nursing outcome

UNFOLDING Reasoning Simulation

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Respiratory/Cardiac Arrest

Introduction You must apply essential knowledge to make the best possible decisions to save a patient's life! In this

unfolding case study that simulates the complexities of clinical practice, you will assume the role of a nurse in a

medical-surgical unit. You will use a holistic approach to provide safe care by making correct clinical

judgments for a patient who goes into respiratory/cardiac arrest due to narcotic oversedation.

Medical History Home Meds Pharm.

Classification

Expected

Outcome

Common SE

• Low back pain with

lumbar

compression

fracture

• Depression

• COPD

• Pulmonary

hypertension

• 2 ppd smoker x 32

years

1. Citalopram 40 mg PO daily

2. Oxycontin SR 40 mg PO

BID

3. Oxycodone 10 mg PO Q4H

PRN for pain

4. Fluticasone/salmeterol

250/50 diskus 1 puff

inhalation Q12H

5. Sildenafil 20 mg PO TID

What Problem Came First? If a patient has multiple problems, one chronic disease usually leads to other illnesses. In this patient, which problem in

the medical history likely came first, and what problems may have followed as a result? Identifying this relationship

connects the knowledge of pathophysiology to practice, strengthening clinical judgment.

Medical History What Came First? What Followed?

• Low back pain with lumbar

compression fracture

• Depression

• COPD

• Pulmonary hypertension

2 ppd smoker x 32 years

UNFOLDING Reasoning Simulation

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Part I: Developing Noticing and Interpreting Skills

1. Which findings from the present problem are most important and noticed by the nurse as clinically significant?

Most Important Findings Clinical Significance

2. Which data from the social history is most important and noticed by the nurse as clinically significant?

Most Important Findings Clinical Significance

3. To provide compassionate, holistic care for this patient, answer the following questions.

What is the patient likely

experiencing/feeling right now in

this situation?

What can you do to engage

yourself with this patient's

experience and show that they

matter to you as a person?

4. Which findings from the contextual factors are most important and noticed by the nurse as clinically significant?

Most Important Findings Clinical Significance

UNFOLDING Reasoning Simulation

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Patient Care Begins

1. For each finding, make a clinical judgment by placing an "x" in the appropriate column if the patient's condition

has improved, has not changed, or has declined.

Assessment Finding Improved No Change Declined

Lethargic, unresponsive

Ashen, pale in color

Minimal spontaneous respiratory effort present

Emesis drooling out the side of her mouth

Unable to palpate pulse

2. Is the overall status of the patient:

Current Status Rationale

a. Improved

b. No change

c. Declined

3. Interpreting clinical data collected, what is the priority problem?

Priority Problem Pathophysiology of Priority Problem

4. Identify the current nursing priority and which action(s) the nurse should take—list interventions by priority and

the expected outcome.

Nursing Priority

Priority Interventions Rationale Expected Outcome

UNFOLDING Reasoning Simulation

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5. What body system(s) will you assess most thoroughly based on the primary problem? What specific assessments

will you implement?

Priority Body System(s) Priority Assessments

The crash cart is brought

into the room

and the patient is placed on the cardiac monitor/defibrillator.

The following rhythm is displayed:

Rhythm Interpretation

Clinical Significance: Intervention (if needed)

Medical Management of Care 6. Identify the rationale for each provider order and its expected outcome.

Care Provider Orders: Rationale: Expected Outcome:

ACLS Priorities:

1. Administer

unsynchronized shock:

360 each time is current

ACLS for unipolar wave

and unsynchronized

shock

2. Proceed with 2" CPR

3. Assess rhythm… is it

"shockable"?

