Simulation Design Template:
Judy Jones-Simulation #1
Date:
Discipline: Nursing
Expected Simulation Run Time: approx.
20 minutes
Location: Hospital
Admission Date: Yesterday |
File Name: Judy Jones
Student Level:
Guided Reflection Time: twice the amount
of simulation run time
Location for Reflection:
Today’s Date: Wednesday (day 2)
Brief Description of Client
Name: Judy Jones
Gender: F Age: 85
Race:
Weight: 52.3 kg Height: 67 in
Religion: Baptist
Major Support: Karen Jones (daughter) Support Phone: 555-555-5566
Allergies: Sulfa
Immunizations: Influenza 3 months ago; Pneumonia 2 years ago
Attending Physician/Team: Annette Parks, MD
Past Medical History: Hypertension, cervical spondylosis, hyperlipidemia controlled by diet, and mild
dementia manifested by short-term memory issues, sequencing and executive function deficits.
History of Present Illness: Illness began with a runny nose and non-productive cough six days ago. On day
six, she went to the doctor’s office with a fever, shortness of breath, wheezing, and a productive cough. She
was admitted from the doctor’s office and started on IV fluids and antibiotics.
Social History: Widow for seven years; lives at home with her daughter.
Primary Medical Diagnosis: Pneumonia
Surgeries/Procedures & Dates: Carpal tunnel surgery on left wrist at age 58, on right wrist at age 60.
Nursing Diagnoses: Ineffective breathing pattern, fluid volume deficit, risk for falls, risk for injury
Judy Jones – Simulation # 1
© National League for Nursing, 2014
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Psychomotor Skills Required Prior to Simulation




General head-to-toe assessment
Applying nasal cannula
Incentive spirometry
Patient transfer/ambulation skills
Cognitive Activities Required Prior to Simulation
[i.e. independent reading (R), video review (V), computer simulations (CS), lecture (L)]


