SIM Scenario (Due 24 hours)

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Simulation Design Template:

Millie Larsen-Simulation #1

Date: 07/01/2013

Discipline: Nursing

Expected Simulation Run Time: 20 minutes

Location: Simulation lab

File Name: Millie Larsen Student Level: Varied

Guided Reflection Time: 20 minutes

Location for Reflection: Classroom/debriefing area

Admission Date: 07/01/2013 | Today’s Date: 07/01/2013

Brief Description of Client

Name: Millie Larsen

Gender: F Age: 84 Race: Caucasian Weight: 48 kg Height: 61 in

Religion: Lutheran

Major Support: Dina (daughter) Support Phone: 555-1210

Allergies: no known allergies Immunizations: Influenza & pneumonia (2 years ago)

Attending Physician/Team: Dr. Eric Lund

Past Medical History: Glaucoma, hypertension, osteoarthritis, stress incontinence, hypercholesterolemia

History of Present Illness:

Millie’s daughter became concerned yesterday when she stopped over to check on her and found her still in her bathrobe at 5:00 PM. The house was very unkempt, and Millie couldn’t remember her daughter’s name. Millie was brought to the emergency department by her daughter and she was finally admitted to the general medical-surgical unit around 9:30 AM. U/A, CBC, and basic metabolic panel labs have been completed and sent to the lab. Results are available.

Social History: Widow for one year; involved in church activities and gardening. Daughter and grandchildren live nearby.

Primary Medical Diagnosis: Dehydration; UTI

Surgeries/Procedures & Dates: Cholecystectomy at age 30

Nursing Diagnoses: Urinary incontinence; acute confusion; fluid volume deficit

Psychomotor Skills Required Prior to Simulation

· General head-to-toe assessment

· SPICES and Confusion Assessment Method (CAM) assessment tools

Cognitive Activities Required Prior to Simulation

[i.e. independent reading (R), video review (V), computer simulations (CS), lecture (L)]

· Basic knowledge of geriatric syndromes and the atypical presentation of older adults. (L, R)

· Tools in the Try This: ® and How to Try This Series, available at http://consultgerirn.org/resources . Specific tools recommended for this scenario are the SPICES and CAM assessment tools, (R)

· Read chapter in fundamentals text related to care of the older adult; stress incontinence and confusion. (R)

Simulation Learning Objectives

General Objectives

1. Practice standard precautions throughout the exam.

1. Employ effective strategies to reduce risk of harm to the client.

1. Assume the role of team leader or member.

1. Perform a focused physical assessment noting abnormal findings.

1. Recognize changes in patient symptoms and/or signs of patient compromise.

1. Perform priority nursing actions based on clinical data.

1. Reassess/monitor patient status following nursing interventions.

1. Perform within scope of practice.

1. Demonstrate knowledge of legal and ethical obligations.

1. Communicate with client in a manner that illustrates caring for his/her overall well-being.

1. Communicate appropriately with physician and/or other healthcare team members in a timely, organized, patient-specific manner.

Simulation Scenario Objectives

1. Conduct a head-to-toe physical assessment.

2. Assess the patient’s individual aging pattern and cognitive status using the Confusion Assessment Method (CAM) and Brief Evaluation of Executive Dysfunction tools.

3. Interpret findings from assessments and recommend a plan of care.

4. Use therapeutic communication techniques to respond to patient and family.

5. Discuss appropriate resources to support maintaining patient independence.

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.

SPICES- An Overall Assessment Tool

Tool: http://consultgerirn.org/uploads/File/trythis/try_this_1.pdf

Video: http://consultgerirn.org/resources/media/?vid_id=4200873#player_container

Confusion Assessment Method: CAM

Tool: http://consultgerirn.org/uploads/File/trythis/try_this_13.pdf

Video: http://consultgerirn.org/resources/media/?vid_id=4361983#player_container

Article:http://journals.lww.com/ajnonline/Fulltext/2007/12000/How_to_Try_This__Detecting_Delirium.27.aspx

Read about geriatric syndromes on the following websites: National Institutes on Aging. HealthinAging.org, created by the American Geriatrics Society's Health in Aging Foundation, to provide consumers and caregivers with up-to-date information on health and aging. http://www.healthinaging.org

Read chapter in fundamentals textbook related to health promotion in the elderly population.

