New Grad Nurse Simulation Scenario 1: CHF with Pulmonary Edema

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
MBON abilities: Effective communication.
Adult female (standard man)
Diaphoretic (spritz)
Ankle edema (hose with batting)
Supplies on
Saline lock
Partial non-rebreather
BP – 170’s/80’s
Lung sounds – rales
RR – 36-40
Gown, slippers
Supplies available
Monitor, BP cuff
Venti-mask/ BiPap
Meds: furosemide, morphine,
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.
 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
Get oxygen saturation. Start 02
via Mask.
Begin admission assessment
 Get medical history from
 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
HR tachy, A-fib
BP – 170’s/80’s
RR – 36-40, rales, SOB
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
IV assessment
Should the patient receive IVF?
NO, but MD may order fluids
What type of fluids: Want
hypertonic fluids to draw fluid from
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
head to toe assessment (cont)
Urine output
helps the patient to sit up
Patient asks to “use the
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
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
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?
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