Safaa Khalil Hamed is one day post major abdominal surgery. Her pain relief is uncontrolled despite a patient controlled analgesic device (PCA). She has a deteriorating saturation and escalating pulse and BP as a result. As she is on an insulin infusion this must also be managed. Safaa arrived in Ireland under the Irish refugee protection programme 6 months ago with limited English language skills. Please refer to simulation frames and critical actions to prepare and facilitate this simulation. The simulation will finish when the time allocated has elapsed or when learning outcomes are achieved.
General Information
| Course | BSc General Nursing |
| Year | 3rd Year |
| Title of Simulation | Simulation 2 |
| Main Focus | Uncontrolled post-operative pain |
| Time | 18 minutes |
| Other |
Learning Outcomes For Course
| Demonstrate the performance of a full systematic patient assessment using the A-E approach with evidence of prioritization. |
| Recognizes subjective and objective signs of deterioration with evidence of underlying knowledge base. |
| Demonstrates clinical decision making and initiates safe and appropriate response. |
| Demonstrates safe technical skills including the prevention and control of infections. |
| Displays patient centered communication. |
| Displays team focused communication including the use of communication escalation protocols (ISBAR). |
| Demonstrates an understanding of individualized culturally competent care. |
Essential Pre-Learning
| Complete National Early Warning Score on-line learning. |
| Read chapter 4 and 5 of module text book. |
| Revise key protocols – relevant to case history. |
| Review on-line cultural competency frameworks. |
| Cultural competency framework: https://www.ceh.org.au/framework-cultural-competence/ |
Summary of Simulation
Debrief:
Please utilize the debrief Model appropriate to your facility and use the expectations and evaluation criteria to guide the debriefing process. .
The post-simulation debrief is an essential part of simulation based education. The aim is to facilitate the reflective process, which assists learners to make connections and integrate new experiences
| Specific Objectives for Simulation | Evaluation Criteria (E=Error) (CE=Critical Error) | |
| Patient Assessment | Systematic patient assessment (ABCDE approach) Focused pain assessment - including pain scale, PCA assessment and abdominal examination. Targeted reassessment in response to patient conditions and interventions. | Failure to complete systematic and focused patient assessment (E) Failure to assess pain effectively (CE) Failure to re-evaluate vital signs (CE) |
| Situation Awareness | Perception and comprehension of deteriorating status (vitals, pain) Understands need for supplemental oxygen Understands requirement for analgesia review Understands need to review insulin transfusion | Failure to recognize deterioration (CE) |
| Clinical Decision making | Decision to reposition patient and encourage deep breathing Decision to review analgesia Decision to review PCA, patient usage, . knowledge and cannula Decision to seek medical review as increased National Early Warning Score (NEWS) Decision to review pain medications Decision to administer prescribed medications Decision to titrate insulin infusion Decision to source interpreter to communicate with patient. | Failure to review PCA usage and knowledge (E) Failure to escalate care specifically relating to increasing NEWS and uncontrolled pain (CE) Delays in adjusting oxygen and insulin infusion (E) Failure to administer break-through pain relief (CE) |
| Technical skills | Correct hand hygiene and infection control measures throughout Technical skills- patient monitor, indwelling urinary catheter, vitals, PCA, Glucometer. 5Rs of medication administration -( IV paracetamol prescribed) Oxygen management | Incomplete checking of 5 Rs (CE) Administrating oral medication when patient NBM (CE) Administering medication that is not due (Tramadol) (CE) Unfamiliarity with technical skills (E) |
| Communication and Team work | Establishes nurse/patient relationship using active listening and appropriate body language. Uses patient friendly language Uses ISBAR to escalate Care Displays team focused communication | Failure to use ISBAR (E) Failure to communicate appropriately with patient (E) Failure to ensure patient can communicate concerns and understand plan of care. Failure to communicate appropriately with colleagues/team (E) |
Case Study Set-up Information
| Simulation 2 Frame 1 | ||
| Facilitator: Alter patient parameters in response to student actions (counting down from 18 minutes – 10 minutes) | Patient - Allow the students 4 minutes before you ask anything or complain of anything. | |
| RR (Respiratory Rate) | 20-23 – gradual deterioration over 6 minutes | You have limited understanding of English but can understand some but speak very little. You are on your own and frightened. Respond with some hesitation and indicate your limited understanding with hand gestures and body language |
| Resp other | If asked equal and bilateral rise no accessory muscle use | If asked about your breathing you can indicate after some time that it is OK. If asked about oxygen mask you can point to it |
| Chest Sounds | Normal | |
| SpO2 (Oxygen Saturations) | 96-94 deteriorate gradually over 6mins [1200 on clock]. Titrate upwards if oxygen therapy increased. Some peripheral cyanosis below 92%.If saturations fall to ≤85% - evidence of central cyanosis | |
| Oxygen therapy | 28% facemask hanging on flowmeter until applied | |
