University of South Dakota Vermillion, South Dakota Department of Nursing

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1 Title: To cite this reference: Simulation Scenario Complex Patient: Multi-System Organ Failure Part 2 (Sepsis) Multi-System Organ Failure (MSOF) Sepsis (Part 2 of 2) Overview Concept: Complex Patient Target Group: Second Year Nursing Students Original by QSEN at Revised by Simulation Champion Team (2012). Simulation scenario; Complex patient: Multi-system organ failure (MSOF) Sepsis (part 2 of 2).Unpublished manuscript., University of South Dakota at Vermillion.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: Approximately three and a half clock hours (see preparation requirements). Prebriefing: Time variable, but should be shorter than debriefing for these students Simulation: Approximately. 20 minutes (no longer than 30 minutes). Debriefing: Time variable, but should be longer than prebriefing for these 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 admitted earlier in the shift with altered mental status, abdominal pain, and chills and probable UTI. Her condition is suddenly deteriorating.

2 Complex Patient: Multi-System Organ Failure Part 2 (Sepsis) 2 AACN Essentials: III and IX Curriculum Alignment Population: Elderly Italian female Concepts Exemplar Complex Patient Multi-System Organ Failure (Sepsis) Knowledge Objectives and Outcomes Area Scenario Objectives Course Outcomes Recognize abnormal subjective and objective patient data and what they might indicate. 5.1, 5.2 Skills Attitudes Identify abnormal lab values, know possible causes, and know what interventions to take. Accurately prioritize and carry out physician orders and nursing interventions based on patient status. Value the need for continuous improvement in clinical practice based on new knowledge obtained via research/ebp. 1.1 Student Preparation Prerequisite assignment (the following information should be sent to the students prior to the scheduled simulation) This Prep is designed to be approximately four hours long and covers both Parts 1 and 2. Students are expected to bring their laptop, drug book, primary text and completed prep to simulation. Organ Failure (Sepsis 1&2)_Student Prep

3 Complex Patient: Multi-System Organ Failure Part 2 (Sepsis) 3 Simulation Setup Manikin Settings: Vital Signs Pulse: 100 Blood pressure: 88/42 Pulse ox: 90% on 2 L. Respiratory rate: 32 Temperature: 95.7 F Cardiac rhythm: Sinus tach Lung sounds: Clear Skin Other: Pale Oriented to self but more agitated now Equipment List Foley cath with 20 ml of cloudy urine with sediment Saline Lock hooked up to IV of 0.45% NS at 80 ml/hr. O2 with nasal cannula at 2 L on patient Non-rebreather mask with equipment IV bag of 0.9% NS with equipment Scenario Setting: Setting: Med-Surg floor Time of day of scenario: 1400 (patient was admitted at 1045 today) Patient Condition Clothing: Props: Moulage: Roles for Students Primary nurse Secondary nurse Documentation nurse Observer Dr. Morris/RT/Rapid Response Team Documents Blank MD order sheet Hospital gown Foley cath with 20 ml of cloudy urine with sediment N/A Student Names (Faculty) Medication Dosage Route N/A Concentration Package IV bag of 0.45% NS hanging IV IV bag of 0.9% NS IV

4 Complex Patient: Multi-System Organ Failure Part 2 (Sepsis) 4 Patient Demographics Last Name: Simmons Patient Background First Name: Eleanor Gender: Female Age: 85 Ht: 5 2 Wt: 99 lbs Ethnicity: Italian Religion: Roman Catholic Language: English English Proficiency: Yes Pre-admission medications (FYI these meds are not actually needed/used in Part 2): -Digoxin mg PO daily -Colace 100 mg PO daily -Atenolol 25 mg PO daily -Lasix 20 mg PO daily -Enalapril 2.5 mg PO daily -Glucophage 500 mg PO BID -ASA 81 mg PO daily History of present illness: This patient was recently hospitalized for management of CHF and urinary retention. She has a history of Type II DM, HTN, CVA, and Dementia. She returned to the hospital earlier today due to altered mental status, abdominal pain, weakness, chills, and nausea. She is in for R/O UTI. Her initial orders have been implemented. It is now afternoon and her status is suddenly deteriorating. Primary Medical Diagnosis/History: Central nervous system Cardiovascular Pulmonary Renal/Hepatic Gastrointestinal Musculoskeletal Integument Developmental history Psychological history Social history Alternative/ Complementary Mild Dementia, CVA, Dysphagia CHF, HTN, Type II DM Urinary retention Diverticulosis Mild Dementia Retired seamstress. Currently admitted from a nursing home facility. Medication allergies None Reaction: Food/other allergies None Reaction:

