Complex Care Day NURS 4617 1 CEC/Sim Workbook 1 Complex Care NURS 4617 Day 1 Clinical Education Center and Simulation Learning Activities Clinical Education Center – 3 rd Floor Simulation Center – 5 th Floor Welcome, Attendance and Questions/Answers Welcome, Attendance and Questions/Answers Activity #1 Non-invasive mechanical ventilation interactive learning Simulation #1 Activity #2 EKG Rhythm Interpretation and review Simulation #2 Activity #3 STEMI video and guided discussion Simulation #3 Simulation #4 The Clinical Education Center has new clinical content and nursing application. Please prepare for the simulation scenarios as you would for a clinical day. Read through the material, look up pathophysiology, and medications regarding your patient. Be prepared to provide knowledgeable, effective, and safe patient care in each of the simulation scenarios today. To prepare for the Complex Care simulation experience, please: Review the “Get with the Guidelines” PowerPoint (provided) and prepare a discharge teaching plan (what are the key items that the patient will need to know prior to going home) for Mr. Pierce utilizing the patient data provided in this workbook. Read before the experience: This workbook Selected procedures as indicated The assigned article(s): Overbaugh, Kristen J. Acute Coronary Syndrome. American Journal of Nursing. 2009; 109(5): 42-52. Ecklund, M. Noninvasive Positive Pressure Ventilation Requires Healthcare Team Spirit. CE Course. Nursing Center. Bring to this experience: This workbook. Please review the simulations in detail. You should be familiar with the patient’s PMH, admitting diagnosis, and possible interventions, which include medications Stethoscope Clinical resources i.e. pen, penlight, clipboard Davis Drug book
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Complex Care Day NURS 4617 1 CEC/Sim Workbook 1
Complex Care NURS 4617 Day 1
Clinical Education Center and Simulation
Learning Activities
Clinical Education Center – 3rd
Floor Simulation Center – 5th
Floor
Welcome, Attendance and Questions/Answers Welcome, Attendance and Questions/Answers
The Clinical Education Center has new clinical content and nursing application.
Please prepare for the simulation scenarios as you would for a clinical day. Read through the material, look up pathophysiology, and medications regarding your patient.
Be prepared to provide knowledgeable, effective, and safe patient care in each of the simulation scenarios today.
To prepare for the Complex Care simulation experience, please:
Review the “Get with the Guidelines” PowerPoint (provided) and prepare a discharge teaching plan (what are the key items that the patient will need to know prior to going home) for Mr. Pierce utilizing the patient data provided in this workbook.
Read before the experience:
This workbook
Selected procedures as indicated
The assigned article(s): Overbaugh, Kristen J. Acute Coronary Syndrome. American Journal of Nursing. 2009; 109(5): 42-52. Ecklund, M. Noninvasive Positive Pressure Ventilation Requires Healthcare Team Spirit. CE Course. Nursing Center.
Bring to this experience:
This workbook. Please review the simulations in detail. You should be familiar with the patient’s PMH, admitting diagnosis, and possible interventions, which include medications
Stethoscope
Clinical resources i.e. pen, penlight, clipboard
Davis Drug book
Complex Care Day NURS 4617 1 CEC/Sim Workbook 2
Clinical Education Center
Activity #1 Non-invasive and Invasive Mechanical Ventilation and Oxygenation.
There will be a guest speaker, Jerome Piccoli, RRT, who will review oxygenation and introduce advanced modes of oxygenation such as CPAP and BiPap. Your role as a student nurse: Review your lecture notes regarding oxygenation as well as mechanical ventilation, both non-invasive and invasive. Procedures: Review Lewis Textbook (Medical-Surgical Nursing), Chapter 66, pp.1703-1713.
Activity #2
EKG Rhythm Interpretation and Review Your role as a student nurse: In small groups, interact with team members and actively participate in learning activities regarding rhythm interpretation. You will be provided with EKG rhythm strips. Answer the questions below.
1. What other assessment data would be helpful for you at this time, as it relates to your patient? 2. What are your priorities at this time? What nursing interventions you would like to implement? 3. What medications you can anticipate preparing for your patient, or potentially obtaining an order for? 4. Create an SBAR Report about your patient.
Activity #3 Acute Coronary Syndromes
Your role as a student nurse: Actively participate in assessment and nursing care for a patient experiencing a Acute Coronary Syndrome event “MONA” is the common acronym used for initial interventions and treatment of Acute coronary Syndromes.
M -- Morphine
O -- Oxygen
N -- Nitroglycerin
A – Aspirin Risk Factors
Expected Unexpected
Smoking (i.e. cigarettes)
Obesity
Age (men 45 years or older, women 55 years or older
Diabetes
Hypertension
Stress
NSAIDS (particularly after previous MI; COX-2 inhibitors – Celebrex)
Chronic steroid use (rheumatoid arthritis, psoriasis, etc.)
