Date:
Discipline: Nursing
Expected Simulation Run Time: approx.
20 minutes
Location: Hospital
File Name: Judy Jones
Student Level:
Guided Reflection Time: twice the amount of simulation run time
Location for Reflection:
Admission Date: 48 hours ago | Today’s Date: Thursday (day 3)
Name: Judy Jones
Gender : F Age : 85 Race : Weight : 52.3 kg Height : 67 in
Religion : Baptist
Major Support: Karen Jones (daughter) Support Phone: 555-555-5566
Allergies: Sulfa Immunizations: Influenza 3 months ago; Pneumonia 2 years ago
Attending Physician/Team: Annette Parks, MD
Past Medical History: Hypertension, cervical spondylosis, hyperlipidemia controlled by diet, and mild dementia manifested by short-term memory issues, sequencing and executive function deficits.
History of Present Illness: Illness began with a runny nose and non-productive cough six days ago. On day six, she went to the doctor’s office with a fever, shortness of breath, wheezing, and a productive cough. She was admitted from the doctor’s office and started on IV fluids and antibiotics.
Social History: Widow for seven years; lives at home with her daughter.
Primary Medical Diagnosis: Pneumonia
Surgeries/Procedures & Dates: Carpal tunnel surgery on left wrist at age 58, on right wrist at age 60.
Nursing Diagnoses: Ineffective breathing pattern, fluid volume deficit, risk for falls, risk for injury
Judy Jones
– Simulation # 2
© National League for Nursing, 2014
1


Assess and flush saline lock.

General head-to-toe assessment
[i.e. independent reading (R), video review (V), computer simulations (CS), lecture (L)]

Read information in textbook and lecture notes on community- acquired pneumonia, dementia and delirium, and care of confused older adult. (R) (L)

Basic knowledge of restraint alternatives. (R)(L)

Tools in the Try This: ® and How to Try This Series, available on ConsultGeriRN.org
( http://consultgerirn.org/resources ). Specific tools recommended for this scenario are the Mini-Cog TM, and Updated Beers Criteria. (R)
1. Practice standard precautions throughout the exam.
2. Employ effective strategies to reduce risk of harm to the client.
3. Assume the role of team leader or member.
4. Perform a focused physical assessment noting abnormal findings.
5. Recognize changes in patient symptoms and/or signs of patient compromise.
6. Perform priority nursing actions based on clinical data.
7. Reassess/monitor patient status following nursing interventions.
8. Perform within scope of practice.
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.
12. Apply the nursing process to initiate care of the Alzheimer’s patient.
1. Conduct a focused assessment.
2. Use updated Beers criteria to assess medications ordered for the patient.
3. Implement safety measures for a client experiencing confusion and delirium.
4. Implement restraint-free alternatives.
5. Assess and flush a saline lock.
6. Perform the Mini-Cog TM assessment.
Judy Jones
– Simulation # 2
© National League for Nursing, 2014
2

These and other tools in the Try This: ® and How to Try This Series are available on the ConsultGeriRN.org
( http://consultgerirn.org/resources ), the website of the Hartford Institute for Geriatric Nursing, at New York
University’s College of Nursing. The tool, an article about using the tool, and a video illustrating the use of the tool, are all available for your use.
Avoiding Restraints in Hospitalized Older Adults with Dementia:
Tool: http://consultgerirn.org/uploads/File/trythis/try_this_d1.pdf
Video: http://consultgerirn.org/resources/media/?vid_id=4475795#player_container
Mental Status Assessment of Older Adults: The Mini-Cog TM
Tool: http://consultgerirn.org/uploads/File/trythis/try_this_3.pdf
Video: http://consultgerirn.org/resources/media/?vid_id=4361918#player_container
Beers Criteria for Potentially Inappropriate Medication Use in Older Adults:
Tool: http://consultgerirn.org/uploads/File/trythis/try_this_16_2.pdf
Video: http://consultgerirn.org/resources/media/?vid_id=4852321#player_container
Article: Fick, D.M., & Semla, T.P. (2012). 2012 American Geriatrics Society Beers Criteria: New Year, New
Criteria, New Perspective. Available online at: http://www.americangeriatrics.org/files/documents/beers/Perspective_JAGS.pdf
Assessing and Managing Delirium in Older Adults with Dementia:
Tool: http://consultgerirn.org/uploads/File/trythis/try_this_d8.pdf
Video: http://consultgerirn.org/resources/media/?vid_id=4361983#player_container
Confusion Assessment Method (CAM)
Tool: http://consultgerirn.org/uploads/File/trythis/try_this_13.pdf
Video: http://consultgerirn.org/resources/media/?vid_id=4361983#player_container
Article: http://journals.lww.com/ajnonline/Fulltext/2007/12000/How_to_Try_This__Detecting_Delirium.27.as
px
Decreasing Patient Agitation:
Waszynski, C., Veronneau, P., Therrien, K., Brousseau, M., Massa, A. & Levick, S. (2013). Decreasing patient agitation using individualized therapeutic activities. AJN, American Journal of Nursing , 113 (10),
32-39. Available at: http://www.nursingcenter.com/lnc/CEArticle?an=00000446-201310000-
00024&Journal_ID=54030&Issue_ID=1606223
Therapeutic Activity Kits: http://consultgerirn.org/uploads/File/trythis/try_this_d4.pdf
Judy Jones
– Simulation # 2
© National League for Nursing, 2014
3

