Standardized Simulation NR325 End of Life Care/Amira Quintona Chamberlain College of Nursing: Nursing Students We want to thank you in advance for your active participation in this standardized simulation. Our purpose is to immerse you in a high quality clinical experience that will enhance critical thinking, decision-making, and prepare you as you move forward in the curriculum and transition into practice. The following material can be used in scenario preparation. You will find preparation documentation that includes course and student learning outcomes as well as general scenario information and resources. A brief patient history will be provided in addition to the most recent physician orders. Be prepared to document your assessment findings, administration of medication, and nursing notes. A medication administration record, laboratory results and patient education material will be provided for you during the simulated experience. One of the most important aspects of simulation is the assessment of performance and debriefing. Keep in mind that the purpose of participation is to enhance your learning and allow you to identify areas of needed remediation. There is no high-stakes testing. We are only asking that you engage in the learning experience and begin to use the feedback provided to enhance your practice. We want you to be able to self-reflect on your actions and interventions and remediate areas that you identify. An assessment matrix has been created that will be used to evaluate your assigned teams performance. The PREPARED Assessment Tool was developed to provide a comprehensive mechanism for evaluating expected behaviors that contribute to advanced critical thinking and decision-making. The tool is simple to use and will be shared by the faculty during the debriefing period. It facilitates a very organized and focused approach to reflecting on your performance. P = Problem Given the data presented and your assessment, what did you identify as the main problems associated with caring for the patient? R= Report Who do you need to report your findings to? What resources do you need to access? Was the report given in an organized manner? E = Execute P = Prioritize A = Anticipate What independent nursing interventions can you perform? What actions should be prioritized in caring for the patient? What can you anticipate and prepare for as you continue caring for the patient? R = Reasoning Do you understand the reasoning behind your decision-making and if not, why not? E = Evaluate D = Discuss What interventions or assessment findings do you need to continue re-evaluating as you care for the patient? Self-reflect on your performance and identify areas of needed remediation. The debriefing component of the simulation is organized in the same fashion. It will be very user-friendly and you, in conjunction with the faculty, will have a positive mechanism for self-reflection, discussing positive behavior and identifying areas of needed remediation. Thank you again for participating. We believe that these scenarios will provide a progressive medium for collaboration and enhanced learning. 1
SIMULATED CLINICAL EXPERIENCE: END OF LIFE CARE Student Version Today s date: 10/16/2013 Name of Lead Scenario Developer: Deb Tauber/Deb Long/Laura Fero GENERAL SCENARIO INFORMATION Estimated Briefing Time: 30 minutes Est. Scenario Time: 30-45 minutes Est. Debriefing Time: 60 minutes Course #: NR 325 Key Concepts End-of-Life; Physiological & Psychosocial Changes over Last 20 Minutes of life Please keep in mind that although each scenario has the potential to be used in various courses and contains multiple potential objectives, the placement of each SCE is aligned with specific focus and leveled purposefully to meet the needs of students at this particular point in their learning. Program Outcomes Level II Integrates the nursing process in providing care to identified populations in a variety of settings from entry to the healthcare system through long-term planning (PO#1). Provides care in collaboration with consumers and other health care providers in health promotion, illness prevention, health restoration and maintenance, and rehabilitative activities (PO#2). Utilizes communication and therapeutic relationship skills in providing care to individuals, families, and aggregates in a variety of healthcare settings (PO#3). Utilizes assessment findings and creative problem-solving to develop a plan of care for patients across the life span (PO#4). Implements available resources to meet own personal, professional, and educational goals (PO#5). Utilizes legal, ethical, and professional standards and principles as a basis for clinical decision-making (PO#6). Assumes nursing roles when providing care to clients from a variety of populations (PO#7). Apply current nursing knowledge, theory, and research findings when providing care to patients across the life span (PO#8). Course Outcomes Provide effective professional nursing care for