SCE: OB Emergency. Simulated Clinical Experience and Facilitator Guide. Perinatal Clinical Academy PHS AND AFFILIATES

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1 PHS AND AFFILIATES SCE: OB Emergency Perinatal Clinical Academy Simulated Clinical Experience and Facilitator Guide Last Revision: July 26, 2016 Perinatal Clinical Academy_ SCE OB Emergency 1

2 Bethany Bell Age: 28 Weight: 90 kg Learner Information The learner is providing care for a 28 year old female who is recovering from spontaneous vaginal delivery after Pitocin induction (for postdates) 4 hours ago. She is a G2 P2002, delivered a 4 kg baby boy at 41 1/7 wks gestation. She was transferred from L&D to Postpartum 4 hours postpartum after an uneventful recovery. Baby has breastfed successfully twice for 30 minutes each time. Bethany is ready for her second hourly assessment and fundal check. Facilitator Information Learners are expected to perform the appropriate postpartum assessments on both mother and baby and recognize increased bleeding related to an over distended bladder. The patient becomes hypotensive and tachycardic. Learner expected to continue fundal massage despite requests from patient to stop, call for additional nursing support, weigh and save pads, manage the patient s pain and notify the provider about the change in condition. Learners are expected to carry out LIP orders, as appropriate, in a timely manner. Learner should also provide emotional and educational support to patient and family regarding hemorrhage event. The scenario ends after completion of handoff report. Perinatal Clinical Academy_ SCE OB Emergency 2

3 Pre SIM Preparation Required Patient: Bethany Bell Age: 28 Weight: 90 kg Bell, Baby Boy 2 hours old, 41 1/7 weeks Weight: 4 Kg You will be providing care a 28 year old female who is 2 hours postpartum from a vaginal delivery. She is a G2 P2002, delivered a 4 kg baby boy at 41 1/7 weeks gestation. Assesses and maintains safe and complete care of both mother and baby Performs Head to Toe physical assessment and focused assessments as indicated Evaluates the patient s condition and response to interventions and modifies the nursing care in timely manner Identifies signs and symptoms of an unstable obstetric patient using a systematic process Identifies outcomes of interventions ordered and proceeds appropriately Demonstrates safe and comprehensive administration of fluids and medications Maintains accurate and precise intake and out take records Utilizes the Nursing Process Maintains effective closed loop communication with all members of the health care team Demonstrates safe and comprehensive medication administration Provides a culture of safety for all patients Demonstrates awareness of clinical environment, infection control, aseptic technique, fall prevention, skin care, behavioral health, and pain management Demonstrates caring and advocacy for patient and family Preparation required: This scenario integrates skills and education from previous simulated and nonsimulated clinical experiences. Please review standards, medications, and didactic education as needed. Suggested medications to review and be prepared to administer: Oxytocin Hemabate Methergine Misoprostol Magnesium sulfate Calcium gluconate Ephedrine Terbutaline Suggested Evidence Based Practice (EBP) and institution specific policies for review: Bleeding Emergency Obstetric Hemorrhage Epidural Catheter Analgesia / Anesthesia In Obstetrics Evacuation of Mothers and Babies Hypertension in Pregnancy Induction or Augmentation of Labor with Oxytocin Labor Patient Management Neonatal Resuscitation Postpartum Management and Discharge Preterm Labor (PTL) Trauma in Pregnancy Perinatal Clinical Academy_ SCE OB Emergency 3

