Title: Obesity Discussion

Client Safety Escape Room - Client with Bariatric Challenges

Authors: Jennifer Scarfe-Brideau & Janice Elliott, School of Nursing, Fanshawe College, Stephanie Ayres & Scott Sumpter, CSTAR

Learning Objectives

Upon completion of this activity, learners will be able to identify the following:

- the correct process for donning and doffing of PPE to promote client and nurse safety
- the chain of infection in a client situation for physical safety
- appropriate communication and psychological support when working with a client who is obese to promote emotional safety and the creation of a therapeutic nurse-client relationship
- infection control practices in a clinic setting for environmental safety
- the correct sequence in abdominal assessment for accurate assessment results
- the importance of checking for allergies for client safety
- an opportunity for continuous quality improvement

Donning

Introduction

You, the nurse, are getting ready to see your next client.  He is a young male who was in the clinic 5 days ago and has called the clinic looking for a follow-up as he has developed a skin reaction and diarrhea.

Credits: by ayress (Author); licence CC BY-SA 3.0

[Image: Nurse]

Client Profile

Name | Robinson, Luke
DOB | 1990-06-03
Sex | Identifies as male
Address | 33 Lanark Drive, Westview, Ontario
OHIP # | 55523410 WY
Diagnosis | Intertriginous Dermatitis
Allergies |
Code Status | Full resuscitation
SDM | Fran Robinson (mother)
Admission History | First visit to walk in clinic. Came to clinic with c/o skin irritation, increased redness, burning sensation and pain in both axillary regions for 3 weeks.
Medical/Surgical History | No significant medical or surgical history.
Support Systems | Lindsey (partner)
Doctor’s Orders
Amoxicillin 500 mg po every 12 hours for 7 days Mupirocin Topical Cream. Apply 3 times per day to affected areas for 10 days.
Consults | None
Lab Work | None
Follow Up/Return Appointment | No follow up at initial visit. Return visit booked today: c/o diarrhea x 3 days and skin rash on back.
Additional Notes |

C. Wong, M.D.
General Practitioner

decision

Based on your client's history and symptoms you decide it is best to err on the side of caution and go for droplet /contact precautions.  As you get ready to don your PPE you need to be mindful of the correct order.

Donning PPE

What is the proper sequence of PPE to be donned?  Flip the cards over to see the numbers on the back and remember the correct sequence to use later to get the key to unlock the next puzzle.

Q: Gloves
A: 7

Q: Faceshield
A: 9

Q: Wash hands
A: 3

Q: N95 mask
A: 2

Q: Gown
A: 6

Credits: by unknown; licence CC BY-NC 3.0

Credits: by Unknown; licence CC BY-NC 3.0

You need to remember the code for later!

You will need the 5 numbers in the correct order to unlock a lock

Chain of Infection

Break the Chain

Break the Chain Exercise - drag the words to identify the chain of infection.

[Image: chain of infection - with six links in circles around outside]

Break the Chain

Drag the words into the correct boxes

Q: Infectious agent: [...]
Reservoir: [...]
Portal of Exit: [...]
Mode of Transmission: [...]
Portal of Entry: [...]
Susceptible Host: Person on [...] Vulnerable to [...]
A: Clostridium difficile; GI Tract; Feces; Contact, fecal oral route; GI Tract Oral; Antibiotics; Infection
Feedback (0 to 99%): Try Again
Feedback (100 to 100%): That is correct - unscramble for your next clue - gshaadnhwin Remember this clue for later!

[Image: Chain of infection diagram with six links in circles around outside]

Start assessment

Nurse: Ok I would like to do your assessment now.  I will be assessing your skin and abdomen.  Is this okay with you?

Client: Yes, that is fine.

Nurse: Can you please put on a gown and lay down on the exam table.  I will come back in when you are ready.

Credits: by unknown (Author); licence CC BY-NC-SA 3.0

[Image: Nurse with PPE]

room readiness

Q: What should you as the nurse do next?
- Just leave the room and let them deal with it. (Not a good response.: You have identified that the client is likely feeling uncomfortable so you should address their concerns.)
- The table looks kind of high and hard to get on. Can I help you by lowering the exam table? (Good choice!: This is the best option as you are helping to deal with the client's anxiety.)
- I have to go find a bigger blood pressure cuff. (Not a good response.: Nurse could go and get the cuff without verbalizing the need for a bigger cuff. Shames patient)
- I will get another gown for you to wear so you can have better coverage and we can protect your privacy. (There are better options.: If larger gowns were available then patient would not feel conspicuous or shamed for having to use two gowns)
- I need to weigh you first - I will take you to the scale. (Not the best answer.: Question why there is a need to weigh patient based on the reason for the visit. Ask permission before weighing someone, and never weigh people in front of others; instead, place weighing scales in private areas)

