Acute Stroke - Simulation Design Template Loyalist College

Simulation Design Template

Acute Stroke - Simulation Design Template – Loyalist College

Program: Nursing Course: NURS 2005Review date:

Original Author/year: Tammy Armstrong(O’Rourke)/2007,Reviewed 2009, Julie Rivers revision 2014

_X_Formativeassessment ___Summative assessment or___OSCE /High stakes assessment

Prep/Pre-meeting Time: 0Expected Simulation Run Time: 15 min

Debrief/Guided Reflection Time:15 min

Alternate Activity Location Required: No

Simulation Learning Objectives (Identify related Course Learning Outcome and ProgramTerminal Outcome by number only)

The Student group will:

Demonstrate understanding of assessment of a person experiencing CVA.(CLO 1,2,3 , PLO 1,2,3)
Carry out a focused neurological assessment of a patient who has a stroke using the Canadian Neurological Scale Tool
Assess vital signs and patient’s symptoms/concerns
Carry out appropriate interventions in response to assessment findings
Identify assessment findings which could lead to complications

Identify and consult appropriate resources while assessing, planning (including prior to lab), and implementing care.(CLO 1,2,3,6 PLO 1,2,3,6)

Respond appropriately to family member question(s) (CLO 1, 2, 3,6 PLO 1, 2, 3, 6)

Participate in creating SBAR report at the end of the simulation(CLO3, PLO3)

Measurement of Objectives

During scenario, identified by handler events in debrief document for a-c.

During debrief discussion for d.

During scenario, identified by handler events in debrief document and discussed in debriefing session
During scenario identified by professor and discussed during debrief.
Written and verbal (time permitting) report at end of simulation.

Skills/Theory required prior to participation in simulation

See Course Documentation for prerequisites and co-requisites
Cardiovascular, neurological assessment and stroke (including use of CNS tool) lecture content of NURS 2004
Familiarization with use of blood glucose meter

Student Preparation for Simulation

Review and research pertinent patient information package provided - see Appendix A

Student preparation package to be distributed:See AppendixAPrior to Simulation - included in Blackboard course materials

References, Evidence-Based Practice Guidelines, Protocols, or Algorithms used for this scenario: (site source, author, year, and page)

Canadian Pharmacists Association. (2013). e-CPS. Ottawa, Ontario, Canada.

Health Quality Ontario & Ministry of Health and Long-Term Care. (2013, September). Quality-Based Procedures Clinical Handbook for Stroke. Retrieved from Ontario Ministry of Health and Long-Term Care:

Jarvis, C. (2009). Physical examination & Health Assessment (1st Canadian ed.). Toronto: Saunders Elsevier.

Lewis, S. H. (2010). Medical-Surgical Nursing in Canada: Assessment and Management of Clinical Problems (2nd Canadian ed.). Toronto: Elsevier Canada.

Lewis, S., Ruff Dirksen, S., Howard, V., Heitkemper, M., Schumacher, L., Weberg, D., and Bucher, L. (2011). Simulation Learning System for Lewis et al: Medical Surgical Nursing. (8th ed). Retrieved from

The Canadian Stroke Strategy. (2014). Retrieved from Canadian Best Practice Recommendations for Stroke Care:

The Canadian Stroke Strategy. (2014) Retrieved from Canadian Best Practice Recommendations for Stroke Care: HyperacuteStroke Care recommendations:

pathophysiology notes re CVA
BPG’s - RNAO Stroke Assessment across the continuum of Care 2011 Supplement found at url

Optional -

Stroke Nurse Pocket guide provided by professor, need to order from Heart and Stroke

External Expert Review

2006, original co-author, Stroke Unit co-ordinator, Sue Kotel

December 2013, Melissa Roblin, RN, BScN - Stroke clinical resource Nurse Quinte Healthcare Corporation and Michelle Slapkauskas, RN, BScN, Stroke prevention clinic nurse, Quinte Healthcare Corporation

Brief Description of Patient:

Name: Mr(s). Sidney Smith Gender:M orF Bdate: 08/05/39

Race:Caucasian

Weight: 92kg Height: 175cm

Religion: Major Support: spouse and children Phone:

Allergies: ASA & Penicillin Immunizations: UTD

Attending Physician/Team: Stroke team

Primary Diagnosis: Right MCA stroke

Surgeries/Procedures:

History of Present Illness: awoke with symptoms and is thus not eligible for tPA

Past Medical History: long-standing hypertension, acute MI 2years ago, CABG X 3 shortly thereafter.