Review the Essential Nursing Actions in the ACES Framework at: http://www.nln.org/professionaldevelopment-programs/teaching-resources/aging/ace-s/nln-aces-framework
(choose all that apply to this simulation)
Setting/Environment:
ER
Med-Surg
Peds
ICU
OR / PACU
Women’s Center
Medications and Fluids:
IV Fluids:
Oral Meds:
IVPB:
IV Push: see chart
IM or SC:
Diagnostics Available: Behavioral Health
Home Health
Pre-Hospital
Other:
Labs
X-rays (Images)
12-Lead EKG
Simulator Manikin/s Needed:
Human patient simulator (e.g. SimMan, Vital
Sim) or standardized patient.
Props: Wrist restraints and a sleeve or stocking that could be placed over the arm should be noticeable in the room, such as on the nightstand or bedside table.
Equipment Attached to Manikin:
IV tubing with primary line running at mL/hr
Other:
Documentation Forms:
Physician Orders
Admit Orders
Flow sheet
Medication Administration Record
Kardex
Graphic Record
Shift Assessment
Triage Forms
Code Record
Secondary IV line
IV pump
Anesthesia / PACU Record
Standing (Protocol) Orders
Foley catheter mL output
PCA pump running
Transfer Orders
IVPB with running at mL/hr
02 2 L via nasal cannula
Other: Students will need copies of the Mini-Cog and CAM tools. You may provide them or assign
Monitor attached
ID band learners to retrieve them from www.consultgerirn.org
.
Other: Saline lock in left hand
Equipment Available in Room:
Recommended Mode for Simulation:
(i.e. manual, programmed, etc.) either
Bedpan/Urinal
Foley kit
Straight Catheter Kit
Student Information Needed Prior to Scenario:
Has been oriented to simulator
Judy Jones
– Simulation # 2
© National League for Nursing, 2014
4

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: Wrist restraints at bedside, stocking or sleeve that may be used to cover the IV site
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: 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
Unlicensed Assistive Personnel
Code Team
Other:
Time: 2300 Thursday, 48 hours after admission (day 3 of hospitalization)
Judy Jones
– Simulation # 2
© National League for Nursing, 2014
5

