Simulation Design Template:
George Palo-Simulation #1
Date:
Discipline: Nursing
Expected Simulation Run Time: approx.
20-30 minutes
Location: Apartment in retirement
community
File Name: George Palo
Student Level:
Guided Reflection Time: twice the amount
of simulation run time
Location for Reflection:
Admission Date: George Palo began residing in
this independent retirement community six months
ago.
Today’s Date:
Brief Description of Client
Name: George Palo
Gender: M Age: 90
Race:
Weight: 85.09 kg Height: 5 ft 11 in
Religion: Lutheran
Major Support: Maggie (daughter) Support Phone: 218-777-8877
Allergies: Penicillin
Immunizations: Up to date
Attending Physician/Team: Ben Casey, MD; Mary Lake, MS, APRN/Geriatric Nurse Practitioner
Past Medical History: Hypertension
History of Present Illness: George was evaluated a year ago by his primary care provider for concerns
addressed by the family regarding his affect and some confusion. He was diagnosed with mild cognitive
impairment.
Social History: George’s wife of 65 years, Anna, died 2 years ago. He moved into a small one-bedroom
apartment in a retirement community for independent living six months ago. He is very independent and loves
to be outdoors, walking his 13-year-old golden retriever, Max. He volunteers at the Humane Society.
Primary Medical Diagnosis: Mild cognitive impairment
Surgeries/Procedures & Dates: None
Nursing Diagnoses: Potential for injury related to cognitive changes
George Palo – Simulation # 1
© National League for Nursing, 2014
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Psychomotor Skills Required Prior to Simulation


Orientation to program’s home visit protocols
Head-to-toe assessment
Cognitive Activities Required Prior to Simulation
[i.e. independent reading (R), video review (V), computer simulations (CS), lecture (L)]




