Video Case Study - Skin Integrity and Wound Care

Nurse Jess works at an urgent care clinic and is caring for Roger, a 56-year-old male, who arrived with a wound on his lower arm. After settling Roger in his room, Nurse Jess goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Roger’s care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

First, Nurse Jess recognizes important cues, including Roger’s vital signs, which are temperature 101 F, or 38.3 C, heart rate 98 per minute, respirations 14 per minute, and blood pressure 125/85 mmHg.

She completes a skin assessment on Roger’s arm, and notes his wound is 1 centimeter across, open, and draining a small amount of purulent drainage. She also notices superficial erythema 2 centimeters around the wound. Extending from the wound towards his upper arm is a red streak, which Nurse Jess recognizes is a sign of lymphangitis, or inflammation of the lymph channels.

When asked about the wound, Roger says he thinks it started with a bug bite he got while boating 3 days ago.

Next, Nurse Jess analyzes cues. While reviewing the electronic health record, or EHR, she notes Roger was treated for a similar wound in the past. She also notes he’s been taking steroids prescribed for rheumatoid arthritis for the past 3 months, which can suppress the immune system. Nurse Jess realizes Roger needs treatment for his infected wound.

Now, using the information she’s gathered, along with Roger’s medical history, Nurse Jess chooses a priority hypothesis of traumatic wound.

Next, she generates solutions to address Roger’s wound that will include pharmacologic and nonpharmacologic interventions. She establishes the expected outcome that after intervening, Roger will correctly demonstrate how to apply a dressing to his wound.

Nurse Jess then takes action to implement these solutions. She begins by notifying the health care provider of Roger’s elevated temperature, purulent drainage, erythema, and lymphangitis on his lower arm wound. The health care provider orders a 7-day course of PO cephalexin, a topical antibiotic, and acetaminophen for fever.

After collecting normal saline, a sterile bandage, gauze wrap, a surgical marker, and a topical antibiotic, Nurse Jess performs hand hygiene, and reenters the room.

Nurse Jess: I talked with the health care provider, and you’ve been prescribed a 7-day course of cephalexin, which is an antibiotic, for your infected wound. It’s important you take it for 7 days, even if it seems like it's getting better.

Roger: Okay, I can do that.

Nurse Jess: Now, let’s get your wound cleaned and bandaged. I’m going to walk you through each step and give you supplies so you can do it at home, okay?

Roger: I don’t know if I’m comfortable with that.

Nurse Jess: That’s understandable, Roger. I’ll walk through each step with you slowly; and be sure to ask any questions if you’re confused, okay? Roger nods and agrees.

First Nurse Jess puts on gloves, and then begins by cleansing Roger’s wound with normal saline. She clarifies Roger isn't in any pain before continuing.

Then, using the surgical marker, Nurse Jess marks a circle around the erythema. She informs Roger that marking where the redness extends will help his health care provider see if the infection is improving at the next appointment.