Simulation Design Template
Date: 09/12/2010
Discipline: Level II and Level IV
Expected Simulation Run Time: 30 minutes
Location: ED
File Name: Assessment / ACS
Student Level: Level II and Level III/IV
Guided Reflection Time: 45 minutes
Location for Reflection: Classroom
MRN: KW-2010-00009
(circle)
Admission Date: 09/11/2010
Today’s Date: 09/13/2010
Brief Description of Client
Name: Sonya Williams
Gender: F Age: 1948 (62) Race: African American
Weight: 100 kg
Height: 62cm
Religion: Baptist Major Support: Spouse
Phone: 281-263-6282
Allergies: ASA "rash"
Immunizations: Current
Attending Physician/Team: Dr. Southworth
Past Medical History: HTN 1999; GERD 2005;
Unstable angina 2009;
History of Present illness: To ED via spouse and
family car with C/O of fatigue, SOB, dyspnea,
nausea, pressure pain between the shoulder blades,
10/10; skin is warm/dry; Discomfort lasting > 20
minutes, began while at rest; 12-Lead EKG nonspecific ST elevation; Troponin's negative.
See further assessment on grid.
Current medications:
1. Norvasc (amloedipeen) 10mg p.o. daily
2. Nexium (es-o-MEP-ra-zole) 20mg p.o. daily
Psychomotor Skills Required Prior to
Simulation
Level II and III/IV Learners:
 Head-to-toe assessment skills
 Vital-signs
 Oriented to the moderate fidelity manikin
 Medication administration "Rights"
 Level II p.o. route only
 Level III/IV all routes
 Med dispense© automated medication
retrieval unit.
Cognitive Activities Required prior to
Simulation [i.e. independent reading (R),
video review (V), computer simulations (CS),
lecture (L)]
Chapter 33 Health and Physical Assessment (Potter
& Perry, 2009) (Level II)--- Review
Ignatavicius, Donna and Workman, Lynda, Medical
Surgical Nursing. 6th edition. 2006. W.B.
Saunders Company. ISBN 0-7216-0671-7.
(Review) Chapters 36 and 40
Review the hand-out within the module An Easy
Guide to Head to Toe Assessment© written by (Mary C.
Vrtis Ph.D., RN , 2008)
Review the patient census listed in the Clinical
Simulation Module-unique for Level II and Level
III/IV
Reviews the 2010 JCAHO Patient Safety Goals (In
Clinical Module)
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3. Tylenol (acetamenophen) 650mg p.o. PRN for
headache
Social History: Smoker: 1-pack-a-day for 33 years;
denies ETOH or Street drugs
Primary Medical Diagnosis: Unstable angina
Surgeries/Procedures & Dates:
appendectomy 2001; 2009 (L) neg for CAD
Nursing Diagnoses: (Gulanick & Myers, 2003)

Acute chest pain related to myocardial
ischemia

Anxiety related to threat of death

Risk for decreased cardiac output related
to decreased contractility

Risk for DVT related to fatigue and
weakness

Knowledge deficit related to disease
process and patient safety ( spouse
bringing patient in family car)

Potential for risk or falls related to
fatigue / weakness / new environment
/medications
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Simulation Learning Objectives
At the end of the Clinical Simulation, the learner will:
Objective/Behavior
1. Perform a head-to-toe
assessment
Level II Learners
 Evaluates all systems in
an organized manner
Level III/IV Learners
 Supports the Level II
learner with assessment
to maintain patient
safety
 Evaluates changes
through a focused
assessment of area of
concern
 Interprets lab and S&S
assessed
Infers why S&S are
potentially occurring
3. Documents the head-to-toe  Writes a narrative nurses  Writes a narrative
assessment
note summarizing the
nurses note
findings of the head-to
summarizing the
toe assessment
findings of a focused
assessment
 Translates in medical
terminology using
 Translates in medical
approved abbreviations
terminology using
only
approved abbreviations
only
4. Creates a therapeutic
 Introduces self to
 Introduces self to
environment through
patient/family
patient/family
communication and
 Generates an
 Generates an
leadership/delegation
environment of caring
environment of caring
through verbal and nonthrough verbal and nonverbal communication
verbal communication
 Explains (reports)
 Explains (reports)
concerns to the Team
concerns to the Team
Leader (Level III/IV
Leader (Level III/IV
Nurse)
Nurse)
2. Recognizes changes in the
patients conditions and
utilizes the chain of
command
 Relates abnormal
findings to the Level
III/IV learner
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5. Applies the principles of
safe medication
administration





