your decision to put the nursing dxes in a table – that was neat. As you know, the APA format for that table was wrong. (That is why we encouraged no tables in the document, but only as attachments.) For this paper, this will be OK; but, if you use tables in the SNL paper, they will need to be APA driven. Again, I liked the concept!!!! Kathy
[KH1]Other
[KH2]?
[KH3]Where was this source used?
[KH4]Where was this source used?
[KH5]Why the month?
[KH6]Not how journals are cited – should be just year.
[KH7]Not a quality journal
[KH8]Not a quality source
[KH9]In text – how do you know which 2005 source you are citing?
[KH10]Where was this cited?
[KH11]Publishers don’t go here or in the citation
NUCO 4430: Transition and Validation Seminar I
October 26, 2010
Kimberely S. Strickland
University of Virginia
One: The most obvious symptom of a compound fracture is the bone protruding through the patient’s skin. Other indications of this type of fracture are edema at the site, pain and tenderness, false motion, and extremity deformity (Nettina, 2006). Another sign is bleeding at the site. Because the bone has burst through muscle, blood vessels, subcutaneous tissue, and skin to make contact with the outside world, these would be damaged as well. Nerve damage is also certain and the clinician can expect to see parasthesia as a result.
As swelling continues, the nurse should look for the classic signs of ischemia: pain, pallor, pulselessness, paralysis, parasthesia, and poikilothermia (Acute limb ischemia, 2006). After only six hours, irreversible changes can occur if ischemia is left untreated (2006). The nurse should also be on alert for signs of shock. Bones are extremely vascular and an injury such as this can lead to loss of large amounts of blood both outside and inside the body. Anxiety, vertigo, shallow breathing, increasing heart rate, clammy skin, unconsciousness, and decreased urine output are all signs of shock.
Because Mr. Vasquez is a smoker, his risk of infection is more than twice that of a non –smoker (Castillo, Bosse, MacKenzie, & Patterson, 2005). His rib fractures will discourage him from deep breathing and could lead to pneumonia. Another serious complication of a fracture is an embolism and the nurse should be alert at all times for respiratory distress, mental status changes, and fever (Nettina, 2006). Decreased mobility is also a potential complication with any fracture of the lower extremities.
To diagnose a compound fracture, the physician would certainly order an X-ray and CT scan of the left leg and ribs. The nurse should also expect a complete blood count, basic metabolic panel, PT/INR, arterial blood gas, cardiac enzyme series, serum albumin, liver function tests, BUN, creatinine and a urine analysis and culture. The patient will also be typed and cross-matched for a possible blood transfusion. The physician would likely order an angiography to assess the extent of blood vessel damage. Because of the soft tissue injuries associated with this fracture, an MRI would probably be ordered as well. She should also expect telemetry and pulse oximetry monitoring. Because Mr. Vasquez has a dry, hacking cough, night sweats, and fatigue, the nurse should expect the chest X-ray to indicate tuberculosis. If this is the case, the patient shall be placed on airborne isolation.
Prior to surgery, the nurse wants to ensure that the patient understands his N.P.O. status to prevent any risk of aspiration during surgery. She should also view all the lab results and alert the doctor to any abnormalities. If her facility requires a pre-operative checklist for the patient, this should be completed and vital signs should be obtained. The patient should be frequently assessed for any signs of complications or change in condition. Urine output should be monitored for any change in color that might indicate hematuria. Pain should be monitored and treated as ordered by the physician. The nurse should also continue to monitor for any blood loss. If a bandage was applied in the emergency department, she must check it frequently for shadowing or saturation.
Also, the nurse needs to talk to the patient and his family and ensure that all their questions have been answered. If the nurse can answer any lingering questions, she must do so. However, if the patient or his family has questions outside her scope of practice, she should alert the physician so that these can be addressed prior to surgery.
After the patient returns from surgery, the nurse should obtain a set of vital signs and perform an assessment immediately. Respiratory function should be closely monitored for any changes, and the patient’s pain must be kept under control. Compartment syndrome and thromboembolism are two serious complications that can develop from this type of injury, and the nurse should be alert to any signs of either condition. Neurological changes such as poor capillary refill, paralysis, pain, tightness, and pulselessness can signal impending compartment syndrome (Nettina, 2006). The physician will likely order anticoagulants to decrease the risk of thromboembolism, but the nurse should monitor the patient closely for calf pain or tenderness, unilateral leg edema, skin warmth and redness, and a fever greater than 100.4 degrees Fahrenheit (Collins, 2009). The area around the fracture area should be monitored for any changes.
