Preclinical Scenario 2

MSU Basic Nursing Regional Simulation Center Preclinical Scenario 2 Learning Outcomes: Demonstrate proper assessment of vital signs Perform a focused assessment Correctly implement aseptic techniques including hand washing & the use of personal protective equipment Demonstrate range of motion (ROM) to reduce hazards of immobility Demonstrate making an occupied bed Demonstrate the application of restraints & appropriate assessment of the restrained patient Demonstrate proper body mechanics when providing patient care Demonstrate moving, turning, & positioning of a patient in and out of bed Correctly utilize various assistive devices; wheelchair, cane, walker, gait belt Demonstrate application of compression stocking Match a variety of oxygen delivery systems to their indications Document assessment and plan of care in DocuCare Resources: Center for Disease Control and Prevention. (2014). Guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. Retrieved from https://www.cdc.gov/infectioncontrol/guidelines/isolation/appendix/ppe.html Centers for Disease Control and Prevention, Healthcare-associated infections (HAIs). (2012). Top CDC Recommendations to Prevent Healthcare-Associated Infections. Retrieved from http://www.cdc.gov/HAI/pdfs/hai/top-cdc-recs-factsheet.pdf Nursing Central Anderson, D.J. and Friedman, N. D. (2017, January 30). General principles of infection control. Retrieved from https://databases.mwsu.edu:2203/contents/infection-prevention-general-principles?search=General%20principles%20of%20infection%20control&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2 Taylor, C., Lillis, C., & Lynn, P. (2015). Fundamentals of nursing (8th ed.). Philadelphia, PA: Lippincott, Williams, & Wilkins. Supplies: Lab bag with supplies in a separate Ziploc bag pulled prior to clinical: Gown Clean gloves that fit your hands Mask Watch with second hand Stethoscope, calculator, pen, blood pressure cuff Text book or e-book Laptop or tablet with access to DocuCare Skills to be demonstrated this scenario. Please review the procedures. They can be found in your basics textbook. Vital signs Hand washing Donning and doffing PPE Making an occupied bed Providing range of motion exercises TED hose/compression stocking application Transfer of patient in and out of bed, chair Transfer of patient from bed to stretcher Gait belt safety Wheelchair safety Safe use of walker and cane Applying an extremity restraint Describe the use and indication for different oxygen delivery systems (nasal cannula, mask, ect) Demonstrate use of Incentive Spirometer Using an inhaled medication device Preclinical Preparation: Review prior to attending the simulation Chapter 23 Asepsis Video: Hand Hygiene Procedure checklist 23-1 Hand hygiene 23-2 PPE Chapter 25 Health Assessment Procedure checklist 25-2 Assess neurological & musculoskeletal system Chapter 26 Safety Procedure checklist: 26-1 Extremity Restraint Chapter 30 Hygiene Videos: Bed bath Occupied bed Procedure checklists 30-1 Bed bath 30-2 Oral care independent 30-3 Oral care dependent 30-4 Bed linen change 30-5 Occupied bed linen change Chapter 32 Activity Video: Range of Motion Procedure checklists 32-1 Compression stockings 32-2 Turning 32-3 Assisting up in bed 32-4 Bed to stretcher 32-5 Bed to chair 32-6 Range of motion YouTube video SCDs at https://www.youtube.com/watch?v=qyof_3CTn1g Chapter 38 Oxygenation 38-3 Administering Oxygen by Nasal Cannula 38-4 Administering Oxygen by Mask For questions 1-3: Identify the isolation precaution(s) to implement in each situation and list the personal protective equipment (PPE) necessary to care for each patient (Box 23-4 pg. 551): 87 y/o female admitted to the medical floor with a history of cough, bloody sputum, night sweats, and malaise. 64 y/o male with a history of diabetes for 30 years complained about a wound that he has had on his heel for the past three weeks. His temperature is 102º and the wound has a foul smell after you clean the debris off. After cleaning the heel you send a wound culture. Three days later you receive a wound culture with a report of Methicillin Resistant Staph Aureus (MRSA). 26 y/o male admitted with diagnosis of HIV and Hepatitis B which he acquired five years previous because of his drug abuse and sharing needles. Describe an N95 Mask and under which circumstances would this mask be appropriate to wear. Is this mask reusable? Activity, Exercise, Mobility, Immobility, & Safety Match the patient position with the definition of that position. _____The position that facilitates respiration by a. Prone allowing maximum chest expansion b. Trendelenburg _____Client lies on the abdomen with head c. Orthopeneic turned to one side d. Fowlers _____Lying on the back with the client’s head e. Dorsal recumbent and shoulder slightly elevated on a small f. Sims pillow _____Semi sitting position with the head of the bed raised to at least 45 _____Posture half way between lateral and prone position _____Position to provide postural drainage of basal lung lobes, head of the bed lowered and the foot raised in a straight incline Hygiene While performing a bed bath of the immobilized patient, list a nursing consideration along with rationale for bathing the following areas: Eyes – Oral care – Arms – Feet – Buttocks – Perineal area – When performing a focused assessment, what are some questions you can ask the patient in order to gather data about a specific problem that has already been identified? Identify focused assessment subjective and objective data needed for a neurologic assessment. Identify focused assessment subjective and objective data needed for a skin assessment. Neurologic: Skin: Oxygenation During oxygen administration to the client, which of the following pieces of equipment would enable the nurse to regulate the amount of oxygen delivered? Flow meter Oximeter Humidifier Nasal cannula What information would a home care nurse provide to a client who is measuring peak expiratory flow rate at home? “Although the test is uncomfortable, it is not painful” “You will be asked to forcefully exhale into a mouthpiece” “The test is used to determine how much air you inhale” “ You will do this each morning while still lying in bed” The nurse is reviewing the chart of a client receiving oxygen therapy. The nurse would question which Physician’s Order for supplemental oxygen? 10 L/min oxygen via Venturi Mask 8 L/min oxygen via partial rebreather mask 8 L/min oxygen via nasal cannula 12 L/min oxygen via nonrebreather mask Fill in the following oxygen delivery table. Keep this table handy for further reference during your clinical learning experiences: Delivery System % Oxygen Liter Flow Nursing Responsibilities: Nasal Cannula Simple Face Mask Non-rebreather Venturi-mask Bag Valve Mask