6. Applies the JCAHO
2010 NGSG during
patient care
 Demonstrates leadership
and delegation skills
through a calm
reassuring environment
/support for the patient;
and effective guidance
and delegation for the
Level II learner
 Communicates the
patients assessment
accurately for the
physician to treat the
patient
 Completes the physician
order sheet and
communicates the needs
to the pharmacist
 Transcribes and
performs the
interventions as ordered
be the physician
Administer p.o.
 Administer all IV, IM,
medication per the 5SC, or IV medication per
rights of drug
the 9-rights of drug
administration
administration
Retrieves the
 Retrieves the
medications from the
medications from the
Med dispense system
Med dispense system
Revaluates effectiveness  Revaluates effectiveness
of the medication
of the medication
Documents
 Documents
appropriately
appropriately
Explains the medication,  Explains the medication,
desired effect and patient
desired effect and
safety concerns
patient safety concerns
 Patient identification
 Improve staff
communication
 Uses medications safely
 Patient identification
 Improve staff
communication
 Uses medications safely
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 Check patient
medications
 Identify patient safety
risks (JCAHO, 2010)
 Check patient
medications
Identify patient safety risks
(JCAHO, 2010)
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Fidelity (choose all that apply to this simulation)
Setting/Environment
Medications and Fluids
X
ER
Med-Surg
Peds
ICU
OR / PACU
Women’s Center
Behavioral Health
Home Health
Pre-Hospital
Other:
Simulator Manikin/s Needed: 1- FemaleAfrican American Vital Sim©
Props:
Equipment attached to manikin:
X
X
IV tubing with primary line
fluids
running at
mL/hr
Secondary IV line
running
at
mL/hr
IV pump
Foley catheter
mL output
PCA pump running
IVPB with
running at
mL/hr
02
Monitor attached
ID band
Other: Allergy band -ASA
Equipment available in room
X
X
X
X
X
X
X
Bedpan/Urinal
Foley kit
Straight Catheter Kit
Incentive Spirometer
Fluids
IV start kit
IV tubing
IVPB Tubing
IV Pump (Alaris)
Feeding Pump
Pressure Bag
02 delivery device (type) NC
Crash cart with airway devices and
emergency medications (on Unit)
X
X
IV Fluids: NS 1000ml bag 75ml/hr
Oral Meds:
 Nitroglycerin Spray 2 puff SL every
5 minutes X3 for C/O chest
discomfort
 ASA 325mg chewable stat and then
daily
 Plavix 300mg p.o. now then daily (if
they catch the allergy to ASA.
IVPB:
X IV Push:
 Morphine sulfate 5mg IV push every 30
minutes for pain > 5; 10mg every 15
minutes for pain <5.
Diagnostics Available
X Labs:
 Troponin
 CPK/MB
 WBC
 Chem 23
 PT/INR and PTT
X X-rays (Images)
 CXR
X 12-Lead EKG stat with pain also (Non
specific ST-elevation)
Other:
Documentation Forms
X
X
X
Physician Orders
Admit Orders
Flow sheet
Medication Administration Record
Kardex
Graphic Record
Shift Assessment
Triage Forms
Code Record
Anesthesia / PACU Record
Standing (Protocol) Orders
Transfer Orders
Other:
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X
Defibrillator/Pacer (on crash cart)
Suction
Other:
Roles/Guidelines for Roles
X Primary Nurse
Secondary Nurse
Clinical Instructor
Family Member #1
Family Member #2
X Observer/s
Recorder
Physician/Advanced Practice Nurse
Respiratory Therapy
Anesthesia
X Pharmacy (per phone)
X Lab (RN to draw)
Imaging
Social Services
Clergy
Unlicensed Assistive Personnel
Code Team
X Other: Team Leader
Important Information Related to Roles:
1. Primary nurse (Level II) primary assessment,
p.o. medications, interventions as delegated by
team leader
2. Team Leader (Level III/IV) performs all
focused assessment, administers all medications
except p.o.
Recommended Mode for Simulation (i.e.
manual, programmed, etc.)
Student Information Needed Prior to
Scenario:
X Has been oriented to simulator
X Understands guidelines /expectations
for scenario
X Has accomplished all pre-simulation
requirements
X All participants understand their
assigned roles
X Has been given time frame expectations
X Other: LSC-Kingwood Hospital ED
Protocol listed in the Clinical Module
and PP book.
Report Students Will Receive Before
Simulation
Time: 6:30am
 Sonya Williams- 62yo- African American female brought to the ED via spouse in the
family car

