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· Cystic Fibrosis

· Chronic Venous Insufficiency

 

Scenario Overview

Patient: Josephine Morrow

Diagnosis: Chronic venous insufficiency with venous stasis ulcer

Brief Summary:

This case presents Josephine Morrow, a white, obese 80-year-female who moved to a skilled nursing home care facility 3 days ago. The patient has a venous stasis ulcer that developed while still living on her own. The students are expected to assess the leg wound, assess the patient’s pain, perform a dressing change, reapply elastic bandage and antiembolism stocking, and communicate findings. The students are also expected to assess lab values and provide patient education on interventions to promote venous return.

Learning Objectives

General:

â–¡ Assess patients to recognize normal versus abnormal findings

â–¡ Respond to changes in patient status

â–¡ Assume accountability for the plan of care by order of priority, implementation, and evaluation

â–¡ Use standard precautions when caring for the patient

â–¡ Ensure patient and healthcare provider safety

â–¡ Collaborate appropriately with the healthcare team in a timely, organized, and patient-specific manner

â–¡ Use critical thinking when making clinical judgments and decisions

â–¡ Establish a therapeutic environment for the patients and their families

â–¡ Use therapeutic communication techniques in a manner that illustrates caring for the patient’s overall well-being

Scenario-Specific:

  Recognize signs and symptoms of chronic venous insufficiency

  Assess the size and appearance of a venous stasis ulcer

  Interpret laboratory results and their relationship to skin integrity

  Perform a simple dressing change

  Provide patient education on measures to improve venous return and prevent venous stasis ulcers

Patient Case 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.

Patient Details

Patient Data: Female, White, 80 years. Weight: 90 kg (198 lb), Height: 160 cm (63 in.)

DOB: 02/23/XX

Allergies: Penicillin

Immunizations: Up to date

Past Medical History:

â–¡ COPD

â–¡ DVT 5 years ago

 

Provider’s Orders

· Admit to skilled nursing home care facility

· Vital signs once a week

· Diet: Regular, with nutritional protein supplement twice daily

· Activity: Out of bed ad lib., keep legs elevated

· Labs: CBC, BMP, total protein, albumin, and prealbumin monthly

· Hydrocolloid dressing to right lower leg ulcer

· Change dressing every 3 days; clean and irrigate wound with normal saline

· Antiembolism stocking to left leg (knee-length) and elastic bandage to right leg

· Medication:

o Multivitamin one tablet orally daily at 0900

o Zinc supplement one tablet orally daily at 0900

o Aspirin 81 mg orally daily at 0900

o Albuterol inhaler 360 mcg prn for wheezing

o Acetaminophen 650 mg orally every 6 hours prn pain

· Call orders:

o HR less than 60/min, greater than 120/min

o RR less than 10/min, greater than 30/min

o SpO2 less than 92%

o Systolic BP less than 90 mm Hg, greater than 160 mm Hg

o Diastolic BP less than 50 mm Hg, greater than 95 mm Hg

o Temperature less than 36 °C (97 °F), greater than 38.5 °C (101.4 °F)

Nursing Diagnoses

Impaired Skin Integrity related to physical immobilization, altered venous circulation, and obesity

Defining characteristics:

· Right lower leg skin ulceration

· Skin hyperpigmentation of lower extremities

· Edema

· Decreased mobility

 

Impaired Physical Mobility related to activity intolerance and decreased strength

Defining characteristics:

· Reluctance to attempt movement

· Decreased muscle strength and movement

· Fatigue

· Requires assistance for bed mobility, transfer, and ambulation

 

Deficient Knowledge related to unfamiliarity with information resources on improving venous return and preventing venous stasis ulcers

Defining characteristics:

· Lack of knowledge on benefits of leg positioning, activity, and compression therapy

· Unfamiliar with the use of antiembolism stockings

· Lack of recall on keeping legs elevated and increasing mobility

 

Risk for Infection related to impaired skin integrity, altered venous circulation, and poor nutrition

Case Considerations

This patient is an obese, 80-year old female in a skilled nursing home care facility with a venous stasis ulcer. The students are expected to assess the leg wound, assess the patient’s pain, and perform a dressing change. The students are also expected to assess lab values, and provide patient education on interventions to promote venous return. Venous stasis ulcers occur in the lower extremities from impaired venous circulation and are usually shallow with an irregular shape over bony prominences, particularly the medial malleolus. Hypertension in the venous system of the legs can lead to pain, edema, varicose veins, skin changes, dermatitis, hyperpigmentation, and venous stasis ulcer formation. The most important aspect of venous ulcer treatment is prevention with adequate compression therapy, using an elastic bandage and antiembolism stocking, and optimizing venous return. The surrounding skin should be inspected daily, and kept clean and well lubricated. Legs should be elevated above the heart to reduce edema

 

Image transcription text

ACTIVE LEARNING
TEMPLATE: System
Disorde… Show more

Scenario Overview

Patient: Christopher Parrish

Diagnosis: Cystic fibrosis, weight loss, and fatigue

Brief Summary:

Christopher Parrish is an 18-year-old adolescent male who is hospitalized for management of cystic fibrosis with weakness and weight loss. He reports fatigue, and he has had a recent 6 kg (13.2 lb) weight loss. He was diagnosed with cystic fibrosis as an infant and has had multiple hospitalizations for respiratory and nutritional support. A nasogastric (NG) tube has been placed for feedings. Students are expected to assess his nutritional status, assess vital signs, administer oral medications, begin tube feeding, and educate the patient about his nutritional needs.

