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Icu Nursing Report Sheet Template

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					                              Simulation Te mplate
                        Stephen F. Austin State University
                   Richard and Lucille DeWitt School of Nursing


Scenario Title :                          Scenario Site :
Course: Nur                               Student Level:
Expected Simulation Run Time :            Debriefing Time :
                                          Debriefing Location:

Admit Date:          Today’s Date:        Psychomotor & Cognitive Skills
                                          Required Prior to Simulation:
Brief Description of Client
Name:
Gende r:                Age:
Ethnicity:              Religion:         Activities Required Prior to Simulation
Support person:                           (independent reading, video review,
Weight:         pounds            kg      computer simulations, lecture, etc) :
Height:        inches
Alle rgies:

Other:

Medications:                              Nursing Diagnoses:

Immunizations :

Provider(s):

Past History:

Present Complaint:

Social History:

Primary Medical Diagnosis:

Surgeries/Procedures & Dates:
Student Learning Objectives for This Simulation:

1.

2.

3.

4.

5.

6.

7.

8.



Course Specific Objectives




Program/Curriculum Specific Objectives
Simulation Set Up Needs (choose all that apply)

Setting/ Environment                                  Medications and Flui ds (fill in type if applicable)
   ER                                                   Oral Meds:
   Med Surg                                             IV Fluids:
   Pediatrics PICU NICU (check area)                    IVPB:
   ICU/ CCU                                             IV Push:
   OR/PA CU                                             IM/Subq/Intradermal:
   L&D      PP Well Nursery (check area)                Other
   Mental Health Outpatient Inpatient (check
area)
   Ho me Health                                       Diagnostics Available (fill in type if applicable)
   Pre-hospital                                          X-ray Images:
   Other                                                 Labs:
                                                         12-Lead EKG:
Simulator/ Mannequin(s) Needed:                          Other

Props:
                                                      Documentation Forms: (fill in type if applicable)
Equi pment Attached to Mannequin:                       Admit Orders
  IV tubing with primary line          running at       Physician Orders
         ml/hr                                          Flo w Sheet (type):
  Secondary IV line         running at        ml/hr     Medication Administration Record
  IV pump                                               Kardex
  PCA pump running            ml/hr                      Graphic Record
  IVPB with         running at         ml/hr            Shift Assessment
  Foley catheter       ml output                        Triage (fro m ER)
  O2 per         at      liters                         Code Record
  Monitor attached (type):                              Anesthesia/PACU Record (circle)
  ID band                                               Standing (Protocol) Orders:
  Other                                                 Transfer Orders
                                                        Other
Equi pment Available in Room: (fill in type if
applicable)
   Bedpan/Urinal (circle)
   Foley Kit                                          Recommended Mode for Simulation (manual –
   Straight Cath Kit                                  on the fly, programmed, etc)
   Incentive Spiro metry
   Unopened Fluids (type)
   IV Start Kit
   IV Tubing
   IVPB Tubing
   IV Pu mp
   Feeding Pu mp
   Pressure Bag
   O2 Delivery Device
   Crash cart with airway devices and emergency
   med ications
   Defibrillator/Pacer (circle)
   Suction
   Other
Simulation Set Up Needs (continued) (choose all that apply)

Roles/Gui delines for Roles                  Student Information Needed Prior to Scenario
   Primary Nurse                                Has been oriented to simulator
   Other RN                                     Understands guidelines/expectations for scenario
   Licensed Vocational Nurse                    Has accomp lished pre-simulat ion requirements
   Clinical Instructor                          Part icipants understand assigned roles
   Student #1                                   Has been given time frame expectations
   Student #2                                   Other
   Family Member #1
   Family Member # 2
   # of Observers                            Report Students Will Recei ve Before Si mulation
   Provider (Doctor/NP/CNM, etc)
   Respiratory Therapist                     Ti me:
   Anesthesia                                Report:
   Pharmacy
   Lab Personnel
   Imaging Personnel
   Social Services
   Clergy
   Unlicensed Assistive Personnel
   Code Team
   Other


Important Informati on Rel ated to Roles :




Significant Lab Val ues:




Provi der Orders:
References, Evidence-Based Practice Guidelines, Protocols, or Algorithms Used for
This Scenario (cite source, author, year, and pages)
2010 NCLEX-RN Test Plan Categories and Subcategories (choose all that apply to
this simulation)

OVERVIEW OF CONTENT
All content categories and subcategories reflect client needs across the lifespan in a
variety of settings.

Safe and Effective Care Environme nt (includes Management of Care and Safety and
Infection Control)

The nurse promotes achievement of client outcomes by providing and directiong nursing
care that enhances the care delivery setting in order to protect clients, family/significant
others and other health care personnel.

Management of Care – providing and directing nursing care that enhances the care
delivery setting to protect clients, family/significant others and other health care
personnel.

