COPD - Simulation Design Template – Loyalist College€¦ · Web view · 2015-03-31-continue use of O2 on pt during med admin -Reassess respiration, O2 sat and possibly other

COPD - Simulation Design Template – Loyalist College

Program: Nursing Course: NURS 2005 Review date: June 2013Original Author/year: Tammy Armstrong(O’Rourke)/2005, Julie Rivers 2013_X_Learning Activity or ___Performance Assessment Prep/Pre-meeting Time: 0 Expected Simulation Run Time: 20 min Debrief/Guided Reflection Time: 20 minAlternate Activity Location Required: No

Simulation Learning Objectives (Identify related Course Learning Outcome and Program Terminal Outcome by number only)

The Student group will:1. Perform a priority assessment of a client with an acute exacerbation of COPD, utilizing elements of the

RNAO COPD BPG (CLO 1,2,3 , PLO 1,2,3)

2. Initiate appropriate nursing interventions and prioritize care for the client with an acute exacerbation of COPD, according to evidence based practice guidelines (CLO 1,2,3 , PLO 1,2,3)

3. Individually identify future learning needs that will augment their knowledge base and support future practice of caring for clients experiencing respiratory distress (CLO 5 , PLO 6.3 )

Measurement of Objectives

1. During scenario, identified by handler events in debrief document2. During scenario, identified by handler events in debrief document, discussed in debriefing session3. Either verbal during debrief, in clinical learning plan, or through delayed debrief written submission

depending on choice of debriefing method.

Skills/Theory required prior to participation in simulation

o See Course Documentation for prerequisites and co-requisiteso Passing of NURS 2005 vital signs and medication competency assessmento Participation in oxygenation lab

Student Preparation for Simulation

Review and research pertinent patient information package provided - see Appendix A

Student preparation package to be distributed: Prior to Simulation - included in Blackboard course materials

References, Evidence-Based Practice Guidelines, Protocols, or Algorithms used for this scenario: (site source, author, year, and page)

Expert Reviewer: name, credentials and comments in Appendix F Lewis et al. Chapter 30 Jarvis, Chapter 18 e-CPS available through Loyalist Library webpage BPG’s - RNAO BPG Nursing Care of Dyspnea, COPD summary and supplement found at:

http://rnao.ca/bpg/guidelines/nursing-care-dyspneathe-6th-vital-sign-individuals-chronic-obstructive-pulmonary-dise

Health Quality Ontario & Ministry of Health and Long-Term Care. (2013, January). Quality-Based Procedures: Clinical Handbook for Chronic Obstructive Pulmonary Disease. pp 46-48

Admission Date: Today’s Date:

Brief Description of Patient:

Name: Mr Sidney Brenner Gender: MDate of Birth: March 28, 1952

Major Support: spouse

Allergies: NKA Immunizations: up to date

Attending Physician/Team: JR Loyalist

Primary Diagnosis: COPD, dyspnea

History of Present Illness/condition: Excessive level of dyspnea. Began coughing up phlegm this morning.

Past Medical History: 3 year history of COPD, Frequent Respiratory Tract infections, Quit smoking 1 year ago

Social History: Lives with spouse. Mother lives in Nursing Home. Gets short of breath with small amount of physical activity

Fidelity/Logistics

Setting: Med-surg

# of Students: 4-5 per group, rotate groups through time frame

Simulator/ Manikin(s) Needed:(Please list) i.e. Sim Man, task trainer

Documentation Forms:

o Physician Orders Yo EDOC No Patient Chart Yo Flow Sheet No MAR Y(backup)o Diagnostics results N



Sim Man

Props/Moulage: (Please list specific)

ID bandMed cartClean holding cartCPSCopy of RNAO BPGLaminated SBARFamily member script

Equipment:

o IV pump: Normal Saline sol’n 75 cc/hro Secondary IV line 100ml N/S with

Ceftriaxone 1 gm emptyo Oxygen: O2 via nasal cannula @ 2 L/min,

need Venturi mask and nebulizer mask in supply cart and aerochamber in med cart

o Monitor ON: For temp and SPO2 others after 1st manual vitals

o Catheter: No Manual V/S: Yes for first assessment of

BP, P and Ro Other

Mode for Simulation: Independent

A/V Logistics:

o Video-recording Yo As debrief reference Yo For Evaluation N

Role / Description

o Nurse 1 Primary, assess patient, direct care and attend to patient

o Nurse 2 Secondary, assist primary

o Documenter Prepare MAR prior to simulation by using documents in student preparation package and bring a copy to lab on simulation day. Will document assessment data during the scenario. Will be asked to comment on the documentation during debriefing.

