Patinet : A-Zebby

FullScenarioforA.Zerby.pdf

Home >Nursing homework help >Patinet : A-Zebby

PNCI MS - Chest Pain Management of a Telemetry Patient

Medical Surgical (MS)

Overview The physiological values documented in this Simulated Clinical Experience (SCE) indicate appropriate learner actions and timely interventions. If learners do not act as anticipated, differences will be encountered. Best practices have been included in this SCE, but since interventions may vary by region, you may wish to include medications, treatments, and standards of care that reflect current practice in your region. No intentional errors, such as incorrect treatments or medication doses, were included in this SCE. Since preparation is key to a successful simulation experience, you should read through the SCE in its entirety before beginning the simulation. You will find suggestions in the Facilitator Notes to assist you in setting up the environment and moulaging the simulator. Your facilitative approach should be learner-centric and driven by the objectives, learner knowledge and/or level of experience and the expected outcomes. It is important to role model professional and ethical integrity and to maintain a safe learning environment, where the learner(s) are encouraged to speak up, share thoughts, and ask for help as needed.

• It is important to prebrief the learner(s) prior to the simulation to review the learning objectives, set expectations, establish ground rules and a fiction contract.

• Be sure to orient the learner(s) to the space, equipment, simulator, roles, and time allotment.

• Determine the method of learner(s) evaluation (formative, summative, or high- stakes) and communicate this to learners prior to the SCE.

A. Zerby Age: 44-years-old

Weight: 79.5 kg

Height: 160 cm

PNCI MS - Chest Pain Management of a Telemetry Patient

Medical Surgical (MS)

Synopsis

The learner(s) will be caring for a 44-year-old individual with a six-year history of hypertension, gastroesophageal reflux, and elevated cholesterol and triglycerides. The scenario starts when the patient arrives on the Medical-Surgical floor at 1600 hours after an angiogram and the learners assume care. Past history this episode includes:

• Admission to the hospital for coronary artery disease (CAD) • Initially presented to primary healthcare provider yesterday with complaints of shortness of

breath that occurs with minimal activity • Symptoms are relieved with rest • Denied any chest, arm or jaw pain, but did have some diaphoresis with one or two episodes • The patient failed exercise tolerance test today with ST segment depression, shortness of

breath and a drop-in blood pressure • The patient was taken directly to the Cardiac Catheterization Lab. Findings revealed three-

vessel disease. Angioplasty and stent placement were not performed • Admitted to the Medical-Surgical Unit following cardiac catheterization and is scheduled for a

coronary artery bypass graft (CABG) tomorrow • Troponin, creatinine phosphokinase (CPK), and isoenzymes were normal and a myocardial

infarction was ruled out This Simulated Clinical Experience (SCE) consists of seven states that transition manually at the facilitator’s discretion. State 1 Initial Assessment: Vital Signs:

• HR in the 80s • BP in the 120s to 130s/60s to 70s • RR in the teens • SpO2 in the high 90s on room air • Temperature of 37C

Other Assessment Findings:

• Pupils are equal, round and reactive to light and accommodation • Breath sounds are clear • Cardiac rhythm is sinus with audible S1 and S2 • Bowel sounds are normoactive in all four quadrants • Skin is pale, warm and dry with no edema • Alert and oriented to person, place and time, but complains of left groin discomfort rated 2

out of 10 • The patient is lying flat in bed • The patient is moderately anxious with many questions about the upcoming surgery

PNCI MS - Chest Pain Management of a Telemetry Patient

Medical Surgical (MS)

Synopsis Continued

• Denies chest pain and shortness of breath • Spouse is present and very quiet • The neurovascular status of left lower extremity is intact and the peripheral pulses on the

left lower extremity are 2+ out of 4 • The dressing on the left groin has a 2 cm by 2 cm area of dried red blood • IV fluids are infusing at 100 mL/hr in the right arm and the site is without redness or swelling

State 2 Complains of Chest Pain: Vital Signs:

• HR in the 110s to 130s, Irregular rhythm • BP in the 140s to 150s/80s to 90s • RR in the 20s • SpO2 in the low 90s on room air • Temperature of 37C

Other Assessment Findings:

• Cardiac rhythm is sinus tachycardia with occasional premature ventricular contractions (PVCs)

• Breath sounds are clear • Peripheral pulses on the left lower extremity are 2+ out of 4, and there is no increase in

bleeding from the left groin site • Alert and oriented to person, place and time and is taking fluids without problems • Skin is pale, warm and slightly diaphoretic on forehead • Complaining of “tight” pain that rates 6 out of 10 in the mid chest region • Anxious and is complaining of mild shortness of breath • The Spouse continues at the bedside and demonstrates concern

When the learner(s) apply the oxygen, the facilitator should select Oxygen: Nasal Cannula 2 LPM in the software. When the learner(s) administer the first dose of nitroglycerin, the facilitator should select Nitroglycerin 0.4 mg SL in the software.

