SIMULATION DESIGN & PLANNING TEMPLATE
Scenario Name: Pneumonia (Target audience: Resident RN & RT)
Program/Curriculum Specific Objectives:
Focus on interdisciplinary problem solving: mucous plug
Measurable Objectives
1. The learner(s) will properly identify self and communicate plan of care to patient
throughout scenario, attend to all aspects of safety including PPE and hand hygiene.
2. The learner(s) will note patient distress, and perform proper respiratory assessment.
3. The learner will attempt suction with proper technique.
4. The learner(s)will call RT and complete SBAR communication: properly identifying
themselves, the patient, the patient’s diagnosis, include that the patient has a trach, thick mucus,
attempt to suction with little improvement, report lung sounds, respiratory effort, cough, current
vital signs and SPO2, immediate problem of respiratory distress. Learner will convey urgency of
situation, and request RT’s immediate presence.
a. RT will ensure he/she understands: clarify current RR, SPO2, severity of patient care
needs
b. RT will instruct RN to increase FIO2 until he/she arrives
c. Ascertain if RN has attempted suction, if not, suggest it
5. Respiratory therapy will arrive, perform assessment, communication will be
professional, direct, and prioritized to key data points (agree on assessment findings,
treatment plan)
6. The learner and RT will share tasks including: admin of albuterol/acetylcysteine via
nebulizer, increase oxygen, reassure patient and explain procedure, call MD.
7. The learners will review CXR and recognize significant mucous plug.
Authors Names’: Elizabeth Hinkson Renton Technical College
Scott Mahoney Providence Regional Medical Center
Date Submitted Spring 2013
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
1
SIMULATION DESIGN & PLANNING TEMPLATE
Will There Be Any Pre-Simulation Lecture?
Yes
Duration: 10 minutes
Expected Scenario Time: 20 minutes Expected Debrief Time:
30 minutes
Report and Information Provided To Learners Prior To Simulation
Face sheet (see attached), MD orders (see attached), patient history (see attached),
(review of systems as report-see attached)
Report will include the information below, as well as the information that the Patient
just had a portable CXR d/t increased RR. Radiology will call them with CXR results.
In order to ensure that learners must critically think and problem solve on their own, we
recommend that calling a rapid response NOT be an option.
“This is Valencia Johnson, a 73 year old African American lady admitted through the
ER a few days ago with right sided pneumonia. She is a full code. She’s had COPD for
about 8 years. She has a tracheostomy but hasn’t taken care of it and that is the likely
source of the pneumonia. She’s underweight and seems withdrawn.
Review of systems:
Neuro: The patient is A&O * 3, but nonverbal. She communicates by writing.
CV: Heart sounds are normal, pulses are present, and there is some edema (1+ or 2+)
Her skin is cool with decreased hair growth.
Resp: Lungs sounds are diminished; she has a lot of thick sputum which she has trouble
expectorating. Her respiratory rate is in the 20’s with marked increase in effort. Her sat
is in the upper 80’s to low 90’s.
GI: Positive bowel sounds and dentures. She says she is too tired to eat. She has lost
about 25 pounds without trying.
GU: Urge incontinence
Skin: is intact but will need watching for pressure areas
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
2
SIMULATION DESIGN & PLANNING TEMPLATE
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
3
SIMULATION DESIGN & PLANNING TEMPLATE
Patient Information
Patient Name:
Valencia Johnson
Age: 52
Birth date: 02/29/19XX
Gender:
F
Height:
Weight:50.9 Kg
5 ft 2in
ID band MR #986723-8 Acct. #
x. Present Illness: The Patient was admitted through the Emergency Department with a recurrence
of severe dyspnea and probable pneumonia. She has had her tracheostomy for about 16 months and
documentation from the ED suggests that it has been poorly managed. It seems that the inner cannula
had neither been cleaned or changed in at least a week and it was a bit surprising she hadn’t occluded it
with mucous. The patient reports some improvement in her shortness of breath now that the situation
has been rectified, but she still is observed to be using accessory muscles. She is requiring more
oxygen than usual.
Social History:
Incidentally, she is reporting some self-image concerns. She seems to think her
grandchildren are afraid of her and this is why they do not visit. She spent about 3 months in rehab
and has been living at home with home health assistance. Her husband is a former accountant with
health issues of his own and their family lives in Atlanta. Social Service will need to consult as there
has been some question about the suitability of the home environment for Mrs. Johnson.
