Date: 09/12/2010File Name: Assessment / ACS

Simulation Design Template

Date: 09/12/2010File Name: Assessment / ACS

Discipline:Level II and Level IVStudent Level: Level II and Level III/IV

Expected Simulation Run Time: 30 minutesGuided Reflection Time:45 minutes

Location: EDLocation for Reflection: Classroom

MRN: KW-2010-00009(circle)

Admission Date: 09/11/2010
Today’s Date: 09/13/2010
Brief Description of Client
Name: Sonya Williams
Gender: F Age: 1948 (62)Race: African American
Weight: 100 kg Height: 62cm
Religion: Baptist Major Support: Spouse
Phone: 281-263-6282
Allergies: ASA "rash"
Immunizations: Current
Attending Physician/Team: Dr. Southworth
Past Medical History: HTN 1999; GERD 2005; Unstable angina 2009;
History of Present illness: To ED via spouse and family car with C/O of fatigue, SOB, dyspnea, nausea, pressure pain between the shoulder blades, 10/10; skin is warm/dry; Discomfort lasting > 20 minutes, began while at rest; 12-Lead EKG non-specific ST elevation; Troponin's negative.
See further assessment on grid.
Current medications:
1. Norvasc (amloedipeen) 10mg p.o. daily
2.Nexium(es-o-MEP-ra-zole) 20mg p.o. daily
3. Tylenol (acetamenophen) 650mg p.o. PRN for headache
Social History: Smoker: 1-pack-a-day for 33 years; denies ETOH or Street drugs
Primary Medical Diagnosis: Unstable angina
Surgeries/Procedures & Dates:
appendectomy 2001; 2009 (L) neg for CAD
Nursing Diagnoses: (Gulanick & Myers, 2003)

Acute chest pain related to myocardial ischemia

Anxiety related to threat of death

Risk for decreased cardiac output related to decreased contractility

Risk for DVT related to fatigue and weakness

Knowledge deficit related to disease process and patient safety ( spouse bringing patient in family car)

Potential for risk or falls related to fatigue / weakness / new environment /medications

/ Psychomotor Skills Required Prior to Simulation
Level II and III/IV Learners:

Head-to-toe assessment skills
Vital-signs
Oriented to the moderate fidelity manikin
Medication administration "Rights"

Level II p.o. route only
Level III/IV all routes

Med dispense© automated medication retrieval unit.

Cognitive Activities Required prior to Simulation [i.e. independent reading (R), video review (V), computer simulations (CS), lecture (L)]
Chapter 33 Health and Physical Assessment (Potter & Perry, 2009) (Level II)--- Review
Ignatavicius, Donna and Workman, Lynda, Medical Surgical Nursing. 6th edition. 2006. W.B. Saunders Company. ISBN 0-7216-0671-7. (Review) Chapters 36 and 40
Review the hand-out within the module An Easy Guide to Head to Toe Assessment© written by (Mary C. Vrtis Ph.D., RN , 2008)
Review the patient census listed in the Clinical Simulation Module-unique for Level II and Level III/IV
Reviews the 2010 JCAHO Patient Safety Goals (In Clinical Module)

Simulation Learning Objectives

At the end of the Clinical Simulation, the learner will:

Objective/Behavior / Level II Learners / Level III/IV Learners
1. Perform a head-to-toe assessment /

Evaluates all systems in an organized manner

Supports the Level II learner with assessment to maintain patient safety

2. Recognizes changes in the patients conditions and utilizes the chain of command /

Relates abnormal findings to the Level III/IV learner

Evaluates changes through a focused assessment of area of concern
Interprets lab and S&S assessed

Infers why S&S are potentially occurring
3. Documents the head-to-toe assessment /

Writes a narrative nurses note summarizing the findings of the head-to toe assessment
Translates in medical terminology using approved abbreviations only

Writes a narrative nurses note summarizing the findings of a focused assessment
Translates in medical terminology using approved abbreviations only

