University of South Dakota Vermillion, South Dakota Department of Nursing. Simulation Scenario Leadership: Triage/Prioritization (Part 2) Overview

Transcription

1 Title: To cite this reference: Triage/Prioritization (Part 2 of 2) University of South Dakota Simulation Scenario Leadership: Triage/Prioritization (Part 2) Overview Target Group: Second Year Concept: Leadership Nursing Students Serfling, J.& Warren, D. (2012). Simulation scenario; Leadership: Triage/prioritization (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 Unpublished manuscript., University of South Dakota at Vermillion.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: Designed to take approximately four hours (see preparation requirements). Prebriefing: Campus specific. Should be shorter than debriefing for second year nursing students. Simulation: Approximately 30 minutes. Debriefing: Campus specific. Should be longer than prebriefing for second year nursing 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 a prioritization/triage scenario in which the RN is assigned to three patients and must employ clinical reasoning in the prioritization of their assessment and care. During this clinical simulation experience, the nurse must provide appropriate care to a DNR patient who becomes unresponsive. There is NO medication administration in this simulation.

2 AACN Essentials: II, VI, VII, VIII, IX University of South Dakota Curriculum Alignment Population: Elderly males and middle age female Leadership: Triage/Prioritization (Part 2) 2 Concepts Leadership Transition into Practice Exemplar Prioritization Resource Management Knowledge Skills Objectives and Outcomes Area Scenario Objectives Course Outcomes Based on assessment findings, implement appropriate care for each patient. Work with healthcare team to meet patient needs and delegate correctly within scope of practice. 1.1, 3.2, 5.2 Attitudes Recognize when a patient is unstable and intervene appropriately. Appreciate need and importance of accurate prioritization when treating multiple patients. Honor physician orders and patient wishes for DNR and act accordingly. 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, primary text and completed prep. following prep is for both Parts I and 2 of this simulation. The Triage Priority 1&2_Student Prep

3 Simulation Setup Leadership: Triage/Prioritization (Part 2) 3 Scenario Setting: Setting: Med-Surg unit Time of day of scenario: 0830 All three patients/rooms separated by curtains/walls if possible and signs for each room (#1, #2, and #3) Roles for Students (same for all 3 patients) Primary nurse Secondary nurse Recorder Nurse s aide Observer Physician(s) Student Names (Faculty) (Faculty)

4 Leadership: Triage/Prioritization (Part 2) 4 Patient #1 Manikin Settings: Initial Vital Signs Pulse: 90 Blood pressure: 136/73 Pulse ox: 90% with O2 on at 3 L Respiratory rate: 20 Temperature: 99.0 F Cardiac rhythm: Lung sounds: Sinus rhythm Minimal expiratory wheezes throughout Bowel sounds: Bowel sounds + Other: Left hip incision slightly pink, no drainage Equipment List O2 tubing Saline lock in manikin arm ID band Dressing to left hip (slightly pink, no drainage) Incentive spirometer (sitting at bedside) Patient Condition Clothing: Hospital gown Props: Moulage: Documents Dressing to left hip (saturated with yellow fluid) Graying of lips (cyanosis) Medication Dosage Route Concentration Package

5 Leadership: Triage/Prioritization (Part 2) 5 Patient Demographics Last Name: Smith Patient Background Patient 1 First Name: John Gender: Male Age: 85 Ht: 5 4 Wt: 135 lbs Ethnicity: Caucasian Religion: Lutheran Language: English English Proficiency: Yes Other: Widowed, lives alone at home. No children. Niece and nephew DPOA. History of present illness: Fell at home three days ago and had left hip fracture. Surgical repair of left hip two days ago. Stable. On 2 L. 02- has chronic COPD Primary Medical History Central nervous system Cardiovascular CHF Pulmonary COPD, smoker 1 PPD x 60 years Renal/Hepatic Some incontinence problems x three years Gastrointestinal Musculoskeletal Integument Developmental history Psychological history Social history Widowed Other DM (orally controlled) Medication allergies NKDA Reaction: Food/other allergies Reaction:

6 Leadership: Triage/Prioritization (Part 2) 6 Patient #2 Manikin Settings: Initial Vital Signs Pulse: 68 Blood pressure: 135/88 Pulse ox: 99% on room air Respiratory rate: 18 Temperature: 97.8 F Cardiac rhythm: Sinus rhythm Lung sounds: Clear Bowel sounds: Present x 4 quad Other: Equipment List ID band Foley cath with 200 ml clear urine Syringes Insulin drip Patient Condition Clothing: Hospital gown Props: Moulage: Documents Orange juice (in another room; nurse s aide will go get) Face diaphoretic Medication Dosage Route Concentration Package Insulin drip (regular) with 1 unit/cc NS at 100 cc/hr