Social History: smokes 1 pack of cigarettes per day

Fidelity

Setting/Environment

Med-Surg

Simulator Manikin/s Needed:
Patient actor or Sim Man
Equipment attached to Patient actor or Sim man:

ID band _ Mr(s). Sidney Smith
Allergy band- ASA, Penicillin
IV- N/S @75ml/hr
Telemetry monitor
Glucose bubbles to Sim Man fingers, or manikin hand for pt actor
Injectapad on abdomen

Equipment available in room

Stethoscopes
Glucometer
Med Cart
Supply cart
Pen light
Computer for Edoc

/ Medications and Fluids

IV Fluids:

Normal Saline

Oral Meds:

Ramipril 5mg po daily
ASA 81 mg po daily
Atorvastatin 20 mg po daily
Nicorette gum 2 mg
Nicoderm 21 mg patch
Acetaminophen 650mg PO/PR q4h prn for temperature > 37.5 or pain

IM or SC:

Regular Insulin Sliding Scale q4h
Diagnostics Available

Glucometer q4h

Documentation Forms

ER History and Physical
ER neuro assessment record
ECG
Head CT results
Lab results
Acute Ischemic Stroke Orderset
Sliding scale insulin order set
Canadian Neurological Scale Observation Record and Canadian Neurological Scale Reference Sheet
Edoc

Recommended Mode for Simulation:
4 students with roles as assigned
Students to work independently from faculty
Roles / Guidelines for Roles

Primary Nurse
Secondary Nurse
Family member
Documenter/resource

Description of Roles
Primary nurse: Assess patient, follow stroke order set and carry out interventions as appropriate. Complete SBAR at end of simulation to report off duty.
Secondary nurse: Assist primary nurse as appropriate and assist with SBAR report.
Family member: Interact in simulation according to script and briefing.
Documenter/resource:Document vitals and stroke assessment in Edoc. Provide cueing assistance to primary and secondary nurse as appropriate and assist with SBAR report
Critical Lab Values:
Chemistry
Glucose: 11.3 (H)– normal 3.5-10.0
BUN: 4.6 - normal 3.5-7.5mmol/L
Creatinine: 67- normal 50-120mmol/L
Sodium: 137- normal 135-145
Potassium: 4.4- normal 3.6-5.2mmol/L
Chloride: 99- normal 99-108mmol/L
Hemoglobin 160 –normal 135-175
Hematocrit 0.48 – normal 0.40-0.50
WBC 6.8 – normal 4.0-11.0
Urinalysis
Urine Colour: Yellow
Appearance: Clear
Specific Gravity:1.025 – normal 1.003-1.030
Glucose: negative
Ketones: negative
Blood: negative
pH: 5.5 (normal 5.0-8.0)
Protein: negative
Nitrites: negative
Other
LKCS: 9.6- normal 4.0-11.0
ERCS: 3.75(L)- normal
Physician Orders:
Acute Ischemic Stroke Orders filled out and on chart / Student Information Needed Prior to Scenario:
Prebrief:
As with all scenarios:
Speak out loud your observations and assessments and discuss with your partner as appropriate
Treat the actor/simulator as a real patient
Carry over all safety, infection control and communication skills you have previously learned
Call for assistance as needed
With this simulation the vitals will appear on the monitor and stay there for future reference. If you are rechecking a vital, please say it out loud so that your partner knows you have checked it and what the value is. The CNS tool and neuro assessment is on Edoc for the documenter/resource to refer to and complete. State your findings for the CNS assessment out loud so that your documenter can enter this on eDoc as you are completing it.
Report students will receive before simulation:
S. I have just brought Sidney Smith up from ER. He/she is being admitted to your unit with a Dx of Rt MCA stroke.
B. He/She has been in emerg for 12 hours. His/her Hx is an acute MI 2 yrs ago and CABG x 3 soon after. (S)He has a long-standing Hx of hypertension and is a pack a day smoker. Sidney awoke with Sx of stroke and was ineligible for tPA. He/She is 70 years old. Sidney is allergic to ASA and penicillin. We have put him/her on telemetry and put a lock in and started N/S @ 75 cc/hr. CNS score in ER was 5.5
A.Last time I checked him/her vitals were OK, BP still elevated and sats low normal. We have been busy, so just time enough to start the IV since he/she got back from CT scan.
R. Sidney is on the standard stroke orders, and I think you have those already.

