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This update to the 2nd edition (2010) of the Preparation Guide for the ProfessionalExamination of the Ordre des infirmières et infirmiers du Québec is a sign of howthe nursing profession is constantly changing. It deals mainly with one of thesituations in the practical section, i.e. situation 14 in Chapter 4, reproduced in its

entirety in the first part of this update. It has been revised in collaboration with Diane St-Cyr,RN, MEd and Danielle Gilbert, RN, BSc, to reflect current wound care practices.

e other changes made to the guide are presented in two tables. e first table shows thecorrections made to the text, and the second lists the corrections relating to medications andthe applicable page numbers.

U2011 Update

490How to intervene in the clinical situationsin the practical part

Clinical situations

4

Instructions

You have 10 minutes to:

1. Assess Mrs. Ouellette’s ulcer by collecting all the relevant data

2. Give the nursing assistant appropriate directives concerning the wound treatment plan

3. Adjust the therapeutic nursing plan if necessary

Available documentation

• Wound treatment plan (TP) no. 1• Wound assessment form• Excerpt from the therapeutic nursing plan (TNP)

Situation 14

INSTRUCTIONS FOR THE CANDIDATE

Clinical setting Long-term care center

Name Mrs. Ouellette

Reason for hospitalization Venous ulcer

IInstructions

Clinical situation

Mrs. Ouellette, age 73, has right hemiplegia as a result of a stroke she suffered 3 months ago.She has been living in a long-term care facility for 1 month now due to a loss of autonomy.Mrs. Ouellette developed a venous ulcer on the lower medial third of her right leg 2 weeks ago.e doctor prescribed vascular studies, including an ankle brachial index (ABI). Her legs areedematous, especially the right leg. To relieve her pain, she takes acetaminophen, 325 mg/tab.1 to 2 tabs q 4 h as needed.

Mrs. Ouellette’s ulcer was last assessed 3 days ago. Today, Carole-Anne Melanson, a nursingassistant, has just changed Mrs. Ouellette’s dressing and reports her observations to you.It is 14:00.


Clinical situations

Wound treatment plan no. 1

• Cleanse wound with NaCl 0.9%

• Hydrocellular foam dressing

Wound assessment form

4 Situation 14

Date of initial assessment: 2011-03-07Wound present on admission on 2011-02-21: noDate of development of wound: 2011-03-07Recurrent wound: noEtiology: vascular (venous insufficiency)Site of wound: lower medial third of right leg

Initial assessment Last assessment

Date 2011-03-07 2011-03-22 (3 days ago)

Location Right leg: Right leg:lower medial third lower medial third

Size- Length 4.8 cm 3.8 cm- Width 2.6 cm 1.7 cm- Depth 0.3 cm 0.2 cm

Tissue (wound bed) % Red granulation 100% Red granulation 100%

Surrounding skin Pink and intact Pink and intact

Exudate- Type Serous Serous- Amount Moderate Moderate- Odour Insignificant Insignificant

Pain 4/10 3/10


4 Situation 14

Clinical situations

INSTRUCTIONS FOR THE CANDIDATE (cont)

Excerpt from the therapeutic nursing plan (TNP) Mrs. Ouellette

IInstructions

ASSESSMENT FINDINGS

CLINICAL FOLLOW-UP

Date Time No. Priority problem or need Initials RESOLVED/SATISFIED Professional/Date Time Initials department involved

2011-03-07 8:30 2 Venous ulcer: lower medial third Dietician, occupational

of right leg DG therapist, physio

3 Pain in right leg DG

4 Edema of lower limbs DG

Date Time No. Nursing directive Initials DISCONTINUED/CARRIED OUT

Date Time Initials

2011-03-07 8:30 2 Nurse to assess wound q Monday or Tuesday or Wednesday

during treatment DG

2 Apply treatment plan no. 1 q 3 days if moderate exudate

or as needed if dressing is saturated DG

2 Notify nurse if wound deteriorates or if signs of infection DG

3 Administer analgesic 30 to 45 min. before

dressing change DG

3 Notify nurse if client unrelieved by 2 tabs acetaminophen DG

3 Nurse to assess pain management q 3 days DG

3-4 Elevate lower limbs when sitting or lying down except

for meals DG

4 Notify nurse if edema worsens DG

Signature of nurse Initials Program/ Signature of nurse Initials Program/dept. dept.

