Title: To cite this reference: Spinal Cord Injury (Part 2 of 2) University of South Dakota Simulation Scenario Neural Transmission: Spinal Cord Injury (Part 2) Overview Concept: Neural Target Group: Second Year Transmission Nursing Students Hunsley-McTighe, A., Luken, R. & Mulder, C. (2012). Simulation scenario; Neural transmission: Spinal cord injury (part 2 of 2). Unpublished manuscript. Department of Nursing, 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: Campus specific (see preparation requirements). Prebriefing: Campus specific (first year students should be longer than second year students according to evidence-based practice [EBP] standards). Simulation: 15-20 minutes (no longer than 30 minutes). Debriefing: Campus specific (first year students shorter than second year students according to EBP standards). If the simulation episode runs less than two hours faculty should consider running the simulation again, creating concept maps, creating teaching plans, performing webquests, or implementing other activities that would be beneficial to the students' learning. DocuCare Information: This is a 21-year old male who sustained a C5-C6 Spinal Cord Injury with a complete lesion after diving head first into a lake. Patient currently in ICU with a halo brace in place for immobilization.
Neural Transmission: Spinal Cord Injury (Part 2) 2 AACN Essentials: II, VI, VIII, IX Curriculum Alignment Population: Adult Concepts Exemplar Neural Transmission Spinal Cord Injury Knowledge Skills Attitudes Objectives and Outcomes Area Scenario Objectives Course Outcomes Student will demonstrate an understanding of risk factors for inflammation and infection at a pin site. Student will perform site care using clean/sterile technique. Student will utilize clinical reasoning skills while planning and implementing patient care. 1.1, 4.1 1.1 1.2, 3.2, 4.1, 5.1 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 a copy of their journal article. The student prep below is for both Parts 1 and 2 of this simulation. Spinal Cord 1&2_Student Prep
Simulation Setup Neural Transmission: Spinal Cord Injury (Part 2) 3 Manikin Settings: Initial Vital Signs Pulse: Blood pressure: Pulse ox: Respiratory rate: Temperature: Cardiac rhythm: Lung sounds: Bowel sounds: Other: Change in Vital Signs How many minutes until change? Pulse: Blood pressure: Pulse ox: Respiratory rate: Temperature: Cardiac rhythm: Lung sounds: Other: 100.2 F Hypoactive NA Equipment List ID and allergy band Heart monitor Halo traction brace Culturette swab for wound culture (if needed) Swabs,alcohol, gloves to cleanse pin sites Equipment for vital signs Foley catheter Scenario Setting: Setting: Intensive Care Unit Time of day of scenario: Patient Condition Clothing: Props: Moulage: Roles for Students Primary nurse Off-going nurse (to give change of shift report) Student nurse Observer Parent - (mother/father/both) Dr. Thompson Recording nurse (into Docucare) Hospital gown slightly damp from sweat Halo brace Halo brace pin sites appear red and inflamed (Faculty) Documents Physician orders (same as SCI scenario 1) MAR Nursing flowsheet History & Physical (see patient background) Medication Dosage Route Methylprednisolone 5.4 mg/kg/hr IV
Neural Transmission: Spinal Cord Injury (Part 2) 4 Patient Demographics Last Name: Smith Patient Background First Name: Kyle Gender: Male Age: 21 Ht: 5 9 Wt: 79 kg Ethnicity: Caucasian Religion: Methodist Language: English English Proficiency: Strong Other: Allergies to PCN and Morphine Sulfate Immunizations up-to-date, strong support system History of present illness: This young man was in his usual state of good health until he dove into Wall Lake yesterday afternoon. Friends who were with him at the scene report that his body surfaced after the dive but that he appeared floating face down in the water. They rushed to his assistance and found him alert but unable to move his arms or legs. The patient was carried to the parking lot by his friends. He was loaded into the back of a pick-up truck and rushed to the local Emergency Department (ED). Upon arrival to the ED patient demonstrated signs and symptoms consistent with an injury to the cervical spinal cord. CT results indicate that patient sustained a C5-C6 SCI with a complete lesion. Patient was placed in halo traction prior to being stabilized surgically with C5-C6 cervical fusion. Patient currently has halo brace in place for immobilization. Primary Medical Diagnosis: Central nervous system Cardiovascular Pulmonary Renal/Hepatic Gastrointestinal Musculoskeletal Integument Developmental history Psychological History Social history Loss of function in bilateral upper and lower extremities. Involuntary spastic movement noted in bilateral lower extremities. Decreased sensation in bilateral upper extremities. No sensation in bilateral lower extremities. Sinus bradycardia. S1, S2 noted. Breathing slightly labored. Lung sounds clear. Muscle flaccidity in bilateral upper and lower extremities. The patient recently graduated from college with a BS in Business Administration. He has been living with his parents while he searches for a job. Surgical/Procedure history Appendectomy at the age of 14. Medication allergies Morphine Sulfate Reaction: PCN Food/other allergies NKA Reaction: Pruritus and rash Rash
Prebriefing Neural Transmission: Spinal Cord Injury (Part 2) 5 Give students the opportunity to discuss their feelings and fears (can use the round table approach) and then have discussion. Discuss the article students were asked to read prior to the simulation. 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.