Two: Mr. Vasquez is an underweight male with body mass index of 19.9 (Centers for Disease Control, n.d.). His family doesn’t eat a lot of meat and relies on beans for most of their protein. The family eats a variety of vegetables and Mrs. Vasquez bakes fresh bread daily. Mr. Vasquez also drinks three beers every day.
Part of any nutritional history includes diet information which is stated above. During the diet history, the nurse should also ask if the patient has any financial difficulty obtaining food. Mr. Vasquez had stated that the family can’t afford a lot of meat and that the family’s primary source of protein is beans. This is a concern because Mr. Vasquez may not be getting enough protein as well as the recommended daily allowance of vitamins and minerals. Other[KH1] s subjects the interviewer would include are the number of restaurant meals in a given period (including fast food); likes, dislikes, and cravings; food storage and preparation; and diet choices. During this part of the assessment, the nurse should also ask about any gastrointestinal-related health changes in the past year (Forsyth, 2005). For example, questions about nausea, vomiting, and diarrhea; weight loss and gain; swallowing difficulties; and appetite changes would be asked during this part of the patient interview (2005).
The physical assessment is a head-to-toe account of a patient’s nutritional status. This process relies on both subjective data from the patient and objective data from the nurse (Lutz & Przytulski, 2006). She should begin with his overall general appearance. Is he sluggish or peppy? Does he appear obese or thin? Are his hair and nails brittle and thin or healthy and thick? Has he had any vision changes? Do his corneas appear hardened or do his conjunctiva appear pink? Does his mouth appear dry and cracked? Are sores inside? Does the tongue appear normal or swollen? Are all the patient’s teeth intact? Are any caries visible? Does the patient have headaches? Do any areas of his head and neck appear swollen? Is the patient having heart palpitations or problems with the peripheral vasculature (Estes, 2006)? Is his abdomen tender? Has he had any nausea, vomiting, or diarrhea? Have his bowel habits changed (Forsyth, 2005)? Does she detect any ascites? Has the patient had any musculoskeletal issues (2005)? How is his muscle tone? Is he agitated or irritable? Has he experienced any numbness? Is his speech slurred? How are his coordination and gait? When the nurse answers all of the above questions, she will have a good idea of the patient’s physical status. As an example of the worst case scenario, the nurse has assessed the patient and found him to have brittle hair and nails. This could be due to a lack of vitamins and minerals or something as serious as kidney disease. Vision changes could be attributed to age or to diabetes. Mouth sores may be caused by a broken tooth. Dental caries may be the result of too little calcium or too many sweets. Headaches may be the result of too many diet sodas sweetened with aspartame. Swollen cheeks might be due to enlarged glands or goiter. Heart palpitations could be caused by too much caffeine. Changes in appetite may be caused by depression. Changes in bowel habits might be a warning sign of malnutrition. Musculoskeletal changes may be solved by correcting vitamin and mineral deficiencies. Agitation and irritability could be caused by one of hundreds of ailments.
Anthropometrics are the measurements of the human body. These measurements include height, weight, and body proportions (Lutz & Przytulski, 2006). The nurse would begin by taking the patient’s height and weight. She would then calculate the body mass index and assess whether the patient’s measurements are normal. Next, she would calculate the waist/hip ratio. This is obtained by measuring the narrowest point of the waist and the widest point of the hips. The number is calculated by dividing the waist by the hip (2006). Abnormal measurements are linked to obesity (2006). The skinfold thickness test determines body fat reserves and nutrition status (Estes, 2006). Using calipers, the nurse measures the subcutaneous fat between the patient’s acromion process and the olecranon process on his tricep (2006). Since most of the body’s fat is in the subcutaneous tissue, this is a very reliable indicator of body fat (Lutz & Przytulski, 2006). Last, the mid-arm circumference is used to obtain information on skeletal muscle mass. The patient flexes his arm at the elbow and the nurse measures the circumference halfway between the two processes mentioned above (2006). The number is then put into a mathematical formula to determine the range into which the patient falls. Abnormal results may be indicative of kwashikor (protein malnutrition) or marasmus (protein-calorie malnutrition) or a mixture of the two (Estes, 2006).
