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Simulation Design Template Date: 11-21-2010 File Name: Recognition of potential pulmonary embolus? Discipline: Nursing- MD Expected Simulation Run Time: 15min Location: Med Surg Admission Date: 11/22/10 Today’s Date: 11/25/10 Brief Description of Client Name: Englasias, Paulina Gender: F Age: 52 Race: Hispanic Weight: 78.9 kg

Height: 165.2 cm

Religion: Catholic Major Support: Husband Phone: 713 255 3232 Allergies: Penicillin, Immunizations: none recently Attending Physician/Team: Dr. Oz/ Team 2

Level: Junior 2 Guided Reflection Time: 30 min Location for Reflection: Simulation lab Psychomotor Skills Required Prior to Simulation Be Proficient in: Receiving report (facilitator will give report) Basic assessment skills- (focus area becomes respiratory) Vital signs- Temp, Pulse, BP, O2 sat Wound assessment and dressing change Medication administration Recording intake and output Cognitive Activities Required prior to Simulation [i.e. independent reading (R), video review (V), computer simulations (CS), lecture (L)] (R) Perry, M. (2008). Knowing the early signs of pulmonary embolism. Practice Nursing, 19(12), 620-623. (V) view the video below What is Pulmonary Embolism

Past Medical History: Chronic HTN, Overweight, (BMI 29%), stopped smoking 6 months ago, Pneumonia in 2008

History of Present illness: Presented in the emergency room 11/22/ 2010 with sharp RUQ pain, nausea and vomiting. Admitted for emergent open cholecystectomy

http://www.youtube.com/watch?v=GJLWwl1Z03k (R) Respiratory assessment in critically ill patients: Airway and breathing. R. Higginson and B. Jones (V) Lung assessment (www.

http://

www.youtube.com/watch?v=sTUbDZxzaMM (V) Abnormal breath sounds http:// www.youtube.com/watch?v=NnuaHGW1cwU Breath sounds http://www.youtube.com/watch? v=h7BtrWATfg8

Social History: Married, children grown, employed as office administrator, Social drinker i.e 2 beers/wk

Primary Medical Diagnosis: Acute

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Nursing Diagnosis Risk for impaired gas exchange Acute pain Impaired physical mobility


cholecystitis Surgeries/Procedures & Dates: 11/22/10 – open cholecystectomy

Risk for Venous Thrombolytic Embolus

Simulation Learning Objectives Assess the post-op patient - include information obtained through communication with patient/family. Determine a plan of care based on the findings. Document appropriately- assessment, interventions and evaluation. Demonstrate therapeutic communication techniques with the patient and family. Demonstrate effective communication techniques with team members to include SBAR when notifying MD. Implement safe, appropriate care.

1.

Introduce yourself and ask the patient what is the problem as you ID the patient

2. Recognize respiratory distress and use critical thinking skill to address the situation. (hypoxia, restlessness, sweating, use of accessory muscles and nasal flaring).

3. Based on clinical assessment, nurse should be able to implement respiratory management strategies (vital signs, initiate pulse oximetry, O2 therapy).

4. Perform a respiratory assessment quickly, efficiently and effectively (recognize abnormal breath sounds, abnormal breathing pattern, color and behavior) 5. Demonstrates appropriate communication with medical team 6. Assess the patient room for emergency airway management equipment 7. Communicates calmly and clearly with the patient and family 8. Implement appropriate nursing interventions for respiratory distress 9. Facilitate in carrying out physician orders: lab, chest x-ray, ABG’s, ECG and oxygen therapy

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Fidelity (choose all that apply to this simulation) Setting/Environment Medications and Fluids ○ ER ○ IV Fluids: * ○ ○ ○ ○ ○ ○ ○ ○ ○

Med-Surg* Peds ICU OR / PACU Women’s Center Behavioral Health Home Health Pre-Hospital Other _________________

Oral Meds:

IVPB:

IV Push:

IM or SC:

Simulator Manikin/s Needed: High FidelityProps: High Fidelity- dressed as female patient, with TED hose on

