Estimated scenario time: 20 minutes
Estimated guided reflection time: 20 minutes
Target groups: Nurses
Complex case
Brief summary:
This scenario presents a patient with a history of congestive heart failure (CHF). The patient has
been admitted to the intensive care unit directly from his physician's office this a.m. because of
severe dyspnea and orthopnea. The student(s) will be expected to perform a cardiac and pulmonary assessment, evaluate lab data, recognize lack of response to treatment, communicate findings to the primary care provider, and provide proper management and care including administration of Natrecor.
General:
n ldentifies the primary nursing diagnosis
n ldentifies relevant patient history information
tr
n
n
n
I
n
n
!
n
n
n
lmplements patient safety measures
Explains physical assessment findings and diagnostics related to patient condition
lmplements clinician orders appropriately
lmplements nursing interventions based on patient care needs
Prioritizes nursing interventions
ldentifies indications, contraindications, and potential adverse effects of prescribed
medications
Demonstrates correct medication administration
Provides relevant patient/family education and teaching
Demonstrates therapeutic and confidential communication
Demonstrates direct and accurate communication with interprofessional team members
Demonstrates effective teamwork
Scenario specific:
!
!
E
m
lmplements a focused cardiac and respiratory assessment
Explains clinical findings and critical lab values
Demonstrates appropriate nursing intervention in a patient with congestive heart failure
I
raydrl
SimMan Scenarios
D
Universal precaution equipment
tr Stethoscope
tr Blood pressure cuff
n SpOz monitor
n SpOz probe
tr Oxygen supply source
tr Oxygen delivery device (nasal eannula and/or
face mask)
Manual resuscitation device/bag-mask device
ECG electrode cables
ECG monitor
n
n
tr
U lhermomeler
n lV pump
n lV tubing
! Urine catheter and urinemeter
[l General medicaiion administration supplres
! Patient gown, compression stockings and memory foam
n
Patient lD band
Student roles:
!
n
tr
[
1 primary nurse
1 secondary nurse
1 relative (wife at bedside)
1 observer
lnstructor roles:
tr
1 primarv care provider
tr
Wash hands
lntroduce self
tr ldentify the patient
tr Obtain BP, pulse, respiratory rate, temperature, SpOz
tr Auscultate heart and lungs
E Assess lV site
tr Evaluate urine output
Evaluate lab data
n Communicate findings directly to PCP
fl Receive orders, repeat back
n Explain lab values and medication to patient
n Calculate and give Natrecor bolus IVP over 60 seconds and initiate maintenance drip using the
"5 rights"
fl Evaluate vital signs
n Evaluate urine output
tr Auscultate lungs
n Communicate therapeutically with patient and family
tr Reinforce patient and family education
Develop plan of care with family
!
!
!
Activity intolerance related to impaired gas exchange
Def in ing characteristics:
Abnormal blood pressure and heart rate
Exertional discomfort and dyspnea
Verbal report of fatigue
.
.
.
Decreased cardiac output related to altered stroke volume
Def i ning characteristics:
Edema, fatigue, weight gain, dyspnea, oliguria, crackles, 53 heart sounds
.
Excess fluid volume related to excess sodium intake
Def in ing characteristics:
Adventitious breath sounds
Blood pressure changes
Dyspnea, oliguria, 53 heart sounds, edema and weight gain
.
.
.
lmpaired gas exchange related to alveolar-capillary membrane changes
Self care deficit
Risk of falls; Risk of impaired skin integrity
General opening questions frequently used to start the debriefing session:
How did the experience feel?
Scenario specif ic questions:
Which lab values need to be evaluated for a patient with acute congestive heart failure?
Why was Natrecor ordered?
Describe how you involved family members in patient care being provided.
What have you learned lrom this patient?
Did you feel that you managed to "share decision making" with your patient?
Describe the scope of practice of all participants in the scenario.
Describe why you called for help.
Was communication closed loop and clear? How do you know this?
What is a reliable source for locating evidence reports and clinical practice guidelines?
Describe equipment used for patient care in the simulation experience that is designed to
enhance safety (bar codes, medication pumps, automatic alarms/alerts).
General wrap-up questions frequently used to close the debriefing session:
What will you take away from this experience?
Congestive heart failure (CHF), or heart failure, is a condition in which the heart can't pump
enough blood to the body's other organs The most common signs of congestive heart failure
are edema of lower legs or ankles and/or dyspnea at rest or with minimal exerlion. Another
symptom is weight gain when fluid builds up. When a specific cause of congestive heart failure
is discovered, it should be treated or, if possible, corrected.
ln this case the patient should receive Nesiritide (Natrecor) for relief of congestive symptoms.
Nesiritide is a recombinant form of B-natriuretic peptide, and is indicated for use in patients
with acute decompensated heart failure who have dyspnea at rest. Nesiritide promotes diuresis
and natriuresis, thereby ameliorating volume overload. Nesiritide also causes a balanced arterial and venous vasodilation decreasing afterload and preload (in addition to natriuresis). Side
effect is hypotension. The safety of Nesiritide has been subject to discussion but according to
FDA it is still indicated for the intravenous treatment of patients with acutely decompensated
congestive heart failure who have dyspnea at rest or with minimal activity. However, some
hospitals have gone back to treating these patients with Milrinone and Dobutamine instead of
Natrecor.
Monitoring labs during an acute decompensated heart failure episode is important to ensure
patient safety and monitor possible side effects of treatment. BNP is a cardiac hormone that
will increase during heart failure. Potassium and magnesium are monitored as deficiencies
increase the risk of arrhythmias. Creatinine blood level is monitored as a fairly reliable indicator
of the kidney function.
