Safety/Quality Improvement Measures Nursing Actions

Sherman “Red” Yoder, Part 2

Guided Reflection Questions

Opening Questions

How did the simulated experience of Red Yoder’s case make you feel?

- I think it was a great experience to assess a patient as an emergency triage nurse.

Assessing the same patient again but with different problem this time and evaluating his

wound care interventions was a good change. I also enjoyed asking questions regarding CAM

assessment.

What nursing actions did you feel were appropriate within this scenario?

- I feel all nursing actions were appropriate for this scenario. Administration of medication,

taking vitals, assessing the wound, completing CAM and SPICES assessment tools,

communicating with a family member, calling ICU and provider were all necessary actions.

Scenario Analysis Questions*

PCC What is the correlation between Red Yoder’s open foot wound, the diagnostic

findings, and treatment modalities including fluid bolus, insulin, and antibiotic therapy?

- A wound culture and sensitivity test was ordered for Red to identify the bacterial

microorganisms in the wound. His diagnostic findings also suggested high white blood

cells (12,000) which suggests an infection from a diabetic foot ulcer. Red was ordered

to start antibiotic therapy to treat Red’s foot wound and prevent further infection from

spreading. Red has type 2 diabetes which could cause nerve damage and numbness in

his foot. Insulin would help control the diabetes and fluid bolus would help red to stay

hydrated and promote wound healing. Fluid bolus will help to prevent the patient from

being hypovolemic and tachycardia.

PCC What potential problems can you identify for Red Yoder if his symptoms are

not managed in a timely manner?

- If the infection gets worse and his foot gets necrotic, his foot might need to be

amputated. If the systemic infection is not controlled, he could possibly go into

septic shock.

S/QI For the following Safety/Quality Improvement measures, what nursing actions should

be taken during Red Yoder’s case?

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Medication administration

- Prepare and administer

medications, using rights of

medication administration

- Assess IV site for infiltration

or extravasation

- Review pertinent data prior to

medication administration (e.g.,

contraindications, lab results,

allergies, potential interactions)

- Administer and document

medications given by parenteral

routes

- Participate in medication

reconciliation process

- Assess pt’s response to the meds

Supportive care

- Educate pt about diabetes and

its complications

- Reposition pt to semi-fowler to

promote lung expansion to aid in

breathing

- Using CAM method, assess

his confusion

- Educate judy and Red on delirium

- Provide education on foot sore,

wound care, medications, and sepsis

- Assess sensation in lower extremities

- Perform focused neurological exam

- Administer insulin as ordered

- Monitor vital signs

- Apply nasal cannula to bring o2 back

up to greater than 94

Safety issues related to infection control

- Pt is at fall risk due to delirium and

should be assess using morse fall

risk scale

- To control the infection, his lab

values should be monitored along

with vitals (sp02, BP)

- His blood sugar should be

checked frequently and

administer insulin accordingly

- Maintain contact isolation as pt

is positive for staph

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