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?
Safety/Quality Improvement Measures Nursing Actions
, - Prepare and administer
Medication administration 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
- Educate pt about diabetes and
Supportive care 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
- Pt is at fall risk due to delirium and
Safety issues related to infection control 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
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?
Safety/Quality Improvement Measures Nursing Actions
, - Prepare and administer
Medication administration 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
- Educate pt about diabetes and
Supportive care 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
- Pt is at fall risk due to delirium and
Safety issues related to infection control 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
