DRAFT: This module has unpublished changes.
DRAFT: This module has unpublished changes.

DRAFT: This module has unpublished changes.

Standardized Patient Training Materials

Mr. Candido

DRAFT: This module has unpublished changes.

Mr. Candido  (55 years old) Larry Candido is a 55-year-old Latino, English speaking male who is three days post op after a colostomy surgery due to a recurrence of colorectal cancer, Larry has a mid-line incision that is stapled but the distal end gave way unknowingly with his last ambulation around the nurse’s station thirty minutes ago.  Larry had not been eating well prior to the surgery due to the RLQ pain he was experiencing. Night nurse Samuel and day nurse Julie arrive for the morning SBAR handoff in Larry’s room. Julie discovers during her assessment a possible infected abdominal dehisced mid line incision that needs to be reported to the surgeon.

 

 

Beginning

Larry Candido is a 55-year-old Latino male, Diabetes type II, morbidly obese, English speaking, Spanish professor, sedentary lifestyle, who is six days’ post op after a colostomy surgery for colorectal cancer. He was first diagnosed for Colon cancer 18 months ago. He had been without symptoms until pain increased in the RLQ.  Within four days his pain increased to a (9/10) on the pain scale. CT scan further revealed adenocarcinoma. The tumor penetrated deep though the entire width of the wall of the ascending colon resulting in a course of chemotherapy and eventual remission. Eighteen months later the patient notices bright red blood on the surface of his stools. The patient had an exploratory laparotomy that revealed the cancer was now in the terminal ileum and the large segment of the descending colon that extended into the rectosigmoid colon. The patient went through having the colostomy surgery that resected out the tumor in the regions of the ileum, descending colon, and rectosignmoid colon. Larry states he was not eating leading up to the colostomy surgery due to the abdominal pain in the RLQ. The midline incision line is stapled and open to the air. Colostomy stoma is protruding and pink, swollen. Mucocutaneous juncture is intact.

 Middle-  The setting is the room of Larry Candido’s at Kirkwood Hospital on the medical/surgical floor. Larry returned recently from walking around the nurses' station. Larry is lying in his bed semi-fowlers when the night nurse Samuel and day shift nurse Julie enter the room to collaborate on the SBAR communication. During Julie’s assessment, she discovers the distal portion of the patient’s mid-line incision has opened and is draining purulent, foul smelling drainage.  Julie decides the surgeon needs to be notified.  Julie assists to coordinate the care needs for Larry Candido as directed by the surgeon concerning the dehisced mid line incision.

 

End- The consequences of the dehisced mid-line incision will delay the healing of the incision and open the door to a possible post-surgical site infection.  Next steps to consider are the long term care needs and teaching that will need to happen with the addition of the dehisced mid-line incision. Follow up for the negative pressure wound therapy dressings changes 3x per week will need to be arranged with home health or an outpatient wound clinic post discharge. Debriefing with the nurses and observers will afford the opportunity to explore the events leading up to the dehisced incision and the interventions that may have helped to prevent or lessen the outcome of the dehisced mid line post-surgical incision.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Chief complaint for this scenario:

  • Your opening statement will be “My low abdomen hurts since I went for my last walk around the nurses desk this morning”

  • You started to feel bad about 20 minutes ago, “my pain is a 3-4 now”, “My incision hurts more when I move”

  • I must have drifted off back to sleep, “I feel something wet down there”

  • I put my call light on because “I was wondering if my colostomy is leaking?”  “Do I need a new appliance?”

 

If asked:

  • Have you experienced any drainage from the mid line incision since the surgery? No, none whatsoever.

  • Your incision is open at the inferior end and draining. “I thought something felt wet down there”

  • Do you know what contact precautions are? “Why do you need to wear a gown now?”

  • I will need to obtain a wound culture, “What is a wound culture?”

  •  “Are you going to poke me with that swab?” “Is the wound culture going to hurt?”

  • I am going to cover up the wound now with a dressing, “Thank you for covering the wound, can I still get out of bed?”

  • The preliminary wound culture results will be back later in the day. “What will the wound culture tell?”

  • We will most likely need to place negative pressure wound therapy over the wound opening. “What is negative pressure wound therapy?” “Will it be painful?”  “I think I am going to need pain mediation prior to the negative pressure wound therapy being placed, the suction part sounds like it may hurt?”

  • Would you like some pain medication prior?  “Yes, please medicate me before the surgeon comes”

    Past medical history (if asked):

  • You have not been eating well the past two weeks

  • You have been eating a diabetic diet

  • You have been experiencing right lower abdominal quad pain

  • You have been anxious about the surgery

  • My surgery was three days ago

  • You have had a previous occurrence of colorectal cancer 18 months ago

  • You have a six-year history of type II diabetes

  • My last A1c3 was 7.5

  • You are up to date on immunizations, but you did not have a flu shot this year.

  • You have no allergies

  • You have 5 medications you take Metformin 500mg po BID, Budesonide 9 mg po QD, Vitamin B12 1000ug IM Q month, Albuterol inhaler PRN (recently less than one per week) Acetaminophen 325mg ii po every 4-6 hr. PRN mild pain

  • You have learned how to empty the colostomy appliance since surgery

  • My vision has been a little blurred since the surgery, it is still hard for me to see the lines on the ostomy appliance to cut the correct opening

  • You do not smoke

  • You do not drink alcohol

  • You usually drink 2-3 cups of coffee a day if asked about caffeine.

  • You don’t follow any special diet, but you haven’t been hungry the past few days. You’ve been eating mainly soup and have been trying to drink more liquids like fruit juices.

  • You have been divorced for 3 years. You do not have any serious romantic relationship right now. Most of your time and energy is spent teaching Spanish at the local community college

  • Your father died of colon cancer 10 years ago, at the age of 69. Your mother is alive and well with no health concerns. You have no siblings.

About 5 minutes into the assessment you should ask or interrupt abruptly

“Will this lengthen my hospital stay?”

  • You need to work to pay your bills, so you will be resistant if the student says you may need to be hospitalized longer and continue to receive negative pressure wound therapy on an outpatient basis

  • “I don’t know if I can go back to work with a wound vac?”

At the end of the exam you should ask:

  • Do you know what is causing this? (failed incisional healing ridge)

  • What can I do to prevent the incision from opening further?

 

 

 

 

 

 

 

 

 

Participant Evaluation Form

Performed = P                  Performed Incorrectly = PI           Not Performed = NP

History Taking Technique:

Student #1 introduced himself/herself                                                               P             PI                NP

Student #2 introduced himself/herself                                                               P             PI                NP

History of illness established                                                                                   P            PI                NP

Any prior history such as medications/injuries established                                   P             PI                NP

Question pace not rushed or two slow                                                                P             PI               NP

Questions were asked in an understandable manner                                           P             PI                NP

Students paid attention to answers                                                                    P            PI                NP

Students attempted to   put me at ease                                                             P             PI                NP

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DRAFT: This module has unpublished changes.
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