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
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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.
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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
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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
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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.
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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
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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

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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?
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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?
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