Simulation Design Template: Butch Sampson-Simulation #1 Date: Discipline: Nursing Expected Simulation Run Time: approx. 20 minutes Location: Hospital File Name: Bradley Leonard “Butch” Sampson Student Level: Guided Reflection Time: twice the amount of simulation run time Location for Reflection: Admission Date: Yesterday | Today’s Date: Brief Description of Client Name: Bradley Leonard “Butch” Sampson Gender: M Age: 62 Race: Weight: 80 kg Height: 70 in Religion: No preference Major Support: None Support Phone: None Allergies: No known allergies Immunizations: Tdap (given today), Influenza (given today), Pneumoccocal (given today) Attending Physician/Team: Samantha Bell, MD Past Medical History: 62-year-old homeless veteran with documented exposure to Agent Orange during military service in Vietnam (1968-1969). Records from prior VA Hospital confirm diagnosis of Type 2 Diabetes with surgical removal of two toes on right foot last year. Reports he seeks intermittent care in whatever Emergency Department is nearest his location. History of Present Illness: Presented at the Healthcare for Homeless Veterans office two days ago with purulent drainage, edema, erythema, and ulceration of the great toe on the right foot. Blood Glucose 190 in the office with HgA1C of 8.9. Reports he received a prescription for oral diabetic medication last year at a prior VA, but only took it a few weeks before it was stolen. Social History: Reports he has been episodically homeless for several years. Served in the US Navy from 1968 to 1971. (History is significant for service time in Vietnam on Riverine Patrol Boat.) Reports he worked several years after honorable discharge from the Navy as a deck hand on various fishing operations, but lost his home and work opportunities as a result of Hurricane Katrina. Reports he has been married and divorced twice with no children. Parents and one brother are deceased. Was placed in transitional housing at a prior VA following his surgical amputation last year, but was evicted due to multiple “rule” violations involving possession of alcohol and smoking in his room. Reports he relocated here with his friend Joe to avoid harassment by individuals who were preying on “older” homeless men in the area. Primary Medical Diagnosis: Cellulitis right great toe, Diabetes Mellitus Type 2 Butch Sampson – Simulation # 1 © National League for Nursing, 2013 1 Surgeries/Procedures & Dates: Surgical debridement of right great toe yesterday Nursing Diagnoses: Impaired skin integrity related to surgical debridement of toe; infection related to cellulitis of toe; knowledge deficit related to medical dx of Type 2 Diabetes, dietary requirements, monitoring, medications; at risk for injury related to hyperglycemia; housing deficit Psychomotor Skills Required Prior to Simulation Sterile dressing change Medication administration Blood glucose monitoring Cognitive Activities Required Prior to Simulation [i.e. independent reading (R), video review (V), computer simulations (CS), lecture (L)] Review care of patients with Type 2 Diabetes in textbook, including diet recommendations (R) Brehove, T., Joslyn, M., Morrison, S., Strehlow, A. J,. & Wismer, B. (2007). Adapting your practice: Treatment and recommendations for homeless patients with diabetes mellitus. Nashville: Health Care for the Homeless Clinicians Network. http://www.nhchc.org/wpcontent/uploads/2011/09/DiabetesMellitus.pdf Department of Veterans Affairs. (2012). Veteran diseases associated with Agent Orange. http://www.publichealth.va.gov/exposures/agentorange/diseases.asp Swift, C. S., & Boucher, J. L. (2005). Nutrition care for hospitalized individuals with diabetes. Diabetes Spectrum, 18(1), 34-88. doi: 10.2337/diaspect.18.1.34 http://spectrum.diabetesjournals.org/content/18/1/34.full.pdf+html Simulation Learning Objectives General Objectives 1. 2. 3. 4. 5. 6. 7. 8. Practice standard precautions throughout the exam. Employ effective strategies to reduce risk of harm to the client. Assume the role of team leader or member. Perform a focused physical assessment noting abnormal findings. Recognize changes in patient symptoms and/or signs of patient compromise. Perform priority nursing actions based on clinical data. Reassess/monitor patient status following nursing interventions. Perform within scope of practice. Butch Sampson – Simulation # 1 © National League for Nursing, 2013 2 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. Simulation Scenario Objectives 1. 2. 3. 