SIMULATION DESIGN & PLANNING TEMPLATE Scenario Chest Pain: Resident RN Program/Curriculum Specific Objectives: Recognize and manage a patient with chest pain in the acute care setting. Measurable Objectives (minimum 2, maximum 10) 1. Learner uses assessment to differentiate between DM, Abd. Pain and Cardiac Pain 2. Learner initiates Chest pain protocol. 3. Learner will strategize ways to stay within scope of practice while carrying out MD orders. 4. Learner will utilize chain of command in finding bed placement for transfer Instructor’s Name Janine Buis, Northwest Hospital & Medical Center Donna Wahbeh, Shoreline Community College Date Submitted Spring 2013 Will There Be Any Pre-Simulation Lecture? Orientation to lab, equipment, expectations Yes Duration 10 minutes Expected Scenario Time 15 minutes Expected Debrief Time 30 minutes Report and Information Provided To Participants Prior To Simulation Sam is on a general med/surg floor that does not have telemetry. Sam is a 65 y/o male who came in with c/o abdominal pain and constipation. He has been newly diagnosed with stage II colon cancer. After undergoing resection and anastomosis, he is POD 2. Past medical history includes Diabetes type 2, Hypercholesterolemia, MI (15 years ago). Today he has been c/o gas pain. Patient Information Patient Name: Age: Sam 65 Gender: Male Birth date: June 18 Weight: 195 Height: 5’7” ID band MR #00001234 Acct. # 1198765432 Hx. Present Illness: Sam is a 65 y/o male who came in with c/o abdominal pain and constipation. He has been newly diagnosed with stage II colon cancer. After undergoing resection and anastomosis, he is POD 2. 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 Social History: Retired assembler Support System:Wife & 3 grown children Allergies: None Immunizations: Current Past medical history: Diabetes type 2, Hypercholesterolemia, MI (15 years ago). Physical description of how you want the manikin to present at start of scenario? Moulage: Patient in hospital gown with slippers, HOB elevated with legs dangling over the side, call bell in hand. Diaphoretic face and arms. Assignment Of Roles (Please indicate below roles to be assigned): Primary Nurse Physician/ ARNP- Staff member Secondary Nurse Respiratory Therapy Family Member #1 Observer(s) 2 Unlicensed Assistive Personnel/CNA/MA Other: Supervisor or charge nurse Important Information Related To Roles: Physician insist on SBAR communication Supervisor/charge nurse: One of the objectives is this scenario is for the learner to stay within their scope of practice. Since it is outside of the learner’s scope to hang nitroglycerine, it will be your job to inform the nurse that there are no beds yet available and that you will provide a tele nurse to stay with the patient until a bed becomes available who will also hang and monitor the nitro drip. SIM Setup Mannequin IV site : High or Moderate fidelity manikin Site Left forearm Gauge 20 G Art Line Yes / No Fidelity (choose all that apply to this simulation) 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 Setting/Environment Med-Surg Props: Equipment attached to manikin: Primary IV Fluid running at 120 ml/hr O2 2l nc Monitor attached/ Type ID band Other Medications and Fluids: Oral Meds nitro SL, baby ASA IV Fluids Nitroglycerin drip, TPA IV Push Morphine sulfate IM/Subcut/Intradermal Other Diagnostics Available: X-Rays (Images) CXR pneumonia L Lung 12 lead EKG atrial fibrillation, ischemia Equipment available in room: Crash cart airway devices and emergency meds Fluids tray with clear fluids at bedside Incentive Spirometer IV tubing IV pump O2 delivery device non-rebreather, ambu, HHN, face mask available Defibrillator/Pacer Other: Other Props: box of tissues Documentation Forms: Full chart if available Flow Sheet MAR Standing (Protocol) Orders Chest Pain protocol and Respiratory emergency protocol Other H&P Significant Lab Values normal CBC and lytes, troponin slightly elevated, BNP and first cardiac enzyme normal Manikin to be used High or moderate fidelity with heart and lunch sounds Recommended Mode for Simulation Manual Programmed Manual/Programmed Hybrid Other 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 #1 Scenario Progression Outline Initial Amount Time in Initial Stage- 5 mins Signs T PR 37-110-14 BP 134/82 SPO292% Cardiac Rhythm chronic a fib Breath Sounds clear Abdominal Sounds hypoactive Other Symptoms: Eyes open Verbalization (Pt/Manikin Cues) I just got back from the bathroom and I don’t feel good, I am nauseous, my chest hurts Expected Interventions -Straighten patient in bed -Assess VS -Assessment of chest pain, respiratory, cardiac and relevant history Alternate or Incorrect Treatment Choice That Will Affect Outcome Doesn't do vitals, elevate HOB, apply O2 or get assistance. Confederate Actions/Additional Role Player Cues Wife at bedside asking simple questions of clarification or to be included in the discussions about her husband. MD with first call: When called MD (Instructor) will: -Order Morphine 1-8 mg IV every 30 minutes PRN for pain if nitro fails to work -Order EKG -Orders CBC, Troponin, CKMB, electrolytes and BNP -Demand report in SBAR format -Mention possible transfer to tele unit for further monitoring. -Wants call back with results. 