Integration I Day 1 Clinical Education Center and Simulation Learning Activities Clinical Education Center – 3rd Floor Welcome, Attendance and Questions/Answers Simulation Center – 5th Floor Welcome, Attendance and Questions/Answers 2 Instructor 2 Instructor 12 students 12 students 1 hour and 45 minutes 2 hours Activity #1 PCA pumps Activity #2 Chest tubes Simulation #1 -Room 2 Scenario #1-New admission Simulation #2-Room 2 Scenario #2 New admission-30 minutes later Activity #3 Mobility Activity #4 Developing a Nursing Plan of Care Simulation #3-Room 3 Scenario #3-1 hour before OR Simulation #4-Room 3 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/fulltext?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 3 SITUATION Emergency Department Faxed Report Form CON Simulation Date:_Today__ Time:__Now___ Room #___Sim____ MD___Mitchell____ James Snow DOB 6/1 MRN: 78980098 Diagnosis or Chief Complaint __L Hip Fx (Femoral Neck displaced) s/p Fall_____ COPD Exacerbation Admission History Yes No Isolation Required: Yes No Type:_____________ BACKGRO UND 79 yo male c/o L hip “gave out” then fell 2 steps off ladder while doing yard work. L hip Fx , femoral neck displaced; Abrasions L cheek & elbow; CT head & CSpine negative. PMH: Osteoporosis, DM type 2, COPD Allergy: Iodine, Morphine ASSESSMENT 1 hour ago Vital Signs Temp. _372__ Pulse Rate/Rhythm_88_/__Reg__ Resp: _20__ O2 Sat.__93%_____RA/O2__RA____ B/P____140/80_______ BG _234__ GCS Yes Scale_ N/A ___ No Other_________ Physical Assessment Neuro: A/O x4 Alert Awake ↓LOC Lethargic Comatose Fluctuating Agitated Confused Combative Other: Integumentary Skin W/D Color WNL Cap Refill < 3 sec Other: Abrasions L cheek, elbow & hip Respiratory: Unlabored Labored Tachypneic Clear Wheezes Rhonchi Diminished Other: Occasional wheezing required Albuterol neb. Now clear, even & unlabored GI: BS Present Other: Hypoactive Hyperactive Abd. Distended MS: No deficits Contracted Cachetic Amputation________ Other: Immobilized L lower extremity, CMS intact Pain Management Pain level before meds: _7_/10 Pain level now: _2_/10 Location of Pain: __ L hip ________________________________ Pain Medication: __Dilaudid 1 mg IV______________________ Last Dose Given At: 1 hour ago Pain Goal: less than 3/10 Interventions Labs: See attached lab results sheet CBC, CMP/BMP, TROP, UA, Other:T & C for 2 units of PRBCs on call to OR Abnormal/Pertinent Results: __See Labs___________________ Radiology: CT, XR , U/S Type: Neg CT head & CSpine ___ Abnormal/Pertinent Results: _L Hip Fx (Femoral Neck) Tubes: Foley Size ___N/A__________ NGT Size____ N/A _____ Chest Tube: R L Air Leak Crepitus Drainage Color_________ Input & Output Admission IV Fluid: __See orders________________________ IV Location/Size: 1.___ 18g / R AC_ 2._________/__________ Input: Oral _ N/A __cc’s IV _ N/A __cc’s Other: _ N/A __cc’s 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 Activity: Social Assessment Independent With Assistance Dependant Pt lives: W/ Family Alone Caregiver Deficits: Deaf/HOH Blind/Vision Impaired Nursing Swallow Evaluation: 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 Yes Pass Fail Other: glasses N/A Not done N/A Type________________ Time ________________ Goals/ Things to watch out for: ED Pathway Initiated:__ N/A ________ Restraints Yes No Plan OR later today Precautions: L hip precautions RECOMMENDATION S Antibiotic Started: Homeless, No Care Issues: Wife dependent on pt. Unable to get a hold of Son. Pt worried about wife. Wife phone #123.123.1212 Son phone #234.234.2323 Special Equipment Needed: Labs or Medications to be done soon: See orders 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: Time: 4 Dispensing by non-proprietary name under formulary system is permitted, unless checked here: DATE: Today ATTENDING PHYSICIAN: 0800 Dr. Spencer UPI ID #3456 TIME: James Snow D.O.B. – 6/1 MRN: 78980098 ORDERING HEALTHCARE PROVIDER: Dr. Mitchell GME/UPI 1223 SERVICE: PAGER: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 Ortho Surgery 3567 CODE STATUS: Full ALLERGIES: Iodine, Morphine Admit to Ortho/Simulation Floor Admit height : 5’11” Admit weight: 86.3 Kg Diagnosis: preoperative L Hip fracture after fall PMH: DM type 2, COPD, Osteoporosis Vital Signs with CMS (circulatory, Motor, Sensory) checks q 4 hours and prn 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 Intake and Output q 8 hours Oxygen as needed for SpO2 < 92% Activity: Bedrest, HOB<30 degrees, Hip precautions Diet: NPO for surgery today Finger stick blood glucose q 6 hours Send CBC, BMP, Pt/PTT, UA, T & C for 2 units of PRBCs on call to OR done