Mr. Vasquez should complete a three-day diet history (2006). The nurse should obtain the times of his meals and snacks as well as the content to establish a clear picture of his eating habits. Portion size information would also be helpful since he is underweight.
Labs ordered in conjunction with the nutritional assessment and diet history would be:
· White blood count (5,000-10,000 / mm3)
· Glucose (70-100 mg / dL)
· BUN (Blood urea nitrogen) (7-20 mg / dL)
· Creatinine (0.6-1.2 mg / dL)
· Sodium (135-145 mEq / L)
· Potassium (3.5 – 5.0 mEq / L)
· Phosphate (2.4-4.1 mg / dL)
· Magnesium (1.7-2.2 mg / dL)
· Calcium (8.5-10.2 mg / dL)
· Chloride (98-106 mEq / L)
· Albumin (3.4-5.4 g / dL)
· Prealbumin (15-35 mg / dL)
· Folic Acid (2.7-17.0 ng / mL)
· Vitamin B12 (200-900 pg / mL)
· Vitamin D (30.0-74.0 ng / mL)
The values listed are the desired level for each blood test (Forsyth, 2005). The physician might also order a twenty-four hour urine test.
Three: Mr. Vasquez has four nursing diagnoses:
· Pain, Acute, related to leg wound and recent surgery;
· Nutrition: Imbalanced, Less than Body Requirements related to inadequate caloric and protein intake;
· Risk for Constipation, related to immobility, diet changes, and pain medication administration; and
· Risk for Falls, related to leg injury, pain medication administration, and unfamiliar environment.
These four diagnoses will be discussed below.
Nursing Diagnosis: Pain, Acute, related to leg wound and recent surgery
Major Suggested Optional
Nursing Outcomes Interventions Interventions Interventions
Pain Control-1605 Medication Simple Guided Surveillance
Management Imagery -monitor patient
-administer -assist patient to for signs of pain
Uses analgesics as pain medicines use his imagination
recommended as ordered to redirect his attention -Monitor behavior
160505 away from his pain patterns
-Monitor for signs -Plan with patient an -Monitor vital signs,
and symptoms of appropriate time to do as appropriate
drug toxicity guided imagery
-Determine the
patient’s know-
ledge about
medication
Patient-Controlled Teaching: Individual Animal-Assisted
Reports uncon- Anesthesia (PCA) -teach patient about Therapy
trolled symptoms Assistance pharmacological -contact volunteer
to health pro- -teach patient how methods of pain services about
fessional to use the PCA relief putting patient on
160507 their rounds
Rating:
1 Never demonstrated
2 Rarely demonstrated
3 Sometimes demonstrated
4 Often demonstrated
5 Consistently demonstrated
Pain Level-2102 Analgesic Admini- Positioning Music Therapy
stration -Premedicate patient -Determine the
-Determine pain before moving as patient’s interest
location, charac- appropriate in music
teristics, quality,
Length of pain and severity before -Position in proper -Inform the patient
episodes 210204 medicating patient body alignment as to the purpose of
the music
Restlessness 210208 -Check history for -Immobilize or support experience
drug allergies the affected body part, as
appropriate -Assist the patient
Agitation 210222 -Determine analgesic in assuming a
selection based on comfortable
type and severity of position
pain
Rating:
1 Severe
2 Substantial
3 Moderate
4 Mild
5 None
Nursing Diagnosis: Nutrition: Imbalanced, Less than Body Requirements related to inadequate caloric and protein intake
Major Suggested Optional
Nursing Outcomes Interventions Interventions Interventions
Appetite-1014 Nutrition Therapy Nutrition Management Weight Gain Assistance
-select nutritional -encourage calorie intake -discuss possible causes
Desire to eat 101401 supplements, as appropriate for body type of low body weight
appropriate and lifestyle
-Monitor food -Inquire if patient has any -Provide a variety of
Food intake 101406 ingested and cal- food allergies high-calorie nutritious
culate daily caloric foods from which to
intake, as appro- choose
priate
Rating:
1 Severely
Compromised
2 Substantially
Compromised
3 Moderately
Compromised
4 Mildly
Compromised
5 Not Compromised
Nutrient intake 101407
Nutritional Status: Nutritional Monitoring Teaching: Prescribed Diet Sustenance Support
Nutrient Intake-1009 -Monitor skin turgor, -Explain the purpose of -Determine adequacy
as appropriate the diet of patient’s financial situation
Caloric Intake -Weigh patient at -Appraise patient’s
100901 specified intervals current knowledge about -Determine adequacy
prescribed diet of food supplies in
Protein Intake -Monitor albumin, home
100902 total protein, hemo- -Provide written meal
globin, and hemato- plans, as appropriate -Discuss financial aid
crit levels support with the patient