Diagnostics Available

Equipment attached to manikin:

Documentation Forms

○ ○ ○ ○ ○ ○ ○ ○ ○ ○

IV tubing with primary line __D5 1/2 NS 20KCl fluids running at 100 cc/hr Secondary IV line __ running at _ cc/hr IV pump* Foley catheter __ PCA pump running IVPB with ___ running at ___ cc/hr 02 _NC @ 4 LPM_ Monitor attached ID band __R wrist_ Other____________________

Equipment available in room ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

Bedpan/Urinal Foley kit* Straight Catheter Kit Incentive Spirometer* Fluids IV start kit IV tubing IVPB Tubing IV Pump Feeding Pump Pressure Bag 02 delivery device (type) Nasal cannula Crash cart with airway devices and emergency medications*

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○ ○ ○ ○

○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

Labs* X-rays (Images)* 12-Lead EKG Other__ABG’s___

Physician Orders * Admit Orders Flow sheet* Medication Administration Record Kardex Graphic Record Shift Assessment* Triage Forms Code Record Anesthesia / PACU Record Standing (Protocol) Orders Transfer Orders Other______________________

Recommended Mode for Simulation (i.e. manual, programmed, etc.) Programmed scenario Pulse 100- increase to 110 Bowel sounds hypoactive Breath sounds- diminished bilaterally in bases O2 sat 92- decrease to 88%


○ ○ ○

Defibrillator/Pacer* Suction Other_Pulse oximeter/Vital sign machine, gloves,

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Walkie talkie placed for patient communication


Roles / Guidelines for Roles ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

Primary Nurse- assessment Secondary Nurse- calls MD Clinical Instructor Family Member #1- husband Family Member #2 Observer/s Recorder- use dry erase board Physician / Advanced Practice Nurse* Respiratory Therapy* Anesthesia Pharmacy Lab* Imaging Social Services Clergy Unlicensed Assistive Personnel Code Team Other_________________________

Important Information Related to Roles Family member #1- is husband. Mr E is concerned that whenever his wife gets up to go to the bathroom she comes back to the bed very short of breath. Onset- the past few hours.

Significant Lab Values Labs drawn this morning are within normal range. Physician Orders STAT ABG’s, BMP, CBC, STAT EKG STAT chest X-ray and Chest CT with contrast-

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Student Information Needed Prior to Scenario: ○ ○ ○ ○ ○ ○

*Has been oriented to simulator *Understands guidelines /expectations for scenario *Has accomplished all pre-simulation requirements *All participants understand their assigned roles *Has been given time frame expectations Other ___________________________

Report Students Will Receive Before Simulation: Students just received patient’s history, diagnosis during change of shift report. Patient has just called for assistance. *****?? The primary nurse just went to pharmacy. Time:


Needs & Roles for Simulation: Equipment: Stethoscope Alcohol based hand gel

Roles: Students Primary nurse - Team leader, assessment Secondary nurse - Treatment RN, Communicate with MD Medication Nurse Documentation nurse SpouseObserver-1

Gloves BP cuffSpO2 monitor & probe, Thermometer Pt. ID band w/name, DOB, & MR# Saline lock right forearm IV pump IV fluid: 0.45 NS with 10mEq KCL at 100cc/hr

Assistance Needed: Patient Voice- faculty Staff member to orient students to environment Lab personnel Staff member to play the role of a physician if called-KV

TED hose on Incision RUQ- drawn on tape secured to manikin Phone at bedside to call MD with number to contact physician and a phone to receive call Pt. chart (content– physician orders, med sheet, Progress note, nurses notes) I and O sheet- ?computer documentation? Form for nurses to take report Form for observers to document their observations Form for pt with cues re: pain/SOB

Simulation Sequence: Monitor Settings (Actions)

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Pt./Manikin (Actions)

Student Interventions (Events)

Cue/Prompt


5 minutes

RR22, HR 100, BP 128/84, SpO2 92% T 100.0 F Breath sounds: diminished bases Bowel soundshypoactive Abd- soft Semi-fowlers position

