Simulation Design Template:
George Palo-Simulation #2
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: Moved into this retirement
community apartment 9 months ago.
Today’s Date: Three months after
community health nurse’s first visit to
George.
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: Dr. Casey, George’s physician, diagnosed him with mild cognitive impairment
about a year before he moved into our retirement community. Three months ago, his daughter requested an
evaluation by a community health nurse because she was concerned about an increase in memory loss. The
community health nurse recommended further evaluation of George by his primary provider and Dr. Casey
reported that George had progressed from mild cognitive impairment to mild dementia, Alzheimer’s type, and
started him on galantamine (Razadyne).
Social History: George’s wife of 65 years, Anna, died almost 3 years ago. He moved into a small onebedroom apartment in this retirement community nine months ago. Two weeks ago, his beloved golden
retriever, Max, died. Up until then he had been very independent and active, out walking with Max several
times a day and volunteering at the Humane Society.
Primary Medical Diagnosis: Mild dementia, Alzheimer’s type
George Palo – Simulation # 2
© National League for Nursing, 2014
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Surgeries/Procedures & Dates: None
Nursing Diagnoses: Potential for injury related to cognitive changes
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 patient with developing dementia.
George Palo – Simulation # 2
© National League for Nursing, 2014
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Simulation Scenario Objectives
1.
2.
3.
4.
5.
Conduct a head-to-toe physical assessment.
Reassess cognition with the Brief Evaluation of Executive Dysfunction tool.
Assess depression with the Geriatric Depression Scale Tool.
Interpret findings from assessments and recommend a plan of care.
Use therapeutic communication techniques to respond to patient and family.
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
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
Geriatric Depression Scale: GDS
Tool: http://consultgerirn.org/uploads/File/trythis/try_this_4.pdf
Video: http://consultgerirn.org/resources/media/?vid_id=4200933#player_container
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.). Space should appear unkempt –
Shift Assessment
clothes on the floor, papers strewn about, dirty
Triage Forms
dishes in the sitting area, wrappers of cookies
Code Record
and other snacks strewn about, etc.
Anesthesia / PACU Record
Pill organizer, open, no pills in container.
Standing (Protocol) Orders
Transfer Orders
Equipment Attached to Manikin:
Other: Students will need copies of Geriatric
IV tubing with primary line running at mL/hr
Depression Scale and Executive Dysfunction
Secondary IV line
tools. You may provide them or assign them to
IV pump
retrieve them from 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:
George is disheveled and still in his pajamas
when Maggie and the nurse visit. He is tearful
and very confused. Maggie is worried.
George Palo – Simulation # 2
© National League for Nursing, 2014
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Report Students Will Receive Before Simulation
Time: 1400
Situation: George Palo is a 90-year-old man living independently in our apartments. Three months ago,
George was evaluated by his primary physician who found that his diagnosis has progressed from mild
cognitive impairment to mild dementia, Alzheimer’s type, and started George on galantamine. He was
managing well until two weeks ago when Max, George’s 13-year-old golden retriever, died. Maggie, his
daughter, contacted us because her dad was calling her at odd hours of the night and not remembering he had
just talked with her. She asked us to contact your agency to make a visit.
Background: One of the nurses from your agency made a visit to George about 3 months ago at the request
of his daughter, who was concerned at that time about his memory loss. Your nurse did a physical and
cognitive assessment with the CAM and Executive Dysfunction tools. The CAM was negative for delirium, but
there was some impairment in executive functioning. You can review his results on the chart. Your nurse
suggested some memory aids and resources to help him maintain independence, and recommended that he
see his physician. Since then he has been managing very well with his new medication. He has allowed
Maggie to help him with his bills and has been coming for weekly BP checks.
Assessment: Mr. Palo’s BP has been well controlled these past few months. He came regularly to the BP
clinic and was seen frequently, taking Max for a walk. He often went to the Humane Society where he
volunteers. But since Max died 2 weeks ago, we rarely see him, and when we do, he looks sad and
disheveled.
Recommendation: Do a complete physical assessment, administer the Geriatric Depression Scale, and
reassess his cognition with the Brief Evaluation of Executive Dysfunction tool. Maggie will be there during your
visit. Communicate your findings to the retirement community resource nurse and his physician if you think he
needs to be seen again before his next scheduled visit.
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 is sitting in his chair.
He is very disheveled and

Role member
providing cue:
Wash hands and
George Palo – Simulation # 2
© National League for Nursing, 2014
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still in his pajamas. Maggie
has just arrived for a visit.