Rating:
1 Not Adequate
2 Slightly Adequate
3 Moderately
Adequate
4 Substantially Adequate
5 Totally Adequate
Nursing Diagnosis: Risk for Constipation, related to immobility, diet changes, and pain medication administration
Major Suggested Optional
Nursing Outcomes Interventions Interventions Interventions
Bowel Elimination- Constipation / Nutritional Medication Adminis-
0501 Impaction Manage- Monitoring tration: Oral
ment
-Monitor for signs -Monitor energy -Follow the five rights of
Elimination and symptoms of level, malaise, medication administration
pattern 050101 constipation fatigue, and
weakness -Note patient’s medical
-Monitor bowel history and history of
sounds -Monitor for allergies
Passage of stool nausea and
without aids -Monitor bowel move- vomiting
050121 ments, including
frequency, consistency,
shape, volume, and
color, as appropriate
Rating:
1 Severely
2 Substantially
Compromised
3 Moderately
Compromised
4 Mildly
Compromised
5 Not Compromised
Self-Care: Toileting Self-Care Assistance: Exercise Therapy: Anxiety Reduction
0310 Toileting Ambulation
-Consider the culture -Dress patient in non- -Use a calm,
of the patient when restrictive clothing reassuring approach
Positions self on promoting self-care
toilet or commode activities -Provide low-height bed, -Clearly state
031005 as appropriate expectations for
-Provide privacy patient’s behavior
during elimination -Consult physical therapist
Gets to toilet between about ambulation plan, as -Explain all
urge and passage of -Remove essential needed procedures,
urine 031014 clothing to allow for including sensations
elimination -Assist patient to transfer, likely to be
Gets to toilet between if needed experienced during
urge and evacuation of the procedure
stool 031015
Rating:
1 Severely
Compromised
2 Substantially
Compromised
3 Moderately
Compromised
4 Mildly
Compromised
5 Not Compromised
Nursing Diagnosis: Risk for Falls, related to leg injury, pain medication administration, and unfamiliar environment
Major Suggested Optional
Nursing Outcomes Interventions Interventions Interventions
Balance-0202 Fall Prevention Environmental Vital Signs Monitoring
Management: Safety
Maintains balance -Identify behaviors -Identify safety needs -Monitor blood pressure,
while standing on and factors that of the patient, based pulse, temperature, and
one foot 020209 affect risk of falls on level of physical respiratory status, as
and cognitive function appropriate
-Monitor gait, and past history of
balance, and behavior -Note trends and wide
Maintains balance fatigue level fluctuations in blood
while walking with ambulation -Modify the environment pressure
020203 to minimize hazards
-Assist unsteady and risk -Monitor lung sounds
Rating: individual with
1 Severely ambulation -Provide adaptive devices -Monitor pulse oximetry
Compromised to increase the safety of
2 Substantially -Place mechanical the environment
Compromised bed in lowest
3 Moderately position
Compromised
4 Mildly
Compromised
5 Not Compromised
Coordinated Body Mechanics Self-Care Assistance Medication Management
Movement Promotion
0212 -Determine patient’s -Assist patient in -Facilitate changes in
commitment to accepting dependency medication with physician,
learning and using needs as appropriate
correct posture
Control of -Instruct patient -Provide desired -Monitor for non-
movement about need for personal articles therapeutic drug
021205 correct posture (e.g., deodorant, reactions
to prevent fatigue, toothbrush, and
strain,or injury bath soap)
-Assist to avoid -Encourage -Determine the patient’s sitting in the same independence but knowledge about
position for intervene when patient medication
prolonged periods is unable to perform
Rating:
1 Severely
Compromised
2 Substantially
Compromised
3 Moderately
Compromised
4 Mildly
Compromised
5 Not Compromised
Four: The Hemovac drainage system is a type of closed drainage system in which blood and exudate are gently sucked out of the patient’s wound and into the reservoir. Removing the exudates serves several purposes. Edema is reduced as are the risk for infection and skin breakdown (Wolters Kluwer / Lippincott Williams & Wilkins, n.d.). Emptying the reservoir every four to six hours ensures optimum suction and reduces strain on the sutures (n.d.). When emptying the drain, the nurse should maintain clean technique and be sure to compress the device fully when she is finished. This will ensure that the system remains closed and continues the gentle suction on the wound. This type of system is commonly seen with orthopedic and abdominal surgeries (n.d.).