SOBwheezy Pain at 8 on 1-10 scale Oriented x 3

Wash hands Introduce self Identify pt. using 2 approved pt. identifiers Provides family education regarding morning initial assessment- deep breathing- moving Implement a head to toe assessment: VS to include Sp02 level, LOC, Breath sounds Assess IV site Assess incision Pain assessment (level on a scale from 1-10, location, characteristics) Auscultate bowel sounds- palpate abdomen Ask if BM since surgery

Patient is SOB, just back from trip to bathroom

Sats are dropping, heart rate is increasing, husband voices concern

IV rt. arm D5 ½ NS w/10 meq KCL

Took a pain med about an hour ago but no help

5-10 minutes

Increase HR to 110, O2Sat at 88%

Patient states she is feeling SOB- a small amount of activity and she is worn out

Elevate HOB Encourages IS use, ambulation Communication of assessment findings w/ physician Reposition pt. to provide comfort

10-15 minutes

RR 28, HR 120, BP 128/84 Sp02 88%

SOB, Chest pain at a 10 with inspiration and after any movement

Calls MD relay message SOB, Increased HR, Can’t get decreased O2Sat. enough air, any movement and Prepare patient for tests ordered by MD I feel chest pain increase and more SOB

Patient Role & Cues: If no introduction is provided ask for one When the nurse starts assessing –state you are short of breath a lot since last night If the nurse doesn’t ask when it started

“Who are you?” Who is with you? “You know every time I get up to the bathroom – I am very SOB when I return to bed plus more pain in my chest.” “During the night- I know they increased the oxygen a little bit one time” “The pain pill is helping much anymore but the pain is not by my incision.”

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Scenario (and report to the nurse): Paulina Englasias is a 52 year old Hispanic female who was admitted to the MedSurg Unit following emergent surgery for cholecystitis 3 days ago. She presented at the ED with severe RUQ abdominal pain temp 102, nausea and vomiting. Lab work on admission showed an elevated WBC. A CT of the abdomen was obtained while in the ED. Based on the pain, lab and CT findings the patient was sent for an emergent open cholecystectomy. She has a history of hypertension. Pneumonia 2 years ago. She stopped smoking 6 months ago. Her weight is 78.9 kg, 165.2 cm tall, BMI 29. An IV was started for fluid replacement, along with broad spectrum antibiotics. Antibiotics completed 24 hours after surgery. ● ● ● ● ● ● ● ● ●

IV of D5.45 Normal Saline with 10 KCl Saline lock right forearm NG removed yesterday- tolerating clear liquid diet but only in small amounts RUQ incision /intact Voiding – urine is dark yellow Requires frequent reminder to use incentive spirometer TED hose currently on Encouraged to walk more and got up twice during the night O2 2l NC- sats range from 92-94 with O2. Dropped to 90% off O2 during the night.

Married, children grown, employed as office administrator, Social drinker i.e 2 beers/wk. She was taking Morphine IV for pain every 2 hours if needed. Since yesterday she has been taking 2 Vicodin about every 4-6 hours for pain. The doctor mentioned in his progress note yesterday that she should be ready to go home today or tomorrow.

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Texas Woman’s University General Hospital Paulina Englasias 1.

Physician Orders

VS every 4 hours. 2. O2 at 2-4L per nasal cannula to maintain SpO2 greater than 92% 3. Incentive spirometer every 2 hours while awake 4. Diet- Clear liquids, advance as tolerated 5. Intake and output every shift- notify MD if <240 every 8 hours 6. Saline Lock 7. IV D5/.45% NS with 20mEq KCL at 100mL/hour 8. Up ad lib 9. Metoprolol 100 mg at HS 10. Colace 100mg BID 11. Vicodin- 2 tabs every 4 hours PRN- Pain level 1-7 12. Morphine- 2 mg IV PRN – Pain level 8-10 13. Notify physician for: HR >100 or <60, SBP <100 or >180, Urine output <240mL/8 hours, Temp > 101⁰F, SpO2 <92%