7 Leadership: Triage/Prioritization (Part 2) 7 Patient Demographics Last Name: Kelley Patient Background Patient 2 First Name: Maria Gender: Female Age: 40 Ht: 5 10 Wt: 190 lbs Ethnicity: Caucasian Religion: Does not practice Language: English English Proficiency: Yes History of present illness: Admitted with DKA yesterday following an illness at home. Blood sugars and status now stable. Primary Medical History Central nervous system Cardiovascular Hypertension Pulmonary Renal/Hepatic Gastrointestinal Musculoskeletal Integument Developmental history Psychological history Social history Married with children; denies ETOH or tobacco use Other Type I DM since age 10 Medication allergies PCN Reaction: Rash Food/other allergies Reaction:

8 Leadership: Triage/Prioritization (Part 2) 8 Patient #3 Manikin Settings: Initial Vital Signs Pulse: 88 Blood pressure: 126/84 Pulse ox: 91% on room air Respiratory rate: 22 Temperature: 98.0 F Cardiac rhythm: Lung sounds: Bowel sounds: Other: SR Scattered wheezes and crackles throughout Present x 4 quad Patient Condition Clothing: Hospital gown Props: Moulage: Documents Breakfast tray with bowl of oatmeal and carton of milk Medication Dosage Route Concentration Package Equipment List ID band DNR band on patient Saline lock hooked up to patient

9 Leadership: Triage/Prioritization (Part 2) 9 Patient Demographics Last Name: Wilson Patient Background Patient 3 First Name: Henry Gender: Male Age: 78 Ht: 5 4 Wt: 185 lbs Ethnicity: Caucasian Religion: Lutheran Language: English English Proficiency: Yes History of present illness: Admitted for acute exacerbation of COPD three days ago. Chronic COPD. Anxious at times. Short of breath with activity. Has DNR/DNI orders. Primary Medical History Central nervous system Cardiovascular Pulmonary Renal/Hepatic Gastrointestinal Musculoskeletal Integument Developmental history Psychological history Social history Other Medication allergies Food/other allergies MI four years ago, hypertension, left sided CHF COPD. Smoked two packs/day x 35 years, quit 10 years ago. Chronic breathing difficulties, on O2 at home. Decided on DRN/DNI two years ago due to health status. Married with three adult children Reaction: Reaction:

10 Prebriefing Leadership: Triage/Prioritization (Part 2) 10 Give students the opportunity to discuss their feelings and fears (can use the round table approach) and then have discussion. The following are suggested discussion questions for this scenario: 1. If you have just received report on your three patients for the day, how will you decide who you will see/assess first? (Have students pair up to discuss answer, then ask a few groups to respond.) 2. As a RN, what tasks can you delegate to the nurse s aide to help you, especially at the beginning of your shift when it is busy? 3. When a person has DNR and/or DNI orders, what does that mean? Talk about the specifics of that. 4. What are the signs and symptoms of hypoglycemia and hyperglycemia (how do they differ and how are they treated)? The above items are listed to assist faculty in leading a prebriefing discussion with students. Feel free to use all or some of the above items depending on the needs of the student group.

11 Scenario Leadership: Triage/Prioritization (Part 2) 11 Change of shift report to students: To be read to all students (by instructor) PRIOR to start of simulation. Students should take notes like they would when receiving report Patient #1: John Smith is an 85-year old male admitted for Dr. Lee. He fell at home. He has a history of mild COPD, smoked one pack per day for 60 years, chronic CHF and DM. He had surgery two days ago for the left hip fracture. We are to change the dressing daily and PRN. The incision site is slightly pink with no drainage. I changed the dressing once in the night. They stopped his IV fluids yesterday. He is saline locked. The patient gets QID blood sugar checks and they have been fine. I checked his vitals at 0630 since he was awake- Temp 99.0, HR 90, R-20, BP 136/73, O2 sat 90s on 3 liters. His lung sounds have a few expiratory wheezes throughout. As for as orientation goes, he was A & O x 3 last night but really hard of hearing. That s it on him. Patient #2: Maria is a 40 year old patient. She was admitted two days ago with DKA. She has a history of poorly controlled DM-Type 1. Apparently her blood sugars have been poorly controlled over the last week when she had a GI bug. Upon admission to the hospital her blood sugar was 530. She is A&O x 3. Lung sounds clear, bowel sounds positive. She has an IV of NS at 100 cc/hr as well as an insulin drip (regular insulin) at 2 units/hr (which is 2 cc/hr). She has a Foley cath draining clear yellow urine. Her vital signs have all been fine, and her sugars have been primarily in the low to mid 100 s. Patient #3: Henry is a 78-year-old male patient of Dr. Stars. He was admitted three days ago with COPD exacerbation. He has severe chronic COPD and has DNR/DNI orders per his wishes. He does not want anything done to him if something happens. He was on oxygen at two liters initially, but we had to turn it to 3 L to keep his sats above 90%. He complains of shortness of breath with activity. He is A & O x 3. Lung sounds have wheezes bilaterally. I believe the plan is to discharge him today or tomorrow but I m not sure he s ready since we had to turn his O2 up. We ll see what Dr. Stars thinks. Any questions?