Five: The purpose of a blood transfusion is to replenish blood products that a patient has lost through hemorrhage or is lacking because of an illness. For example, a patient involved in a life-threatening car accident has lost a lot of blood and is rushed to the hospital. Lab tests reveal that his hemoglobin is 7.5 gm / dL. The physician would most likely order at least one unit of packed red blood cells to replace some of what the patient has lost. In other cases, illness keeps the hemoglobin level low enough to warrant a unit of packed red blood cells, usually below 8.0 gm / dL. Patients with anemia sometimes find themselves on the receiving end of a bag of blood. Red blood cells carry oxygen in the blood. Anemic patients with low hemoglobin don’t have enough red blood cells to carry the oxygen to their tissues and may need a transfusion to help their blood do its job. Other patients with thrombocytopenia may receive platelets. The normal platelet count is 150,000-450,000 per deciliter. Patients with this disorder have less than 150,000 platelets per deciliter.
Fresh frozen plasma is administered when the patient’s stable plasma coagulation factors are decreased (Forsyth, 2008). The patient may have an allergic reaction with this type of transfusion. Albumin is also administered to patients occasionally to treat shock, trauma, infection, electrolyte imbalances, and hypoproteinamia (2008).
Another less common types of blood transfusion is granulocytes (white blood cells) which is given to patients with very low white blood counts to help them fight infection. Some donors prefer to bank their own blood and this is called an autologous blood transfusion.
Before any patient gets the first drop of blood, a physician’s order must be on the chart and the patient will sign a blood consent form. Then the lab will type and cross-match his blood for compatibility. This usually takes approximately one to two hours. Before the patient’s nurse initiates the transfusion, two nurses must verify the patient’s name, his date of birth, his corporate identification number, and his blood bank number. Four identifiers are always checked at the bedside for patient safety. If any identifier does not match, the blood is returned to the lab immediately.
Although most blood in the United States is safe for transfusions, reactions do occur. If a reaction occurs, the nurse should immediately stop the transfusion and obtain a set of vital signs before notifying the patient’s physician. Depending on the type of reaction, the physician may elect to stop the transfusion or continue. If the transfusion if halted, the blood, saline bag, and all tubing is then hand delivered to the lab along with the slip that accompanied the blood. The nurse should complete the reaction portion of the slip and place one copy on the chart (one copy goes to the lab).
One reaction that can occur is an acute lung injury. The patient will suddenly become short of breath, have chills, decreased blood pressure, and increased temperature (Novant, 2010). Hypoxia results and oxygen should be titrated to keep saturation greater than ninety-two percent (2010). Another type of reaction is an acute hemolytic or febrile non-hemolytic reaction. In this reaction, the blood pressure drops, but the heart rate and respirations increase (2010). The patient’s immune system is attacking the transfused cells. The patient may experience “severe flank or back pain”, hemoglobin in the urine, “shock, nausea, chills, (and) burning at the infusion site” (2010). Other times, a patient may experience increased temperature, chills, increased heart rate and systolic blood pressure changes which are indicative of bacterial contamination (2010). If a patient is having an allergic reaction, he is likely flushed, itching, and breaking out in hives (2010). In all the above reactions, the physician should be notified at once.
Six: The first priority is to apply oxygen at two liters nasal cannula and bring the saturation above ninety-two percent. After assessing the patient’s heart and lung sounds, the nurse should immediately administer nitroglycerin and morphine for the chest pain while notifying her charge nurse to order the following stat: an ABG (arterial blood gas), twelve-lead EKG, and a cardiac enzyme series. Most units have standing protocols for chest pain and enlisting the help of the charge nurse will increase the efficiency of care as well as improving the odds of a better outcome for the patient.
The doctor should also be notified, and the charge nurse can assist by paging him to the nurse’s phone. The nurse should expect a diagnosis of a pulmonary embolism (PE). Mr. Vasquez had two classic signs of a PE: unexplained shortness of breath and chest pain.
