PCA Student handout - University of Colorado Denve · The Clinical Education Center is packed with new clinical content and nursing ... No prep work is necessary ... Your role as

Integration I Day 1 CEC/Sim Workbook 1

Integration I NURS 3122 Day 1 Clinical Education Center and Simulation

Learning Activities

Clinical Education Center – 3rd Floor Simulation Center – 5th Floor

Welcome, Attendance and Questions/Answers p.2 2 Instructor 12 students 1 hour and 45 minutes

Welcome, Attendance and Questions/Answers p.82 Instructor12 students 2 hours

Activity #1 p.3 PCA pumps Including Narcan, Sedation scale, Ampules

Simulation #1 ‐Room 2 p.15Scenario #1‐New admission

Activity #2 p.5 Glucometer Including D50

Simulation #2‐Room 2 p.15Scenario #2 New admission‐30 minutes later

Activity #3 p.6 Mobility

Simulation #3‐Room 3 p.15Scenario #3‐1 hour before OR

Activity #4 Developing a Nursing Plan of Care

Simulation #4‐Room 3 p.15Scenario #4‐Transfering to pre‐op

The Clinical Education Center is packed with new clinical content and nursing application Please prepare for the simulation scenarios as you would for a clinical day. Be prepared to provide knowledgeable, effective, and safe patient care in each of the simulation

scenarios today. You will need to prepare for simulation in advance.

Please prepare before this experience:

Complete the Nursing Care Plan tool utilizing the patient data for simulation patient James Snow provided in this workbook.

You will be responsible for pages 1‐4 for simulation experience #1 and pages 5 – 10 for simulation experience #2.

No prep work is necessary for the skills you will be doing in the CEC except for the Care Plan. Just review readings as needed. These will be hands‐on learning activities, so be ready for active engagement.

Please read before this experience:

This workbook

Selected procedures

The assigned article: Bass, N. (2009). Care of the Patient with a Hip Fracture, www.nursingconsult.com. Retrieved from http://www.nursingconsult.com/nursing/clinical‐updates/full‐text?clinical_update_id=191742

Please bring to this experience:

This workbook, please review the simulation in detail. You should be familiar with the patient’s PMH, admitting diagnosis, possible interventions which include medications

Completed Care Plan including medication cards for James Snow

Stethoscope

Clinical resources i.e. pen, penlight, clipboard

Davis Drug book

Enthusiasm and the thirst to acquire nursing knowledge


Clinical Education Center

Activity #1

PCA pumps 30 minutes Your role as a student nurse: Review Pain Management: Patient‐Controlled Analgesia, Craven Procedure 34‐1 p. 1174 and p 1163 and p. 486 Review Lewis, Dirksen, Heitkemper, Bucher& Camera (2011) Pain, Chapter 10 p. 144 Preparing medications from Ampules Craven Procedure 19‐4 p. 450 Critical Thinking Exercise:

You are assigned to care for a patient with a PCA. Please provide patient education and verify dose settings including medication, concentration, loading dosed, bolus dose, basal rate, demand dose with lockout time. Also perform a pain assessment, obtain a patient sedation level with respiratory rate, and document total medication dose for 4 hours including dose given, dose attempts and amount infused.

The patient has a respiratory rate of 6 and is unresponsive. Prepare and give 0.1 mg Narcan IV STAT. Narcan is available in a 1mL ampule with a concentration of. 0.4mg/mL.

Activity #2

Glucometer 30 minutes Your role as a student nurse: Review Lewis, Dirksen, Heitkemper, Bucher& Camera (2011) Monitoring Blood Glucose, Chapter 49 p. 1233‐1235 Measuring Blood Glucose by Skin Puncture Craven Procedure 28‐1 p. 914 Critical Thinking Exercise:

You are assigned to obtain blood glucose on James Snow admitted to your medical/surgical unit with a surgical dx of left hip fracture. He is NPO for surgery this afternoon. How would you proceed?

Activity #3

Patient Safety: Mobility 20 minutes Your role as a student nurse: Review Using Body Mechanics to Move Patients, Craven Procedure 24‐1 p. 701 Positioning a patient in Bed, Craven Procedure 24‐2 p. 703 Assisting with Ambulation, Craven Procedure 24‐4 p. 717 Transferring a Patient to a Wheelchair, Craven Procedure 24‐7 p. 727 Critical Thinking Exercise:

Mobility Scenario I: Get patient up to WC or chair BID, Ambulate with walker a minimum of QD. May clamp NG while OOB. (p. 7 in workbook)

Mobility Scenario II: Get patient up to WC or chair BID, Ambulate with walker a minimum of QD. Can place CT to water seal while OOB. (p. 7 in workbook)

Activity #4

Developing a Nursing Plan of Care 20 minutes Your role as a student nurse: Review Lewis, Dirksen, Heitkemper, Bucher& Camera (2011) Concepts in Nursing Practice; Nursing Process in Nursing Practice pg 10 – 17. Critical Thinking Exercise:

Interactive discussion and review of Care Plan for James Snow.