Religion:
Baptist
Support System: Husband/home health
Allergies:
PCN
Immunizations: Needs PNA and flu vaccine before discharge
Attending Physician:
Michelle Toth, MD
Past medical history:
She has been treated for emphysema for about 12 years. She smoked
from the age of 16 to about 45. She experiences dyspnea with ADL’s and frequent fatigue that
prevents her from leaving her home. She says she has occasional coughing fits, generally in the
morning. Her FEV 1 is 45% of predicted. She is noted to have lost 25 pounds in the past 18 months
without trying. CXR shows hyperinflation and right lower lobe pneumonia. A sputum sample will be
sent. More troubling, Mrs. Johnson has 2+ peripheral edema of the lower extremities and some mild
JVD.
About a year and a half ago, Ms. Johnson received a tracheostomy following a case of ARDS
that occurred during treatment of a strep A pneumonia. She was on the ventilator for about 13 days
prior to the tracheostomy and for another 16 after.
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
4
SIMULATION DESIGN & PLANNING TEMPLATE
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
5
SIMULATION DESIGN & PLANNING TEMPLATE
Physical description of how you want the manikin to present at start of scenario?
Moulage:




Middle-aged African American woman
Dressed in a hospital gown
Use black wig, lipstick/eye shadow to denote gender
Sputum for trach, soiled trach dressing
Assignment Of Roles (Please indicate below roles to be assigned):
Primary Nurse
Respiratory therapist (Primary)
Observer(s)
Secondary Nurse
Respiratory therapist (Secondary)
Physician available via phone
Important Information Related To Roles:
Secondary role is supportive and to assist with problem solving, collaboration and to
accept delegated responsibilities.
Observers are responsible for noting specific behaviors as noted on checklist.
Physician/charge role is primarily via phone and should be played by instructor. This
role redirects learners to proper treatment, appropriate action.
SIM Setup





Size 4 shiley dct tracheostomy
Foam trach tie
Trach collar with aerosol delivery
Small volume nebulizer with delivery source
Acetylcysteine, albuterol for nebulizing
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
6
SIMULATION DESIGN & PLANNING TEMPLATE
Fidelity (choose all that apply to this simulation)
Setting/Environment
Med-Surg
Props:
Equipment attached to manikin:
Foley catheter 100 ml output; Urine color yellow
O2 40% cool aerosol (O2 flow meter at 15L/min)
Monitor attached: Bedside monitor “big numbers”
ID band
Other: BVM
Equipment available in room:
O2 delivery device 40% cool aerosol
(O2 flow meter at 15L/min)
Suction
Other: Ambu bag, trach obturator, suction kits (2) trach
care kits (2), normal saline 250ml, inner cannula (2), spare
trach in box
Other Props: Large purse with bible, glasses on chain
Medications and Fluids:
Other: Small volume nebulizer and unit dose
albuterol, Acetylcysteine, and saline
Physician Orders see attached
Significant Lab Values see attached
Diagnostics Available:
Labs Values (CBC, ABG, Chem 7) see attached
X-Rays (Images) (See attached)
Documentation Forms:
Physician Orders
MAR
Shift Assessment
Other: face sheet and history
Recommended Mode for Simulation
Manual
Manikin to be used Simman 3G (high fidelity)
Scenario Progression Outline
Verbalization Expected
Incorrect
Confederate
(Pt/Manikin
Interventions
Treatment Choice
Actions/Additional
Cues)
That Will Affect Outcome
Role Player Cues
Patient
verbalization
Baseline Vital Signs Patient NonIntroduce self If learners fail to recognize
Respiratory Therapy
TPR: 39C/102.2F,
Verbal.
and state
that patient is in distress,
and Physician available
108, 28
purpose of
patient will patient will
via phone.
BP: 162/86
Has a note
visit.
exhibit signs of increasing
SPO2: 84% on
pad that says
distress including; increased IF the physician is
40% cool aerosol
“I can’t
Perform Hand HR with increased ectopy,
called, the physician
trach collar
breathe. Help Hygiene
increased RR, increased BP will order a RT consult
Cardiac Rhythm ST me.”
and decreased SpO2,
with PACs
Recognize
increased cough.
IF a rapid response is
Breath Sounds
Patient is non- If fluids are available,
called at this point, the
Course crackles on
verbal and in
patient may cry as well.
hospital operator will
(L)
distress
report that the rapid
Absent breath
response is already
sounds on (R)
Raise head of
occupied in a different
Heart Sounds
bed.
location and will not be
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
7
Stage 1
Initial Amount
Time in Initial
Stage- 5 mins
SIMULATION DESIGN & PLANNING TEMPLATE
normal S1, S2
Abdominal Sounds
normal bowel
sounds
Other Symptoms:
Eyes open, frequent
coughing
Encourage
Cough and
deep breath
able to arrive for
several minutes.
