Download Senior Level: Chest Pain

SIMULATION DESIGN & PLANNING TEMPLATE
Scenario Chest Pain Senior level
Program/Curriculum Specific Objectives:
Recognize and manage a patient with chest pain in the acute care setting.
Measurable Objectives (minimum 2, maximum 10)
1. Learner uses assessment to differentiate between DM, Abd. Pain and Cardiac Pain
2. Learner appropriately contacts MD about patient’s change in condition
3. Learner uses information garnered through assessment to implement at least 3
appropriate nursing interventions
4. Learner integrates therapeutic communication including SBAR when dealing with
MD
Level of Scenario:
Authors’ Names: Janine Buis, Northwest Hospital & Medical Center
Donna Wahbeh, Shoreline Community College
Date Submitted Spring 2013
Will There Be Any Pre-Simulation Lecture?
Orientation to lab, expectations, and roles
Expected Scenario Time 15 minutes
Yes
Duration
Expected Debrief Time
10min
30 minutes
Report and Information Provided To Participants Prior To Simulation
Sam is on a general med/surg floor that does not have telemetry.
Sam is a 65 y/o male who came in with c/o abdominal pain and constipation. He has
been newly diagnosed with colon cancer. He is waiting for a second opinion. Since
admission, his constipation has been resolved. Past medical history includes Diabetes
type 2, Hypercholesterolemia, MI (15 years ago). Today he has been c/o gas pain.
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
1
SIMULATION DESIGN & PLANNING TEMPLATE
Patient Information
Patient Name:
Age:
Sam
65
Gender:
Male
Birth date: June 18
Weight:
Height:
195
5’7”
ID band MR #00001234 Acct. # 1198765432
Hx. Present Illness: Sam is a 65 y/o male who came in with c/o abdominal pain and
constipation. He has been newly diagnosed with colon cancer. He is waiting for a
second opinion. Since admission, his constipation has been resolved.
Social History:Plane assembley
Allergies: None
Past medical history:
Support System: Wife with 3 grown children
Immunizations: Current
Diabetes type 2, Hypercholesterolemia, MI (15 years ago)
Physical description of how you want the manikin to present at start of scenario?
Moulage: Patient in hospital gown with slippers, HOB elevated with legs dangling
over the side, call bell in hand. Diaphoretic face and arms.
Assignment Of Roles (Please indicate below roles to be assigned):
Primary Nurse
Physician/ARNP- Instructor
Secondary Nurse
Respiratory Therapy
Family Member #1Wife
Observer(s) 2
Unlicensed Assistive Personnel/CNA/MA
Other: Student nurse
Important Information Related To Roles: Student should be engaging wife who is
calm.
Physician will order Morphine for pain, labs and EKG and demand report in SBAR
format. Mention possible transfer to telemetry unit. Second phone call wants test results.
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
2
SIMULATION DESIGN & PLANNING TEMPLATE
SIM Setup
Mannequin
IV site :
High or moderate fidelity manikin
Site L forearm Gauge 20G
Fidelity (choose all that apply to this simulation)
Setting/Environment
Med-Surg
Props:
Equipment attached to manikin:
Primary IV Fluid running at 80 ml/hr
O2 2l nc
Monitor attached/ Type if available
ID band
IV tubing for nitro
Equipment available in room:
Crash cart airway devices and emergency meds
Incentive Spirometer
IV tubing
IV pump if available
O2 delivery device non-rebreather, ambu, HHN, face
mask available
Defibrillator/Pacer
Other: emesis basin
Other Props:
box of tissues
Significant Lab Values normal CBC, and electrolytes,
troponin, BNP, cardiac enzymes
Medications and Fluids:
Oral Meds nitro SL, baby ASA
IV Fluids Nitroglycerin drip
IV Push Morphine sulfate
Note: Original MAR NOT
to have Morphine on it.
Other Saline flush, Maalox
MD to order.
Diagnostics Available:
Labs Values CBC lytes
12 lead EKG atrial fibrillation, ischemia
Documentation Forms:
Physician Orders
Flow Sheet or Shift Assessment
MAR
Standing (Protocol) Orders Chest Pain protocol and
Respiratory emergency protocol
Recommended Mode for Simulation
Manual
Programmed
Manual/Programmed Hybrid
Other
Manikin to be used High or moderate fidelity with
heart and lung sounds
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
3
SIMULATION DESIGN & PLANNING TEMPLATE
#1 Scenario Progression Outline
Initial Amount
Time in Initial
Stage- 5 mins
Baseline Vital Signs
T PR 37-110-14
BP 134/82
SPO2 92%
Cardiac Rhythm
sinus tachycardia
Breath Sounds clear
Heart Sounds slight
murmur
Abdominal Sounds
hypoactive
Other Symptoms:
Eyes open, half
closed, or closed
Diaphoretic face
and arms
Verbalization
(Pt/Manikin
Cues)
I just got
back from
the bathroom
and I don’t
feel good, I
am nauseous,
my chest
hurts
Patient will
continue to
verbalize
pain with
nitro.
Patient will
state pain
relief with
Morphine.
Expected
Interventions
-Straighten
patient in bed
-Delegate VS
-Assess chest
pain,
respiratory,
cardiac &
relevant history
-Contacts MD
per chest pain
protocol
-Obtains EKG
& labs
-Administers
Nitro x 3 with
appropriate
vital signs
-When no relief
with nitro,
administers
Morphine
-Ends with
callback to MD
who orders
another dose of
morphine and
transfer to tele
Alternate or Incorrect
Treatment Choice
That Will Affect Outcome
Gets help without assessing
vital signs
Confederate
Actions/Additional
Role Player Cues
Wife at bedside asking
simple questions of
clarification or to be
included in the
discussions about her
husband.