Q: How can you respond to ensure that the client feels emotionally safe?
- Would you like to meet with a dietician? (Not the best answer.: Not appropriate to assume that the patient wants to change their eating habits.)
- Do you exercise? (Not a good response.: Assuming that the client does not exercise perhaps based on their weight. Close ended question. Obesity is a medical condition that can be caused by multiple factors. However, people often think that individuals living with obesity are personally responsible for their weight because they just eat too much or do not exercise enough. This belief is a fundamental driver of weight bias, stigma and discrimination.)
- Let me calculate your BMI and it may guide us to look at your health. (Not the best response.: Obesity needs to be diagnosed by qualified health professionals using medical assessment tools that go beyond body weight and BMI. People come in different shapes and sizes and that health can happen at a range of BMI levels)
- Perhaps one thing you can do it try to cut out fast food or try to take the stairs more often. (Not a good response.: You may signal overly simplified assumptions about the causes of obesity, by suggesting, for example, that he cuts back on fast food or consider taking the stairs instead of elevators. These assumptions ignore the complexity of energy balance and propagate a common misunderstanding that weight loss is as simple as ‘calories in < calories out’)
- There are more then 300 factors that contribute to being over weight. It is not always a matter of eating healthy and being active. (Best response: It is not always about simply eating healthier and being more active. More than 300 factors contribute to obesity ranging from physiological and psychological factors to genetic, social and environmental factors, many of which may be beyond your control.)

Lose weight

Credits: by Obesity Action Coalition (Licensee); licence C

[Image: Obese man looking sad]

I know I need to lose weight but it is not easy.

Abdominal Assessment

[Image: Nurse with PPE]

Intro

Nurse:  Okay Mr. Robinson,  I am ready to do your abdominal assessment now.

Abdominal Assessment - drag pictures to the correct order and scroll down to check

- [Image: Stethoscope]
- [Image: Picture of face with focus on eyes]
- [Image: person performing percussion on abdomen]
- [Image: Palpation]
Q: Step 1
A: [Image: Picture of face with focus on eyes]
Q: Step 2
A: [Image: Stethoscope]
Q: Step 3
A: [Image: Palpation]
Q: Step 4
A: [Image: person performing percussion on abdomen]
Credits: by unknown (Author); licence CC BY-NC-SA 4.0

Credits: by unknown (Author); licence CC BY-NC-ND 3.0

Good job

Continue with your assessment.

Key #1

Q: What was the sequence of numbers from the Donning exercise?
- 62937 (Try again!: That is not the right order!)
- 32967 (Try again!: That is not the right order)
- 36297 (Correct!: You are ready to start your assessment.)
- 63297 (Try again!: That is not the right order)

Cause for visit

[Image: Nurse with PPE on]

Hello Mr. Robinson.  My name is Nancy and I will be your nurse. Can you tell me what brought you to the clinic today?

Credits: by © Obesity Action Coalition (Author); licence C

[Image: obese man standing]

I was here a few days ago with a skin rash and I got a prescription for antibiotics and some cream.  Then a couple of days ago my skin got worse and I started having diarrhea.

Q: What is the most likely cause for this return visit? Choose the correct answer.
- Clostridium difficile (C. Diff) (correct)
- Methicillin Resistant Staphylococcus aureus (MRSA)
- Vancomycin Resistant Enterococci (VRE)
- Covid-19
Feedback (0 to 99%): Try Again
Feedback (100 to 100%): You are correct - unscramble for the clue - qtfrneeu Remember this clue for later!

Prevent spread

Q: From your scrambled words - What is important for stopping the spread of infection?
- frequent handwashing (Correct: You can continue your assessment.)
- social distancing (Try again: This is not the correct response.)
- always wear a mask (Try again: While important, this is not the correct response to the scramble.)

Skin Assessment

[Image: Nurse with PPE on]

Skin assessment

Ok Mr. Robinson, I am going to examine your skin now.

Skin assessment

- [Image: joint with redness and bumps]
- [Image: back with red blotches]
Q: Intertriginous dermatitis
A: [Image: joint with redness and bumps]
Q: Allergic Reaction
A: [Image: back with red blotches]

Drag and drop

To identify which picture applies to the client drag the pictures to the correct diagnosis

Letter

Dear Health Care Team Members

I am writing you to tell you how it feels to be a 300 lb person.  I am writing to provide some suggestions on how the team can better meet my needs.

