Care Transitions Education Project SIMS MEDICAL Center ... · PDF file Care Transitions...

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Transcript of Care Transitions Education Project SIMS MEDICAL Center ... · PDF file Care Transitions...

  • Care Transitions Education Project (CTEP) Care of the CHF Patient - Part 1

    SIMS MEDICAL Center

    SCENARIO OVERVIEW

    ESTIMATED PRE-SCENARIO TIME: 10 MINUTES ESTIMATED SCENARIO TIME: 20 MINUTES DEBRIEFING/GUIDED REFLECTION TIME: 30 MINUTES

    TARGET GROUPS: ALL HEALTH CARE PROFESSIONALS (Nursing, Respiratory Care)

    BRIEF SUMMARY:

    This case will presents a patient who has been admitted to a rehabilitation care facility for strengthening, due to recent increases in weakness and decreased ADLʼs. The patient will start to experience orthopnea and dyspnea while being treated at this facility. The student(s) will be expected to perform a cardiac and pulmonary assessment, evaluate lab data, recognize lack of response to treatment, communicate findings to the primary care provider, and provide proper management and care including coordinating transport of the patient to an emergency department.

    LEARNING OBJECTIVES

    GENERAL:

    Identifies the primary nursing diagnosis Implements patient safety measures Identifies relevant patient history information Explains physical assessment findings and diagnostics related to patient condition Implements clinician orders appropriately Demonstrates therapeutic and confidential communication Demonstrates direct and accurate communication with multidisciplinary team members implements nursing interventions based on patient care needs Prioritizes nursing interventions Identifies indications, contraindications and potential adverse effects of prescribed medications. Demonstrates correct medication administration

    SCENARIO SPECIFIC:

    Implements a focused cardiac and respiratory assessment Explains clinical findings and critical lab values Recognizes the need for patient transfer to an emergency department setting and obtains orders for transfer. Demonstrates appropriate nursing intervention in a patient with congestive heart failure Completes necessary paperwork and communication for transition of Care

    1

  • Equipment Universal precaution equipment Hand Sanitizer Stethoscope Blood Pressure Cuff Spo2 Monitor with probe Thermometer Patient Identification Band Oxygen Supply Source Manual Resuscitation Device/BVM Oxygen Delivery Devices EKG Monitor and Electrodes Tape Normal Saline, IV, IV Pump Moulage Supplies (creams, sponge,cup) Urine Catheter with 80ml Urine (yellow) General Medication Administration Supplies CPAP Equipment Allergy Bracelet

    Equipment Checklist

    SIMS MEDICAL CENTER

    Medications and Fluids Lasix IV

    Nitroglycerin SL Tabs

    Morphine IV

    Documentation Forms

    Physician Orders Data Collection Forms

    Diagnostics Available

    BNP,CMP, CBC, CPK-MB, Troponin - I, Pre-albumin

    CXR PA/LAT

    EKG

    PREPARATION OF THE SIMULATOR

    NUMBER OF PARTICIPANTS

    Student Roles:

    Instructorʼs Roles: Evaluator and Primary Care Provider available by phone

    Two (2) Nurses One (1) Relative - wife One (1) Respiratory Care provider

    Medical - Rehabilitation Unit Place in semi-fowlerʼs position in hospital bed Apply compression stocking with memory foam to simulate lower extremity edema Dress simulator in patient gown Insert Foley catheter with 80ml yellow urine Insert IV angio with J-Loop apply oxygen 4L/min per nasal cannula Secure ID Band with patientʼs name, DOB and MR# Chart Prep with H&P, Admission Note, Discharge Summary, Med Reconciliation Form

    2

    Care Transitions Education Project (CTEP) Care of the CHF Patient - Part 1

  • PATIENT DATA:

    SIMS MEDICAL CENTER

    REPORT TO STUDENTS

    ADDITIONAL INFORMATION & MEDICAL HISTORY

    TIME: 15:00 Peter Stevyanovich is a 71 year old male patient who was admitted to the acute rehabilitation unit three days ago after being transferred from a local hospital with a diagnosis of Acute Decompensated Heart Failure. Peter experienced multiple setbacks during his hospitalization and he has become progressively weakened. His care team recommended transfer to the rehabilitation unit to increase his endurance, improve his ability to perform ADLʼs, reduce his home oxygen usage dependency and return home with the ability to care for himself with limited assistance. Last night, Peter began with complaints of shortness of breath while at rest. The nurse caring for him noticed slight increase in pedal edema, but was unable to weigh Peter due to his fatigue. She contacted his PCP, who then ordered labs, oxygen PRN, and increased his lasix by 10mg BID and scheduled a follow up in two days. Peter remained restless through the night and showed no improvement throughout the day. Upon checking on the patient, the covering nurse found Peter with decreased oxygen saturation at 90% and increased work of breathing. She increased his oxygen level to 4LPM and contacted his PCP. She report to you that she is still waiting for updated labs and a call back from Peterʼs PCP.

