University of South Dakota Vermillion, South Dakota Department of Nursing. Simulation Scenario Complex Patient: Acute MI. Overview

Transcription

1 Simulation Scenario Complex Patient: Acute MI Overview Title: Acute MI with Dysrhythmias Concept: Complex Patient To cite this reference: Target Group: Second Year Nursing Students Kisner, T. & Warren, D., (2012). Simulation scenario; Complex patient: Acute MI with dysrhythmias. Unpublished manuscript., University of South Dakota at Vermillion. Time Allotment (each simulation is designed to be run in a two hour block of time which equals four clinical hours): Prep: Worth approximately two hours (see preparation requirements). Prebriefing: Site specific. Should be shorter than prebriefing for second year students. Simulation: Approximately 30 minutes. Debriefing: Should be longer than debriefing for second year students. If the simulation episode runs less than two hours consider running the simulation again, create concept maps, create teaching plans, perform web quests to further understanding or other activities you feel would be beneficial to the students learning. DocuCare Information: This is an elderly female with a history of CHF, DM, and Chronic Renal Failure. While on vacation, she develops shortness of breath at Mt. Rushmore. She presents to the ED with symptoms of a MI and then dysrhythmias.

2 Complex Patient: Acute MI 2 AACN Essentials: I, II, III, VI, IX Curriculum Alignment Population: 64 year old Spanish female Concepts Exemplar Complex Patient Acute MI with Dysrhythmias Knowledge Skills Attitudes Objectives and Outcomes Area Scenario Objectives Course Outcomes Recognize signs and symptoms of a Myocardial Infarction and Dysrhythmias, then implement therapeutic nursing interventions appropriately. Compare and contrast varying leadership styles utilized by nurses as patient condition changes. Evaluate the impact of utilizing evidence-based practice [EBP] when treating an acute MI patient. Student Preparation Prerequisite assignment (the following information should be sent to the students prior to the scheduled simulation) Students are expected to bring their laptop, drug book, and primary text to all simulations. Acute MI&Dysrhythmias_Student Prep

3 Complex Patient: Acute MI 3 Simulation Setup Manikin Settings: Initial Vital Signs Pulse: 52 Blood pressure: 86/60 Pulse ox: 91% on room air Respiratory rate: 22 Temperature: 97.6 F PO Cardiac rhythm: Sinus brady with ST elevation Lung sounds: Scattered rhonchi Bowel sounds: Present x 4 quad Other: Chest pain 5/10 Change in Vital Signs How many minutes until change? Approx minutes after nurses turn on O2 and give IV bolus Pulse: Blood pressure: 112/70 Pulse ox: 96% on O2 Respiratory rate: Temperature: Cardiac rhythm: Lung sounds: Other: (still Sinus brady with ST elevation) Equipment List Oxygen via nasal cannula Saline locked hooked up to NS at 15 cc/hr (was started by paramedics) Crash cart with defibrillator and pads on it Ambu bag Monitor showing change in heart rhythm and VS. (If site does not have this, use attached pictures of rhythm and verbalize VS) Scenario Setting: Setting: Emergency department at large urban hospital Time of day of scenario: 2:20 p.m. Patient Condition Clothing: Street clothes Props: Moulage: Roles for Students Primary nurse Secondary nurse Recording nurse Mr. Rodriguez Medication nurse Physician Diaphoretic (glycerine spray) Student Names (Faculty) Documents MD ER orders Lab results Tele strip of SB with ST elevation Tele strip of Ventricular Tachycardia Medication Dosage Route Morphine Syringe label IV push 2mg/ml Aspirin 81 mg PO Nitroglycerin 0.4 mg (3 tabs, SL with each one labeled 0.4 mg) Lopressor 5 mg IV push Concentration Package 0.9% NS- 250 cc bolus IV

4 Complex Patient: Acute MI 4 Patient Demographics Last Name: Rodriguez Patient Background First Name: Marcella Gender: Female Age: 64 Ht: 5 2 Wt: 212 lbs Ethnicity: Spanish Religion: Methodist Language: Primarily Spanish English Proficiency: Speaks basic/limited English. Husband speaks English well History of present illness: 64-year old Spanish female with S/S of acute MI and dysrhythmias. History of Type II DM, CHF and Chronic Renal Insufficiency. Primary Medical History: Central nervous system Cardiovascular Pulmonary Renal/Hepatic Gastrointestinal Musculoskeletal Integument Developmental history Psychological history Social history Alternative/ Complementary CHF, frequent problems with pedal edema Occasional problems with rhonchi and shortness of breath Chronic Renal Insufficiency (is on diuretics, does not require dialysis) Married, recently retired secretary Medication allergies Sulfa Reaction: Breathing problems Food/other allergies Reaction:

5 Complex Patient: Acute MI 5 Prebriefing Give students the opportunity to discuss their feelings and fears (can use the round table approach) and then have discussion. Have students get into small groups of two to three and discuss the most significant things they learned when doing their prep. Then have each group share what their discussion involved. Ask students the following questions and have group discussion: 1. Have any of you witnessed a patient or loved one having a MI? Describe what happened. What did the medical and nursing personnel do for treatment? 2. Have any of you witnessed a patient or loved one go into cardiac arrest? What do you remember? Describe the teamwork that occurred between healthcare professionals during that event. 3. If a patient having dysrhythmias is symptomatic (not tolerating it well), how will you know? What signs and symptoms will be present? 4. What are the basic essential cares that need to be given to every patient experiencing dysrhythmias that are symptomatic? 5. If a patient is experiencing dysrhythmias, at what point do you need to get help and/or contact the MD? 6. What electrolytes impact a person s cardiac function? How should nursing intervene if the electrolytes are abnormal? At what point does an abnormal lab need to be reported to the MD? The above items are listed to assist faculty in leading a prebriefing discussion with students. Feel free to use some or all of the items depending on the needs of the student group.