4. Creates a therapeutic environment through communication and leadership/delegation /

Introduces self to patient/family
Generates an environment of caring through verbal and non-verbal communication
Explains (reports) concerns to the Team Leader (Level III/IV Nurse)

Introduces self to patient/family
Generates an environment of caring through verbal and non-verbal communication
Explains (reports) concerns to the Team Leader (Level III/IV Nurse)
Demonstrates leadership and delegation skills through a calm reassuring environment /support for the patient; and effective guidance and delegation for the Level II learner
Communicates the patients assessment accurately for the physician to treat the patient
Completes the physician order sheet and communicates the needs to the pharmacist
Transcribes and performs the interventions as ordered be the physician

5. Applies the principles of safe medication administration
6. Applies the JCAHO 2010 NGSG during patient care /

Administer p.o. medication per the 5-rights of drug administration
Retrieves the medications from the Med dispense system
Revaluates effectiveness of the medication
Documents appropriately
Explains the medication, desired effect and patient safety concerns

Patient identification
Improve staff communication
Uses medications safely
Check patient medications
Identify patient safety risks (JCAHO, 2010)

Administer all IV, IM, SC, or IV medication per the 9-rights of drug administration
Retrieves the medications from the Med dispense system
Revaluates effectiveness of the medication
Documents appropriately
Explains the medication, desired effect and patient safety concerns

Patient identification
Improve staff communication
Uses medications safely
Check patient medications

Identify patient safety risks
(JCAHO, 2010)

Fidelity (choose all that apply to this simulation)

Setting/Environment
X ER
Med-Surg
Peds
ICU
OR / PACU
Women’s Center
Behavioral Health
Home Health
Pre-Hospital
Other:
Simulator Manikin/s Needed:1- Female- African American Vital Sim©
Props:

Equipment attached to manikin:

IV tubing with primary line fluids running at mL/hr
Secondary IV line running at mL/hr
IV pump
Foley catheter mL output
PCA pump running
IVPB with running at mL/hr
02
Monitor attached
XID band
X Other: Allergy band -ASA

Equipment available in room

Bedpan/Urinal
XFoley kit
Straight Catheter Kit
Incentive Spirometer
XFluids
XIV start kit
XIV tubing
IVPB Tubing
X IV Pump (Alaris)
Feeding Pump
Pressure Bag
X02 delivery device (type) NC
XCrash cart with airway devices and emergency medications (on Unit)
XDefibrillator/Pacer (on crash cart)
Suction
Other: / Medications and Fluids
X IV Fluids: NS 1000ml bag 75ml/hr
X Oral Meds:

Nitroglycerin Spray 2 puff SL every 5 minutes X3 for C/O chest discomfort
ASA 325mg chewable stat and then daily
Plavix 300mg p.o. now then daily (if they catch the allergy to ASA.

IVPB:
XIV Push:

Morphine sulfate 5mg IV push every 30 minutes for pain 5; 10mg every 15 minutes for pain <5.

Diagnostics Available
X Labs:

Troponin
CPK/MB
WBC
Chem 23
PT/INR and PTT

XX-rays (Images)

X12-Lead EKG stat with pain also (Non specific ST-elevation)
Other:

Documentation Forms

X Physician Orders
Admit Orders
Flow sheet
X Medication Administration Record
Kardex
Graphic Record
Shift Assessment
Triage Forms
Code Record
Anesthesia / PACU Record
X Standing (Protocol) Orders
Transfer Orders
Other:
Recommended Mode for Simulation (i.e. manual, programmed, etc.)
Roles/Guidelines for Roles
XPrimary Nurse
Secondary Nurse
Clinical Instructor
Family Member #1
Family Member #2
X Observer/s
Recorder
Physician/Advanced Practice Nurse
Respiratory Therapy
Anesthesia
X Pharmacy (per phone)
X Lab (RN to draw)
Imaging
Social Services
Clergy
Unlicensed Assistive Personnel
Code Team
X Other: Team Leader
Important Information Related to Roles:
1. Primary nurse (Level II) primary assessment, p.o. medications, interventions as delegated by team leader
2. Team Leader (Level III/IV) performs all focused assessment, administers all medications except p.o.
Significant Lab Values:
Troponin T (0) range 0 – 0.2 ng/ml
Physician Orders:

Nitroglycerin Spray 2 puff SL every 5 minutes X3 for C/O chest discomfort
ASA 325mg chewable stat and then daily
Plavix 300mg p.o. now then daily (if they catch the allergy to ASA
O2 4L NC to keep sats greater than 96%
Stat EKG and troponins with Chest discomfort
Contact ER physician with onset

/ Student Information Needed Prior to Scenario:
XHas been oriented to simulator
XUnderstands guidelines /expectations for scenario
XHas accomplished all pre-simulation requirements
XAll participants understand their assigned roles
XHas been given time frame expectations
XOther: LSC-Kingwood Hospital ED Protocol listed in the Clinical Module and PP book.
Report Students Will Receive Before Simulation
Time: 6:30am

Sonya Williams- 62yo- African American -female brought to the ED via spouse in the family car

C/O of dizziness and nausea at home so her

husband brought her to the ED "to see the Dr"

Placed in ED-2

References, Evidence-Based Practice Guidelines, Protocols, or Algorithms Used For This Scenario (site source, author, year, and page):

Reference List

Gulanick, M., & Myers, J. L. (2003). Nursing Care Plans: Nursing Diagnosis and Interventions. St. Louis: Mosby.

Potter, P. A., & Perry, A. G. (2009). Fundamentals of Nursing. St. Louis: Mosby.

Vrtis, M. C. (2008). An Easy Guide to a Head to Toe Assessmnet. Retrieved September 11, 2010, from

Timing
(approximate) / Manikin Actions / Expected Interventions / May Use the Following Cues
6:30am
(10-minutes to complete) / Neuro: AX3 PERRLA 3mm-WNL;
Cardiac: S3 -
VS: 188/62-108-24-98.6
O2 sat:91%
Pulm: SOB, crackles bilat lobes; cap refill delayed;
GI: +BS, tired, fatigue, soft no tenderness;
GU: Stool yesterday; UA WNL
Skin:2+ edema above the ankles-+ pulses skin WD
Pain: mid-sternal -10/10-
Non-radiating / Level II learner will complete a head-to-toe assessment / Instructor to facilitate: Patient states..."they always check my ____ when I go to the Doctor do you want to check? "
6:40am / If Team Leader does not begin focused assessment / Instructor to facilitate: Patient to C/O increased pain...moan....nauseated
6:42am / Unchanged above assessment...
Moaning
Monitor alarm sounding / Team leader to instruct Level II to place the patient on the monitor while assessing patient; apply O2; and get the ASA, nitroglycerin, from med dispense
Realizes the need to IV access-calls for assistance nurse and physician, lab, EKG / Instructor to facilitate: cue: "The pain is getting worse"
6:50am / If medications and IV present completed / Patient will improve after 2 doses of NTG Spray, ASA, O2 / No improvement if nit given accurately
6:55am / Pain relieved...BP122/62-SR 88-14-99% 4 LNC. NS @ 75ml/hr
Level II giving report of Troponins Neg EKG non-specific ST to Team Leader / Physician, nurses discussing plan of care after report of labs and EKG / Instructor as patient voice--Did I have a heart attack?
TL-unstable angina

Debriefing/Guided Reflection Questions for This Simulation

(Remember to identify important concepts or curricular threads that are specific to your program)

The Clinical Instructor will evaluate the scenario thru debriefing for 45 minutes; students in a circle in the classroom.

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 – Simple to Complex

Suggestions for Changing the Complexity of This Scenario to Adapt to Different Levels of Learners

1. If performed on level IV after ACLS ...the patient could have cardiac dysrhythmias.