Patients should be educated regarding not only diet, but also to monitor daily weight and report
their weight gain to physician in order to prevent recurrent episodes of decompensated heart
faih rre
tt,
o
Initial state:
PERRL
awRR: 24
HR: 102
Rhythm: ST with PVC
BP:102178
SpO2: 93% on 4L 02
Temp: 37.2"C (98.9"F)
53 gallop
,=
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o
Urine output: 80 ml
Vocal sounds:
"My chest does NOT
hurt it is just hard to
breathe"
awRR: 24
HR: 104
BP: 100/76
o
o
Lungs sounds with
crackles throughout
bilaterally
SpO2:
o
lO
HR: 90
o
N
BP: 100/64
SpO2: 96% on 4L 02
o
a
F
g
m
Vocal sounds:
"l am feeling much
better"
o
I raydrl
Wife cue:
"Last time Charles
received Lasix the
nurse had to empty the
urine bag often...Now
he has not gone at all?"
Evaluate vital sings
Auscultate lungs
Evaluate urine output
Communicate therapeutically with palient and
family
Reinforce patient and
family educalion
Develop plan of care
with family
E
o
E
having such a hard
time breathing".
Lung sounds with
crackles only in bases
bilaterally
92/" on 4LC2
awRR:22
Cue:
"l am very tired and
Communicate findings Role member
providing cue:
directly to PCP
Wife
Receive orders, repeat
back
Gue:
lf student does NOT
call to report urine outExplain lab values and
put wife will say, "lt has
medication to patient
been 4 hours since the
last nurse gave the lV
give
Calculate and
medicine, Charles has
Natrecor bolus IVP over
not urinated as much
60 seconds and initiate
as he usually does
maintenance drip
and I think the doctor
wanted to know"
Temp: 37.2"C (98.9'F)
Following administration of IVP Natrecor:
Evaluate urine output
Evaluate lab data
I Role member
: providing cue:
, Patient
Vocal sounds:
"l don't feel any better"
E
o
o
Wash hands
Introduce self
ldentify patient
Obtain vital signs
Obtain SpO2
Auscultate heart
Auscultate lungs
Assess lV site
Sirn,ulation tn .Niris.i-ng:rEd:uceit'lon Volume
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Gender: Male
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inches)
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Height: 1.83
(72
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Social History: Mr. Jones lives with wife. Both retired
3 years ago. He worked as a school maintenance
supervisor. Mr. Jones has three adult children who are
very supportive to their parents.
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Prior medical history:
Mr. Jones has had for hypertension the last 10 years, and was diagnosed with atrial fib and
congestive heart failure 5 years ago. He has hyperlipidemia. He has been smoking 1 pack
a day for 20 years, but quit smoking 2 years ago. He is a social drinker only. No known drug
allergies, immunizations current with annual flu vaccine.
Recent medical history:
Mr. Jones presented to the emergency departmeni two days ago with dyspnea, orthopnea,
fatigue, a weight gain of 10 pounds, and ankle edema. His appetite is poor, he complains of
slight nausea, no emesis. Patient has received lV Lasix twice daily and has diuresed
approximately 2L (weight down 4 lbs). Last lung auscultation revealed fine rales in the bases
bilaterally, no cough, and 2+ edema in lower extremities
Time: 8.45 a.m.
Report: Charles Jones is a 68-year-old male with history of congestive heart failure (CHF)
who presented to emergency department two days ago with shortness of breath, fatigue, and
weight gain and ankle edema. An echo performed upon admission showed ejection fraction
(EF) of 35%. The chest x-ray revealed bilateral congestion to the lower lungs. Mr. Jones was
transferred to the medical unit yesterday. Despite lV Lasix, resulting in a weight loss of 4 lbs.,
he remains short of breath and requires oxygen 2 L on nasal cannula to maintain a saturation
> 92o/". He complains of lightheadedness when standing and has required assistance when out
of bed. You are preparing his morning medications.
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I Name: Gharles
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Jones
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Gender:
Male
DoB: ofit2otxx
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I Height: 1.83 meters
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I Weight: 82
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Wife
] nna;or Support: Wife
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Allergies; No known allergies
I Social History: Mr. Jones lives with wife. Both retired
I 3 years ago. He worked as a school maintenance
I supervisor. Mr. Jones has three adult children who are
I very supportive to their parents.
Prior medical history:
Mr. Jones has had for hypertension the last 10 years, and was diagnosed with atrial fib and
congestive heart failure 5 years ago. He has hyperlipidemia. He has been smoking 1 pack
a day tor 2O years, but quit smoking 2 years ago. He is a social drinker only. No known drug
allergies, immunizations current with annual flu vaccine.
Recent medical history:
Mr. Jones was seen in his physician's office this morning. He presented with a 12 lb weight
gain, severe dyspnea, 02 saturation of 87"/" on room air, orthopnea and lower extremity
edema. Dr. Smith admitted Mr. Jones from the office with diagnosis of severe decompensated
heart failure (DHF). An echocardiogram upon admission reveals high filling pressures and ejection fraction (EF) ot 2A%.
Time: 2.00 p.m.
Report: Charles Jones is a 68-year-old male with a history of congestive heart failure (CHF),
who was admitted to the intensive care unit from a physician's office at 9 a.m. this morning.
Upon admission the patient had severe dyspnea and orthopnea. Auscultation of the lungs
revealed rales that are noted bilaterally in lower lobes. The patient is on oxygen 4 L/min and
the saturation is on average 92-94%. Patient has received lV Lasix of 160 mg over 20 minutes
lV piggy back. Total urine output is 800 cc over the past 4 hours. His BP is stable 102/78 and
he has 3+ bilateral lower extremity edema. Mr. Jones is oriented to place, time and person and
he denies any pain.
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