Read information in textbook and lecture notes on dementia, Alzheimer’s disease, and cognitive
changes in older adults. (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 Confusion
Assessment Method (CAM), and Brief Evaluation of Executive Dysfunction tool. (R)
SBAR or other standardized communication tool. (R)
Become familiar with typical services provided in retirement housing facilities and other resources for
older adults in your community.
Simulation Learning Objectives
General Objectives
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.
Simulation Scenario Objectives
1. Conduct a head-to-toe physical assessment.
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2. Assess the patient’s individual aging pattern and cognitive status using the Confusion Assessment
Method (CAM) and Brief Evaluation of Executive Dysfunction tools.
3. Interpret findings from assessments and recommend a plan of care.
4. Use therapeutic communication techniques to respond to patient and family.
5. Discuss appropriate resources to support maintaining patient independence.
References, Evidence-Based Practice Guidelines, Protocols, or
Algorithms Used for This Scenario:
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.
Dementia: Nursing Standard of Practice Protocol: Recognition and Management of Dementia
http://consultgerirn.org/topics/dementia/want_to_know_more
Brief Evaluation of Executive Dysfunction:
Tool: http://consultgerirn.org/uploads/File/trythis/try_this_d3.pdf
Video: http://consultgerirn.org/resources/media/?vid_id=5004177
Article: http://www.nursingcenter.com/lnc/cearticle?tid=828679
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
Additional Cognitive Screening Tools:
Mental Status Assessment in Older Adults: Montreal Cognitive Assessment MoCA Versiion 7.1
http://consultgerirn.org/uploads/File/trythis/try_this_3_2.pdf
The AD8: The Washington University Dementia Screening Test
Eight-item Interview to Differentiate Aging and Dementia
http://consultgerirn.org/uploads/File/trythis/try_this_d14.pdf
Review the Essential Nursing Actions in the ACES Framework at: http://www.nln.org/professionaldevelopment-programs/teaching-resources/aging/ace-s/nln-aces-framework
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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: Apartment in retirement community
Medications and Fluids:
IV Fluids:
Oral Meds: see chart
IVPB:
IV Push:
IM or SC:
Diagnostics Available:
Labs
X-rays (Images)
12-Lead EKG
Other:
Simulator Manikin/s Needed:
Recommend standardized/simulated patient
(SP) for George and daughter Maggie, but a
manikin can be used for one or both.
Documentation Forms:
Physician Orders
Admit Orders
Flow sheet
Props: Props that make setting look like a
Medication Administration Record
living room (e.g., phone, books, chair with quilt
Kardex
or blanket, clock with large numbers, pictures,
Graphic Record
rug, etc.)
Shift Assessment
Triage Forms
Several bottles of various vitamins and one
Code Record
bottle labeled atenolol. Envelopes with bills.
Anesthesia / PACU Record
Checkbook
Standing (Protocol) Orders
Transfer Orders
Equipment Attached to Manikin:
Other: Students will need copies of CAM and
IV tubing with primary line running at mL/hr Executive Dysfunction tools. You may provide
Secondary IV line
them or assign learners to retrieve them from
IV pump
www.consultgerirn.org
Foley catheter mL output
PCA pump running
Recommended Mode for Simulation:
IVPB with running at mL/hr
(i.e. manual, programmed, etc.)
02
Recommend standardized/simulated patient (SP)
Monitor attached
for George and daughter Maggie. A manikin can
ID band
be used for one or both. If using a manikin, no
Other:
programming required.
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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:
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:
Roles/Guidelines for Roles:
Primary Nurse
Secondary Nurse
Clinical Instructor
Family Member #1 – daughter Maggie
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:
Important Information Related to Roles:
Students are playing role of community health
nurses.
George is a bit annoyed at all “the fuss” about his
not attending BP clinics and the “accusation” that
he is not taking his meds. Maggie is concerned
about her dad.
George Palo – Simulation # 1
© National League for Nursing, 2014
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Report Students Will Receive Before Simulation
Time: 1100
Situation: George Palo is a 90-year-old man living independently in our apartments. The resident nurse for
the retirement community conducts a weekly blood pressure clinic. Three weeks ago, she found a marked
increase in George’s blood pressure. He became annoyed when she asked if he was taking his medications.
George has not returned for the past 2 weeks so the nurse contacted his daughter Maggie, who also reported
other behavioral and cognitive changes. Maggie said she suggested that her dad go to the doctor, but he
refused. He did agree to have a nurse come for a visit, so she requested that we find a community health
nurse to assess her dad.
Background: George has been very healthy and active. He walks daily with his golden retriever, Max, of 13
years. He has hypertension that has been controlled by atenolol up until now.
Assessment: Recent BPs recorded show a systolic running in the 150s and a diastolic running between 90
and 100. He told the nurse he does not take any other medications except for Tylenol, which he takes prn for
aches and pains, and several vitamins.
Recommendation: Complete a physical assessment of George, administer the Brief Evaluation of Executive
Dysfunction, and use the Confusion Assessment Method tool. Based on your findings, make some
recommendations about his ability to remain independent. Maybe some additional help will allow him to stay in
his apartment. Also communicate your findings to the retirement community resource nurse.
Significant Lab Values:
refer to chart
Physician Orders:
refer to chart
Home Medications:
refer to chart
Scenario Progression Outline
Timing
(approx.)
0-5 min
Manikin Actions
Expected Interventions
May Use the
Following Cues
George and Maggie are
sitting in chairs.

Role member
providing cue:
George
Cue: If students do
not introduce
themselves, George
Maggie: “Remember I told
you that the nurses were
coming to see how you’re


Wash hands and
introduce self.
Explain purpose of
visit.
Take vital signs,
George Palo – Simulation # 1
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doing. I’m concerned
because you forgot to pay
some bills last month, your
blood pressure is high, and
you stopped going to the
blood pressure clinic in the
community room.”

George: “I pay the bills on
time. I have always paid
them on time. Sometimes I
get tired and fall asleep
before I finish. Sometimes I
forget to put them in the mail.
Are you wanting to take over
my money, Maggie?”
conduct head-to-toe
assessment.
Use therapeutic
communication
throughout the
scenario when
addressing George’s
frustrations and
Maggie’s concerns.
asks, “Who are you?
Why are you here?”
State that George’s
BP is higher than
normal.
Ask if he has any
difficulty remembering
to take his
medications.
Confusion
Assessment Method
Tool:
- Students observe
George’s behavior
and verbalizations
for items 2A
through 8B on tool.
Role member
providing cue:
Maggie
Cue: If student does
not initiate a
conversation to
assess medications,
Maggie will say, “I’m
worried that he’s not
taking his medicine. I
know high blood
pressure is bad for
you.”
If students forget to
ask George how he
feels, George will
say, “Don’t you want
to ask about my
aches and pains?
What kind of nurses
are you? I’m stiff in
the morning, but once
me and Max have our
walk, I limber up and
am OK.”
T-98.6, P-78, BP 150/92, R16. All assessment findings
are within normal limits.
George repeats himself
several times during this
encounter. He frequently
says things like, “I’m just fine
–don’t go blowing this out of
proportion.”
Note: Over
the next 15
minutes,
students can
do
assessments
and
administer
tools in any
order.
Answers and
responses
are on the
attached
sheets.
Medications:
George: “I take my pills every
day. See the bottles stacked
up there? I keep them lined
up over there by my sink so I
remember to take them in the
morning – my BP med and
my vitamins. What makes
you think I’m not taking
them?”
George: “I just forgot to go
over to the community
center. No big deal! You
worry too much, Maggie. My
BP is fine.”



