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Integration I Day 1
Clinical Education Center and Simulation
Learning Activities
rd th
Clinical Education Center – 3 Floor Simulation Center – 5 Floor
Welcome, Attendance and Questions/Answers Welcome, Attendance and Questions/Answers
2 Instructor 2 Instructor
12 students 12 students
1 hour and 45 minutes 2 hours
Activity #1 Simulation #1 -Room 2
PCA pumps Scenario #1-New admission
Activity #2 Simulation #2-Room 2
Chest tubes Scenario #2 New admission-30 minutes later
Activity #3 Simulation #3-Room 3
Mobility Scenario #3-1 hour before OR
Activity #4 Simulation #4-Room 3
Developing a Nursing Plan of Care Scenario #4-Transfering to pre-op
The Clinical Education Center is packed with new clinical content and nursing application
Please prepare for the simulation scenarios as you would for a clinical day.
Be prepared to provide knowledgeable, effective, and safe patient care in each of the simulation
scenarios today. You will need to prepare for simulation in advance.
Please prepare before this experience:
Complete the Nursing Care Plan tool utilizing the patient data for simulation patient James Snow provided
in this workbook.
You will be responsible for pages 1-4 for simulation experience #1 and pages 5 – 10 for simulation
experience #2.
Please read before this experience:
This workbook
Selected procedures
The assigned article: Bass, N. (2009). Care of the Patient with a Hip Fracture, www.nursingconsult.com.
Retrieved from http://www.nursingconsult.com/nursing/clinical-updates/full-
text?clinical_update_id=191742
Please bring to this experience:
This workbook, please review the simulation in detail. You should be familiar with the patient’s PMH,
admitting diagnosis, possible interventions which include medications
Completed Care Plan
Stethoscope
Clinical resources i.e. pen, penlight, clipboard
Davis Drug book
Enthusiasm and the thirst to acquire nursing knowledge
Integration I Day 1 CEC/Sim Workbook
1
Clinical Education Center
Activity #1
PCA pumps
30 minutes
Your role as a student nurse:
Review Pain Management: Patient-Controlled Analgesia, Craven Procedure 34-1 p. 1174 and also p 1163 and p.
486
Review Lewis, Dirksen, Heitkemper, Bucher& Camera (2011) Pain, Chapter 10 p. 144
Critical Thinking Exercise:
You are assigned to care for a patient with a PCA. Please provide patient education and verify dose settings
including medication, concentration, loading dosed, bolus dose, basal rate, demand dose with lockout time.
Also perform a pain assessment, obtain a patient sedation level with respiratory rate, and document total
medication dose for 4 hours including dose given, dose attempts and amount infused.
Activity #2
Chest Tube Management
30 minutes
Your role as a student nurse:
Review Monitoring a Patient with a Chest Drainage System, Craven Procedure 25-8 p. 797 and also p 763
Review Lewis, Dirksen, Heitkemper, Bucher& Camera (2011) Chest Tubes and Pleural Drainage, p. 569-571
Critical Thinking Exercise:
You are assigned to provide care for a patient with a Left pleural chest tube on your medical/surgical unit.
Provide a brief report of an assessment of a chest tube along with nurse chest tube management
considerations?
Activity #3
Patient Safety: Mobility
20 minutes
Your role as a student nurse:
Review Using Body Mechanics to Move Patients, Craven Procedure 24-1 p. 701
Using Positioning a patient in Bed, Craven Procedure 24-2 p. 703
Assisting with Ambulation, Craven Procedure 24-4 p. 717
Transferring a Patient to a Wheelchair, Craven Procedure 24-7 p. 727
Critical Thinking Exercise:
You are assigned to provide care for a patient with a Left pleural chest tube, a PIV with NS going at 100ml/Hr,
4 L of oxygen per NC, and a foley catheter to gravity on your medical/surgical unit. Prepare and transfer this
patient to a chair and then for ambulation.