o Resource will have the COPD guideline, CPS and textbook to refer to. The resource person is to help the primary or secondary nurse with information and/or prompts.

o **Optional role of Peer Reviewer is to make their own notes about their observations of the scenario, particularly in regards to assessment and interventions carried out. The recorder will

Pre-brief script: Provided by Sim Specialist

Report students will receive before simulation:

o Refer to Hx of present illness N

S - Mr. Sidney Brenner is male in his sixties with a 3 year history of COPD. He is being admitted to the medical ward for IV corticosteroid and antibiotic therapy.B - His antibiotic was given in emerg, he is on oxygen by nasal cannula @ 2 L/min, his last sats were 88%, his last set of vitals were 38.5-90-30 BP 90/60. His family member has accompanied him to the unit.A - Mr. Brenner is having difficulty communicating due to his excessive level of dyspneaR - You are to do an initial assessment of Mr. Brenner, and implement appropriate nursing interventions.

be asked to comment on their observation during debriefing

o Charge RN played by Faculty if required as confederate to assist student(s)

Scenario Progression OutlineTiming(approximate)

Manikin Actions Expected Interventions May use the following Cues:

0-1 min

1-6 min

6-15 min

BP 90/60 Vol.9 GapTemp 38.4P - 96R – 34O2 sats – 85%

Auscultation SoundsLungs: WheezesHeart: NormalBowel: Hyperactive

O2 sats improve slightly (86) if HOB raised,

O2 sats improve more if venturi mask applied (88)

O2 sats improve more

-raise HOB

-Assess T, P, R, BP, O2 sat*recognize T high, P high, R high, BP low and O2 sat critically low-Assess current Level of dyspnea using a rating scale-Auscultate lungs-Auscultate the chest*recognize wheeze sound in lungs

-assess O2 delivery system-may increase flow up to 5 L/min via nasal cannula-check Dr orders regarding oxygen-reassess O2 sat-change O2 delivery system to venturi mask with O2 flow rate 4-6 and 24 or 28% nozzle

-Check Dr orders/MAR for medications to improve respiratory status

Imbedded cues:Patient will c/o SOB until nurse raises HOB. If HOB not raised within 1 min pt will ask to sit up

Patient will refer nurse to family member if asked questions due to severe dyspnea

Family member follows Family member script provided to answer patient Hx questions See Appendix E

If no meds given by 10 min patient will cue nurses, “can’t you give me something to help with my breathing”

if meds administered (90-92)

-Administer Salbutamol .-continue use of O2 on pt during med admin-Reassess respiration, O2 sat and possibly other vitals

Additional actions if dyspnea resolved….-Check the IV site, pump and med- Encourage deep breathing and coughing- Inquire about Hx of illness and Hx of dyspnea

Debriefing / Guided Reflection for this Simulation:

Immediate Verbal Debrief session - 20 minQuestions to guide discussion:What assessments were important in this client situation?Were you able to complete all assessments?What client behaviours required immediate action?What actions were required for specific behaviours?What client behaviours or symptoms most concerned you?Which components of the RNAO BPG were you able to apply in this situation?Were there any components of the RNAO BPG that you were not able to apply and if so please comment on that.

Reflective learning submissionStudents are to submit by email to professor a reflection on this learning activity within 36 hours. Reflection should consist of 1-2 paragraphs and comment on application of RNAO BPG and learning to take forward from participation in this simulation learning activity/including debrief.

Simulation Evaluation Process

For Faculty - See Appendix C

For Students - See Appendix D

Appendix AStudent preparation package for COPD Simulation

Simulation Learning Objectives

The Student group will:1. Perform a priority assessment of a client with an acute exacerbation of COPD, utilizing elements of the

RNAO COPD BPG.

