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Simulation Design Template: Sherman “Red” Yoder-Simulation #2 Date: Discipline: Nursing Expected Simulation Run Time: 20 minutes Location: Simulated emergency room Admission Date: File Name: Sherman “Red” Yoder Student Level: Guided Reflection Time: 20 minutes Location for Reflection: Classroom | Today’s Date: Brief Description of Client Name: Sherman “Red” Yoder Gender: M Age: 80 Race: Caucasian Weight: 109 kg Height: 72 in Religion: Protestant Major Support: Jon (son) Support Phone: 869-555-3452 Allergies: no known allergies Immunizations: Influenza last fall; tetanus – 4 years ago Attending Physician/Team: Dr. Frank Baker Past Medical History: Diabetes Type 2 diagnosed ______ (insert month that is six months prior) History of Present Illness: This patient developed an ulcer on his big toe 5 weeks ago. He is currently being treated with an oral antibiotic and wet to moist saline soaked dressing daily. The home health nurse last assessed the foot 3 days ago. Social History: Widower; his son Jon lives nearby Primary Medical Diagnosis: R/O sepsis Surgeries/Procedures & Dates: L4-5 laminectomy – 25 years ago; transurethral resection of the prostate – 6 years ago Nursing Diagnoses: Ineffective Health Maintenance; Ineffective Self Health Management; Impaired Skin Integrity; Risk for Shock Red Yoder Simulation 2 © National League for Nursing, 2015 1 Psychomotor Skills Required Prior to Simulation General head to toe assessment including vital signs Focused assessment of circulatory and neurovascular status of foot and wound Specimen collection: Blood cultures, labs, wound Medication administration: IV, Subcutaneous Oxygen administration Cognitive Activities Required Prior to Simulation [i.e. independent reading (R), video review (V), computer simulations (CS), lecture (L)] SBAR or other standardized communication tool. (R) Review care of the client with an infection, specifically sepsis (R) Read atypical presentation of infection by older adults (R) Tools in the Try This ® and How to Try This Series, available at http://consultgerirn.org/resources Specific tool recommended for this scenario is the Confusion Assessment Method (CAM) tool. (R) Review the Essential Nursing Actions in the ACES Framework. (R) Simulation Learning Objectives General Objectives 1. Practice standard precautions throughout the exam. 2. Employ effective strategies to reduce risk of harm to the client. 3. Assume the role of team leader or member. 4. Perform a focused physical assessment noting abnormal findings. 5. Recognize changes in patient symptoms and/or signs of patient compromise. 6. Perform priority nursing actions based on clinical data. 7. Reassess/monitor patient status following nursing interventions. 8. Perform within scope of practice. 9. Demonstrate knowledge of legal and ethical obligations. 10. Communicate with client in a manner that illustrates caring for his/her overall well-being. 11. Communicate appropriately with physician and/or other healthcare team members in a timely, organized, patient-specific manner. Simulation Scenario Objectives 1. Demonstrate a general head-to-toe assessment and focused assessments as appropriate. 2. Assess the patient’s delirium (acute confusion) using standardized assessment tool. Red Yoder Simulation 2 © National League for Nursing, 2015 2 3. Use communication techniques to recognize, respond to, and respect an older adult’s strengths, wishes, and expectations. 4. Use the SBAR or another standardized tool to communicate with other health care providers regarding Red’s transfer to the medical intensive care unit. 5. Discuss pertinent assessment findings and what was found that was specific to the older adult patient. 6. Implement appropriate interventions based on the assessments and primary health care provider orders. References, Evidence-Based Practice Guidelines, Protocols, or Algorithms Used for This Scenario: These and other tools in the Try This: ® and How to Try This Series are available on the ConsultGeriRN.org (http://consultgerirn.org/resources), the website of the Hartford Institute for Geriatric Nursing at New York University’s College of Nursing. The tool, an article about using the tool, and a video illustrating the use of the tool, are all available for your use. Review medical-surgical nursing text related to care of the patient with sepsis. Confusion Assessment Method Tool: Tool: http://consultgerirn.org/uploads/File/trythis/try_this_13.pdf Video: http://consultgerirn.org/resources/media/?vid_id=4361983#player_container Insights into severe sepsis in older patients: Girard T.D., Opal S.M., Ely, E.W., (2005) Insights into severe sepsis in older patients: from epidemiology to evidence-based management. Clinical Infectious Diseases: An official publication of the Infectious Diseases Society of America. 40:719-27. Recognizing sepsis in the adult patient: Nelson, D.P., LeMaster, T.H., Plost, G.N., Zahner, M.L., (2009) Recognizing sepsis in the adult patient. American Journal of Nursing. 