4. Employ therapeutic communication. Assess knowledge of dietary recommendations related to disease process. Apply knowledge of disease process. Assess needs for discharge planning. References, Evidence-Based Practice Guidelines, Protocols, or Algorithms Used for This Scenario: American Diabetes Association. (2012). Standards of medical care in diabetes-2012. Diabetes Care 35(Supp 1), s11-s63. doi: 10.2337.dc12-s011. Beaulieu, A., & Fessele, K. (2003). Agent Orange: Management of patients exposed in Vietnam. Clinical Journal of Oncology Nursing, 7(3). Doi: 10.1188/03.CJON.320-323. Brehove, T., Joslyn, M., Morrison, S., Strehlow, A. J., & Wismer, B. (2007). Adapting your practice: Treatment and recommendations for homeless patients with diabetes mellitus. Nashville: Health Care for the Homeless Clinicians Network. http://www.nhchc.org/wpcontent/uploads/2011/09/DiabetesMellitus.pdf Department of Veterans Affairs. (2012). Veteran diseases associated with Agent Orange. http://www.publichealth.va.gov/exposures/agentorange/diseases.asp Fargo, J., Metraux, S., Byrne, T., Muley, E., Montgomery, A. E., Jones, H., & Culhane, D. (2012). Prevalence and risk of homelessness among US Veterans. Prevent Chronic Disease, 9, 110-112. doi: http://dx.doi.org/10.5888/pcd9.110112 Infectious Diseases Society of America. (2012). 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clinical Infectious Diseases 54. E132-e173. doi: 10.1093/cid/cis346 Nooe, R. M., & Patterson, D. A. (2010). The ecology of homelessness. Journal of Human Behavior in the Social Environment, 20 (2), 105-152. http://dx.doi.org/10.1080/10911350903269757 Butch Sampson – Simulation # 1 © National League for Nursing, 2013 3 O’Toole, T. P., Conde-Martel, A., Givvon, J. L., Hanusa, B. H., & Fine, M. J. (2003). Health care of homeless veterans. Why are some individuals falling through the safety net? Journal of General Internal Medicine, 18, 929-933. Swift, C. S., & Boucher, J. L. (2005). Nutrition care for hospitalized individuals with diabetes. Diabetes Spectrum, 18(1), 34-88. doi: 10.2337/diaspect.18.1.34 http://spectrum.diabetesjournals.org/content/18/1/34.full.pdf+html 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: see chart IVPB: see chart IV Push: IM or SC: Diagnostics Available: Labs X-rays (Images) 12-Lead EKG Other: Simulator Manikin/s Needed: Documentation Forms: Standardized patient or moderate fidelity or high fidelity wireless manikin. Right foot should Physician Orders be moulaged to represent diabetic ulceration of Admit Orders right great toe. Flow sheet Medication Administration Record Props: Moulage for diabetic foot ulcer or photo Kardex of surgically debrided foot ulcer, dressing Graphic Record change supplies, compression stockings, IV Shift Assessment medication. Triage Forms Code Record Equipment Attached to Manikin: Anesthesia / PACU Record IV tubing with primary line normal saline Standing (Protocol) Orders fluids running at 50 mL/hr Transfer Orders Secondary IV line Unasyn 1.5 grams Other: see chart materials running at 100 mL/hr IV pump Recommended Mode for Simulation: Foley catheter mL output (i.e. manual, programmed, etc.) PCA pump running Mode will not change for this scenario. Simulator Butch Sampson – Simulation # 1 © National League for Nursing, 2013 4 IVPB with running at mL/hr 02 Monitor attached ID band (date consistent with 62-year-old) Other: Equipment Available in Room: Bedpan/Urinal Foley kit Straight Catheter Kit Incentive Spirometer Fluids IV start kit IV tubing IVPB Tubing IV Pump Feeding Pump Pressure Bag 02 delivery device (type) Crash cart with airway devices and emergency medications Defibrillator/Pacer Suction Other: dressing change supplies; compression stockings 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 Clergy may be set manually or programmed or this simulation may be conducted with a standardized patient. Student Information Needed Prior to Scenario: Has been oriented to simulator Understands guidelines /expectations for scenario Has accomplished all pre-simulation requirements All participants understand their assigned roles Has been given time frame expectations Other: Important Information Related to Roles: One nurse can be responsible for the medication administration and one can be responsible for the dressing change. Dietary teaching can be shared. Observers may be in the room or in an observation room. Butch Sampson – Simulation # 1 © National League for Nursing, 2013 5 Unlicensed Assistive Personnel Code Team Other: Report Students Will Receive Before Simulation Time: 1130 Situation: Bradley Leonard Sampson is a 62-year-old patient of Dr. Bell. He prefers to be called “Butch.” He was admitted yesterday with cellulitis of great right toe and had surgical debridement of his right great toe shortly after admission. Background: Butch is a chronically and episodically homeless Navy veteran who presented yesterday at the Healthcare for Homeless Veterans office. The nurse practitioner referred him to the VA hospital after noting purulent drainage to his right great toe and noting blood glucose of 190. His HgA1C was 8.9 on admission. He reports that he had received a prescription for oral diabetic medication last year at a VA in another community, but only took it a few weeks before it was stolen. He has documented Agent Orange exposure from his service time in 1968-1969 on a patrol boat on the Mekong Delta in Vietnam. He says after he was discharged he worked as a deck hand for several years with various fishing operations, but lost his home and work opportunities in Hurricane Katrina. He has no known relatives. He says his parents and brother are deceased and although