Most of the time, a PE begins as a blood clot deep in the leg veins. This is a condition known as deep vein thrombosis (DVT) (NIH, n.d.). The clot then breaks off from the vein and travels to the lungs where it blocks an artery (n.d.). A PE is not uncommon after orthopedic surgery and can be fatal if left untreated.
The patient’s doctor will most likely order an ultrasound of the left leg. He may also order a CT scan. An angiogram, D-dimer, and chest X-ray are also likely (NIH, n.d.).
The physician will probably order a regimen of heparin and Coumadin. The patient will most likely be placed on a heparin drip. The physician can choose either low-dose protocol or high-dose protocol for the drip. In either case, an unfractionated heparin blood test is drawn every six hours until the patient’s result is therapeutic. After two consecutive therapeutic results, the lab is checked every morning per protocol. The other medication, Coumadin, is given orally in conjunction with heparin. A daily PT / INR lab test is checked while the patient is on Coumadin. The physician decides whether to continue or stop the Coumadin based on the daily results.
Seven: Heparin is administered intravenously (IV) for Mr. Vasquez. This drug may be administered IV or subcutaneously (SC). Heparin has three uses. First, it is used to prevent and treat a PE (Weinstock et al, 2006). Second, heparin is used on surgery patients post-operatively to prevent clot formation(2006). Third, heparin is also used to diagnose disseminated intravascular coagulation (DIC) which is a disorder that leads to small clot formation within the vessels (2006). Fourth, heparin is also used as a flush to maintain patency of heparin locks (2006).
The most important nursing consideration when administering heparin is to ensure that the patient does not have an allergy to the drug. The nurse should also check the patient’s lab work, particularly the partial thromboplastin time (aPTT) (2006). If the patient is on IV heparin, the physician will also be checking his unfractionated heparin level every six hours until two therapeutic results are achieved. According to Weinstock et al (2006), heparin is incompatible with many drugs and the nurse should check with the pharmacy to ensure that no compatibility issues exist. Heparin can also cause many allergic reactions, ranging from alopecia to uticaria (2006). The nurse should not give heparin intramuscularly (IM) because doing so can cause “hematoma, irritation, and pain” (2006). For safety purposes, the nurse should keep a drug book close because of all the contraindications, adverse reactions, and nursing considerations associated with this drug.
Coumadin is administered orally and IV but not SC. This drug is used to prevent and treat PE, recurrent myocardial infarction, patients with heart valve replacements, and venous thrombosis (Weinstock et al, 2006). In the simplest explanation possible, Coumadin works by inhibiting the vitamin-K dependent clotting factors produced by the liver. This explains why part of the patient teaching includes no green leafy vegetables because they are loaded with vitamin K. This would serve as an antidote to the drug.
Coumadin has more drug interactions listed than heparin (Weinstock et al, 2006). Any patient with bleeding tendencies should not take Coumadin. The patient should not smoke or drink alcohol with this drug because they will alter the affects (2006).
Like heparin, the nurse should avoid IM injections because they produce the same side effects (Weinstock et al, 2006). Since this drug has as many safety considerations as heparin if not more, the nurse should keep the drug book close and pharmacy on speed dial.