Diane Guérin DG Geriatrics 4 S


Clinical situations

4 Situation 14

Clinical situation

What is the relevant information in this clinical situation?

Instructions

What do the instructions mean?

1. Assess Mrs. Ouellette’s ulcer by collecting all the relevant data.

This means…

2. Give the nursing assistant appropriate directives concerning the wound treatment plan.

This means…

3. Adjust the therapeutic nursing plan if necessary.

This means…

Documentation

What is the relevant information in the available documentation?

IDENTIFICATION OF RELEVANT INFORMATION


Clinical situations

4 Situation 14

Clinical situation

Relevant information in the clinical situation:

• right hemiplegia for 3 months

• admitted to long-term care facility 1 month ago

• venous ulcer on right leg for 2 weeks

• edema of lower limbs, especially the right leg

• pain relieved by acetaminophen 325 mg/tab. 1 to 2 tabs q 4 h PRN

• wound last assessed 3 days ago

• dressing change today by a nursing assistant

Instructions

The instructions mean:

1. Assess Mrs. Ouellette’s ulcer by collecting all the relevant data• this means collecting relevant clinical data about the condition and progress of the wound

by asking the nursing assistant questions and examining and analysing and interpretingthe data collected.

2. Give the nursing assistant appropriate directives concerning the wound treatment plan• this means determining the appropriate treatment plan based on the current condition

of the wound and giving the nursing assistant directives.

3. Adjust the therapeutic nursing plan if necessary• this means entering any change in the wound that has an impact on clinical follow-up

in the therapeutic nursing plan and adjusting the nursing directives if necessary.

IDENTIFICATION OF RELEVANT INFORMATION/ANSWERS

AAnswers


Clinical situations

4 Situation 14

Documentation

Relevant information in the available documentation:

• Treatment plan:

- cleanse wound with NaCl 0.9%- hydrocellular foam dressing

• Wound assessment form:

- improvement in the wound in the past two weeks

• TNP:

- directives: assess wound q weekTP q 3 days if moderate exudate and as needed if dressing is saturatedassess pain management q 3 days


4

When you arrive at the nurses’ station, you observe:• e nursing assistant

1. Contextual elements• Your nurse colleague carried out an initial assessment of the venous ulcer on Mrs. Ouellette’s

right leg 2 weeks ago• e last time the wound was assessed, 3 days ago, progress was satisfactory

2. e nursing assistant’s attitude and behaviour during the interview• She shows an interest in reporting her observations to you, being cooperative and learning• At your request, she provides information about the evolution of Mrs. Ouellette’s wound• She does not give the information spontaneously, but answers your questions willingly

and satisfactorily

3. Current situation• e nursing assistant gives you the following information about Mrs. Ouellette’s wound:

1. whitish skin around the wound2. dressing 2/3 saturated with exudate

4. Available documentation• Wound treatment plan no.1• Wound assessment form: characteristics of the wound since it developed• Excerpt from the therapeutic nursing plan (TNP)

ReminderIf necessary, read the instructions again to find out what you have to do:1. Assess Mrs. Ouellette’s ulcer by collecting all the relevant data2. Give the nursing assistant appropriate directives concerning the wound treatment plan3. Adjust the therapeutic nursing plan if necessary

Situation 14

Clinical situations

STATION OVERVIEW


1. Assess Mrs. Ouellette’s ulcer

• What data must you collect from the nursing assistant concerning the evolution of the wound?

• What must you do if the nursing assistant reports data that indicate a change in the woundcompared to the last assessment?