Learning Objectives

General:

â–¡ Assess patients to recognize normal versus abnormal findings

â–¡ Respond to changes in patient status

â–¡ Assume accountability for the plan of care by order of priority, implementation, and evaluation

â–¡ Use standard precautions when caring for the patient

â–¡ Ensure patient and healthcare provider safety

â–¡ Collaborate appropriately with the healthcare team in a timely, organized, and patient-specific manner

â–¡ Use critical thinking when making clinical judgments and decisions

â–¡ Establish a therapeutic environment for the patients and their families

â–¡ Use therapeutic communication techniques in a manner that illustrates caring for the patient’s overall well-being

Scenario-Specific:

  Implement safety precautions for a patient receiving enteral feeding

  Implement enteral feeding through NG tube

  Assess patient’s diet intake

  Provide patient education on nutritional needs and nutritional therapy

Patient Case Introduction

Location: Medical-Surgical Unit 2315

Report from day shift nurse:

Situation: Christopher Parrish is an 18-year-old male who was admitted at 1900 today. His mother visited him at his college dormitory and was very concerned with his health; he seemed weak and had lost weight since she last saw him. She took him to see his primary care provider, and the provider admitted him and has ordered a tube feeding. I placed an 8-Fr, 42-inch feeding tube in his right nares about an hour ago, and x-ray just called and confirmed placement in the stomach. The pump is in his room. He is up to the bathroom prn; otherwise bed rest.

Background: Christopher was diagnosed with cystic fibrosis as a child and has had frequent hospitalizations previously. He reports fatigue and has recently lost 6 kg (13.2 lb) after he registered at the local college and moved to live in a dormitory. Chris’s mom was here earlier, but she is a single parent and has two younger boys, so she had to go home.

Assessment: Christopher is awake and alert. His heart rate and rhythm are regular at 80-85/min. Breath sounds are fine with a respiratory rate at 18/min. His color is a bit pale. Blood pressure is 118/78 mm Hg. He reports no pain and states he’s not had much appetite the past few weeks. His belly is flat and nontender. Bowel sounds are normoactive.

Recommendation: Christopher is due for vital signs and assessment. The tube feeding just arrived, and you will need to start it on the pump. He needs 720 kilocalories over 8 hours overnight. His regular diet is high calorie, high fat, but he wasn’t too hungry this evening; just had a bit of his chocolate shake. You will need to give his pancreatic enzymes orally before you start the tube feeding. You should also assess his diet and reinforce patient education on nutrition.

Patient Details

Patient Data: Male, White, 18 years. Weight: 56 kg (124 lb), Height: 180 cm (71 in.)

DOB: 2/1/XX

Allergies: No known allergies

Immunizations: Up to date through Tdap (diphtheria, tetanus, pertussis booster) at age 15 years; recent flu vaccine

Past Medical History:

â–¡ Diagnosed with cystic fibrosis at age 1

â–¡ Hospitalized for respiratory complications multiple times since age 5 years

â–¡ Surgery for PEG (percutaneous endoscopic gastrostomy) tube placement at age 5-7 years

â–¡ No other surgeries

 

Provider’s Orders

· Vital signs every 4 hours

· Daily intake and output, and weight

· Chest X-ray: AP and lateral tomorrow morning.

· Insert nasogastric tube

· Nutrition consult

· Diet:

o High-fat, high-calorie, high-protein regular diet, supplement with high-protein snacks

o Fluid nutrition (1.5 kcal/mL) in nasogastric tube; administer 720 kcal over 8 hours at night

· Medication:

o Pancrelipase enzymes five capsules orally with meals and tube feedings; three capsules orally with snacks

o Multivitamin two tablets orally every morning

· Call orders:

o HR less than 60/min, greater than 110/min

o RR less than 12/min, greater than 22/min

o SpO2 less than 94%

o Systolic BP less than 110 mm Hg, greater than 140 mm Hg

o Diastolic BP less than 65 mm Hg, greater than 90 mm Hg

o Temperature greater than 38.5 °C (101.3 °F)

o Fasting blood glucose less than 80 mg/dL, greater than 180 mg/dL

Nursing Diagnoses

Imbalanced Nutrition: Less than Body Requirements related to cystic fibrosis and malabsorption

Defining Characteristics:

· Weight loss of greater than 2 kg in past 2 weeks

· Patient appears fatigued and undernourished

· BMI = 17.3

Readiness for Enhanced Nutrition related to need to improve nutritional intake

Defining characteristics:

· Verbal reports of understanding nutritional needs

· Establishing independence in self-care management away from home

Activity Intolerance related to impaired oxygen transport secondary to mucopurulent secretions

Defining Characteristics:

· Dyspnea with activity

· Verbal reports of being tired and weak

· Weakness when carrying out activities of daily living – including meal preparation

Case Considerations

This patient has been hospitalized for management of cystic fibrosis and associated weakness and weight loss. He reports fatigue, and he has had a recent 6 kg (13.2 lb) weight loss. He was diagnosed with cystic fibrosis as an infant and has had multiple hospitalizations for respiratory and nutritional support. A nasogastric (NG) tube has been placed for feedings. Students are expected to assess his nutritional status, assess vital signs, administer oral medications, begin tube feeding, and educate the patient about his nutritional needs. The steps for administering feedings are similar regardless of the tube used. Feeding can be provided on an intermittent or continuous basis. Position the patient with the head of bed elevated at least 30 to 45 degrees or as near normal position for eating as possible. This position minimizes the possibility of aspiration into the trachea. Assure correct placement of the feeding tube before administering the feedings. The nurse should ensure proper placement of the NG tube by relying on multiple methods and not on one method alone.

Image transcription text

ACTIVE LEARNING
TEMPLATE: System
Disorde… Show more

 

SCIENCE
HEALTH SCIENCE
NURSING
NURSING BS NURS 327

 

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