SCE: OB Blood Administration

Size: px

Start display at page:

Download "SCE: OB Blood Administration"

Andrew Jones
5 years ago
Views:

1 PHS AND AFFILIATES SCE: OB Blood Administration Perinatal Clinical Academy Simulated Clinical Experience and Facilitator Guide Last Revision: June 13, 2016

2 Leena Singh Age: 28 Weight: 70 kg Learner Information You will be providing care for a 28 year old female G1 P1001 who is status post c section for postdates. She had a mild postpartum hemorrhage in the OR and her recovery has been going well. She is slightly hypotensive with a BP of 90/50 and her hematocrit is pending. Baby Girl Singh was born at 42 weeks gestation and weighed 4.4kg, the baby is on the glucose protocol, and the last glucose was 55. Facilitator Information In this scenario the learner is expected to perform safety checks, verify orders and complete a full and accurate assessment of the patient. The patient will receive PRBC s according to protocol and the learner will practice the psychomotor and standards process for blood administration, including; conditions to receive blood, ordering blood, blood component pick up, independent double checking of blood products and blood administration. The patient will begin to decompensate into a respiratory distress from anaphylaxis and will need to be recovered with epinephrine according to standards. Perinatal Clinical Academy_ SCE OB Blood Administration 2

3 Pre SIM Preparation Required Patient: Leena Singh Age: 28 Weight: 70 kg You will be providing care for a 28 year old female G1 P1001 who is status post c section for postdates. She had a mild postpartum hemorrhage in the OR and her recovery has been going well. She is slightly hypotensive with a BP of 90/50 and her hematocrit is pending. Baby Girl Singh was born at 42 weeks gestation and weighed 4.4kg, the baby is on the glucose protocol, and the last glucose was 55. Assesses and maintains safe and complete care of both mother and baby Performs head to toe physical assessment and focused assessments as indicated Administers blood products per policy Prioritizes the nursing management of a patient receiving blood or blood products Recognizes the signs and symptoms of an adverse reaction to blood component administration Evaluates the patient s response to interventions and modifies the nursing care as appropriate for the patient experiencing an adverse reaction to blood component administration Administers medications per protocol 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: Review the following medications and be prepared to administer: Epinephrine (for anaphylaxis) Diphenhydramine Acetaminophen Oxygen Blood: Packed Red Cells Review the following Evidence Based Practice (EBP) and institution specific policies around: Blood and Blood Component Administration Anaphylaxis/Hypersensitivity Treatment Oxygen Administration Neonatal Glucose Screening Neonate and Infant Heel Stick Blood Sampling Newborn Management Skin To Skin Benefits of Breastfeeding Perinatal Clinical Academy_ SCE OB Blood Administration 3

4 SIM Set Up Checklist SCE: OB Blood Administration Print patient labels with correct birthdate and MRN, then label patient, labs, orders appropriately. Standard Room Supplies may differ by facility 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 Supplies for OB Blood Administration Sim Manikin BABY: Adult female and o Bassinet with blue bulb suction, and crib card infant o Check that baby has: ID Band, Hugs Tag, hat, t shirt, diaper, swaddle blanket. o Baby in patients arms MOTHER: o Patient in bed o IV infusion capability; IV (18 gauge) in both arms. o IV fluids; LR at 125 ml/hr in left arm, Right IV saline locked o Patient ID band and baby band, BP cuff on, sat monitor, and gown on patient o Patient paper chart on WOW includes: Fall risk sign, blood component pick up form, verification of informed consent for blood transfusion form o Postpartum belly with hard fundus at umbilicus o Post C/S Dressing: ABD dressing on lower abdomen with the thick foamy/stretchy tape. o SCD s on bilateral lower extremities Tech Recording equipment ready if available Manikin specific control software ready to go Facilitator guide Perinatal Clinical Academy_ SCE OB Blood Administration 4

5 Medication and Diphenhydramine 25mg IV Supplies Place in Acetaminophen 650mg PO med room Epinephrine for anaphylaxis Normal Saline One unit PRBC [with transfusion report and lab sign out paperwork and placed in a bio hazard bag] Runner: Supplies Facilitator guide (marked as revision guide) to be placed in Handoff/SBAR control room Labs Conference Room Flipchart and Markers Facilitator Guide Learners Roles and Responsibilities For demonstration Blood Tubing, PRBC bag and transfusion report, 500cc NS OPTIONAL: Blood administration step by step ( blank for learner; answer key for facilitator) Perinatal Clinical Academy_ SCE OB Blood Administration 5

