Scenario Name
Pediatrics-Asthma Management- Toddler Junior level
Program/Curriculum Specific Objectives:
1. The learner will apply health assessment techniques to a pediatric client with
respiratory symptoms
2. The learner will use pharmacology knowledge to provide proper patient and family
education about prescribed medications
3. The learner will demonstrate safe medication administration in a pediatric client
4. The learner will apply principles of health promotion, maintenance, and teaching with
a pediatric client and family member
5. The learner will apply appropriate therapeutic communication and interprofessional
communication techniques
Measurable Objectives
1. The learner will demonstrate a focused respiratory assessment on a pediatric patient
2. The learner will administer a metered dose inhaled drug to a pediatric patient using
proper technique
3. The learner will provide an appropriate SBAR report to the ARNP or MD and obtain
an order for MDI bronchodilator and oral prednisone.
4. The learner will provide teaching to the patient and family using a developmentally
appropriate approach regarding oral corticosteroid administration
5. The learner will provide teaching to the patient and family using a developmentally
appropriate approach regarding use of a metered dose inhalation system
Author: Heather Bissmeyer, Swedish Medical Center
Tiffany Jasperson, Seattle University College of Nursing
Date: Spring 2013
Will There Be Any Pre-Simulation Lecture?
Yes
Duration 30 min
Expected Scenario Time: 30 min
Expected Debrief Time:
60 min
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
Report and Information Provided To Participants Prior To Simulation
Situation
This is a 2 year old male brought to the clinic today by his foster father/mother for
runny nose and cough x 10 days. The foster parent reports using over the counter
medications like acetaminophen and ibuprofen to help but the child “isn’t getting better”
and reportedly has “noisy breathing.”
Background
This 2 year old male has had multiple clinic and emergency department visits for
wheezing, stridor, and chronic ear infections. He has received albuterol nebulizer
treatments, albuterol metered dose inhaler treatment, and antibiotics for these past
medical issues. He was a 36 week premie and the birth mother had no prenatal care.
Assessment
Vital Signs: T 98.9F, HR 110, RR 32, BP 90/60 SPO2 95% on room air
General Appearance: Child appears of average height, weight, and nutrition for stated
age. He presents as shy, anxious, and in mild respiratory distress.
Cardiovascular: Sinus rhythm, no murmurs
Respiratory: Clear mucus draining from nose, watery eyes, cough, wheezing in lower
lobes
GI: Active bowel sounds in all 4 quadrants; foster parent reports child’s eating and
drinking has decreased but is still adequate
GU: Wet diaper
Extremities: No difficulties with ambulation; moving all extremities freely and
symmetrically
Skin: Warm, dry, and pale. Good turgor.
Neurological: Alert and oriented to person, place, and time as age appropriate; Pupils
equal, round, and reactive to light and accommodation. No neurological deficits. Shy
and anxious.
Pain: Denies pain. Score of 2-3 on FLACC pediatric pain scale.
Recommendation:
Complete a pediatric sick clinic visit assessment and focused respiratory assessment.
Report findings to provider and consider treatment of respiratory symptoms and family
education about respiratory illness/disease pending assessment findings.
Guiding Questions:
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
1. When caring for a child presenting with upper respiratory symptoms including
wheezing, what kind of assessment that should be completed by the nurse?
Describe.
2. How can the nurse foster trust and cooperation with a toddler during a physical
examination?
3. What are the common and current evidenced-based treatments including
medications for pediatric patients with wheezing and Asthma?
4. What are the developmental milestones during toddler years?
5. What health promotion topics are important to a family with a toddler?
Reading Assignments:
 Please use 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 young children with Asthma.
 Please use your nursing care of children textbook or the American Academy of
Pediatrics website (www.aap.org ) to read about: Developmental Milestones of
the Toddler
 Please use your pharmacology textbook or online formulary to review inhaled
bronchodilators and corticosteroids and oral corticosteroids
Patient Information
Patient Name: James Evans
Age: 2yrs
Gender: Male
Birth date: April 7
Weight: 12.6 kg
Height: 86cm
Hx. Present Illness: Presents with runny nose and cough for 10 days.
Social History: Foster Care – no biological parental involvement
Religion: None
Support System: Foster Father (or Mother) in Room
Allergies: NKDA
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
Immunizations: Up to date
Attending Physician: Dr. Heather Hill
Past medical history: This 2 year old male has had multiple emergency department
visits for wheezing, stridor, and chronic ear infections. He was a 36 week premie and
mother had no prenatal care.
Physical description of how you want the manikin to present at start of scenario?