6 Complex Patient: Acute MI 6 Scenario Paramedic report to Nurses in ER: (to be read by faculty) This is Marcella Rodriguez. She is 64 years old; she s on vacation here from Miami, Florida. She was walking at Mt. Rushmore and developed acute shortness of breath and mild nausea. She has a history of Type II DM, CHF, and Chronic Renal Insufficiency. I did start an 18 gauge saline lock and it is hooked up to Normal Saline at TKO. Her tele shows sinus brady with possibly some ST elevation. I gave her two mg of morphine in route and also one sublingual nitro and that took care of the pain. Just in the last minute or so she said the pain is back. Also, she speaks Spanish. She can speak limited English so I asked her husband questions when she didn t understand and he would interpret for us. Her meds are back at the hotel and her husband just said she s on a water pill, diabetes pill, and some heart meds. Timing Patient actions live faculty Expected interventions May use the following cues: Approx. 10 minutes Marcella s VS/assessment: HR- 52 Tele- Sinus brady with ST elevation BP- 86/60 O2-91% on room air RR- 22 Pain 5/10 is substernal and radiates to left arm & neck c/o some nausea but no vomiting Nurses do focused cardiac assessment including VS. Nurses note diaphoresis and ask about nausea and shortness of breath. Nurses assess pain (location, intensity, description, radiation). Nurses put O2 on at approx. 2 L/NC. Nurses make sure IV is patent. Role member providing cue: Mr. Rodriguez: Someone tell me what is going on. What are you doing to her? What is happening? Nurses explain to Mr. Rodriguez what they are doing and what is happening. Nurses get MD (played by instructor). MD/instructor goes in to room and comes back out but states that she evaluated patient and has orders.

7 Complex Patient: Acute MI 7 Approx. 10 minutes MD (faculty person) hands orders to nurses stating, Please get these started- I have paged the cardiologist and lab is on the way to draw blood. After IV bolus and increase in O2: Nurses correctly prioritize orders: Must give IV NS bolus to get BP up BEFORE giving Nitro and Morphine. Nurses turn O2 up until sats >95%. Mr. Rodriguez: Marcella said the pain is better after those medications; a 1 or 2 now. -BP now 112/70 -O2 sat now 96% Nurses give ASA. Nurses reassess pain level after Morphine and 1 st nitro. Approx. 10 minutes Suddenly Marcella becomes unresponsive. Monitor shows Ventricular Tachycardia. There is no pulse. Faculty person tells students that MD is with a trauma patient and will be in shortly but to start CPR and defibrillating per ACLS protocol. Nurses confirm that there is no pulse and acknowledge that she is in VT. One nurse gets defibrillator while another nurse lays patient flat and starts CPR (chest compressions and ventilations via ambu bag). Nurses call out loud for MD/help. Mr. Rodriguez: What is happening (emotional/upset) Nurses defibrillate patient correctly and state all clear. Lab results come back and are handed to nurses (by instructor): K 6.9 (H) Mg 0.2 (L) BNP 1640 (H) Triponin 14.3 (H) BUN 42 (H) Creatinine 3.8 (H) After Marcella is defibrillated twice (and CPR continues), pulses come back and Marcella starts to breathe and cough. One nurse explains events to Mr. Rodriguez (may choose to take him out of room). Nurses acknowledge abnormal labs and report them to MD. Simulation is now over.

8 Complex Patient: Acute MI 8 Debriefing Start by asking students about their feelings/thoughts related to the experience. It is alright to let the students lead the discussion at first. Utilize the questions below at your discretion. Debriefing / Guided Reflection Questions for this Simulation: 1. Talk about how you felt when you saw that she had ST elevation and was clearly having a myocardial infarction. 2. What is the significance of MONA, and why is it so important that MONA be started ASAP? 3. When prioritizing the initial MD orders, what did you take into consideration when prioritizing what to do first, second, etc? 4. Talk about when Marcella went into Ventricular Tachycardia. What thoughts were going through your head? 5. What leadership styles were used by the nurses during the beginning of the simulation vs. at the end when she was in V-Tach? 6. Marcella had a language barrier but it was not severe and her husband was there to help. What if he had not been there and she couldn t speak any English? 7. Do you feel that you have a full understanding of DNR/DNI? What questions do you have about that? 8. After Marcella s pulse came back and she started breathing again, what care would be important before sending her to the ICU or cath lab? Final thoughts/feelings? The above items are listed to assist faculty in leading a debriefing discussion with students. Feel free to use some or all of the items depending on the needs of the student group.

9 Complex Patient: Acute MI 9 Supporting Documents Forms Patient Chart Information/Forms Script/Roles Acute MI&Dysrhythmias_Charts Give copy of scenario to student playing Mr. Rodriguez. No scripts necessary for other roles. Recommendations For Online Use This simulation could be performed in the mobile simulation unit and streamed to distance students. Role of recording nurse could be played by a distance student and entered into DocuCare. Documentation students at a distance could participate in the pre-briefing and debriefing sessions using webinar.