6 Introduce yourself Pull up Standards for the learners o o PREBRIEF Use the links to access job aids and pinpoint specific education Use EPIC to review documentation Check in with residents: Ask learners about their experience with blood administration OPTIONAL: (see appendix) Use the blood administration Step by Step educational aid to explore the blood administration process EXPLORE THE BLOOD ADMINISTRATION PROCESS WHAT IS THE DIFFERENCE BETWEEN A TYPE & CROSS AND A TYPE & SCREEN? DISCUSS RH FACTOR AND IMPORTANCE IN PREGNANT WOMEN WHEN DO YOU NEED TRANSFUSION CONSENT? WHO IS RESPONSIBLE FOR OBTAINING WRITTEN CONSENT FOR A BLOOD TRANSFUSION AND WHAT FORM IS USED? WHAT SUPPLIES DO YOU NEED? WHAT ASSESSMENTS DO YOU NEED TO COMPLETE? HOW DO YOU PICK UP THE BLOOD? HOW DO YOU CHECK THE BLOOD? IF THE INFORMATION ON THE BLOOD COMPONENT DOES NOT MATCH THE INFORMATION ON THE PATIENT S CHART EXACTLY, WHAT SHOULD YOU DO? SHOW PRIMING OF BLOOD TUBING WHAT TYPE OF PATIENT EDUCATION DO WE GIVE? HOW DO YOU SET THE PUMP? RATE? VOLUME? TO START BLOOD? THEN TO ADMINISTER? RECHECKS? WHERE/WHAT DO YOU DOCUMENT FOR BLOOD ADMINISTRATION? EXPLORE SUSPECTED TRANSFUSION REACTIONS AND TREATMENT TYPES OF TRANSFUSION REACTIONS DISCUSS POLICY AND PROCEDURES: HOW TO ACCESS AND USE WHILE ADMINISTERING BLOOD REVIEW OBJECTIVES FOR 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 Perinatal Clinical Academy_ SCE OB Blood Administration 6

7 Administers blood products per policy Prioritizes the nursing management of a patient receiving blood or blood products Recognizes the signs and symptoms of an adverse reaction to blood component administration Evaluates the patient s response to interventions and modifies the nursing care as appropriate for the patient experiencing an adverse reaction to blood component administration Administers medications per protocol 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 Blood Administration 7

8 State 1: Initial Assessment Overview Chart of SIM Highlights Mother VS: HR in the 100s, BP in the 90s/50s, RR in the 20s, SpO2 in the mid 90s on room air and a Temp of 98.6 F. Pain: 2/10 Baby VS: HR 140, RR 52, Temp 98.9 F Physical Assessment: Normal Glucose: 58 Learners Facilitator Patient TECH Alert and Oriented All entering room should gel hands 1. Introduce self to patient 2. Begin comprehensive maternal assessment; VS, pain level, SpO 2 level, CMS 3. Comprehensive newborn assessment; VS, head totoe, BF/Latch, I&O 4. Ensure saline lock intact & patent 5. Performs pre transfusion checks Consent signed VS taken Patient education 6. Sends runner for first unit of PRBC with proper paperwork. 7. Documents information Cues tech to transition to State 2 Blood Arrives when blood has arrived in room. Dizzy, lightheaded Minimal pain, feel okay, just tired? Ask if getting blood is going to be ok with breastfeeding. Why do I need blood, can I just take more iron pills? Is the blood transfusion safe? Pt is anxious about effect on newborn. RUNNER: Give SBAR report. State that labs are pending and LIP will want to transfuse if Hct remains low PRBCs are available in TSL. Perinatal Clinical Academy_ SCE OB Blood Administration 8

9 State 2: Blood Arrives Mother VS: HR in the 100s, BP in the 90s/50s, RR in the 20s, SpO2 in the mid 90s on room air and a Temp of 98.6 F. Pain: 2/10 Baby VS: HR 155, RR 50, Temp 98.6 F Physical Assessment: Normal Learners Facilitator Patient TECH All entering room should gel hands 1. Verifies blood product with another approved HCP 2. Documents on transfusion report 3. Hangs blood using proper tubing 4. Starts blood infusion slowly When all steps are complete: Announces: 10 minutes have passed Cue patient c/o anaphylaxis Cue tech to transition to State 3 Mild Anaphylaxis. Voice of Patient responding calmly to RN s questions Somewhat quiet so residents can focus on task. Pt wants to be napping. **Bookmark when the blood arrives in the room** 5. Documents data LIP ORDERS: None Perinatal Clinical Academy_ SCE OB Blood Administration 9