4 SIM Set Up Checklist SCE: OB Emergency Print patient labels with correct birthdate and MRN, then label patient, labs, orders appropriately. Standard Room Supplies Family observer clipboard and SAFETY /QUALITY OBSERVER CHECKLIST Oxygen regulators x2 with Adult ambu bag hanging and Non rebreather mask on O2 regulator Suction regulators, canister, suction tubing and yankuar in package sitting on top x2 Adult and Newborn Stethoscopes x4 Bathroom: peri care supplies (Pink bucket with Mesh panties, chuks pads x4, large pads x2, small pads x2, peri bottle) and urine hat Call Bell, thermometer (oral and temporal), flashlight, reflex hammer Code cart in hallway with first responder box on top Extra pillows IV pump Monitor Neonatal code cart in hall Over the bed table WOW For PP/ANTE Bassinet with bulb suction in bed o Top drawer; neonatal ambu bag, pink basin with bath supplies ( yellow comb, J&J soap, dry washcloths) diapers and wipes, shirts, blankets Breast pump and parts Manikin: Birthing manikin/adult female and infant Supplies for OB EMERGENCY Sim MOTHER: o Patient ID Band and Matching Baby ID band o Postpartum Gown on o Birthing manikin with hemorrhage capabilities o Small pool of blood and light clots inside vagina o Mesh underwear with peripad (moderate red blood on pad at start of sim) o BP Cuff and sat probe on o IV (18 gauge) in L arm o IV pump on pole o Emesis basin on bedside table BABY: o Bassinet with blue bulb suction, and crib card o Check that baby has: ID Band, Hugs Tag, hat, t shirt, diaper, swaddle blanket. o Baby in patients arms Tech Recording equipment ready if available Manikin specific control software ready to go Facilitator guide Perinatal Clinical Academy_ SCE OB Emergency 4

5 Medication and 2 bags of Oxytocin (Pitocin) 500 ml Supplies Place in Fentanyl 100 mcg/ml vial med room Motrin 600 mg tabs packet Percocet 5/325 mg tabs packet OB Hemorrhage med kit (per facility) o Hemobate 250 mcg in ampule o Methergine 200 mcg in vial o misoprostol 200 mcg tabs OB Hemorrhage cart with supplies Scale for weighing pads Runner: Supplies Facilitator guide ( marked as revision guide) to be placed in Handoff/SBAR control room Extra blood clots Foley to be quickly placed in the patient ( not the objective of this sim) Conference Room Flipchart and Markers Facilitator Guide Learners Roles and Responsibilities Perinatal Clinical Academy_ SCE OB Emergency 5

6 Introduce yourself Check in with residents Pre Brief A little about today Today s scenario is meant to use what you ve learned over the past few weeks and your critical thinking to decide what interventions are needed for your patients and what orders/diagnostics you should expect. A note about realism Yes we know that an LIP would be making decisions but we want to see how you think through the patient situation. What is your process in prioritizing the needs for your patients? What questions do you ask yourself to make conclusions about your patient? DO YOU FEEL LIKE YOU KNOW HOW TO RECOGNIZE A PATIENT EMERGENCY? WHAT SORT OF EMERGENCY ARE YOU CONCERNED ABOUT? WHAT IS THE MINIMUM YOU NEED TO KNOW TO RESPOND TO AN EMERGENCY? Example: where to find the code cart, hemorrhage meds, C/S tray, etc WHAT IS THE NURSE S ROLE IN AN EMERGENCY? Code Blue o Primary Nurse o Responding Nurse Neonatal Code o Primary Nurse o Responding Nurse Prolapse Cord o Primary Nurse o Responding Nurse PPH o Primary Nurse o Responding Nurse Shoulder Dystocia o Primary Nurse o Responding Nurse REVIEW OBJECTIVES OF THIS SIM: Assesses and maintains safe and complete care of both mother and baby Performs Head to Toe physical assessment and focused assessments as indicated Evaluates the patient s condition and response to interventions and modifies the nursing care in timely manner Identifies signs and symptoms of postpartum hemorrhage using a systematic process Identifies outcomes of interventions ordered and proceeds appropriately Demonstrates safe and comprehensive administration of fluids and medications Perinatal Clinical Academy_ SCE OB Emergency 6

7 Maintains accurate and precise intake and out take records REVIEW THE EXPECTATION OF SIMULATION When in doubt, treat it as real Operate as a TEAM Think OUT LOUD Use SBAR for all communication Educate the patient and family member Demonstrate caring and compassion Demonstrate excellent safety practices o Patient identification o Infection prevention Gel in Gel out o Skin management o Pain management o Fall prevention o Medication safety and double checks Care for yourselves o Wear gloves o Protect your body ASSIGN ROLES FOR SIMULATION See Appendix for Roles descriptions Give reminder about EPIC (signed and held orders, if applicable) and send to learners to break. Please let support staff know you are on break so they can finish preparation for SIM Perinatal Clinical Academy_ SCE OB Emergency 7