5 Complex Patient: Multi-System Organ Failure Part 2 (Sepsis) 5 Prebriefing Give students the opportunity to discuss their feelings and fears (can use the round table approach) and then have discussion. The following are suggestions/ideas for the prebriefing discussion: Review what occurred (key parts) in Part 1 of the Simulation -urine cloudy with sediment -mentation had changed -abnormal labs (BUN, Creat, WBC, Lactate) -obtained UA and C&S -started antibiotic after UA sent -called about CT with dye order (pt on metformin) Ask students the following; What is the patient at greatest risk for (and what are you on alert for), and why? - Now? - In 12 hours? - In 24 hours? How would you know if a patient is becoming Septic? 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: Multi-System Organ Failure Part 2 (Sepsis) 6 Scenario Scenario is to be read by faculty to all students: (encourage students to take notes) This is 85 year old female, Eleanor Simmons, who was admitted to the Med-Surg floor earlier today with increased confusion and agitation and abnormal urine, for R/O UTI. She was in the hospital 10 days ago with CHF and urinary retention. She has a history of minor Dementia, CHF, HTN, and Type II DM. This morning her daughter was with her, but she has since gone home. Her initial admit orders have all been implemented. She has a Foley cath in place, O2 on at 2 L per Nasal cannula, and an IV of 0.45% NS infusing at 80 cc/hr. Her labs this morning (drawn in the ER) were: WBC 10,500, Glucose 135, BUN 54, Creatinine 1.8, and Lactate 6.0. Her last set of VS 2-3 hrs prior were 118/ PO. Her O2 sat was 96% on 2 L. It is now mid-afternoon and you note the following changes in Eleanor: She has been trying to get out of bed saying, I want off of this airplane! She is more restless and agitated. Her physical assessment now shows: *Skin is pale and warm *Temp PO *P- 100 *BP- 88/42 *Resp rate- 32 *O2 sat- 90% (still on 2L) *Urine output- 20 ml total in 2 hours *Bowel sounds absent in lower quadrants

7 Complex Patient: Multi-System Organ Failure Part 2 (Sepsis) 7 Timing Actions/events Expected Interventions May use the following Cues: Approx. 30 minutes Instructor reads: It is now mid-afternoon and you note the following changes in Eleanor: She has been trying to get out of bed saying I want off of this airplane!. She is more restless and agitated. Her physical assessment now shows: *Skin is pale and warm *Temp 95.7 PO *P-100 *BP 88/42 *Resp rate- 32 *O2 sat 90% (still on 2 L) *Urine output 20 ml total in last 2 hrs *bowel sounds absent in lower quadrants Nurses do assessment and note abnormalities. Nurses either call a Rapid Response and/or call MD. Nurse takes off orders onto MD order sheet and does read back and verified. Nurses start IV fluid bolus. Dr. Morris (Instructor) gives telephone orders: -IV fluid bolus of 0.9% NS 500 ml in one hour. -Change O2 to nonrebreather mask. -Transfer to ICU. -Stat CMP, CBC, lactate level, ABGs, blood cultures. Nurses contact Respiratory Therapy and start non-rebreather mask (and turn up O2). Nurses let charge nurse know that patient needs to go to ICU.

8 Complex Patient: Multi-System Organ Failure Part 2 (Sepsis) 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. Describe evidence-based interventions that were implemented to manage her Sepsis. 2. What signs of Sepsis and Multi System Organ Failure were occurring? 3. Why do you think the MD ordered the specific labs that he did? 4. What are the criteria of a Rapid Response? If you called one, do you think it was appropriate? If you did not call one, do you think you should have? 5. What things did you do in this case to ensure safety? 6. Please review the documentation. Was anything missed? What areas were especially well done? What areas could have been better and why? 7. Describe the strengths and limitations of the teamwork in this scenario. 8. How did you prioritize the new MD orders and why? 9. Assuming her sepsis progresses into complete Multi-System Organ Failure, what other organ failure problems do you anticipate, and how will they be manifested? 10. If you could experience this simulation again, what would you do differently? 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: Multi-System Organ Failure Part 2 (Sepsis) 9 Supporting Documents Forms Patient Chart Information/Forms Organ Failure (Sepsis 2)_Chart Script/Roles No script cards needed for this scenario. Recommendations For Online Use This simulation could be performed in the mobile simulation unit and streamed to distance students. The role of the documentation nurse could be played by a distance student and information entered into DocuCare. Students at a distance could participate in the pre-briefing and debriefing sessions using webinar.

University of South Dakota Vermillion, South Dakota Department of Nursing. Simulation Scenario Safety: Patient Safety. Overview

University of South Dakota Vermillion, South Dakota Department of Nursing. Simulation Scenario Safety: Patient Safety. Overview Simulation Scenario Safety: Patient Safety Overview Title: Patient Safety Concept: Safety Target Course: First Year Nursing Students To cite this reference Dreke, C. (2012). Simulation scenario; Safety: