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Simulation Design Template:
Julia Morales-Simulation #2
Date:
Discipline: Nursing
Expected Simulation Run Time: 20
minutes
Location: Simulation lab room
Admission Date:
File Name: Julia Morales
Student Level:
Guided Reflection Time: 20 minutes
Location for Reflection: Debriefing
|
Today’s Date:
Brief Description of Client
Name: Julia Morales
Gender: F Age: 65
Race: Caucasian Weight: 50 kg Height: 64 in
Religion: Unitarian
Major Support: Lucy Grey Support Phone: 555-1210
Allergies: no known allergies
Immunizations: Influenza and H1N1, last fall
Attending Physician/Team: Dr. Ann Davis
Past Medical History: Stage 4 adenocarcinoma of the lung, diagnosed 4 years ago, treated with radiation and
chemotherapy.
Hysterectomy age 44
History of Present Illness:
Julia has been on home hospice care for the past 2 months. Her partner Lucy continues to care for her with the
help of a home health aide from the hospice agency. Julia has been bedridden and uncommunicative for the
past 4 days.
Social History: Retired from work in local nursery/garden center. Lives with partner Lucy. Son Neil, age 42,
lives 20 miles away. Private insurance.
Primary Medical Diagnosis: Stage 4 adenocarcinoma of the lung, diagnosed 4 years ago.
Surgeries/Procedures & Dates: Hysterectomy at age 44
Nursing Diagnoses: Chronic pain, grieving
Julia Morales Simulation 2
© National League for Nursing, 2015
1
Psychomotor Skills Required Prior to Simulation



Physical assessment
Management of fentanyl patches
Care at time of death
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)
Basic assessment skills
Readings related to adenocarcinoma of the lung and palliative care. (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. Perform limited physical assessment appropriate for patient who is dying.
2. Communicate with patient and her partner in a comforting and supportive manner, maintaining
patient dignity and integrity.
3. Follow protocols appropriate at time of death, i.e., support of partner and notification of provider and
hospice agency.
4. Use the SBAR or another standardized tool to communicate with other health care professionals.
Julia Morales Simulation 2
© National League for Nursing, 2015
2
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 Hospice care resource:
http://www.cancer.org/
Hospice: A guide to bereavement, mourning and grief:
Retrieved from: http://www.hospicenet.org/html/grief_guide.html
Readings, faculty choice, about end-of-life decision making, the cancer experience, anticipatory
grieving: Examples are:
Maude, Pagie, River, Sutphin, Godown. (1997). Phenomenological study of nurses caring for dying
patients. Cancer Nursing, 20, 115-119.
Bent & Magilvy. (2006). When a partner dies: Lesbian widows. Issues in Mental Health Nursing, 27, 447459.
Wardhere, I. (2014). How do we deal with death of a patient? Journal of Community Nursing, 28(1), 17-20.
ISSN: 0263-4465
IOM (Institute of Medicine). 2015. Dying in America: Improving quality and honoring individual preferences
near the end of life. Washington, DC: The National Academies Press
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
OR / PACU
Women’s Center
Behavioral Health
Medications and Fluids:
IV Fluids:
Oral Meds: see chart
IVPB:
IV Push:
IM or SC:
Julia Morales Simulation 2
© National League for Nursing, 2015
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Diagnostics Available:
Labs
X-rays (Images)
12-Lead EKG
Simulator Manikin/s Needed:
Other:
Documentation Forms:
Simulator or standardized patient for Julia
Morales and standardized patient for family
Physician Orders
member, Lucy Grey, age 73.
Admit Orders
Flow sheet
Props: Home set-up. Bed and chairs in
Medication Administration Record
patient’s bedroom with manikin in bed. Has
Kardex
fentanyl patches, scarf on bald head, soft music
Graphic Record
playing, family pictures at bedside, gently lit
Shift Assessment
environment. Needs to look very comfortable
Triage Forms
and homey.
Code Record
Anesthesia / PACU Record
Equipment Attached to Manikin:
Standing (Protocol) Orders
IV tubing with primary line
Transfer Orders
fluids running at mL/hr
Other:
Secondary IV line running at mL/hr
Home Health
Pre-Hospital
Other:
IV pump
Foley catheter mL output
PCA pump running
IVPB with running at mL/hr
02 Home oxygen tank and nasal cannula
available
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
Feeding Pump
Recommended Mode for Simulation:
(i.e. manual, programmed, etc.)
Any type of human patient simulator or
standardized patient. Fidelity is maximized if
simulator used for Julia has ability of chest rise to
provide cue and aid students in identifying time of
death.
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:
Julia Morales Simulation 2
© National League for Nursing, 2015
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Pressure Bag
02 delivery device (type) oxygen 2 liters per
nasal cannula
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:
Important Information Related to Roles:
Family member is Julia's 73-year-old partner
Lucy Grey who is providing her care. Lucy is
healthy but has decreased strength and mobility
related to arthritis and past knee surgery.
Report Students Will Receive Before Simulation
Time: 9:00 AM
Julia is a 65 year old woman who has Stage 4 lung cancer and stopped treatment a few months ago.
Samantha is the home health aide who has been in the home the past week, helping Lucy with Julia's care.
Her pain is controlled with fentanyl patches, and she is being repositioned every 2 hours. We are no longer
checking her blood pressure, which was painful for her. Her respirations have been around 8. She is
expected to die very soon and Lucy is aware. She will probably not make it through your shift. Dr. Davis
wants to be called when she dies. His number is 555-2222.
Julia Morales Simulation 2
© National League for Nursing, 2015
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Significant Lab Values:
refer to chart
Physician Orders:
refer to chart
Home Medications:
refer to chart
Scenario Progression Outline
Timing
(approx.)
0-5 min
Manikin Actions
Expected
Interventions
May Use the
Following Cues
Julia is lying in bed, no
movement, respirations slow
and uneven. Lucy answers door
and greets nurses. She is
tearful and quiet.