8 As the facilitator and tech of this scenario, please remember to be flexible as far as the flow of the simulation. Based on the learner s choices the facilitator may need to change the course of the simulation. Our goal, as always will be to keep the learners on path to meet the educational objectives. State 1 Initial Assessment Overview Chart of SIM Highlights VS: HR 90 s, BP 110s/60s, RR teens, SPO2 97% on room air, Temp 98.6F Baby: HR 148, RR 44, Temp 98.6F, Glucose 45 Learners Facilitator Patient TECH All entering room should gel hands 1. Introduce self to patient 2. Begin comprehensive postvaginal delivery assessment; VS, Pain level, Fundal check 3. Assists patient to bathroom after recognizing distended bladder 4. Reassess fundus/lochia after voiding; educates pt about frequent voiding Cues tech to transition to State 2 Beginning Hemorrhage when assessments is complete. If patient is not taken to bathroom to void, then transition to State 3 Progressing Hemorrhage Voice of Patient responding to RN s questions Tired, but happy about baby Pain 4/10 with mild cramping, tolerable When asked about voiding, responds that she does not feel like she has to go, but is willing to try Fundus firm and deviated to the right Bleeding turned off, change at facilitator discretion After voiding: Fundus firm, midline, at umbilicus Bleeding mild, no clots 5. Newborn assessment and vitals 6. Documents information RUNNER: Respond as Charge RN if called and suggest emptying the bladder (after asking what they think is going on FIRST!) Call into room as Charge RN after the patient is back from bathroom and reassessed to report that another patient needs them MD ORDERS: If RN calls about fundus/bleeding; ask when she last voided Perinatal Clinical Academy_ SCE OB Emergency 8

9 (One Hour Later) State 2 Beginning Hemorrhage VS: HR 110 s; BP 90s/50s; RR in the 20s, SpO2 96% on RA, Temp 98.6F Baby: Stable and sleeping Learners Facilitator Patient TECH All entering room should gel hands 1. Assesses VS, fundus and lochia; recognizes changes in condition 2. Initiates fundal massage and calls for additional help 3. Weighs/saves pads 4. Notifies provider about change in condition and for further orders 5. Carries out orders or delegates in a timely manner as appropriate Cue tech to transition to State 3 Progressing Hemorrhage once orders are completed If the bleeding is to your satisfaction cue tech to stay in State 2 Beginning Hemorrhage. Moving to State 3 Progressing Hemorrhage will increase the bleeding Voice of Patient responding to RN s questions Anxious about bleeding and in pain from fundal massage I don t understand why you have to keep pressing on my stomach when it hurts so bad!! ANNOUNCE: 1 hour has passed Fundus boggy Bleeding off, turn on and then back off when instructed by facilitator 5. Documents data RUNNER: Respond as charge RN as needed and let the participants direct you in what they need; ask if they have notified LIP if they have not already MD ORDERS: (verbal orders) Restart Pitocin at 150 ml/hr Give Methergine 0.2 mg IM x 1 STAT Notify me if bleeding does not improve Perinatal Clinical Academy_ SCE OB Emergency 9

10 State 3 Progressing Hemorrhage VS: HR in the 110s, BP in high 90s/50s, RR in upper 20s and SpO 2 above 95% on O2 (low 90 s if not on O2), Temp 98.6F LOC: Dizzy, light headed; still responsive Baby: Stable, sleeping Learners Facilitator Patient TECH All entering room should gel hands 1. Notes changes in VS, patient s LOC, fundus/lochia 2. Calls for additional assistance and initiates oxygen delivery based on dropping O2 sats Cue tech to transition to State 4 Slight Improvement with Provider Intervention once LIP is called Report feeling dizzy, light headed with tingling in lips and fingers Very anxious and concerned about baby Bleeding off, turn on and then back off when instructed by facilitator 3. Using ISBAR, notifies provider of continued bleeding and changes in condition, asks for provider to come to bedside 4. Carries out orders or delegates in a timely manner as appropriate 5. Supports patient and family emotionally by providing communication and updates 6. Documents data RUNNER: Come into room as a helper and place the catheter and 2 nd IV (Foley insertion is not a learner objective for this SIM) Announce that you have drawn the OB Hemorrhage panel during IV start. MD ORDERS: Place indwelling Foley catheter Place 2 nd IV with LR fluid bolus of 1000 ml Asks about total EBL to this point OB Hemorrhage Panel and Type and Cross 2 units PRBCs Perinatal Clinical Academy_ SCE OB Emergency 10