C/O of dizziness and nausea at home so her
husband brought her to the ED "to see the Dr"

Placed in ED-2
Significant Lab Values:
Troponin T
(0) range 0 – 0.2 ng/ml
Physician Orders:






Nitroglycerin Spray 2 puff SL every 5 minutes
X3 for C/O chest discomfort
ASA 325mg chewable stat and then daily
Plavix 300mg p.o. now then daily (if they
catch the allergy to ASA
O2 4L NC to keep sats greater than 96%
Stat EKG and troponins with Chest
discomfort
Contact ER physician with onset
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References, Evidence-Based Practice Guidelines, Protocols, or Algorithms Used For
This Scenario (site source, author, year, and page):
Reference List
Gulanick, M., & Myers, J. L. (2003). Nursing Care Plans: Nursing Diagnosis and Interventions. St. Louis: Mosby.
Potter, P. A., & Perry, A. G. (2009). Fundamentals of Nursing. St. Louis: Mosby.
Vrtis, M. C. (2008). An Easy Guide to a Head to Toe Assessmnet. Retrieved September 11, 2010, from
www.aperiomle.com
Copyright © 2010 American Heart Association, Inc.
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Scenario Progression Outline
Timing
(approximate)
6:30am
(10-minutes to
complete)
Manikin Actions
Expected
Interventions
May Use the
Following Cues
Neuro: AX3 PERRLA
3mm-WNL;
Cardiac: S3 VS: 188/62-108-24-98.6
O2 sat:91%
Pulm: SOB, crackles bilat
lobes; cap refill delayed;
GI: +BS, tired, fatigue,
soft no tenderness;
GU: Stool yesterday; UA
WNL
Skin:2+ edema above the
ankles-+ pulses skin WD
Pain: mid-sternal -10/10Non-radiating
Level II learner will
complete a head-to-toe
assessment
Instructor to facilitate:
Patient states..."they
always check my ____
when I go to the Doctor
do you want to check? "
If Team Leader does not
begin focused assessment
Instructor to facilitate:
Patient to C/O increased
pain...moan....nauseated
6:40am
6:42am
Unchanged above
assessment...
Moaning
Monitor alarm sounding
Team leader to instruct
Instructor to facilitate:
Level II to place the patient cue: "The pain is getting
on the monitor while
worse"
assessing patient; apply O2;
and get the ASA,
nitroglycerin, from med
dispense
Realizes the need to IV
access-calls for assistance
nurse and physician, lab,
EKG
6:50am
If medications and IV
present completed
6:55am
Pain relieved...BP122/62SR 88-14-99% 4 LNC. NS
@ 75ml/hr
Level II giving report of
Troponins Neg EKG nonspecific ST to Team Leader
Patient will improve after 2
doses of NTG Spray, ASA,
O2
Physician, nurses
discussing plan of care
after report of labs and
EKG
No improvement if nit
given accurately
Instructor as patient voice-Did I have a heart attack?
TL-unstable angina
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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)
The Clinical Instructor will evaluate the scenario thru debriefing for 45 minutes; students in a circle
in the classroom.
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.
What were the key assessments and interventions?
11.
Is there anything else you would like to discuss?
Complexity – Simple to Complex
Suggestions for Changing the Complexity of This Scenario to Adapt to Different
Levels of Learners
1. If performed on level IV after ACLS ...the patient could have cardiac dysrhythmias.
2. Can be run in its entirety with a Level III or IV
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