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Team Texas-Central Region

Simulation Scenario



Level of Scenario:



Beginning ______ Intermediate ___X___ Complex ______



Specialty: ______Medical COPD Exacerbation _________________________________

Brief Overview of Scenario:



A 62 year old female presented to the emergency department with shortness of breath and

a very productive cough. Patient states she has smoked for 40 years 1 pack a day but

recently quit 2 weeks ago. Patient states “I thought I was coughing a lot because my

lungs are breathing again”.





Patient admitted to the medical floor for COPD exacerbation, rule out pneumonia.

It is 0900 and you are entering the room to give morning medications. The patient is

lying in the bed:

 Productive cough dark greenish sputum

 Pale, in color

 Wheezes to all other lung fields

 SpO2 82% on room air









Developed by: _Central Texas Region Faculty______________________________

2







Simulation Design Template



Discipline: Nursing/Medicine/Respiratory Therapy

Debrief/Guided Reflection Time: 45 minutes

Expected Simulation Run Time: 20 minutes



Brief Description of Patient: Psychomotor Skills Required prior to

simulation:

A 62 year old female presented to the

emergency department with shortness of -Physical Assessment

breath and a very productive cough. -Focused respiratory assessment

Patient states she has smoked for 40 -Intravenous Catheter

years 1 pack a day but recently quit 2 Maintenance.

weeks ago. Patient states she thought she -Communication techniques using a

was coughing a lot because her lungs are standardized report mechanism. I-SBAR

breathing again. -Oxygen therapy





Patient admitted to the medical floor for

COPD exacerbation, rule out

pneumonia.

It is 0900 and you are entering the room

to give morning medications. The Cognitive Skills Required prior to

patient is lying in the bed: simulation: (i.e. independent reading,

 Productive cough dark greenish video review, computer simulations,

sputum lecture)

 Pale, in color

 Wheezes to all other lung fields (L)-Chronic Respiratory Disease

 SpO2 82% on room air Diabetes

Name:

Gender: Female (IR)-Alcohol abuse, CAGE assessment

Age: 62 years old Musculoskeletal and orthopedic

Race: Caucasian (V)-Respiratory assessment

Weight: _____/kg _200____lb Oxygen therapy/administration

Height: ______cm __5’3_____ft/in

Religion: Catholic

Major Support: Son

Phone: 512-XXX-XXXX

Allergies: Iodine and Penicillin

Immunizations: Flu Shot

Attending Physician/Team: Hospitalist

PMH: Type II Diabetes, COPD,

osteoporosis, and ETOH abuse.



History of Present illness: Shortness of

3





Breath, very productive cough, quit

smoking two weeks ago.

Social History: Widow alienated from

only son, lives independently, smoked

cigarettes until recently and drinks

alcohol occasionally, patient is on

disability and unable to work because of

respiratory disease process.

Primary Diagnosis:

COPD exacerbation rule out pneumonia

Surgeries/Procedures: T&A as a child,

abdominal hysterectomy at age 45.





Simulation Learning Objectives:

1. Gathers objective and subjective assessment findings to prioritize patient care.



2. Identify changes in patient’s status and perform nursing interventions to promote

positive patient outcomes.



3. Communicate with other healthcare disciplines using I-SBAR to improve

communication techniques and promote a well-balanced healthcare team.



4. Identify baseline respiratory assessment findings for a patient with chronic obstructive

pulmonary disorder.



5. Safely administers oxygen therapy to a patient with chronic obstructive pulmonary

disorder.

4







Fidelity

Setting/Environment Medications and Fluids

○ ER ○ IV Fluids:

○ Med-Surg

○ ICU ○ Oral Meds:

○ OR/PACU

○ Women’s Center ○ IVPB

○ Behavioral Health Ancef 1 gram IV every 12 hours

○ Home Health

○ Pre-Hospital ○ IV Push:

○ Other Solu-Medrol 125mg IV every 6 hours



Simulator Manikin/s Needed: ○ IM or SC:

Manikin/Hybrid

Props: Diagnostics Available:

Equipment attached to manikin: ○ Labs

○ IV tubing with primary line _D5 ½ NS ○ X-rays (Images)

with 20 mEq KCL at 100ml/hr on ○ 12 lead EKG

pump_______ ○ Other:

○ Secondary IV line _________ running at

______ cc/hr

○ Foley catheter ________cc output Documentation Forms

color ______________________ ○ Physician Orders

○ PCA pump running ○ Admit Orders

○ O2 ○ Flow sheet

○ Monitor attached ○ Medication Administration Record

○ ID band ○ Kardex

○ Other ○ Graphic Record

○ Shift Assessment

Equipment available in room: ○ Triage Forms

○ Bedpan/Urinal ○ Code Record

○ Foley kit ○ Anesthesia/PACU Record

○ Straight Catheter Kit ○ Standing (Protocol) Orders

○ Incentive Spirometer ○ Transfer Orders

○ Fluids

○ IV start kit

○ IV tubing Other Props

○ IVPB tubing

○ IV pump Recommended Mode for simulation:

○ Feeding bag Sim-Man AVS

○ Pressure bag

○ 02 delivery devices type Programmed

○ Crash cart with airway devices and

emergency medications

○ Defibrillator/Pacer

5





○ Suction complete suction set-up

○ Other



Recommended Student Group Size: ___________________



Assignment of Roles: Student Information Needed Prior to

NS = Nursing Student Scenario:

F=Faculty • Has been oriented to simulator

MS= Medical Student • Understands guidelines/expectations for

_NS__ Primary Nurse scenario

_NS_ Secondary Nurse • Has accomplished all pre-simulation

___ Clinical Instructor requirement

___ Family Member #1 • All participants understand their

___ Family Member #2 assigned roles

___ Observer(s) • Has been given time frame

_MS_ Physician/ Advanced Practice Nurse expectations

_F__ Respiratory Therapy

__F_ Anesthesia Pre-scenario questions/information that

___ Pharmacy students use for discussion (i.e. when will

_F__ Lab lab values/physician orders be presented

_F__ Imaging to the students – prior to lab, during report,

___ Social Services or during the simulation)

___ Clergy

___ Unlicensed Assistive Personnel  Review of COPD

__F_ Code Team  Oxygen administration

___ Other:  Communication

Identify Faculty Roles Needed:

Nursing faculty will facilitate nursing

students simulation experience also making Report students will receive prior to

sure to evaluate the students performance. starting the simulation (report from ICU

Medical Faculty will facilitate medical nurse, OR, night nurse, etc.)

students learning experience in simulation

and evaluate performance. -Verbal report (RN to RN)



Important information related to roles:





Critical Lab Values:

Physician Orders (Use separate page(s)

6







References, Evidence-Based Practice Guidelines, Protocols,

or Algorithms used for this scenario:





Center for Disease Control and Prevention (2010). Recommended Adult Immunization



Schedule United States.



The Joint Commission (2007). Improving Handoff Communication.



Oakbrook Terrace, IL: Joint Commission Resources



L. and Rounds, LA Conjoint screening questionnaires for alcohol and drug abuse.



Wisconsin Medical Journal 94: 135-140, 1995.

7







Scenario Progression Outline

Timing Programming Data Expected Teaching Points for

(Manikin Actions) Interventions Debriefing

Initial Stage: 0900 Auscultation  Wash hands 1.Handwashing

Assessment Focus sounds: Breath  Introduce self decreases the risk of

sounds wheezing  Identify patient spread of infection

5-10 minutes bilaterally  Position patient

Baseline Vital Signs upright for 2. Safety identify

-T- 100.2 Pt vocal sounds: comfort and client prevents medical

-P- 92 “could I get some ease of care/procedures from

-R- 28 more tissues I am breathing. being done on the

-BP- 142/84 coughing up a lot of  Apply O2 2 wrong client.

-SPO2-80% mucus” liters via nasal

cannula 3. Immediately obtain

Coughing  Encourage purse vital signs when a

lip breathing client is

admitted/transferred to

 Obtain vital

your unit. Identify

signs with SPO2

neurological,

level.

respiratory, cardiac,

 Provides

GI/GU and if the client

appropriate

has any IV access or if

disposal of

they need O2 therapy.

tissues wearing

gloves.

4. By not disposing of

used tissue will

promote bacterial

growth.





Review Physician If student fails to call

Intervention Phase Vocal Sounds: orders call (Medical for RT for breathing

Continues to cough Student will call for treatment patient will

B/P 145/90 patient status report prompt student by

SpO2>93% over 5 and give orders) saying “I’m having a

minutes really hard time

Call respiratory breathing, at home I

therapist for use the breathing

breathing treatment machine”

(order proventil

neb)



Administer Solu-

medrol IV and

Ancef IVPB

8









Stage 2- Conclusion Lung sounds: Student will monitor

of remain course patient for any

Scenario bilaterally adverse reactions to

Evaluation medications.



SpO2 increase 94%

on 2 L/nc

9









Debriefing/Guided Reflection Questions for this Simulation



1. What were your primary concerns in this scenario?



2. Did you miss anything in getting report on this patient?



3. Did you have sufficient knowledge/skills to manage this situation?



4. What were your primary nursing diagnoses in this scenario? What nursing

interventions did you use, what outcomes did you measure? Where is your patient in

terms of these outcomes now?