adult patients and their families in acute care settings using the nursing process (PO#1) Demonstrate effective communication skills necessary for collaboration with other health team members and for providing professional nursing care to adult patient and their families (PO#3) Apply critical thinking strategies to make good clinical decisions in the adult patient clinical setting (PO#4) Relate knowledge and principles of legal, ethical, and professional standards to clinical practice in the acute care setting, with adult patient and their families (PO#6) Exhibit behaviors consistent with professional nursing roles and responsibilities while providing cost-effective nursing care to individuals and families (PO#7) Module 4 Student Learning Outcomes Integrate knowledge form the general sciences and foundational nursing courses to care for persons experiencing hepatobilliary system alterations (CO 2,4,6,7) Determine individualized nursing care required for persons experiencing an alteration in hepatobilliary system function (CO 1,2,4) 2
Module 6 Student Learning Outcomes Integrate knowledge from the general sciences and foundational nursing courses to care for persons experiencing reproductive alterations (CO 2,4,6,7) Determine individualized nursing care required for persons experiencing reproductive alterations (CO 1,2,4) Module 7 Student Learning Outcomes Integrate knowledge from the general sciences and foundational nursing courses to care for persons with cancer and those receiving palliative end of life care (CO 2,4,6,7) Determine individualized nursing care required for persons with cancer and those receiving palliative end of life care (CO 1,2,4) Apply evidence-based research to care for persons with cancer and those receiving palliative end of life care (CO 2,4,6,7,8) Identify learning needs to optimize care, safety, and promote self-care (CO 1,2,3,6,7) Identify therapeutic interventions to facilitate end of life care and support for family (CO 1,2,3,6,7) SimChart Outcome Record assessment findings, procedures and patient outcomes accurately, as appropriate for role Prerequisite Knowledge Reflecting Previous Curricular Content NR222: Communication, healthcare ethics NR224: Nursing process, thermoregulation-temperature (vital signs), assessment, bowel pattern, urinary pattern, gastrointestinal, oxygenation, medication NR226: Nursing process, professional practice, cognition and perception, coping and stress tolerance: loss and grief NR281: Alteration in cell and tissue function, cancer NR282: Gastrointestinal system, interrelations of pathophysiological processes NR291: Respiratory drugs, musculoskeletal drugs, analgesics, professional nursing role NR292: Technological roles NR302: Health assessment, interview, physical assessment, head, neck and lymph assessment, respiratory assessment, cardiovascular assessment, integumentary assessment NR304: Peripheral vascular assessment, gastrointestinal assessment, urinary assessment, focused assessment NR320: Therapeutic communication, anxiety disorders NR324: Respiratory system alterations, cardiovascular system alterations, gastrointestinal system alterations, professional nursing role PREBRIEFING INFORMATION Required Knowledge & Reading (assigned a minimum of one week prior to simulation): Per faculty assignment Consider using all or some of the following questions in preparation for the scenario: 1. Describe the ethical and legal issues of advanced directives including the role and responsibilities of the healthcare surrogate decision-maker. 2. How do the Physician Order Scope of Treatment (POST) and Physician Order for Life Sustaining Treatment (POLST) forms differ from an advanced directive? 3. Discuss the nursing management of the patient-family unit at end-of-life. 4. Providing fluids and nourishment during the terminal phase of illness is sometimes controversial. Discuss the key issues in this controversy. 5. Discuss how pain, agitation, anxiety and dyspnea are identified and managed in the increasingly less 3
responsive patient at end-of-life. 6. Discuss the rationale for use of medications such as morphine, LORazepam, haloperidol and glycopyrrolate in the treatment of the patient at end-of-life. 7. Identify all potential nursing diagnoses and their related interventions. 8. Discuss nursing care of the patient/family unit after the death of the patient Setting: Hospice in patient unit SCENARIO INFORMATION Student Roles: Charge Nurse, Assessment Nurse, Medication Nurse, Documentation Nurse, Observer Patient Name: Amira Quintona Gender: M F Age: 85 years months Height: 64 in cm Weight: 55 lbs. kg Allergies: None Code Status: Do not resuscitate. Spouse named as her healthcare surrogate decision-maker Social History: The patient is married with two children who live out of state. Her husband and daughter are with her at the bedside. Her son is married and cares for his two small grandchildren. The son has visited three times since the patient s symptoms began two months ago. No history of tobacco, alcohol or illicit drug use Past Medical History (including medications): The patient is an 85-year-old female diagnosed with ovarian cancer 5 years ago. She was treated with surgery and chemotherapy. Surgical treatment included bilateral salpingo-oophorectomy and total abdominal hysterectomy. At that time, the patient was found to be BRCA1 positive. She declined any prophylactic surgery or treatment. She was subsequently diagnosed with breast cancer 18 months ago and underwent a lumpectomy of the right breast, followed by chemotherapy and radiation. Two months ago, she was diagnosed with metastatic disease in her bones, brain and liver 4
