Download N205 Simulation #1FundamentalsCreated by: S. Orth

University of South Dakota
Vermillion, South Dakota
Department of Nursing
Simulation Scenario
Metabolism: Diabetic Hypoglycemia
Overview
Target Group: First Year
Nursing Students
Yockey, J. (2012). Simulation scenario; Metabolism: Diabetic hypoglycemia.
To cite this
Unpublished manuscript. Department of Nursing, University of South Dakota at
reference:
Vermillion.
Time Allotment (each simulation is designed to be run in a two hour block of time which equals four
clinical hours):
Title:
Diabetic Hypoglycemia
Concept: Metabolism
Prep: Campus specific (see preparation requirements).
Prebriefing: Campus specific (first year students should be longer than second year students
according to evidence-based practice [EBP] standards).
Simulation: 15-20 minutes (no longer than 30 minutes).
Debriefing: Campus specific (first year students shorter than second year students according to EBP
standards).
If the simulation episode runs less than two hours faculty should consider running the simulation
again, creating concept maps, creating teaching plans, performing webquests, or implementing other
activities that would be beneficial to the students' learning.
DocuCare Information:
The case presents Winnie Anderson, who has Type 2 Diabetes, and experiences a hypoglycemia
event. She has come to the medical clinic for a check-up.
Metabolism: Diabetic Hypoglycemia 2
University of South Dakota
Vermillion, South Dakota
Department of Nursing
Curriculum Alignment
AACN Essentials: IX
Population: Elderly
Concepts
Exemplar
Metabolism
Infection
Diabetes
Objectives and Outcomes
Area
Knowledge
Skills
Attitudes
Scenario Objectives
Demonstrates understanding of risk factors/
signs & symptoms of hypoglycemia.
Performs age appropriate assessment and
provides patient and family education
related to Diabetes.
Appreciate the patient’s values and beliefs
when providing care.
Course Outcomes
1.2, 3.1, 4.1, 5.2
5.1, 5.3
2.2
Student Preparation
Prerequisite assignment (the following information should be sent to the students prior to the
scheduled simulation).
Students are expected to bring their laptop, drug book, primary text, and completed prep to simulation.
Metabolism_Hypoglycemia_Student Prep
Metabolism: Diabetic Hypoglycemia 3
University of South Dakota
Vermillion, South Dakota
Department of Nursing
Simulation Setup
Manikin Settings:
Scenario Setting: Clinic
Setting: Clinic
Time of day of scenario: 1000 (may change)
Initial Vital Signs
Pulse:
Blood pressure:
Pulse ox:
Respiratory rate:
Temperature:
Cardiac rhythm:
Lung sounds:
Bowel sounds:
Other:
92
116/80
99% RA
20
98.0 F
NS
Clear
Active x 4 quads
Change in Vital Signs
How many minutes until
change?
Pulse:
5-10
Patient Condition
Clothing:
Props:
Moulage:
Increases during
assessment to
124
Blood pressure:
Pulse ox:
Respiratory rate:
Temperature:
Cardiac rhythm:
Lung sounds:
Other:
Equipment List
Universal precautions equipment
Vital sign equipment
SpO2 monitor
Alcohol wipes
Orange juice, glass
Peanut butter crackers
Dress manikin in street
clothes (if not using
student as patient)
Place in sitting position
in exam room, or sitting
up on edge of bed
Diabetic ulcer wound left
ankle with gauze wrap
over it. Also glycerin
spray bottle for
diaphoresis.
Roles for Students
Primary nurse
Secondary nurse
Observers
Patient – If manikin
not used, student could
play this role.
Dr. Winters
Recording nurse
Family member
Student Names
(Faculty)
Documents
Medication administration form (not included)
Physician orders
Patient education form (not included)
I & O form
Lab results: UA, CBC, CMP, Glucose,
Medication
NA
Dosage
Route
Metabolism: Diabetic Hypoglycemia 4
University of South Dakota
Vermillion, South Dakota
Department of Nursing
Patient Background
Patient Demographics
Last Name: Anderson
Gender: Female
First Name: Winnie
Age: 65
Religion: Lutheran
Ht: 167 cm
66”
Language: English
Wt: 77.2 Kg
170 lb
Ethnicity: Caucasian
English Proficiency: 6th grade
History of present illness: Mrs. Anderson is a 65-year old woman with a long history of Diabetes that is
not well controlled. She has a history of hypertension and atrial fibrillation. She has smoked half a pack
of cigarettes/day for 45 years. Recently Mrs. James developed an ulcer on her ankle, resulting in
greater difficulty in managing her blood sugar level.