Heparin
Coumadin
Routes
IV or SC
IV or Oral
Uses
Prevent / treat PE; prevent clot formation on post-op patients; diagnose DIC; heparin lock flush
Prevent / treat PE, MI; heart valve replacement, venous thrombosis
Mechanism of Action
Prevents the conversion of prothrombin to thrombin which is needed for the conversion of fibrinogen to fibrin; without fibrin, clots are unable to form (Weinstock et al, 2006)
Inhibits vitamin-K dependent clotting factors from forming in the liver
Contraindications
Heparin hypersensitivity; uncon-
trolled bleeding; severe thrombo-
cytopenia
Bleeding or bleeding tendencies; cerebral aneurysm; severe hepatic or renal disease
Drug Interactions
(see drug book for full details)
Antihistamines, digoxin, NSAIDS, platelet aggregation inhibitors, nitroglycerin (IV), thrombolytics
Acetaminophen, beta blockers, corticosteroids, barbiturates, vitamin C, vitamin K
Adverse Reactions
(see drug book for full details)
Fever, angina, hematuria, dyspnea, anaphylaxis, pain, nausea, vomiting
Intracranial hemorrhage, weakness, epistaxis, hepatitis, nausea, vomiting
Nursing Considerations
(see drug book for full details)
Use cautiously in alcoholics; avoid IM route; keep protamine sulfate on hand to use as an antidote
Monitor INR (daily in acute setting); avoid IM injections
Patient Teaching
(see drug book for full details)
Explain that heparin can’t be taken orally; advise patients to avoid NSAIDS and carry appropriate medical identification
Avoid green leafy vegetable; patient should avoid activities that could lead to trauma
(Weinstock et al, 2006)
Eight: In Winston-Salem, North Carolina, Mr. Vasquez has many resources available to him. The first of these begins before he is ever released from the hospital. The case worker, “Alice,” works tirelessly to ensure that each patient receives any resources for which they qualify. Alice would use the monies available in the social worker fund to help Mr. Vasquez obtain a month’s supply of his medicines to take home with him when he is discharged from the hospital. She would also set up home health services, home physical therapy, occupational therapy in the home, and oxygen therapy as prescribed by the patient’s physician. These services are available to everyone, not just immigrants and non-citizens. All of the above would be set up prior to discharge.
Many organizations offer services for Hispanics only but most have their doors open to all. The Hispanic League of the Triad is a non-profit organization that promotes awareness of Hispanic culture but also offers translation services at health clinics (First Line, 2008). The Second Harvest Food Bank of Northwest NC aims to decrease hunger and contributes food to 350 agencies across the region (2008). Although the agency does not provide direct service to individuals, it may be a starting point for Mr. Vasquez and his family to enrich their pantry. The nurse should also refer the family to the Forsyth County Department of Social Services for family and children’s Medicaid as well as food and nutrition services. The agency also has a Low Income Energy Assistance Program to help with heating bills. The Experiment in Self-Reliance provides financial services and counseling to low-income families who want to improve their living conditions and station in life.
Crisis Control Ministry is an excellent resource for low-income families. They provide emergency assistance with “rent/mortgage, utilities and fuel, food, and prescription medications” (First Line, 2008). The agency charges no fees and only requires that the recipients be residents of Forsyth County (2008).
Upon discharge, the patient will receive information about the above agencies. If he does not receive a flyer about each agency, he will at least receive a phone number. He will also receive three sheets minimum per policy:
· Physician’s Medical Patient Discharge Instructions
o Contains patient’s diagnosis, diet, activity level, referrals, wound management instructions, follow-up appointments and tests
· Nurse’s Medical Patient Discharge Instructions
o States that patient received information on the physician’s form as well as drug teaching (below); information regarding vaccinations, personal belongings, patient teaching, tobacco cessation, discharge destination and medications can be found on this sheet
· Patient Discharge Medication List
o Gives the patient a complete list of medications, including his home and hospital medications; which ones to stop and which ones to continue; new medications are also included on this sheet as are the times for the next dose of each medication
In addition to the information about the agencies and the facility’s three discharge sheets, the nurse should also individualize the discharge package for this patient a bit more. He will be discharged on crutches so that information needs to go home with him. Splint care will be sent as well. Wound care will be performed by the home health nurse, at least for a while. She will then determine what type of teaching is necessary after her work comes to an end.
Coumadin teaching is necessary. The patient will most likely be discharged on Lovenox, another anticoagulant, and the manufacturer provides a teaching kit with a DVD, booklet, and a needle box. Teaching will be completed before the patient is discharged. Optimally, the patient will be able to self-administer the SC Lovenox injections prior to discharge. Materials will be provided in Spanish whenever possible.
References
In Mostafa, G., Cathey, L., & Greene, F.L. (Eds.), Review of surgery: Basic science and clinical topics for ABSITE (pp. 300-301). Charlotte, NC: Springer Science +[KH2] Business Media, LLC.
Bagaria, V[KH3] ., Modi, N., Panghate, A., & Vaidya, S. (2006). Incidence and risk factors for development of venous thromboembolism in Indian patients undergoing major orthopaedic surgery: Results of a prospective study. Postgraduate Medical Journal, 82(964), 136-139.
Bulechek, G., Butcher, H.K., & Dochterman, J.M., (Eds.). (2008). Nursing interventions classification (NIC) (5th ed.). St. Louis, MO: Mosby Elsevier.