12 Leadership: Triage/Prioritization (Part 2) 12 Timing Patient actions live faculty Expected interventions May use the following cues: Approx. 5 minutes Henry (Pt #3) puts call light on. Nurses are looking at their report sheets and deciding who to go see first. Role member providing cue: Henry states to nurse, The doc came in last night, said I am doing pretty good.. just my usual shortness of breath. I want to go home. Can you get the paperwork going and take this IV out? Nurse s aide (faculty person) reports that Henry s VS are: HR- 88 BP- 126/84 RR- 22 SpO2-91% on 3L Temp F Nurses explain to Henry that they need to see what the MD says about discharge. Nurse also reminds patient that O2 needed to be turned up. Nurses know not to remove saline lock. Nurses do Henry s assessment and acknowledge VS. Nurse s aide tells nurse that Henry wants to talk to him/her. Nurse s aide brings in breakfast tray and Henry starts eating oatmeal and drinking milk.

13 Leadership: Triage/Prioritization (Part 2) 13 Approx. 10 minutes Maria (Pt #2) puts call light on. I m not feeling very good. I m light-headed and sweaty and kind of have an upset stomach. Maria s VS: Temp F HR- 68 RR- 18 BP- 135/88 SpO2:- 99% on room air Maria s glucometer reading: 52 Nurses know that Maria could be hypoglycemic and they ask the nurse s aide to do glucometer and/or go get juice (but do not give the juice until glucometer checked). Nurses also check VS or ask nurse s aide to check VS. Nurse gives patient juice after seeing glucometer level. Nurses tell Maria they will be back in a few minutes to recheck her glucometer.

14 Leadership: Triage/Prioritization (Part 2) 14 Approx. 5 minutes John (pt #1) is found to be sitting up in bed, alert and oriented x3. John s VS: HR- 90 BP- 136/73 RR- 20 SpO2-90% on 3L. Temp- 99.0% F Lungs- some wheezes Bowel sounds positive John states, The nurse last night said I should be doing this breathing thing (points to incentive spirometer) but I don t know how to do it. Can you help me? Why do I need to do that? Nurse s aide states, You wanted me to remind you to recheck Maria s glucometer too; should I do that now? While the nurse is teaching about the IS, the nurse s aide runs in and states, Something is wrong with Henry; come quick Nurses go in to assess John. Nurses ask nurse s aide to do VS. Nurses explain why IS is important and then correctly explains how to do it. Nurses agree and send nurse s aide out to check Maria s glucometer, telling aide that she/he will be in shortly to assess Maria. Nurses stop IS instruction and go quickly to Henry s room.

15 Leadership: Triage/Prioritization (Part 2) 15 Approx. 10 minutes Henry (Pt #3) is found unresponsive with oatmeal in his mouth and rolling out of his mouth. VS: R- 8 and shallow BP- 84/42 HR- 108 O2 sat- 74% Nurses quickly attempt to clear airway (remove oatmeal) and assess Henry, including key VS. Nurses remember that patient is a DNR/DNI. Nurses talk to patient calmly telling him they are with him. Nurses raise HOB and increase O2. Nurses ask someone to get charge nurse. Nurses call MD to make him aware of situation (MD mentions DNR/DNI and says to, Keep him comfortable; I m on the way. Nurses call Henry s wife and/or children. (Simulation ends)

16 Debriefing Leadership: Triage/Prioritization (Part 2) 16 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. After you heard report on all three patients, what thoughts were going through your head about how to organize and prioritize your patients and their care? 2. Talk about the incentive spirometer. Do you feel you did well teaching the patient why it is important to prevent pneumonia? How did you handle it when you got interrupted while teaching the patient? 3. When you heard in report that Henry had DNR/DNI orders, did it register how important that was and did you remember it when aspirated and his status deteriorated? 4. When you went in to see Maria and she said she didn t feel well, how did you prioritize your assessment and interventions? 5. Talk about delegation. Do you feel you correctly delegated to the nurse s aide? Is there anything else you could have or should have delegated to him/her? 6. If you could repeat this scenario, what do you think the nursing team could have done differently? Final Thoughts? The above items are listed to assist faculty in leading a debriefing discussion with students. Feel free to use all or some of the above items depending on the needs of the student group.

17 Leadership: Triage/Prioritization (Part 2) 17 Supporting Documents Forms Patient Chart Information/Forms Script/Roles None If students play the roles of the patients they will need a copy of the script to review. No other scripts cards needed. Recommendations For Online Use This simulation would be difficult to perform in the mobile simulation unit. A video-taped version of the simulation (performed in a simulation lab) could be streamed to distance students. Students at a distance could participate in the pre-briefing and debriefing sessions using webinar.