Download File - Kathy Bowers Nurse Educator Portfolio

Burt McReynolds-Diabetic ketoacidosis-BKA
Burt McReynolds
Age: 53 years
Weight: 70.0 kg
Base: Stan D. Ardman II
Overview
Synopsis
The learner is caring for a 53 year old who is divorced and lives alone in an apartment on the
second floor He has no insurance and has been seeing the local federally qualified health clinic
for management of his Type 1 diabetes mellitus. He attempts to manage but has trouble
remembering to monitor his blood sugar 4 times a day and admits to missing insulin doses at
times. His neighbor had not seen Burt in a few days so he called Burt’s daughter who had a key
to the apartment. Upon entering the apartment they found him lying on the floor unresponsive so
EMS was called. When EMS arrived the blood sugar reading was 520 so they gave 12 units of
regular insulin and transported to the emergency department of the local hospital.
The SCE prepare the learners for the following items of the NCLEX-RN test format:
NCLEX_RN Test Plan:
X Safe and Effective Care Environment
X Management of Care
X Safety and Infection Control
X Health Promotion and Maintenance
X Psychosocial Integrity
X Physiological Integrity
X Basic Care and Comfort
X Pharmacological and Parenteral Therapies
X Reduction of Risk Potential
X Physiological Adaptations
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Background
Patient History
Past Medical History: Diagnosed with Type 1 diabetes mellitus at the age of 13, hyperlipidemia
Past Surgical History: Right Below knee amputation 2yrs ago
Allergies: No known drug allergies
Medications: Insulin glargine 40 units at bedtime, aspart insulin 1 unit for every 15gms carbs ac
tid, aspart insulin per sliding scale before meals and at bedtime 0-12 units, Lipitor 20mg daily
Code Status: Full code
Social/Family History: Married at age 20. His wife helped him with a proper diet, exercise and
blood glucose level monitoring. At age 50, his wife divorced him and he became depressed and
moved out into an apartment and after his BKA went on full disability.
He has been following up at the federally qualified health clinic for management of diabetes but
has missed several appointments.
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Handoff Report
The learner is to assess and stabilize patient for admission to the ICU
The report should follow the SBAR format and include:
Situation:
The patient was found unconscious in his apartment with a blood sugar of 520. He has been
living alone and after his wife divorced him he became depressed and has had trouble
remembering to check blood sugars and take insulin. He has been going the federally qualified
health clinic because he has no insurance, but has missed several appointments. His daughter
states that he has not been eating well and that her father may have missed some insulin doses.
She reports he has been very depressed and last time she visited he appeared to have poor
hygiene but she could not get him to go to the doctor. She stated that he told her he “just did not
want to live like this anymore.”
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Assessment
Vital Signs: HR 120, BP 110/60, RR 30 and rapid with fruity smell, SpO2 98% on 3L NC,
Temperature 37C
General Appearance: Clothing is old, worn and does not fit well. Appears older than stated age
Cardiovascular: Sinus
Respiratory: Breath sounds clear
GI: Normal bowel sounds. States
GU: has been incontinent of urine
Extremities: Full range of motion in all four extremities
Skin: pale, cool, and poor turgor. Mucous membranes dry
Neurological: semi conscious pupils equal and reactive to light bilaterally
Labs: Blood glucose 535
Fall Risk: high-risk for falls
Pain: moans with painful stimulation
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Initial Healthcare Providers Orders:
Start IV fluid 0.9NS @ 15mL/kg/hr for 2 hrs. then 7.5/kg/hr.
Start 2nd IV Insulin infusion at 2units hr
Give 20 units aspart now x1.
Monitor blood sugars and vital signs every 1 hr.
NPO
Monitor I &O if no void in 6 hrs. foley catheter insertion
Neurological checks every 1 hr.
Labs Chem. Panel, CBC, Phosphorus, serum ketones & ABG stat
EKG and chest X-ray stat
Transfer patient to ICU after IV infusion, subcutaneous insulin and labs and x-rays
completed
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Preparation
Learning Objectives
Student will demonstrate knowledge of the nursing process in planning and caring for patients
with diabetes.