1. The team needs to look at their assumptions and biases around larger people because weight bias is all around and fatness is reviled in our culture. I know my weight so please do not tell me I need to lose weight.

2.  Make your office physically accessible. I am nervous getting up on the exam table. I worry about how I will get up there. I am not sure I can fit in the chairs or walk into your clinic without running into something. The patient gown is not large enough to fit me. It is embarrassing and demoralizing.

3. Ask for consent before discussing my weight. Don’t assume that every problem I come in with is related to my weight. I feel that at times I get dismissed and that the team members spend less time with me due to my size.

4. Most health care professionals that I have had contact with assume that I am sedentary, that I am lazy, that I eat fast food regularly, and perhaps most perplexingly, that I don’t know I’m fat.  Rather than jumping to conclusions, ask me what I am doing to stay healthy and believe me when I tell you.

5. Don’t call me an obese patient and please value me as a person and treat me with respect.

Thank you.

Q: Is this situation a near miss, adverse event, or never event?
- Near Miss (Near miss: A near miss is an unintentional incident that could have caused damage, injury or death but was narrowly avoided. In this case the patient had the reaction due to the allergy not being communicated.)
- Adverse Event (Adverse Event: That is correct. You would need to follow the organization's process for documenting and follow-up of an adverse event.)
- Never event (Never event: This is a serious incident or error that should not occur if proper safety procedures are followed:Try another response.)

Allergy

Client Profile2

Client Profile

Name | Robinson, Luke
DOB | 1990-06-03
Sex | Identifies as male
Address | 33 Lanark Drive, Westview, Ontario
OHIP # | 55523410 WY
Diagnosis | Intertriginous Dermatitis
Allergies |
Code Status | Full resuscitation
SDM | Fran Robinson (mother)
Admission History | First visit to walk in clinic. Came to clinic with c/o skin irritation, increased redness, burning sensation and pain in both axillary regions for 3 weeks.
Medical/Surgical History | No significant medical or surgical history.
Support Systems | Lindsey (partner)
Doctor’s Orders
Amoxicillin 500 mg po every 12 hours for 7 days  Mupirocin Topical Cream. Apply 3 times per day to affected areas for 10 days
Consults | None
Lab Work | None
Follow Up/Return Appointment | No follow up at initial visit. Return visit booked today: c/o diarrhea x 3 days and skin rash on back.
Additional Notes |

C. Wong, M.D.
General Practitioner

Nurse: It looks like a skin reaction to something? Do you have any allergies? To medications?

Client: Yes, I am allergic to Bactroban.

Allergy communication

client profile with Allergy

Client Profile

Name | Robinson, Luke
DOB | 1990-06-03
Sex | Identifies as male
Address | 33 Lanark Drive, Westview, Ontario
OHIP # | 55523410 WY
Diagnosis | Intertriginous Dermatitis
Allergies | Bactroban (Mupirocin)
Code Status | Full resuscitation
SDM | Fran Robinson (mother)
Admission History | First visit to walk in clinic. Came to clinic with c/o skin irritation, increased redness, burning sensation and pain in both axillary regions for 3 weeks.
Medical/Surgical History | No significant medical or surgical history.
Support Systems | Lindsey (partner)
Doctor’s Orders
Amoxicillin 500 mg po every 12 hours for 7 days  Mupirocin Topical Cream. Apply 3 times per day to affected areas for 10 days
Consults | None
Lab Work | None
Follow Up/Return Appointment | No follow up at initial visit. Return visit booked today: c/o diarrhea x 3 days and skin rash on back.
Additional Notes |

C. Wong, M.D.
General Practitioner

Nurse: It looks like you have had an allergic reaction to the Bactroban which is also called Mupirocin. Unfortunately, your allergy to Mupirocin was missed on your first visit.   Your allergy has been added to the chart and will be kept on your records. Just to be on the safe side it is always a good idea to tell any health care members about your allergies.

Credits: by unknown (Author); licence CC BY 3.0

[Image: 2 drawers with padlock on top corner]

Nurse:  Also, when you take antibiotics it can result in diarrhea so we will need to get a stool sample from you. I will go get the bottle for you to take home so you can provide us with a sample.

collecting a sample

Drag the words into the correct boxes

Q: If the nurse was collecting a sample at today's visit what would they need to remember:

Be sure to [...] the [...] correctly.
Place the [...] sample in a [...] bag.
Wear the right [...] for safety of the [...].
A: label; bottle; stool; biohazard; PPE; nurse
Feedback (0 to 99%): try again!
Feedback (100 to 100%): That is correct!

[Image: obese man looking sad]

nurse return

Nurse comes back in room with stool sample bottle.  Notices that the client is looking unhappy.

