Question

Patient Introduction

Location: Skilled Nursing Home Care Facility 0800

Report from charge nurse:

Situation: Mrs. Morrow is an obese, 80-year-old white female who developed a venous stasis ulcer on her right medial malleolus while still living at home. She moved into our skilled nursing home care facility 3 days ago. The current plan of care is focused on promoting wound healing, improving venous return, and preventing skin breakdown.

Background: Mrs. Morrow has a past medical history of chronic obstructive pulmonary disease (COPD), chronic venous insufficiency, and deep vein thrombosis (DVT). Peripheral arterial disease is ruled out by duplex ultrasound. Her daughter had her admitted to this skilled nursing home care facility due to concern for her safety with impaired mobility, an unhealthy diet, and inability to adequately care for herself at home.

Assessment: Mrs. Morrow is alert and oriented, but sometimes forgetful of recent events. Vital signs have been within normal limits and are performed weekly. Results from yesterday's labs are in the chart. She is on a regular diet with nutritional supplement and has been eating the majority of her meals since admission. She requires assistance with positioning in bed and assistance times 1 to get out of bed to the chair or ambulate. Her gait is unsteady, and she is easily fatigued. Her Braden Scale score is 16, and her skin is intact except for the venous stasis ulcer on the right medial malleolus. She has brown hyperpigmentation on both lower legs with +2 edema. The venous stasis ulcer is covered with a hydrocolloid dressing, which is due to be changed. In preparation for her dressing change, she was medicated for pain half an hour ago.

Recommendation: You should complete a basic assessment, review the labs, perform a wound assessment and dressing change, and then reposition the patient to optimize venous return. Please provide patient education on improving venous return to prevent further stasis ulcers, and continue compression therapy with the use of elastic bandage and an antiembolism stocking.

Josephine Morrow

Guided Reflection Questions

Opening Questions

How did the simulated experience of Josephine Morrow’s case make you feel?

Talk about what went well in the scenario.

Reflecting on Josephine Morrow’s case, were there any actions you would do differently if you were to repeat this scenario? If so, how would your patient care change?

Scenario Analysis Questions*

S                What priority problem(s) did you identify for Josephine Morrow?

PCC         Identify in Josephine Morrow’s health history any factors that predisposed her to having chronic venous insufficiency.

PCC/S    Discuss the assessment findings and diagnostic studies that correlate with chronic venous insufficiency and venous stasis ulceration. Provide the reasons behind these findings.

S                What is the rationale for the daily dose of ASA?

EBP/I      What is the rationale for compression therapy?

EBP/I      What is the rationale for performing a Braden scale assessment on Josephine Morrow?

T&C         What other interprofessional team members should be involved in Josephine Morrow’s care?

Concluding Questions

Describe how you would apply the knowledge and skills that you acquired in Josephine Morrow’s case to an actual patient care situation

Answer 1

A 1.I feel if she gets better medical attention ,something can be done to relieve her from her present condition.

2 The best part of the scenario is she has been shifted to a nursing care home ,before her condition worsened.

3 Since she has a history of DVT ,I would recommend to elevate the affected extremity to the heart level and measure and monitor the circumference of calf muscles.

4.My top priority will be to improve venous return by instructing the client to elevate legs for 10-20 minutes every few hours and advise her to wear stockings.

B 1.Top priority will be given for increasing the venous return,impaired mobility,altered nutritional status and skin integrity.

2.The possible risk factor for Josephhne is DVT and immobility and the history doesnt signify any other potential problem.Peripheral arterial disease is ruled out by doing duplex ultrasound.

3 Assessment findings are stasis dermatitis or brown discolouration along the ankles,extending up to the calf,edema,ulcer formation in which edges are uneven,ulcer bed is pink,and granulation is present.

4A venous duplex Ultrasound examination can confirm the presence of venous obstruction or valvular incompetence as the cause of venous hypertension and is used for planning venous ablation procedures,but is not necessary in all cases of suspected venous insufficiency.Air plethysmography is used when complications of venous insufficiency have been shown to corelate with the severity of venous disease and is often assessed with the venous filling index and ejection capacity .This technique provides quantitative information about several aspects of global venous function and may be used in the selection of intervention and assessment of the response to intervention.

5 ASA is an acronymn for Aspirin.It has many potential benefits ie it is cardioprotective,antiinflammatory,analgesic,antipyretic and chemopreventive.

6 It is used for improving venous,arterial and lymphatic circulation.

7 Braden scale assessment is done on Josephine to evaluate risk of pressure ulcer.It is based in 6 categories sensory perception,moisture,activity,mobility,nutrition and friction.

15-18 at risk

13-14 moderate risk

10-12 high risk

9- very high risk.

Josephine has a scale of 16 ,so she belongs to at risk group.

8 The other interprofessional team members are certified wound care nurse,physical therapist,surgeon and podiatrist