PROVIDER ORDERS Chamberlain Community Hospital NAME: Amira Quintona DOB: 11/28/1928 MR#: 3394465 Physician: Dr. Banders DATE HOUR CHART COPY OF ORDER Admit to hospice bed on Medical-Surgical unit Diagnosis: Advanced breast cancer with extensive metastases to bones, brain and liver Do Not Resuscitate Nothing by mouth Vital signs every 4 hours Complete bedrest Oxygen at 2 LPM via nasal cannula; titrate as needed for dyspnea Dextrose 5% in ½ NS at 30 ml/hour Morphine sulfate per continuous IV infusion at 1 mg/hour Morphine sulfate 5 mg IV every 2 hours PRN for breakthrough pain, call healthcare provider if pain not relieved LORazepam 1 mg IV every 4 hours PRN for anxiety Haloperidol 5 mg IM two times every day Glycopyrrolate 0.2 mg IV every 4 hours End-of-life comfort measures Apply barrier cream to skin after each bowel and bladder incontinence Dr. Banders DEA NO. TIME FAX ( ) 5
ROLES AND RESPONSIBILITIES Charge Nurse The Charge Nurse is responsible for the overall organization of safe, quality patient care. You are the team leader and serve as a resource to all interdisciplinary members and are responsible for appropriate delegation of duties. You will serve as the point person for communication and can anticipate speaking with the physician or other primary care provider, ancillary support services, and others directly involved with the care being provided. You must be knowledgeable about the patient s condition and able to dictate orders obtained and assist with implementation if needed. Additionally, be prepared to prioritize care and anticipate future needs. Assessment Nurse The Assessment Nurse is responsible for overseeing a comprehensive assessment of the patient. This includes but is not limited to obtaining vital signs, head-to-toe assessment of all systems, and psych/social assessment of the patient. You will be prioritizing care, executing independent interventions, collaborating with interdisciplinary team members, anticipating the needs of the patient/family, and re-assessing or continually monitoring the patient for any changes in condition. You are responsible for implementing all non-medication related interventions, verbalizing your finding to the team, and recommending any actions/interventions required. Additionally, you will be providing appropriate education to the patient and family/significant others. Medication Nurse The Medication Nurse is responsible for all actions and documentation related to safe administration of medications. You will identify and correct any medication errors related to prescribing or distribution. This may include speaking with the physician or primary care provider. Prior to administering medication, you will assure the Rights of Medication Administration. You must be knowledgeable regarding the action and expected effects of the medications being administered and are responsible for monitoring and reporting any adverse reactions or unforeseen consequences of administration. Part of your role includes verifying medication calculations with a colleague and identifying any incompatible drug combinations. Documentation Nurse The Documentation Nurse is responsible for recording of all patient event activities during the simulation with the exception of medication administration. You are responsible for documenting assessments, interventions, and outcomes on the designated tool (paper or electronic). Be prepared to read back and verify your documentation when requested and/or clarifying the details. Additionally, you will be part of the interdisciplinary team and will contribute observational assessment findings to include but not limited to changes in vital signs, alerts, psychosocial needs, and anticipated care. Observer The Observer is a non-participant role and will not communicate directly with the simulation team. Instead, you will be given an observation guide to complete during the simulation. The data you collect will help the team during the debriefing process and facilitate an open and active discussion regarding the simulation experience. You will be an active participant in the debriefing and will be encouraged to share your observations and thoughts. Please keep in mind that your observations should be conveyed in a respectful, educational manner. The goal is to work together as colleagues in providing safe and effective care. 6