in ED 1 hour ago IV Infusions: NS at 75 ml / hr while pt is NPO Glyburide 5 mg orally once daily 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 Zofran 4 mg IV push every 8 hours as needed for nausea Dilaudid 1 mg IV push every 2 hours as needed for moderate-severe pain 4-10 given in ED 1 hour ago Tylenol 500mg orally every 4 hours as needed for mild pain 1- 3, HA, or temp greater 38 C Vancomycin 1 g IVPB x 1 on call to OR Measure and place TED hose -on call to OR Order and place SCDs -on call to OR (ORDERS CONT. on next page Page 1 of 2) IS x 10 every hour while awake –on call to OR Verified by: SIGNATURE/TITLE Dr. Mitchell MD Integration I Day 1 CEC/Sim Workbook 5 Title: Title: Date: Date: Time: Time: Dispensing by non-proprietary name under formulary system is permitted, unless checked here: 0800 ATTENDING PHYSICIAN: Dr. Spencer UPI ID # 3456 DATE: Today TIME: ORDERING HEALTHCARE PROVIDER: Dr. Mitchell SERVICE: Ortho Surgery PAGER: 3567 ALLERGIES: James Snow D.O.B. – 6/1 MRN: 78980098 GME/UPI 1223 CODE STATUS: Full 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 Dr. Mitchell MD SIGNATURE/TITLE Orders transcribed by: Title: Date: Time: Verified by: Title: Date: Time: Integration I Day 1 CEC/Sim Workbook 6 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 NS at 75ml/hr Started in ED 1 hour ago SS Continuous While patient is NPO Glyburide 5 mg orally once daily Vancomycin 1 g IVPB x 1 0900 On call to OR on call to OR Signature Sue Sterwart RN Initial Signature SS Integration I Day 1 CEC/Sim Workbook 7 Initial Signature Initial 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: PRN Medications 86.3 Kg Time Yesterday Today Tomorrow Page 2 of 3 given in ED 1 hour ago SS Albuterol 5mg Nebulized Treatment every 2 hours as needed OR Albuterol MDI Inhaler with spacer 2 puffs every 2 hours as needed given in ED 1 hour ago SS Dilaudid 1 mg IV push every 2 hour 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 Sue Sterwart RN Initial Signature SS Integration I Day 1 CEC/Sim Workbook 8 Initial Signature Initial 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: PRN Medications Insulin Sliding Scale 86.3 Kg Time Yesterday Today Tomorrow 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 given in ED 1 hour ago SS 231-250 Regular Insulin 6unit SQ >250 notify MD Signature Sue Sterwart RN Initial Signature SS Integration I Day 1 CEC/Sim Workbook 10 Initial Signature Initial 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 11 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______________ Size______________ RUE_____LUE______ Report given to:_____________________________________ ALLERGIES:____________________________________________ Site______________ Size______________ RUE_____LUE______ Patient Care Checklist: MAR updated ID band present RUE / LUE / RLE / LLE / Other__________ Antibiotics ordered /type ____________________________ Current Blood identification band present Antibiotic sent with patient RUE / LUE / RLE / LLE / Other__________ Blood refused Refusal form signed N/A Yes Eye wear removed Hearing aid removed NA NA Yes No NA Jewelry / Body piercing removed Blood glucose, most recent result__________ time_______ Documentation Verification No Yes Surgical consent on chart (within 90 days) No NA Anesthesia consent on chart Yes No Hospital Gown only SCD (sleeves) Labs drawn ____________________and sent at _________ Labs to be drawn in Pre-op/OR_______________________ No Yes Antibiotic given at _______ Labs “NO BLOOD” band on RUE / LUE / RLE / LLE / Other_______ Dentures / Partials MAR sent History and Physical on chart (within 30 days) Pre-procedure note on chart (if H & P > 7 days old) 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 Last Void Time_______________________________am / pm Last 24 hour I & O: I___________O____________ This shift’s I & O: I___________O____________ Vital Signs Time_______ Temp_______ B/P_______ HR_______ By whom:___________________________________________ Belongings form completed / Initiated Belongings sent with patient to OR / home with family Tubes Lumbar drain Ventriculostomy/Bolt Zero at____________________________________ RR_______ O2 Sat_______ Pain Scale_______ Cardiac monitoring Continuous Pulse oximetry Patient Precautions NG tube J-tube Dobhoff PEG tube/G-tube 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 Translator required Dialysis lines Translator ordered A/V fistula Other Notes: _____________________________________________________ Reason:__________________________________________ Integration CEC/Sim Workbook Signature InitialI Day 1Signature Initial 13