Scenario Change of shift report to be read to students by nurse going off duty: Neural Transmission: Spinal Cord Injury (Part 2) 6 Neuro ICU Kyle Smith Day 2 of hospitalization. Patient currently has a halo brace in place for immobilization. Kyle Smith, 21 year old male, was admitted to ICU after a C5-C6 cervical fusion. He was boating with friends at Wall Lake and decided to take a swim. He dove head first into the water. When he surfaced he was face down and unresponsive. His friends retrieved him from the water and he stated that he could not move his arms or legs. They rushed him to the ED and after a CT it was found that he has a C5-C6 spinal cord injury with a complete lesion. Complete VS and neuro checks have been done every two hours. Neuro checks show no movement in upper and lower extremities. He elicits minimal response to sensation in his upper extremities (shoulder area) and no response to sensation in his lower extremities. His pupils are equal and reactive to light. No drainage noted from nose or ears. Blood pressure and pulse have been on the lower end but stable. Lung sounds clear bilaterally. A halo is in place for immobilization and pin sites are clean, dry, and intact. Swelling noted in neck and at pin sites. Family is at the bedside and very supportive. Head of bed needs to be elevated at 45 degrees and repositioned every two hours. He has a 20 G IV with an infusion of D5 ½ NS @ 125 ml/hr and Methylprednisolone 5.4 mg/kg/hr for 23 hours. It needs to be infused for one more hour and can be discontinued. Foley cath placed and it has drained 500 ml of clear amber urine. Site care needs to be performed on the halo brace pins. Dressings are CDI at each site. Let me know if you have any questions and have a good shift. Timing Patient actions live faculty Expected interventions May use the following cues: 5 minutes Kyle is lying in a supine position in bed with the halo brace in place. Kyle s parent is sitting in a chair by the bed reading a magazine. Kyle complains of pain at pin sites during repositioning. The nurse will: Reposition the patient using the logroll technique. Request assistance from student nurse for repositioning. Assess for correct anatomical spinal alignment. Role member providing cue: Parent can state, I think it s time for Kyle to be turned if nurse does not turn patient. Student nurse can ask, How do we have to turn him? if nurse does not explain repositioning procedure to student.
Neural Transmission: Spinal Cord Injury (Part 2) 7 10 minutes Kyle continues to complain of pain at pin sites and says he feels slightly hot and sweaty. Kyle s gown is damp from sweat. Kyle s parent is concerned about Kyle s complaints and sweatiness. Physician will explain that they will come to the unit and assess Kyle s condition. The nurse will: Complete a head-to-toe assessment including vital signs. Perform site care using clean/sterile technique. Recognize signs and symptoms of inflammation and infection. Notify the physician regarding patient s current status. Obtain a wound culture if ordered. Parent can ask, Are you going to look him over to make sure he s OK? if nurse does not begin assessment. Student nurse can ask, Do you know how to clean the pin sites? I ve never done it before if nurse does not begin site care or appears to be completing it incorrectly. Kyle s parent can state, Those areas where that thing is attached to him don t look good. Are they supposed to be so red? if nurse does not verbalize possible infection.
Neural Transmission: Spinal Cord Injury (Part 2) 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. What where the nurses primary concerns in this scenario? What were the patient s concerns? 2. Did you have sufficient knowledge/skills to manage this situation? 3. Was correct anatomical position maintained when logrolling the patient? 4. Was pin care done according to policy and procedure? 5. Did the nurse recognize the signs and symptoms of inflammation/infection at the pin site? 6. Was SBAR utilized when communicating with the physician? 7. What went well in this scenario? 8. If you were able to do this scenario 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.
Neural Transmission: Spinal Cord Injury (Part 2) 9 Supporting Documents Forms Patient Chart Information/Forms Spinal Cord 1&2_Charts Script/Roles Spinal Cord 2_Script Recommendations For Online Use This simulation could be performed in the mobile simulation unit and streamed to distance students. Students at a distance could participate in the pre-briefing and debriefing sessions using webinar.