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Simulation Design Template: Lucy Grey-Simulation #3 Date: Discipline: Nursing Expected Simulation Run Time: 20 minutes Location: Simulation lab Admission Date: File Name: Lucy Grey Student Level: Guided Reflection Time: 20 minutes Location for Reflection: Debriefing room | Today’s Date: Brief Description of Client Name: Lucy Grey Gender: F Age: 74 Race: Caucasian Weight: 50 kg Height: 64 in Religion: Unitarian Major Support: Lucy Grey Support Phone: 555-1210 Allergies: no known allergies Immunizations: Influenza vaccine, yearly Attending Physician/Team: Dr. Barbara Green Past Medical History: osteoarthritis; right knee replacement at age 65 History of Present Illness: History of falls, once a month since the death of her partner. Had comprehensive neurological work-up with no physiological abnormalities noted. Social History: Single, lives alone, partner Julia Morales died 3 months ago. Retired teacher. Primary Medical Diagnosis: Fall at home Surgeries/Procedures & Dates: Right total knee replacement at age 65 Nursing Diagnoses: Anxiety, grieving, risk for falls, risk for injury, ineffective coping, risk for loneliness Psychomotor Skills Required Prior to Simulation General assessment skills Lucy Grey Simulation 3 © National League for Nursing, 2015 1 Cognitive Activities Required Prior to Simulation [i.e. independent reading (R), video review (V), computer simulations (CS), lecture (L)] SBAR or other standardized tool to communication tool. (R) Basic knowledge of geriatric syndromes and the atypical presentation of older adults. (L, R) Tools in the Try This: ® and How to Try This Series, available at http://consultgerirn.org/resources. Specific tools recommended for this scenario are the SPICES, and Hendrich II Fall Risk Model and the Geriatric Depression Scale.(R) The Generalized Anxiety Disorder 7 (GAD-7). (R) Readings related to grieving and to the care of the older adult. (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. 2. 3. 4. 5. Perform physical and other assessments as necessary of an older adult. Identify client’s concerns of loneliness and grieving. Assess and inform physician of normal exam except for abrasion on right forearm. Use therapeutic communication techniques and help client identify her concerns. Assist client and family member to identify plan for frequent visits and “checking in” with client to decrease her anxiety and fears. 6. Use the SBAR or another standardized tool to communicate with other health care professionals. Lucy Grey Simulation 3 © 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. SPICES- An Overall Assessment Tool: Tool: http://consultgerirn.org/uploads/File/trythis/try_this_1.pdf Video: http://consultgerirn.org/resources/media/?vid_id=4200873#player_container The Geriatric Depression Scale: Tool: http://consultgerirn.org/uploads/File/trythis/try_this_4.pdf Video: http://consultgerirn.org/resources/media/?vid_id=4200933#player_container The Fall Risk Assessment: Tool: http://consultgerirn.org/uploads/File/trythis/try_this_8.pdf Video: http://consultgerirn.org/resources/media/?vid_id=4200978#player_container Readings related to grieving after loss of a family member: Example: Article: Bent & Magilvy. (2006). When a partner dies: Lesbian widows. Issues in Mental Health Nursing, 27, 447-459. Explore resources in the community available to older adults with identified needs. A Brief Measure for Assessing Generalized Anxiety Disorder: Spitzer, R.L., Kroenke, K., Williams, J.B., Lowe, B. (2006) A brief measure for assessing generalized anxiey disorder: The GAD-7. Archives of Internal Medicine, 166, !092-1097. Retrieved from: http://archinte.ama-assn.org/cgi/content/full/166/10/1092/IOI60000F1. 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: IVPB: IV Push: IM or SC: Diagnostics Available: Lucy Grey Simulation 3 © National League for Nursing, 2015 3 Home Health Pre-Hospital Other: Labs X-rays (Images) 12-Lead EKG Other: Simulator Manikin/s Needed: manikin or standardized patient Documentation Forms: Physician Orders Props: Patient needs scrape on right arm with Admit Orders bleeding. Flow sheet Medication Administration Record Equipment Attached to Manikin: Kardex IV tubing with primary line Graphic Record fluids running at mL/hr Shift Assessment Secondary IV line running at mL/hr Triage Forms IV pump Code Record Foley catheter mL output Anesthesia / PACU Record PCA pump running Standing (Protocol) Orders IVPB with running at mL/hr Transfer Orders 02 Other: Monitor attached ID band Recommended Mode for Simulation: Other: IV to saline lock (i.e. manual, programmed, etc.) 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 Pressure Bag 02 delivery device (type) Crash cart with airway devices and emergency medications Defibrillator/Pacer Suction Other: Any type of human patient simulator. Fidelity in communication is improved if actor or standardized patient is used for Lucy in this scenario. Can use monitor display to provide vital signs. 