PCA Student handout


Sedation Scales

UCH PCA Sedation Scale

5 = wide awake

4 = drowsy 3 = sleeping arousable

2 = difficult to arouse

1 = not able to arouse

Risk Factors for Opioid‐Induced Respiratory Depression:

1. Use of a basal infusion dose in the non opioid tolerant patient.

2. Obstructive Sleep Apnea (OSA), or suspected of having OSA.

3. Pulmonary disease or dysfunction (e.g., COPD).

4. Obesity, BMI ≥ 35 kg/m2

5. Greater than 64 years old.

6. Receiving other opioid or sedative drugs in addition to PCA.

7. Impaired renal or hepatic function.


Glucometer

Normal Values for FSBG: Before meals: 70‐130 mg/dL After meals: >180 mg/dL Critical values: <40 mg/dL or >450 mg/dL Procedure:

1. Review provider orders to determine type and frequency of glucose monitoring 2. Wash hands and don clean gloves. 3. Identify the patient by asking the patient to state his/her name. Also check the client’s identification band (confirm patient’s identity

using two patient identifiers, based on the hospital protocol). 4. Explain the procedure to the patient or parents (if patient is a child) to gain cooperation. 5. Choose the puncture site. For adults and children fingertips (and earlobe?) can be used. May massage fingertip gently and hold in a

dependent position.

For infants, the tip of the great toe or heel can be the site of puncture. 6. When glucometer is used, load the strip into the device beforehand. Remove test strip from the container and handle according to the

manufacturer’s instructions. May need to do QC with high and low controls (usually done every 24 hours). Make sure the strips have not expired and they are the correct lot number.

7. Swab alcohol pad to the chosen puncture site and allow drying thoroughly. Piecing the skin with a wet skin (alcohol) allows the chemical to pass through the outer layer of the skin thus, causing the procedure more painful and uncomfortable, and causing erroneous readings.

May have patient wash hands with soap and water to clean fingers and to vasodilate 8. To collect a blood sample, position the lancet (pricking needle) at the side of the site. To minimize pain and patient’s anxiety pierce the

skin sharply and briefly. This technique also increases blood flow. For better results, some agencies are using a lancing device (mechanical blood‐letting device) wherein the lancets are simply loaded in the spring of the equipment. (It’s like using a spring‐loaded pen, once you click the button the spring releases the lancet and immediately retracts it after piercing the skin). However, be sure to load an unused lancet before using to prevent spread of blood‐transmitted diseases.

9. May gently squeeze the finger or milk the skin toward the puncture site to obtain a large drop of blood. Don’t squeeze the puncture site hard to prevent diluting the sample with fluids from tissues.

10. Wipe away the first drop of blood. 11. Hold the test strip next to the drop of blood. Cover the entire patch of strip with

blood. Do not smear blood or incompletely cover test strip as this could lead to inaccurate glucose readings.

12. Place gauze over the punctured area and briefly apply pressure until the bleeding stops. Ask the parents of a child to do this.

13. After recommended period, read the results. Ensures a correct reading, simply follow the manufacturer’s instruction.

14. May, apply an adhesive bandage once the bleeding on the puncture site has stopped.

15. Remove gloves and record the resulting glucose level from the digital display for glucometer. Pearls for Glucose Monitoring

To make sure that the patient hands are clean (food, lotions, etc can interfere with the readings)

If using alcohol to clean off the finger, make sure it has dried before poking the finger as it can mix the blood sample and cause an inaccurate reading

Wipe the first drop of blood and don’t “milk” the finger excessively to get enough blood

Glucometers really are not as accurate as we would like them to be and can vary by 20 mg/dL and still be considered accurate. For example you can do a fingerstick and get a result of 120 and recheck it and get a result of 140 and this is still in the expectable margin of error.

When in doubt, perform a fingerstick. If pt with known diabetes has a change in heart rate, alertness, behavior, checking a glucose level should be part of the assessment

Each institution has its own policy of confirming the fingerstick reading with a lab draw if the BG is very low or very high


+

MOBILITYIntegration I – Day I

+GATHERING STAGE

What information do I need to get this patient up safely? Do I have an order to mobilize this patient? Has PT already seen them? What were their recommendations? Does the

patient have a transfer sheet? What meds have they gotten recently? What have their vitals signs been like? Have they gotten out of bed before? What safety issues do I need to be aware of – fall risk, impulsivity, confusion,

neurologic deficits, do they need glasses or contacts, orthostatic hypotension?

What equipment do I need to get this patient up safely? What medical devices do they need when OOB – Oxygen, IV fluids/meds,

tube feeding, chest tubes etc. Do they need an orthopedic brace – cervical collar, TLSO, Jewett, splints Do I need any safety equipment – restraints, put on non-skid foot wear/shoes Do I need mobility equipment – walker, gait belt, wheel chair etc.