• What does the presence of whitish skin around the wound signify?

• What other data do you need to assess the wound? How will you collect it?

2. Give the nursing assistant appropriate directives concerning the dressing change

• Based on your finding, what directives will you give the nursing assistant concerning thewound treatment plan and dressing change?

• How will you respond to the suggestion that the wound be exposed to the air to reducemoisture?

• Why is a hydrocellular foam dressing used in wound care?

Clinical situations

IDENTIFICATION OF INTERVENTIONS

4 Situation 14


Clinical situations

4 Situation 14

IDENTIFICATION OF INTERVENTIONS (cont.)

3. Adjust the therapeutic nursing plan (TNP) if necessary

• Does the TNP need to be adjusted in this situation?If so, indicate the adjustments you will make in the form below.

ASSESSMENT FINDINGS

CLINICAL FOLLOW-UP


2011-03-07 8:30 2 Venous ulcer: lower medial third Dietician, occupational





Date Time Initials

2011-03-07 8:30 2 Nurse to assess wound q Monday or Tuesday or Wednesday

during treatment DG


or as needed if dressing is saturated DG



dressing change DG



3-4 Elevate lower limbs when sitting or lying down except for meals DG





If not, explain why.

4. Communication skills

• What principles must be respected to promote a climate of interprofessional collaborationbetween yourself and the nursing assistant?

Clinical situations

4 Situation 14


Clinical situations

OBSERVATION CHECKLIST

e candidate: � if done1. Wound assessment1.1 Collects data about the evolution of the wound from the nursing assistant:1.1.1 Checks for changes since the last dressing change:1.1.1.1 Saturation of the dressing.........................................................................................�1.1.1.2 Appearance of the exudate: type and amount and odour .........................................�1.1.1.3 Appearance of the skin around the wound ...............................................................�1.1.1.4 Presence of pain .......................................................................................................�1.2 Examines the wound:1.2.1 Says that she needs to see the client to assess the wound (IO) .................................�1.2.2 Says that the whitish tissue on the surrounding skin is maceration due to

excess moisture .......................................................................................................�1.2.3 Identifies two possible causes of the maceration problem (IO) .................................�1.2.4 Says that the size of the wound must be measured (IO) ...........................................�1.2.5 Says that the bed or bottom or base of the wound is red or

that granulation tissue is present ............................................................................�

2. Directives concerning the treatment plan and dressing change (IO)2.1 Gives one reason why the wound must not be exposed to the air and explains

why before the nursing assistant asks (IO) ...............................................................�2.2 Identifies at least two benefits of a moist environment (IO) .....................................�2.3 Asks the nursing assistant to apply a barrier cream around the wound at each

dressing change........................................................................................................�2.4 Says that the dressing must be changed every 2 days ................................................�2.5 Reminds her that it is important to report any relevant observation.........................�

3. Adjustment of the TNPSee the answer key form (p. 503) .............................................................................�

4. Communication skills4.1 Stresses the relevance of the data provided to the nursing assistant ...........................�4.2 Checks the method used by the nursing assistant to change the dressing before

giving her directives .................................................................................................�4.3 Makes sure the nursing assistant understands the directives by asking her to

summarize the steps explained .................................................................................�4.4 Tells her that she will be available if needed .............................................................�

4 Situation 14


Clinical situations

INSTRUCTIONS FOR OBSERVERS (IO)

1. Wound assessment1.2.1 When the candidate says that it is important that she go and assess the wound,

give her the photo of the wound and say to her “Describe what you observe.”

To obtain the mark “done,” the candidate must:

1.2.3 Identify two of the following possible causes of the maceration problem:• increased wound drainage• no skin barrier cream used around the wound• insufficient frequency of dressing change

1.2.4 When the candidate says that the size of the wound must be measured, tell her that ithasn’t changed since the last assessment.