Read information in textbook and lecture notes on community acquired pneumonia, dementia and
delirium, and care of confused older adult. (R) (L)
Tools in the Try This: ® and How to Try This Series, available on ConsultGeriRN.org
(http://consultgerirn.org/resources). Specific tools recommended for this scenario are the Confusion
Assessment Method (CAM), Mini-Cog TM, Updated Beers Criteria and Family Questionnaire. (R)
Simulation Learning Objectives
General Objectives
1. Practice standard precautions throughout the exam.
2. Employ effective strategies to reduce risk of harm to the client.
3. Assume the role of team leader or member.
4. Perform a focused physical assessment noting abnormal findings.
5. Recognize changes in patient symptoms and/or signs of patient compromise.
6. Perform priority nursing actions based on clinical data.
7. Reassess/monitor patient status following nursing interventions.
8. Perform within scope of practice.
9. Demonstrate knowledge of legal and ethical obligations.
10. Communicate with client in a manner that illustrates caring for his/her overall well-being.
11. Communicate appropriately with physician and/or other healthcare team members in a timely,
organized, patient-specific manner.
12. Apply the nursing process to initiate care of the Alzheimer’s patient.
Simulation Scenario Objectives
1.
2.
3.
4.
Conduct a focused assessment.
Use updated Beers criteria to assess medications ordered for the patient.
Demonstrate use of non-pharmacological methods to manage an agitated patient.
Respond to patient-specific physical and emotional needs related to ineffective breathing patterns.
Judy Jones – Simulation # 1
© National League for Nursing, 2014
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5. Perform the Mini-Cog TM assessment,
6. Use the Confusion Assessment Method to evaluate the client for delirium versus dementia after the
scenario is completed.
References, Evidence-Based Practice Guidelines, Protocols, or
Algorithms Used for This Scenario:
These and other tools in the Try This: ® and How to Try This Series are available on the ConsultGeriRN.org
(http://consultgerirn.org/resources), the website of the Hartford Institute for Geriatric Nursing, at New York
University’s College of Nursing. The tool, an article about using the tool, and a video illustrating the use of the
tool, are all available for your use.
Beers Criteria for Potentially Inappropriate Medication Use in Older Adults:
Tool: http://consultgerirn.org/uploads/File/trythis/try_this_16.pdf
Video: http://consultgerirn.org/resources/media/?vid_id=4852321#player_container
Article: Fick, D.M., & Semla, T.P. (2012). 2012 American Geriatrics Society Beers Criteria: New Year, New
Criteria, New Perspective. Available online at:
http://www.americangeriatrics.org/files/documents/beers/Perspective_JAGS.pdf
Confusion Assessment Method (CAM):
Tool: http://consultgerirn.org/uploads/File/trythis/try_this_13.pdf
Video: http://consultgerirn.org/resources/media/?vid_id=4361983#player_container
Article:http://journals.lww.com/ajnonline/Fulltext/2007/12000/How_to_Try_This__Detecting_Delirium.27.as
px
Dementia: Nursing Standard of Practice Protocol: Recognition and Management of Dementia:
http://consultgerirn.org/topics/dementia/want_to_know_more
Assessing and Managing Delirium in Older Adults with Dementia:
Tool: http://consultgerirn.org/uploads/File/trythis/try_this_d8.pdf
Video: http://consultgerirn.org/resources/media/?vid_id=4361983#player_container
Mental Status Assessment of Older Adults: The Mini-Cog TM
Tool: http://consultgerirn.org/uploads/File/trythis/try_this_3.pdf
Video: http://consultgerirn.org/resources/media/?vid_id=4361918#player_container
Recognition of Dementia in Hospitalized Older Adults:
Tool: http://consultgerirn.org/uploads/File/trythis/try_this_d5.pdf
Video: http://consultgerirn.org/resources/media/?vid_id=4361882#player_container
Judy Jones – Simulation # 1
© National League for Nursing, 2014
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Decreasing Patient Agitation:
Waszynski, C., Veronneau, P., Therrien, K., Brousseau, M., Massa, A. & Levick, S. (2013). Decreasing
patient agitation using individualized therapeutic activities. AJN, American Journal of Nursing, 113 (10),
32-39. Available at: http://www.nursingcenter.com/lnc/CEArticle?an=00000446-20131000000024&Journal_ID=54030&Issue_ID=1606223
Therapeutic Activity Kits:
http://consultgerirn.org/uploads/File/trythis/try_this_d4.pdf
Review the Essential Nursing Actions in the ACES Framework at: http://www.nln.org/professionaldevelopment-programs/teaching-resources/aging/ace-s/nln-aces-framework
Fidelity (choose all that apply to this simulation)
Setting/Environment:
ER
Med-Surg
Peds
ICU
OR / PACU
Women’s Center
Behavioral Health
Home Health
Pre-Hospital
Other:
Medications and Fluids:
IV Fluids: see chart
Oral Meds:
IVPB:
IV Push:
IM or SC:
Diagnostics Available:
Labs
X-rays (Images)
12-Lead EKG
Other:
Simulator Manikin/s Needed:
Human patient simulator (e.g. SimMan, Vital
Sim) or standardized patient.
Props: Patient is sitting on the floor looking
under bed. On the bedside table is an incentive