PNCI MS - Chest Pain Management of a Telemetry Patient

Medical Surgical (MS)

Synopsis Continued

State 3 Complains of Continuing Chest Pain: Vital Signs:

• Irregular HR in the 100s to 130s • BP in the 130s to 160s/90s to 100s • RR in the teens to 20s • SpO2 mid 90s with oxygen at 2 LPM per nasal cannula • Temperature of 37C

Other Assessment Findings:

• Breath sounds are clear • Cardiac rhythm is sinus tachycardia with occasional PVCs • Alert and oriented to person, place and time • Skin is pale, warm and slightly diaphoretic on her forehead • Continues to complain of “tight” pain that she rates 4 out of 10 in the mid chest region • Anxious and says it is difficult to take a deep breath • Continues to voice concerns about surgery

The SCE should be manually transitioned to State 4 Chest Pain Continues five minutes after the nitroglycerin is administered. When the learner(s) apply and/or titrate oxygen therapy, the facilitator should select Oxygen: Nasal Cannula 4 LPM in the software. When the learner(s) administer the second dose of nitroglycerin, the facilitator should select Nitroglycerin 0.4 mg SL in the software. State 4 Chest Pain Continues, the patient becomes very anxious and starts to panic. Vital Signs:

• Irregular HR in the 110s to 130s • BP in the 90s to 110s/60s to 70s • RR in the teens to 20s • SpO2 in the mid 90s on oxygen at 4 LPM per nasal cannula • Temperature of 37C

Other Assessment Findings:

• Breath sounds are clear • Cardiac rhythm is sinus tachycardia with occasional PVCs • Rates chest pain as 3 out of 10 in the mid chest region

PNCI MS - Chest Pain Management of a Telemetry Patient

Medical Surgical (MS)

Synopsis Continued

The SCE should be manually transitioned to State 5 Condition Worsens five minutes after the third dose of nitroglycerine is administered When the learner(s) administer the third dose of nitroglycerin, the facilitator should select Nitroglycerin 0.4 mg SL in the software State 5 Condition Worsens, five minutes have passed since the third dose of nitroglycerin. Vital Signs:

• Irregular HR in the 120s to 130s • BP in the 80s to 100s/60s to 70s • RR in the 20s • SpO2 in the mid 90s on oxygen at 4 LPM per nasal cannula • Temperature of 37C

Other Assessment Findings:

• Breath sounds are clear • Cardiac rhythm continues to show sinus tachycardia with occasional PVCs • Alert and oriented to person, place and time • Skin is pale and warm with increased diaphoresis • pain is rated as 3 out of 10

When the learner(s) administer the medications, the facilitator should select Morphine 2mg IV and Metoprolol 5 mg in the software. State 6 Pain Free, it has been 10 minutes since the patient has received morphine sulfate and metoprolol. The patient’s condition improves. Vital Signs:

• HR in the 100s to 110s • BP in the 110s to 120s/70s to80s • RR in the 10s to 20s • SpO2 in the high 90s on oxygen at 4 LPM via nasal cannula • Temperature remains at 37C

Other Assessment Findings:

• Breath sounds are clear • Cardiac rhythm is sinus tachycardia with PVCs • Skin is pale, warm and dry with no diaphoresis present • There is no increase in bleeding from the left groin site • Alert and oriented

PNCI MS - Chest Pain Management of a Telemetry Patient

Medical Surgical (MS)

Synopsis Continued

• Denies chest pain, shortness of breath, feelings of light-headedness and nausea • States anxiety has decreased

The vital signs in State 7 Stable 1 Hour Later have been programmed to reflect the patient’s response to interventions. Therefore, the facilitator does not need to administer subsequent doses of metoprolol in the software as the learners administer them at the bedside. State 7 Stable 1 Hour Later, the patient’s condition continues to improve. Vital Signs:

• HR in the 80s • BP in the 110s to 120s/70s to 80s • RR in the high teens • SpO2 in the high 90s on oxygen at 4 LPM via nasal cannula

Other Assessment Findings:

• Breath sounds are clear • Cardiac rhythm is sinus rhythm • Skin is pink, warm and dry • Alert, oriented and asking questions about surgery • Anxiety has decreased and denies chest pain • Oral intake is 1250 mL since returning to the room

This SCE prepares the learner for the following items of the NCLEX-RN test format: NCLEX-RN Test Plan: X Safe and Effective Care Environment X Management of Care Safety and Infection Control X Health Promotion and Maintenance X Psychosocial Integrity X Physiological Integrity X Basic Care and Comfort X Pharmacological and Parenteral Therapies Reduction of Risk Potential Physiological Adaptations

PNCI MS - Chest Pain Management of a Telemetry Patient

Medical Surgical (MS)

Synopsis Continued

This SCE addresses the following QSEN Competencies: X Patient-Centered Care X Teamwork and Collaboration X Evidence-Based Practice Quality Improvement X Safety Informatics

Authors

Original: Kathleen Gendron, Fox Valley Technical College - Appleton, WI. Reviewed by: Cathleen M Deckers, California State University - Long Beach, CA, and Diane Mathe, CAE Healthcare, Sarasota, FL 2018.

PNCI MS - Chest Pain Management of a Telemetry Patient

Medical Surgical (MS)

Background

Patient History

Past Medical History: • Obesity • Gastroesophageal reflux • Elevated cholesterol 252, HDL 46, LDL 180, triglycerides 140 • Hypertension • Situational anxiety • Total abdominal hysterectomy six years ago • Right carpal tunnel surgery two years ago

Allergies:

• NKDA Medications:

• Atenolol • Ranitidine

Code Status:

• Full code Social/Family History:

• Married with three healthy children ages 14 to 18 • Spouse at bedside • Employed fulltime as a paralegal • Reports tobacco and caffeine use • Denies alcohol use • Mother had a myocardial infarction at 55 and died at 66 secondary to complications of

coronary artery bypass graft • Older sister died at 54 from sudden cardiac death • Father recently had a stroke • Has two younger brothers who are alive and well

PNCI MS - Chest Pain Management of a Telemetry Patient

Medical Surgical (MS)

Handoff Report

The learners are expected to notify the healthcare provider of abnormal assessment findings where appropriate and necessary. The report should follow the SBAR format and include: Situation:

• This patient is a 44-year-old individual who is being transported back to the room from the Cardiac Catheterization Lab

• The patient was sent to the Cardiac Catheterization Lab for possible angioplasty and stent placement, but the physician was unable to perform these interventions secondary to findings of three-vessel disease and poor coronary anatomy

• Scheduled for a CABG tomorrow and she is aware of this • Medicated with lorazapam 2 mg two hours ago • Tolerated the procedure with no complications • Vital signs have been stable • Patient is anxious about the impending surgery • Spouse is at the bedside

Background:

• The patient initially presented to the primary healthcare provider yesterday with complaints of recent episodes of shortness of breath that occur with minimal activity and with increased stress

• Symptoms are relieved with rest • Denied any chest, arm or jaw pain but did have some diaphoresis with one or two episodes • Cardiac enzymes were normal and an MI was ruled out • Past medical history includes obesity, gastroesophageal reflux, elevated cholesterol 252,

HDL 46, LDL 180, triglycerides 140, hypertension, a total abdominal hysterectomy six years ago and right carpal tunnel surgery two years ago

• Attributed her symptoms of shortness of breath to smoking one pack per day for the past 20 years and situational anxiety since mother’s death following complications of a CABG

Assessment: Vital Signs:

• HR 80 • BP 128/70 • RR 16 • SpO2 98% on room air • Temperature 37C

General Appearance: • Obese • Appears stated age

PNCI MS - Chest Pain Management of a Telemetry Patient

Medical Surgical (MS)

Handoff Report Continued

Cardiovascular: • Sinus rhythm with audible S1 and S2 • Left lower extremity pulse is 2+ out of 4

Respiratory: • Breath sounds clear

GI: • Normoactive in all four quadrants

GU: • Voiding clear, yellow urine

Extremities: • Left leg straight • Full ROM of ankle and toes

Skin: • Warm, dry, pale with adequate turgor • Intact left groin dressing with small amount dried red blood present