Appropriate
greeting
Assess patient, no
BP needed,
assess for signs of
pain
Provide
information to
family about
changes in
respiration during
the dying process,
specifically the
breath sounds
Support family
member and
encourage her to
continue talking to
Julia
Role member
providing cue: Lucy
Cue: “I hope she's
not in pain. She
hasn’t really been
able to speak to me
the past few days. I
didn’t think it would
happen this fast. I’ve
been at her side and
I keep talking to her.
Can she hear me?”
Check for pulse
and signs of
respiratory effort.
Role member
providing cue: Lucy
Cue: “It's OK Julia.
You don’t have to
hurt anymore. I'll be
OK.” (tears)



5-10 min
Allow learners time to assess
patient and reposition Julia,
then the respirations and pulse
can cease.

Julia Morales Simulation 2
© National League for Nursing, 2015
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10-20 min
Lucy: I talked to Neil an hour
ago and he is on his way. My
niece Nora has been here a lot.
She said she’ll come over any
time I call her. Will you call her
for me?

Notify Dr. Davis
and Lucy's niece
about Julia's
death.
Scenario can end with either
son Neil or niece Nora entering
home. They could ask for some
private time with Lucy at Julia’s
bedside.
Role member
providing cue: Lucy
Cue: “I want to just
sit here by her side.
You just make
phone calls and do
what you have to
do.”
Debriefing/Guided Reflection Questions for This Simulation
(Remember to identify important concepts or curricular threads that are specific to your program)
Because of the intensity of this end-of-life experience, faculty may want to refrain from using traditional
simulation debriefing questions and encourage students to develop an appreciation for the important life
transition that occurred, both for Julia, Lucy, and the nursing team.
1.
How did you feel throughout the simulation experience?
2.
How did you feel when you realized Julia had stopped breathing?
3.
How did you support Lucy and her family during this time?
4.
How did Lucy prepare herself for this life transition? What help will she need now?
5.
What were the key assessments and interventions for Julia?
6.
What were the key assessments and interventions for Lucy?
7.
What does Lucy need now and going forward? How can you engage in self-care when you, as a nurse,
have an emotional experience such as losing a patient?
8.
How were physical and mental health aspects interrelated in this case?
9.
How were you able to use the ACES Framework with Julia’s situation? (Assess Function and
Expectations, Coordinate and Manage Care, Use Evolving Knowledge, Make Situational Decisions)
Julia Morales Simulation 2
© National League for Nursing, 2015
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10. Is there anything else you would like to discuss? Faculty may expect students to be sad or emotional. It
will be very important to listen and support them through this experience.
Complexity – Simple to Complex
Suggestions for Changing the Complexity of This Scenario to Adapt to Different Levels of Learners
1. To increase complexity may add IV drip or an indwelling catheter to the manikin. Have these in place
while the learners reposition the patient without hurting her.
2.
May notice the patient becoming increasingly restless, indicating that the pain medication is not
working. Learner may need to call the physician for guidance on what to give Julia since she has
already received her pain medications.
3. Have another simulation about the dying experience. Ask the learners how they could have prepared
the family for what to expect during this process.
Julia Morales Simulation 2
© National League for Nursing, 2015
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