UNFOLDING Reasoning Simulation

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4. Epinephrine 1:10,000

1mg/10 mL IV push

5. Proceed w/2" CPR

6. Amiodarone 300 mg IV

push

Medication Dosage Calculation: Medication/Dose:

Mechanism of Action: Volume/time frame to

Safely Administer:

Nursing Assessment/Considerations:

Epinephrine 1:10,000

1 mg/10 mL IV/IO every

3-5" push

Medication/Dose:

Mechanism of Action: Volume/time frame to

Safely Administer:

Nursing Assessment/Considerations:

Amiodarone

300 mg IV push

UNFOLDING Reasoning Simulation

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150 mg/3 mL vial

Ten Minutes Later

Rhythm Interpretation

Regular or Irregular: P wave present? Rate : Palpable pulse :

Interpretation:

Clinical Significance: Intervention (if needed)

Arterial Blood Gas (ABG)

pH paCO2 paO2 HCO3 O2 sat Reference Range: 7.38-7.42 38-42 mmHg 75-100 mmHg 18-26 mEq/L 94-100%

Current 7.19 ! 75 ! 60 ! 20 90 !

Which diagnostic findings are most important and noticed by the nurse as clinically significant?

Most Important Data Clinical Significance

UNFOLDING Reasoning Simulation

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Lab Planning Activity A care plan can be developed around a relevant, abnormal lab value.

With each lab, record the normal range, critical or red flag value, physiologic

significance, and priority nursing assessments/interventions to respond appropriately.

Lab Name Clinical Significance Priority Nursing Assessments/Interventions

pH

Current Value:

7.19

Critical Value

Lab Name Clinical Significance Priority Nursing Assessments/Interventions

paO2

Current Value:

60

Critical Value

Lab Name Clinical Significance Priority Nursing Assessments/Interventions

paCO2

Current Value:

75

Critical Value

UNFOLDING Reasoning Simulation

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One Minute Post-Resuscitation The nurse collects the following assessment data

7. For each finding, make a clinical judgment by placing an "x" in the appropriate column if the patient's condition

has improved, has not changed, or has declined since the respiratory arrest.

Assessment Finding Improved No Change Declined

Heart rate 120/regular-sinus tachycardia

BP: 108/60

O2 sat: 91% 100% Ambu resuscitation assisted breathing-rate 20/minute

Lethargic and responds appropriately to pain stimuli but not to verbal

commands

Auscultate Anterior Breath Sounds

Place a circle on the chest where the nurse would place the stethoscope to

auscultate the right lower lobe.

Click this link to listen. Identify what type of breath sounds are heard, and

interpret their clinical significance.

Auscultate Heart Sounds

Place a circle on the chest where the nurse would place the stethoscope to

auscultate the apical pulse.

Click this link to hear heart tones. Identify what type of heart sounds are

heard, and interpret their clinical significance.

Breath Sounds Clinical Significance

Heart Sounds Clinical Significance

UNFOLDING Reasoning Simulation

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8. Is the overall status of the patient:

Current Status Rationale

d. Improved

e. No change

f. Declined

9. After evaluating the patient, identify the current nursing priority and which action(s) the nurse should take. List

interventions by priority and the expected outcome.

Nursing Priority

Priority Interventions Rationale Expected

Outcome

10. Identify the psychosocial/holistic care priority based on the findings you noticed as most important. List

appropriate interventions, rationale, and expected outcomes.

Psychosocial/Holistic Care Priority

Priority Interventions Rationale Expected Outcome

The room is now ready and it is time to transfer

Michelle to ICU.

Write out your handoff SBAR report to the nurse

who will be caring for your patient.

Situation:

Name/age:

Concise summary of primary problem:

Day of admission/post-op #:

UNFOLDING Reasoning Simulation

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To safely administer this medication, apply your knowledge of pharmacology to complete this table.

Medication/Dose:

Mechanism of Action: Volume/time frame to

Safely Administer:

Nursing Assessment/Considerations:

0.02 mg IV push

every 2 minutes

0.4 mg maximum

dose

Background:

Primary problem/diagnosis:

Most important past medical history

Most important background data:

Assessment:

Most important clinical data:

• Vital signs

• Assessment

• Diagnostics/lab values

Trend of most important clinical data (stable-increasing/decreasing):

How have you advanced the plan of care?