    CLINICAL SIGNS IMMEDIATELY AVAILABLE

    - Restless and appearing uncomfortable - Minor Confusion

    MEDICAL RECORD #: PAST MEDICAL HISTORY

    RECENT MEDICAL HISTORY:

    Male - Age 71 Years Weight 90 kgs Height 72 inches

    DATE OF BIRTH: 06/10/1941

    98126534

    Mr. Stevanovich has had hypertension for the last ten years. and was diagnosed with atrial fib and congestive heart failure five years ago. He has hyperlipidemia. He had been smoking one pack per day for twenty years but quit four years ago. he is a social drinker only. He is current with his vaccinations and has received his annual flu vaccine. He retired six years ago as a foreman and lives with his wife. He has two grown children who are very supportive to their parents.

    Mr. Stevyanovich was admitted to a local hospital due to rapid weight gain and CHF exacerbation. He had been increasingly lethargic and was unable to conduct any adlʼs and began with increased respiratory difficulty. He was released to the rehabilitation unit after a 7 day admission. He is hopeful to regain his strength and return home.

    ALLERGIES: Inapsine

    3

    Care Transitions Education Project (CTEP) Care of the CHF Patient - Part 1

  • SIMS MEDICAL CENTER

    INITIAL STATE (START)

    Blood Pressure: 184/88 Heart Rate: 110 Respiratory Rate 36 SPO2: 85% on 4 lpm N/C Temperature 98.8 F

    After 5 Minutes

    Increase Blood Pressure to: 220/102 Increase HR to: 138 Decrease SPO2 to 78% (Increased vital sign due to further decompensation)

    If care is not being effectively delivered after 10 minutes:

    If care is progressing effectively after 10 minutes:

    BP to 180/82 HR to 118 RR Remains 30 sp02 to 88%

    Increase Blood Pressure to: 260/120 Increase Heart Rate to: 150 Increase Respiratory Rate to: 44 Decrease spo2 to 65% IDecreased LOC

    Decrease Blood Pressure to: 162/80 Decrease Heart Rate to: 110 Decrease Respiratory Rate to: 26 with CPAP

    If the effectiveness of delivery of care improves: Move Back to Green Box

    If care is not being effectively delivered after 15 minutes:

    Increase Blood Pressure to: 80/40 Increase Heart Rate to: 180 Increase Respiratory Rate to: 4 unresponsive

    If Care is Progressing effectively after 15 Minutes, Decrease vital signs to:

    At 30 Minutes, if scenario is not successfully completed, please end scenario and move to debriefing

    scenario is successfully when patient is transferred or 30 minutes has elapsed, please end scenario and move to debriefing

    4

    Care Transitions Education Project (CTEP) Care of the CHF Patient - Part 1

  • INITIAL VITAL SIGNS

    BP: 184/80 HR: 110 RR: 36 SPO2: 85% (on 4lpm n/c) TEMP: 98.9 F

    PERRL s3 Gallop Lung sounds with crackles throughout bilaterally

    Patientʼs wife will try to answer every question for patient even if not asked to.

    - Wash Hands - Universal Precautions - Introduce Self - Identify the Patient - Obtains vital signs - Obtains Spo2 - Auscultates heart and

    lungs - Assess IV site - Evaluate Urine output - Evaluate Lab Data

    Patient: “ I am very tired and am having such as hard time breathing”

    Patientʼs Wife: “ Last time Peter received Lasix the nurse had to empty the urine bag often..Now he has not gone at all?”

    BP: 220/102 HR: 138 RR: 36 SPO2: 78% (on 4lpm n/c) TEMP: 98.9 F

    (Increased vital signs due to further decompensation)

    Vocal Sound:

    “ I donʼt feel any better!”

    PT becoming more diaphoretic, slight cyanosis present, pt becomes more agitated.

    - Communicate findings directly to PCP

    - Receive orders, repeat back

    - explain lab values and medications to patient

    - request respiratory care provider for assistance

    - properly administer one SL NTG

    - properly administer 80mg Lasix IV & Morphine 4mg IV

    Patientʼs wife:

    “ Peter doesnʼt seem right!! he is really short of breath and I havenʼt seem him like this in a long time! please help him!

    If treatment is not progressing effectively after 10 minutes, change Vital Signs to: BP: 260/120 HR:150 RR 44 spo2 to 65% decreased loc

    Patient will become more less responsive, with increased work of breathing, increased cyanosis and diaphoresis.

    - Recognizes Respiratory Distress

    - Begins treatment plan listed above

    Patientʼs Wife: “ it has been eight hours since the last nurse gave Peter any medicine, Peter has not urinated as much as he usually does and I think the doctor wanted to know”

    If students successfully deliver care or turn arou