4 Situation 14

Source: Danielle Gilbert,R.N., B.Sc., Enterostomal erapist


Clinical situations

4 Situation 14

INSTRUCTIONS FOR OBSERVERS (IO) (cont.)

2. Directives concerning the treatment plan and dressing changeIf the candidate says that she is going to refer the client to the enterostomal therapist,that there isn’t one in the facility and that she must give directives to the nursing assistant.

To obtain the mark “done,” the candidate must:

2.1 Give one of the following reasons why the wound should not be exposed to the air:• to avoid crust formation or• crust formation is a physical obstacle to cellular proliferation or• crusting slows the healing process or• the wound must be protected from exogenous contamination

2.2 Mention 2 of the following benefits of a moist environment:• prevents crust formation• promotes autolysis• supports all the phases of the healing process• maintains temperature stability• accelerates the formation of granulation and epithelial tissue• reduces inflammation and pain• causes less scarring• prevents cellular dehydration

3. Adjustment of the TNPAs soon as the candidate has finished reading the documents, give her the TNPand tell her that she may complete it, if necessary, whenever it suits her.Eight (8) minutes after the beginning of the station, tell the candidate that there aretwo (2) minutes left if she wants to adjust the TNP.


Clinical situations

4 Situation 14

Answer key form: excerpt from the therapeutic nursing plan (TNP)

Mrs. Ouellette

ASSESSMENT FINDINGS

CLINICAL FOLLOW-UP


2011-03-07 8:30 2 Venous ulcer: lower medial third — — Your initials Dietician, occupational




2011-03-25 15:00 2 Venous ulcer: lower

medial third of right leg: maceration Your initials


Date Time Initials

2011-03-07 8 :30 2 Nurse to assess wound q Monday or Tuesday or Wednesday

during treatment DG


or as needed if dressing is saturated DG 2011-03-25 15:00 Your initials



dressing change DG



3-4 Elevate lower limbs when sitting or lying down except for meals DG


2011-03-25 15:00 2 Apply treatment plan no. 1 q 2 days or as needed

if dressing is saturated AND Your initials

2 Add the application of a liquid skin barrier OR zinc oxide OR

barrier cream to treatment plan no. 1 Your initials



Your name Your initials


4

e goal of this station is to evaluate your ability to assess a venous ulcer, follow its evolutionand assess the effectiveness of the treatment plan by collecting data from a nursing assistant,and to adjust the therapeutic nursing plan (TNP), giving appropriate directives to thenursing assistant.

Clinical situation

ere are several types of leg ulcers of vascular etiology. Venous ulcers account for approxi-mately 70% of all cases. “A venous ulcer is a wound that develops in the lower third of theleg, most commonly over the medial malleolus, and is caused by a dysfunction of the venoussystem” (OIIQ, 2007f, p. 205). Over time, venous hypertension resulting from chronicvenous insufficiency “compromises the supply of nutrients needed to maintain skin integrity”.(OIIQ, 2007f, p. 205).

According to the OIIQ (2007f), a number of risk factors associated with venous hypertensionare responsible for venous ulcers, including aging, family history, reduced mobility, decreasedor loss of muscle mass, obesity and a history of deep vein thrombosis. In the present situation,Mrs. Ouellette has had a venous ulcer on her right leg for 2 weeks. e risk factors for her areassociated with her hemiplegia, in particular, loss of muscle mass and decreased mobility.ese which cause calf pump failure and leave her vulnerable to venous ulcers.

“Until recently, venous ulcers were believed to be relatively painless wounds. Numerous studieshave, however, demonstrated the opposite (…). e pain associated with a venous ulcer startsas a sensation of burning and heaviness in the leg.” (OIIQ, 2007f, p. 217). As it progresses,the pain becomes localized around and at the surface of the wound and elsewhere in the leg.e pain is worse in hot, humid weather and at the end of the day, especially after prolongedsitting with the legs dangling. One method suggested to bring relief is to rest with the legs elevated.