Student will demonstrate knowledge of integrating evidence based practice research into clinical
practice to provide safe care for patients with health alterations.
Student will demonstrate use of appropriate technology to gather information regarding the
patients disease process, and plan and document interventions.
Student will demonstrate therapeutic communication skills through verbal and non-verbal means
with patient and family.
Student will demonstrate recognition of the distinction between moderate depression and major
depression disorder
This SCE addresses the following QSEN Competencies;
X Patient-Centered Care
X Team Work and Collaboration
X Evidence-Based Practice
Quality Improvement
X Safety
Informatics
Learning Performance Measures
Essential Performance Measures for the SCE:
Reviews patient’s medical record
Performs hand hygiene before and after patient contact
Demonstrates appropriate use of personal protective equipment
Introduces self to patient
Verifies patient identity with two identifiers
Conducts basic environmental safety assessment and maintains safety measures
Uses therapeutic communication to establish rapport and reduce patient anxiety
Provides developmentally appropriate education
Evaluates effectiveness of education
Documents all findings, interventions and patient responses
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Preparation Questions
Describe the difference between type 1 and type 2 diabetes mellitus.
Why is the recognition and treatment of acute changes in blood sugar levels important?
Identify chronic complications of diabetes mellitus.
What risk factors are associated with diabetes mellitus?
Outline a teaching plan for a patient with type 1 diabetes mellitus.
What is the cardinal rule of insulin administration?
Why is it best to take blood sugar readings in pairs (before and after administration of insulin)?
What laboratory values indicate a patient has diabetes mellitus?
Why is a patient with diabetes mellitus at risk for developing neuropathies, macro-vascular and
microvascular diseases?
What is carbohydrate counting and why is it the preferred diet regimen for patients with
diabetes?
Why is depression a psychological component in diabetes?
What is the role of the nurse for a patient with suicidal ideation or attempt?
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Equipment & Supplies
Medication Supplies
Alcohol wipes
Distilled water 10mL vials (2) labeled
Aspart insulin
Human insulin regular
Miscellaneous
Patient chart with appropriate forms and order sheets
Patient identification band
Stethoscope
BP cuff adapted for use with simulator
Non-sterile gloves (1 box)
Sharps container
Audio and video recording devices
Glucometer
Glucometer test strips
Jar of cotton balls
Jar of tongue depressors
Flashlight
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Notes
Facilitator Notes
This SCE was created with the patient Burt McReynolds and only this patient can be used.
The physiological values documented indicate appropriate and timely interventions. Differences
will be encountered when care is not appropriate or timely. The facilitator should not click "Run"
until ready to start the SCE.
Students should perform an appropriate physical exam. The facilitator or patient should verbalize
the physical findings the students are seeking but not enabled by the simulator (such as pain on
palpation).
The facilitator should use the microphone and/or preprogrammed vocal or audio sounds to
respond to the learners' questions, if present on your simulator.
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Where appropriate, do not provide information unless specifically asked by the learners. In
addition, ancillary results (e.g., ECG, chest x-ray, labs) should not be provided until the learners
request them.
For this patient: Dress the simulator in old, worn, ill-fitting clothing appropriate for the weather
Place the simulator in a sitting position
To further enhance the appearance of a clinic setting, place a standing scale, jar of cotton balls,
jar of cotton tipped swabs and a jar of tongue depressors, unsterile gloves and alcohol wipes in
the room
Simulation personnel should play the following roles:
Transferring nurse
Make a patient chart with the appropriate written order forms, MARs, diagnostic results, etc. for
learners to utilize. The chart should include the specific patient identification information.
Begin the simulation with the transferring nurse (simulation personnel) providing verbal handoff
using SBAR.
Have the learner’s role-play inter-professional communication by reporting the patient's response
to interventions. If the data presented is disorganized or missing vital components, have the
healthcare provider respond inappropriately. Emphasize the importance of data organization and
completeness when communicating.
