Clinical Education Center and Simulation

Integration I Day 1 Clinical Education Center and Simulation

Learning Activities

Clinical Education Center – 3rd Floor Simulation Center – 5th 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.

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

Emergency Department Faxed Report Form CON Simulation

N Date:_Today__ Time:__Now___ Room #___Sim____ MD___Mitchell____ O I James Snow T

A DOB 6/1 Diagnosis or Chief Complaint __ L Hip Fx (Femoral Neck displaced) s/p Fall _____ U COPD Exacerbation T MRN: 78980098 I

S Admission History Yes No Isolation Required: Yes No Type:______

D 79 yo male c/o L hip “gave out” then fell 2 steps off ladder while doing yard work. L N

U hip Fx , femoral neck displaced; Abrasions L cheek & elbow; CT head & CSpine negative. O

R PMH: Osteoporosis, DM type 2, COPD G

K Allergy: Iodine, Morphine C A B

T 1 hour ago Vital Signs Interventions N 2 Labs: See attached lab results sheet E Temp. _37 __ Pulse Rate/Rhythm_88_/__Reg__ Resp:

M CBC, CMP/BMP, TROP, UA, Other: _20__ T & C S

S O2 Sat.__93%_____RA/O2__RA____ B/P____140/80______for 2 units of PRBCs on call to OR E Abnormal/Pertinent Results: __See S BG _234__ GCS Yes Scale_ N/A ___ No S Labs______

A Other______Physical Assessment Radiology: CT, XR , U/S Type: Neg CT head & CSpine Neuro: A/O x4 Alert Awake ↓LOC Lethargic ___ Comatose Fluctuating Agitated Confused Abnormal/Pertinent Results: _L Hip Fx (Femoral Neck) Combative Tubes: Foley Size ___N/A______NGT Size____ N/A Other: _____ Integumentary Skin W/D Color WNL Cap Refill < 3 sec Chest Tube: R L Air Leak Crepitus Drainage Other: Abrasions L cheek, elbow & hip Color______

Respiratory: Unlabored Labored Tachypneic Input & Output Clear Wheezes Rhonchi Diminished Admission IV Fluid: __See orders______Other: Occasional wheezing required Albuterol neb. Now clear, even & unlabored IV Location/Size: 1.___ 18g / R AC_ 2.______/______GI: BS Present Hypoactive Hyperactive Abd. Distended Input: Oral _ N/A __cc’s IV _ N/A __cc’s Other: _ Other: N/A __cc’s

MS: No deficits Contracted Cachetic Output: Urine _300_cc’s Emesis N/A _cc’s NGT_ Amputation______N/A cc’s Other: Immobilized L lower extremity, CMS intact CT Drainage _ N/A _ cc’s Other: __N/A cc’s

Pain Management Social Assessment Pain level before meds: _7_/10 Pain level now: _2_/10 Activity: Independent With Assistance Location of Pain: __ L hip ______Dependant Pain Medication: __Dilaudid 1 mg IV______Last Dose Given At: 1 hour ago Pain Goal: less than Pt lives: W/ Family Alone Homeless, Caregiver 3/10 Deficits: Deaf/HOH Blind/Vision Impaired Other: glasses

Nursing Swallow Evaluation: Pass Fail N/A Not done Comment:

Integration I Day 1 CEC/Sim Workbook

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 ______

S ED Pathway Initiated:__ N/A ______Restraints Yes Goals/ Things to watch out for: N O

I No Plan OR later today T

A Precautions: L hip precautions D N

E Labs or Medications to be done soon: Care Issues: Wife dependent on pt. Unable to get a M See orders M hold of Son. Pt worried about wife. Wife phone O

C #123.123.1212 E

R Son phone #234.234.2323 Special Equipment Needed: Signatures (PRINT) ED RN Completing Report: Sue Sterwart RN______Ext__1234__ Staff Confirming Fax Receipt: ______Time: ______Pt. Transported By tech Patient Received By: Time:

Integration I Day 1 CEC/Sim Workbook

Dispensing by non-proprietary name under formulary system is permitted, unless checked here:  DATE: Today TIME: 0800 James Snow ATTENDING PHYSICIAN: Dr. Spencer UPI ID #3456 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

Dispensing by non-proprietary name under formulary system is permitted, unless checked here:  DATE: Today TIME: 0800 ATTENDING PHYSICIAN: Dr. Spencer UPI ID # 3456 ORDERING HEALTHCARE PROVIDER: GME/UPI James Snow Dr. Mitchell 1223 D.O.B. – 6/1 MRN: 78980098 SERVICE: Ortho Surgery CODE STATUS: Full 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

>250 – notify MD

Orders transcribed by: Title: Date: Time:

Dr. Mitchell MD Verified by: Title: Date: Time: SIGNATURE/TITLE

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 NS at 75ml/hr 1 hour ago SS 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

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 every 2 hours as needed OR hour ago SS Albuterol MDI Inhaler with spacer 2 puffs every 2 hours as needed

Dilaudid 1 mg IV push every 2 hour as given in ED 1 needed for pain moderate-severe (4- 10) hour ago SS 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

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

231-250 Regular Insulin given in 6unit SQ ED 1 hour ago SS >250 notify MD Signature Initial Signature Initial Signature Initial Sue Sterwart RN SS

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 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) 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 / Other______MAR updated MAR sent Current Blood identification band present Antibiotics ordered /type ______RUE / LUE / RLE / LLE / Other______N/A Antibiotic sent with patient Antibiotic given at ______Blood refused Refusal form signed Yes No Labs “NO BLOOD” band on RUE / LUE / RLE / LLE / Labs drawn ______and sent at ______Other______Labs to be drawn in Pre-op/OR______Dentures / Partials NA Yes No Blood glucose, most recent result______time______Eye wear removed NA Yes No Documentation Verification Hearing aid removed NA Yes No Surgical consent on chart (within 90 days) Jewelry / Body piercing removed NA Yes No Anesthesia consent on chart Hospital Gown only History and Physical on chart (within 30 days) SCD (sleeves) Elastic Stockings Foot Pump Pre-procedure note on chart (if H & P > 7 days old) LLE: Calf ______Thigh______Length______Advance directive declaration form on chart / computer RLE: Calf ______Thigh______Length______Correct site / side ______NPO Since______am / pm Correct site marked Yes / No Last Void Time ______am / pm By whom:______Last 24 hour I & O: I______O______Belongings form completed / Initiated This shift’s I & O: I______O______Belongings sent with patient to OR / home with family Vital Signs Tubes 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 Initial Signature Initial