Wound assessment

Section 36 of the Nurses Act stipulates that, with respect to wound care, the nurse determinesthe treatment plan for wounds and alterations of the skin and teguments.e nursing assistantcontributes to wound care by applying the treatment plan.

Wound assessment is an activity reserved to nurses. Assessment is usually weekly, or moreoften, depending on the nature of the wound and its evolution. According to the OIIQ(2007b), systematic wound assessment is necessary in some clinical situations:

Situation 14

Clinical situations

RATIONALE AND ADDITIONAL INFORMATION


4 Situation 14

Clinical situations

1) when a client is admitted to an institution; 2) after surgery; 3) after debridement; 4) if signsof deterioration or a copious, foul-smelling or purulent exudate are present and 5) followinga change in topical treatment. e nurse collects data from the nursing assistant about thecharacteristics of the wound, the condition of the surrounding skin and the exudate.

In this situation, the nurse’s assessment of the wound based on her examination of the woundand the data collected from the nursing assistant confirm the maceration around the wound.

e venous ulcer has been present on the right leg for 2 weeks. e skin around the woundis soft and whitish, whereas it was pink and intact 3 days ago. e wound bed is still red.Drainage is serous and heavier than 3 days ago. e wound and dressing have no significantodour. e wound is the same size as during the last assessment.

Maceration, which is defined as softening of the skin caused by an overly moist environment,can significantly impair wound healing. e exudate is managed by keeping the wound bedmoist and the surrounding skin intact and dry (OIIQ, 2007e, p. 428). Increased exudatefrom the wound, failure to apply a skin barrier to the skin around the wound, dressingchanges only every 3 days are potential causes of skin maceration.

Directives concerning the wound treatment plan and dressing change

e treatment plan is based on evidence and best practices in wound care. e nurse musthave a thorough knowledge of the indications and selection criteria for different types ofdressings. Mrs. Ouellette’s treatment plan indicates that the wound must be cleansed withNaCl 0.9%. Used at room temperature, this non-cytotoxic isotonic saline solution is one ofthe best treatment choices in this situation and is economical.

e primary dressing is applied directly to the wound. In the present situation, Mrs. Ouellette’swound is covered with a primary hydrocellular foam dressing. is provides thermal insulationand is permeable to gases and water vapour. is type of dressing also maintains a moist woundenvironment by absorbing excess exudate without, however, drying the wound. e dressingscoated with a silicon film or equivalent product have selective micro-adherent properties,which minimizes tissue damage and pain when the dressing is removed.

e application of a skin barrier to the surrounding skin in the form of a liquid, cream orointment is not always necessary when a hydrocellular foam dressing is used. However, if thesurrounding skin is macerated, these products protect the skin from the harmful effects ofwound exudates (OIIQe, 2007, p. 430).


4

Keeping the wound moist promotes healing by preventing crust formation, which is a physicalobstacle to granulation (cellular proliferation). A moist environment also promotes autolysis,supports all the phases of the healing process, maintains temperature stability, acceleratesthe formation of granulation and epithelial tissue, reduces inflammation and pain, causes lessscarring and prevents cellular dehydration. erefore, in the present situation, the nursestresses to the nursing assistant the importance of keeping a dressing on the wound.

Once re-epithelialization is progressing well and the wound is practically closed by epithelialtissue and there is very little exudate, the type of dressing can be changed. e applicationof a moisture-retentive dressing, such as a hydrocolloid dressing, to be changed every 5 days,will retain enough moisture to allow the wound to close completely.

Adjustment of the therapeutic nursing plan (TNP)

e maceration of the skin around Mrs. Ouellette’s wound is a significant change in the woundand the TNP must be adjusted accordingly. is nurse indicates this development by puttingdashes in the spaces for the date and time the problem is resolved and by writing her initials.She then enters a new finding in the TNP regarding the deterioration of the wound (mace-ration) using the same problem number. She also adjusts the directives concerning clinicalfollow-up, increasing the frequency of dressing changes to every 2 days and adds the appli-cation of a skin barrier around the wound. is directive replaces the directive to apply thetreatment plan every 3 days.