When called MD
(Instructor) will:
-Order Morphine 1-8
mg IV every 30
minutes PRN for pain if
nitro fails to work
-Order EKG
-Orders CBC,
Troponin, CKMB,
electrolytes and BNP
-Demand report in
SBAR format
-Mention possible
transfer to tele unit for
further monitoring.
-Wants call back with
results.
Key for Roles:
Wife in Blue
Patient in Yellow
MD in
Green
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
4
SIMULATION DESIGN & PLANNING TEMPLATE
Correct Treatment Choice
Stage 2
Timing Sequence
Expected
5 minutes
Interventions
Baseline Vital Signs
Reports SBAR
T same P 100
lab results
R 18 BP 112/74
Second dose of
SPO298%
morphine ordered
Cardiac Rhythm same
Orders transfer to
Breath Sounds same
telemetry
Heart Sounds same
Abdominal Sound same
Primary should
speak with charge
nurse about
transfer
Alternate or Incorrect Treatment choice
Stage 2A
Timing Sequence
Expected
Interventions
Baseline Vital Signs
T same P 155
R 20
Provide SBAR
BP 150/90
report to charge
SPO292%
nurse
Cardiac Rhythm same
Breath Sounds same
Wife: Why aren't
Heart Sounds increase
you doing
volume
something, isn't
Abdominal Sound same there medication
Other Symptoms:
you can give?
Verbalization
Pt. much more anxious Call scenario and
and chest pain is
discuss in debrief
crushing, 12
appropriate steps
for managing
patient with chest
pain
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
5
SIMULATION DESIGN & PLANNING TEMPLATE
Instructor Check List
(return to CHESC assistant at the end of class)
Pre-Scenario Check List
1.
2.
3.
4.
5.
6.
7.
8.
Equipment is staged as requested.
The learner has been oriented to the simulator.
The learner understands the guidelines/expectations for the
scenario.
Participants understand their assigned roles.
The time frame Expectations for simulation met: Yes No.
The time frame Expectations for debrief met:
Yes
No.
Audio/Visual Consent signed and turned into CHESC sheet.
Attendance sheet completed and given to CHESC staff.
Post Scenario
If you could change anything next time, what would it be?
Comments:
________________________________________________________
________________________________________________________
________________________________________________________
CHESC Assistant Name:
Did the person provide excellent support for the scenario?
Yes
No Comment
Instructor signature ________________________________
Date
________________________
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
6
SIMULATION DESIGN & PLANNING TEMPLATE
Participant Check List
(return to Instructor at the end of class)
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
7
SIMULATION DESIGN & PLANNING TEMPLATE
Pre-Scenario Check List
1.
2.
3.
4.
5.
I have been oriented to the simulator.
I understand the guidelines/expectations for the scenario.
I understand the assigned role.
My questions about the simulation have been answered.
I have all necessary equipment for the simulation.
Post Scenario
If you could change anything next time, what would it be?
Comments:
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
Participant Signature ____________________________________
Date
________________________
Simulation Post-Assessment Methods
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
8
SIMULATION DESIGN & PLANNING TEMPLATE
Checklist
Tests
Evaluations
Turning Point
Jeopardy
Other
Debriefing Guidelines
(Remember to identify important concepts or curricular threads that are specific to your
program)
1. Leave the simulation room and go to a conference room, if possible. It allows for deescalation of emotions.
2. Solicit and validate emotions briefly. Validate simisms (the simulation isn’t 100% accurate
due to different equipment, personnel etc)
3. What went WELL in this simulation?
4. What DID NOT go well in this simulation?
5. If you could do it again, what would you do differently?
6. Summarize:
“What I hear you saying is . . .”
Resources:
Harvey, S. (2004) The nursing assessment and management of patients with angina. British Journal of Nursing 13(10), 598601.
Smeltzer, S.C., Bare, B.G., Hinkle, J. L. & Cheever, K.H. (2010). Chapter 28 Management of Patients with Coronary
Vascular Disorders. In Brunner & Suddarth’s textbook of medical-surgical nursing 12th ed (pp 755-796).
Philadelphia: Lippincott Williams & Wilkins.
CHEST PAIN STANDING ORDERS
____ Call a Rapid Response and Notify Attending MD STAT
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
9
SIMULATION DESIGN & PLANNING TEMPLATE
Monitoring:
____ Assess vital signs stat and every 15 minutes while chest pain persists.
____ Cardiac monitor, oximeter
____ Oxygen via NC at 2-4 L
Tests:
____ ECG
____ CBC, BMP, PT, PTT, CKMB and total CK, Trop I
Medications:
____ ASA Dose 81 mg PO, chew
____ Nitroglycerine SL x3 if Systolic >90 Dose 0.4 mg PO
____ Morphine Sulfate 1-8 mg IV x3 every 30 minutes prn chest pain
____ NTG by infusion: 50 mg/250 cc D5W at 3mcg/min, titrate to pain and SBP > ___ torr
____ Heparin _____u bolus then infuse at ____ u/hr OR Lovenox ___ mg IV and ___ mg SQ
____ Metoprolol 5mg IV over 5 min, repeat x 2 additional doses (total 15 mg over 15 min)
____ Metoprolol 25 mg PO 60 min after IV metoprolol
____ other: _______________________________
IV:
____ Start one peripheral saline lock
____ other: _______________________________
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
10