109(3):40-45. Review the Essential Nursing Actions in the ACES Framework at: http://www.nln.org/professionaldevelopment-programs/teaching-resources/aging/ace-s/nln-aces-framework Fidelity (choose all that apply to this simulation) Setting/Environment: ER Med-Surg Peds ICU Medications and Fluids: IV Fluids: see chart Oral Meds: IVPB: see chart IV Push: Red Yoder Simulation 2 © National League for Nursing, 2015 3 OR / PACU Women’s Center Behavioral Health Home Health Pre-Hospital Other: IM or SC: Diagnostics Available: Labs X-rays (Images) 12-Lead EKG Other: Simulator Manikin/s Needed: Minimally, manikin with vital sign assessment capability, or standardized patient Props: Wound moulage: right great toe should have a wound that has some depth, has bright red tissue with opaque drainage. If available, may consider using the foot with the wound on the toe (Laerdal product). Entire foot should be red. Equipment Attached to Manikin: IV tubing with primary line IV 0.9% NS fluids running at 500 cc’s bolus, repeat once 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 ID band Other: Equipment Available in Room: Bedpan/Urinal Foley kit Straight Catheter Kit Incentive Spirometer Fluids IV start kit IV tubing IVPB Tubing IV Pump Documentation Forms: Physician Orders Admit Orders Flow sheet Medication Administration Record Kardex Graphic Record Shift Assessment Triage Forms Code Record Anesthesia / PACU Record Standing (Protocol) Orders Transfer Orders Other: Recommended Mode for Simulation: (i.e. manual, programmed, etc.) Manual or programmed; mechanism needed for transmission of the voice of the patient via manikin Student Information Needed Prior to Scenario: Has been oriented to simulator Understands guidelines /expectations for scenario Has accomplished all pre-simulation requirements All participants understand their assigned roles Has been given time frame expectations Other: Knowledge of previous “Red” Red Yoder Simulation 2 © National League for Nursing, 2015 4 Feeding Pump Pressure Bag 02 delivery device (type) Crash cart with airway devices and emergency medications Defibrillator/Pacer Suction Other: Roles/Guidelines for Roles: Primary Nurse Secondary Nurse Clinical Instructor Family Member #1 Family Member #2 Observer/s Recorder Physician/Advanced Practice Nurse Respiratory Therapy Anesthesia Pharmacy Lab Imaging Social Services Clergy Unlicensed Assistive Personnel Code Team Other: monologues and simulation Important Information Related to Roles: Family member may be present. (daughter-in-law or son to give history) Report Students Will Receive Before Simulation Time: Red Yoder is an 80-year-old with a pressure ulcer on his right great toe which developed about 5 weeks ago. He has been treated at home with an oral antibiotic and wet to damp saline dressings daily. He will arrive here in the ER momentarily. Dr. Baker has written preliminary orders. Significant Lab Values: refer to chart Physician Orders: refer to chart Red Yoder Simulation 2 © National League for Nursing, 2015 5 Home Medications: refer to chart Scenario Progression Outline Timing (approx.) 0-5 min Manikin Actions Expected Interventions May Use the Following Cues Patient drowsy but easily aroused; has trouble keeping track of what is said. Wash hands Introduce self Identify patient Head to toe assessment Role member providing cue: Family member Cue: “Red is usually awake and alert. This is really a change for him.” Apply O2 Draw labs Initiate IV fluid Begin IV antibiotic Insert Foley catheter and monitor urine output Assess wound and take culture. Assess pain/sensation Assess wound size including: color of wound tissue, wound margins, depth, color and temperature of foot; edema, odor, drainage, pulses Use CAM assessment tool Role member providing cue: Family member Cue: “How come you said he has an infection? He hasn’t had a fever at home and he doesn’t have one now.” Temperature: 38C/100F; pulse 86; respiratory rate 28; blood pressure 116/64 5-15 min Patient status remains the same. Able to answer most questions. Not able to focus attention. Rambles at times. Vital signs unchanged. Red Yoder Simulation 2 © National League for Nursing, 2015 6 Request lab results. Give report to the nurse in medical intensive care unit using a standardized hand off tool. 15-20 min Role member providing cue: Family member Cue: “Is he going to be o.k.? Can we go to the ICU with him?” Debriefing/Guided Reflection Questions for This Simulation (Remember to identify important concepts or curricular threads that are specific to your program) 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. How were physical and mental health aspects interrelated in this case? 11. What were the key assessments and interventions? 12. How were you able to use the ACES Framework with Red’s situation? (Assess Function and Expectations, Coordinate and Manage Care, Use Evolving Knowledge, Make Situational Decisions) 13. Is there anything else you would like to discuss? Red Yoder Simulation 2 © National League for Nursing, 2015 7 Complexity – Simple to Complex Suggestions for Changing the Complexity of This Scenario to Adapt to Different Levels of Learners 1. For more advanced students, have them start IV, perform venipuncture to draw labs, administer IV medication, insert catheter, apply ECG leads. Students at a more basic level can monitor IV, urinary output, etc. 2. Include additional findings/information that will require more assessment, e.g., an additional pressure ulcer, potential elder neglect, financial concerns. 3. Students could begin to manage his ketoacidosis. 4. Create another scenario that would take place in the ICU and provide an experience caring for a patient with sepsis.The Institute for Healthcare Improvement website contains excellent information on sepsis (http://www.ihi.org/IHI/Topics/CriticalCare/Sepsis/). Red Yoder Simulation 2 © National League for Nursing, 2015 8