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Texas Woman’s University General Hospital MEDICATION ADMINISTRATION RECORD Patient Name: Englasias, Paulina

Medical Record No.: 12345 Room Number: GH 032 Attending Healthcare Provider: Dr. Anderson

Birthdate: 1-9-1958 Allergies: Penicillan

Gender: Female

Order Date

Height: 165.2 cm

Discontin ue Date

11-22-2010

Weight: 78.9 kg

Medications

Date: 11-242010 7am7pm

7pm7am

D5/0.45NS with 20mEq KCL at 100mL/hour 0700infusing

11-22-2010

11-232010

Vancomycin 1Gm IVPB x 1 24 hours post op

11-22-2010

Morphine 2mg IVP every 2 hours PRN pain level 8-10

11-24-2010

Vicodin 2 tabs PO every 4 PRN pain level 1-7

11-24-2010

Metoprolol 100 mg PO at HS

11-24-2010

Colace 100 mg PO BID

2100 0900 1700

INITIALS

SIGNATURE/TITLE

OMITTED DOSE CODES

A – NPO DIAGNOSTIC

INITIALS

SIGNATURE/TITLE

INJECTABLE SITE CODES (SITE ROUTE) E – HOLD DOSE

ANTERIOR THIGH

RUQ – RIGHT UPPER QUADRANT RRIGHT

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B – NPO SURGERY C – PATIENT REFUSED DOSE D - NAUSEA

F – PATIENT AWAY FROM ROOM G- OTHER (SEE STAFFF NOTES)

GLUTEAL REGION

RLQ – RIGHT LOWER QUADRANT

DELTOID

LUQ – LEFT UPPER QUADRANT L - LEFT

ABDOMINAL

LLQ – LEFT LOWER QUADRANT

References, Evidence-Based Practice Guidelines, Protocols, or Algorithms Used For This Scenario: (site source, author, year, and page) Abnormal breath sounds retrieved from http://www.youtube.com/watch?v=NnuaHGW1cwU Breath sounds retrieved from http://www.youtube.com/watch?v=h7BtrWATfg8 Feet to cm online conversion tool retrieved from http://www.convertunits.com/from/feet/to/cm Higginson, R. & Jones, B. (2009). Respiratory assessment in critically ill patient: airway and breathing. British Journal of Nursing, 18(8), 456-461. Lung assessment retrieved from http://www.youtube.com/watch?v=sTUbDZxzaMM Nadeau, S. & Rucker, K P. (2010). Take a deep breath: Assessing postop respiratory status. OR Nurse, 4(3), pp. 13 -15. Online conversion tool retrieved from http://www.onlineconversion.com/weight_common.htm Perry, M. (2008). Knowing the early signs of pulmonary embolism. Practice Nursing, 19(12), 620-623. Retrieved from CINAHL Plus with Full Text database.

Pulmonary embolism: What is a pulmonary embolism[Video]. Retrieved from http://www.youtube.com/watch? v=GJLWwl1Z03k SBAR Technique for Communication: A Situational Briefing Model- retrieved 11-21-2010 http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/ SBARTechniqueforCommunicationASituationalBriefingModel.htm

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2007 NCLEX-RN Test Plan Categories and Subcategories Choose all areas included in the simulation

Safe and Effective Care Environment Management of Care ● ● ● ● ● ● ● ● ● ●

Advance Directives Advocacy Case Management Client Rights Collaboration with Interdisciplinary Team Concepts of Management Confidentiality / Information Security Consultation Continuity of Care Delegation

● ● ● ● ● ● ● ● ● ●

Establishing Priorities Ethical Practice Informed Consent Information Technology Legal Rights and Responsibilities Performance Improvement (QI) Referrals Resource Management Staff Education Supervision

● ●

● ●

Medical and Surgical Asepsis Reporting of Incident/Event/ Irregular Occurrence/Variance Security Plan Standard /Transmission-Based / Other Precautions Use of Restraints/Safety Devices Safe Use of Equipment