Neurological: • Alert and oriented to person, place and time • Pupils equal, round, reactive to light and accommodation • Left lower extremity neurovascular status is intact

IVs: • 20-gauge in the right arm with D5 ½ NS infusing at 100 mL/hr • Site patent and non-reddened

Labs: • Preoperative labs ordered

Fall Risk: • High-risk

Pain: • Denies pain

Recommendations:

• Complete admission orders • Monitor for bleeding • Implement preoperative teaching for CABG

PNCI MS - Chest Pain Management of a Telemetry Patient

Medical Surgical (MS)

Orders

Initial Healthcare Provider’s Orders: • Admit to Telemetry Unit • Diagnosis: Unstable angina; CABG in AM • Telemetry monitoring with pulse oximetry • Full code • Low cholesterol, low-fat diet • Encourage oral fluids • Post procedure angiography orders for the next eight hours:

o Bedrest for eight hours then bathroom privileges o Bed flat with left leg straight for four hours; then 30-degree elevation for two hours;

then progress to 45-degree elevation prior to bathroom privileges o Vital signs every 15 minutes for one hour, then every 30 minutes times four, and then

hourly until stable o Assessment of left groin site for pulsatile mass, bruit, and bleeding, along with left

lower extremity pulses and neurovascular checks on same schedule as vital signs • Notify healthcare provider with acute changes • Oxygen per nasal cannula to keep SpO2 greater than 90% • Dressing location: Left groin occlusive transparent dressing • Dextrose 5% in ½ normal saline at 100 mL/hr • Atorvastatin calcium 10 mg by PO daily • ALPRAZolam 0.5 mg PO every six hours prn anxiety • Nitroglycerin 0.4 mg SL every five minutes prn chest pain; if pain unrelieved after 3 doses

notify healthcare provider • Aspirin 81 mg chewable prn chest pain • Morphine 2 mg IV push up to a total of 8 mg repeated at 5 minute intervals for chest pain

unrelieved by nitroglycerin and beta blockers • If chest pain unrelieved by 3 nitroglycerin tablets then give metoprolol 5 mg IVP every 5 min

to maximum dose of 15 mg or desired heart rate of 60-100; Do not give if systolic BP less than 98

• Aluminum hydroxide and magnesium hydroxide 30 mL PO prn indigestion • Acetaminophen 650 mg PO every four hours prn pain • 12-lead ECG for acute chest pain • Preoperative education for coronary artery bypass graft surgery • Preoperative labs for CABG: CBC with differential, electrolytes, BUN, creatinine, Glucose,

ALT, AST, Pre-Albumin and Albumin, Bilirubin, Troponin Orders Received in State 5:

• Notify healthcare provider if chest pain not relieved by morphine sulfate or further drop in BP

PNCI MS - Chest Pain Management of a Telemetry Patient

Medical Surgical (MS)

Preparation

Learning Objectives

• Identifies the risk factors associated with coronary artery disease (REMEMBERING) • Formulates a nursing plan of care for the patient with cardiac vascular disease (CREATING) • Prioritizes nursing management of a patient having acute chest pain (APPLYING) • Evaluates outcome of nursing interventions for the patient having chest pain (EVALUATING) • Identifies the causes of preoperative anxiety and takes measures to decrease it

(UNDERSTANDING) • Creates and organizes a nursing plan of care to prepare a patient for a CABG (CREATING) • Develops a teaching plan for education of the CABG patient and family (CREATING)

Learner Performance Measures

Essential Performance Measures for the SCE: • Reviews patient’s medical record • Performs hand hygiene before and after patient contact • Demonstrates appropriate use of personal protective equipment • Introduces self to patient • Verifies patient identity with two identifiers • Conducts basic environmental safety assessment and maintains safety measures • Uses therapeutic communication to establish rapport and reduce patient anxiety • Calculates and administers medications safely according to the Six Rights • Provides developmentally appropriate education • Evaluates effectiveness of communication • Evaluates effectiveness of education • Documents all findings, interventions and patient responses

State 1 Initial Assessment:

• Performs a comprehensive physical assessment • Establishes ECG monitoring and interprets cardiac rhythm • Assesses neurovascular status of left extremity • Monitors IV site and infusion • Assesses the left groin for signs of bleeding • Monitors neurovascular status of the lower extremities • Offers oral fluids • Places sign on head of bed (HOB) regarding bedrest and lying flat with HOB not greater than