2nd MD call: -Orders Nitroglycerin drip and transfer to tele 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 Correct Treatment Choice Stage 2 Timing Sequence Expected after assessment and Interventions return to bed Baseline Vital Signs -Apply nasal TPR 140-18 cannula at 2L BP 140/86 SPO294% -Elevate HOB Cardiac Rhythm afib Breath Sounds clear -VS Q 15 minutes Abdominal Sounds hypoactive -EKG Other Symptoms: -Chest pain Verbalization protocol My jaw hurts. Is this gas Nitro 3 tab SL from the surgery? with no relief BELCH! Pain will go from a -Call MD scale of 10 to7 but no total relief. Accelerate clock with meds. Correct Treatment Choice Stage 3 Timing Sequence Expected after places call to MD Interventions Baseline Vital -Reports SBAR to SignsTPR 130-16 MD, who orders BP 136/78 labs and views SPO296% EKG, orders Cardiac Rhythm a fib morphine and Breath Sounds clear mentions transfer Other Symptoms: to telemetry for possible MI. Verbalization: Relief of pain after -Nurse calls back second dose of MD with labs, morphine. Pain level verifies second now a 2. morphine given with relief. Alternate or Incorrect Treatment choice Stage 2A Timing Sequence Expected Interventions Baseline Vital Signs TPR 140-18 BP 150/92 SPO292% Cardiac Rhythm afib Breath Sounds clear Nurse should be Heart Sounds bounding seeking more Abdominal Sounds experienced hypoactive assistance. If Other Symptoms: follows orders Verbalization continue with Patient continues to scenario. verbalize about jaw pain, increases in severity and increase in diaphoresis. Now complains of nausea. Key for Roles: Wife in Blue Patient in Yellow MD in Green 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 Correct Treatment Choice Stage 4 Timing Sequence Expected Interventions Baseline Vital Signs -MD orders TPR 112-16 nitroglycerine IV BP 128/82 drip. SPO296% Orders telemetry Cardiac Rhythm Afib transfer, but no Breath Sounds clear beds available. Verbalization Telemetry bed not available. -Discussion with supervisor to provide telemetry nurse to stay with patient and hang nitroglycerine drip. 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 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. Participants 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). 7 SIMULATION DESIGN & PLANNING TEMPLATE Participant 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: ________________________________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ Participant 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). 8 SIMULATION DESIGN & PLANNING TEMPLATE Simulation Post-Assessment Methods Checklist Tests Evaluations Turning Point Jeopardy Other 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 . . .” Resources: Harvey, S. (2004) The nursing assessment and management of patients with angina. British Journal of Nursing 13(10), 598601. Smeltzer, S.C., Bare, B.G., Hinkle, J. L. & Cheever, K.H. (2010). Chapter 28 Management of Patients with Coronary Vascular Disorders. In Brunner & Suddarth’s textbook of medical-surgical nursing 12th ed (pp 755-796). Philadelphia: Lippincott Williams & Wilkins. 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 CHEST PAIN STANDING ORDERS ____ Call a Rapid Response and Notify Attending MD STAT Monitoring: ____ Assess vital signs stat and every 15 minutes while chest pain persists. ____ Cardiac monitor, oximeter ____ Oxygen via NC at 2-4 L Tests: ____ ECG ____ CBC, BMP, PT, PTT, CKMB and total CK, Trop I Medications: ____ ASA Dose 81 mg PO, chew ____ Nitroglycerine SL x3 if Systolic >90 Dose 0.4 mg PO ____ Morphine Sulfate 1-8 mg IV x3 every 30 minutes prn chest pain ____ NTG by infusion: 50 mg/250 cc D5W at 3mcg/min, titrate to pain and SBP > ___ torr ____ Heparin _____u bolus then infuse at ____ u/hr OR Lovenox ___ mg IV and ___ mg SQ ____ Metoprolol 5mg IV over 5 min, repeat x 2 additional doses (total 15 mg over 15 min) ____ Metoprolol 25 mg PO 60 min after IV metoprolol ____ other: _______________________________ IV: ____ Start one peripheral saline lock ____ other: _______________________________ 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 Medication Administration Record As Needed Medications Diagnosis Room/Bed# Drug, Dose, Route, Frequency 2400-0659 0700-1459 1500-2359 Printed name Initials Printed Name Initials Printed Name Initial Printed Name Initials Printed Name Initials Printed Name Initial 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 Medication Administration Record Scheduled Medications Diagnosis Room/Bed# Drug, Dose, Route, Frequency 2400-0659 0700-1459 1500-2359 Printed name Initials Printed Name Initials Printed Name Initial Printed Name Initials Printed Name Initials Printed Name Initial 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