+CRITICAL THINKING STAGE

YOU HAVE GATHERED ALL NEEDED INFO & SUPPLIES… NOW WHAT? Is this person OK to get up RIGHT now?

What assessment’s can I do to determine this?

LOC

Orthostatic BP & Pulse

Assessment for trunk control:

While lying supine have the patient place his/her arms straight up over their head

Assessment for ability to bear weight:

While lying supine have patient grasp their left foot with their right hand, then their right foot with their left hand

Ask the patient how they were getting around prior to hospital admission

+Key Concepts in Patient Transfers

ALWAYS lock the breaks

ALWAYS make sure you have prepared the environment, your patient, and yourself properly prior to the transfer Always verbalize to your patient your expectations for them during the

transfer

Have the patient do as much as they can for themselves

Never have the patient hold on to your neck

Position what they are transferring to and what they are transferring from as close as possible to each other, at a 35-60 degree angle

Initially transfer the patient toward the stronger side to help them gain confidence

The transfer is only complete once the patient is safely positioned, draped, and has all necessary equipment within reach

+Criteria for Independent Transfers

The patient must CONSISTENTLY perform ALL parts of the transfer.

The patient does not need help with set-up.

The patient does not need to be cued to perform aspects of the transfer.

The patient is able to perform the transfer in a safe and timely manner without assistance.

*If they do not meet these criteria they need to have assistance to transfer*

+Functional Levels

Term Definition

Total Assistance Patient performs <25% of the effort.

Maximum Assistance(Max Assist)

Patient performs 25-49% of the effort.

Moderate Assistance(Mod Assist)

Patient performs 50-74% of the effort.

Minimal Assistance(Min Assist)

Patient performs 75% or more of the effort.

Supervision/Setup Requires supervision but no touching. May need cueing or item/device set up.

Modified Independence

Requires assistive devices. Has issues with timeliness or safety.

Complete Independence

No help. No devices. Is safe and timely.


+Types of Transfers

Type of Transfer

Level of Assistance (from most to least)

Patient Characteristics

Lifts Maximum Assistance - Non-weight bearing- Too weak to squat pivot

Squat Pivot Maximum to Moderate Assistance

- Unable to stand independently- Can weight bear on LE- Too weak to stand-pivot

Stand Pivot Moderate assistance and above

- Unable to stand fully- Can bear some weight on LE

+Other Helpful Tips for Pivot Transfers

Break down the transfer into it’s component parts

Have patient scoot to the edge of the bed

Position their feet directly under their knees

Have patient put their shoes on if possible

Have them lean forward

Remove arm rests if possible

Mobility Scenario I

SITUATION: Your patient has a foley catheter, an NG tube set to low‐ intermittent suction, and is on IV fluids for dehydration. Last set of VS: 96.9⁰F, 20RR, 102/64, 98BPM, 94% on RA BACKGROUND: You are caring for a 60 year‐old patient with a 4 day history of severe nausea and vomiting and a history of urinary obstruction. ORDERS: Get patient up to WC or chair BID, Ambulate with walker a minimum of QD. May clamp NG while OOB. PT EVAL: Two person, Mod‐Assist, Stand‐Pivot transfer to WC or bedside commode Critical Thinking:

What other information might you want on this patient?

What supplies might you need to gather to get him OOB safely?

What assessments might you perform?

Mobility Scenario II

SITUATION: Your patient has a left sided chest tube to 20 cm of suction, is on 5L of O2 via NC, and has IV fluids running. Last Set of VS: 98.5⁰F, 20RR, 125/86, 70BPM, 93% on 5L via NC BACKGROUND: You are caring for a 65 year‐old patient s/p unrestrained MVA with pneumothorax secondary to rib fractures. ORDERS: Get patient up to WC or chair BID, Ambulate with walker a minimum of QD. Can place CT to water seal while OOB. PT EVAL: Two person, Max‐Assist, Squat‐Pivot transfer to WC or bedside commode Critical Thinking:

What other information might you want on this patient?

What supplies might you need to gather to get him OOB safely?

What assessments might you perform?


Simulation Your role as a student nurse: Please review this workbook including each scenario, the patient’s medical orders, MAR, and admission report Review Lewis, Dirksen, Heitkemper, Bucher& Camera (2011) Chapter 63 p. 1605‐1608 Review Article: Bass, N. (2009). Care of the Patient with a Hip Fracture, www.nursingconsult.com. Retrieved from http://www.nursingconsult.com/nursing/clinical‐updates/full‐text?clinical_update_id=191742 Critical Thinking Exercise:

Be prepared to work for 15 minutes in groups of 3 to complete objectives for each scenario

Three students will actively participate in simulation and 3 students will actively observe

All 6 students will actively participate for 15 minutes with an instructor guided debrief

General Patient Medical Information for All Scenarios Today Primary Medical Diagnosis: Hip Fracture after mechanical fall

History of Present Illness:

Mr. James Snow is a 79 year old male who you are receiving on your Medical Surgical Unit from the Emergency Department. His

diagnosis is left hip fracture (Displaced Femoral Neck) and he is scheduled for surgery later today.