2. Initiate appropriate nursing interventions and prioritize care for the client with an acute exacerbation of COPD, according to evidence based practice guidelines.

3. Individually identify learning and future intended action(s) that will augment their knowledge base and support future practice of caring for clients experiencing respiratory distress.

Brief Description of Patient:

Name: Mr Sidney Brenner Gender: M Date of Birth: March 28, 1952 Major Support: spouse Allergies: NKA Immunizations: up to dateAttending Physician/Team: Dr Loyalist

Primary Diagnosis: COPD, dyspnea

History of Present Illness/condition: Excessive level of dyspnea. Began coughing up phlegm this morning.

Past Medical History: 3 year history of COPD, Frequent Respiratory Tract infections, Quit smoking 1 year ago

Social History: Lives with spouse. Mother lives in Nursing Home. Gets short of breath with small amount of physical activity

Readings/Resources:

Jarvis, C. (2009). Physical examination & Health Assessment (1st Canadian ed.). Toronto: Saunders Elsevier.Review Chapter 18 with specific attention to assessment and obstructive pulmonary disease informationLewis, S. H. (2010). Medical-Surgical Nursing in Canada: Assessment and Management of Clinical Problems

(2nd Canadian ed.). Toronto: Elsevier Canada.Review Chapter 30Registered Nurses Association of Ontario. (n.d.). Nursing Care of Dyspnea:The 6th Vital Sign in Individuals

with Chronic Obstructive Pulmonary Disease. Retrieved from Registered Nurses' Association of Ontario: http://rnao.ca/bpg/guidelines/nursing-care-dyspneathe-6th-vital-sign-individuals-chronic-obstructive-pulmonary-dise


Canadian Pharmacists Association. (2013). e-CPS. Ottawa, Ontario, Canada.



Available from Loyalist Library site http://www.e-therapeutics.ca/home.whatsnew.action Health Quality Ontario & Ministry of Health and Long-Term Care. (2013, January). Quality-Based Procedures: Clinical Handbook for Chronic Obstructive Pulmonary Disease. pp 46-48http://health.gov.on.ca/en/pro/programs/ecfa/docs/qbp_copd.pdf

Role / Description

Nurse 1 Primary - assess patient, direct care and attend to patient

Nurse 2 Secondary - assist primary nurse and document assessment data during the scenario

**It would also be helpful for Primary and Secondary nurse to make point form notes or a plan of action prior to lab and give to documenter/resource to use during simulation

Documenter/Resource - Prepare MAR prior to simulation by using documents in student preparation package and bring a copy to lab on simulation day. You will have the COPD guideline, CPS and textbook to refer to. The resource person is to help the primary or secondary nurse with information and/or prompts during the simulation.

Family member - Will have a script and will participate in simulation as directed by faculty or sim specialist

Doctor’s orders

HSL HEALTH CARE

PHYSICIAN’S ORDERS

DATE TIME

Ceftriaxone 1 gram IV daily for 7 daysSalbutamol 100 micrograms/puff, 2-6 puffs inhaled via Metered Dose Inhaler (MDI) with spacer/mask q2h PRNIpratropium 20 micrograms/puff, 4 puffs inhaled via Metered Dose Inhaler (MDI) with spacer/mask q4hTitrate oxygen to achieve a target of 88-92% with an O2 flow rate of 1-2 L/min by nasal prongs or venturi mask - 24-28%Fluticasone 500 micrograms/salmeterol 50 micrograms per inhalation (Advair Diskus) 1 inhalation BIDPrednisone 30 mg PO daily for 7 daysAcetaminophen 650 mg PO q 4 h prn for temp >38.6Continuous infusion IV Normal Saline 75 ml/hr until drinking well

Dr.

Sidney BrennerBD: March 28, 1952Hosp #:

ALLERGIES: NKA

http://www.e-therapeutics.ca/home.whatsnew.action

Loyalist

MAR Template

HSL HEALTH CAREMEDICATION ADMINISTRATION RECORD

PAT: MAR START DATE:ID#: DX: MAR START TIME:AGE: BIRTHDATE: SEX: WT:ADMITTED: PHYSICIAN: LOCATION:ALLERGIES:

CHARTING LEGEND1 - Pt. REFUSED 2 - Pt. NPO 3 - HOLD 4 - NAUSEA/VOMITTING 5 - IV SITE OUT6 - Pt. OUT ON PASS 7 - HR < 60 8 - Pt. SLEEPING 9 - SELF MED PROGRAM 10 - ALTERNATE ROUTE GIVEN

******CONTINUOUS INFUSIONS******Rx# MEDICATION 0000 - 0729 0730 - 1529 1530 - 2359IV SOLUTIONRATE

DATE TIME RATE RN/RPN

TRANSCRIBED BY: CP CHECKED BY:BY: J R DATE/TIME:

0000 - 0729 0730 - 1529 1530 - 2359IV SOLUTIONRATE


TRANSCRIBED BY: CHECKED BY: DATE/TIME:0000 - 0729 0730 - 1529 1530 - 2359

IV SOLUTIONRATE


TRANSCRIBED BY: CHECKED BY: DATE/TIME:


Pat: MAR START DATE:ID #: Dx: MAR START TIME:AGE: BIRTHDATE: SEX: WT:ADMITTED: PHYSICIAN: LOCATION:ALLERGIES:


****** STAT & NON - RECURRING ORDERS ******MEDICATION DOSE ROUTE DATE TIME INITIALS

******SCHEDULED MEDS******Rx# MEDICATION 0000 - 0729 0730 - 1529 1530 - 2359DRUG:DOSE:

ROUTE: SIG:DIRECTIONS:

ORD DR: START: STOP:TRANSCRIBED BY: CP CHECKED BY: J R DATE/TIME:

0000 - 0729 0730 - 1529 1530 - 2359DRUG:DOSE:

ROUTE: SIG:DIRECTIONS:

ORD DR: START: STOP:TRANSCRIBED BY: CHECKED BY: DATE/TIME:

0000 - 0729 0730 - 1529 1530 - 2359DRUG:DOSE:

ROUTE: SIG:

DIRECTIONS:ORD DR: START: STOP:


0000 - 0729 0730 - 1529 1530 - 2359DRUG:

DOSE:ROUTE: SIG:

DIRECTIONS:ORD DR: START: STOP:


0000 - 0729 0730 - 1529 1530 - 2359DRUG:DOSE:ROUTE: SIG:DIRECTIONS:ORD DR: START: STOP:TRANSCRIBED BY: CHECKED BY: DATE/TIME:


PAT: MAR START DATE:ID #: Dx: MAR START TIME:AGE: BIRTHDATE: SEX: WT:ADMITTED: PHYSICIAN: LOCATION:ALLERGIES:


***PRN MEDS***Rx# MEDICATION 0000 - 0729 0730 - 1529 1530 - 2359DRUG:DOSE:ROUTE: SIG:DIRECTIONS:ORD DR: START: STOP:TRANSCRIBED BY: CHECKED BY: DATE/TIME:





Appendix B

COPD completed MAR


PAT: Sidney Brenner MAR START DATE:ID#: DX: COPD MAR START TIME:AGE: BIRTHDATE: 28/03/1952 SEX: WT:ADMITTED: PHYSICIAN: JR Loyalist LOCATION:ALLERGIES: NKA


******CONTINUOUS INFUSIONS******Rx# MEDICATION 0000 - 0729 0730 - 1529 1530 - 2359IV SOLUTION 0.9% NaClRATE 75 ml/hr


TRANSCRIBED BY: CP CHECKED BY:BY: J R DATE/TIME:

0000 - 0729 0730 - 1529 1530 - 2359IV SOLUTIONRATE


TRANSCRIBED BY: CHECKED BY: DATE/TIME:0000 - 0729 0730 - 1529 1530 - 2359

IV SOLUTIONRATE




Pat: Sidney Brenner MAR START DATE:ID #: Dx: COPD MAR START TIME:AGE: BIRTHDATE: 28/03/1952 SEX: WT:ADMITTED: PHYSICIAN: JR Loyalist LOCATION:ALLERGIES:


****** STAT & NON - RECURRING ORDERS ******MEDICATION DOSE ROUTE DATE TIME INITIALS

******SCHEDULED MEDS******Rx# MEDICATION 0000 - 0729 0730 - 1529 1530 - 2359DRUG: Ceftriaxone

DOSE: 1 gram

ROUTE: IV SIG:

DIRECTIONS: OD x 7 days


0000 - 0729 0730 - 1529 1530 - 2359DRUG: Ipratropium 20 micrograms/puff

DOSE: 4 puffs

ROUTE: inhalation SIG:

DIRECTIONS: 4 puffs MDI via spacer/mask q 4 h

ORD DR: START: STOP:


0000 - 0729 0730 - 1529 1530 - 2359DRUG: Fluticasone 500 micrograms/salmeterol 50 micrograms per inhalation (Advair Discus)

DOSE: 1 inhalation


DIRECTIONS: 1 inhalation BID



0000 - 0729 0730 - 1529 1530 - 2359DRUG: Prednisone

DOSE: 30 mg

ROUTE: PO SIG:

DIRECTIONS: daily x 7 days





Pat: Sidney Brenner MAR START DATE:ID #: Dx: MAR START TIME:AGE: BIRTHDATE: 28/03/1952 SEX: WT:ADMITTED: PHYSICIAN: JR Loyalist LOCATION:ALLERGIES:


******PRN MEDS******Rx# MEDICATION 0000 - 0729 0730 - 1529 1530 - 2359DRUG: Salbutamol 100 mcg/puff

DOSE: 2-6 puffs


DIRECTIONS: 2-6 puffs MDI via spacer/mask 2 h prn


0000 - 0729 0730 - 1529 1530 - 2359DRUG: Acetaminophen 325 mg

DOSE: 650 mg (2 tabs)

ROUTE: PO SIG:

DIRECTIONS: PO q 4 h prn for temp > 38.6



0000 - 0729 0730 - 1529 1530 - 2359DRUG:

DOSE:

ROUTE: SIG:

DIRECTIONS:



0000 - 0729 0730 - 1529 1530 - 2359DRUG:

DOSE:

ROUTE: SIG:

DIRECTIONS:



Appendix C

FACULTY SIMULATION EVALUATION – COPD sim

Please select from Likert scale the extent to which you felt this group of students met the learning activity objectives.

1 2 3 4 5

< 50% met with < 50% met with > 50% met >75% met 90-100% met

Critical elements non critical elements

missed missed

1. Performed a comprehensive assessment of a client with COPD, utilizing elements of the RNAO COPD BPG

1 2 3 4 5

2. Initiated appropriate nursing interventions and prioritized care for the client with COPD, according to evidence based practice guidelines 1 2 3 4 5

3. Individually identified future learning needs that will augment their knowledge base and support future practice of COPD clients

1 2 3 4 5

Please enter any comments related to ratings for learning objectives completion.

Please comment on the flow of the simulation, ie time factors for this activity.

Please note any changes or definite “keepers” that you would suggest for running this simulation in the future.

Appendix DStudent COPD Evaluation

STANDARD STUDENT COPD SIMULATION EVALUATION

1. The simulation provided my group the opportunity to perform a comprehensive assessment of a client with

COPD, utilizing elements of the RNAO COPD BPG

Strongly Disagree -------------Disagree -------------------Agree --------------Strongly Agree

2. The simulation provided my group the opportunity to initiate appropriate nursing interventions and prioritize

care for the client with COPD, according to evidence based practice guidelines

Strongly Disagree -------------Disagree --------------------Agree --------------Strongly Agree

3. The simulation provided me the opportunity to identify future learning needs that will augment my knowledge

base and support future practice of caring for COPD clients

Strongly Disagree -------------Disagree ---------------------Agree --------------Strongly Agree

**Alternate student evaluation for more in-depth analysis Questions can be used on survey format such as Socrative, Survey monkey or Fluid Survey.

What was your role in the simulation?Did you read the RNAO COPD BPG prior to coming to lab today?To what degree did the RNAO COPD BPG prepare you for this learning activity?How would you rate your understanding of care of the COPD patient before the scenario?Did you sense urgency at any point in the COPD patient scenario? What degree of anxiety did you feel during the scenario?What would you say your major learning style is?How would you rate your understanding of care of the COPD patient after the scenario?Overall, how would you rate this learning activity?Would you recommend this learning activity for other concepts?If yes, please list other concepts you would find this helpful for:Additional comments:

Appendix E

COPD

Family Member Script

Does he have any allergies?No

When did this episode of dyspnea start?He started having trouble yesterday after dinner. You know his mother has a cold and she lives in a nursing home. I told him not to go visit her! Would you visit your mother if she was sick and you had a lung condition?