Activity #4
Developing a Nursing Plan of Care
20 minutes
Your role as a student nurse:
Review Lewis, Dirksen, Heitkemper, Bucher& Camera (2011) Concepts in Nursing Practice; Nursing Process in
Nursing Practice pg 10 – 17.
Critical Thinking Exercise:
Interactive discussion and review of Care Plan for James Snow.
Integration I Day 1 CEC/Sim Workbook
2
Simulation
Your role as a student nurse:
Please review this workbook including each scenario, the patient’s medical orders, MAR, and admission report
Review Lewis, Dirksen, Heitkemper, Bucher& Camera (2011) Chapter 63 p. 1605-1608
Review Article: Bass, N. (2009). Care of the Patient with a Hip Fracture, www.nursingconsult.com. Retrieved from
http://www.nursingconsult.com/nursing/clinical-updates/full-text?clinical_update_id=191742
Critical Thinking Exercise:
Be prepared to work for 15 minutes in groups of 3 to complete objectives for each scenario
Three students will actively participate in simulation and 3 students will actively observe
All 6 students will actively participate for 15 minutes with an instructor guided debrief
General Patient Medical Information for All Scenarios Today
Primary Medical Diagnosis: Hip Fracture after mechanical fall
History of Present Illness:
Mr. James Snow is a 79 year old male who you are receiving on your Medical Surgical Unit from the Emergency
Department. His diagnosis is left hip fracture (Displaced Femoral Neck) and he is scheduled for surgery later today.
Situation
79 year old male admitted to orthopedic surgeon Dr. Oliver Mitchell with Dx: left hip fracture, plan for surgery
later today
Back Ground
Patient is 79 year old male who fell from a ladder this morning while working in his yard. He arrived to the
Emergency Department via ambulance with obvious deformity to left hip and inability to bear weight. He was
found to have a hip fracture on X-Ray left femoral neck displaced; CT scan of head was negative. An IV was started
in the ED, labs were drawn & sent, fluid was started.
He was given 1 mg of Dilaudid for pain in the Emergency Department. He has complained of occasional shortness
of breath in the Emergency Department with a long standing history of COPD and has required Albuterol nebulizer
treatment to relieve symptoms of shortness of breath and wheezing. He also has a history of IDDM & Osteoporosis
PMH: Type 2 DM, COPD, Osteoporosis
He is very anxious about his wife. He is the primary caretaker for his wife who had a stroke last year and requires
help with daily ADLs. He has a son who lives locally and a daughter who lives in California, either of which the
Emergency Department personnel have not been able to reach.
Assessment:
ED assessment: A & O x 4. S1 S2 no murmurs. Respiratory effort labored with wheezing at times. Now, after
Albuterol neb, even and unlabored with clear breath sounds throughout. BS active x 4 quads. Left cheek and elbow
with abrasions. Left Hip with bruising and abrasions. Left lower extremity CMS intact. Right AC with 18 gauge PIV.
Please see each scenario for specific assessment changes
Recommendations:
Please see each scenario for specific objectives
Integration I Day 1 CEC/Sim Workbook
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Emergency Department Faxed Report Form CON Simulation
Date:_Today__ Time:__Now___ Room #___Sim____ MD___Mitchell____
SITUATION
James Snow
DOB 6/1 Diagnosis or Chief Complaint __L Hip Fx (Femoral Neck displaced) s/p Fall_____
MRN: 78980098 COPD Exacerbation
Admission History Yes No Isolation Required: Yes No Type:_____________
79 yo male c/o L hip “gave out” then fell 2 steps off ladder while doing yard work. L hip Fx , femoral
BACKGRO
neck displaced; Abrasions L cheek & elbow; CT head & CSpine negative.