Role-play intra-professional communication by having the learners hand off to the admitting
unit or have the learners hand off to the next shift.
Debriefing and instruction after the scenario are critical. Learners and facilitators may wish to
view a video of the scenario afterward for instructional and debriefing purposes.
Debriefing Points
The facilitator will begin by introducing the process of debriefing:
Introduction: Discuss faculty role as a facilitator, expectations, confidentiality, safe-discussion
environment.
Personal Reactions: Allow student to recognize and release emotions, explore learners' reactions
Discussion of Events: Analyze what happened during the SCE, using video playback if available
Summary: Review what went well and what did not, identify areas for improvement and evaluate
the experience
Questions to be asked during debriefing:
What was the experience like for you?
What happened and why?
What did you do and was it effective?
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Teaching Q & A
What is the cardinal rule of insulin administration?
The blood glucose levels should be normal when the amount of insulin administered peaks
How would the nurse assess the patient's readiness to learn?
Assess the patient's level of education
Understanding of disease process
Socioeconomic and psychological level
Strengths and weaknesses
Barriers to learning
Physical capabilities
Identify coping strategies and support systems used in past
Identify community resources
What are the priorities in this patient's discharge teaching?
Recognition of signs and symptoms and management of hypoglycemia and hyperglycemia
When to contact healthcare provider
Monitor blood glucose levels
Proper administration of medications
Sick day guidelines
What are possible referrals for this patient?
Social services
Dietitian
Diabetic nurse educator
Local community resources
Community case nurse manager
References
Butler, M. K., Kaiser, M., Johnson, J., Besse, J., & Horswell, R. (2010).Diabetes mellitus disease
management in a safety net hospital system: Translating evidence into practice.
Population Health Management, 13(6), 319-324. doi:10.1089/pop.2009.0078.
DeFronzo, R. A., Stonehouse, A. H., Han, J., & Wintle, M. E. (2010).Relationship of baseline
HbA1cand efficacy of current glucose-lowering therapies: A meta-analysis of
randomized clinical trials. Diabetic Medicine, 27(3), 309-317. doi:10.1111/j.14645491.2010.0294.x
Edelman, C.L., & Mandle, C.L. (2010). Health promotion throughout the life span (7th ed.). St.
Louis, MO: Mosby Elsevier.
Forehand, M. (2010).Bloom's taxonomy: Emerging perspectives on learning, teaching, and
technology, Department of Educational Psychology and Instructional Technology,
University of Georgia.
Retrievedfromhttp://projects.coe.uga.edu/epltt/index.php?title=Bloom%27s_Taxonomy
Giger, J.N., & Davidhizar, R.E. (2008) Transcultural nursing: Assessment and intervention (5th
ed.). St. Louis, MO: Mosby Elsevier.
Johnson-Russell, J. (2010). Facilitated debriefing in W.M. Nehring & F.R. Lashely (Eds.) High
fidelity patient simulation in nursing education, pp. 369-385. Sudbury, MA: Jones and
Bartlett.
Lewis, S.L., Dirkse, S.R., Heitkemper, M.M., & Bucher, L. (2011).Medical-surgical nursing:
Assessment and management of clinical problems (8th ed.).St. Louis, MO: Elsevier
Mosby.
Melnyk, B.M., & Fineout-Overholt, E. (2010).Evidence-based practice in nursing & healthcare:
A guide to best practice (2nd ed.). Philadelphia, PA: Lippincott Williams & Wilkins
National Council of State Boards of Nursing.(2010).2010 NCLEX-RN test plan. Retrieved from
https://www.ncsbn.org/2010 NCLEX RN Testplan.pdf
Quality and Safety Education for Nurses.(2011).Quality and safety competencies. Retrieved
January 30 2014from http://www.qsen.org/competencies.php
The Joint Commission.(2014). National patient safety goals, Retrieved February 19, 2014 from
http://www.jointcommission.org/standards_information/npsgs.aspx