Can you rate his dyspnea on a scale of 1 - 10 right now?I would say it is about a 7 right now.

What is his usual level of dyspnea, on a scale of 1 - 10?He is usually a 3.

Have you noticed if his feet have been swollen?No, but mine swell up all the time.

Does he use his accessory muscles to breath?I don=t know what you mean.Yes, I noticed he was doing that last night.

Does he have a cough?He didn’t have one last night, but I noticed this morning that he started to cough up some phlegm.

What colour was the phlegm?Yellowish white and thick.

Does he usually have a cough and phlegm?No, not usually.

Does he experience frequent respiratory tract infections?Yes, he usually gets at least 4 or 5 every winter. That is one of the reasons I told him not to visit his mom. I make him get his flu shot, but it doesn’t seem to help.

Does he get short of breath with activity?Yes, he’s OK if he sits still, but if he gets up and walks he gets short of breath. He can hardly make it up the stairs any more.

Edit Date: April 2013 File Name: Acute Illness - COPDIs he a smoker?He used to smoke until a year ago, when he got home oxygen. I made him quit because I was afraid he would blow the house up.

How much did he smoke?About 2 packs per day.

How long did he smoke for?30 years

Is he on oxygen at home?Yes

What is it set at?We put the dial to number 1 or 2.

Is he on medications at home?Yes he takes puffers a blue one, a green one and an orange one.

Does he use a spacer with his puffers?No. They gave him one, but he says it doesn’t work.

Simulation Design TemplateAppendix F - External Review documentation

External Peer Review Feedback for COPD Sim review May 2013

External Reviewer information

Louanne Melburn, RN, BSN, M A EdProfessional Practice Leader for Medicine and Emergency at QHCPrevious experience clinical work in Medicine, Emergency and ICU

Review Feedback

Email correspondence below:

Looks good Julie. I might add crackles to the lung sounds and change puffs to 2-6 puffs. If the patient is in acute distress and able to use a puffer we would often start with 6 puffs of each. If unable to use an areo-chamber then we would use a nebulizer. I have attached the draft order set that is almost complete you can have a look. The only thing that has not been decided is on whether it should be 6 or 8 puffs and if we will give a range. For example 2-8 puffs. I also attached the order set for oxygen. Hope this helpsLouanneFrom: Julie Rivers [mailto:[email protected]] Sent: May-23-13 10:43 AMTo: Melburn, LouAnneSubject: COPD simulation adviceHi Louanne,I have attached orders used for our COPD sim, can you advise if they correlate with COPD pathway? If you have any other info to share re COPD guidelines I would appreciate it.Also I have included below vitals, would they be realistic in your estimation?Initial vitals:BP 90/60 Vol.9 Gap Temp 38.4P - 96R – 34O2 sats – 85%Lungs: WheezesHeart: NormalO2 sats improve slightly (86) if HOB raised or O2 nasal cannula flow rate increased from 2-5L/min, more if venturi mask applied (88) and more if meds administered properly (90-92)Thanks,Julie

QUINTE HEALTH CARE OXYGEN ORDER SETOxygen/MD/04-11/V3 Sent to Pharmacy Date: __________ Time: __________ Page 1/1 Respiratory Oxygen _______ % or _______ L/minute Adjust O2 to (check one only): Achieve target SpO2 of 92% OR Achieve target SpO2 of _______ -- _______% If SpO2 is greater than the target ordered above, decrease O2 by 1 – 2 L/minute or 10% increments until the target SpO2 is achieved If SpO2 is below the target ordered above, increase O2 as necessary to achieve the target SpO2

Simulation Design TemplateRepeat and record SpO2 at least 10 minutes after each oxygen change

Repeat SpO2 at least once every shift and continue to adjust O2 as necessary

Check SpO2 on room air q24h if patient is receiving O2 at 3 L or less, except when using chronic home oxygen

Discontinue oxygen when patient is on room air for 24 hours. If patient on home oxygen, maintain at the pre-admission levels unless otherwise ordered Notify MD if Sp02 is below 80% and/or the patient requires an increase of the delivered oxygen level to 50% or greater Consult RT Lab Investigations Obtain arterial blood gas (ABG) if unable to measure SpO2 or indications for ABG analysis present Additional Orders:

QUINTE HEALTH CARE COPD ADMISSION ORDER SET Admit to: _____________________ Short Stay Unit (Trenton Only) Dr. ____________________________________

Diagnosis: Acute Exacerbation COPD with: Pneumonia CHFInitiate COPD pathway. Reassess is not eligible daily.

Estimated Length of stay:______________________________________________________________________________Comorbidities: _______________________________________________________________________________________Pre Existing Conditions: _______________________________________________________________________________Allergies: ____________________________________________________________________________________________Precautions: Contact Droplet Airborne - Reason: _________________________________________________Code Status: Full Resuscitation or ______________________________________________________________________ Fax notification of admission to Primary Care Provider

Consults RRT –( BG site Only) Assessment and treatment – Reason:_______________________________________________

PT - Assessment and treatment - Reason: ______________________________________________________________

Dietitian - AECOPD – for evaluate for Patient BMI less then 18: ____________________________________________ OT - Assessment and treatment - Reason:_______________________________________________________________ Patient Flow Coordinator (PFC)

Other: _______________________________________________________________________________________________

Diet NPO, medications with sips NPO, no PO medications Sips to Regular Diet Sips to Diabetic Diet kJ Cardiac Diet

Other: _______________________________________________________________________________________________

Activity AAT Other:

Vitals/MonitoringVitals Height and Weight on admission

T, HR, RR, full respiratory assessment, BP, SpO2 q4h x 48 hours then q shift and PRN T, HR, RR, full respiratory assessment, BP, SpO2 q h and PRN

Simulation Design TemplateMonitoring

Telemetry x______ days then reassess May take telemetry off for shower May take telemetry off for diagnostic tests within facility Intake and Output q ______ h x ______ hours

Respiratory

Respiratory Spirometry as per RRT

Nocturnal CPAP/BIPAP according to patient's previous home use (patient to use own device from home)

Oxygen Therapy O2 ______ L/minute via nasal prongs or ________________________________________ Titrate O2 to keep SpO2 greater than 92%. Discontinue O2 when oxygen saturation greater than 96% on room air Patient with known chronically elevated PaCO2: Titrate O2 to keep SpO2 between 88% and 92%

Lab Investigations

Lab Investigations on admission (if not already done in ER) CBC Electrolytes Creatinine Glucose

Stat arterial blood gases if SpO2 less than:________________ Influenza A and B Rapid test by nasopharyngeal swab (consider during flu season) Blood Cultures x 2 sets Sputum C + S (especially for patients at risk for pseudomonas infection) Additional Labs:____________________________________________________________________________________ Follow-up labs:_____________________________________________________________________________________

Capillary Blood Glucose Monitoring Capillary Blood Glucose daily x______________days

Other: _________________________________________________________________

Diagnostics

Investigations on admission (if not already done in ER) CXR PA + Lateral - Reason:__________________________________________________________________________

CXR Portable -Reason:_______________________________________________________________________________ ECG

Additional Investigations ECG STAT with chest pain and notify MD immediately

IV TherapyIV Fluid: 0.9% NaCl 2/3 + 1/3 D5W Other ________________________ at __________ mL/h

With 20 mmol KCl/L of IV fluid With 40 mmol KCl/L of IV fluid Saline Lock when drinking well

Acid Suppression Aluminum Hydroxide/Magnesium Hydroxide oral suspension 30 mL PO q4h PRN

Antibiotic Therapy Administer first dose of antibiotics STAT if not administered in ER

Complicated exacerbation of COPDRisk factors e.g. FEV1 less than 50% predicted , 4 exacerbations /year or more, cardiac disease, home O2 use, oral steroid use

amoxicillin -clavulanic acid 875/125 mg PO q12h for 7 daysOR

Simulation Design Template ceftriaxone 1 g IV q24h for 7 days, if unable to take oral medications

ORIf allergic to penicillins, or if history of amoxicillin/clavulanate within the last three months

levofloxacin 750 mg ___PO/IV q24h for 5 days, reserve IV for patients unable to take oral medication

For Suspected Pseudomonas Infection in pattients with structural ling disease eg bronchiectasis levofloxacin 750 mg ___PO/IV q24h for 10 days, reserve IV for patients unable to take oral medication

Bronchodilator TherapyShort Acting Beta-agonist

salbutamol 100 micrograms/puff, puffs inhaled via Metered Dose Inhaler (MDI) with spacer/mask q2h PRN

Other:

Anticholinergic ipratropium 20 micrograms/puff, 4 puffs inhaled via Metered Dose Inhaler (MDI) with spacer/mask q4h for

hours tiotropium 18 micrograms inhalation daily. Start only when ipratropium has been discontinued Other:

Inhaled Corticosteriod/Long Acting Beta-agonistfluticasone 250 micrograms/salmeterol 50 micrograms per inhalation (Advair Diskus) 1 inhalation BIDfluticasone 500 micrograms/salmeterol 50 micrograms per inhalation (Advair Diskus) 1 inhalation BID Other:

Corticosteroid Therapy (Systemic) methylPREDNISolone mg IV for 1 dose if not already administered in ER

THEN predniSONE mg PO daily for days predniSONE mg PO daily for days (30 – 40 mg daily

recommended for 7 –14 days) (lower dose preferred if frail elderly or comorbidities of diabetes or osteoporosis) Other:

Glycemic Management***MD to complete Diabetes Management Order Set as applicable***

Refer to Diabetes Management Order Set (NPO Patient) Refer to Diabetes Management Order Set (Patient Eating Meals) Refer to Diabetes Management Order Set (Tube Feeding/Total Parenteral Nutrition) Other:

Nausea Management***MD to consider ordering lower dose/low dose ranges for the elderly/frail***

dimenhyDRINATE 12.5 – 50 mg PO/NG/IV/PR q4h PRN Other:

Pain/Fever Management***max acetaminophen from all sources 4,000 mg in 24 hours***

acetaminophen 325 – 650 mg PO/NG/PR q4h PRN for pain acetaminophen 650 mg PO/NG/PR q4h PRN for T greater than/equal to 38.5°C

Simulation Design Template

AnticoagulationVTE Prophylaxis

***LMWH is preferred due to decreased risk of Heparin Induced Thrombocytopenia***

No Pharmacological VTE Prophylaxis Reason: Patient on therapeutic anticoagulation

Other: ________________________________________________ Reassess VTE Prophylaxis daily if not ordered

Antiembolic stockingsIf only Mechanical Prophylaxis ordered reassess daily for change to Pharmacological ProphylaxisCBC prior to initiating therapy if not already ordered AND CBC day 1, 3, 7 and weekly while on therapy

Pharmacological Prophylaxis Dalteparin 2,500 units Subcutaneous daily (for weight less than 40 kg) Dalteparin 5,000 units Subcutaneous daily

Dalteparin 5,000 units Subcutaneous BID (for weight greater than 100 kg) Heparin 5,000 units Subcutaneous q 8h

Heparin 5,000 units Subcutaneous q 12h

Discharge PlanningConsults/Referrals: Book the following community/outpatient clinic appointments

COPD Clinic in days/ weeks Smoking CessationClinic_____________________________________________________________________________ Respirologist Reason:_______________________________________________________________________________ Pulmonary Rehabilitation Day Hospital – Reason : ________________________________________________________

Fax notification of discharge to Primary Care Provider

Other: ______________________________________________________________________________________________

Additional Orders:

ADDITIONAL REFERENCE:

Health Quality Ontario & Ministry of Health and Long-Term Care. (2013, January). Quality-Based Procedures: Clinical Handbook for Chronic Obstructive Pulmonary Disease.

Found at url http://health.gov.on.ca/en/pro/programs/ecfa/docs/qbp_copd.pdf

http://health.gov.on.ca/en/pro/programs/ecfa/docs/qbp_copd.pdf

Documents

COPD - Simulation Design Template – Loyalist College€¦ · Web view · 2015-03-31-continue use of O2 on pt during med admin -Reassess respiration, O2 sat and possibly other