● ● ● ● ● ● ● ● ●

Health Promotion Programs Health Screening High Risk Behaviors Human Sexuality Immunizations Lifestyle Choices Principles of Teaching/Learning Self-Care Techniques of Physical Assessment

● ●

Psychopathology Religious and Spiritual Influences on Health Sensory/Perceptual Alterations Situational Role Changes Stress Management Support Systems Therapeutic Communications

Safety and Infection Control ● ● ● ● ● ● ● ●

Accident Prevention Disaster Planning Emergency Response Plan Ergonomic Response Plan Error Prevention Handling Hazardous and Infectious Materials Home Safety Injury Prevention

● ●

Health Promotion and Maintenance ● ● ● ● ● ● ● ● ●

Aging Process Ante/Intra/Postpartum and Newborn Care Developmental Stages and Transitions Disease Prevention Expected Body Image Changes Family Planning Family Systems Growth and Development Health and Wellness

Psychosocial Integrity ● ● ● ● ● ● ● ●

Abuse/Neglect Behavioral Interventions Chemical and Other Dependencies Coping Mechanisms Crisis Intervention Cultural Diversity End of Life Care Family Dynamics

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● ● ● ● ●


● ●

Grief and Loss Mental Health Concepts

● ●

Therapeutic Environment Unexpected Body Image Changes

● ● ● ●

Nutrition and Oral Hydration Palliative/Comfort Care Personal Hygiene Rest and Sleep

● ● ● ● ●

Parenteral/Intravenous Therapies Pharmacological Agents/Actions Pharmacological Interactions Pharmacological Pain Management Total Parenteral Nutrition

● ● ● ●

Potential for Complications from Surgical Procedures and Health Alterations System Specific Assessments Therapeutic Procedures Vital Signs

● ● ● ●

Medical Emergencies Pathophysiology Radiation Therapy Unexpected Response to Therapies

Physiologic Integrity Basic Care and Comfort ● ● ● ● ●

Assistive Devices Complementary and Alternative Therapies Elimination Mobility/Immobility Non-Pharmacological Comfort Interventions

Pharmacological and Parenteral Therapies ● ● ● ● ● ●

Adverse Effects/Contraindications Blood and Blood Products Central Venous Access Devices Dosage Calculation Expected Effects/Outcomes Medication Administration

Reduction of Risk Potential ● ● ● ● ●

Diagnostic Tests Lab Values Monitoring Conscious Sedation Potential for Alterations in Body Systems Potential for Complications of Diagnostic Tests/Treatments/Procedures

Physiologic Adaptation ● ● ● ● ●

Alterations in Body Systems Fluid and Electrolyte Imbalances Hemodynamics Illness Management Infectious Diseases

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Timing (approximate)

Scenario Progression Outline Manikin Actions Expected Interventions

May Use the Following Cues Role member providing cue: Cue:

Role member providing cue: Cue:

Role member providing cue: Cue:

Role member providing cue: Cue:

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Role member providing cue: Cue:

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Debriefing / Guided Reflection Questions for This Simulation (Remember to identify important concepts or curricular threads that are specific to your program) 1.

How did you feel throughout the simulation experience?

2.

Describe the objectives you were able to achieve?

3.

Which ones were you unable to achieve (if any)?

4.

Did you have the knowledge and skills to meet objectives?

5.

Were you satisfied with your ability to work through the simulation?

6.

To Observer: Could the nurses have handled any aspects of the simulation differently?

7.

If you were able to do this again, how could you have handled the situation differently?

8.

What did the group do well?

9.

What did the team feel was the primary nursing diagnosis?

10.

What were the key assessments and interventions?

11.

Is there anything else you would like to discuss?

Complexity â&#x20AC;&#x201C; Simple to Complex Suggestions for Changing the Complexity of This Scenario to Adapt to Different Levels of Learners

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Student Nurses and s/s of Pulmonary Embolism