Penny Case Study and Oxygen Therapy Notes

Penny Case Overview

  • Context: Nursing home/rehabilitation facility setting focusing on patient assessment, clinical judgment, and routine care planning. Emphasis on documenting patient information, monitoring intervention effectiveness, and using a standardized model to guide care decisions.
  • Scenario focus: Penny, a 79-year-old female with a history of stroke and left-sided weakness.
  • Key issues identified in case: skin integrity concerns, oral hygiene issues, ADL dependency, left heel pressure injury, numbness/weakness in left leg, dry lips, thick/discolored toenails, and limited functional mobility requiring a wheelchair for daily movement.
  • Nursing student activity: Observe a video case study, take notes, and be prepared for a quiz on findings.

CJMM and Care Process

  • Clinical Judgment Measurement Model (CJMM) steps referenced:
    • Recognize cues
    • Analyze cues
    • Prioritize hypotheses
    • Generate solutions
    • Take action
    • Evaluate outcomes
  • Example in Penny case:
    • Cues gathered from: skin assessment (dry, cracked lips; yellow-brown film on teeth; dry, flaky skin on lower extremities; thick/discolored toenails), presence of a pressure injury on the left heel, ADL assessment, and EHR/OT notes.
    • Priority hypothesis chosen: self-care deficit.
    • Solutions generated: bathing assistance, oral care, hydration/nutrition considerations, and podiatry consult.
    • Actions taken: gather supplies, involve UAP for support, assist with bathing, oral care, and dressing, and arrange a podiatry consult.
    • Outcomes evaluated: Penny able to participate in self-care activities to some extent; skin and mucous membrane condition improved; dressing dry and intact; lips warm and moist; teeth clean; planning of care deemed successful.
  • Additional emphasis:
    • The importance of documenting cues, assessment findings, interventions, and outcomes.
    • Role of RN in teaching and support of team (including UAP) and ensuring tasks are carried out properly.
    • Discharge planning should begin at arrival to facilitate care continuity post-discharge.

Cues from Penny's Assessment

  • Demographics and medical history:
    • Age: 79, female
    • History: stroke with left-sided weakness; left leg numbness; functional impairment.
  • Physical findings:
    • Skin/integument: dry, cracked lips; yellow-brown film on teeth; dry, flaky skin on lower extremities; thick, discolored toenails; pressure injury on left heel.
    • Mobility: can walk short distances but uses a wheelchair for mobility.
    • ADLs: moderate assistance required; difficulty with brushing teeth and self-care due to left arm weakness.
  • Functional status: occupational therapy notes indicate moderate assistance with ADLs and moderate strength/tone in right hand with poor strength/tone in left hand.
  • Nursing diagnosis (priority): Self-care deficit (related to stroke, weakness, and ADL limitations).

Interventions and Actions (Hygiene, Skin Integrity, and Nutrition)

  • Nursing plan and goals:
    • Expected outcome: Penny will participate in bathing once per day and oral care twice per day.
  • Implementation steps:
    • Gather supplies for bathing and oral care.
    • Involve UAP to assist; implement a team approach.
    • During bathing:
    • Penny uses her right hand to clean her face and chest with a wet washcloth; caregiver assists with back and legs.
    • UAP applies moisturizer after bathing; nurse applies dressing to left heel.
    • Oral care:
    • Penny assisted in brushing teeth; encouragement given to use affected left hand; nurse supports as needed.
    • Post-care:
    • Penny dressed and settled in bed; nurse and UAP provide emotional encouragement and support.
    • Nutritional and skin integrity considerations:
    • Nurse orders a lunch tray rich in protein and nutrients to prevent dehydration/malnutrition and support skin health.
    • Podiatry: recommend a podiatry consult due to thick, dry nails that can contribute to skin breakdown and pressure risk.
  • Educational and team considerations:
    • RN role modeling appropriate hygiene care (oral and general hygiene).
    • Clarification that UAP tasks should align with their training and be closely supervised by RN.
    • Emphasis on empowering patient to participate in self-care as much as possible.
  • Discharge planning considerations:
    • Start planning at arrival; anticipate home or facility discharge needs and supports.

Outcomes and Evaluation (Reassessment)

  • Evening reassessment findings:
    • Skin looks clean and soft; dressing remains dry and intact.
    • Lips were warm and moist; teeth remained clean.
  • Overall assessment: The care plan targeting self-care deficit and hygiene was successful; Penny’s ability to participate in some self-care activities improved; skin integrity and mucosal hydration improved with nutrition and hygiene interventions.
  • Recap emphasis: Focus on recognizing cues, prioritizing the self-care deficit hypothesis, implementing hygiene interventions, and evaluating outcomes against expected goals.

Discharge Planning and Team Dynamics

  • Discharge planning concept:
    • Initiated early—questions about home care, caregiver needs, and post-discharge support.
  • Team dynamics and leadership:
    • RN's responsibility to teach and support the team (including UAP).
    • Role modeling and guiding independent patient participation in care.
    • Discussion about role clarity for UAP and the need for proper training to perform hygiene-related tasks.

