Download Student Preclinical Scenario 4 MSU Foundations Regional

MSU Foundations
Regional Simulation Center
Student Preclinical
Scenario 4
*This is NOT a group assignment and therefore must reflect your own work*
Please refer to page 119-120 in the electronic BSN student handbook
or page 120-121 in the written BSN student handbook.
Learning Outcomes:
 Demonstrate application of sterile gloves using sterile technique
 Demonstrate dressing change for existing central venous access (not in book)
 Demonstrate the insertion and removal of indwelling urinary catheter
 Describe indications, monitoring and perineal hygiene for an indwelling catheter
Resources:
Agency for Healthcare Research and Quality, National Guideline Clearinghouse. (2012).
Standardizing central venous catheter care: hospital to home. Retrieved June 28, 2016
from http://www.guideline.gov/content.aspx?id=38459
Centers for Disease Control and Prevention. (2015). Healthcare- associated infections. Retrieved
from http://www.cdc.gov/HAI/ca_uti/uti.html
Doenges, M. E., et al. (2013). Nurse’s pocket guide: Diagnoses, prioritized interventions, and
rationales. (13th ed.). Philadelphia: F. A. Davis.
Scales, K. (2011). Reducing infection associated with central venous access devices. Nursing
Standard, Vol. 25, No. 36, and pgs.49-56.
Taylor, C., Lillis, C., & Lynn, P. (2014). Fundamentals of nursing (8th ed.). Philadelphia, PA:
Lippincott, Williams, & Wilkins.
Supplies:
1. Lab bags with supplies already pulled and ready to go prior to lab:
a. Foley Catheter Kit
b. Central Line Kit
c. Sterile Gloves x 4 ( that fit your hands)
2. Watch with second hand
3. Stethoscope, calculator, pen
4. Gloves
5. Textbook
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Skills to be demonstrated this scenario. Please review the procedures. They can be found
in your basics textbook or in the You Tube video posted above.
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Application of Sterile Gloves 36-5, 36-6
Central Line Dressing (not in book)
Urinary Catheterization pg. 1292-1295
Lab Preparation: Answer the following questions
Sterile Field:
1. Which of the following are basic principles of surgical asepsis? Select all that apply.
a. Never turn your back on a sterile field
b. Hold sterile objects at hip level or above
c. Forceps soaked in disinfectant can be used to add items to a sterile field
d. Consider the outer one inch of a sterile field to be contaminated
e. Only a sterile object can touch another sterile object
f. Avoid talking, coughing, sneezing, or reaching over a sterile field
2. Opening a commercially prepared sterile package, describe the way you will open the
flaps.
3. When adding sterile items to your sterile field created, how far above the surface will
your drop the item? Why?
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Catheter Insertion:
4. In the acute care setting, the most common healthcare-associated infections are urinary
tract infections accounting for over 30% of reported infections. Approximately 75% of
those are associated with a urinary catheter. The biggest risk factor for developing a
catheter associated urinary tract infection (CAUTI) is extended use of a urinary catheter
(CDC, 2015). List the interventions that are outlined in the CDC CAUTI (Gould article
above) guideline to avoid and /or minimize the duration of an indwelling urinary catheter
use?
5. Describe the difference between an indwelling catheter and an intermittent/straight
catheter.
6. List indications for use of an indwelling and/or intermittent urinary catheter:
7. How can we assess a post void residual (PVR) non-invasively and what is an adequate
PVR? What would constitute an intervention?
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8. Define CVC or CVAD (central venous catheter or central venous access device). Where
is a CVC inserted and advanced to?
9. Define PICC (peripherally inserted central catheters). Where is a PICC inserted and
advanced to?
10. What is the difference between a central venous catheter (CVC) and a peripherally
inserted central catheter (PICC)? What makes them similar?
Questions 7-10 use The National Guideline Clearinghouse guideline link posted above on
standardizing central venous catheter care to answer questions:
11. How often should a central venous catheter be changed?
12. How long should you scrub/cleanse the insertion site for?
13. What type of procedure is accessing and changing a central venous catheter dressing?
14. What size syringe should be used when accessing any central venous catheter?
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Read the following scenario. Write a nursing process note using ADPI aE. (You will not be able
to write the evaluation). The assessment and nursing diagnosis have been provided for you.
Assessment
June Anderson was admitted two days ago for pneumonia. At that time a PICC line was placed
for IV antibiotics. You are caring for her today. Upon your initial assessment, you notice a
loose dressing over the PICC line and the area is reddened with slight drainage. Her VS are T100.8, HR-98, R-18, BP-115/70, SpO2-98%
Write a nursing process that relates to possible risk for infection related to break in skin integrity
secondary to central line placement.
Nursing Diagnosis
Risk for Infection
Write 3 Patient Outcomes:
List 6 Nursing Actions/Interventions (Nursing interventions with rationale):
Calculation
Physician’s order: Tegretol 0.3g. PO TID for seizures (On hand 100mg /5ml)
a. How many mL would you administer in each dose?
b. Is the ordered dose safe?
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