10 State 3 : Mild Anaphylaxis Mother VS: HR in the 100s, BP in 80s/50s, RR in low 20s and SpO 2 in mid 90s on RA,T 98.6F Progresses to HR 120s, BP remains low, RR 20s and SpO 2 in high 80s on RA Learners Facilitator Patient TECH All entering room should gel hands 1. Notes change in VS and performs focused assessment 2. Calls for another nurse and moves baby from mom s arms to bassinet 3. Stops blood 4. Calls RRT/Code Blue If time in State 3 is more than 2 minutes, progress to State 4 Severe Anaphylaxis. If epinephrine given IV cue tech to State 7 Ventricular Fibrillation Very anxious Patient stating she is having trouble breathing, talking and is feeling anxious; SOB, tongue feels funny There s something wrong with me! Why does my toungue feel like it s swelling? If time in State 3 is more than 2 minutes, progress to State 4 Severe Anaphylaxis. 5. Informs LIP of patient s condition using SBAR I m scared. 6. Clarifies epinephrine order as IM route, and reads back order 7. TORB diphenhydramine 25 mg IV and normal saline bolus 500ml 8. Gives epinephrine using correct syringe/needle 9. Initiates NS bolus 10. Applies oxygen LIP ORDERS: Epinephrine 0.3 mg (no route given). If questioned about route of administration, healthcare provider replies IM. Diphenhydramine 25 mg IV and Start 500 ml normal saline bolus. Perinatal Clinical Academy_ SCE OB Blood Administration 10

11 State 4: Severe Anaphylaxis VS: HR in the 140s, BP70s/40s, RR in low 30s and SpO 2 in mid 80s with oxygen, T 98.6F Learners Facilitator Patient TECH Continued from State 3 1. Focused ongoing assessment 2. Initiates Emergency response 3. Gives epinephrine using correct syringe/needle Cue tech to transition to State 5 Epinephrine given IM when Epinephrine is given If epinephrine given IV cue tech to State 7 Ventricular Fibrillation Wheezing and can t breathe, not talking much, grunting. Pt acts panicked **Bookmark video of epinephrine injection** LIP ORDERS: Epinephrine 0.3 mg (no route given). If questioned about route of administration, healthcare provider replies IM. Diphenhydramine 25 mg IV and Start 500 ml normal saline bolus. Perinatal Clinical Academy_ SCE OB Blood Administration 11

12 State 5: Epinephrine given IM Mother VS: HR in the 170s, BP in the 120s/90s, RR in 20s and SpO 2 in low 90s with oxygen and Temp F Learners Facilitator Patient TECH All entering room should gel hands 1. Performs focused assessment 2. May perform double check on blood unit and patient ID Cues tech to transition to State 6 Recovery when assessment complete. Slow improvement, deep breathes, scared, but less anxious. Alert and oriented LIP ORDERS: Perinatal Clinical Academy_ SCE OB Blood Administration 12

13 State 6: Recovery Change of Shift Report Mother VS: HR in 100s 110s, BP in 100s/70s, RR in teens, SpO 2 in upper 90s with oxygen at 2l per nasal prongs, T 100.5F Baby VS: HR 155, RR 50, Temp 98.6 F Learners Facilitator Patient TECH All entering room should gel hands 1. Titrate oxygen down and Exchange NRB for nasal prongs. 2. Notifies TSL of blood reaction 3. Gives shift handoff report uses SBAR Simulation Complete! Voice of Patient responding to RN s questions Patient asking for clarification of what happened. LIP ORDERS: Perinatal Clinical Academy_ SCE OB Blood Administration 13

