Pediatrics - Asthma Management -School Age Child Senior level
Program/Curriculum Specific Objectives:
1. The learner will apply health assessment techniques to a school age client
2. The learner will use pharmacology knowledge to provide proper patient education
about prescribed medications
3. The learner will demonstrate safe medication administration in a pediatric client
4. The learner will apply principles of coordination of care in considering client referrals
4. The learner will apply principles of management of care in planning for ED discharge
5. The learner will apply appropriate therapeutic communication and interprofessional
communication techniques
Measurable Objectives
1. Learner completes a school age appropriate intake assessment including information
about drug/alcohol use
2. Learner asks child about use of “inhalants” and/or “huffing” frequency
3. Learner administers an IV piggyback medication on a syringe pump using proper
technique
4. Learner considers and evaluates child’s need for a referral to social work
5. Learner teaches the child how to administer his home medications using a
developmentally appropriate approach
6. Learner addresses inhalant abuse through client/support education and referral
Authors: Heather Bissmeyer, Swedish Medical Center;
Tiffany Jasperson, Seattle University College of Nursing
Date: Spring 2013
Will There Be Any Pre-Simulation Lecture?
Yes
Duration 15 min
Expected Scenario Time: 45 min Expected Debrief Time: 45-90 min
Report and Information Provided To Participants Prior To Simulation
This is a 10 year old male brought to the ED today by a friend’s parents for a sudden
onset of difficulty breathing, wheezing, coughing, dizziness, and a short loss of
consciousness. Reportedly, he was with his friend, when symptoms developed suddenly.
The client reports that he would normally use his albuterol inhaler, but he didn’t have it
with him at his friend’s house.
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
Background
This 10 year old male has had multiple clinic and emergency department visits for
asthma exacerbation and upper respiratory infections. Asthma diagnosed at age 2yrs. No
history of intubations or ICU admissions. Asthma managed at home with pulmicort mdi
and albuterol mdi. He has been in the foster care system since birth.
Assessment
Vital Signs: T 98.6F, HR 90, RR 34, BP 100/80, SPO2 93% on room air
General Appearance: Child appears of average height, weight, and nutrition for stated
age. He presents as shy, quiet, making little or no eye contact, and in moderate
respiratory distress.
Cardiovascular: Sinus rhythm, no murmurs
Respiratory: Nonproductive cough, tachypnea, subcostal, intercostal, and suprasternal
retractions, wheezing in all lung fields
GI: Active bowel sounds in all 4 quadrants
GU: No reported problems with urination. No current concerns.
Extremities: Moving all extremities well and symmetrically, good strength in grips,
arms, feet, and legs
Skin: Warm, dry, and pale. Flushed cheeks. No clubbing. Good turgor.
Neurological: Alert and oriented to person, place, and time; Pupils equal, round, and
reactive to light and accommodation. No neurological deficits. Shy and anxious. Shaky.
Pain: Reports of pain of 3-4 in his throat and lungs when he coughs
Labs: Capillary Blood Gas: pH 7.34, pCO2 49 mm Hg, HCO3 22 mEq
Medications: The respiratory therapist started James on Albuterol 9mg continuous neb inhalation x
1 hour per provider orders and it is still running
Recommendation:
Complete a more detailed history and physical regarding presenting symptoms.
Consider inhaled bronchodilator for wheezing and IV corticosteroid to decrease
respiratory inflammation
Reading Assignments:
 Review your nursing care of children textbook or the American Academy of
Pediatrics website (www.aap.org ) to read about the assessment, nursing care,
medications, and patient teaching involved in school-age children with Asthma.
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
 Review your nursing care of children textbook or the American Academy of
Pediatrics website (www.aap.org ) to read about: Developmental Milestones of
the School Age Child
 Review your nursing care of children textbook, mental health textbook, or X
regarding appropriate health screenings for drug/alcohol abuse in the school-age
child
 Review your nursing skills/procedures text on the procedure for IV drug
administration
 Review your pharmacology textbook or online formulary for information on
inhaled bronchodilators and inhaled and IV corticosteroids
Guiding Questions:
1. What is included in an ED intake assessment for a pediatric client?
2. What are reasons a school-age child might experience an asthma exacerbation?
3. What are current evidenced-based interventions for school-age children with
asthma?
4. What interprofessional services might be involved in the care of a school age
child with asthma in the ED? What are their roles?
5. What are risk factors associated with drug/alcohol abuse in pediatric clients?
Patient Information
Patient Name: James Evans
Age: 10 yrs.