Scenario Progression Outline

Timing
(approximate) / Patient Actions / Expected Interventions / May use the following Cues:
Time of Day for simulation is: Noon
First Phase
Assessment / Patient actor/Sim-Man’s initial condition:
Vitals on monitor
T- 37.2
P- 86
R- 22
BP- 185/90
O2 sat- 94%-
Pupils are equal bilaterally and react to light
LOC is alert to a bit drowsy
CNS responses
Orientation normal for place and time(month,year)
Receptive speech normal to close eyes answer yes to does a stone sink in water and point to ceiling with Right hand.
Expressive speech normal - can name 3 items and identify their use
Motor function - Left facial droop. Left side unable to move except if asked to squeeze then very weak in left and can wiggle left toes
If asked how body feels respond
My entire left side – face, arm and leg feel kind of numb and heavy / Hand Hygiene
Introduce self, explains what she/he is about to do
Assess vital signs
TPR, BP, O2 sat
Assess pupil size and reaction to light
Assess Level of Consciousness
CNS assessment
Orientation
Location, month, year
Receptive speech
Close eyes
Stone sink in water
Point to ceiling
Expressive speech
Identify 3 items and purpose
Motor function
Face, proximal arm, distal arm, proximal leg, distal leg
Motor response to resistance
arms, legs
CNS score should be 5.5
Student should identify deficits and may ask documenter how CNS score relates to previous CNS score / Family member has script see Appendix B and will interact in simulation as per script and pre-brief instructions
Second Phase
Medication administration and
Blood Glucose / T-37.2 P-86 R-22 BP 185/100
Sats 93%
Blood glucose 11.0 / Recognize BP elevated and check orders or knows no prntreatment required according to BPG/orders
Check blood glucose with glucometer
Respond to patient question regarding blood glucose testing as body’s reaction to stress and pt is not diagnosed as diabetic
Check orders or ask resource nurse what treatment parameters and if med needed
Administer Insulin as ordered / Role member providing cue:
Pt Actor/SimMan
Cue: Why have they been checking my sugar, nurse? I’m not diabetic.
Third Phase
Reporting of pertinent information / Gives written report in SBAR format to faculty member acting as nurse coming on duty to relieve team
SBAR should include: See Appendix C- CNS score and specific noted limitations VS including blood glucose, motor function/strength and sensation AND any interventions performed or complications to be monitoring for.

Debriefing / Guided Reflection for this Simulation:

What elements of the RNAO BPG Stroke assessment across the continuum of care were you able to implement during the simulation?
Were you able to use the CNS tool to assess this patient? What did the results indicate to you?
What assessment findings were abnormal for this person, would you act on them and what would your actions be
Did you note any potential complication(s) of stroke with your assessment findings? If so what were the findings and potential complication(s). If not what might some be?
Can you identify members of the collaborative team for this patient and when their involvement would start and end? During sim and beyond day 2 after a stroke.
Tell me about your experience with preparing an SBAR report for this situation.

Optional Activity

Have the group remain after simulation and complete a concept map using SLS format for Naomi Reed case study

Simulation Evaluation Process

For Faculty - See Appendix E

For Students - See Appendix F

Appendix A

Student preparation package for

ACUTE STROKE SIMULATION

LEARNING OBJECTIVES

The Student group will:

Demonstrate understanding of assessment of a person experiencing CVA
Carry out a focused neurological assessment of a patient who has a stroke using the Canadian Neurological Scale Tool
Assess vital signs and patient’s symptoms/concerns
Carry out appropriate interventions in response to assessment findings
Identify assessment findings which could lead to complications

Identify and consult appropriate resources while assessing, planning (including prior to lab), and implementing care.

Respond appropriately to family member question(s)

Participate in creating SBAR report at the end of the simulation

TOOLS FOR PRACTICE

Lab coat, notes for documenter/resource, Stroke nurse pocket guide, RNAO BPG Acute Stroke

Lab set up, equipment and medical supplies for simulation, Edoc, SBAR tool

STUDENT PREPARATION FOR SIMULATION:

Lewis et al. Chapter 59
Jarvis Chapter 23 review with specific focus on Stroke assessment and check Index
Pathophysiology Notes: Cerebrovascular Accident

Stroke Assessment Across the Continuum of Care: Summary of BPG Recommendations 2005 and Supplement 2011 available at:
The Canadian Stroke Strategy. (2014) Retrieved from Canadian Best Practice Recommendations for Stroke Care: Hyperacute Stroke Care recommendations:
Stroke Nurse Pocket Guide, Heart and Stroke Foundation *Attention CNS tool (provided by professor)
Review and research pertinent data related to brief description and Doctor’s orders of patient provided
SLS for Lewis Medical Surgical Nursing navigate to Content home > Acute Stroke Simulation Preparation > simulation 20 Naomi Reed and complete pre-simulation quiz and review SBAR report and make notes to help you prepare to produce SBAR report in the simulation experience

Brief Description of Patient:

Name: Sidney Smith Gender: F DOB: 08/05/1939

Race: Caucasian

Weight: 92kg Height: 175cm

Religion: Catholic Major Support: daughter/son

Allergies: ASA & Penicillin Immunizations: UTD

Attending Physician/Team: Stroke team

Primary Diagnosis: Right Hemisphere mid cerebral CVA

History of Present Illness: awoke with symptoms and is thus not eligible for TPA

Past Medical History: long-standing hypertension, acute MI 2years ago, CABG X 3 shortly thereafter.