Situation

79 year old male admitted to orthopedic surgeon Dr. Oliver Mitchell with Dx: left hip fracture, plan for surgery later today

Back Ground

Patient is 79 year old male who fell from a ladder this morning while working in his yard. He arrived to the Emergency Department

via ambulance with obvious deformity to left hip and inability to bear weight. He was found to have a hip fracture on X‐Ray left

femoral neck displaced; CT scan of head was negative. An IV was started in the ED, labs were drawn & sent, fluid was started.

He was given 1 mg of Dilaudid for pain in the Emergency Department. He has complained of occasional shortness of breath in the

Emergency Department with a long standing history of COPD and has required Albuterol nebulizer treatment to relieve symptoms of

shortness of breath and wheezing. He also has a history of IDDM & Osteoporosis

PMH: Type 2 DM, COPD, Osteoporosis

He is very anxious about his wife. He is the primary caretaker for his wife who had a stroke last year and requires help with daily

ADLs. He has a son who lives locally and a daughter who lives in California, neither of which the Emergency Department personnel

have not been able to reach.

Assessment:

ED assessment: A & O x 4. S1 S2 no murmurs. Respiratory effort labored with wheezing at times. Now, after Albuterol neb, even and

unlabored with clear breath sounds throughout. BS active x 4 quads. Left cheek and elbow with abrasions. Left Hip with bruising and

abrasions. Left lower extremity CMS intact. Right AC with 18 gauge PIV.

Please see each scenario for specific assessment changes

Recommendations:

Please see each scenario for specific objectives


Emergency Department Faxed Report Form CON Simulation SI

TUA

TIO

N Date:_Today__ Time:__Now___ Room #___Sim____ MD___Mitchell____

Diagnosis or Chief Complaint __L Hip Fx (Femoral Neck displaced) s/p Fall_____

COPD Exacerbation Admission History Yes No Isolation Required: Yes No Type:_____________

BA

CK

GR

O 79 yo male c/o L hip “gave out” then fell 2 steps off ladder while doing yard work. L hip Fx , femoral neck displaced; Abrasions L cheek & elbow; CT head & CSpine negative. PMH: Osteoporosis, DM type 2, COPD Allergy: Iodine, Morphine

ASS

ESSM

ENT

1 hour ago Vital Signs Temp. _372__ Pulse Rate/Rhythm_88_/__Reg__ Resp: _20__ O2 Sat.__93%_____RA/O2__RA____ B/P____140/80_______ BG _234__ GCS Yes Scale_ N/A ___ No Other_________

Physical Assessment Neuro: A/O x4 Alert Awake ↓LOC Lethargic

Comatose Fluctuating Agitated Confused Combative Other:

Integumentary Skin W/D Color WNL Cap Refill < 3 sec Other: Abrasions L cheek, elbow & hip

Respiratory: Unlabored Labored Tachypneic

Clear Wheezes Rhonchi Diminished Other: Occasional wheezing required Albuterol neb. Now

clear, even & unlabored GI: BS Present Hypoactive Hyperactive Abd. Distended

Other: MS: No deficits Contracted Cachetic Amputation________

Other: Immobilized L lower extremity, CMS intact

Pain Management Pain level before meds: _7_/10 Pain level now: _2_/10 Location of Pain: __ L hip ________________________________ Pain Medication: __Dilaudid 1 mg IV______________________ Last Dose Given At: 1 hour ago Pain Goal: less than 3/10

Interventions Labs: See attached lab results sheet

CBC, CMP/BMP, TROP, UA, Other:T & C for 2 units of PRBCs on call to OR Abnormal/Pertinent Results: __See Labs___________________ Radiology: CT, XR , U/S Type: Neg CT head & CSpine ___ Abnormal/Pertinent Results: _L Hip Fx (Femoral Neck) Tubes: Foley Size ___N/A__________ NGT Size____ N/A _____ Chest Tube: R L Air Leak Crepitus Drainage Color_________

Input & Output Admission IV Fluid: __See orders________________________ IV Location/Size: 1.___ 18g / R AC_ 2._________/__________ Input: Oral _ N/A __cc’s IV _ N/A __cc’s Other: _ N/A __cc’s Output: Urine _300_cc’s Emesis N/A _cc’s NGT_ N/A cc’s CT Drainage _ N/A _ cc’s Other: __N/A cc’s

Social Assessment

Activity: Independent With Assistance Dependant Pt lives: W/ Family Alone Homeless, Caregiver Deficits: Deaf/HOH Blind/Vision Impaired Other: glasses