Maggie: “Dad, it’s 2 o’clock
and you aren’t dressed yet.”

T-98.6, P-78, BP 140/88, R16
All assessment findings are
within normal limits.


Tearful when talking about
his losses – Anna 2 years
ago, Max 2 weeks ago.
Note: Over
the next 15
minutes,
students can
do
assessments
and
administer
tools in any
order.
Answers and
responses
are on the
attached
sheets.
Geriatric Depression Scale
George’s answers to
questions on the GDS are
attached
George continues to be
tearful:
“I tried to go to the Humane
society but I got lost and just
came home. Besides, seeing
those other dogs would just
make me miss Max more.”




Maggie: “I know how much
you miss him, Dad. But do
you know that you’ve been
calling me at all hours of the
night and not remembering
that you called?”

“He isn’t really eating much. I
wonder if he lost weight.”

“I’m also worried about his
overall energy level; it seems
low – he’s not walking
anymore since Max died.”
introduce self.
Explain purpose of
visit.
Express sympathy for
loss of his dog.
Take vital signs,
conduct head-to-toe
assessment.
Use therapeutic
communication
throughout the
scenario with both
George and Maggie.
George
Cue: If students do
not introduce
themselves, George
asks, “Who are you
and why are you
here? What do you
want with me – don’t
you know my best
friend Max just died?”
Administer the GDS.
Students should also
determine if George
has any disturbances
in his appetite and
sleep.
Administer Brief
Evaluation of
Executive Dysfunction
tool.
Ask George to draw
clock.
Controlled Oral Word
Association Test:
- Ask George to give
you 10 words
beginning with the
letters F, A, and S.
Trail Making Test:
- Ask George to
count from 1-25
and recite the
letters of the
alphabet.
Role member
providing cue:
Maggie
Cue: If student does
not initiate GDS,
Maggie will say, “I’m
worried about him.
He has been so
tearful lately – you
know his dog Max
died recently. He
loved that dog so. He
became his best
friend after Mom died.
Do you think he’s
depressed?”
If the student does
not initiate the Brief
Evaluation of
Executive
Dysfunction tool
Maggie will say, “I’m
concerned about
whether Dad’s
dementia is getting
worse.”
George Palo – Simulation # 2
© National League for Nursing, 2014
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Brief Executive
Dysfunction tool
George’s clock drawing
attached
Only draws one clock then
says, “I don’t know what you
want me to do. – I don’t want
to do any more.”
George’s responses for
Controlled Oral Word
Association Test:
F= fish, friend, photo. “I can’t
do this – I don’t know.”
George’s responses for Trail
Making Test:
Counts from 1 to 10, then
gets angry. “I can’t do this – I
don’t know what you mean.”
15-20
minutes
“I don’t want to go back and
see the doctor – I don’t need
more pills – I need my Max.”
“I haven’t been able to walk –
just don’t feel like doing it
without Max.”




Summarize and
communicate findings
to George and
Maggie.
Recommend a followup visit to physician for
depression.
Offer some ways for
George to cope with
his loss and begin to
get active again.
Note: Allow students
to come up with their
own ideas. If they are
unable to accomplish
this, here are a few
the facilitator might
mention in debriefing
to stimulate their
ideas:
Role member
providing cue:
Maggie
Cue: If student does
not initiate a
conversation on the
findings, Maggie will
ask, “What did the
findings of your
assessment show?
Aren’t there some
things we can do to
help Dad? I’m
worried about this.”
George Palo – Simulation # 2
© National League for Nursing, 2014
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- Encourage a
regular walking
routine, perhaps
with a buddy from
the community
center.
- Walk to the coffee
shop.
- Set up a
ride/buddy system
to go to the
Humane Society.
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 # 2
© National League for Nursing, 2014
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George’s answers to GDS:
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George’s clock:
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?
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© National League for Nursing, 2014
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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 assessment tools you used today, how would you differentiate their
uses?

Do you think George’s behavior is related to his depression, a decline in cognitive functioning, or both?

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:

What kind of support will George need to remain independent at this time?

What kind of support will Maggie need?

Can you think of any community services that could be useful at this time?
Use Evolving Knowledge:

What is unique in George’s presentation today?

Why do you think George’s cognitive tool findings used today have not changed, but behaviorally and
the way that he is engaging look very different?

Are depression and cognitive changes to be expected in older adults? How would you differentiate
these?
Make Situational Decisions:

What are the risks and benefits of George remaining in his apartment at this time?

What concerns or feelings do you have about George’s overall situation at this time?
George Palo – Simulation # 2
© National League for Nursing, 2014
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