Situation: Judy Jones is an 85-year-old female patient of Dr. Annette Parks who was admitted 2 days ago with a diagnosis of community-acquired pneumonia. We are currently treating her with IV antibiotics and respiratory treatments.
Background: Ms. Jones has a medical history of hypertension that is controlled by spironolactone, cervical spondylosis - she takes ibuprofen for pain as needed, and hyperlipidemia that is controlled by diet. She has mild dementia manifested by short-term memory issues, and sequencing and executive functioning deficits.
During the day she is easily redirected, but earlier tonight was much more interesting. She went into the employee refrigerator and took two sandwiches back to her room and ate a little of each. Then she proceeded to take out her saline lock and placed it like a toothpick in one of the sandwiches. The resident on call doubled her dose of Ativan (lorazapem) to 2mg. She is sleeping now. I predict a calm night.
Assessment: Ms. Jones is alert and oriented to self. She needs to be reoriented often to place and time.
She is forgetful. Her vital signs at 2000 were temp 99.2, HR 96 and rhythm regular. RR was 24, BP 128/62.
Pulse ox was 95% on 2 liters of oxygen via nasal cannula. She frequently removes her cannula, and when she takes it off I have seen her pulse oximetry go as low as 90%. Upon auscultation she has rhonchi bilaterally and occasional wheezing. There are PRN respiratory treatments if she is wheezing. We are encouraging her to use the incentive spirometer every hour.
She is on a regular diet, and her appetite is good. Her abdomen is soft with positive bowel sounds; she had a bowel movement today.
Judy has been ambulating to the bathroom and urinating without difficulty. Her gait is steady. She forgets to reapply her nasal cannula when she gets back into bed after ambulating. Her skin looks good; there are no areas of breakdown. She has a saline lock in her left hand.
Recommendation: I would recommend checking on her frequently due to the forgetfulness and removing of the oxygen. It is important that we continually assess her respiratory status and encourage the incentive spirometry; her last albuterol treatment was at 1830.
When you go to assess Ms. Jones she will need her saline lock flushed and her Mini-Cog assessment completed. I was unable to do the Mini-Cog on her because she was asleep when I went back to reassess her after the lorazepam.
Significant Lab Values:
Physician Orders: refer to chart refer to chart refer to chart Home Medications:
Judy Jones
– Simulation # 2
© National League for Nursing, 2014
6

Timing
(approx.)
0-5 min
Manikin Actions
Patient is sleeping.
Temperature: 99
HR: 90
RR: 20
BP:132/60
Pulse ox: 94%
Expected Interventions

Wash hands and introduce self.

Wake and identify patient.

Introduce selves.

Take vital signs.
May Use the
Following Cues
Role member providing cue:
Patient
Cue: If students don’t introduce themselves,
Judy says. “Hey. do you know the date or the president?
They’re always asking me and I don’t know.”
Role member providing cue:
Cue:
5-10 min Patient has a productive cough of thin yellow sputum.
Lung Sounds: Rhonchi
During the assessment patient says, “Listening for quiet things” as the assessment continues “boom boom bap, scat goes the cat pushing, pressing coughing, making a pie.”
Patient attempts to pull out the IV site several times or says. “I’m taking this thing
OUT of my arm.”
Judy tries to get out of bed or says “I am getting OUT of this b ed and going HOME!”
Patient calms down and reorients for a short period with restraint- free interventions.

Assess patient.

Communicate therapeutically with client.

Implement restraint- free alternatives.
Judy Jones
– Simulation # 2
© National League for Nursing, 2014
7

10-15 min Judy says “What are you doing to me?”
15-20 min Judy draws a clock.
Completed clock drawing attached
Judy cannot remember any of the three words but responds “Meow…good kitty.”

Explain procedure in layman’s terms.

Administer the IV flush.
Role member providing cue:
Patient
Cue:
If students don’t explain what they are doing Judy says,
“HELP! They’re trying poison me!” and will start to pull at
IV site.

When Judy is calm, administer the Mini-
Cog.
Judy’s Clock Drawing:
Judy Jones
– Simulation # 2
© National League for Nursing, 2014
8

(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. If you were able to do this again, how could you have handled the situation differently?
8. What did the group do well?
9. What did the team feel was the primary nursing diagnosis?
10. How were physical and mental health aspects interrelated in this case?
11. What were the key assessments and interventions?
12. Is there anything else you would like to discuss?
Assess Function and Expectations:

What were you expecting when you entered the room?

Looking back, would you have communicated with Judy differently?

As a health care provider, how did it feel to maintain your professionalism with a patient who is confused and delirious?
Coordinate and Manage Care:

Besides medication, what other options can be used with a patient who is confused and delirious?

Are restraints an option?

Do you feel the safety measures you implemented for Judy were adequate?
Use Evolving Knowledge:
 What did you find when reviewing Judy’s medications using the updated Beers criteria?
 Do you think any of the medications contributed to the increase in Judy’s delirium?
Judy Jones
– Simulation # 2
© National League for Nursing, 2014
9


What conclusions can you draw by evaluating Judy with the CAM diagnostic algorithm?
Make Situational Decisions:
 Is Judy’s dementia becoming worse or is Judy experiencing an increased delirium? What evidence supports your answer?

What information do you get when you compare the clock drawing in the chart to the one Judy did today? What are appropriate interventions for a client experiencing delirium?
Judy Jones
– Simulation # 2
© National League for Nursing, 2014
10