Simulation Request/Development Form

Simulation Request/Development Form

Date of Request: __/___/____

Proposed Simulation dates/Required by: __/___/____

Student Level: Year 3 Year 4

Number of Students/Group size ______

Specialty: Rural Acute Community Health Mental health Other

Complexity of Scenario:

Simple Intermediate Complex

Expected Simulation Run Time: _____

Guided Reflection/Debriefing Time: _____

Simulation Health Center Staff Assistance Required:

Development Presentation/Debriefing Standardized Patient Recruitment

Simulation Learning Objectives: Identify Important Concepts

Brief Overview of Scenario:

Description of Client (Complete if you require specific content)

Name: ______
Gender: ___M ___F
Age: ____
Weight: _____/kg _____lb
Height: ______cm ______ft/in
Allergies:
History of Present illness:
Primary Diagnosis:
Past Medical History / Social History:
Family:
Religion:
Cultural Considerations:

Simulation Requirements (choose all that apply to this simulation)

Setting/Environment
Med-Surg
ICU
Mental Health
Community Health
Home Care
Other:
Simulator Manikin/s Needed:
iStan
VitalSim
Nursing Anne/Kelly
Standardized Patient:

Equipment attached to manikin:

IV ____ running at ____ mL/hr
Secondary IV ___ running at ___mL/hr
IV pump
Foley catheter
NG
Feeding Tube
PCA pump
02 by ____ @___lpm
Monitor
ID band
Other:

Supplies and Equipment available in room

Catheterization Tray/ Supplies
Dressing Tray
IV Fluids
IV Tubing-Primary
IV Tubing - Secondary
IV Pump
Feeding Pump
02 Delivery Devices:
Suction
Incentive Spirometer
Crash Cart
Other: / Medications and Fluids
IV Fluids: ______
Oral Meds:
-
-
-
-
IV Meds:
-
-
-
IM or SC:
-
-
-
Diagnostics Available
Labs:______
X-rays ______
12-Lead EKG
Other:

Documentation Forms

Physician Orders
Frequent Assessment Record
Flow sheet
Medication Administration Record
Kardex
Graphic Record
Multidisciplinary Progress Notes
Code Record
Anesthesia / PACU Record
Standing (Protocol) Orders
Transfer Orders
Other:
Props:
Report Students Will Receive Before Simulation

Policy and Procedure Documents, References, Practice Guidelines, Protocols, or Algorithms Needed

Scenario Progression Outline

Timing
(approximate) / Manikin Actions / Expected Interventions / May Use the Following Cues
Initial Stage:
Baseline Vital Signs
-T
-P
-R
-BP
-spO2
-Cardiac Rhythm
-Breath Sounds
-Heart Sounds
-Abdominal Sounds
-Other symptoms
-Verbalization(s) of
Simulator
Stage 1
-Worsening ofCondition
Vital Signs
-T
-P
-R
-BP
-spO2
-Cardiac Rhythm
-Breath Sounds
-Heart Sounds
-Abdominal Sounds
-Other symptoms
-Verbalization(s) of
Simulator
Multiple stages are
possible depending
on the complexity of
the scenario
Conclusion of
Scenario

Debriefing/Guided Reflection Questions for This Simulation