Primary Medical Diagnosis:
Central nervous system
Cardiovascular
Pulmonary
Renal/Hepatic
Gastrointestinal
Musculoskeletal
Integument
Developmental History
Psychological history
Social history
Alternative/ Complementary
Medication allergies
Food/other allergies
Home medications
Ulcer on left ankle
Widow who currently lives alone; 45 yr smoker of half pack per day
NKA
Reaction:
NKA
Reaction:
Glipizide (Glucotrol) 2.5 mg daily
Captopril (capoten) 25 mg TID
Lanoxin (digoxin) 0.25 mg daily
Coumadin (warfarin) 2.0 mg daily
Metabolism: Diabetic Hypoglycemia 5
University of South Dakota
Vermillion, South Dakota
Department of Nursing
Prebriefing
Give students the opportunity to discuss their feelings and fears (can use the round table
approach) and then have discussion.
Below are ideas for discussion prior to implementing the simulation:
1. Discuss the assessment differences between a clinic visit and assessing a
patient admitted to the hospital.
2. Compare and contrast Type 1 Diabetes and Type 2 Diabetes.
3. Compare and contrast oral hypoglycemic with insulin (discuss appropriate use of
medications and any possible special considerations).
4. Discuss the signs and symptoms of hypoglycemia.
5. Identify situations that could place a patient at risk for becoming hypoglycemic.
6. Discuss appropriate nursing interventions to treat hypoglycemic events/episodes.
Have students discuss the rationale for the interventions.
7. Compare and contrast when a patient would require Glucagon, D10, or high
protein snack.
8. Discuss teaching strategies to assist patients to recognize hypoglycemic
episodes, identify when they could be at risk for hypoglycemic episodes, and/or
how to treat these episodes.
Major symptoms related to hypoglycemia are tremors, palpitations, nervousness,
sweating, hunger, and weakness that can progress to seizures and coma.
The goal of therapy is to safely increase blood glucose levels. This can be accomplished
with oral intake of carbohydrate foods such as orange juice if the patient is conscious, or
administration of parenteral dextrose solutions.
The above items are listed to assist faculty in leading a prebriefing discussion
with students. Feel free to use some or all of the items depending on the needs of
the student group.
Metabolism: Diabetic Hypoglycemia 6
University of South Dakota
Vermillion, South Dakota
Department of Nursing
Scenario
Change of shift report read to students by faculty:
Mrs. Winnie Anderson is coming into the clinic for follow-up on her Diabetes as she “doesn’t feel
well and my blood sugars are off.” She stopped in the lab on her way up for blood work.
Mrs. Anderson is a 65-year old widow who lives alone. She has a long history of Diabetes that is
not well controlled. She has a history of hypertension and atrial fibrillation. She has smoked half
a pack of cigarettes/day for 45 years. Recently, Winnie developed an ulcer on her ankle,
resulting in greater difficulty in managing her blood sugar level.
She was just put in an exam room. Current home meds include Glucotrol (Glipizide), Capoten
(Captopril), digoxin (Linoxin), and Warfarin (Coumadin). A gauze wrap is noted on the ankle.
She states her blood sugar was “too high” this morning, so she took two of her Glucatrol pills.
Her labs are pending and she needs some teaching. She is waiting in the exam room.
Timing
Patient actions
live faculty
Expected interventions
May use the following
cues:
5 minutes
VS: 98° -92-20-116/80
SpO2-99% on RA
Wash hands.
Role member providing
cue:
Introduce self.
Respirations regular, no
adventitious sounds.
Bowel sounds normal.
No heart murmur.
Vocal Sounds: Alert and
oriented.
Facilitator distracts the nurse
with a call from the lab
regarding a question about
the medical record number
of Mrs. Anderson since they
have two W. Anderson files.
While student away from
patient, spray the patient
with water/glycerin to
simulate diaphoresis.
Ask about reason for visit.
Ask specifically about
glucose monitoring,
(keeping a record?)
levels, medications.
Patient:
Came in because “My
blood sugars have been
high.”
“Glucose has been 180240 for a couple of weeks,
evening levels have been
about 140 when I
remember to take it. This
morning it was 186.”
“I had my lab work drawn
on my way to Dr. Winter’s
waiting area.”
“No regular exercise
because my ankle is too
sore.”
Metabolism: Diabetic Hypoglycemia 7
University of South Dakota
Vermillion, South Dakota
Department of Nursing
5-10 min
VS: heart rate increases to
124 during assessment.
Student returns to room
or is still present in room
–should reassess patient
if already done, or assess
NOW if not done.
Patient:
Becomes more anxious,
agitated during
assessment, “Something
is wrong—I don’t feel
right!”