Gender: Male
Birth date: April 7
Weight: 30 kg
Height: 136 cm
Hx. Present Illness: Presents to the emergency department with wheezing, coughing,
dizziness, and short loss of consciousness. Was with friend when symptoms developed
suddenly.
Social History: In foster care since birth – no biological parental involvement, Multiple
foster care homes.
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
Religion: None
Support System: Brought in to the emergency department by friend’s parents. Lives
with foster mom, dad, and two foster siblings
Allergies: NKDA
Immunizations: Unknown if up to date
Attending Physician: Dr. Heather Hill
Past medical history: Asthma diagnosed at age 2yrs. multiple emergency department
visits for wheezing and upper respiratory symptoms. No history of intubations or ICU
admissions. Asthma managed at home with pulmicort mdi and albuterol mdi.
Physical description of how you want the manikin to present at start of scenario?
Moulage:
Manikin dressed in baseball cap, jeans, t-shirt, too big shoes.
Have backpack and cell phone at bedside or in bed
Assignment of Roles (Color Key)
Primary Nurse
Physician/ Advanced Practice Nurse
Respiratory Therapy
Pharmacy
Social Services
Unlicensed Assistive Personnel/CNA/MA
Observer roles Developmental/Communication Focus, Positive Feedback Focus,
Constructive Criticism Focus, Safety Focus
Other: Friend’s parent or parents
Important Information Related To Roles:
Primary Nurse: Your role is as manager and coordinator of care. You may delegate
tasks to other appropriate personnel on the healthcare team.
Physician/ Advanced Practice Nurse: Your role is as the ED provider in this scenario.
You are busy, but kind. You know this client from his multiple ED visits, but need a
little reminding about his history. Your role in this scenario is to provide proper
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
medication and treatment orders to the nursing staff upon receiving a proper SBAR
report.
Respiratory Therapy Your role in this scenario is to conduct respiratory assessments and
recommendations to the healthcare team when necessary. You may be asked to initiate
and manage the respiratory interventions in this scenario.
Pharmacy: Your role in this scenario is to provide consultation for other members on the
healthcare team regarding medications and medication administration. You also may be
asked to provide patient/family education about new or discharge medications.
Social Services: Your role in this scenario is to provide consultation on the social needs
of this child during a crisis. Your emphasis is on assessing the child and family’s social
network and resource strengths and encouraging them to rely on those existing
resources. You also assess for areas of social service and network weakness and provide
suggestions on available social resources.
Unlicensed Assistive Personnel/CNA/MA: Your role in this scenario is to take vital
signs on the pediatric client and provide any basic care that is delegated to you. You can
provide input to the healthcare team from your perspective. If playing the role of an
MA, you can also be delegated to administer medications and/or perform teaching.
Other: Observer roles: If you have learners observing the simulation it is helpful to give
them active observation foci. These are suggestions and you can always add more:
 Developmental/Communication Focus: During the simulation, your role is to
observe and take notes for feedback on pediatric developmental issues that arise
Additionally you will take notes on your observations regarding team
communication and communication with the family and child
 Positive Feedback Focus: During the simulation, your role is to observe and take
notes on things that went well during the simulation (e.g. hand washing, working
as a team)
 Constructive Criticism Focus: During the simulation, your role is to observe areas
where the participating learners may want to improve in the future (e.g. more
detailed SBAR report). For this role, it is helpful to use statements like: “I
noticed” and “When I saw you do X, I didn’t understand why. Can you clarify
what you were thinking?”
 Safety Focus: During the simulation, your role is to observe and take notes on
safety issues that arise during the scenario (e.g. during medication administration)
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
Friend’s parents: Your role is to be kind and cooperative, but not very knowledgeable or
willing to get involved other than to get the child medical help. You are distressed as
you can’t get ahold of the foster parents. Your knowledge of the client is that he is
“troubled” but you think he is a “good kid who has just had a tough life.”