Depression
Thyroid disease (i.e., hypo-, hyperthyroidism)
Sleep Apnea
You will be provided with a patient scenario. Answer the questions below.
1. What are some modifiable risk factors for ACS? Non-modifiable? 2. What symptoms might you expect from your patient who is experiencing ACS? 3. What are your nursing priorities?
Simulation
Your role as a student nurse:
Be familiar with the patient’s medical orders, MAR, and EMS (hard copy) 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 Guiding points:
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 indicated
Role recommendations: 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.
Complex Care Day NURS 4617 1 CEC/Sim Workbook 4
General Patient Medical Information for All Scenarios Today Primary Medical Diagnosis: Anterolateral MI
History of Present Illness: Mr. Martin Pierce is a 62 year-old patient
Situation: Mr. Martin Pierce is a 62 year-old patient brought in by ambulance for acute onset chest pain at 0530.
His wife called 911 when Mr. Pierce began complaining of tingling in his left arm. Additionally, he was clutching his
chest with his fist, and she became concerned. The 911 operator advised her to have him chew a regular strength
Aspirin; she stated she did not have any in the home. Once in the ambulance, EKG changes were noted on the
monitor, so the Paramedics gave him the Aspirin to chew. Paramedics contacted the Emergency Department (ED)
to notify them that Mr. Pierce was having an MI, most likely anterior-lateral.
Background: History of Hypertension (HTN), Nicotine use/abuse.
Allergy: Iodine
Medication(s): Hydralazine 25 mg PO twice daily
Assessment:
Neuro: Alert & Oriented, no neuro deficits. Respiratory: lungs clear, on 2 liters n/c sats about 90%
Cardiac: Chest pain treated on scene with Nitroglycerin 0.4 mg with result of pain dropping to 4/10 for 7/10. Rhythm remains SR with ST elevation. Pulses 2+/2+ bilaterally upper and lower extremities. Capillary refill <3 seconds.
GI: Abdomen rounded, soft. Bowel sounds active in all quads to auscultation. Non-tender to palpation.
GU: He has not voided at this point in time.
Msk: Gait steady, smooth movement noted. No crepitation, pain noted on palpation of all joints. Muscle strength 5/5 upper and lower extremities.
For access, he has an IV in his right antecubital space. Both lines are saline locked at this time.
Recommendations: See Simulation Scenarios Below
Scenario #1 New Admission
Sim room 3
Recommendations: Admit to the ED by verifying orders as well as implementing them, and educating the patient on the plan of care. As a team please admit this patient to your clinical area and provide any nursing care he may need. Your role as a student nurse:
A basic assessment including any needed focused assessments. Please include a set of vital signs.
Provide patient education to hospital environment, safety issues and overall plan of care.
Verify admission orders, verify MAR, and IV fluids
Also provide any nursing care for patient and communication to provider as needed.
In preparation for patient transfer to the Cath Lab, prepare and provide report to Cath Lab RN.
Complex Care Day NURS 4617 1 CEC/Sim Workbook 5
Clinical Education and Simulation Lab
Chest Pain/Acute Coronary Syndrome
Emergency Department Orders
General
Date: Today Time: 0600
Admit to: CCU Telemetry ⊠ Cath Lab __________ SERVICE: Cardiology
Diagnosis ⊠ STEMI Non-STEMI Unstable Angina Chest Pain Other __________
Condition Good Fair ⊠ Guarded
Allergies NKDA ⊠ Allergy: Iodine
Nursing
Vital Signs ⊠ Per unit routine ⊠ Every 15 min in ED
⊠ Call MD if: SBP > _____ mmHg or SBP < _____ mmHg; HR >_____ or HR < _____;
RR > _____ or RR < _____; T > _____
Activity ⊠ Bed rest Bed rest with commode privileges
Out of bed to chair with assistance (BID, TID) Ambulate in hall with assistance (BID, TID) Physical therapy consultation Cardiac rehabilitation consultation
Diet ⊠NPO (except for meds)
_____ calorie-restricted diet, no caffeine CAD/ACS Diet (4 gram Na, low cholesterol), no caffeine Heart Failure Diet (2 gram Na), no caffeine Other ______________________________________________
IV Fluids HEPLOCK with 3 mL normal saline flush Q12 hours (document on flow sheet 0800H and 2000H) ⊠ 500 ml_ NS with _____ mEq KCL/L @ 25__mL/hour x _____ hours