Communication skills, coordination of the health care team and clinical leadership

e nurse recognizes the importance and effectiveness of interprofessional collaboration inproviding quality care. In the present situation, she stresses to the nursing assistant the relevanceof the information provided, checks the method she used to change the dressing and makessure she understands the treatment plan in order to optimize the moisture level to promotewound healing. e nurse says that she will be available if needed.

Situation 14

Clinical situations

RATIONALE AND ADDITIONAL INFORMATION (cont.)

4 Situation 14

Further reading

• wound assessment criteria;• dressing selection criteria;• assessment of the risk of pressure sores, including the Braden scale;• ankle-brachial index;• chronic wounds: pressure sore, venous ulcer, arterial ulcer, diabetic foot ulcer;• acute wounds: burns, traumatic wounds, surgical wounds, skin tears;• wound bed preparation, including wound debridement principles;• wound culture technique;• wound measurement technique;• compression therapy.

References

Huynh, T., and Nadon, M. (2007). “Rouages de la collaboration infirmière-infirmière auxiliairedans les soins des plaies,” Perspective infirmière, vol. 5, no. 1, p. 12–22.Ordre des infirmières et infirmiers du Québec (2003). Guide d’application de la nouvelle Loi sur lesinfirmières et les infirmiers et de la Loi modifiant le Code des professions et d’autres dispositions législativesdans le domaine de la santé, Westmount, OIIQ.Ordre des infirmières et infirmiers du Québec (2006). L’intégration du plan thérapeutique infirmierà la pratique clinique, Westmount, OIIQ.Ordre des infirmières et infirmiers du Québec (ed.) (2007a). “La douleur liée aux plaies,” in Les soinsde plaies: au cœur du savoir infirmier, Westmount, OIIQ, pp. 99–117.Ordre des infirmières et infirmiers du Québec (ed.) (2007b). “L’évaluation de la plaie,” in Les soinsde plaies: au cœur du savoir infirmier, Westmount, OIIQ, pp. 47–74.Ordre des infirmières et infirmiers du Québec (ed.) (2007c). “Les modalités adjuvantes,” in Lessoins de plaies: au cœur du savoir infirmier, Montreal, OIIQ, pp. 453–467.Ordre des infirmières et infirmiers du Québec (ed.) (2007d). “La préparation du lit de la plaie,” inLes soins de plaies: au cœur du savoir infirmier, Westmount, OIIQ, pp. 25–44.Ordre des infirmières et infirmiers du Québec (ed.) (2007e). “Les produits et les pansements,” inLes soins de plaies: au cœur du savoir infirmier, Westmount, OIIQ, pp. 425–450.Ordre des infirmières et infirmiers du Québec (ed.) (2007f ). “Les ulcères des membres inférieurs,”in Les soins de plaies: au cœur du savoir infirmier, Westmount, OIIQ, pp. 205–265.Voyer, P. (ed.) (2006). Soins infirmiers aux aînés en perte d’autonomie: une approche adaptée auxCHSLD, Saint-Laurent, Éditions du Renouveau Pédagogique.


Clinical situations


Clinical situations

Occupation

• You have worked as a nursing assistant at the long-term care facility for 4 months.• You work full time.

Dress

• You are wearing a uniform (colour of your choice).

Position

• You are sitting at the nurses’ station.

Attitude and behaviour during the interview

• You cooperate with the nurse (the candidate).• You are enthusiastic about sharing your observations with the candidate.• You reply only to the questions the candidate asks.• You like to understand the exact nature of the care you provide.• You want to understand wound treatment modalities.• You listen carefully to the directives the candidate gives you and you tell her that you will

apply implement them.• If she shows you a photo of the wound, you look at it with her and listen to her explanations.

e goal of this station is to evaluate the candidate’s ability to assess the wound based onthe information she collects from you and a photo of the wound and to adjust the therapeuticnursing plan.