he was married and divorced twice he has no known children. Assessment: His vital signs are stable. His toe is pink. The surgical wound bed is red and left open to heal by secondary intention. Wound is approximate size of a quarter on its anterior aspect (pad of big toe, not the top) and ¾ of a centimeter deep . There is some sero-sanguinous drainage on the dressing. He’s getting Unasyn by IV piggyback every six hours and it’s about time for his next dose. Dr. Bell started him on Metformin 500 mg twice daily. He’s a long-time smoker and Dr. Bell wrote him an order so he can go out and smoke after his nurse yesterday caught him smoking in his room. Recommendation: He didn’t fill out his choices for supper yet. Dr. Bell wants him on a medium caloriecarbohydrate consistent diet so you can help him look over the options and see what he understands about his diet. He needs his dressing changed on his foot and his next dose of Unasyn. We really need to begin his discharge planning and teaching. Dr. Bell hopes we can discharge him to transitional housing so she wants us to do as much teaching as we can, given the limitations of his potential return to homelessness. He was in transitional housing for a little while last year, but left because he says there were too many rules. The social worker is trying to arrange some “low demand” housing options. Significant Lab Values: refer to chart Physician Orders: refer to chart Home Medications: refer to chart Butch Sampson – Simulation # 1 © National League for Nursing, 2013 6 Scenario Progression Outline Timing (approx.) 0-5 min Manikin Actions Expected Interventions May Use the Following Cues Resting in a wheelchair with right foot elevated on a pillow. Greet patient, check ID. Introduce self. Wash hands. Establish therapeutic communication (interest and concern). Explain reason for assessments. Role member providing cue: Patient Cue: If pain assessment done, Butch says, “It doesn’t hurt as much as you’d think really. Only about a 3/10.” Remove dressing, assesses wound and reapply dressing using sterile technique. Administer IV medication. Assess knowledge of Type 2 Diabetes. Role member providing cue: Cue: Assess understanding of diet by helping Butch make selections from Role member providing cue: Patient Cue: “Hey, I’m hungry. Are they “You can just call me Butch.” (BP 120/80, pulse 80, resp 16, temp 98.6) 5-10 min Dressing intact with slight amount of drainage. “How’s my foot looking? It’s the only way for me to get around so I hope it heals up good. The doctor said she’d give me some kind of special shoe or boot to wear when I leave.” “I know if you don’t take care of diabetes lots of bad things can happen – like these toes -- and you can go blind. That’s kinda scary.” Answers questions appropriately. If students ask personal questions about why he is homeless or specifics about his military combat patient will say, “That’s none of your business.” 10-15 min “I know I should try to eat better, but it’s hard to get the right things that are really good for you at the soup kitchen. We get a lot of spaghetti and Butch Sampson – Simulation # 1 © National League for Nursing, 2013 7 macaroni.” “I like fruits and vegetables and I’ve always liked fish, but that’s just not what they serve unless it’s tuna casserole.” “I tried that medicine they gave me down south, but if anyone sees you taking pills or shots, the next thing you know someone’s trying to steal from you no matter what the medicine is for.” 15-20 min “Hey, can one of you unhook me from some of this stuff so I can go out and smoke? That nurse got mad at me for smoking in here yesterday. That’s the problem…just too many rules in a place like this.” hospital menu. Assess knowledge of medications. Conduct dietary teaching. Gather further information for discharge planning Discuss and check orders. going to bring me dinner or do I need to go somewhere to get it?” Role member providing cue: Patient Cue: “You can look in my chart. The doctor said she’d write something about letting me go smoke.” 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. Have you ever served in the military, or do you know someone who has? If so, how did your personal experience with these individuals influence your participation in the scenario? 8. If you were able to do this again, how could you have handled the situation differently? Butch Sampson – Simulation # 1 © National League for Nursing, 2013 8 9. What did the group do well? 10. What did the team feel was the primary nursing diagnosis? 11. How were physical and mental health aspects interrelated in this case? 12. What were the key assessments and interventions? 13. Is there anything else you would like to discuss? Specific Debriefing Questions for this Scenario: 1. What does Butch know about his disease, prescribed diet and medications? 2. Will he be able to change his dressing and care for his foot? 3. What other information were you able to gather about Butch that will help in planning for his discharge? Butch Sampson – Simulation # 1 © National League for Nursing, 2013 9