Nursing Swallow Evaluation: Pass Fail N/A Not done Comment:

See triage note for list of home meds Medications Meds given in ED: Dilaudid 1 mg IV 1 hour ago; Albuterol neb. 1 hour ago ; 6 units Reg. Insulin 1 hour ago

Antibiotic Started: Yes No N/A Type________________ Time ________________

REC

OM

MEN

DA

TIO

N ED Pathway Initiated:__ N/A ________ Restraints Yes No Precautions: L hip precautions Care Issues: Wife dependent on pt. Unable to get a hold of Son. Pt worried about wife. Wife phone #123.123.1212 Son phone #234.234.2323 Special Equipment Needed:

Goals/ Things to watch out for: Plan OR later today Labs or Medications to be done soon: See orders

Signatures (PRINT) ED RN Completing Report: Sue Sterwart RN_____________________Ext__1234__ Staff Confirming Fax Receipt: _______Time: _________ Pt. Transported By tech Patient Received By: Time:

James Snow DOB 6/1

MRN: 78980098


Dispensing by non‐proprietary name under formulary system is permitted, unless checked here:

DATE: Today TIME: 0800

James Snow D.O.B. – 6/1

MRN: 78980098

ATTENDING PHYSICIAN: Dr. Spencer UPI ID #3456

ORDERING HEALTHCARE PROVIDER:

Dr. Mitchell GME/UPI

1223 SERVICE: Ortho Surgery CODE STATUS: Full

PAGER: 3567 ALLERGIES: Iodine, Morphine 1 Admit to Ortho/Simulation Floor

2 Admit height : 5’11” Admit weight: 86.3 Kg

3 Diagnosis: preoperative L Hip fracture after fall

4 PMH: DM type 2, COPD, Osteoporosis

5 Vital Signs with CMS (circulatory, Motor, Sensory) checks q 4 hours and prn

6 Call HO: Temp ≥ 38.4 C or ≤ 35, SBP ≥ 160 or ≤ 80, DBP ≥ 100 or ≤ 40, HR ≥ 120 or ≤ 50, RR ≥ 24 or ≤ 8, BG ≥ 250 or ≤ 60, loss or change in CMS

7 Intake and Output q 8 hours

8 Oxygen as needed for SpO2 < 92%

9 Activity: Bedrest, HOB<30 degrees, Hip precautions

10 Diet: NPO for surgery today

11 Finger stick blood glucose q 6 hours

12 Send CBC, BMP, Pt/PTT, UA, T & C for 2 units of PRBCs on call to OR done in ED 1 hour ago

13 IV Infusions: NS at 75 ml / hr while pt is NPO

14 Glyburide 5 mg orally once daily

15 Albuterol 5mg Nebulized treatment or Albuterol MDI Inhaler with spacer 2 puffs every 2 hours as needed for SOB given in ED 1 hour ago

16 Zofran 4 mg IV push every 8 hours as needed for nausea

17 Dilaudid 1 mg IV push every 2 hours as needed for moderate-severe pain 4-10 given in ED 1 hour ago

18 Tylenol 500mg orally every 4 hours as needed for mild pain 1- 3, HA, or temp greater 38 C

19 Vancomycin 1 g IVPB x 1 on call to OR

20 Measure and place TED hose -on call to OR

21 Order and place SCDs -on call to OR (ORDERS CONT. on next page Page 1 of 2)

22 IS x 10 every hour while awake –on call to OR

SIGNATURE/TITLE Dr. Mitchell MD

Orders transcribed by:

Title: Date: Time:

Verified by:

Title:

Date: Time:


Dispensing by non‐proprietary name under formulary system is permitted, unless checked here:

DATE: Today TIME: 0800

James Snow D.O.B. – 6/1

MRN: 78980098

ATTENDING PHYSICIAN: Dr. Spencer UPI ID # 3456

ORDERING HEALTHCARE PROVIDER: GME/UPI

Dr. Mitchell 1223 SERVICE: Ortho Surgery CODE STATUS: Full

PAGER: 3567 ALLERGIES: Iodine, Morphine

(ORDERS CONT. BELOW Page 2 of 2)

Insulin for sliding scale

< 60 notify MD

61-120 – NO coverage

121--150 – 1 unit Regular insulin SQ

151-170 – 2 units Regular insulin SQ





>250 – notify MD

Dr. Mitchell MD SIGNATURE/TITLE

Orders transcribed by:

Title: Date: Time:

Verified by:

Title:

Date: Time:


Medication Administration Record (MAR) Date: Today

Name: James Snow

MRN: 78980098

Date of Birth: 06/1

Allergies: Iodine, Morphine

Admit height : 5’11” Admit weight: 86.3 Kg

Scheduled Medications Page 1 of 3

Time Yesterday Today

Tomorrow

Maintenance IV fluid NS at 75ml/hr

Continuous Started in ED 1 hour ago SS

While patient is NPO

Glyburide 5 mg orally once daily 0900

Vancomycin 1 g IVPB x 1 on call to OR

On call to OR

Signature

Initial Signature Initial Signature Initial

Sue Sterwart RN SS



Name: James Snow

MRN: 78980098

Date of Birth: 06/1



PRN Medications Page 2 of 3

Time Yesterday Today

Tomorrow

Albuterol 5mg Nebulized Treatment every 2 hours as needed OR

given in ED 1 hour ago SS

Albuterol MDI Inhaler with spacer 2 puffs every 2 hours as needed

Dilaudid 1 mg IV push every 2 hour as needed for pain moderate‐severe (4‐10)

given in ED 1 hour ago SS

Zofran 4 mg IV push every 8 hours as needed for nausea

Tylenol 500 mg orally every 4 hours as needed for mild pain (1‐3), HA or temp greater than 38 C

Signature

Initial Signature Initial Signature Initial

Sue Sterwart RN SS



Name: James Snow

MRN: 78980098

Date of Birth: 06/1



PRN Medications

Insulin Sliding Scale Page 3 of 3

Time Yesterday Today Tomorrow

<60 notify MD

61‐120‐ NO coverage

121‐150 Regular Insulin 1unit SQ





231‐250 Regular Insulin 6unit SQ given in ED 1 hour ago SS

>250 notify MD

Signature Initial Signature Initial Signature Initial

Sue Sterwart RN SS


Simulation Scenarios

Your role as a student nurse:

Be familiar with the patient’s medical orders, MAR, and ED faxed report

The instructor will give you a minute to pre‐brief and review the scenario’s objectives

Be prepared to work for 15 minutes in groups of 3 to complete objectives for each scenario

Three students will actively participate in simulation and 3 students will actively observe

All 6 students will actively participate for 15 minutes with an instructor guided debrief Critical Thinking Exercise:

3 active simulation participants should divide into nursing roles to meet the patient’s needs and scenario objectives

You are working with an interdisciplinary team and may consult by phone a Physician, Provider, Charge Nurse, CNA, Pharmacist, Case Manager, Respiratory Therapist, Social Worker, Chaplin, Physical Therapist and others as available

Role recommendations: 1 assessment/VS nurse, 1 intervention/medication nurse, 1 leader/primary nurse

The team will be randomly assigned to roles. o Student 1: Assessment/VS nurse Role to complete basic assessment, vital signs and communicate findings with team members o Student 2: Interventions/Medication administration nurse Role to implement nursing interventions to include medication administration o Student 3: Intervention/Primary nurse Role as leader, situational awareness, communication with provider and to implement nursing interventions

3 active observers should focus on observing simulation and be able to highlight successes and deficits in patient assessment, nursing interventions, and safety

ADDITIONAL NOTES


Scenario #1‐New Admission Sim room 3

Recommendations: Admit James Snow to your unit by verifying orders, implementing orders, and educating the patient on the plan of care. As a team please admit this patient to your unit and provide any nursing care he may need. At minimum please complete:

A basic assessment including any needed focused assessments. Please include a set of vital signs.

Complete Patient Admission Assessment‐Nursing form

Implement orders and provide patient education to hospital process and care, orders including hip precautions, and overall plan of care.

Verify admission orders, verify MAR, and verify IVF along with review what medications the patient received in ED.

Also provide any nursing care for patient and communication to provider as needed

Scenario #2 New admission‐30 minutes later Sim room 3

Recommendations: It is 30 minutes later and James Snow requires his 0900 medications, a basic assessment, perform a glucose check, and as a team provide him with any nursing care he may need. At minimum please complete:


Verify IVF and provide patient 0900 medications as ordered

Check glucose


Scenario #3‐1 hour before OR Sim room 2

Recommendations: It is 1 hour before James Snow will go to the OR. He is anxious and he is asking what he should expect for his post surgery recovery. Please provide him preoperative education and as a team provide him with any nursing care he may need. At minimum please complete:


Provide pre‐operative patient education on IS, TED hose, SCD, and post operative plan of care (use article as a guide)

Implement any pre‐operative orders i.e safely place TED hose and SCDs on patient and give patient IS


Scenario #4‐Transfering to pre‐op Sim room 3

Recommendations: The OR is ready for James Snow. Please complete the pre‐surgical checklist, prepare the patient for transfer to the OR, call the OR RN Mandy with a brief SBAR report before transfer, and as a team provide him with any nursing care he may need. At minimum please complete:

Complete any assessment data needed before transfer to the OR

Complete the pre‐surgical checklist

Prepare the patient for transfer to the OR (use the OR surgical checklist as a guide)

Call the OR RN Mandy with a brief SBAR report before transfer (use the OR surgical checklist as a guide along with the physician orders and patient MAR. Include Dx‐why he is going to OR, PMH, allergies, recent meds given plus on‐call meds, priority & abnormal assessments, IV, tubes, precautions)


University of Colorado College of Nursing Simulation and CEC

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Patient Admission Assessment‐NURSING Medication Reconciliation Orders Completed □ Yes □ No (on separate orders) Admit Date: __________ Unit: _______________ Service: ___ ___________ Attending, Residents, and Providers: _____________ ______________________________________________________ Diagnosis: __ ______________________________________________________________________________________ Main reason for today’s visit: _________________________________________________________________________ Other concerns: ____________________________________________________________________________________

Have you completed an Advance Directive for Health Care (ADHC) □ Yes □ No If yes, Type: □ Living Will □ CPR direc ve □ Medical power of attorney Name of MPOA_______________________________ □ Copy made and entered into EMR Do you have religious, cultural, or ethnic practices that we should consider while you are in the hospital? □ Yes □ No Explain:_____________________________________ Religious preference:____________________________________ Allergies or intolerance to medications and food (include type of reaction): □ NONE □ Yes _______________________ __________________________________________________________________________________________________ Surgical History. Include type of surgery and date □ NONE □ Yes_____________________________________________ __________________________________________________________________________________________________ Depression/Suicide Screening Over the past 2 weeks, have you felt down, depressed, or hopeless? □ Yes □ No If yes: Over the past 2 weeks, have you had thoughts of killing or hurting yourself? □ Yes □ No If yes: Have you ever attempted to kill yourself? □ Yes □ No If yes to any screening question, call provider and consult social work immediately. Confirm patient is in safe current environment. History of Falls Have you fallen in the last month? □ Yes □ No If yes place patient on High Fall Risk Tobacco Use Do you currently smoke or use any form of tobacco? □ Yes □ No Tobacco History: □ Never □ Yes Quit date: _________ How many years did/do you smoke? _______ Approximately how many packs a day did/do you smoke? ___________ Tobacco type: □Cigare es □ Pipe □ Cigar □ Snuff □ Chew Alcohol Use When was the last time you had more than 3 (for women/men >65yrs)/4 (for men) drinks in one day? _____________ Not within the past 3 months □ Yes □ No If yes: # of drinks/week: ___________ □ Beer □ Wine □ Liquor Drug Use In the past 12 months, have you used drugs other than those required for medical reasons? □ Yes □ No ____________ Do you use marijuana or recreational drugs? □ Yes □ No Have you ever used needles to inject drugs? □ Yes □ No Abuse/Neglect Have you been hit, slapped or kicked in the last month? □ Yes □ No Do you feel safe at home? □ Yes □ No Do you feel safe in your relationship? □ Yes □ No Are you in immediate danger? □ Yes □ No If yes SW & provider notified Denies physical abuse? □ Yes □ No Denies verbal abuse? □ Yes □ No Denies sexual abuse? □ Yes □ No Immunizations (Influenza screen during Oct‐March flu season) ___Influenza ___Pneumovax (PNA) ___Zostavax ___Meningitis ___TDaP OR ___ Tetanus & ___ Pertussis If you qualify for vaccine, would you accept it? □ Yes □ No If yes: Pharmacy consulted for screening □ Yes □ No

Name: DOB: MRN:


University of Colorado College of Nursing Simulation and CEC

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Patient Admission Assessment‐NURSING

REVIEW OF SYMPTOMS: Please mark any diagnoses or persistent symptoms from the past few months. List other concerns above.

General ___ Unexplained weight loss / gain ___ Unexplained fatigue / weakness ___ Fall asleep during day when sitting ___ Fever, chills ___ No problems

Allergic/Immune ___ Hay fever / allergies ___ Frequent infections ___ No problems

Skin ___ New or change in mole ___ Rash / itching ___ No problems

Ears/Nose/Throat ___ Nosebleeds, trouble swallowing ___ Frequent sore throat, hoarseness ___ Hearing loss / ringing in ears ___ No problems

Eyes ___ Change in vision / eye pain / redness ___ No problems

Psychiatric ___ Anxiety / stress / irritability ___ Sleep problem ___ Lack of concentration ___ Depression ___ Psychiatric conditions ___ No problems

Neurological ___ Headache ___ Hx of CVA ___ Seizures ___Memory loss ___ Fainting ___ Dizziness ___ Numbness / tingling ___ Unsteady gait ___ Frequent falls ___ No problems

Gastrointestinal ___ Heartburn / reflux / indigestion ___ Blood or change in BM ___Liver disease/hepatitis ___ Constipation ___ Trouble swallowing ___ No problems

Genitourinary ___ Kidney disease ___ Leaking urine ___ Blood in urine ___ Nighttime urination or inc. freq. ___ Discharge: penis or vagina ___ Concern with sexual function ___ No problems

Musculoskeletal ___ Neck pain ___ Back pain ___ Muscle / joint pain ___ No problems

Cardiovascular ___ Chest pain / discomfort ___ Palpitations (irr. heartbeat) ___ MI/Heart attack ___High blood pressure ___ No problems