11 State 4 Slight Improvement with Provider Intervention (Provider Performs a Manual Evacuation) VS: HR in the 120s, BP 90s/50s, RR in the low 20s and SpO 2 97% with 2 L O2 via NC, Temp 98.6F LOC: Alert but anxious Baby: Stable, still sleeping Learners Facilitator Patient TECH All entering room should gel hands 1. Assist provider with manual evacuation of clots/products of conception 2. Continue to monitor for changes in condition, increased bleeding 3. Supports patient and family Cue tech to transition to State 5 Bleeding Stable and Patient Recovering after clots removed and meds given Responds to RN s questions. Wants to know she can have anything else for the pain when provider doing manual evacuation (pain at 7/10 from cramping) Anxious about how much she is bleeding Fundus firm at U/U after provider intervention Clots expressed by provider Bleeding off, turn on and then back off when instructed by facilitator 4. Advocates for patient regarding pain during procedure 5. Carries out orders or delegates in a timely manner as appropriate Vaginal pain ( hurts to sit) feels like pressure or throbbing 6. Documents data RUNNER: As MD, come in to room and preform a manual evacuation of clots MD ORDERS: Give 800 mg Misoprostol PR x 1 STAT Continue Pitocin at 125 ml/hr Continue monitoring with increased frequency of vitals/fundal checks and report any continued bleeding Perinatal Clinical Academy_ SCE OB Emergency 11

12 State 5 Bleeding Stable and Patient Recovering VS: HR in the 90s, BP in the 100s/60s, RR in the teens and SpO 2 in upper 98% on RA, Temp 98.6F LOC: Alert and oriented, less anxious, no longer dizzy/light headed Baby: Stable, awake and rooting Learners Facilitator Patient TECH All entering room should gel hands 1. Performs repeat assessment of VS and fundal check Simulation Complete! Responds to RN questions. Wants to breastfeed after baby awakens. Bleeding off One patient stabilizes turn on baby crying 2. Promotes breastfeeding and educates patient about benefits of breastfeeding r/t to fundal tone Pain 2/ Provides emotional and educational support to patient and family regarding events 4. Documents data RUNNER: None MD ORDERS: None Perinatal Clinical Academy_ SCE OB Emergency 12

13 DEBRIEF The goal of the debrief is to provide the opportunity for the residents to share and reflect as a group on areas for improvement and recognize practice behaviors that demonstrate excellence. Remember to: Remind residents that the debrief is a safe place and the purpose is for them to learn from their experiences Try to use the video when it fits Ask the family member their observations Use standards as needed for clarity/guidance Use what if questions Embrace the silence END with: What one thing are you going to take away from this experience? The template below is available for groups that struggle to facilitate the debrief on their own REVIEW OBJECTIVES OF THIS SIM: Assesses and maintains safe and complete care of both mother and baby Performs Head to Toe physical assessment and focused assessments as indicated Evaluates the patient s condition and response to interventions and modifies the nursing care in timely manner Identifies signs and symptoms of postpartum hemorrhage using a systematic process Identifies outcomes of interventions ordered and proceeds appropriately Demonstrates safe and comprehensive administration of fluids and medications Maintains accurate and precise intake and out take records General What worked, what didn t work and what will you do differently next time? 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 Were they performed 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 for this patient and family members (recognition of culture, age, concerns, anxiety)? Discuss your teamwork. How did you communicate and collaborate? WHAT ARE YOU GOING TO TAKE AWAY FROM THIS EXPERIENCE? Perinatal Clinical Academy_ SCE OB Emergency 13

14 APPENDIX References: Micromedix AWHONN. (2014). Perinatal nursing. (4 th Ed.). Simpson, K.R. and Creehan, P.A. (Eds.). Philadelphia, PA: Lippincott Williams & Wilkins. AWHONN. (2015). Quantification of Blood Loss: AWHONN Practice Brief Number 1. JOGNN, 44, ; DOI: / Perinatal Clinical Academy_ SCE OB Emergency 14

15 Initial Lab Results Procedure WBC 11.3 Pt results Reference Ranger per Facility RBC 2.48 Hgb 13.2 HCT 34.6 ABO RH Antibody Screen Product O Positive Negative Red Blood Cells Unit ID W Interpretation Product Status GB Strep DNA Compatible Cross Matched Negative Perinatal Clinical Academy_ SCE OB Emergency 15

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