14 State 7 : Ventricular Fibrillation Patient s condition deteriorates VS: HR 0, BP in the 20s/20s, RR 0 CV: cardiac monitor shows course VF Lungs: Breath sounds absent, patient is cyanotic Learners Facilitator Patient TECH All entering room should gel hands 1. Recognize and verbalize emergency Scenario complete after participants recognize the emergency. >>If epi is given via IV: Once learners recognize change in patient, STOP the scenario IMMEDIATELY DEBRIEF Do not speak, you are unresponsive! If you get to this state: 1. Facilitator will stop scenario Reset the room and prepare to restart at State 3 Mild Anaphylaxis Debrief for Adverse Patient Event Remember to convey a commitment to respecting learners and understanding their perspective 1. What happened to the Patient? Why? 2. How did you know? What changes did you see? 3. If that happen on your unit what steps would you do next? 4. What is the correct way to give epinephrine? ( walk them through it, show them the supplies) 5. Reinforce that this is why we do simulation, no one was hurt and we learned what to do! 6. Take a break and breathe 7. Go back to simulation room; restart simulation at State 3 Mild Anaphylaxis a. Team may require high level of coaching to ensure a successful outcome 8. After completion of successful scenario continue to debrief the entire experience. After completion of successful scenario continue to debrief the entire experience Perinatal Clinical Academy_ SCE OB Blood Administration 14

15 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 ( if applicable) 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 FOR 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 Administers blood products per policy Prioritizes the nursing management of a patient receiving blood or blood products Recognizes the signs and symptoms of an adverse reaction to blood component administration Evaluates the patient s response to interventions and modifies the nursing care as appropriate for the patient experiencing an adverse reaction to blood component administration Administers medications per protocol Utilizes the Nursing Process 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). o Were they performed appropriately o 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 Blood Administration 15

16 APPENDIX References: Micromedix AWHONN. (2014). Perinatal nursing. (4 th Ed.). Simpson, K.R. and Creehan, P.A. (Eds.). Philadelphia, PA: Lippincott Williams & Wilkins. Adapted from: CAE Nurse Residency Program Perinatal Clinical Academy_ SCE OB Blood Administration 16

17 SAFETY /QUALITY OBSERVER CHECKLIST As the safety and quality observer, it is your job to watch for the safety and quality of care given to the patient, as well as ask questions and advocate for the patient. Please make note of the following safety/quality behaviors, plus any other observations you think could enhance the learning of your team. Were they observed? How often? What was done well, what could have been done better? Hand washing RN1 RN2 Data Introduction to patient Bedside report Whiteboard Initial safety check & ID checks Assessment of skin, pain, environment, falls risk, etc. Appropriate choice of equipment/supplies Medication administration & Medication double checks (using the 5 rights) Aseptic technique & Infection control Explanation & education to patient Sharing of information Team communication & delegation Other notes to share with the team: Perinatal Clinical Academy_ SCE OB Blood Administration 17

18 Learners Roles and Responsibilities Role RN 1 Primary nurse assigned to the patient RN 2 Partners with primary nurse to provide patient care RN 3 & Data Collector Facilitates communication and participates as additional support Family Member Patient Advocate and Safety Observer Responsibility Coordinates overall care of the patient including triage and focused assessments Demonstrates effective and efficient collaboration and communication with team members Obtains history/admit information in the EPIC ED Navigator Delegates interventions and tasks appropriate for situation Family and patient support and education Utilizes resources appropriately (charge nurse, RT, preceptors, providers, code teams) Actively assists with triage assessments and admit tasks Prioritizes interventions and tasks Gathers supplies and equipment as needed Family and patient support and education Demonstrates effective and efficient communication Utilizes resources appropriately (charge nurse, RT, preceptors, providers, code teams) Performs and manages patient care as directed by primary nurse Gathers supplies and equipment as needed Family and patient support and education Demonstrates effective and efficient communication Ongoing data collection and documentation (included but not limited to assessment, labs, observations) Analyzes data collected for trends and missing information Advocates for patient and self Asks questions and expects services, support, and education Acts as Safety Observer: May prompt team if gaps are noted Examples: Safety Hand hygiene Patient identifiers Medication administration Environmental awareness Patient satisfiers Introductions completed by all staff / name and role Pain management Receives information regarding treatment plan Communication Delegation Closed loop communication Sharing of information Expected to report back to team observations during debrief Perinatal Clinical Academy_ SCE OB Blood Administration 18

19 Perinatal Clinical Academy_ SCE OB Blood Administration 19

20 Perinatal Clinical Academy_ SCE OB Blood Administration 20

21 Procedure Pt results Initial Lab Results Reference Ranger per Facility WBC 4.8 RBC 2.48 Hgb 6.9 HCT 20.2 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 Blood Administration 21

22 Perinatal Clinical Academy_ SCE OB Blood Administration 22

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

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