30 degrees

PNCI MS - Chest Pain Management of a Telemetry Patient

Medical Surgical (MS)

Learner Performance Measures Continued

State 2 Complains of Chest Pain: • Performs a focused assessment • Recognizes abnormal findings:

o Chest pain o Decreased oxygen saturation levels o Occasional premature ventricular contractions

• Applies oxygen at 2 LPM per nasal cannula • Monitors pulse oximetry • Identifies cardiac rhythm • Orders a STAT 12-lead ECG • Administers 1 dose of nitroglycerin 0.4 mg sublingually according to the Six rights • Administers chewable aspirin 81mg according to the Six Rights • Correctly administers alprazolam 0.5 mg according to the Six rights • Anticipates and monitors for effectiveness and side effects of medications • Communicates appropriately with patient and husband

State 3 Complains of Continuing Chest Pain:

• Performs a focused assessment • Reassesses vital signs • Monitors pulse oximetry • Monitors cardiac rhythm • Titrates oxygen to 4 LPM via nasal cannula • Administers second dose of nitroglycerin according to the Six Rights • Communicates appropriately with patient and husband

State 4 Chest Pain Continues:

• Performs a focused assessment • Reassesses vital signs • Monitors pulse oximetry • Monitors cardiac rhythm • Reassesses pain level • Administers third dose of nitroglycerin according to the Six Rights

State 5 Condition Worsens:

• Performs a focused assessment • Reassesses vital signs • Monitors pulse oximetry • Monitors cardiac rhythm • Reassesses pain level • Administers morphine sulfate and metoprolol according to the Six Rights • Notifies healthcare provider of unrelieved chest pain following nitroglycerin administration

PNCI MS - Chest Pain Management of a Telemetry Patient

Medical Surgical (MS)

Synopsis Continued

State 6 Pain Free: • Performs a focused assessment • Reassesses vital signs • Monitors pulse oximetry • Monitors cardiac rhythm • Reassesses pain level • Continues giving metoprolol IV push every five minutes until the heart rate is between 60

and 100 beats per minute or a maximum dose of 15 mg is achieved State 7 Stable 1 Hour Later:

• Performs a focused assessment • Reassesses vital signs • Monitors pulse oximetry • Monitors cardiac rhythm • Reassesses pain level • Discontinues oxygen • Provides preoperative teaching, to include:

o Surgical procedure o Postoperative course o ICU environment o Incentive spirometry o Cough and deep breathing with splinting o Antiembolic stockings o Mobility and activity o Pain management o Coping strategies o Nutrition

• Identifies patient health promotion needs: diet, cholesterol, exercise, smoking, risk factors, blood pressure medication, effects of caffeine on the heart, relaxation techniques and social support

• Displays sensitivity when providing education • Discusses cardiac rehabilitation • Evaluates effectiveness of education

PNCI MS - Chest Pain Management of a Telemetry Patient

Medical Surgical (MS)

Preparation Questions

• Describe the pathophysiology of CAD. • Discuss risk factors for CAD and health promotion measures for the patient with CAD. • What are the classic and non-classic symptoms of chest pain? How are they different in men

and women? • What is the difference between stable and unstable angina? • Review the 2014 ACC-AHA & 2016 ESC guidelines for management of NSTEMI acute

coronary syndromes. • Discuss the precautions that are to be taken with oxygen, morphine and nitroglycerin in the

management of chest pain in the patient with acute coronary syndrome. • Discuss the following medications: nitroglycerin, morphine sulfate, aspirin, atenolol,

aluminum hydroxide/magnesium hydroxide, alprazolam, atorvastatin calcium and lorazepam. Include indications, actions, contraindications, side effects, normal dosage and nursing implications.

• Discuss the nursing and medical management of the patient post cardiac angiogram- particularly with regard to post procedure complications.

• Describe how to intervene and care for the patient with chest pain and anxiety. • Outline and discuss the preoperative education plan for a patient and family for coronary

artery bypass graft surgery. This should include preoperative education, instruction on the surgical procedure, postoperative course and avoidance of complications.

• Discuss the basic components of cardiac rehabilitation.