Client’s inner dialogue:

Great that is all I need. I wonder if these people are listening to me or really care about me. How did this get missed?  And if I wasn’t so fat would this have happened at all?  I let the infection fester – I did not want to come to clinic to be made to feel worse about myself.  I don’t want to be weighed, I don’t want to discuss my weight but I feel at times that is all they see.

[Image: obese man looking pensive, hand on chin]

Nurse asks the client: “Are you feeling okay – you seem a bit quiet?”

Client states: “I feel frustrated, I feel like this is all my fault but I am also concerned about the allergy being missed.”

Nurse states: “I am hearing that you are frustrated and understand your concerns.  How can we work together to help resolve these feelings?  What helps you work through your feelings?

Client - “Usually I think about a situation and I like to journal.”

Nurse - “That sounds like a very good strategy.  Maybe in this situation you can share your experience through reflecting on your experience and writing it down.  It would be very helpful if you would feel comfortable providing us with feedback, some ways we can improve.  We take feedback very seriously.  We have a Quality Improvement Committee that would like to hear about your experience .”

Diagnosis

Q: What is the likely diagnosis for this visit?
- MRSA and intertriginous dermatitis (Try again!)
- Clostridium difficile infection with a skin allergy to an antibiotic (That is correct!)
- Clostridium difficile infection and a food allergy (Try again!)

End of course and learning points

[Image: obese man waving good-bye]

end of visit

Congratulations - you have completed the escape room!!

Mr. Robinson received a follow-up call from a patient advocate to talk about his concerns and changes have been made to have better supports available!

The following slides outlines the key learning points from this activity - please take time to review them to help to re-inforce your learning.

Donning and Doffing of PPE

You can view the You tube videos from Public Health Ontario for donning and doffing of PPE.  See references on our website for more details.

Breaking the Chain of Infection

1. Infectious agents (microorganisms)

These include bacteria, viruses, fungi and parasites.

Breaking this link: Antimicrobials, disinfectants and hand hygiene with ABHRs

2. Reservoirs in health care

Humans, animals and the environment are reservoirs of infectious agents (microorganisms) relevant to health care.

Breaking this link: Hand hygiene following contact with individuals or their environment, preoperative skin preparation and cleaning the environment all reduce the number of microorganisms present in a reservoir

Breaking the Chain of Infection (cont.)

3. Portals of exit

A portal of exit is the route by which an infectious agent (microorganism) leaves the reservoir, although not all reservoirs have an obvious portal of exit (e.g., the environment). Infectious agents are contained in blood, body fluids, excretions, secretions and skin of human reservoirs, depending on the agent, and leave the reservoir through the respiratory, gastrointestinal or integumentary (skin/mucous membranes) system.

Breaking this link: Reduction of excretions or secretions or covering portals of exit (e.g., dressings on wounds, masks)

Breaking the Chain of Infection

4. Routes of transmission

Routes of transmission of infectious agents (microorganisms) are conventionally categorized into five routes: contact, droplet, airborne, common vehicle and vectorborne.

Breaking this link: The appropriate use of barriers and adherence to hand hygiene

5. Portals of entry

A portal of entry is the route by which an infectious agent enters the host. Examples include mucous membranes of the respiratory tract, the gastrointestinal tract, the urinary tract, breaks in the skin (e.g., wounds) and devices such as intravenous lines.

Breaking this link: Protecting portals of entry by covering wounds, wearing PPE, reducing breaches in the mechanical barriers of the skin and mucous membranes, using sterilized equipment when required, or by performing hand hygiene

Breaking the Chain of Infection

6. Susceptible host

An individual must be susceptible to the infectious agent (microorganism) for an infection to occur.

Breaking this link: Ensuring host defences are maximized (e.g., through immunization, optimal nutrition, reduction of smoking and control of diabetes).

From: https://www.canada.ca/en/public-health/services/publications/diseases-conditions/routine-practices-precautions-healthcare-associated-infections/part-a.html

Emotional and Psychological Safety for the Client with Obesity

Obesity stigma is associated with significant physiological and psychological consequences, including increased depression, anxiety and decreased self-esteem. It can also lead to disordered eating, avoidance of physical activity and avoidance of medical care.

Individuals with obesity experience stigma from educators, employers, health professionals, the media and even from friends and family.

Over-simplifying the causes of obesity and implying that easy solutions will lead to quick and sustainable results – for example, “eat less, be more active” – contribute to weight bias and can set unrealistic expectations, masking the challenges people with obesity can face in changing behaviour. Additionally, this often focuses discussion around individual behaviours and perceived failures, while neglecting to take into consideration important social and environmental factors.