5. What did you do well in this scenario?



6. If you were able to do this again, what would you do differently?

10









NCLEX – RN Test Plan Categories

Safe Effective Care Environment Health Promotion & Psychosocial Integrity

Maintenance

Management of Safety & Infection Control Aging Process Abuse/Neglect

Care Accident Prevention Disease Prevention Behavior Interventions

Advance Disaster Planning Family Planning Chemical Dependency

Directives Emergency Response Family Systems Coping Mechanisms

Advocacy Plan Growth & Development Crisis Intervention

Case Management Error Prevention Health & Wellness Cultural Diversity

Client Rights Home Safety Health Promotion End of Life

Collaboration with Injury Prevention Health Screening Family Dynamics

Multidisciplinary Medical & Surgical High Risk Behaviors Grief and Loss

Team Asepsis Safe use of Human Sexuality Mental Health

Management Equipment Immunizations Concepts

Confidentiality Security Plan Lifestyle Choices Psychopathology

Consultation Use of restraints/ Safety Teaching/Learning Situational Role

Continuity of Care Devices Self Care Changes

Delegation Reporting of Techniques of Physical Stress Management

Prioritization Incident/Event/ Irregular Assessment Support Systems

Ethical Practice Occurrence/Variance Developmental stages and Therapeutic

Informed Consent Handling Hazardous and Transitions Environment

Quality Assurance Infectious Materials Expected Body Image Sensory/Perceptual

Referrals Changes Alterations

Resource Ante/Intra/Postpartum & Religious and Spiritual

Management Newborn Care Influences on

Staff Education Health

Supervision

Legal Rights &

Responsibilities





Physiological Integrity

Basic Care and Pharmacological and Reduction of Risk Physiological

Comfort Parenteral Therapies Potential Adaptation



Alternative & Adverse Effects Diagnostic Tests Alterations in Body

Complementary Contraindications Laboratory Values Systems

Therapies Side Effects Monitoring Conscious Fluid & Electrolyte

Assistive Devices Blood and Blood Sedation Imbalances

Elimination Products Potential for Alterations Hemodynamics

Mobility/Immobility Central Venous in Illness Management

11





Non-Pharmacological Access Body Systems Infectious Diseases

Comfort Interventions Devices Potential for Medical Emergencies

Nutrition & Oral Dosage Calculation Complications Pathophysiology

Hydration Expected of Diagnostic Tests/ Radiation Therapy

Palliative/Comfort Care Outcomes/Effects Treatment/Procedures Unexpected

Personal Hygiene Intravenous Therapy Potential of Response

Rest & Sleep Medication Complications To Therapies

Administration for Surgical Procedures

Parenteral Fluids and Health Alterations

Pharmacological System Specific

Agents/ Assessments

Actions Therapeutic Procedures

Pharmacological Vital Signs

Interactions

Pharmacological Pain

Management

Total Parenteral

Nutrition







Safe Effective Care Environment Health Promotion & Psychosocial Integrity

Maintenance

Management of Safety & Infection Aging Process Abuse or Neglect

Care Control Data Collection Behavior Interventions

Advance Directives Accident Prevention Techniques Behavior Management

Advocacy Error Prevention Disease Prevention Coping Mechanisms

Client Care Home Safety Family Planning Crisis Intervention

Assignments Injury Prevention Family Interaction Patterns Cultural Awareness

Client Rights Medical & Surgical Growth & Development End of Life Concepts

Concepts of Asepsis Safe use of Health & Wellness Grief and Loss

Management Equipment Health Mental Health Concepts

& Supervision Security Plans Promotion/Screening Mental Illness Concepts

Consultation with Use of restraints/ Programs Sensory/Perceptual

Multidisciplinary Safety High Risk Behaviors Alterations

Team Devices Human Sexuality Situational Role Changes

Confidentiality Reporting of Immunizations Stress Management

Continuity of Care Incident/Event/ Lifestyle Choices Substance-Related

Ethical Practice Irregular Occurrence/ Self Care Disorders

Informed Consent Variance Techniques of Physical Suicide/Violence

Legal Handling Hazardous Assessment Precautions

Responsibilities and Developmental stages and Support Systems

Quality Assurance Infectious Materials Transitions Therapeutic Environment

Referral process Expected Body Image Therapeutic

Resource Changes Communication

Management Ante/Intra/Postpartum& Religious and Spiritual

12

Physiological Integrity

Basic Care and Pharmacological and Reduction of Risk Physiological

Comfort Adverse Effects Potential Adaptation

Assistive Devices Expected Effects Diagnostic Tests Alterations in Body

Elimination Medication Laboratory Values Systems

Mobility/Immobility Administration Potential for Basic Pathophysiology

Non-Pharmacological Side Effects Alterations in Fluid & Electrolyte

Comfort Interventions Pharmacological Body Systems Imbalances

Nutrition & Oral Actions Potential for Medical Emergencies

Hydration Pharmacological Complications Radiation Therapy

Palliative/Comfort Care Agents of Diagnostic Tests/ Unexpected Response

Personal Hygiene Treatment/Procedures to

Rest & Sleep Potential of Therapies

Complications

for Surgical Procedures

and Health Alterations

Therapeutic Procedures

Vital Signs



Newborn Care Influences on Health



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