D:\533565034.doc ADN Nurse Simulation Scenario 1: CHF with Pulmonary Edema Goal: Recognize declining respiratory status. Identify assessments needed for this situation. Take corrective actions within their scope of practice. Understand Patient safety issues tied to hypoxia and confusion. MBON abilities: Effective communication. Manikin Adult female (standard man) Diaphoretic (spritz) Ankle edema (hose with batting) Supplies on Saline lock Partial non-rebreather BP – 170’s/80’s Alert Lung sounds – rales RR – 36-40 Gown, slippers Supplies available Monitor, BP cuff Venti-mask/ BiPap Meds: furosemide, morphine, metoprolol Situation: Mary Jones was planning a car trip. She did not feel good in the morning, but decided to go anyway. In route, she developed shortness of breath and a weak cough. She then began to have frothy pink sputum. She was located in a remote rural area. Family drove her to the closest hospital. She came to the ED, was treated with Lasix 20 mg IV and now has come to your unit. Background history of Diet controlled diabetes, hypertension, hypercholesteremia Smoked 1 ppd for 20 years, quit 10 years ago. Meds: Atenolol 50 mg daily, Lipitor 20 mg daily, Lasix 20 mg daily, Potassium 10 meq daily Allergies: PCN Code status: Full code Clinical Course for CHF Student Actions Introduce self. Connect monitoring equipment Baseline: Seen in ED, given Lasix 20 mg IV and sent to your unit Get oxygen saturation. Start 02 via Mask. Begin admission assessment Get medical history from patient Where does she usually receive healthcare? What is her code status? Who should we call? head to toe assessment Listen to lung sounds Check for edema Patient Condition/ Response Educator Cues Walk them through the process Alert Diaphoretic HR tachy, A-fib BP – 170’s/80’s RR – 36-40, rales, SOB What Patient appears a little confused – changes answers – not sure of what is happening What is your initial impression? Rales, SOB Lower extremity edema Where else would you look for edema? Sacrum D:\533565034.doc IV assessment Should the patient receive IVF? NO, but MD may order fluids What type of fluids: Want hypertonic fluids to draw fluid from cells NS = isotonic .45% NS = hypotonic D5 ½ = hypertonic D5 NS = hypertonic D5W = hypotonic Diabetes Assessment Blood glucose 89 Symptoms unrelated to high or low blood glucose Clinical Course for CHF – Continued Student head to toe assessment (cont) Urine output helps the patient to sit up Patient Educator Patient asks to “use the bathroom” They should think of her mobility, amount and color of urine, amount of edema in legs and lung sounds Second dose of IV Lasix® Patient changes: Patient complains of increasing SOB. “I need to sit up more – can’t someone help me? I can’t breath.” What do you think is happening? Pulmonary Edema O2 sats 90% on 10L mask What else might be ordered? morphine Increase in O2, ABGs EKG due to story Metoprolol 5 mg IV for ongoing rx of HTN Gets another set of vital signs Calls MD with findings and requests second dose of IV Lasix, IV Metoprolol, increase O2 and reads back order Increases O2 to 40% via ventimask Gives 2nd dose of Lasix 20 mg IV Gives Metoprolol 5 mg IV What would happen if the patient’s O2 sats continued to drop? The patient would get hypoxic and continued to get more confused. What interventions would you take to keep the patient safe? Restraints? Sedation? Safety Assistant? Who else could you call to help with the patient’s respiratory status? Respiratory Therapy? Rapid Response Team? D:\533565034.doc This workforce solution was funded by a grant awarded under the President’s CommunityBased Job Training Grants as implemented by the U.S. Department of Labor’s Employment and Training Administration. The solution was created by the grantee and does not necessarily reflect the official position of the U.S. Department of Labor. The Department of Labor makes no guarantees, warranties, or assurances of any kind, express or implied, with respect to such information, including any information on linked sites and including, but not limited to, accuracy of the information or its completeness, timeliness, usefulness, adequacy, continued availability, or ownership. This solution is copyrighted by the institution that created it. Internal use by an organization and/or personal use by an individual for noncommercial purposes is permissible. All other uses require the prior authorization of the copyright owner.