SIM Setup
Mannequin
IV site :
Pediatric simulator or task trainer arm
Site _Right hand_______ Gauge _22g___
Fidelity (choose all that apply to this simulation)
Setting/Environment
ER
Medications and Fluids:
IVPB: Dexamethasone per IV syringe pump
Labs Values: after drawn – capillary blood gas
Props:
Equipment attached to manikin:
O2 via continuous nebulizer
ID band
Other: IV saline locked with extension tubing
Documentation Forms:
Physician Orders
Flow Sheet
MAR
Triage Forms
Equipment available in room:
Crash cart c airway devices and emergency meds
Fluids
Other: IV syringe pump
Other Props:
Continuous nebulizer in place on child upon start of
scenario
Recommended Mode for Simulation
Manual/Programmed Hybrid
Manikin to be used: high fidelity pediatric manikin or
standardized patient
Significant Lab Values
Capillary Blood Gas
pH 7.34
pCO2 49 mm Hg
HCO3 22 mEq
Physician Orders
Dexamethasone 4mg IV x 1
Albuterol 9mg continuous neb inhalation x 1 hour
Upon discharge:
Albuterol 2 puffs (216 mcg) every 4 to 6 hours as
needed
Pulmicort flexhaler (budesonide) aerosol, powder 1
puff (180 mcg) twice daily
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
Scenario Progression Outline
Stage 1
Initial Amount
Time in Initial
Stage 0 - 5 mins
Baseline Vital
Signs
T PR 98.6, 90, 34
BP 100/80
SPO2 93%
Cardiac Rhythm
Sinus
Breath Sounds
wheeze, stridor
Heart Sounds
Normal, S1, S2
Abdominal Sounds
Normal
Other Symptoms:
Eyes open, half
closed, or closed
Trending:
VS ↑ or↓ over time
Verbalization
(Pt/Manikin
Cues)
Patient is
coughing and
still a little
dizzy and
“feels fuzzy”
He is quiet
and shy but
cooperative.
If asked, he
will admit to
“huffing” if
not in front of
friend’s
parents
Expected
Interventions
Wash hands
Check patient’s
ID band for
name and
birthdate
Incorrect
Treatment Choice
That Will Affect Outcome
Failure to ask about
allergies can lead to an
allergic reaction or negative
side effect to administered
medications.
Confederate
Actions/Additional
Role Player Cues
Friend’s parents are
concerned but visibly
uncomfortable. They
want the child to be
well-cared for, but feel
overwhelmed.
Ask about the
child’s allergies
to medications
Consider/discuss
issues of consent
due to parental
absence
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
Correct Treatment Choice
Stage 2
Timing Sequence
Expected
Interventions
Stage 1: 15 min
*1 hour time
acceleration from Stage
0
Baseline Vital Signs
T PR 98.6, 90, 34
Intake assessment
BP 100/80
of school age
SPO2 93%
child including
Cardiac Rhythm Sinus
questions about
Breath Sounds wheeze, drugs/alcohol
stridor
(e.g. inhalants and
Heart Sounds
huffing)
Normal, S1, S2
Abdominal Sounds
Removal of
Normal
continuous
Other Symptoms:
nebulizer and
evaluation of the
Verbalization
effect after it is
“I’m dizzy.” “I feel
complete.
fuzzy.” Coughing. “It’s
hard to breathe.” “I’m
Provide SBAR
feeling better with the
report to provider
nebulizer.”
Admit to the huffing if
If proper
asked not in the
information is
presence of the friend’s given to the
parents.
provider and in
SBAR format, the
provider should
order:
Dexamethasone
4mg IV x 1
Incorrect Treatment choice Stage 2a
Learners forget to remove nebulizer
Timing Sequence
Expected
Interventions
Stage 1: 15 min
*1 hour time
acceleration from Stage
0
Baseline Vital Signs
Learners remove
T PR 98.6, 90, 34
nebulizer and
BP 100/80
complete and
SPO2 93%
evaluation of the
Cardiac Rhythm Sinus
treatment including
Breath Sounds wheeze, a full set of vital
stridor
signs.
Heart Sounds
Normal, S1, S2
Provide SBAR
Abdominal Sounds
report to provider
Normal
Other Symptoms:
If proper
information is
Verbalization
given to the
“Can I take this off my provider and in
face? I think it is done.” SBAR format, the
provider should
order:
Dexamethasone
4mg IV x 1
Consider referral to
social work
Consider referral
to Social Work
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
Correct Treatment Choice
Stage 3
Timing Sequence
Expected
Interventions
Stage 2: 5 min
Baseline Vital Signs
T 98.6
Assessment of IV
P 108
site
R 26
BP 100/80
Administration of
SPO2 96%
IV
Cardiac Rhythm Sinus
dexamethasone
Mild expiratory wheeze
Heart Sounds
Normal, S1, S2
Abdominal Sounds
Normal
Other Symptoms:
Verbalization
“What are you doing
with my IV?” “Will it
hurt.” “That feels cold.”
Incorrect Treatment choice
Administer IV dexamethasone incorrectly by
fast direct IV push Stage 3a
Timing Sequence
Expected
Interventions
Stage 2: 5 min
Baseline Vital Signs
Call provider to
T 98.6
report medication
P 108
administration
R 26
error
BP 130/90
SPO2 96%
Cardiac Rhythm Sinus
Mild expiratory wheeze
Heart Sounds
Normal, S1, S2
Abdominal Sounds
Normal
Other Symptoms:
Verbalization
“Hey can you leave me
alone.”