PMH: Osteoporosis, DM type 2, COPD
UND
Allergy: Iodine, Morphine
1 hour ago Vital Signs Interventions
Temp. _372__ Pulse Rate/Rhythm_88_/__Reg__ Resp: _20__ Labs: See attached lab results sheet
O2 Sat.__93%_____RA/O2__RA____ B/P____140/80_______ CBC, CMP/BMP, TROP, UA, Other:T & C for 2
BG _234__ GCS Yes Scale_ N/A ___ No Other_________ units of PRBCs on call to OR
Physical Assessment Abnormal/Pertinent Results: __See Labs___________________
Neuro: A/O x4 Alert Awake ↓LOC Lethargic Radiology: CT, XR , U/S Type: Neg CT head & CSpine ___
Comatose Fluctuating Agitated Confused Combative Abnormal/Pertinent Results: _L Hip Fx (Femoral Neck)
Other: Tubes: Foley Size ___N/A__________ NGT Size____ N/A _____
Integumentary Skin W/D Color WNL Cap Refill < 3 sec
Other: Abrasions L cheek, elbow & hip Chest Tube: R L Air Leak Crepitus Drainage Color_________
Input & Output
Respiratory: Unlabored Labored Tachypneic
Admission IV Fluid: __See orders________________________
Clear Wheezes Rhonchi Diminished
Other: Occasional wheezing required Albuterol neb. Now IV Location/Size: 1.___ 18g / R AC_ 2._________/__________
ASSESSMENT
clear, even & unlabored
Input: Oral _ N/A __cc’s IV _ N/A __cc’s Other: _ N/A __cc’s
GI: BS Present Hypoactive Hyperactive Abd. Distended
Other: Output: Urine _300_cc’s Emesis N/A _cc’s NGT_ N/A cc’s
CT Drainage _ N/A _ cc’s Other: __N/A cc’s
MS: No deficits Contracted Cachetic Amputation________
Other: Immobilized L lower extremity, CMS intact
Social Assessment
Activity: Independent With Assistance Dependant
Pain Management
Pain level before meds: _7_/10 Pain level now: _2_/10
Pt lives: W/ Family Alone Homeless, Caregiver
Location of Pain: __ L hip ________________________________
Pain Medication: __Dilaudid 1 mg IV______________________ Deficits: Deaf/HOH Blind/Vision Impaired Other: glasses
Last Dose Given At: 1 hour ago Pain Goal: less than 3/10
Nursing Swallow Evaluation: Pass Fail N/A Not done
Comment:
See triage note for list of home meds Medications
Meds given in ED: Dilaudid 1 mg IV 1 hour ago; Albuterol neb. 1 hour ago ;
6 units Reg. Insulin 1 hour ago
Antibiotic Started: Yes No N/A Type________________ Time ________________
ED Pathway Initiated:__ N/A ________ Restraints Yes No Goals/ Things to watch out for:
RECOMMENDATION
Precautions: L hip precautions Plan OR later today
Care Issues: Wife dependent on pt. Unable to get a hold of Son.
S
Labs or Medications to be done soon:
Pt worried about wife. Wife phone #123.123.1212 See orders
Son phone #234.234.2323
Special Equipment Needed:
Signatures (PRINT)
ED RN Completing Report: Sue Sterwart RN_____________________Ext__1234__ Staff Confirming Fax Receipt: _______Time: _________
Integration I Day 1 CEC/Sim Workbook
Pt. Transported By tech Patient Received By:
4 Time:
Dispensing by non-proprietary name under formulary system is permitted, unless checked here:
DATE: Today 0800
TIME:
ATTENDING PHYSICIAN: Dr. Spencer UPI ID #3456 James Snow
ORDERING HEALTHCARE PROVIDER: D.O.B. – 6/1
Dr. Mitchell MRN: 78980098
GME/UPI
1223
SERVICE: Ortho Surgery CODE STATUS: Full
PAGER: 3567
ALLERGIES: Iodine, Morphine
1 Admit to Ortho/Simulation Floor
2 Admit height : 5’11” Admit weight: 86.3 Kg
3 Diagnosis: preoperative L Hip fracture after fall
4 PMH: DM type 2, COPD, Osteoporosis
5 Vital Signs with CMS (circulatory, Motor, Sensory) checks q 4 hours and prn
6 Call HO: Temp ≥ 38.4 C or ≤ 35, SBP ≥ 160 or ≤ 80, DBP ≥ 100 or ≤ 40, HR ≥ 120 or ≤ 50,
RR ≥ 24 or ≤ 8, BG ≥ 250 or ≤ 60, loss or change in CMS
7 Intake and Output q 8 hours
8 Oxygen as needed for SpO2 < 92%