I/O and Weight Strict recording of Ins and Outs with running totals of urine output to be recorded Daily AM weights; record in chart
Foley ⊠ If patient is unable to void, place Foley catheter
Monitoring ⊠ Pulse oximetry: ⊠ continuous Q _____
Accucheck Q _____
Oxygen ⊠ O2 4 L/min nasal cannula for chest pain, shortness of breath, SaO2 < 93%
(ACC/ AHA Guideline Class I Recommendations Indicated in Bold)
Aspirin
⊠Aspirin 325 mg PO NOW chewed Given by EMS
Other: ______________________________
Clopidogrel per Cardiology
Clopidogrel 600 mg PO NOW
Beta-Blocker per Cardiology
Metoprolol tartrate 5 mg IVP over 2 min NOW, repeat Q 5 min X 2 (hold for SBP < 90 mmHg, symptomatic bradycardia, severe reactive airway disease, decompensated HF) Metoprolol 50 mg PO NOW Hold Beta Blocker per MD order Nitroglycerin
⊠ Nitroglycerin 0.4 mg SL Q 5 min PRN chest pain; MR x 2
Nitroglycerin 100 mg/250 mL D5W IV @ 20 mcg/min, titrate to relief of CP, keep SBP > 100 mmHg
Source of medication list (circle all that apply) patient medication list, patient/family
recall, pharmacy, PCP list, previous discharge paperwork, MAR for facility
Reviewed on Transfer by _______________________ Date_____________
Reviewed on Discharge by ______________________ Date_____________
Scan to pharmacy
Medication Name Dose Route Frequency Last Dose Continue/DC
1. Hydralazine 25 mg PO Twice daily Yesterday
PM C DC
2. C DC
3. C DC
Signature Provider R. Bowler, MD Print Name Bowler Date Today
Signature RN K.Reid, RN Print Name Reid Date Today
Complex Care Day NURS 4617 1 CEC/Sim Workbook 8
Scenario #2
Post Procedure Sim room 3
Recommendations: It is 90 minutes later and Martin Pierce is being transferred from the Cath Lab, post Percutaneous Coronary Intervention (PCI) to your Cardiac clinical area. He received angioplasty and a stent placed to Left Anterior Descending (LAD) coronary artery.
He requires a basic assessment, monitoring of PCI puncture site, and, as a team, any nursing care he may need.
Complex Care Day NURS 4617 1 CEC/Sim Workbook 9
Clinical Education and Simulation Lab
Cath Lab Post Procedure
Admission Orders
MD Signature: R. Bowler, MD _______ Pager: 555-321-4567
Inpatient Admit to: ⊠ CICU Telemetry Other __________ SERVICE: Cardiology
Diagnosis ⊠ STEMI Non-STEMI Unstable Angina Chest Pain Other __________
Condition Good ⊠ Fair Guarded
Allergies NKDA ⊠ Allergy: Iodine
Nursing
Vital Signs ⊠ VS every 15 min x 4, every 30 min x 2, then every 1 hour x 4. Then, unit routine if stable.
Call MD if: SBP > _____ mmHg or SBP < _____ mmHg; HR >_____ or HR < _____;
RR > _____ or RR < _____; T > _____
⊠ Groin checks, dorsalis pedis, and post tibial pulses every 15 min x 4, every 30 min x 2, then every
1 hour x 4. Call MD for bleeding, loss of pulses
Activity ⊠ Bed rest until morning Bed rest with commode privileges
Out of bed to chair with assistance (BID, TID) Ambulate in hall with assistance (BID, TID) Physical therapy consultation ⊠ Cardiac rehabilitation consultation
Diet NPO (except for meds) _____ calorie-restricted diet, no caffeine
⊠ CAD/ACS Diet (4 gram Na, low cholesterol), no caffeine
Heart Failure Diet (2 gram Na), no caffeine Other ______________________________________________
IV Fluids HEPLOCK with 3 mL normal saline flush Q12 hours (document on flow sheet 0800H and 2000H) ⊠ 500 mL NS with _____ mEq KCL/L @ _25_ mL/hours; discontinue in a.m.
I/O and Weight ⊠ Strict recording of Ins and Outs with running totals of urine output to be recorded
⊠ Daily AM weights; record in chart
Foley ⊠ If patient is unable to void, place Foley catheter
Monitoring ⊠ Pulse oximetry: ⊠ continuous Q _____
Accucheck Q _____
Oxygen ⊠ O2 __4___ L/min nasal cannula for chest pain, shortness of breath, SaO2 < 93%
Recommendations: It is now hospital day 3 at 1600. Discharge orders have been placed on Mr. Pierce’s chart. Your role as a student nurse:
Complete any assessment data as needed for patient prior to discharge.
Complete the discharge checklist
Prepare the patient for discharge. Utilize the teaching plans that you developed in preparation for the simulation.
Resources:
Get with the Guidelines (GWTG) PowerPoint presentation (provided)
Website for Core Measures Acute Myocardial Infarction (able to access through AMC library) http://www.nursingconsult.com/nursing-images/core-measures/AMI_Core_Measure.pdf?from=core-measure/