spirometer, box of tissues and a small bag for
used tissues with green sputum.
Equipment Attached to Manikin:
IV tubing with primary line D5. 45 NSS
running at 42 mL/hr
Secondary IV line
IV pump
Foley catheter mL output
PCA pump running
Documentation Forms:
Physician Orders
Admit Orders
Flow sheet
Medication Administration Record
Kardex
Graphic Record
Shift Assessment
Triage Forms
Code Record
Anesthesia / PACU Record
Standing (Protocol) Orders
Transfer Orders
Other: Students will need copies of the Mini-Cog
Judy Jones – Simulation # 1
© National League for Nursing, 2014
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IVPB with running at mL/hr
02 set at 2L; nasal cannula in an empty bed
Monitor attached
ID band
Other:
and CAM tools. You may provide them or assign
learners to retrieve them from
www.consultgerirn.org.
Recommended Mode for Simulation:
(i.e. manual, programmed, etc.)
either
Equipment Available in Room:
Bedpan/Urinal
Student Information Needed Prior to Scenario:
Foley kit
Straight Catheter Kit
Has been oriented to simulator
Incentive Spirometer
Understands guidelines /expectations for
Fluids
scenario
IV start kit
Has accomplished all pre-simulation
IV tubing
requirements
IVPB Tubing
All participants understand their assigned
IV Pump
roles
Feeding Pump
Has been given time frame expectations
Other: Students will need copy of Mini-Cog
Pressure Bag
02 delivery device (type)
Crash cart with airway devices and
emergency medications
Defibrillator/Pacer
Suction
Other: Tissues and a small container/bag for
the used tissues
Roles/Guidelines for Roles:
Primary Nurse
Secondary Nurse
Clinical Instructor
Family Member #1
Family Member #2
Observer/s
Recorder
Physician/Advanced Practice Nurse
Respiratory Therapy
Anesthesia
Pharmacy
Lab
Imaging
Social Services
Important Information Related to Roles:
The primary nurse will enter the scenario alone and
will call for the second nurse when help is needed.
Judy Jones – Simulation # 1
© National League for Nursing, 2014
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Clergy
Unlicensed Assistive Personnel
Code Team
Other:
Report Students Will Receive Before Simulation
Time: 1900, 24 hours after admission
Situation: Judy Jones is an 85-year-old female patient of Dr. Annette Parks who was admitted yesterday
afternoon with a diagnosis of community-acquired pneumonia. She is being treated with IV Azithromycin and
IV fluids.
Background: Judy Jones has a medical history of hypertension, which is controlled by spironolactone,
cervical spondylosis with pain controlled with ibuprofen when needed, hyperlipidemia that is controlled by diet.
She also has mild dementia. She hasn’t been confused but is forgetful and easily redirected. She has a history
of carpal tunnel surgery on both wrists.
Assessment: She is alert and oriented to self, but needs frequent reorientation to place and time. She is
forgetful. At 1600 her vital signs were temp 99.9, heart rate 103, respirations 24, BP 130/68, pulse ox 95% on 2
liters of O2 via nasal cannula. Her heart rhythm is regular. She has D5 .45 NSS running at 42 mL/hr into her
left forearm.
She frequently removes her nasal cannula, and when she does, her pulse ox goes down as low as 90%. Upon
auscultation she has rhonchi bilaterally and occasional wheezing. There are PRN respiratory treatments
ordered to relieve her wheezing. We are encouraging her to use the incentive spirometer every hour.
Ms. Jones is on a regular diet; her appetite is poor. Her abdomen is soft with positive bowel sounds. Her last
bowel movement was two days ago and she denies any feelings of constipation at this time.
She has been urinating without difficulty in the bathroom, but needs someone’s help to get into the bathroom,
basically to manage the IV pole. Her skin looks great. I didn’t see any areas of breakdown, but she is at risk for
skin breakdown because she is sitting a lot in the bed.
Recommendation: I recommend checking on her frequently due to the forgetfulness and to be sure she
keeps her nasal cannula on. It is important that we continually assess her respiratory status. Her last albuterol
treatment was at 1200, and she can have her next one whenever she needs it. Be sure to remind and reteach
her each time how to use the incentive spirometer; she forgets. Don’t forget we are starting our new Quality
Improvement project today. We are doing Mini-Cog assessments three times a week on each patient that
scored a 3 or more on the Family Questionnaire for Dementia. You will need to do the Mini-Cog assessment
on Ms. Jones before the end of your shift.
Judy Jones – Simulation # 1
© National League for Nursing, 2014
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Significant Lab Values:
refer to chart
Physician Orders:
refer to chart
Home Medications:
refer to chart
Scenario Progression Outline
Timing
(approx.)
0-5 min
Manikin Actions
Expected Interventions
May Use the
Following Cues
Manikin or standardized
patient is sitting on the floor
looking under the bed and
saying, “Come on out baby
girl . . .it’s OK . . .I’ll help you.
It’s time for a snack.”

