week 7 simulation
Simulation Design Template
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Date: Discipline: Expected Simulation Run Time: Location: |
Sim Name: Your Name: Target Learning Group: Estimated Debriefing Time: Guided Reflection Time:
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Brief Description of Patient
Admission Date: Today’s Date:
Name:
Gender: Age: Race: Weight: Height:
Religion:
Major Support: Support Phone:
Allergies: Immunizations:
Primary Care Provider/Team:
Past Medical History:
History of Present Illness:
Social History:
Primary Medical Diagnosis:
Surgeries/Procedures & Dates:
Nursing Diagnoses:
Simulation Summary
Educational Rationale
Learning Objectives
· General Objectives:
· Simulation Scenario Objectives:
Standards aligned
Supplies and Equipment Needed
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© 2015, National League for Nursing. Adapted from Child, Sepples, Chambers (2007). Designing simulations for nursing education. In P.R. Jeffries (Ed.) Simulation in nursing education: From conceptualization to evaluation (p 42-58). Washington, DC: National League for Nursing. This Simulation Design Template may be reproduced and used as a template for the purpose of adding content for specific simulations for non-commercial use as long as the NLN copyright statement is retained on the Template. When used for this purpose, no specific permission is required from the NLN. |
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Adapted from : © 2015, National League for Nursing. Adapted from Child, Sepples, Chambers (2007). Designing simulations for nursing education. In P.R. Jeffries (Ed.) Simulation in nursing education: From conceptualization to evaluation (p 42-58). Washington, DC: National League for Nursing.
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Psychomotor Skills Required Prior to Simulation:
Cognitive Activities Required Prior to Simulation:
[i.e. independent reading (R), video review (V), computer simulations (CS), lecture (L)]
References, Evidence-Based Practice Guidelines, Protocols, or Algorithms Used for This Scenario:
Fidelity (choose all that apply to this simulation)
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Setting/Environment: |_| ER |_| Med-Surg |_| Peds |_| ICU |_| OR / PACU |_| Women’s Center |_| Behavioral Health |_| Home Health |_| Pre-Hospital |_| Other:
Simulator Manikin/s Needed:
Props:
Equipment Attached to Manikin: |_| 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:
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:
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Medications and Fluids: (see chart) |_| IV Fluids |_| Oral Meds |_| IVPB |_| IV Push |_| IM or SC
Diagnostics Available: (see chart) |_| Labs |_| X-rays (Images) |_| 12-Lead EKG |_| Other:
Documentation Forms: |_| Provider Orders |_| Admit Orders |_| Flow sheet |_| Medication Administration Record |_| Graphic Record |_| Shift Assessment |_| Triage Forms |_| Code Record |_| Anesthesia / PACU Record |_| Standing (Protocol) Orders |_| Transfer Orders |_| Other:
Recommended Mode for Simulation: (i.e. manual, programmed, etc.)
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: |
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Roles/Guidelines for Roles: |_| Primary Nurse |_| Secondary Nurse |_| Clinical Instructor |_| Family Member #1 |_| 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: |
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Important Information Related to Roles:
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Report Students Will Receive Before Simulation
Student Roles
Instructor Role
Environment
Overview of Expected Student Interventions
Correct Treatment
Scenario Progression Outline
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Timing (approx.) |
Manikin/SP Actions
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Expected Interventions
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May Use the Following Cues
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0-5 min
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Role member providing cue: Cue:
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5-10 min |
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Role member providing cue: Cue:
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10-15 min
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Role member providing cue: Cue: |
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15-20 min |
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Role member providing cue: Cue: |
Debriefing/Guided Reflection Questions for This Simulation
Complexity – Simple to Complex
Suggestions for Changing the Complexity of This Scenario to Adapt to Different Levels of Learners
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