Oxygenation and Oxygen Therapy Fundamentals

  • Core concept: Oxygen therapy is the delivery of extra oxygen to patients with conditions causing hypoxia (inadequate oxygen at the tissue level).
  • Conditions that may cause hypoxia include:
    • Lung diseases (e.g., pneumonia, chronic bronchitis, emphysema, sleep apnea).
    • Blood problems affecting oxygen transport (e.g., anemia).
  • Pathophysiology notes:
    • Hypoxia results when the lungs cannot adequately exchange oxygen and carbon dioxide.
    • Sleep apnea can impact brain function and healing if not well managed.
  • Oxygen as a medication:
    • Oxygen delivery requires a provider order and nursing administration with ongoing monitoring.
  • Oxygen delivery system components:
    • Oxygen source (wall outlet, oxygen tank, liquid oxygen system, oxygen concentrator).
    • Delivery device (nasal cannula, various masks).
    • Flow meter to regulate liters per minute (L/min).
    • Humidifier bottle and distilled water when humidification is ordered.
  • Oxygen flow and delivery basics:
    • Typical flow range: 1 \, \le \, \text{flow} \, \le \, 15 \, \text{L/min}
    • Humidification helps prevent drying of nasal/oral mucosa and supports patient comfort.
  • Delivery devices:
    • Nasal cannula: two prongs in nostrils with tubing behind ears; allows eating/drinking; simple and less intrusive; high flow can dry mucosa; potential skin irritation if tight or prolonged.
    • Face masks: more effective for higher oxygen needs but less comfortable and harder for eating/drinking; include simple masks, partial rebreather, non-rebreather, and Venturi masks (for precise FiO2).
    • Airway adjuncts: nasopharyngeal airway (through nose to pharynx) and oropharyngeal airway (through mouth to pharynx) to keep the airway open in sedated/unconscious patients.
  • Practical considerations for oxygen therapy:
    • Always wear the delivery device unless the plan of care specifies otherwise; assess for device tolerance.
    • Store and operate oxygen in well-ventilated areas; avoid confinement behind curtains or in cabinets.
    • Oxygen supports combustion; keep at least 5 \text{ feet} away from flames or heat sources; prohibit smoking around oxygen use or storage.
    • Avoid oil-based products near oxygen delivery; use water-based moisturizers around the nose.
    • Avoid static electricity (cotton bedding preferred).
    • Check humidity bottle water level and ensure there are no kinks in tubing; ensure prongs/bags are positioned properly to avoid mucosal irritation or blocked airflow.
    • For nasal cannula: ensure prongs face upward; check for mucus on prongs; ensure comfort.
    • For mask with reservoir bag: monitor that the bag inflates to indicate adequate flow.
  • Setup steps for an oxygen system (brief):
    • Gather equipment: oxygen delivery device with tubing, flow meter, humidifier bottle if ordered, distilled water.
    • Connect flow meter to oxygen source; attach humidifier to flow meter and to delivery device; fill humidifier with distilled water if needed.
    • Ensure humidification and flow rate match order; check for bubbles in humidifier; confirm patient comfort.
    • Turn on and adjust flow according to order; assess SpO2 before and after application to determine effectiveness.
  • Patient assessment and monitoring while on oxygen:
    • Before applying oxygen: assess baseline SpO2 and monitor patient for signs of distress or airway issues.
    • Monitor for: abrupt chest discomfort, shortness of breath, new or increasing cough with colored sputum (white, black, green, yellow, or brown), changes in vital signs, changes in level of consciousness, cyanosis, irritation or breakdown around nose/cheeks/ears, and any kinks or dislodgement in tubing.
    • Documentation: date and time of assessments, observations, and response to therapy.

Safety Considerations and Best Practices for Oxygen Therapy

  • Standard precautions:
    • Do not remove oxygen delivery device without a care plan change.
    • Ensure adequate ventilation; avoid enclosed spaces that trap oxygen.
    • Keep oxygen equipment and reservoirs away from heat sources and liquids that could ignite.
  • Humidification and skin care:
    • Regular oral care to mitigate dryness from oxygen therapy.
    • Skin care around device contact points to prevent breakdown.
  • Documentation and quality improvement:
    • Record assessment findings, oxygen saturation changes, and adherence to care protocols.
    • Reassess the care plan if patient does not respond as expected to oxygen therapy.

Quick Recap and Group Activity Orientation

  • Recap of Penny case:
    • CJMM guided the care process from cue recognition to outcome evaluation.
    • Interventions targeted self-care deficit, hygiene, and skin integrity.
    • Multidisciplinary approach including RN supervision and UAP assistance; discharge planning initiated early.
  • Oxygen therapy review:
    • Hypoxia risk; oxygen as medication; various delivery systems; safety and monitoring priorities; setup and documentation.
  • Group activity (upcoming):
    • Apply CJMM and oxygenation knowledge to a new patient case in groups; prepare to discuss cues, hypotheses, actions, and evaluation.
  • Final takeaway:
    • Consistent practice of assessment, prioritization, and patient-centered interventions improves functional outcomes and supports safe transitions from facility to home or another care setting.