Nasal cannula on bed,
oxygen set at 2L.


Wash hands and
introduce self.
Identify patient.
Reapply nasal
cannula, check oxygen
settings.
Reorient patient.
Call for help to get
patient into bed.
Role member
providing cue:
Patient
Cue: If the students
do not introduce
themselves the
patient will say, “Who
are you? Do you see
the children? I
haven’t seen you
before.”
Take vital signs.
Assess patient.
Role member
providing cue:


Pulse ox – 88% on room air;
increases to 93% after nasal
cannula is reapplied.
When the nurse reorients
Judy, she only remains
oriented briefly, then reverts
to thinking she is at the day
care center. “Come on,
Susan, let’s go outside.”
Judy cooperates with
whatever the nurse instructs
her to do but is easily
distracted, switching from
realizing she is in the hospital
to being at the day care.
“Does anyone want to go
down the slide?”
5-10 min
Patient has a productive
cough.


Judy Jones – Simulation # 1
© National League for Nursing, 2014
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Temperature: 99.9 F
HR: 115
RR: 28
BP: 126/66
Patient
Cue: If oxygen is not
reapplied patient
says, “The person
who was here before
you kept trying to
shove things in my
nose.”
Pulse ox – 88% on room air;
increases to 93% after nasal
cannula is reapplied.
Lung sounds: Rhonchi with
crackles in bases of both
lungs.
10-15 min
15-20 min
Judy remains focused during
the incentive spirometry
teaching and uses spirometer
correctly.

Judy forgets what she is
doing several times: “What
am I drawing?”

Completed clock drawing
attached
When asked to recall the
three words, Judy responds,
“Duck, duck, goose.”


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
Teach how to use
incentive spirometer.
Encourage Judy to
use spirometer.
Role member
providing cue:
Patient
Cue: If patient is not
asked to perform
incentive spirometry
patient asks, “What is
that thing for?”
pointing to incentive
spirometer.
Adminster Mini-Cog
TM
Give Judy three words
to remember.
Ask Judy to draw a
clock at 11:10.
Ask Judy to repeat the
three words.
After the scenario is completed ask all participants to evaluate the patient using CAM Diagnostic Algorithm
available at: http://consultgerirn.org/uploads/File/trythis/try_this_13.pdf
Judy Jones – Simulation # 1
© National League for Nursing, 2014
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Judy’s clock drawing:
Debriefing/Guided Reflection Questions for This Simulation
(Remember to identify important concepts or curricular threads that are specific to your program)
1.
How did you feel throughout the simulation experience?
2.
Describe the objectives you were able to achieve.
3.
Which ones were you unable to achieve (if any)?
4.
Did you have the knowledge and skills to meet objectives?
5.
Were you satisfied with your ability to work through the simulation?
6.
To Observer: Could the nurses have handled any aspects of the simulation differently?
7.
If you were able to do this again, how could you have handled the situation differently?
8.
What did the group do well?
9.
What did the team feel was the primary nursing diagnosis?
10. How were physical and mental health aspects interrelated in this case?
Judy Jones – Simulation # 1
© National League for Nursing, 2014
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11. What were the key assessments and interventions?
12. Is there anything else you would like to discuss?
Specific Debriefing Questions for this Scenario:
Assess Function and Expectations:
 After your initial assessment of Judy, what were your priority interventions?
Coordinate and Manage Care:
 The medications aldactone and ibuprofen are both listed on the Beers Criteria list. How does this
affect the coordination and management of care?
 What was it like to figure out behavioral interventions to address the psychotic behavior?
Use Evolving Knowledge:
 What kind of psychotic behaviors were present?
 Would these behaviors be part of the client’s dementia or the onset of delirium? To clarify,
review/discuss student ratings of Judy on the Confusion Assessment Method (CAM) Diagnostic
Algorithm.
Make Situational Decisions:
 What was it like to work with Judy while she was having hallucinations and needing immediate
respiratory interventions?
Judy Jones – Simulation # 1
© National League for Nursing, 2014
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