10-20 min
Instructor: Glucose level of
68 from lab. If student gets
another before interventions,
level is now 49.
Student recognizes s/s of
hypoglycemia (should
check BS.
Treats with 15 g of
carbohydrate (orange
juice).
Patient:
“What is making my blood
sugar be so off? I took 2
of my Glucatrol this
morning to try to bring it
back down.”
Facilitate appropriate care
for patient if student does not
intervene correctly in role of
Stay with patient and
HCP or a nursing supervisor. reassure.
Glucose after interventions is
now 104.
Call for lab results
Recheck capillary blood
glucose after 15 minutes
(verbalized simulation
time).
Teaching: Low blood
sugar is from doubling
dose of Glucatrol.
Instruct patient to have a
high protein snack after
leaving clinic, or offer
protein snack (peanut
butter crackers available).
High glucose is related to
ankle ulcer—needs care
to improve glucose
control.
Need to monitor glucose
but not adjust
medications without
checking with HCP.
Give report to HCP—no
new orders.
“What levels should I
expect at home?”
Metabolism: Diabetic Hypoglycemia 8
University of South Dakota
Vermillion, South Dakota
Department of Nursing
Debriefing
Start by asking students about their feelings/thoughts related to the experience. It is alright to let the
students lead the discussion at first. Utilize the questions below at your discretion.
Debriefing / Guided Reflection Questions for this Simulation:
Potential Review Post-Simulation:
How did your expectations match your actual identified priority nursing intervention
needs for the patient?
S: Reason for admission:
Primary medical diagnosis:
Past medical history:
Significant events during hospitalization; IV site & fluids
Code status:
B: Story of admission:
Living situation:
Fall risk:
Allergies:
ADL/assistive device needs:
A: Vital signs:
I/O:
Assessment features:
Pain
Mobility
Sensory
Skin
Perfusion
Elimination
Oxygenation
R: Special precautions:
Scheduled tests/therapies:
Anticipated discharge date:
Follow-up:
Abnormal or critical labs
Procedure follow-up
Calls to HCP
Concerns
Potential Debriefing / Guided Reflection Questions for this Simulation:
Background:
1. Did you miss anything on the patient history that would affect her care?
2. What risk factors from the patient’s history are pertinent to her care today?
3. How does the patient’s medication regimen affect her health or wellness?
4. What lab results or diagnostics are relevant? Any additional ones needed?
Metabolism: Diabetic Hypoglycemia 9
University of South Dakota
Vermillion, South Dakota
Department of Nursing
Noticing:
1. What did you notice about your patient upon entering her room? Respiratory status? Overall
status?
2. Did you notice anything in regards to his/her family?
Interpreting:
1. Did you have sufficient knowledge to interpret and respond to this situation?
2. Based on your observations, what is of highest priority for the patient?
3. What other concerns do you have about this patient?
Responding:
1. What were your priorities in responding to the patient? How did you prioritize your care?
2. Did you adhere to safe medication administration practices?
3. How has the client’s culture/ethnicity influenced your care, if at all?
4. Was developmentally appropriate communication utilized with the patient? Family?
5. How can the nurse partner with the patient/family to improve the health status?
6. What teaching plan would be appropriate?
Evaluation:
7. What went well in this scenario?
8. If you were able to do this again, what would you like to see done differently?
9. What is the most important thing you learned from this case?
References
Adapted from: Real nursing simulations facilitator’s guide (Institutional version). Upper Saddle River,
NJ: Pearson Education, Inc.
Osborn, K., Wraa, C., & Watson, A. (2010). Medical-surgical nursing: Preparation for practice. Upper
Saddle River, NJ: Pearson Education, Inc.
The above items are listed to assist faculty in leading a debriefing discussion with students.
Feel free to use some or all of the items depending on the needs of the student group.
Metabolism: Diabetic Hypoglycemia 10
University of South Dakota
Vermillion, South Dakota
Department of Nursing
Supporting Documents
Forms
Patient Chart
Information/Forms
Metabolism_Hypoglycemia_Charts
Scripts/Roles
Metabolism_Hypoglycemia_Script
Recommendations For Online Use
This simulation could be performed in the mobile simulation unit and streamed to
distance students. Students at a distance could participate in the pre-briefing and
debriefing sessions using webinar. A distance student could play the role of the
concerned family member by calling in to talk to the patient and the patient hands the
phone to the nurse to answer the family member’s questions. A speaker phone should
be used for this strategy.
Reference: Yockey, J. & Dixon, L. (2011). Cases for nursing simulation: A student guide. McGrawHill: Chicago.