Castillo, R., Bosse, M., MacKenzie, E., & Patterson, B. (2005). Impact of smoking on fracture healing and risk of complications in limb-threatening open tibia fractures. Journal of Orthopaedic Trauma, 19(3), 151-157.
Cawley, Y.[KH4] (June, 2008)[KH5] . Mechanical thromboprophylaxis in the perioperative setting. MEDSURG Nursing, 17(3), 177-182.
Centers for Disease Control (n.d.). Healthy living: It’s not a diet, it’s a lifestyle! Retrieved October 24, 2010 from http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/english_bmi_calculator/bmi_calculator.html
Collins, S. (May 8, 2009).[KH6] Deep vein thrombosis -- an overview. Practice Nurse[KH7] , 37(9).
Coumadin (n.d.). Retrieved October 21, 2010 from http://allnurses.com/nursing-articles/patient-teaching-guide-262172.htm[KH8]
Estes, M. E. Z. (2006), Health assessment & physical examination (3rd ed.). Clifton Park, NY: Thomson Delmar Learning.
First Line (2008). Directory of community resources for Forsyth County. Winston-Salem, NC: Forsyth County Public Library.
Forsyth Medical Center (2005). Patient admission history. Retrieved October 2, 2010 from employee intranet.
Forsyth Medical Center (2005). Laboratory data. Retrieved October 2, 2010 from employee intranet.[KH9]
Lutz, C. & Przytulski, K (2006). Nutrition & diet therapy: Evidence-based applications (4th ed.). Philadelphia, PA: F.A. Davis Company.
Johnson, M., Bulechek, G., Butcher, H., Dochterman, J. M., Maas, M., Moorhead, S., & Swanson, E. (Eds.). (2006). NANDA, NOC, and NIC linkages (2nd ed.). St. Louis, MO: Mosby Elsevier.
Moorhead, S., Johnson, M., Maas, M.L., & Swanson, E. (2008). Nursing outcomes classification (NOC) (4th ed.). St. Louis, MO: Mosby Elsevier.
Nettina, S. M. (2006). Lippincott manual of nursing practice (8th ed.). Ambler, PA: Lippincott Williams & Wilkins.
Novant Health (2010). Blood and blood product administration. Retrived October 2, 2010 from employee intranet.
National Institute of Health (NIH) (n.d.). Pulmonary embolism. Retrieved October 21, 2010 from [KH10] http://www.nhlbi.nih.gov/health/dci/Diseases/pe/pe_causes.html
Weinstock, D., Bryant, J., Cray, J., Dodds, K.D., Harold, C.E., Lyons, D. Priff, N., & Shaw, M. (2006). Nurse’s drug handbook (5th ed.). Hicksville, NY: Blanchard & Loeb.
Wolters Kluwer / Lippincott Williams & Wilkins (n.d.).[KH11]
Closed wound drain management (JP or Hemovac). Retrieved October 21, 2010 from http://procedures.lww.com/lnp/view.do?pId=39341&s=p&fromSearch=true&searchQuery=hemovac
Pass
Kimberely, your case study was well written, complete and accurate! you Passed!!! thanks, carollynn
APA / Writing – This was more of a content paper, with writing reviewed mainly for basics and less focus to grammar/style. Overall, your paper was very good and I did like that table on nursing dxes. The SNL paper will be reviewed more for formal writing and APA and the following will need to be done correctly in your SNL paper in order to pass the SNL paper.
· Margins, spacing, font – margins on all sides must be 1 inch.
· Quality of references – not great. You need to use more credible nursing journals. See the reference page for comments.
· Reference list and citations – several minor errors, but you need to fine-tune these for the SNL paper.
I was impressed with your decision to put the nursing dxes in a table – that was neat. As you know, the APA format for that table was wrong. (That is why we encouraged no tables in the document, but only as attachments.) For this paper, this will be OK; but, if you use tables in the SNL paper, they will need to be APA driven. Again, I liked the concept!!!! Kathy
[KH1]Other
[KH2]?
[KH3]Where was this source used?
[KH4]Where was this source used?
[KH5]Why the month?
[KH6]Not how journals are cited – should be just year.
[KH7]Not a quality journal
[KH8]Not a quality source
[KH9]In text – how do you know which 2005 source you are citing?
[KH10]Where was this cited?
[KH11]Publishers don’t go here or in the citation
Subscribe to:
Comments (Atom)