If the student does
not initiate any
assessments of
George Palo – Simulation # 1
© National League for Nursing, 2014
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Maggie: “Well, it’s just that
missing bill payments is new
for Dad. That never
happened before, and I also
found checks in the
checkbook that were filled in
– like he forgot to finish and
send them out. And then he
paid a few bills twice.”
-
Question 1 on
tool (acute change
in mental status
from baseline )
requires response
by Maggie.
- Students need to
ask George about
his sleep to get
answer to
Question 9 on tool.
George: “I sleep just fine and
I don’t nap during the day.”
Brief Executive
Dysfunction tool:
George’s clock drawings
attached
George’s responses for
Controlled Oral Word
Association Test:
F= frank, fish, friend, fink,
finish, photo, freedom, fort,
find, phone
A= Anna, apple, anise,
Andrew, actor, ache, ant,
Anna, angry, anger
cognitive function
Maggie will say, “I’m
concerned about
Dad’s memory – I
guess I mean
whether we’re seeing
anything unusual.”
 Administer Brief
Evaluation of
Executive Dysfunction
tool:
- Per instructions on
tool, students ask
George to draw
clocks and do
Controlled Oral
Word Association
Test and Trail
Making Test.
S= stew, superman, sick,
socks, saint, sidewalk,
stupid…. I don’t know – this
is stupid
George’s responses for Trail
Making Test:
1-A, 2-B, 3-C, 4-E, 5-F, 6-G,
7-H, 9-I, 10-K, 11-L, 12-M,
13-N, I don’t know
Last few
minutes
George: “I’m willing to talk
about some help but I am not
moving out of my apartment.
Max and I are just fine here –

Summarize findings of
assessments with
George and Maggie.
Role member
providing cue:
Maggie
Cue: If student does
George Palo – Simulation # 1
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you’re not putting me in any
old folks home!!”
“I don’t need to see the
doctor – I’m just fine.” I don’t
have that Alzheimer’s
disease. I know who you are;
I’m not confused. I just
missed taking my pills a
couple of days and missed a
couple bills, that’s all.”



Recommend a followup visit to physician.
Students should
reassure George that
everyone wants him to
remain independent
for as long as possible
and accepting some
help will make that
possible.
Students should come
up with their own
ideas of ways to assist
George to remain as
independent as
possible for as long as
possible. They might
include:
- Pill organizer
- Reduce number of
pills to take by
replacing several
individual vitamin
pills with one
multivitamin
- Encourage
George to let
Maggie assist him
with bill paying.
not initiate a
summary of findings
and
recommendations,
Maggie will ask,
“What did the findings
of your assessment
show?” And/or
“Aren’t there some
things we can do to
help Dad?”
At end of simulation, have students call retirement community resource nurse and report their findings using
SBAR or other standardized communication tool.
George Palo – Simulation # 1
© National League for Nursing, 2014
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George’s 1St clock drawing:
George’s copied clock drawing:
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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.
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?
Specific Debriefing Questions for this Scenario: (Using the ACES Precepts)
Assess Function and Expectations:
 Reflecting on the standardized tools you used today, how do you see George’s ability to remain
independent?
 What services will be important so he can remain independent for as long as possible?
 Discuss the expectations of George’s daughter Maggie. How did Maggie’s comments, reactions, etc.
impact your assessment and prioritization of care issues?
Coordinate and Manage Care:
 How were you able to assist George with resources?
 How were you able to assist Maggie with resources?
 Are you aware of other community services that might be helpful to George?
 How were you able to address caregiver needs?
George Palo – Simulation # 1
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Use Evolving Knowledge:
 What is unique in George’s presentation today?
 What do you think he is experiencing?
 What do you understand about his diagnosis?
Make Situational Decisions:
 Discuss your feelings surrounding decisions made during the visit today.
 How might these decisions impact the ways in which you think about the care management issues?
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© National League for Nursing, 2014
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