9 Activity: Bedrest, HOB<30 degrees, Hip precautions
10 Diet: NPO for surgery today
11 Finger stick blood glucose q 6 hours
12 Send CBC, BMP, Pt/PTT, UA, T & C for 2 units of PRBCs on call to OR done in ED 1 hour ago
13 IV Infusions: NS at 75 ml / hr while pt is NPO
14 Glyburide 5 mg orally once daily
15 Albuterol 5mg Nebulized treatment or Albuterol MDI Inhaler with spacer 2 puffs every 2 hours as needed for SOB
given in ED 1 hour ago
16 Zofran 4 mg IV push every 8 hours as needed for nausea
17 Dilaudid 1 mg IV push every 2 hours as needed for moderate-severe pain 4-10 given in ED 1 hour ago
18 Tylenol 500mg orally every 4 hours as needed for mild pain 1- 3, HA, or temp greater 38 C
19 Vancomycin 1 g IVPB x 1 on call to OR
20 Measure and place TED hose -on call to OR
21 Order and place SCDs -on call to OR (ORDERS CONT. on next page Page 1 of 2)
22 IS x 10 every hour while awake –on call to OR
Title: Date: Time:
Verified by: Title: Date: Time:
SIGNATURE/TITLE
Dr. Mitchell MD
Integration I Day 1 CEC/Sim Workbook
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Dispensing by non-proprietary name under formulary system is permitted, unless checked here:
DATE: Today 0800 TIME:
ATTENDING PHYSICIAN: Dr. Spencer UPI ID # 3456
ORDERING HEALTHCARE PROVIDER: GME/UPI James Snow
Dr. Mitchell 1223 D.O.B. – 6/1
SERVICE: Ortho Surgery CODE STATUS: Full MRN: 78980098
PAGER: 3567
ALLERGIES: Iodine, Morphine
(ORDERS CONT. BELOW Page 2 of 2)
Insulin for sliding scale
< 60 notify MD
61-120 – NO coverage
121--150 – 1 unit Regular insulin SQ
151-170 – 2 units Regular insulin SQ
171-190 – 3 units Regular insulin SQ
191-210 – 4 units Regular insulin SQ
211-230 – 5 units Regular insulin SQ
231-250 – 6 units Regular insulin SQ
>250 – notify MD
Orders transcribed by: Title: Date: Time:
Dr. Mitchell MD
Verified by: Title: Date: Time:
SIGNATURE/TITLE
Integration I Day 1 CEC/Sim Workbook
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Medication Administration Record (MAR) Date: Today
Name: James Snow
MRN: 78980098
Date of Birth: 06/1
Allergies: Iodine, Morphine
Admit height : 5’11” Admit weight: 86.3 Kg
Scheduled Medications Time Yesterday Today Tomorrow
Page 1 of 3
Maintenance IV fluid Continuous Started in ED 1 hour ago SS
NS at 75ml/hr
While patient is NPO
Glyburide 5 mg orally once daily 0900
Vancomycin 1 g IVPB x 1 On call to
OR
on call to OR
Signature Initial Signature Initial Signature Initial
Sue Sterwart RN SS
Integration I Day 1 CEC/Sim Workbook
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Medication Administration Record (MAR) Date: Today
Name: James Snow
MRN: 78980098
Date of Birth: 06/1
Allergies: Iodine, Morphine
Admit height : 5’11” Admit weight: 86.3 Kg
PRN Medications Time Yesterday Today Tomorrow
Page 2 of 3
Albuterol 5mg Nebulized Treatment given in ED 1 hour ago SS
every 2 hours as needed
OR
Albuterol MDI Inhaler with spacer 2
puffs every 2 hours as needed
Dilaudid 1 mg IV push every 2 hour given in ED 1 hour ago SS
as needed for pain moderate-severe
(4-10)
Zofran 4 mg IV push every 8 hours as
needed for nausea
Tylenol 500 mg orally every 4 hours
as needed for mild pain (1-3), HA or
temp greater than 38 C
Signature Initial Signature Initial Signature Initial
Sue Sterwart RN SS
Integration I Day 1 CEC/Sim Workbook
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Integration I Day 1 CEC/Sim Workbook
9
Medication Administration Record (MAR) Date: Today
Name: James Snow
MRN: 78980098
Date of Birth: 06/1
Allergies: Iodine, Morphine
Admit height : 5’11” Admit weight: 86.3 Kg
PRN Medications Time Yesterday Today Tomorrow
Insulin Sliding Scale