Read and review information regarding SBAR communication: Institute for Health Improvement includes several tools and references. http://www.ihi.org/resources/pages/tools/sbartoolkit.aspx

Look up the following medications in pharmacology text or nurse’s drug guide: Ciprofloxacin, pilocarpine, Lipitor, metoprolol, furosemide, Fosamax, Celebrex, tramadol, acetaminophen

Review the Essential Nursing Actions in the ACES Framework at: http://www.nln.org/professional-development-programs/teaching-resources/aging/ace-s/nln-aces-framework

Fidelity (choose all that apply to this simulation)

Setting/Environment:

|_| ER

|X| Med-Surg

|_| Peds

|_| ICU

|_| OR / PACU

|_| Women’s Center

|_| Behavioral Health

|_| Home Health

|_| Pre-Hospital

|_| Other:

Simulator Manikin/s Needed:

Human patient simulator (example: SimMan, VitalSim); standardized patient

Props: IV bag

Equipment Attached to Manikin:

|X| IV tubing with primary line D 5. 45 w/

20 mEq KCL fluids running at 60

mL/hr

|_| Secondary IV line running at mL/hr

|X| IV pump

|_| Foley catheter mL output

|_| PCA pump running

|_| IVPB with running at mL/hr

|_| 02

|_| Monitor attached

|X| ID band

|_| Other:

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:

Medications and Fluids:

|X| IV Fluids: see chart

|X| Oral Meds: see chart

|X| IVPB: see chart

|_| IV Push:

|_| IM or SC:

Diagnostics Available:

|X| Labs

|_| X-rays (Images)

|_| 12-Lead EKG

|_| Other:

Documentation Forms:

|X| Physician Orders

|X| Admit Orders

|X| Flow sheet

|X| Medication Administration Record

|X| Kardex

|X| Graphic Record

|X| Shift Assessment

|_| Triage Forms

|_| Code Record

|_| Anesthesia / PACU Record

|_| Standing (Protocol) Orders

|_| Transfer Orders

|_| Other:

Recommended Mode for Simulation:

(i.e. manual, programmed, etc.) either

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

|_| Other:

Roles/Guidelines for Roles:

|X| Primary Nurse

|X| Secondary Nurse

|_| Clinical Instructor

|X| Family Member #1

|_| Family Member #2

|X| Observer/s

|X| 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:

Secondary nurse is in orientation. Family member is a 50-year-old daughter.

Student for family member role (Dina). Prepare student actors by supplying script and objectives. Explain the roles and emphasize that the student should represent the family member's perspective.

Report Students Will Receive Before Simulation

Time: 2:45 PM Shift report

ML is an 84-year-old female admitted from home with confusion. Her daughter noticed she wasn’t making sense or acting right when she stopped in to visit her yesterday evening. Her daughter brought her in to the ED last night; she sat in the ED all night until a bed came available a couple of hours ago. ML has a history of hypertension, glaucoma, osteoporosis, arthritis, elevated cholesterol, and stress incontinence. It is unclear whether she has taken her medications properly the past few days, her daughter couldn't tell from looking at her medication box. Labs just came back, I haven’t had a chance to look at them. She has medications ordered, but they just came up from pharmacy and they all need to be given. She has not had any pain.

Significant Lab Values:

refer to chart

Physician Orders:

refer to chart

Home Medications:

refer to chart

Scenario Progression Outline

Timing (approx.)

Manikin Actions

Expected Interventions

May Use the Following Cues

0-5 min

Disoriented and confused, can't answer questions appropriately.

VS - BP 180/110, P - 80

R - 16; T - 98.4

“My daughter dropped me off and left me here. I’m not quite sure where I am or why I’m here. I feel ok. I can’t believe how my life has changed in the past couple of weeks now. Harold died a couple of weeks, no months ago. I can’t remember. Why can’t I remember? Things have changed. I don’t like that; I’ve always been a strong woman. I feel ok and I take a lot of pills – not sure what they all are you can look on the kitchen counter or ask my daughter what they are. Where is Dina? I haven’t seen her in 6 years; no one ever comes to see me.”

· Wash hands

· Introduce self

· Identify patient

· Takes vital signs (or have assistant take vital signs)

· Begins head-to-toe, SPICES and CAM assessment

Role member providing cue: Daughter

Cue: “I don't think she's been taking her medicine.”

5-10 min

Complains of headache

“Has anyone checked on Snuggles lately?"

· Continues assessment

· Notice elevated BP

Role member providing cue: Daughter - 7-8 minutes into scenario

Cue: “Isn't her blood pressure too high?”

10-20 min

(If student asks about medications)

“I don't remember when I took my Lopressor last.” Continues to complains of headache

· Calls primary care provider (PCP) to notify of BP using SBAR communication tool.

Role member providing cue:

PCP:

Cue: “Has she taken her antihypertensives? I'll be down right away.

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?

9. What did the team feel was the primary nursing diagnosis?

10. Were Millie Larsen’s presenting symptoms what you expected? How were her symptoms different?

11. What were the key assessments and interventions?

12. How were you able to use the ACES Framework with Millie’s situation? (Assess Function and Expectations, Coordinate and Manage Care, Use Evolving Knowledge, Make Situational Decisions)

13. 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. Have student start IV, perform venipuncture to draw labs, administer medication – oral or parenteral.

2. Include additional findings/information that will require more assessment, such as pressure ulcer, potential elder neglect, and financial concerns.

3. Review of the changes in Millie’s functional status from the beginning of the scenario to the end, and engage daughter in a discussion of the risks/benefits of her staying at home.

Millie Larsen Simulation 1