PNCI MS - Chest Pain Management of a Telemetry Patient

Medical Surgical (MS)

Equipment and Supplies

This list is considered a starting point for managing the SCE. Supplies should be added to or taken away from this list depending upon what is currently used in patient management following local and regional protocols. IV Supplies Saline lock IV pump tubing (2) IV pump (2) Distilled water 1000 mL IV bag (labeled Dextrose 5% in 0.45% Sodium Chloride) Distilled water 30 mL vial (labeled 0.9% Sodium Chloride) 3 mL syringe (3) Medication Supplies Simulated oral medication labeled:

• ALPRAZolam 0.5 mg • Aspirin 81 mg • Atorvastatin calcium 10 mg • Acetaminophen 325 mg • Nitroglycerin 0.4 mg

Bottle of water 20 mL labeled: • Aluminum hydroxide/Magnesium hydroxide • Metoprolol 1 mg/1 mL

Sterile water 10 mL vial (labeled Morphine sulfate 1 mg/mL) Bottle of Aspirin 81 mg chewables 3 mL syringe (2) Oxygen, Airway and Ventilation Supplies Nasal cannula Oxygen flowmeter Oxygen source Pulse oximeter probe Genitourinary Supplies Bedpan Dressing Supplies 4” x 4” gauze (4) 5”x 9” dressing (2) Tape

PNCI MS - Chest Pain Management of a Telemetry Patient

Medical Surgical (MS)

Equipment and Supplies Continued

Miscellaneous Patient chart Patient identification band Stethoscope BP cuff adapted for use with simulator Nonsterile gloves (1 box) Audio and visual recording devices Sharps container 12-lead ECG tracing depicting greater than 1 mm ST depression Telemetry monitoring strip depicting sinus tachycardia and occasional PVCs Sign indicating the patient should be lying flat with head of bed not greater than 30 degrees Preoperative educational materials Red food coloring Emergency Code Blue Cart Female / Male wig Simulated breasts (optional) Petroleum jelly Talcum powder Monitors Required ECG NIBP SpO2

PNCI MS - Chest Pain Management of a Telemetry Patient

Medical Surgical (MS)

Notes

Facilitator Notes

You can adjust the complexity of the SCE depending on the level of learners by modifying the Learning Objectives and Learner Performance Measures. This SCE may be supplied with custom Patient Record files (Lab Reports, Ultrasounds, Xrays etc.) and can be displayed on the TouchPro monitor or printed and used for this SCE. (See User Guide for instructions on importing patient records). Learners should perform an appropriate physical exam. The facilitator or patient should verbalize the physical findings the learners are seeking but are not enabled by the simulator (such as pain on palpation). The facilitator should use the microphone and/or preprogrammed vocal or audio sounds to respond to the learners’ questions, if present on your simulator. Where appropriate, do not provide information unless specifically asked by the learners. In addition, ancillary results (e.g., ECG, chest x-ray, labs) should not be provided until the learners request them. If the patient becomes unconscious in the SCE, then speaking and vocalization should cease. It is important to moulage the simulator to enhance the fidelity or realism of the SCE. For this patient:

• Apply correct patient identity band to simulator • Dress simulator in a hospital gown and place in bed with the head of bed flat • Place an occlusive transparent dressing to the left groin. Using red food coloring, simulate a

2 x 2 cm area of blood showing through • Place an IV in the right arm of the simulator and connect to a bag of distilled water labeled

as Dextrose 5% in 0.45% Sodium Chloride. Set the fluid to infuse at 100 mL/hr • to simulate diaphoresis, spray the face and other appropriate body areas with water • To simulate a pale appearance, place a very thick layer of petroleum jelly on the nose,

cheeks and forehead of the simulator and coat finely with talcum powder • After State 6, the facilitator should remove the nasal cannula as the patient is on room air in

State 7 When the learners initiate cardiac monitoring, the tracing and heart rate appear on a real ECG monitor. For facilities without ECG monitoring, have the learners apply ECG electrodes to the mannequin and attach the leads. Once all 3 or 5 leads are in place, reveal the TouchPro ECG tracing. At the start of the scenario, position the spouse in a chair at the bedside.