Social History: smokes 1 pack of cigarettes per day

Lab Tests and Values

Chemistry

Serum Glucose: 11.3 mmol/L

BUN: 4.6 mmol/L

Creatinine: 67 mmol/L

Sodium: 137 mmol/L

Potassium: 4.4 mmol/L

Chloride: 99 mmol/L

Hemoglobin: 160 g/L

Hematocrit: 0.48

WBC: 6.8

Urinalysis

Urine colour: yellow

Appearance: clear

Specific Gravity: 1.025

Glucose: negative

Ketones: negative

Blood: negative

pH: 5.5

Protein: negative

Nitrites: negative

Other

LKCS: 9.6

ERCS: 3.75

Stroke Standard Order set

ORDER AND SIGNATURE
Check box if order is to be followed and sign bottom of each page
Vital signs monitoring
X / Vital signs and Canadian Neurological Scale (for alert or drowsy patients)
Q 1 h x 4, q 2h x8, q 4h then reassess
Vital signs and Glasgow Coma Scale (for stuporous patients)
Q ½h x 4 h, q 2-4 h x 24 h, q 4-6 h x 48 h, then reassess
Notify physician if:
Systolic BP greater than _220_mmHg, or less than _90_mmHg or
Diastolic BP greater than _120_mmHg, or less than _40_mmHg
*Guidelines suggest Antihypertensive therapy only if SBP>220 or DBP >120 of if stroke is accompanied by MI, acute renal failure or aortic dissection.
Activity
Bedrest for 24 h, then AAT
X / AAT Physio to assess
Nutrition
X / NPO until swallowing assessment completed. If patient passes swallowing screen order diet indicated below. If patient does not pass swallowing screen refer to speech language pathology
Regular
Dysphagia Modified texture
NPO
X / No added salt (if hypertensive)
X / Low cholesterol (if elevated)
Other diet: ______
Head of bed elevated (high fowler’s or upright) during and 1 h pc meals
Weigh if possible
Oxygen Therapy
X / O2 therapy orders: oxygenby nasal prongs @ 3L for SaO2 < 92
______
Physician signature: K Koch
Printed name: K Koch
Date and time: 0100 day of simulation
Monitoring
X / Cardiac monitoring x 24 h
X / Portable chest x-ray
X / Intermittent catheterization prn for urinary retention
X / 12 lead ECG
X / Intake and output
Investigations
X / CT Head
Echocardiogram
X / Carotid Doppler studies
X / Blood sugar by glucose meter q 4 h for 24 h, then QID for 2 days, then reassess
X / CBC, electrolytes, urea, creatinine, glucose, albumin, calcium, magnesium, CK, ALP, ALT, AST, LDH, Total bilirubin, INR, PTT, total cholesterol, Cholesterol/HDL ration, triglycerides fasting in am, Hb A1C
Other investigations: ______
Intravenous therapy
X / IV 0.9% sodium chloride at _75_ ml/h while NPO
IV 0.9% sodium chloride at ____ ml/h with ____ mEqKCl/L (20 mEq/L or 40 mEq/L)
Iv saline lock, flush with 5 ml 0.9% sodium chloride BID and prn
Antipyretic therapy
X / Acetaminophen 650 mg PO/PR q4h prn for temperature >37.5 or pain
Antiplatelet therapy
ASA 650 mg sup PR daily
ASA 325 mg PO daily
X / ASA 81 mg PO daily
Clopidrogel 75 mg PO daily
ASA 25 mg/dipyridamole XR 200 mg (Aggrenox) 1 capsule PO bid
Secondary prevention medications
X / Atorvastatin _20_ mg PO daily
X / Ramipril _5_ mg PO daily start date:_after swallowing screen if negative
X / Nicotine replacement patch/gum: Nicorette gum 2mg, one piece of gum per hour as required for nicotine cravings, if not effective then Nicoderm 21 mg patch, apply one patch q 24 h prn for nicotine cravings
Physician signature: K Koch
Printed name: K Koch
Date and time: 0100 day of simulation
Consults
Internal medicine
X / Physiotherapy
X / Speech language pathology
Clinical nutrition
X / Occupational therapy
Social work
Continuing stay coordinator
Physician signature: K Koch
Printed name: K Koch
Date and time: 0100 day of simulation

Role / Description

Nurse 1: Primary - assess patient, direct care and attend to patient, create an SBAR report at the end of the simulation

Nurse 2: Secondary - assist primary nurse during simulation and with SBAR report.

**It would also be helpful for Primary and Secondary nurse to make point form notes or a plan of action prior to lab and give to documenter/resource to use during simulation, and to have CNS in pocket for reference. Remember to research medications on Physician’s orders as preparation.