ADVANCE DIRECTIVE Part I: Power of Attorney for Health Care I, Amira Quintona, appoint Sam Houston, whose address is 1111 N South Street, Chicago, IL and whose telephone number is 616-717-1234, as my attorney in fact for health care. I authorize my attorney in fact appointed by this document to make health care decisions for me when I am determined to be incapable of making my own health care decisions, including decisions to withhold or withdraw life-sustaining treatment and artificially administered nutrition and hydration. I have read the warning which accompanies this document and understand the consequences of executing a power of attorney for health care. When making health care decisions for me, my attorney in fact should think about what action would be consistent with past conversations we have had, my treatment preferences as expressed in this advance directive or other legal or nonlegal document, my religious and other beliefs and values, and how I have handled medical and other important issues in the past. If what I would decide is still unclear, then my health care attorney in fact should make decisions for me that my health care attorney in fact believes are in my best interest, considering the benefits, burdens, and risks of my current circumstances and treatment options. I direct that my attorney in fact comply with the following instructions on life-sustaining treatment: withdraw life support if it has been determined that continued treatment will not improve my condition I direct that my attorney in fact comply with the following on artificially administered nutrition and hydration: (optional) no artificial food or fluids to be given by any method other than by my own means I direct that my power of attorney comply with the following instructions or limitations: (optional) Ensure that comfort and pain relieving measures be given I HAVE READ THIS POWER OF ATTORNEY FOR HEALTH CARE. I UNDERSTAND THAT IT ALLOWS ANOTHER PERSON TO MAKE LIFE AND DEATH DECISIONS FOR ME IF I AM INCAPABLE OF MAKING SUCH DECISIONS. I ALSO UNDERSTAND THAT I CAN REVOKE THIS POWER OF ATTORNEY FOR HEALTH CARE AT ANY TIME BY NOTIFYING MY POWER OF ATTORNEY, MY PHYSICIAN, OR THE FACILITY IN WHICH I AM A PATIENT OR RESIDENT. I ALSO UNDERSTAND THAT I CAN REQUIRE IN THIS POWER OF ATTORNEY FOR HEALTH CARE THAT THE FACT OF MY INCAPACITY IN THE FUTURE BE CONFIRMED BY A SECOND PHYSICIAN. Part II: Declaration Relating to the Use of Life-Sustaining Treatment If I should lapse into a persistent vegetative state or have an incurable and irreversible condition that, without the administration of life-sustaining treatment, will, in the opinion of my attending physician, cause my death within a relatively short time and I am no longer able to make decisions regarding my medical treatment, I direct my attending physician, pursuant to the Rights of the Terminally Ill Act, to: _AQ_ 1. Keep me comfortable and allow natural death to occur. I do not want any life-sustaining treatment or other medical interventions used to try to extend my life. I do not want to receive nutrition and fluids by tube or other medical means. ((or)) 2. Keep me comfortable and allow natural death to occur. I do not want any life-sustaining treatment or other medical interventions used to try to extend my life. If I am unable to take enough nourishment by mouth, however, I want to receive nutrition and fluids by tube or other medical means. ((or)) 7
3. Try to extend my life for as long as possible, using all available life-sustaining treatment or other medical interventions that in reasonable medical judgment would prevent or delay my death. If I am unable to take enough nourishment by mouth, I want to receive nutrition and fluids by tube or other medical means. Any questions regarding how to interpret or apply my declaration shall be resolved by my attorney in fact appointed under a durable power of attorney for health care (Part I), if I have appointed one. _ Amira Quintona 2/11/13 Amira Quintona (signature) (date) (printed name) State of Nebraska, County of _Lancaster On this 11th day of February 2013, before me, Sandy Mays, a notary public in Lancaster County, personally known to be the identical person whose name is affixed to the above advance directive as principal of power of attorney for health care, if Part I is filled out, and/or as declarant of declaration relating to the use of life-sustaining treatment, if Part II is filled out, and I declare that he or she appears in sound mind and not under duress or undue influence, that he or she acknowledges the execution of the same to be his or her voluntary act and deed, and that I am not the attorney in fact or successor attorney in fact designated in Part I, if it has been completed. Witness my hand and notarial seal at _18 Jones Street, Lincoln, NE in such county the day and year last above written. _Sandy Mays Signature of notary public 8
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