Increase FiO2
Perform
respiratory
assessment
Identify need
for suction
Properly
perform
suctioning in a
timely manner
Correct Treatment Choice:
Incorrect Treatment choice:
Expected
Expected
Stage 2
Stage 2A
Timing Sequence
Interventions
Timing Sequence
Interventions
5 minutes
5 minutes
Baseline Vital Signs
Realize that
T 102.2 / 39
T 102.2 / 39
interventions are
P 128
Call RT with
P 124
unsuccessful.
R
36
proper SBAR
R
32
BP 182/94
Convey patient
BP 174/90
Call RT using
SPO2 76% on Current
data, interventions
SPO2 80% on current
SBAR:
FiO2 aerosol trach
performed, and
FiO2 aerosol trach
Convey priority
collar
severity of the
collar
patient data,
Cardiac Rhythm ST
situation
Cardiac Rhythm ST
interventions
with PVCs
with PACs
performed, and
Breath Sounds Breath
Breath Sounds
severity of the
Sounds
Course crackles on (L)
situation
Course crackles on (L)
Absent breath sounds on
Absent breath sounds
IF student calls
(R)
RT will respond
on (R)
MD, MD will
professionally and
Heart Sounds normal
direct student to
Heart Sounds normal
plan to arrive
S1, S2
call RT
S1, S2
ASAP
Abdominal Sounds
Abdominal Sounds
normal bowel
normal bowel
sounds
sounds
IF student calls
MD, MD will
Other Symptoms:
IF a rapid response
Other Symptoms:
direct student to
Eyes closed,
is called at this
Eyes open, rapid blink,
call RT
increasingly frequent
point, the hospital
increasingly frequent
coughing, crying and
operator will report
coughing
oral secretions,
that the rapid
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
8
SIMULATION DESIGN & PLANNING TEMPLATE
“difficulty breathing”
Verbalization
non-verbal
Correct Treatment Choice
Expected Interventions
Stage 3
Timing Sequence
5 minutes
Baseline Vital
Signs
RT arrives
T 102.2 / 39
P 124
Brief, accurate,
R
32
professional, specific
BP 174/90
communication
SPO2 80% on
Current FiO2
Collaborate and divide
aerosol trach collar tasks for patient care:
Cardiac Rhythm
recognize the
ST with PACs
probability of a
Breath Sounds
mucous plug, admin of
Course crackles on albuterol/acetylcysteine
(L)
via nebulizer, increase
Absent breath
oxygen, reassure
sounds on
patient and explain
(R)Heart Sounds
procedure, call MD.
normal S1,
S2
Abdominal Sounds
normal bowel
sounds
Other Symptoms:
Eyes open,
increasingly
frequent coughing
response is already
occupied in a
different location
and will not be able
to arrive for several
minutes.
Incorrect Treatment choice
Expected
Stage 3A
Timing Sequence
Interventions
5 minutes
Baseline Vital Signs
T 102.2 / 39
P 132
If interventions are
R 40
delayed, patient
BP 88/44
will worsen
SPO2 70% on current
FiO2
Charge nurse/ MD
Cardiac Rhythm ST
arrives to direct
with frequent PVC’s
care if care delayed
Breath Sounds
Course crackles on (L)
Absent breath sounds
on (R)Heart Sounds
normal S1, S2
Abdominal Sounds
normal bowel
sounds
IF a rapid response
Other Symptoms:
is called at this
Cyanosis and
point, the hospital
diaphoresis,
operator will report
increasingly frequent
that the rapid
coughing
response is already
Closed eyes
occupied in a
different location
Verbalization
and will not be able
non-verbal
to arrive for several
minutes.
Verbalization
non-verbal
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
9
SIMULATION DESIGN & PLANNING TEMPLATE
Correct Treatment Choice
Assess and Treat
Expected
Stage 4
Timing Sequence
Interventions
5 minutes
Baseline Vital Signs
T 102.2 / 39
Suction and
P 124
postural
R 32
drainage/percussion
BP 174/90
to (R) side
SPO2 80% on Current
FiO2 aerosol trach
collar
Cardiac Rhythm ST
with PACs
Breath Sounds
Course crackles on (L)
Absent breath sounds
on (R)Heart Sounds
normal S1, S2
Abdominal Sounds
normal bowel sounds
Incorrect Treatment choice
Other Symptoms:
Eyes open,
increasingly frequent
coughing
Stage 4A
Timing Sequence
5 minutes
Baseline Vital Signs
T 102.2 / 39
P 132
R 40
BP 88/44
SPO2 70% on current
FiO2
Cardiac Rhythm ST
with frequent PVC’s
Breath Sounds
Course crackles on (L)
Absent breath sounds
on (R)Heart Sounds
normal S1, S2
Abdominal Sounds
normal bowel sounds
Other Symptoms:
Cyanosis and
diaphoresis,
increasingly frequent
coughing
Closed eyes
Verbalization
non-verbal
Verbalization
non-verbal
Expected
Interventions
Charge nurse/ MD
arrives to direct
care if care delayed
States: “What is
the situation? Let’s
suction the
patient.”