Current situation

• You know the nurse you are working with today (the candidate).• You know Mrs. Ouellette: she has been living at the long-term care facility for 1 month.• You have changed her dressing twice: 3 days ago and today.• You know that the client has had a venous ulcer on the lower medial third of her right leg

for 2 weeks.

Scenario for the simulated nursing assistant

Name Carole-Anne Melanson

Age 22

Reason for the interview Deterioration of Mrs. Ouellette’s venous ulcer

SS c e n a r i o4 Situation 14


Instructions for the beginning of the interview with the candidate

• You have your notes about the wound observation notes with you.• You wait for the candidate to start the conversation before speaking.• If the candidate starts the data collection by asking a very broad question, for example,

“Describe the condition of Mrs. Ouellette’s wound,” tell her that:1. the dressing was very wet and2. the skin around the wound seemed to be whiter today than 3 days ago.

Information about Mrs. Ouellette’s wound

• You answer the candidate’s questions about the condition of the woundand the dressing as she asks them.

• You noticed that it has changed since the last dressing change.

is morning, during the dressing change, you observed:

Dressing• e dressing is very wet or 2/3 saturated.• e dressing is wetter than 3 days ago.

Exudate• e drainage is serous and copious.

Odour• Neither the wound nor the dressing have any particular odour.

Skin around the wound• e skin around the wound is whitish.• ree days ago, the skin around the wound was pink and intact.• If the candidate does not react to this information, ask her:

“Do you know why the skin around the wound is whitish?”

Wound bed (base) or granulation tissue• e wound bed is red.

Size of the wound• You didn’t observe any significant change in the size of the wound.

Clinical situations

4 Situation 14


Clinical situations

4 Situation 14

Scenario for the simulated nursing assistant (cont.)

Clinical signs of infection• You didn’t observe any clinical signs of infection: no odour, no redness around the wound,

no purulent exudate.

Pain

• If the candidate checks whether the dressing change was painful for the client, you reply:“e client rated her pain at 3/10 in the right leg before the dressing change” and“I gave her 2 tabs of acetaminophen 325 mg/tab. 45 minutes before the dressing changeto alleviate the pain” and“e pain was completely relieved and she didn’t experience any pain during the dressingchange.”

Method used to change the dressing

• You followed the treatment plan:- Cleanse the wound with normal saline.- Hydrocellular foam dressing.- If the candidate asks you if you applied a barrier to the skin around the wound, you say “no.”

Treatment plan

• When the candidate talks about the treatment plan, ask her:“Can the wound be exposed to the air to let it dry?” If she replies “no,” ask her: “Why not?”

Transmission of new nursing directives regarding the TNP

• You are quick to understand the instructions the nurse gives you. If she asks you to repeatthe instructions she has given you, you do so.

SScenario


Reminders for the simulated nursing assistant

Questions to ask during the interview:

• Can the wound be exposed to the air since it is very moist?• What is the whitish skin around the wound?• Why did the whitish skin appear?

Material required

• An excerpt from the therapeutic nursing plan (TNP) comprising the initial data fromthe beginning of the station

• e wound assessment form comprising the wound assessment characteristics providedin the situation

• e wound treatment plan• A photograph of a leg wound with maceration

Clinical situations

4 Situation 14

TABLE 1: CORRECTIONS TO WORDING

Page Location Wording (in red) Replaced by (in red)

80, 83,182, (Insulin…) U (Insulin…) units189, 190,298, 305

119 Rationale and Oral prednisolone (Pediapred) should be administered Oral prednisolone (Pediapred) should be administeredadditional as soon as it is prescribed, then every morning, as soon as it is prescribed, then every morning,information for blood cortisol levels are at their lowest for blood cortisol levels are at their highest

at this time. at this time.