Correct Treatment Choice
Alternate Treatment choice
Learners teach child about dangers of huffers
Stage 4
and inhalants Stage 4a
Timing Sequence
Expected
Interventions
Timing Sequence
Expected
Stage 3: 10 min
Interventions
Stage 3: 10 min
T 98.6
P 108
Evaluation of
Baseline Vital Signs
Learners assess
R 26
respiratory
T 98.6
child for
BP 100/80
symptoms after
P 108
background of
SPO2 96%
previous
R 26
using huffers and
Cardiac Rhythm Sinus
interventions
BP 100/80
inhalants
Mild expiratory wheeze
SPO2 96%
Heart Sounds
If proper
Cardiac Rhythm Sinus
Assess readiness to
Normal, S1, S2
information is
Mild expiratory wheeze change behavior
Abdominal Sounds
given to the
Heart Sounds
Normal
provider and in
Normal, S1, S2
Teach child about
Other Symptoms:
SBAR format, the
Abdominal Sounds
the dangers and
provider should
Normal
effects of
Verbalization
order:
Other Symptoms:
huffers/inhalants
“So I need to do this
myself?” “Why do I
Albuterol 2 puffs
Considers or
have to learn this?”
(216 mcg) every 4
Verbalization
provides resources
to 6 hours as
“Can I go home now?” to child and or
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
needed
Pulmicort
flexhaler
(budesonide)
aerosol, powder 1
puff (180 mcg)
twice daily
Teaches child
about home
medication
administration at
a developmentally
appropriate level
“I don’t want to come
back here.” “But I feel
good when I huff.”
“This is how my friends
and I get away.” “We
escape this way.” “It’s
not gonna hurt me long
term.” “It’s just for
fun.” “I could stop if I
want.”
friend’s parents on
prevention and
recognition of
inhalant abuse
What will be discussed in Debrief?
 Student observers will provide feedback to the group on:
o Developmental/Communication Focus; What went well with the
developmental approaches of the team to the toddler? What went well with
team or foster parent communication? What might you do differently in the
future?
o Positive Feedback: What went well during your observation of this patient
care scenario?
o Constructive Criticism Focus: What would you like to see done differently?
o Safety Focus: Were there any safety issues that you observed? Please
describe what you noticed.
 When parents aren’t present, how does consent for care work with a pediatric
client?
 What resources did you have available in the ED to you to help you care for this
client (i.e. interprofessional team members, teaching materials, etc.)?
 What referral resources will be appropriate for this child in the community?
 What did it feel like to approach the child/family about drug, alcohol, inhalant
use? Why did you choose your particular approach? (e.g. child alone, friend’s
parents in room)
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
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).
11
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).
12
Simulation Post-Assessment Methods
Checklist
Tests
Evaluations
Turning Point
Jeopardy
Other
Literature References
Hockenberry, M. & Wilson, D. (Ed). (2011). Wong’s Nursing Care of Infants and Children, (9th
Edition). Mosby Elsevier: St Louis.
Hockenberry, M. (Ed.) (2011). Wong’s Clinical Manual of Pediatric Nursing, (9th edition). Mosby: St
Louis.
INASCL Board of Directors. (2011). Standard III. Participant Objectives. Clinical Simulation in
Nursing. 7(4), p. S10-S11, doi: 10.1016/j.ecns.2011.05.007)
INASCL Board of Directors. (2011). Standard VI: The Debriefing Process. Clinical Simulation in
Nursing. 7(4), p. s16-s17. doi:10.1016/j.ecns.2011.05.010
Jeffries, P. (2012). Simulation in nursing education: From conceptualization to evaluation. (2nd ed.).
New York, NY: National League for Nursing.
Jones, J. S., Fitzpatrick, J. J., & Rogers, V. L. (2012). Psychiatric mental health nursing: An
interpersonal approach. New York, NY: Springer.
Martinez, F. (2009). Managing childhood asthma: Challenge of preventing exacerbations. Pediatric,
123(3), p. S146 -S150. doi: 10.1542/peds.2008-2233D
National Heart, Lung, and Blood Institute. (2007) National Asthma Education and Prevention Program
Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Bethesda,
MD: National Institutes of Health. Retrieved from http://www.nhlbi.nih.gov/guidelines/asthma/
asthgdln.pdf
O’Malley, P. (2012). This pretty balloon might kill you: the rise of inhalant abuse and resources for
practice. Clinical Nurse Specialist, 26(4), p. 200-202. doi: 10.1097/NUR.0b013e31825d8f86
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
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).
14