Moulage:
Patient Picture:
Toddler shirt and sweat pants
Old torn up blanket
Assignment of Roles (Color Key)
Primary Nurse
Secondary Nurse
Physician/ Advanced Practice Nurse
Family Member
Unlicensed Assistive Personnel/CNA/MA
Other: Observer roles of Developmental/Communication Focus, Positive Feedback
Focus, Constructive Criticism Focus, Safety Focus
Important Information Related To Roles:
Primary Nurse: This person takes the nurse leadership role in the scenario. The person
in this role may delegate the assessment, medication administration, and patient
teaching to other members of the healthcare team. You may provide SBAR report to
other healthcare team members.
Secondary Nurse: The person in this role may take delegation from the primary nurse
and may provide hands-on nursing care including assessment, interventions, and
teaching. You may provide SBAR report to other healthcare team members.
Family Member: This person takes on the role of the foster father or mother. You are
loving and caring toward your foster son and are concerned about him and his difficulty
breathing. You want to learn about his asthma, his medications, and his needs, but are
cognizant that you may only be in his life for a short time. You have only had “James”
in your care for a couple of months now. You will need to be able to answer questions
about his history, but can’t provide all information as you haven’t had him that long.
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
You know that he has had multiple visits to the doctor for stridor/wheezing. You are a
nonsmoker.
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.
Physician/Advanced Practice Nurse: Your role in this scenario is to provide proper
medication and treatment orders to the nursing staff upon receiving a proper SBAR
report. You are a collaborative provider and enjoy working with new nurses and taking
the opportunity to teach them about pediatric care and clients.
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)
SIM Setup
Moulage:
Moulage for Manikin/Standardized Patient: Dress child manikin or standardized patient in a simple
shirt and sweatpants and give the child an old torn-up blanket that looks “well-loved.” This is an
outpatient clinic setting, so the ID band is optional.
Moulage for Room Set-up: The simulation room should be set up to look like an outpatient clinic
setting with health education posters on the wall, toys, children’s books, puzzles, and/or childhood
magazines. An exam table or stretcher should be used if available and covered with exam paper rather
than a hospital bed. Pediatric examination equipment should be made available in the room: pediatric
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
stethoscope, pediatric sphygmomanometer, otoscope (with pediatric sized probe-covers),
ophthalmoscope, and tympanic or temporal artery thermometer
Fidelity (choose all that apply to this simulation)
Setting/Environment
Other: Clinic
Medications and Fluids:
Oral Meds: Prednisone liquid
Other: Pulmicort nebulizer and albuterol metered
dose inhaler Albuterol
Other Props:
Metered dose inhaler, spacer, nebulizer or compressed air
on wall
Documentation Forms:
Other: Sick child clinic visit form
Recommended Mode for Simulation
Programmed
Manikin to be used: high fidelity, mid-fidelity or
standardized patient could be used for this scenario
Significant Lab Values: None
Physician Orders:
Albuterol 2 puffs (216 mcg) every 4 to 6 hours as
needed
Pulmicort respules (budesonide inhalation suspension)
0.5mg inhalation via nebulizer once daily
Prednisone 12 mg orally once daily for 3 days
Scenario Progression Outline
Stage 1
Initial Amount
Verbalization Expected
Incorrect
Confederate
Time in Initial
(Pt/Manikin
Interventions
Treatment Choice
Actions/Additional
Cues)
That Will Affect Outcome
Role Player Cues
Stage 0- 5 mins
Baseline Vital Signs Manikin/SP is Wash hands
Failure to ask about allergies Foster father/mother is
T PR 98.9, 110, 32
clutching an
can lead to an allergic
concerned about the
BP 90/60
old torn up
Check
reaction or negative side
child and is sitting at
SPO2 95%
blanket.
patient’s ID
effect to the Albuterol MDI. the child’s side. The
Cardiac Rhythm
Wheezing.
by asking
foster father/mother is
Sinus
Sneezing.
father the
cooperative with
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
Breath Sounds
Wheezing
Heart Sounds
Normal, S1, S2
Abdominal Sounds
Normal
Other Symptoms:
Eyes open, half
closed, or closed
Trending:
VS ↑ or↓ over time
Coughing.
Simple one
word answers
or no answer
indicating a
shy child.
patient’s name
and birthdate
Ask about the
child’s
allergies to
medications
Correct Treatment Choice
Stage 2
Timing Sequence
Expected
Interventions
Stage 1: 10 minutes
Baseline Vital Signs
Assess vital signs
T 98.9
P 110
Perform focused
R 32
respiratory
BP 90/60
assessment
SPO295%
Cardiac Rhythm Sinus
Notify provider of
Breath Sounds
abnormal vital
Wheezing
signs/assessment
Heart Sounds Normal
findings using
S1, S2
SBAR format
Abdominal Sounds
Normal
If correct SBAR
Other Symptoms:
report is given,
Verbalization
the provider
Wheezing. Sneezing.
should order:
Coughing. “Don’t’”
Albuterol 2 puffs
“Stop.” “No”
(216 mcg) every 4
to 6 hours as
needed
nurses. This is a new
foster family
assignment for the child
though, so the
father/mother doesn’t
know much about the
child’s history.