Page 3 of 3
<60 notify MD
61-120- NO coverage
121-150 Regular Insulin 1unit SQ
151-170 Regular Insulin 2unit SQ
171-190 Regular Insulin 3unit SQ
191-210 Regular Insulin 4unit SQ
211-230 Regular Insulin 5unit SQ
231-250 Regular Insulin 6unit SQ given in ED 1 hour ago SS
>250 notify MD
Signature Initial Signature Initial Signature Initial
Sue Sterwart RN SS
Integration I Day 1 CEC/Sim Workbook
10
Simulation Scenarios
Your role as a student nurse:
Be familiar with the patient’s medical orders, MAR, and ED faxed report
The instructor will give you a minute to pre-brief and review the scenario’s objectives
Be prepared to work for 15 minutes in groups of 3 to complete objectives for each scenario
Three students will actively participate in simulation and 3 students will actively observe
All 6 students will actively participate for 15 minutes with an instructor guided debrief
Critical Thinking Exercise:
3 active simulation participants should divide into nursing roles to meet the patient’s needs and scenario objectives
You are working with an interdisciplinary team and may consult by phone a Physician, Provider, Charge Nurse, CNA,
Pharmacist, Case Manager, Respiratory Therapist, Social Worker, Chaplin, Physical Therapist and others as available
Role recommendations: 1 assessment/VS nurse, 1 intervention/medication nurse, 1 leader/primary nurse
The team will be randomly assigned to roles.
o Student 1: Assessment/VS nurse
Role to complete basic assessment, vital signs and communicate findings with team members
o Student 2: Interventions/Medication administration nurse
Role to implement nursing interventions to include medication administration
o Student 3: Intervention/Primary nurse
Role as leader, situational awareness, communication with provider and to implement nursing interventions
3 active observers should focus on observing simulation and be able to highlight successes and deficits in patient
assessment, nursing interventions, and safety
ADDITIONAL NOTES
Integration I Day 1 CEC/Sim Workbook
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Scenario #1-New Admission
Sim room 3
Recommendations: Admit James Snow to your unit by verifying orders, implementing orders, and educating the patient on the plan of
care. As a team please admit this patient to your unit and provide any nursing care he may need.
At minimum please complete:
A basic assessment including any needed focused assessments. Please include a set of vital signs.
Provide patient education to hospital process and care, orders including hip precautions, and overall plan of care.
Verify admission orders, verify MAR, and verify IVF along with review what medications the patient received in ED.
Also provide any nursing care for patient and communication to provider as needed
Scenario #2 New admission-30 minutes later
Sim room 3
Recommendations: It is 30 minutes later and James Snow requires his 0900 medications, a basic assessment, perform a glucose check, and
as a team provide him with any nursing care he may need.
At minimum please complete:
A basic assessment including any needed focused assessments. Please include a set of vital signs.
Verify IVF and provide patient 0900 medications as ordered
Check glucose
Also provide any nursing care for patient and communication to provider as needed
Scenario #3-1 hour before OR
Sim room 2
Recommendations: It is 1 hour before James Snow will go to the OR. He is anxious and he is asking what he should expect for his post
surgery recovery. Please provide him preoperative education and as a team provide him with any nursing care he may need.