Patient response:

Current status (stable/unstable/worsening):

Recommendation:

Suggestions to advance the plan of care:

UNFOLDING Reasoning Simulation

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Radiology Reports What radiology findings are most important and noticed by the nurse as clinically significant?

Radiology: Chest X-Ray

Results Clinical Significance

Tip of ET tube 1 cm above

the carina. Heart size

normal.

Arterial Blood Gas (ABG)

pH paCO2 paO2 HCO3 O2 sat

Which diagnostic findings are most important and noticed by the nurse as clinically significant?

Most Important Data Clinical Significance TREND Improved/Declined/No Change

Write a concise narrative nurse's note to document what was most important in the medical record at the end of

your shift.

Nurse Reflection To strengthen your clinical judgment skills, reflect on your knowledge and the decisions made caring for this patient by

answering the reflection questions below.

Reflection Question Nurse Reflection

As you worked through this

simulation, how did it make you

feel?

What did you already know and

do well on this simulation?

What areas do you need to

develop/improve?

What did you learn? How will

you apply what was learned to

improve patient care?

1. Medical History:
2. Home Meds:
3. Classification: SSRI (Selective Serotonin Reuptake Inhibitor)
4. Medical History_2:
5. What Came FirstLow back pain with lumbar compression fracture Depression COPD Pulmonary hypertension 2 ppd smoker x 32 years:
6. What FollowedLow back pain with lumbar compression fracture Depression COPD Pulmonary hypertension 2 ppd smoker x 32 years:
7. Most Important FindingsRow1:
8. Clinical SignificanceRow1:
9. Most Important FindingsRow1_2:
10. Clinical SignificanceRow1_2:
11. What is the patient likely experiencingfeeling right now in this situation:
12. What can you do to engage yourself with this patients experience and show that they matter to you as a person:
13. Most Important FindingsRow1_3:
14. Clinical SignificanceRow1_3:
15. Assessment Finding:
16. ImprovedLethargic unresponsive:
17. No ChangeLethargic unresponsive:
18. DeclinedLethargic unresponsive:
19. ImprovedAshen pale in color:
20. No ChangeAshen pale in color:
21. DeclinedAshen pale in color:
22. ImprovedMinimal spontaneous respiratory effort present:
23. No ChangeMinimal spontaneous respiratory effort present:
24. DeclinedMinimal spontaneous respiratory effort present:
25. ImprovedEmesis drooling out the side of her mouth:
26. No ChangeEmesis drooling out the side of her mouth:
27. DeclinedEmesis drooling out the side of her mouth:
28. ImprovedUnable to palpate pulse:
29. No ChangeUnable to palpate pulse:
30. DeclinedUnable to palpate pulse:
31. Current Status:
32. Rationalea Improved b No change c Declined:
33. Priority ProblemRow1:
34. Pathophysiology of Priority ProblemRow1:
35. Nursing Priority:
36. Priority InterventionsRow1:
37. RationaleRow1:
38. Expected OutcomeRow1:
39. Priority Body SystemsRow1:
40. Priority AssessmentsRow1:
41. Rhythm InterpretationRow1:
42. Clinical SignificanceRow1_4:
43. Intervention if neededRow1:
44. RationaleACLS Priorities 1 Administer unsynchronized shock 360 each time is current ACLS for unipolar wave and unsynchronized shock 2 Proceed with 2 CPR 3 Assess rhythm is it shockable:
45. Expected OutcomeACLS Priorities 1 Administer unsynchronized shock 360 each time is current ACLS for unipolar wave and unsynchronized shock 2 Proceed with 2 CPR 3 Assess rhythm is it shockable:
46. 4 Epinephrine 110000 1mg10 mL IV push 5 Proceed w2 CPR 6 Amiodarone 300 mg IV push:
47. MedicationDose:
48. Mechanism of ActionEpinephrine 110000 1 mg10 mL IVIO every 35 push:
49. Volumetime frame to Safely AdministerEpinephrine 110000 1 mg10 mL IVIO every 35 push:
50. Nursing AssessmentConsiderationsEpinephrine 110000 1 mg10 mL IVIO every 35 push:
51. MedicationDose_2:
52. Mechanism of ActionAmiodarone 300 mg IV push:
53. Volumetime frame to Safely AdministerAmiodarone 300 mg IV push:
54. Nursing AssessmentConsiderationsAmiodarone 300 mg IV push:
55. 150 mg3 mL vial:
56. Rhythm Interpretation:
57. Clinical SignificanceRow1_5:
58. Intervention if neededRow1_2:
59. Arterial Blood Gas ABGRow1:
60. Current:
61. Most Important DataRow1:
62. Clinical SignificanceRow1_6:
63. Clinical SignificancepH Current Value 719 Critical Value:
64. Priority Nursing AssessmentsInterventionspH Current Value 719 Critical Value:
65. Clinical SignificancepaO2 Current Value 60 Critical Value:
66. Priority Nursing AssessmentsInterventionspaO2 Current Value 60 Critical Value:
67. Clinical SignificancepaCO2 Current Value 75 Critical Value:
68. Priority Nursing AssessmentsInterventionspaCO2 Current Value 75 Critical Value:
69. Assessment Finding_2:
70. ImprovedHeart rate 120regularsinus tachycardia:
71. No ChangeHeart rate 120regularsinus tachycardia:
72. DeclinedHeart rate 120regularsinus tachycardia:
73. ImprovedBP 10860:
74. No ChangeBP 10860:
75. DeclinedBP 10860:
76. ImprovedO2 sat 91 100 Ambu resuscitation assisted breathingrate 20minute:
77. No ChangeO2 sat 91 100 Ambu resuscitation assisted breathingrate 20minute:
78. DeclinedO2 sat 91 100 Ambu resuscitation assisted breathingrate 20minute:
79. ImprovedLethargic and responds appropriately to pain stimuli but not to verbal commands:
80. No ChangeLethargic and responds appropriately to pain stimuli but not to verbal commands:
81. DeclinedLethargic and responds appropriately to pain stimuli but not to verbal commands:
82. Breath SoundsRow1:
83. Clinical SignificanceRow1_7:
84. Heart SoundsRow1:
85. Clinical SignificanceRow1_8:
86. Current Status_2:
87. Rationaled Improved e No change f Declined:
88. Nursing Priority_2:
89. Priority InterventionsRow1_2:
90. RationaleRow1_2:
91. Expected OutcomeRow1_2:
92. PsychosocialHolistic Care Priority:
93. Priority InterventionsRow1_3:
94. RationaleRow1_3:
95. Expected OutcomeRow1_3:
96. Situation:
97. Nameage Concise summary of primary problem Day of admissionpostop:
98. Background:
99. Primary problemdiagnosis Most important past medical history Most important background data:
100. Assessment:
101. Most important clinical data Vital signs Assessment Diagnosticslab values Trend of most important clinical data stableincreasingdecreasing How have you advanced the plan of care Patient response Current status stableunstableworsening:
102. Recommendation:
103. Suggestions to advance the plan of care:
104. MedicationDose_3:
105. Safely Administer:
106. Nursing AssessmentConsiderations002 mg IV push every 2 minutes 04 mg maximum dose:
107. Radiology Chest X Ray:
108. Results:
109. Clinical Significance:
110. Arterial Blood Gas ABGRow1_2:
111. Most Important Data:
112. Clinical Significance_2:
113. ImprovedDeclinedNo Change:
114. your shift:
115. Reflection Question:
116. Nurse Reflection:
117. Nurse ReflectionWhat did you already know and do well on this simulation:
118. Nurse ReflectionWhat areas do you need to developimprove:
119. Nurse ReflectionWhat did you learn How will you apply what was learned to improve patient care:
120. Text1: Improves mood, decreases symptoms of depression and anxiety
121. Text2: Nausea, insomnia, dry mouth, sexual dysfunction, QT prolongation
122. Text3:
123. Text4:
124. Text5:
125. Text6:
126. Text7:
127. Text9:
128. Text10:
129. Text11: