Download Resident Level: Chest Pain

SIMULATION DESIGN & PLANNING TEMPLATE
Scenario Chest Pain: Resident RN
Program/Curriculum Specific Objectives:
Recognize and manage a patient with chest pain in the acute care setting.
Measurable Objectives (minimum 2, maximum 10)
1. Learner uses assessment to differentiate between DM, Abd. Pain and Cardiac Pain
2. Learner initiates Chest pain protocol.
3. Learner will strategize ways to stay within scope of practice while carrying out MD
orders.
4. Learner will utilize chain of command in finding bed placement for transfer
Instructor’s Name Janine Buis, Northwest Hospital & Medical Center
Donna Wahbeh, Shoreline Community College
Date Submitted Spring 2013
Will There Be Any Pre-Simulation Lecture?
Orientation to lab, equipment, expectations
Yes
Duration 10 minutes
Expected Scenario Time 15 minutes Expected Debrief Time
30 minutes
Report and Information Provided To Participants Prior To Simulation
Sam is on a general med/surg floor that does not have telemetry.
Sam is a 65 y/o male who came in with c/o abdominal pain and constipation. He has
been newly diagnosed with stage II colon cancer. After undergoing resection and
anastomosis, he is POD 2. Past medical history includes Diabetes type 2,
Hypercholesterolemia, MI (15 years ago). Today he has been c/o gas pain.
Patient Information
Patient Name:
Age:
Sam
65
Gender:
Male
Birth date: June 18
Weight:
195
Height: 5’7”
ID band MR #00001234 Acct. # 1198765432
Hx. Present Illness: Sam is a 65 y/o male who came in with c/o abdominal pain and
constipation. He has been newly diagnosed with stage II colon cancer. After
undergoing resection and anastomosis, he is POD 2.
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
1
SIMULATION DESIGN & PLANNING TEMPLATE
Social History: Retired assembler Support System:Wife & 3 grown children
Allergies: None Immunizations: Current
Past medical history: Diabetes type 2, Hypercholesterolemia, MI (15 years ago).
Physical description of how you want the manikin to present at start of scenario?
Moulage: Patient in hospital gown with slippers, HOB elevated with legs dangling
over the side, call bell in hand. Diaphoretic face and arms.
Assignment Of Roles (Please indicate below roles to be assigned):
Primary Nurse
Physician/ ARNP- Staff member
Secondary Nurse
Respiratory Therapy
Family Member #1
Observer(s) 2
Unlicensed Assistive Personnel/CNA/MA
Other: Supervisor or charge nurse
Important Information Related To Roles:
Physician insist on SBAR communication
Supervisor/charge nurse: One of the objectives is this scenario is for the learner to stay
within their scope of practice. Since it is outside of the learner’s scope to hang
nitroglycerine, it will be your job to inform the nurse that there are no beds yet available
and that you will provide a tele nurse to stay with the patient until a bed becomes
available who will also hang and monitor the nitro drip.
SIM Setup
Mannequin
IV site :
High or Moderate fidelity manikin
Site Left forearm Gauge 20 G
Art Line
Yes / No
Fidelity (choose all that apply to this simulation)
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
2
SIMULATION DESIGN & PLANNING TEMPLATE
Setting/Environment
Med-Surg
Props:
Equipment attached to manikin:
Primary IV Fluid running at 120 ml/hr
O2 2l nc
Monitor attached/ Type
ID band
Other
Medications and Fluids:
Oral Meds nitro SL, baby ASA
IV Fluids Nitroglycerin drip, TPA
IV Push Morphine sulfate
IM/Subcut/Intradermal
Other
Diagnostics Available:
X-Rays (Images) CXR pneumonia L Lung
12 lead EKG atrial fibrillation, ischemia
Equipment available in room:
Crash cart airway devices and emergency meds
Fluids tray with clear fluids at bedside
Incentive Spirometer
IV tubing
IV pump
O2 delivery device non-rebreather, ambu, HHN, face
mask available
Defibrillator/Pacer
Other:
Other Props:
box of tissues
Documentation Forms:
Full chart if available
Flow Sheet
MAR
Standing (Protocol) Orders Chest Pain protocol and
Respiratory emergency protocol
Other H&P
Significant Lab Values normal CBC and lytes, troponin
slightly elevated, BNP and first cardiac enzyme normal
Manikin to be used High or moderate fidelity with
heart and lunch sounds
Recommended Mode for Simulation
Manual
Programmed
Manual/Programmed Hybrid
Other
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
3
SIMULATION DESIGN & PLANNING TEMPLATE
#1 Scenario Progression Outline
Initial Amount
Time in Initial
Stage- 5 mins
Signs
T PR 37-110-14
BP 134/82
SPO292%
Cardiac Rhythm
chronic a fib
Breath Sounds clear
Abdominal Sounds
hypoactive
Other Symptoms:
Eyes open
Verbalization
(Pt/Manikin
Cues)
I just got back
from the
bathroom and
I don’t feel
good, I am
nauseous, my
chest hurts
Expected
Interventions
-Straighten
patient in bed
-Assess VS
-Assessment
of chest pain,
respiratory,
cardiac and
relevant
history
Alternate or Incorrect
Treatment Choice
That Will Affect Outcome
Doesn't do vitals, elevate
HOB, apply O2 or get
assistance.
Confederate
Actions/Additional
Role Player Cues
Wife at bedside
asking simple questions
of clarification or to be
included in the
discussions about her
husband.
MD with first call:
When called MD
(Instructor) will:
-Order Morphine 1-8
mg IV every 30 minutes
PRN for pain if nitro
fails to work
-Order EKG
-Orders CBC,
Troponin, CKMB,
electrolytes and BNP
-Demand report in
SBAR format
-Mention possible
transfer to tele unit for
further monitoring.
-Wants call back with
results.
2nd MD call:
-Orders Nitroglycerin
drip and transfer to tele
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
4
SIMULATION DESIGN & PLANNING TEMPLATE
Correct Treatment Choice
Stage 2
Timing Sequence
Expected
after assessment and
Interventions
return to bed
Baseline Vital Signs
-Apply nasal
TPR 140-18
cannula at 2L
BP 140/86
SPO294%
-Elevate HOB
Cardiac Rhythm afib
Breath Sounds clear
-VS Q 15 minutes
Abdominal Sounds
hypoactive
-EKG
Other Symptoms:
-Chest pain
Verbalization
protocol
My jaw hurts. Is this gas Nitro 3 tab SL
from the surgery?
with no relief
BELCH!
Pain will go from a
-Call MD
scale of 10 to7 but no
total relief.
Accelerate clock with
meds.
Correct Treatment Choice
Stage 3
Timing Sequence
Expected
after places call to MD
Interventions
Baseline Vital
-Reports SBAR to
SignsTPR 130-16
MD, who orders
BP 136/78
labs and views
SPO296%
EKG, orders
Cardiac Rhythm a fib
morphine and
Breath Sounds clear
mentions transfer
Other Symptoms:
to telemetry for
possible MI.
Verbalization:
Relief of pain after
-Nurse calls back
second dose of
MD with labs,
morphine. Pain level
verifies second
now a 2.
morphine given
with relief.
Alternate or Incorrect Treatment choice
Stage 2A
Timing Sequence
Expected
Interventions
Baseline Vital Signs
TPR 140-18
BP 150/92
SPO292%
Cardiac Rhythm afib
Breath Sounds clear
Nurse should be
Heart Sounds bounding seeking more
Abdominal Sounds
experienced
hypoactive
assistance. If
Other Symptoms:
follows orders
Verbalization
continue with
Patient continues to
scenario.
verbalize about jaw
pain, increases in
severity and increase in
diaphoresis. Now
complains of nausea.
Key for Roles:
Wife in Blue
Patient in Yellow
MD in
Green
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
5
SIMULATION DESIGN & PLANNING TEMPLATE
Correct Treatment Choice
Stage 4
Timing Sequence
Expected
Interventions
Baseline Vital Signs
-MD orders
TPR 112-16
nitroglycerine IV
BP 128/82
drip.
SPO296%
Orders telemetry
Cardiac Rhythm Afib
transfer, but no
Breath Sounds clear
beds available.
Verbalization
Telemetry bed not
available.
-Discussion with
supervisor to
provide telemetry
nurse to stay with
patient and hang
nitroglycerine
drip.
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
6
SIMULATION DESIGN & PLANNING TEMPLATE
Instructor Check List
(return to CHESC assistant at the end of class)
Pre-Scenario Check List
1.
2.
3.
4.
5.
6.
7.
8.
Equipment is staged as requested.
The learner has been oriented to the simulator.
The learner understands the guidelines/expectations for the
scenario.
Participants understand their assigned roles.
The time frame Expectations for simulation met: Yes No.
The time frame Expectations for debrief met:
Yes
No.
Audio/Visual Consent signed and turned into CHESC sheet.
Attendance sheet completed and given to CHESC staff.
Post Scenario
If you could change anything next time, what would it be?
Comments:
________________________________________________________
________________________________________________________
________________________________________________________
CHESC Assistant Name:
Did the person provide excellent support for the scenario?
Yes
No Comment
Instructor signature ________________________________
Date
________________________
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
7
SIMULATION DESIGN & PLANNING TEMPLATE
Participant Check List
(return to Instructor at the end of class)
Pre-Scenario Check List
1.
2.
3.
4.
5.
I have been oriented to the simulator.
I understand the guidelines/expectations for the scenario.
I understand the assigned role.
My questions about the simulation have been answered.
I have all necessary equipment for the simulation.
Post Scenario
If you could change anything next time, what would it be?
Comments:
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
Participant Signature ____________________________________
Date
________________________
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
8
SIMULATION DESIGN & PLANNING TEMPLATE
Simulation Post-Assessment Methods
Checklist
Tests
Evaluations
Turning Point
Jeopardy
Other
Debriefing Guidelines
(Remember to identify important concepts or curricular threads that are specific to your
program)
1. Leave the simulation room and go to a conference room, if possible. It allows for deescalation of emotions.
2. Solicit and validate emotions briefly. Validate simisms (the simulation isn’t 100% accurate
due to different equipment, personnel etc)
3. What went WELL in this simulation?
4. What DID NOT go well in this simulation?
5. If you could do it again, what would you do differently?
6. Summarize:
“What I hear you saying is . . .”
Resources:
Harvey, S. (2004) The nursing assessment and management of patients with angina. British Journal of Nursing 13(10), 598601.
Smeltzer, S.C., Bare, B.G., Hinkle, J. L. & Cheever, K.H. (2010). Chapter 28 Management of Patients with Coronary
Vascular Disorders. In Brunner & Suddarth’s textbook of medical-surgical nursing 12th ed (pp 755-796).
Philadelphia: Lippincott Williams & Wilkins.
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
9
SIMULATION DESIGN & PLANNING TEMPLATE
CHEST PAIN STANDING ORDERS
____ Call a Rapid Response and Notify Attending MD STAT
Monitoring:
____ Assess vital signs stat and every 15 minutes while chest pain persists.
____ Cardiac monitor, oximeter
____ Oxygen via NC at 2-4 L
Tests:
____ ECG
____ CBC, BMP, PT, PTT, CKMB and total CK, Trop I
Medications:
____ ASA Dose 81 mg PO, chew
____ Nitroglycerine SL x3 if Systolic >90 Dose 0.4 mg PO
____ Morphine Sulfate 1-8 mg IV x3 every 30 minutes prn chest pain
____ NTG by infusion: 50 mg/250 cc D5W at 3mcg/min, titrate to pain and SBP > ___ torr
____ Heparin _____u bolus then infuse at ____ u/hr OR Lovenox ___ mg IV and ___ mg SQ
____ Metoprolol 5mg IV over 5 min, repeat x 2 additional doses (total 15 mg over 15 min)
____ Metoprolol 25 mg PO 60 min after IV metoprolol
____ other: _______________________________
IV:
____ Start one peripheral saline lock
____ other: _______________________________
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
10