| BP (Blood pressure) | 124/70 -140/96 deteriorate gradually over 6mins [1200 on clock] | it is the first day after your surgery, you feel tired and weak, and have a lot of drips and drains |
| HR (Heart Rate) | 88 -94 deteriorate gradually over 6mins [1200 on clock] | |
| AVPU (Alert, Verbal, Pain , Unresponsive) | Alert | |
| Temperature | 37.2 | |
| EWS (Early Warning System) | Student to calculate | |
| Cardiac Monitor | Sinus Rhythm (if attached to CM) | |
| Capillary refill | less than 2 secs To get result: student must press for 5 secs on nailbed (until nailbed is blanched) | |
| Skin | pink, warm, dry/no odeama, | |
| Cap blood sugar(Capillary blood sugar) | 9.6 mmol/ - Students must open glucometer pouch, insert strip into machine and hold lancet at manikins finger before you give them the result - [insulin infusion should then be changed from 4 units/hour to 2iu/hr] | |
| Urinary Output | students to assess 40mls in top chamber of hourly urinary monitoring unit (minimum requirement 0.5ml/kg/hr here 39mls/hr - patient weight 78kg) | |
| IV cannula (Intravenous cannula) | VIP score zero Student must attempt to assess [visual phebitis score] | |
| IV hydration | Dextrose Saline -8hrly | |
| Pain | 4/10 student to assess - role-player will report soreness at surgery site | Pain 4/10. It is worse when you move/you are trying to take deep breaths as the nurse asked. It is very sore if they press on your tummy, if this is attempted respond with a gasp. Other wise just start by looking uncomfortable, repeat the word PAIN and increase this as the simulation progresses |
| PCA (Patient Controlled Analgesia) | 34mls in syringe; 38 demands, 32 successful | |
| Bowel Sounds | Absent - student to assess | |
| Abdomen | No distension - If asked – | |
| NG (Naso-Gastric Tube) | 60 mls on aspirate – student to assess free drainage | |
| Wound | Student to assess - they should report some exudate [blood stained] evident on dressing if asked there is some erythema but no swelling evident | |
| Drain | Students to assess drainage & site [students should report: that drain site dressing is dry and intact and drainage as is present] | |
| Other | Ileostomy – students to assess (it is pink) | |
| LIFESAVER | Enter any instruction that will help facilitators or Role-player/standardize patient move students on if not progressing |
| Simulation 2 Frame 2 | ||
| Facilitator: Alter patient parameters in response to student actions (counting down from 10 minutes – 0 minutes) | Patient – You are having increased pain respond as per the information below | |
| RR (Respiratory Rate) | 23 – Gradual deterioration over 6 minutes in response to student actions. | If the nurse shows you pain faces rather than a pain scale indicate the last face. Point to your stomach when they ask about pain, indicate you don’t understand if the nurse starts teaching you about PCA pump. Increase moaning gradually. |
| Resp other | If asked equal and bilateral rise no accessory muscle use | You pain will not improve until the student administers some extra pain relief. If this is given through your drip or as an injection into your leg - it should improve after three minutes. |
| Chest Sounds | Normal | 0600-end |
| SpO2 (Oxygen Saturations) | 94 titrate up or down in response to actions… Some peripheral cyanosis below 92%.If saturations fall to ≤85% - evidence of central cyanosis | If no pain relief - continue to increase your pain symptoms – become agitated and anxious/un -cooperative. |
| Oxygen therapy | 28% facemask hanging on flowmeter until applied | If SpO2 90-93 % - confused as to time & date - you think it is Wednesday/end of August 2017 |
| BP (Blood pressure) | 124/70 -140/96 deteriorate gradually over 6mins [1200 on clock] | |
| HR (Heart Rate) | 140/96 | |
| AVPU (Alert, Verbal, Pain , Unresponsive) | Alert – see sats above | |
| Temperature | 37.2 | |
| EWS (Early Warning System) | Student to calculate | |
| Cardiac Monitor | Sinus Rhythm (if attached to CM) | |
| Capillary refill | 2 secs To get result: student must press for 5 secs on nailbed (until nailbed is blanched) | |
| Skin | pink, warm, dry/no odeama, | |
| Cap blood sugar(Capillary blood sugar) | 9.6 mmols Students must open glucometer pouch, insert strip into machine and hold lancet at manikins finger before you give them the result.[insulin infusion should then be changed from 4 units/hour to 2iu/hr] | |
| Urinary Output | students to assess 40mls in top chamber of hourly urinary monitoring unit (minimum requirement 0.5ml/kg/hr here 39mls/hr - patient weight 78kg) | |
| IV cannula (Intravenous cannula) | VIP =0 Student must attempt to assess [visual phlebitis score] | |
| IV hydration | Dextrose Saline -8hrly | |
| Pain | student to assess - role-player will report soreness at surgery site 1-4/10 | Pain increasing form 4/10 – 9/10 depending on actions as detailed above. |
| PCA (Patient Controlled Analgesia) | 34mls in syringe; 38 demands, 32 successful | |
| Bowel Sounds | Absent - student to assess | |
| Abdomen | No distension - If asked – | |
| NG (Naso-Gastric Tube) | 60 mls on aspirate – student to assess free drainage, ph 5, | |
| Wound | Student to assess - they should report some exudate [blood stained] evident on dressing if asked there is some erythema but no swelling evident | |
| Drain | students to assess drainage & site [students should report: that drain site dressing is dry and intact and drainage as is present] | |
| Other | Ileostomy – students to assess (it is pink) | |
| LIFESAVER | Enter any instruction that will help facilitators or Role-player/standardize patient move students on if not progressing |