PNCI MS - Chest Pain Management of a Telemetry Patient

Medical Surgical (MS)

Facilitator Notes Continued

Simulation personnel should play the following roles: • Spouse • Healthcare provider • Transferring nurse • Monitor technician • Cardiac Catheterization Lab RN

Make a patient chart with the appropriate written order forms, MARs, diagnostic results, etc. for learners to utilize. The chart should include the specific patient identification information. Begin the simulation with the cardiac catheterization RN (simulation personnel) providing verbal handoff to the oncoming nurse (learner) using SBAR. Have the learners roleplay inter-professional communication by reporting the patient’s response to interventions. If the data presented is disorganized or missing vital components, have the healthcare provider respond accordingly. Emphasize the importance of data organization and completeness when communicating. Role play intra-professional communication by having the learners hand off to the admitting or transferring unit or have the learners hand off to the next shift.

PNCI MS - Chest Pain Management of a Telemetry Patient

Medical Surgical (MS)

Debriefing Points

Debriefing after the SCE is critical. The debrief should be conducted in an environment that is conducive to learning and one that supports confidentiality and open communication. It should be facilitated by those who have observed the simulation. Learners and facilitators may wish to view a recording of the simulation made with CAE Audio Visual Solutions for debriefing and feedback purposes The Facilitator Should Begin by Introducing the Process of Debriefing: Introduction:

• Discuss faculty role as a facilitator • Expectations • Confidentiality • Safe environment for discussion

Personal Reactions:

• Allow learners to recognize and release emotions, explore learner reactions Discussion of Events:

• Analyze what happened during the SCE • Utilize LearningSpace or Replay recordings to playback if available

Summary:

• Review what went well and what did not • Identify areas for improvement and evaluate the experience

Questions to be asked during debriefing:

• What was the experience like for you? • What happened and why? • What did you do and was it effective?

Discuss Your Interventions: (technical and non-technical)

• Were they performed appropriately and in a timely manner? • How did you decide on your priorities for care and what would you change? • How did patient safety concerns influence your care? What did you overlook? • In what ways did you personalize your care (recognition of culture, concerns, anxiety) for

this patient and family members? Discuss Your Teamwork:

• How did you communicate and collaborate? • What worked, what didn't work and what you will do differently next time? • What are you going to take away from this experience?

PNCI MS - Chest Pain Management of a Telemetry Patient

Medical Surgical (MS)

Teaching Q&A

State 1 Initial Assessment: What is the importance of frequently assessing vital signs, the groin site and lower extremity pulses after an arterial angiogram?

• To ensure the patient is not bleeding internally or externally and has not had a disruption to the arterial circulation of the lower extremity

What is the importance of encouraging fluids?

• To promote excretion of the contrast media used in the cardiac catheterization procedure and preserve kidney function

What interventions should the nurse employ to decrease the patient’s anxiety?

• Education • Answers to patient’s questions • A tranquil environment • Physical presence

What risk factors does the patient have that relate to her current health status?

• Family history • Hyperlipidemia • Smoking • Sedentary lifestyle • Hypertension

State 2 Complains of Chest Pain: What assessment data correlate to the patient’s complaint of chest pain?

• Decrease in oxygen saturation (SpO2) • Increase in blood pressure and heart rate • PVCs

Discuss the use of nitroglycerin and potential side effects.

• Nitroglycerin is a potent arterial and venous dilator. Arterial and venous dilation increase blood flow, and thus oxygen, to the heart

• Hypotension may result Discuss the use of administering a baby aspirin for a patient experiencing chest pain.

• Aspirin inhibits platelet aggregation and thins blood, thus increasing blood flow through the arteries

How will oxygen help the patient?

• It will increase partial pressure of arterial oxygen (PaO2) and oxygen delivery to the tissues, resulting in decreased pain

PNCI MS - Chest Pain Management of a Telemetry Patient

Medical Surgical (MS)

Teaching Q&A Continued

What is the importance of treating the patient for her anxiety? • Increased anxiety may predispose her to chest pain • Medicating her with an anti-anxiety agent will promote relaxation

What will the ECG tell the nurse?

• ST depression indicates myocardial ischemia State 3 Complains of Continuing Chest Pain: Besides medications, what other nursing interventions can be implemented to decrease the patient’s anxiety?

• Guided imagery • Distraction • Relaxation techniques • Therapeutic communication

State 4 Chest Pain Continues: What significance does the change in blood pressure have?

• Reflects of the vasodilatation effect of the nitroglycerin and indicates increased blood flow to the myocardium

What interventions could be implemented if the patient becomes symptomatic and hypotensive?

• Place in modified Trendelenburg position • Raise legs and support on pillow • Notify healthcare provider to obtain order for fluid bolus of 0.9% normal saline

State 5 Condition Worsens: Why is the patient given metoprolol?