From: https://www.euro.who.int/en/health-topics/noncommunicable-diseases/mental-health/news/news/2017/10/world-obesity-day-understanding-the-social-consequences-of-obesity

Infection Control in a Clinic Setting - Infection Control Measures

Avoid:

- Hand hygiene over gloves
- Placing clipboard on bed
- Nurse touching hair
- Dangling lanyard

Remember:

- Clean equipment before use
- Don and doff PPE correctly
- Wear appropriate PPE depending on situation

Sequence of Abdominal Assessment

1. Inspection
2. Auscultation
3. Palpation
4. Percussion

The sequence is different from IPPA because palpation may stimulate bowel activity and falsely increase bowel sounds if performed before auscultation.

Assessing for Allergies

Allergic reactions can result from administration of the medication to which the patient is allergic (primary allergen). Lack of assessment for allergies and poor documentation compounds the problem of identifying drug allergies and can result in the occurrence of a preventable medication error, which may in turn result in patient harm and if in hospital an extended hospital stay.

From: https://www.ismp-canada.org/download/safetyBulletins/2016/ISMPCSB2016-10-AllergyNeverEvents.pdf

Preparation for assessment

[Image: obese man looking concerned]

Thinking to himself:

I don't feel comfortable with this - that gown is never going to fit me, the bed looks so small.  I don't know how I will get up on it and what if I fall off.  This is why I don't like coming here.

Says out loud:  "okay - I guess"

Clinic space

Bed

How might this bed be challenging for a bariatric client?

Chair

Perhaps consider the availability of a bariatric chair.

[Image: bariatric chair]

Vitals machine

Consider the challenge for taking vital signs.  You may need a larger blood pressure cuff.

Credits: licence CC BY-NC 4.0

Preparation for assessment

Credits: by unknown (Author); licence CC BY-NC 3.0

[Image: cartoon of bugs with red line through them]

ready for assessment

Next you are going to do your physical assessment of the client - you will need to get everything set up before you begin and be sure to follow good infection control practices.

Q: Which of the following are NOT good practices for infection control (check all that apply):
- Dons PPE in correct order
- Performs hand hygiene over clean gloves (correct)
- Uses a CAVI wipe to clean the blood pressure cuff
- Places clipboard on client's bed (correct)
- Nurse tucks loose hair behind ears with PPE on (correct)
- Performs hand hygiene before putting on gloves
- Has her nametag on a lanyard (correct)
- Wipes thermometer with a CAVI wipe
- Does not clean stethoscope (correct)
Feedback (0 to 99%): Try again!
Feedback (100 to 100%): That is correct. Remember your patient has C-diff!

doffing

end of visit

Mr. Robinson is now ready to go and you are on to your next client.  Your last step is to safely remove your PPE.

Donning PPE

What is the proper sequence of PPE to be doffed?  Flip the cards over to see the numbers on the back and remember the correct sequence to use later to get the key to unlock the next puzzle.

Q: Gloves
A: 7

Q: Faceshield
A: 9

Q: Wash hands
A: 3

Q: N95 mask
A: 2

Q: Gown
A: 6

Credits: by unknown; licence CC BY-NC-SA 3.0

Credits: by Unknown; licence CC BY-SA 3.0

Credits: by unknown; licence CC BY-NC-SA 4.0

You need to remember the code for later!

order of Doffing

Q: What is the correct sequence of activities for doffing PPE?
- 3736923 (That is not correct.: You do not preform hand hygiene with gloves on.)
- 739263 (You have some items out of order.: The gown needs to be removed before the face protection.)
- 736923 (That is correct!: Proceed to the next slide.)
- 73639323 (This is not necessary.: In this case you do not likely need to wash your hands after every action.)

Message in letter

Q: What is the message hidden in the letter?
- Accessibility is key. (Not quite.: While this is important it is not the hidden message!)
- Mentor peers (Look more closely!: It is important to share experiences with your peers so that you can learn from each other - but not the hidden message!)
- Temperment (Try again!: A good temperment is important but it is not the hidden message!)
- Empowerment (Yes!: This is what we want for all of our clients!)

Navigation

Some information to know before you get started:

- You will need to click the Proceed or Back buttons in the top right corner to navigate from one activity to the next.
- To review the slides in a presentation click on the arrow at the bottom to advance to the next slide.
- You may need to scroll down to see all of the information or to reveal the Check button to check your answers.
- Sometimes when you check the response you will be given a clue that you will need later in the game!

Congratulations on completing the Escape Room exercise! I knew you could do it!

Credits: by © Obesity Action Coalition; licence C

Credits: logos; licence C