Respiratory ___ Loud snoring ___ Sleep apnea ___ Cough / wheeze ___ COPD ___ Asthma ___ Short of breath with exertion ___ No problems

Endocrine ___ Heat or cold sensitivity ___ Diabetes ___ Thyroid disorder ___ No problems

Hematologic/Lymphatic ___ Swollen glands ___ Easy bruising ___ DVT ___ No problems

Women only ___ Pre‐menstrual symptoms ___ Problem with menstrual periods ___ Hot flashes / night sweats ___ Breast lump / pain / discharge ___ No problems

Functional Assessment Nutrition Screen: > 10lb unintentional weight loss in the last 3 months□ Yes □ No; Unable to tolerate oral intake or NPO >4 days □ Yes □ No; Open non‐healing wound □ Yes □ No; Home Tube Feeding □ Yes □ No; Home TPN □ Yes □ No

Functional: Vision adequate to safely complete daily activities □ Yes □ No □ Blind □ Glasses □ Contacts Hearing is functional‐Right ear □ Yes □ No Left ear □ Yes □ No □ Hearing aid □ 1 □ 2 Patient’s judgment adequate to safely complete daily activities □ Yes □ No; Pa ent’s memory adequate to safely complete daily activities □ Yes □ No; Pa ent able to express needs/desires □ Yes □ No Patient functionally independent in: Dressing □ Yes □ No; Grooming □ Yes □ No; Feeding □ Yes □ No; Bathing □ Yes □ No; Toileting □ Yes □ No; In/Out Bed □ Yes □ No; Walking □ Yes □ No; LE weakness □ Yes □ No; UE weakness □ Yes □ No

Discharge planning: Lives independent □ Yes □ No; Lives with significant other □ Yes □ No with whom: ______________ Current home care services □ Yes □ No Type: _________________; Expected discharge location: ____________________ Consult made to: Dietician□ Yes □ No OT □ Yes □ No PT□ Yes □ No SW□ Yes □ No CM□ Yes □ No

Name DOB: MRN:


PRE‐PROCEDURE CHECKLIST

NIC: SURGICAL PREPARATION

Date____________ Time:___________

Report given to:_____________________________________

ALLERGIES:____________________________________________

Patient Care Checklist:

ID band present RUE / LUE / RLE / LLE /

Other__________

Current Blood identification band present

RUE / LUE / RLE / LLE / Other__________ N/A

Blood refused Refusal form signed Yes No

“NO BLOOD” band on RUE / LUE / RLE / LLE /

Other_______

Dentures / Partials NA Yes No

Eye wear removed NA Yes No

Hearing aid removed NA Yes No

Jewelry / Body piercing removed NA Yes No

Hospital Gown only

SCD (sleeves) Elastic Stockings Foot Pump

LLE: Calf ________ Thigh_________ Length__________

RLE: Calf ________ Thigh_________ Length__________

NPO Since____________________________________am / pm

Last Void Time_______________________________am / pm

Last 24 hour I & O: I___________O____________

This shift’s I & O: I___________O____________

Vital Signs

Time_______ Temp_______ B/P_______ HR_______

RR_______ O2 Sat_______ Pain Scale_______

Cardiac monitoring Continuous Pulse oximetry

Patient Precautions

Aspiration Airborne

Contact Droplet

Fall Latex

Seizure Unable to communicate

Combative Sitter required / sent

Translator required Dialysis lines

Translator ordered A/V fistula

Reason:__________________________________________

IV Site/Vascular Access

MAR updated MAR sent

Antibiotics ordered /type ____________________________

Antibiotic sent with patient Antibiotic given at _______

Labs

Labs drawn ____________________and sent at _________

Labs to be drawn in Pre‐op/OR_______________________

Blood glucose, most recent result__________ time_______

Documentation Verification

Surgical consent on chart (within 90 days)

Anesthesia consent on chart

History and Physical on chart (within 30 days)

Pre‐procedure note on chart (if H & P > 7 days old)

Advance directive declaration form on chart / computer

Correct site / side _________________________________

Correct site marked Yes / No

By whom:___________________________________________

Belongings form completed / Initiated

Belongings sent with patient to OR / home with family

Tubes

Lumbar drain Ventriculostomy/Bolt

Zero at____________________________________

NG tube J‐tube

Dobhoff PEG tube/G‐tube

Chest tube _______ to suction_________ to gravity

Hemovac_________ JP drain__________

Foley Nephrostomy_____

Wound Vac_______ other_____________________

other___________ other___________

Other Notes:

_____________________________________________________

Signature Initial Signature Initial

Site______________Size______________ RUE_____LUE______

Site______________Size______________ RUE_____LUE______

Documents

PCA Student handout - University of Colorado Denve · The Clinical Education Center is packed with new clinical content and nursing ... No prep work is necessary ... Your role as