129 References Brassard, Y. (2006). Apprendre à rédiger des notes Brassard, Y. (2008). Apprendre à rédiger des notesd’observation au dossier, 4th ed., Longueuil, d’évolution au dossier, 4th ed., Longueuil,Loze-Dion éditeur, vol. 1. Loze-Dion éditeur, vol. 1.

268 Clinical Intermittent tube feeding to be administered Intermittent tube feeding to be administered bysituation by gravity at 11:00 pump at 11:00

272 Observation 1.3.2 Cleans both nostrils with swabs and 1.3.2 Says that she will clean both nostrils withchecklist physiologic serum swabs and physiologic serum (IO)

1.4.2 Starts to moisten… the teeth 1.4.2 Amorce le geste… les dents (IO)

2.4 Mentions the importance of flushing the tube 2.5 Mentions the importance of flushing the tubewith sterile water to check patency with sterile water to check patency

2.5 Auscultates the abdomen to check for 2.4 Auscultates the abdomen to check forperistalsis (IO) peristalsis (IO)

273 Instructions for 1.3.2 If the candidate mentions cleaning or starts toobservers clean the nostrils, tell her to consider it done.

1.4.2 As soon as the candidate starts to moisten orrinse the mucous membranes with the mouthwash orstarts to brush the teeth, tell her that she does nothave to continue.

338 Documentation Client’s blood group and Rh group : O+ Client’s blood group and Rh factor:O+

342 Observation 2.2.2 Checks the compatibility of the client’s blood 2.2.2 Checks the compatibility of the client’s bloodchecklist group and Rh group with those of the donor group and Rh factor with those of the donor

2.3.3 Checks the blood group and Rh group 2.3.3 Checks the blood group and the Rh factor

347 Verification of Blood group and Rh group (indicated on the blood unit) Blood group and Rh factor (indicated on the blood unit)the material

363 Adjustment of As soon as the candidate finishes her call to the As soon as the candidate has finished reading thethe TNP nurse at the home, you ask her : «Given the infor- documents, give her the TNP and tell her that she may

mation obtained, do you have to adjust TNP?» complete it, if necessary, whenever it suits her.If the candidate replies «yes» give her Mrs. Labrie’sTNP form, where problems 1, 2 and 3 and directives Eight (8) minutes after the beginning of the station,have already been entered. Ask her to make tell the candidate that there are two (2) minutes left ifthe necessary adjustments. she wants to adjust the TNP.

404 Adjustment of When the candidate has finished her assessment and As soon as the candidate has finished reading thethe TNP has tried to respond to the client’s concerns or seven documents, give her the TNP and tell her that she may

minutes after the beginning of the interview, ask her if complete it, if necessary, whenever it suits her.she thinks the TNP needs to be adjusted. If she replies«yes», give her a TNP form and ask her to adjust it. Eight (8) minutes after the beginning of the station,

tell the candidate that there are two (2) minutesleft if she wants to adjust the TNP.

TABLE 2: CORRECTIONS TO MEDICATIONS

Medication Replaced by Page

8 methylprednisone 5mg tablets 10 methylprednisolone 4 mg tablets 61, 132

methylprednisone methylprednisolone 61, 132

aluminium hydroxide (Maalox) aluminium hydroxide / magnesium hydroxide (Diovol) 85, 195

haloperidol (Haldol) haloperidol 94, 96, 220, 221, 225, 226, 227, 228

chloral hydrate (Noctec) 500 mg chloral hydrate 500 mg syrup PO hs 96, 225, 2261 cap hs

benztropine mesylate (Cogentin) benztropine mesylate 96, 225

cefalozine (Ancef) cefalozine 315, 316, 329, 330

diphehydramine (Benadryl) diphehydramine 315

metoclopramide (Maxeran) metoclopramide 316

naloxone (Narcan) naloxone 316, 322, 326, 327, 330, 483

cprofloxacin (Cipro) ciprofloxacin 355

dexamethasone (Decadron) dexamethasone 394, 395, 412, 413

prochlorperazine (Stemetil) prochlorperazine 395, 412, 413

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