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
10
SIMULATION DESIGN & PLANNING TEMPLATE
Correct Treatment Choice
End.
Expected
Stage 5
Timing Sequence
Interventions
5 minutes
Baseline Vital Signs
T 102.2 / 39
CXR is available
P 88
on screen for RN
R
28
and RT to review.
BP 136/82
SPO2 93% on current
Note white out of
FiO2 aerosol trach
R side.
collar
Cardiac Rhythm NSR
Note patient
with PAC's
symptom
Breath Sounds
improvement.
(L) side clear
(R) side diminished
Heart Sounds normal
S1, S2
Abdominal Sounds
normal bowel
sounds
Other Symptoms:
Eyes open,
Verbalization
non-verbal
What will be discussed in debrief:
 Did the learner recognize the gravity of the situation?
 Did the learner perform interventions, skillfully, calmly, and correctly?
 Was the patient kept informed?
 Was the SBAR complete?
 Did the learners demonstrate effective teamwork?
 Was the respiratory assessment completed properly by both professions, and were findings
shared?
 Were patient care responsibilities shared successfully and did both professions contribute
optimally?
 Did communication unnecessarily delay treatment of patient?
 Was there evidence of collaboration?
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
11
SIMULATION DESIGN & PLANNING TEMPLATE
 Did professional communication occur between disciplines AND include the patient?
 Did both disciplines fulfill their professional responsibilities, or did they defer to the other
discipline?
References:
Mandell, L.A, Wunderink, R. G., Anzueto, A., Bartlett, J. G., Campbell G. D., Dean N. C., Dowell
S.F., File T.M. Jr, Musher D. M., Niederman M.S., Torres A., Whitney C. G. (2007). Infectious
diseases Society of America/American Thoracic Society consensus guidelines on the management
of community-acquired pneumonia in adults. Clinical Infectious Diseases, 44 (Suppl 2), S27-72.
File, T. M., Bartlett, J. G., Thorner, A. R. (2013). Treatment of community acquired pneumonia in
adults who require hospitalization. UpToDate. Retrieved from
http://www.uptodate.com/contents/treatment-of-community-acquired-pneumonia-in-adults-whorequire-hospitalization
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
12
SIMULATION DESIGN & PLANNING TEMPLATE
Instructor Check List
(return to CHESC assistant at the end of class)
Pre-Scenario Check List
1.
2.
3.
4.
5.
6.
7.
8.
Equipment is staged as requested.
The learner has been oriented to the simulator.
The learner understands the guidelines/expectations for the
scenario.
Learners understand their assigned roles.
The time frame Expectations for simulation met: Yes No.
The time frame Expectations for debrief met:
Yes
No.
Audio/Visual Consent signed and turned into CHESC sheet.
Attendance sheet completed and given to CHESC staff.
Post Scenario
If you could change anything next time, what would it be?
Comments:
________________________________________________________
________________________________________________________
________________________________________________________
CHESC Assistant Name:
Did the person provide excellent support for the scenario?
Yes
No Comment
Instructor signature ________________________________
Date
________________________
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
13
SIMULATION DESIGN & PLANNING TEMPLATE
Learner Check List
(return to Instructor at the end of class)
Pre-Scenario Check List
1.
2.
3.
4.
5.
I have been oriented to the simulator.
I understand the guidelines/expectations for the scenario.
I understand the assigned role.
My questions about the simulation have been answered.
I have all necessary equipment for the simulation.
Post Scenario
If you could change anything next time, what would it be?
Comments:
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
Learner Signature ____________________________________
Date
________________________
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
14
SIMULATION DESIGN & PLANNING TEMPLATE
Simulation Post-Assessment Methods
Checklist
Tests
Evaluations
Turning Point
Jeopardy
Other
Optional Literature References
Debriefing Guidelines
(Remember to identify important concepts or curricular threads that are specific to your
program)
1. Leave the simulation room and go to a conference room, if possible. It allows for deescalation of emotions.
2. Solicit and validate emotions briefly. Validate simisms (the simulation isn’t 100% accurate
due to different equipment, personnel etc)
3. What went WELL in this simulation?
4. What DID NOT go well in this simulation?
5. If you could do it again, what would you do differently?
6. Summarize:
“What I hear you saying is . . .”
HEET V Grant Simulation Scenario Template 2013. Excerpts adapted and used by permission
from National League for Nursing's & Laerdal Medical Corporation's Simulation Design Template
(2008), and Northwest Medical Center's Scenario Planning Worksheet (last accessed March 2013).
15