Minnesota Simulation in Healthcare Education Professionals (M-SHEP)
Intestinal Obstruction Simulation
45 year old woman who was admitted yesterday with a small bowel obstruction.
Date:
Discipline:
Expected Simulation Run Time:
Location:
Admission Date: Today’s Date:
Brief Description of Patient:
File Name:
Student Level:
Debrief /Guided Reflection Time:
Location for Reflection:
Psychomotor Skills Required prior
to simulation:
Name: Emily Grace Gender: F Age: 45
Race:
Weight: ____kg
Height: ____cm
Religion:
Major Support:
Phone:
Allergies:
Immunizations:
Attending Physician/Team:
PMH:
- Hypertension
- Appendectomy 5 years ago
History of Present illness:
Emily Grace is a 45 year old woman who was
admitted yesterday with a small bowel
obstruction. She has a history of
hypertension, and an appendectomy 5 years
ago. She was admitted with a four day
history of abdominal pain and emesis- up to 5
per day.
Social History:
Cognitive Skills Required prior to
Simulation: i.e. independent reading (R),
video review (V), computer simulations
(CS), lecture(L)
1. Review information on NG tube
management—ensuring patency, how
tube functions, purpose of the tube,
etc.
2. Review the pathophysiology of
intestinal obstruction—small bowel
obstruction. What would you expect
to see?
3. Review head to toe assessment and
focused abdominal assessment.
Primary Diagnosis:
Surgeries/Procedures:
Simulation Learning Objectives:
1. Manage an NG tube: ensure patency, trouble shoot for malfunction, irrigate the tube, and
manipulate suction equipment.
2. Demonstrate and prioritize care for a patient with an intestinal obstruction.
Submitted 2007 – Updated 2015
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Minnesota Simulation in Healthcare Education Professionals (M-SHEP)
3. Recognize and correct medication errors.
Fidelity
Setting/Environment
o Med-Surg
Medications and Fluids
o IV Fluids: D5 0.45% NS with 20
mEq KCl/L at 125 cc/hr
Simulator Manikin/s Needed:
o Oral Meds:
Props:
Equipment attached to manikin:
o IV tubing with primary line D5 0.45%
NS with 20 mEq KCl/L fluids
running at 125 ml/hr
o Secondary IV line __ running at _
cc/hr
o IV pump
o Foley catheter ________cc output
o PCA pump running
o IVPB with Ceftrioxone 1 gm
o 02 _______
o Monitor attached
o ID band _______
Equipment available in room
o
o
o
o
o
o
o
o
o
o
o
o
o
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 devices type
Crash cart with airway devices and
emergency medications
o Defibrillator/Pacer
o Suction
o Other_________
Roles / Guidelines for Roles
o Primary Nurse
o Secondary Nurse
Submitted 2007 – Updated 2015
o IVPB: Ceftrioxone 1gm IV q8h
o IV Push: Dilaudid 1-2mg IV (or
IM) q6h PRN pain
o IM or SC: Dilaudid 1-2mg IM (or
IV Push) q6h PRN pain
Diagnostics Available
o
o
o
o
Labs
X-rays (Images)
12-Lead EKG
Other
Documentation Forms
o
o
o
o
o
o
o
o
o
o
o
o
Physician Orders
Admit Orders
Flow sheet
Medication Administration Record
Kardex
Graphic Record
Shift Assessment
Triage Forms
Code Record
Anesthesia / PACU Record
Standing (Protocol) Orders
Transfer Orders
Other Props
Recommended Mode for simulation:
Student Information Needed Prior
to Scenario:
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Minnesota Simulation in Healthcare Education Professionals (M-SHEP)
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Clinical Instructor
Family Member #1
Family Member #2
Observer/s
Physician / Advanced Practice Nurse
Respiratory Therapy
Anesthesia
Pharmacy
Lab
Imaging
Social Services
Clergy
Unlicensed Assistive Personnel
Code Team
Other
Important information related to
roles:
Critical Lab Values:
Physician Orders:
Admit simulation unit; dx- small bowel
obstruction
up as tol with assistance
NPO- may have ice chips
CBC, Lytes q day
D5 0.45% NaCl with 20mEqKCl/L @
125cc/hr.
Ceftrioxone 1 Gm. IV q 8 hr.
Ng to low continuous suction; may irrigate
PRN
Routine VS
Dilaudid 1 -2 mg IV or IM q 6 hrs. prn pain
Accurate intake & output
Submitted 2007 – Updated 2015





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
Report students will receive before
simulation:
Time:
Emily Grace is a 45 year old woman who
was admitted yesterday with a small bowel
obstruction. She has a history of
hypertension, and an appendectomy 5 years
ago. She was admitted with a four day
history of abdominal pain and emesis- up to 5
per day.
Patient rates pain at 6-8. Minimal relief from
Dilaudid. Patient is alert & oriented X 3.
Skin warm, dry and intact. NG drained 600
cc of dark brown green drainage from 23000600. UO = 75 cc- dark yellow color.
Abdomen quiet- hypoactive bowel sounds.
Abd tender to palpation over RUQ. Abd
distended. No stool or flatus.
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Minnesota Simulation in Healthcare Education Professionals (M-SHEP)
References, Evidence-Based Practice Guidelines, Protocols, or Algorithms
used for this scenario: (site source, author, year, and page)
http://www.acssurgerynews.com/specialty-focus/general-surgery/single-article-page/protocolfor-small-bowel-obstruction/a17d6c0db3f076ab244685ab264a52e1.html
Submitted 2007 – Updated 2015
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Minnesota Simulation in Healthcare Education Professionals (M-SHEP)
Scenario Progression Outline
Timing
Manikin Actions
(approximate)
When nurses enter the
room
Expected Interventions
May use the following
Cues:
Patient is vomiting, and moaning in
pain. NG is not attached to
suction—tubing is under patient’s
pillow.
Attach NG tube to suction. Assess
patency-and placement: bowel
sounds; test pH of secretions.
400 cc dark green secretions returned
after suction resumed
0.9% NS is hanging. Order is for
D50.45%NaCl with 20 mEq
KCL/liter @ 125cc/hr
establish correct IV solution
Role member providing
cue:
Husband
Cue: continues to demand
that nurse do something.
Provides cue that nothing
is coming out of NG tube.
Role member providing
cue:
Husband
Cue: IV usually has an
orange sticker on it
(medication added sticker)
Physician to be updated
Using SBAR format, student should
telephone physician with change in
patient condition.
Role member providing
cue:
Husband
Cue: prompt student that
his wife is not the same as
she usually is, and wonders
whether the doctor knows
this
.
Submitted 2007 – Updated 2015
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Minnesota Simulation in Healthcare Education Professionals (M-SHEP)
Scenario Progression Outline
Timing
Manikin Actions
Expected Interventions
(approximate)
May use the following
Cues:
Role member providing
cue:
Cue:
Role member providing
cue:
Cue:
Submitted 2007 – Updated 2015
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Minnesota Simulation in Healthcare Education Professionals (M-SHEP)
Debriefing / Guided Reflection Questions for this Simulation
Link to Participant Outcomes and Professional Standards
(i.e. QSEN, NLN {Nursing}, National EMS Standards {EMS}, etc.)
1.
2.
3.
4.
5.
What do you feel went well in this simulation?
What could have gone better?
Did you have the knowledge and skills to meet the objectives?
For observers: what things might you have done differently?
How did it feel to try and do what is right for the patient while having a family member be
upset with you? How can you handle this situation?
6. What does the team feel was the primary nursing diagnosis? (fluid volume deficit)
Preparation questions –
A. You are caring for a patient who has an NG tube to continuous low suction. As you enter the
room, you notice that the patient has vomited 100 cc of light green fluid. The most important
initial intervention is:
1. Check the MAR for an anti-emetic.
2. Check the NG tube placement.
3. Add the emesis to the total shift output.
4. Ask the patient if she still feels nauseated.
The answer is 2. Vomiting should not be experienced with the use of an NG tube. Tube
placement should be assessed. Option 1 is not the initial intervention and options 3 and 4
are not the most important interventions.
B. You are caring for a patient who was admitted with an upper GI bleed. The patient has an
NG tube to continuous low suction, and has an order for Mylanta 20 cc via NG tube q 4 hr.
You administer 30 cc of Mylanta at 0900. A priority follow-up nursing intervention is to:
1. Maintain the tube to low continuous suction.
2. Document medication administration.
3. Ensure NG tube placement.
4. Clamp the NG tube for 30 minutes.
The answer is 4. It is important to clamp the tube for 30 minutes to allow for drug
absorption. Answer 1 is an on-going nursing action, option 2 should be done after drug
administration, and option 3 should have been done before medication administration.
C. Your patient is receiving continuous full strength formula tube feeding through an NG
feeding tube. The rate is 75 ml/hr and there are 100 ml left in the feeding bag. You are
preparing to administer the 0800 routine medications through the feeding tube. Which
technique is best in administering the 0800 medications?
1. Crush the medications, dissolve in water, and put in the feeding bag.
2. Crush the medications, dissolve in water, and give using a 50cc syringe.
3. Crush the medications, dissolve in water, and check tube placement.
Submitted 2007 – Updated 2015
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Minnesota Simulation in Healthcare Education Professionals (M-SHEP)
4. Crush the medications, dissolve in water, and check residual before giving.
The answer is 3. Tube placement should be checked before administration of
medication or formula feeding. Options 1, 2, and 4 do not describe the best technique
Submitted 2007 – Updated 2015
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Minnesota Simulation in Healthcare Education Professionals (M-SHEP)
Metro Alliance Nursing Simulation Task Force
SIMULATION SCENARIO
Intestinal Obstruction
Student Copy
LEARNING OBJECTIVES
1. Manage an NG tube: ensure patency, trouble shoot for malfunction, irrigate the tube, and
manipulate suction equipment.
2. Demonstrate and prioritize care for a patient with an intestinal obstruction
3. Recognize and correct medication errors
SUPPLIES NEEDED
Stethoscope
Medical-Surgical text if desired
PATIENT DATA
Emily Grace is a 45 year old woman who was admitted yesterday with a small bowel
obstruction. She has a history of hypertension, and an appendectomy 5 years ago. She was
admitted with a four day history of abdominal pain and emesis – up to 5 per day.
Physician orders are as follows:
- Admit medical/surgical floor; dx – small bowel obstruction
- Up as tolerated with assistance
- NPO – may have ice chips
- CBC, Lytes q day
- D5 0.45% NaCl with 20 mEq KCl/L @ 125 ml/hr
- Ceftrioxone 1 Gm IV q 8 hr
- Dilaudid 1-2 mg IM/IV q6h prn pain
- NG to low continuous suction; may irrigate PRN
- Routine VS
- Accurate intake and output
REFERENCES
http://www.acssurgerynews.com/specialty-focus/general-surgery/single-article-page/protocolfor-small-bowel-obstruction/a17d6c0db3f076ab244685ab264a52e1.html
Submitted 2007 – Updated 2015
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