At minimum please complete:
A basic assessment including any needed focused assessments. Please include a set of vital signs.
Provide pre-operative patient education on IS, TED hose, SCD, and post operative plan of care (use article as a guide)
Implement any pre-operative orders i.e safely place TED hose and SCDs on patient and give patient IS
Also provide any nursing care for patient and communication to provider as needed
Scenario #4-Transfering to pre-op
Sim room 3
Recommendations: The OR is ready for James Snow. Please complete the pre-surgical checklist, prepare the patient for transfer to the OR,
call the OR RN Mandy with a brief SBAR report before transfer, and as a team provide him with any nursing care he may need.
At minimum please complete:
Complete any assessment data needed before transfer to the OR
Complete the pre-surgical checklist
Prepare the patient for transfer to the OR (use the OR surgical checklist as a guide)
Call the OR RN Mandy with a brief SBAR report before transfer (use the OR surgical checklist as a guide along with the physician
orders and patient MAR. Include Dx-why he is going to OR, PMH, allergies, recent meds given plus on-call meds, priority &
abnormal assessments, IV, tubes, precautions)
Integration I Day 1 CEC/Sim Workbook
12
PRE-PROCEDURE CHECKLIST
NIC: SURGICAL PREPARATION IV Site/Vascular Access
Date____________ Time:___________
Site______________ Site______________
Report given to:_____________________________________ Size______________ Size______________
ALLERGIES:____________________________________________ RUE_____LUE______ RUE_____LUE______
Patient Care Checklist:
ID band present RUE / LUE / RLE / LLE / MAR updated MAR sent
Other__________ Antibiotics ordered /type ____________________________
Current Blood identification band present Antibiotic sent with patient Antibiotic given at _______
RUE / LUE / RLE / LLE / Other__________ N/A Labs
Blood refused Refusal form signed Yes No Labs drawn ____________________and sent at _________
“NO BLOOD” band on RUE / LUE / RLE / LLE / Labs to be drawn in Pre-op/OR_______________________
Other_______
Blood glucose, most recent result__________ time_______
Dentures / Partials NA Yes No Documentation Verification
Eye wear removed NA Yes No Surgical consent on chart (within 90 days)
Hearing aid removed NA Yes No Anesthesia consent on chart
Jewelry / Body piercing removed NA Yes No History and Physical on chart (within 30 days)
Hospital Gown only Pre-procedure note on chart (if H & P > 7 days old)
SCD (sleeves) Elastic Stockings Foot Pump Advance directive declaration form on chart / computer
LLE: Calf ________ Thigh_________ Length__________ Correct site / side _________________________________
RLE: Calf ________ Thigh_________ Length__________ Correct site marked Yes / No
NPO Since____________________________________am / pm By whom:___________________________________________
Last Void Time_______________________________am / pm
Belongings form completed / Initiated
Last 24 hour I & O: I___________O____________
Belongings sent with patient to OR / home with family
This shift’s I & O: I___________O____________
Tubes
Vital Signs
Time_______ Temp_______ B/P_______ HR_______ Lumbar drain Ventriculostomy/Bolt
Zero at____________________________________
RR_______ O2 Sat_______ Pain Scale_______ NG tube J-tube
Cardiac monitoring Continuous Pulse oximetry Dobhoff PEG tube/G-tube
Patient Precautions Chest tube _______ to suction_________ to gravity
Aspiration Airborne Hemovac_________ JP drain__________
Contact Droplet Foley Nephrostomy_____
Fall Latex Wound Vac_______ other_____________________
Seizure Unable to communicate other___________ other___________
Combative Sitter required / sent Other Notes:
Translator required Dialysis lines
Translator ordered A/V fistula
_____________________________________________________
Reason:__________________________________________
Signature Integration I Day 1 CEC/Sim Workbook
Initial Signature Initial
13
