PALMETTO HEALTH
RICHLAND
Scenario #6A: Geriatric End-of-Life Issues — #3
Goals & Objectives:
1.
Demonstrate recognition and correction of impending respiratory failure
2.
Demonstrate proper intubation of geriatric patients
3.
Demonstrate knowledge of post-intubation cardiopulmonary management
4.
Recognize healthcare-associated pneumonia and institute proper antibiotics
5.
Improve communication skills with family members
6.
Review principles of DNR orders
7.
Learn the definition of decisional capacity
Equipment:
1.
2.
3.
4.
SimMan
Code cart
Live patient relative (son)
DNR (valid, signed, dated, and notarized)
Moulage:
1.
2.
3.
Heel protectors
Depends diaper
Dentures
Sim Spec Instructions:
1.
Make intubation difficult: stiff jaw/neck, dentures
2.
“Rhonchorous,” shallow breath sounds
3.
Thready tachycardic pulse
Initial Vignette:
91-year-old male nursing home resident is brought in by EMS. EMS was called for
decreased mental status and found him unresponsive. Initial vital signs per EMS:
BP 80/60 Pulse 112 RR 24 O2 sat 88% (2 L nasal cannula)
Initial Appearance: Obtunded. Moans in response to painful stimuli but does not move.
If checked, rectal temp is 101
If checked, there is no gag reflex
If placed on 100% oxygen, pulse ox improves to 90%
Over the next 2 minutes, respiratory rate decreases to 0
Nursing Home Documentation: lung cancer, hypertension, diabetes, COPD
Meds: albuterol, Norvasc, metformin, ASA, Lipitor
Allergies: morphine, penicillin
Code status is not listed
PALMETTO HEALTH
RICHLAND
Scenario Flow (medical management 10 minutes; family stage 5 minutes):
 Oxygen, pulse oximetry, cardiac monitor, BP
 Intubation for respiratory distress/failure: RSI to relax the jaw and neck (must
demonstrate correct dosages). Post-intubation CXR and ABG, and verify
position of endotracheal tube.
 IVF bolus for hypotension: BP improves to 110/66 and pulse drops to 104
 Labs ordered: abnormal WBC, glucose, lytes, CXR: lung cancer, pneumonia
 Antibiotics administered for healthcare-associated pneumonia
Son arrives any time after intubation done (at tester’s preference):
 He is upset because he says his dad requested no heroic interventions
 Learner must:
o Introduce self to son
o Explain what has happened and why his father was intubated
o Explain the lack of code status from the nursing home
o Ask the son if the father has written down his desires for no heroic
intervention
o Examine the DHEC DNR order that the son shows for: date, physician
signature, patient signature
o After validating the DNR order, ask the son if he wants the father off the
ventilator
 When son asks if his father will die without the ventilator, answer yes. Son will
agree. Physician must wait an appropriate time to disconnect the ventilator to
allow the paralytic agents to wear off.
Critical Actions
 Identifies respiratory failure prior to apnea
 Demonstrates proper meds and dosages for RSI
 Demonstrates proper intubation technique
 Obtains rectal temp
 Initiates proper antibiotics for healthcare-associated pneumonia
 Introduces self to son
 Explains to son what happened
 Recognizes valid DNR form
 Offers to take father off of ventilator
Facilitator Debriefing Points
 Review the legal forms one might encounter. DNR, HCPOA, advance directive
 Principles of DNR orders
 Definition of decisional capacity
 Ways to improve communication with family members of patients
 Post-resuscitation care of the geriatric patient
PALMETTO HEALTH
RICHLAND
For Geriatric Scenario #6 (A, B, C)
CBC
WBC: 12,300
Polys: 65%
Bands: 4%
Lymph: 28%
Hgb: 11.9
Hct: 34%
Platelets: 220,000
PALMETTO HEALTH
RICHLAND
For Geriatric Scenario #6 (A, B, C)
BMP
Na: 139
K: 4.6
Cl: 100
HCO: 24
BUN: 26
Creat: 1.6
PALMETTO HEALTH
RICHLAND
For Geriatric Scenario #6 (A, B, C)
ABG (100% oxygen, post-intubation)
pH: 7.42
pO2: 155
pCO2: 38
O2 Sat: 100%
PALMETTO HEALTH
RICHLAND
For Geriatric Scenario #6 (A, B, C)
Urinalysis
Specific gravity: 1.022
pH: 7.0
Protein: None
Glucose: None
Blood: None
Ketones: None
WBC: 5–10
RBC: 0–1
Epithelial: 5–10
Bacteria: 1+
PALMETTO HEALTH
RICHLAND
For Geriatric Scenario #6 (A, B, C)
Cardiac Enzymes
CPK: 172
CK-MB: 1.2
Troponin: 0.2