  Advance Directives                              Establishing Priorities
  Advocacy                                        Eth ical Pract ice
  Case Management                                  Informed Consent
  Client Rights                                   Informat ion Technology
  Co llaboration with Interdisciplinary Team      Legal Rights and Responsibilities
  Concepts of Management                          Performance Imp rovement (Quality Imp rovement)
  Confidentiality/Information Security            Referrals
  Consultation                                    Resource Management
  Continuity of Care                              Staff Education
  Delegation                                      Supervision



Safety and Infection Control – protecting clients, family/significant others and health
care personnel from health and environmental hazards.

  Accident/Injury Prevention                      Reporting of Incident/Event/Irregular
  Emergency Response Plan                         Occurrence/ Variance
  Ergonomic Principles                            Safe Use of Equip ment
  Error Prevention                                Security Plan
  Handling Hazardous and Infectious Materials     Standard Precautions/Transmission-Based
  Ho me Safety                                    Precautions/Surgical Asepsis
                                                  Use of Restraints/Safety Devices




Health Promotion and Maintenance
The nurse provides and directs nursing care of the client and family/significant others that
incorporates the knowledge of expected growth and development principles, prevention
and/or early detection of health problems, and strategies to achieve o ptimal health.

  Aging Process                                   High Risk Behaviors
  Ante/Intra/Postpartum and Newborn Care          Lifestyle Choices
  Develop mental Stages and Transitions           Princip les of Teaching/Learn ing
  Health and Wellness                             Self-Care
  Health Pro motion/Disease Prevention            Techniques of Physical Assessment
  Health Screening




Psychosocial Integrity

The nurse provides and directs nursing care that promotes and supports the emotional,
mental and social well-being of the clients and family/significant others experiencing
stressful events, as well as clients with acute or chronic mental illness.

  Abuse/Neglect                                   Grief and Loss
  Behavioral Interventions                        Mental Health Concepts
  Chemical and Other Dependencies                 Religious and Spiritual Influences on Health
  Coping Mechanisms                               Sensory/Perceptual Alterations
  Crisis Intervention                             Stress Management
  Cu ltural Diversity                             Support Systems
  End of Life Care                                Therapeutic Co mmun ications
  Family Dynamics                                 Therapeutic Environ ment
Physiological Integrity (includes Basic Care and Comfort, Pharmacological and
Parenteral Therapies, Reduction of Risk Potential, and Physiological Adaptation)

The nurse promotes physical health and wellness by providing care and comfort,
reducing client risk potential and managing health alterations.

Basic Care and Comfort – providing comfort and assistance in the performance of
activities of daily living.

  Assistive Devices                             Nutrit ion and Oral Hydration
  Elimination                                   Personal Hygiene
  Mobility/Immobility                           Rest and Sleep
  Non-Pharmaco logical Co mfort Interventions



Pharmacological and Parental Therapies – providing care related to the administration
of medications and parenteral therapies.

  Adverse Effects/Contraindications/Side        Expected Effects/Outcomes
  Effects/Interactions                          Medication Administration
  Blood and Blood Products                      Parenteral/ Intravenous Therapies
  Central Venous Access Devices                 Pharmacological Pain Management
  Dosage Calculat ion                           Total Parenteral Nutrit ion



Reduction of Risk – reducing the likelihood that clients will develop complications or
health problems related to existing conditions, treatments or procedures.

  Changes /Abnormalit ies in Vital Signs        Potential for Co mplications fro m Surgical
  Diagnostic Tests                              Procedures and Health Alterations
  Laboratory Values                             System Specific Assessments
  Potential for Alterat ions in Body Systems    Therapeutic Procedures
  Potential for Co mplications of Diagnostic
  Tests/Treatments/Procedures



Physiological Adaptation – managing and providing care for clients with acute, chronic
or life threatening physical health conditions.

  Alterations in Body Systems                   Medical Emergencies
  Flu id and Electro lyte Imbalances            Pathophysiology
  Hemodynamics                                  Unexpected Response to Therapies
  Illness Management
Scenario Progression Outline

Ti ming         Mannequin Acti ons   Expected         May Use the Following Cues
Approxi mate                         Interventi ons
First 5                                               Role member providing cue:
minutes

                                                      Cue:

                                                      Role member providing cue:


                                                      Cue:
                                                      Role member providing cue:


                                                      Cue:

Next 5 – 10                                           Role member providing cue:
minutes

                                                      Cue:

                                                      Role member providing cue:


                                                      Cue:

                                                      Role member providing cue:


                                                      Cue:

Final 15 – 20                                         Role member providing cue:
minutes

                                                      Cue:

                                                      Role member providing cue:


                                                      Cue:

                                                      Role member providing cue:


                                                      Cue:
Debriefing/Guided Reflection Questions for this Simulation

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.



Complexity – Simple to Complex
Suggestions for changing the complexity of this scenario to adapt to different levels of
learners:




This form (with minimal adaptation) from: Jeffries, P. R. (Ed.). (2007). Simulation in
nursing education: From conceptualization to evaluation. New York: National League for
Nursing.

NCLEX content areas taken from the 2010 NCLEX-RN Test Plan (2010). URL:
https://www.ncsbn.org/2010_NCLEX_RN_TestPlan.pdf

				
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