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: Lucy Grey Simulation 3 © National League for Nursing, 2015 4 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: neighbor Adele Important Information Related to Roles: Report Students Will Receive Before Simulation Time: 12:30 PM (From paramedics who brought Lucy to the ED.) “Patient called 911 after having a dizzy spell and near fall in her home. When we arrived she was sitting on her couch in her living room. Her blood pressure is 160/88, heart rate is 102, respirations are 20, and her oxygen saturation is in the 90s. She is on 2 liters of oxygen per nasal cannula. She was alert and coherent and apologetic for calling us. Denies taking any medications today, states she had tea and oatmeal for breakfast. No complaints of pain, she has good mobility, a little slow due to ‘stiff knees.’ There is a scrape on her arm; we just taped a gauze pad on it. We have a saline lock in her right forearm.” Significant Lab Values: refer to chart Physician Orders: refer to chart Home Medications: refer to chart Scenario Progression Outline Lucy Grey Simulation 3 © National League for Nursing, 2015 5 Timing (approx.) 0-5 min Manikin Actions Expected Interventions May Use the Following Cues Lucy: “I'm sorry to be a bother. I'm probably fine. I scraped my arm on the coffee table I think.” Introduce self Identify patient Take vital signs Should do orthostatic blood pressures. Begin assessments, both the general assessment and use tools students deem appropriate. Role member providing cue: Cue: Nurses should ask about details of medications, when, dose, how often, effects of medications on sleep and general cognition Continue assessment Use therapeutic communication, listening to patient's concerns. Encourage Lucy to verbalize her fears. Role member providing cue: Cue: Role member providing cue: Nora Cue: What else do you think we could do to help Aunt Lucy not be so scared?” Can we get Meals on Wheels, or what else is out there for her? “You know my neighbor died in his home a few weeks ago. He lived alone. They found him on the floor. Probably his heart.” 5-10 min “I don’t like being alone. I’m afraid sometimes.” “Sometimes I can't sleep and I have to take a pill. Ambien… or Benadryl.” 10-20 min Niece Nora and/or neighbor Adele arrive. “Aunt Lucy, what happened!? I was so worried!” Lucy: “Oh, I’m sorry to worry you. I just got a little dizzy. I suspect I’ll be fine. Don't anyone tell me I need to move out of my house.” Note patient’s concerns and explore fears. Involve friend/family in forming plan for patient. Help discover ways to alleviate fears using Lucy Grey Simulation 3 © National League for Nursing, 2015 6 Emergency room physician enters room and Lucy states: “Oh, doctor, I’m here again, so sorry. I think I’m probably OK now; they are taking care of me.” resources available. Nurses need to give report Should follow SBAR or other tool. Need to include vital signs and address other concerns as well, including cognitive state, and patient's fears. Role member providing cue: Physician Cue: Order labs CBC and electrolytes, order social service consult for help with resources including a bereavement support group. 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. What were Lucy’s objectives? Why do you think she is really calling 911? 3. Were you satisfied with your ability to work through the simulation? 4. To Observer: Could the nurses have handled any aspects of the simulation differently? 5. If you were able to do this again, how could you have handled the situation differently? 6. What did the group do well? 7. What did the team believe was the primary nursing diagnosis? Is this the same as Lucy’s primary concern? 8. What were the key assessments and interventions? 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) 10. How were physical and mental health aspects interrelated in this case? 11. Is there anything else you would like to discuss? Complexity – Simple to Complex Lucy Grey Simulation 3 © National League for Nursing, 2015 7 Suggestions for Changing the Complexity of This Scenario to Adapt to Different Levels of Learners 1. The simulation could be modified with the addition of abnormal assessments showing an increase in confusion, possibly Alzheimer’s disease. 2. Learners could have an in-depth discussion of normal grieving versus dysfunctional grieving patterns. 3. Learners could be expected to find appropriate services for Lucy during the simulation. These could be available in a resource book in the simulation lab. 4. Students could use the Texas Revised Inventory of Grief (http://www.apa.org/pi/about/publications/caregivers/practice-settings/assessment/tools/texasgrief.aspx) a tool that can provide additional information to help differentiate the origin of Lucy’s difficulties adjusting to life without her partner. 5. Lucy could have a panic attack and students could use the Impact of Event Scale - Revised (IES-R), (http://consultgerirn.org/uploads/File/trythis/try_this_19.pdf) to assess her current stress level. Lucy Grey Simulation 3 © National League for Nursing, 2015 8