• Metoprolol decreases myocardial oxygen demand by reducing heart rate, contractility and arterial pressure

How does morphine sulfate physiologically reduce chest pain?

• It is a vasodilator • It helps reduce anxiety and fear • Hypotension may result

State 6 Pain Free: Why is her chest pain now relieved?

• MONA (morphine, oxygen, nitroglycerin and aspirin) evidence-based protocol was followed according to the 2014 ACC/AHA & 2016 ESC NSTEMI acute coronary syndrome guidelines and was effective

PNCI MS - Chest Pain Management of a Telemetry Patient

Medical Surgical (MS)

Teaching Q&A Continued

Should the patient continue getting metoprolol? • Yes, because the heart rate is still elevated and not within the parameters ordered by the

healthcare provider. Healthcare provider orders should continue to be followed State 7 Stable 1 Hour Later: Briefly describe the surgical procedure of CABG.

• A surgical incision is made through the sternum • During the procedure, the patient is placed on a heart/lung pump machine • A vein is harvested from the leg (great saphenous) or chest (internal mammary) to use as an

arterial graft • This vein is sewn proximally above site of occlusion and distally below the occlusion • Patient will be in the intensive care unit (ICU) following surgery

What education should the nurse provide to prevent post-operative complications?

• Incentive spirometry • Cough and deep breathe with splinting • Use of sequential compression device and antiembolitic stockings • Activity and mobility • Pain management • Coping strategies

If the patient or a family member asks for more details about cardiac rehabilitation, what information should the nurse provide?

• Includes lifestyle modifications of controlled factors such as smoking cessation, heart healthy diet, exercise and weight loss

• Includes reducing risk factors for metabolic syndrome • Includes taking appropriate medications to control BP and cholesterol

References

Ackley, B. J., Ladwig, G. B., & Makic, M. B. F. (2017). Nursing diagnosis handbook: An evidence-based guide to planning care (11th ed.). St. Louis, MO: Elsevier Mosby. Amsterdam, E. A., Wenger, N. K. Brindis, R. G., Casey Jr., D. E., Ganiats, T. G., Holmes Jr., D. R., … Zieman S. J. (2014). 2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes, Journal of the American College of Cardiology. doi: 10.1016/j.jacc.2014.09.017

PNCI MS - Chest Pain Management of a Telemetry Patient

Medical Surgical (MS)

References Continued

Diercks, D. B., Owen, K. P., Kontos, M. C., Blomkalns, A., Chen, A. Y., Miller, C., Wiviott, S., & Peterson, E. D. (2010). Gender differences in time to presentation for myocardial infarction before and after a national women’s cardiovascular awareness campaign: A temporal analysis from the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation (CRUSADE) and the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network-Get with the Guidelines (NCDR ACTION Registry-GWTG). American Heart Journal, 160, 80-87. Edelman, C. L., Kudzma, E. C., & Mandle, C. L. (2013). Health promotion throughout the life span (8th ed.). St. Louis, MO: Mosby Elsevier. European Society of Cardiology Guidelines (ESC). (2016). 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. European Heart Journal, 37, 267-315. Http://dx.doi.org/10.1093/eurheartj/3hv320 Giger, J. N. (2016). Transcultural nursing: Assessment and intervention (7th ed.). St. Louis, MO: Mosby Elsevier. Ignatavicius, D. D., & Workman, M. L. (2016). Medical-surgical nursing: Patient-centered collaborative care (8th ed.). St. Louis, MO: Elsevier Saunders. McCarthy, C. P., Mullins, K. V., Sidhu, S. S., Schulman, S. P. & McEvoy, J. W. (2016). The on-and off-target effects of morphine in acute coronary syndrome: A narrative review. American Heart Journal, 176, 114- 121. Melnyk, B. M., & Fineout-Overholt, E. (2014). Evidence-based practice in nursing & healthcare: A guide to best practice (3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins. National Council of State Boards of Nursing. (2017). Test plans. Retrieved from https://www.ncsbn.org/testplans.htm Quality and Safety Education for Nurses. (2017). QSEN competencies. Retrieved from http://qsen.org/competencies/pre-licensure-ksas/ The Joint Commission. (2017). 2018 National patient safety goals. Retrieved from http://www.jointcommission.org/standards_information/npsgs.aspx