Incorrect Treatment choice Stage 2A
If vital signs or respiratory assessment is missed
Timing Sequence
Expected
Interventions
Stage 1: 10 minutes
Baseline Vital Signs
Assess vital signs
T 98.9
and respiratory
P 132
assessment.
R 34
SPO2 93%
Notify provider of
Cardiac Rhythm
abnormal vital
tachycardia
signs/assessment
Breath Sounds
findings using
wheezing
SBAR format
Heart Sounds
Normal, S1, S2
*If proper
Abdominal Sounds
information is not
Normal
given by the nurse
Other Symptoms:
to the provider or if
SBAR is not done,
Verbalization
medication orders
Silent or mumbling or
will not be given
whispering to father
If proper
information is
given to the
Pulmicort
provider and in
respules
SBAR format, the
(budesonide
provider should
inhalation
order:
suspension)
Albuterol 2 puffs
0.5mg inhalation
(216 mcg) every 4
via nebulizer once
to 6 hours as
daily
needed
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
Prednisone 12 mg
orally once daily
for 3 days
Pulmicort respules
(budesonide
inhalation
suspension)
0.5mg inhalation
via nebulizer once
daily
Prednisone 12 mg
orally once daily
for 3 days
Correct Treatment Choice
Stage 3
Timing Sequence
Expected
Interventions
Stage 2 - 5 minutes
Baseline Vital Signs
Administer
T 98.9
albuterol metered
P 120
dose inhaler to
R 30
patient
BP 92/66
SPO2 98%
Cardiac Rhythm Sinus
Breath Sounds
Wheezing
Heart Sounds Normal,
S1, S2
Abdominal Sounds
Normal
Other Symptoms:
Verbalization
“No” “Stop” “Go away”
Incorrect Treatment choice Stage 3a
Not administering albuterol MDI
Timing Sequence
Expected
Interventions
Stage 2 - 5 minutes
Baseline Vital Signs
Administer
T 98.9
albuterol metered
P 120
dose inhaler
R 34
BP 96/68
Notify the provider
SPO2 92%
of abnormal vital
Cardiac Rhythm Sinus
signs/assessment
Breath Sounds:
findings in SBAR
Increased inspiratory
format
and expiratory
wheezing
* If abnormal
Heart Sounds Normal,
assessment is
S1, S2
recognized and
Abdominal Sounds
communicated
Normal
during this stage,
Other Symptoms:
then the provider
can order:
Verbalization
Silent or mumbling or
Albuterol 2 puffs
whispering to father
(216 mcg) every 4
to 6 hours as
needed
Pulmicort respules
(budesonide
inhalation
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
suspension)
0.5mg inhalation
via nebulizer once
daily
Prednisone 12 mg
orally once daily
for 3 days
Correct Treatment Choice
Stage 4
Timing Sequence
Expected
Interventions
Stage 3: 10 min
Baseline Vital Signs
Foster father is
T 98.9
taught how to
P 126
measure oral
R 24
liquid prednisone
BP 94/64
and administer it
SPO2 98%
to the child.
Cardiac Rhythm Sinus
Breath Sounds Clear to
auscultation bilat
Heart Sounds Normal,
S1, S2
Abdominal Sounds
Normal
Other Symptoms:
Verbalization
“I’m thirsty.” Otherwise
silent and shy. “I want
to go home.”
Incorrect Treatment choice
No teaching occurs Stage 4a
Timing Sequence
Expected
Interventions
Stage 3: 10 min
Baseline Vital Signs
Assessment of
T 98.9
home medication
P 126
management
R 24
knowledge.
BP 94/64
SPO2 98%
Teaching provided
Cardiac Rhythm Sinus
on knowledge
Breath Sounds Clear to deficits on home
auscultation bilat
medications
Heart Sounds Normal,
prescribed by
S1, S2
provider for
Abdominal Sounds
Asthma treatment.
Normal
Other Symptoms:
Verbalization:
Silent or mumbling or
whispering to father.
Parent acts confused
about home medication
management
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
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.
 Pediatric Assessment: How is the assessment of a toddler different than an older
child? An adult? How will you apply that to practice?
 Foster Families: How can you support foster families caring for young children?
 Patient/Family Teaching: How do you know your teaching is effective?
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), pp. 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), pp. 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.
Martinez, F. (2009). Managing childhood asthma: Challenge of preventing exacerbations. Pediatric,
123(3), 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
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