Complex Care NURS 4617 Day 1 Clinical Education Center and Simulation Learning Activities Clinical Education Center

3 Floor Welcome, Attendance and Questions/Answers Activity #1 Non-invasive mechanical ventilation interactive learning Activity #2 EKG Rhythm Interpretation and review Activity #3 STEMI video and guided discussion
rd

Simulation Center 5 Floor Welcome, Attendance and Questions/Answers Simulation #1 Simulation #2 Simulation #3 Simulation #4

th

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 patients 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 1

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. 2. 3. 4. What other assessment data would be helpful for you at this time, as it relates to your patient? What are your priorities at this time? What nursing interventions you would like to implement? What medications you can anticipate preparing for your patient, or potentially obtaining an order for? 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 Smoking (i.e. cigarettes) Obesity Age (men 45 years or older, women 55 years or older Diabetes Hypertension Stress Unexpected NSAIDS (particularly after previous MI; COX-2 inhibitors Celebrex) Poor oral hygiene Chlamydia infection Stimulants (e.g., cocaine, methamphetamine, caffeine, ephedra, etc.) Women 50 years or younger (e.g. cigarette

Complex Care Day NURS 4617 1 CEC/Sim Workbook 2

Hypercholestremia Alcohol (i.e., chronic heavy drinking) Sex (male > female) Diet (e.g., high fat, sodium) Sedentary Lifestyle Family history Ethnicity and Race (i.e. African-Americans)

smoking) Trauma 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. 2. 3. What are some modifiable risk factors for ACS? Non-modifiable? What symptoms might you expect from your patient who is experiencing ACS? What are your nursing priorities?

Simulation
Your role as a student nurse: Be familiar with the patients medical orders, MAR, and EMS (hard copy) report The instructor will give you a minute to pre-brief and review the scenarios 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 patients n eeds 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 3

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 4

Clinical Education and Simulation Lab

Chest Pain/Acute Coronary Syndrome Emergency Department Orders
General Date: Today
Time: 0600

Admit to: Diagnosis Condition Allergies STEMI Good NKDA

CCU

Telemetry

Cath Lab __________ Chest Pain

SERVICE: Cardiology Other __________

Non-STEMI Fair

Unstable Angina

Guarded

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
Out of bed to chair with assistance (BID, TID) Physical therapy consultation

Bed rest with commode privileges Ambulate in hall with assistance (BID, TID) 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 ______________________________________________ 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 Strict recording of Ins and Outs with running totals of urine output to be recorded Daily AM weights; record in chart If patient is unable to void, place Foley catheter Pulse oximetry: continuous Accucheck Q _____ Q _____

IV Fluids I/O and Weight Foley Monitoring

Oxygen

O2 4 L/min nasal cannula for chest pain, shortness of breath, SaO2 < 93%

MD Signature: ___R. Bowler, MD_____________________ Pager: ___555-321-4567______________ Date/Time: __Today / 0600_________________________________________

Complex Care Day NURS 4617 1 CEC/Sim Workbook 5

Clinical Education and Simulation Lab

Chest Pain/Acute Coronary Syndrome Emergency Department Orders (Contd)
Laboratory Laboratory Draw the following labs and run STAT: CBC with differential and platelets Basic metabolic panel Cardiac Troponin I NOW PT/INR PTT Other:__________________________________________________________________ Other:__________________________________________________________________ Medication
(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 Morphine Sulfate 1 mg IVP PRN severe pain__ ____________________________________________ ____________________________________________ ____________________________________________

MD Signature: ___R. Bowler, MD_____________________ Pager: ___555-321-4567______________ Date/Time: __Today / 0600__________________________________________

Complex Care Day NURS 4617 1 CEC/Sim Workbook 6

Clinical Education and Simulation Lab

Medication Reconciliation Inpatient Admission

Allergies: _Iodine_______________________________________

Source of medication list (circle all that apply) patient medication list, patient/family recall, pharmacy, PCP list, previous discharge paperwork, MAR for facility Medication Name 1. Hydralazine 2. 3.
Signature Provider R. Bowler, MD Signature RN K.Reid, RN Print Name Bowler Print Name Reid

Dose 25 mg

Route PO

Frequency Twice daily

Last Dose Yesterday PM

Continue/DC C C C
Date Today Date Today

DC DC DC

Reviewed on Transfer by _______________________ Date_____________ Reviewed on Discharge by ______________________ Date_____________ Scan to pharmacy

Complex Care Day NURS 4617 1 CEC/Sim Workbook 7

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 8

Clinical Education and Simulation Lab Cath Lab Post Procedure Admission Orders
General Date: Today Inpatient Diagnosis Condition Allergies Time: 0830 Admit to: STEMI Good NKDA CICU Telemetry
Ht: 72 inches Wt: 90 Kg

Other __________

SERVICE: Cardiology Other __________

Non-STEMI Fair

Unstable Angina

Chest Pain

Guarded

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 Bed rest until morning Out of bed to chair with assistance (BID, TID) Physical therapy consultation Bed rest with commode privileges Ambulate in hall with assistance (BID, TID) Cardiac rehabilitation consultation

Activity

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 ______________________________________________ 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. Strict recording of Ins and Outs with running totals of urine output to be recorded Daily AM weights; record in chart If patient is unable to void, place Foley catheter Pulse oximetry: continuous Accucheck Q _____ Q _____

IV Fluids I/O and Weight

Foley Monitoring

Oxygen

O2 __4___ L/min nasal cannula for chest pain, shortness of breath, SaO2 < 93%

MD Signature: R. Bowler, MD _______ Pager: 555-321-4567 Date/Time: ______Today_/ 0830________________________

Complex Care Day NURS 4617 1 CEC/Sim Workbook 9

Clinical Education and Simulation Lab Cath Lab Post Procedure Admission Orders (contd)
Labs / Tests On Admission to Nursing Unit In A.M. EKG on arrival and 6 hours later and with CP Portable Chest X-ray on arrival Basic metabolic panel CBC with differential PT/INR PTT (see unit admission order) Portable Chest X-ray in a.m. EKG Others: Fasting Lipid Panel____________________________________________________ Others:___________________________________________________________________ Medications Aspirin 325 mg PO daily Enteric coated Aspirin 81 mg PO QAM Clopidogrel 75 mg PO daily Metoprolol Tartrate 25 mg PO daily (hold for SBP < 90 mmHg, HR < 50) Metoprolol Tartrate 50 mg PO daily (hold for SBP < 90 mmHg, HR < 50) Other: _______________________________________________ Statin Simvastatin 40 mg PO daily Other lipid lowering agent _______________ ______ mg PO _____________ (if indicated) Cardiac Heparin Protocol (see attached order) Nitroglycerin 0.4 mg SL every 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 Other: Morphine Sulfate 1 mg IVP Q 2H PRN severe chest pain Docusate Sodium (Colace ) 100 mg PO BID

Lisinopril 5 mg PO daily ____________________________________________

MD Signature: R. Bowler, MD Pager: 555-321-4567 ______ Date/Time: Today / 0830 ________________________________

Complex Care Day NURS 4617 1 CEC/Sim Workbook 10

Scenario #3 Day 2
Sim Room 2 Recommendations: It is 1 day post PCI (Hospital Day 2) at 0900. Martin Pierce is anxious and uncomfortable. Your role as a student nurse: A basic assessment. Evaluating the Heparin infusion. Evaluate lab values provided during the simulation. Provide nursing care for patient and communication to provider as needed. You can utilize the order set from Scenario #2 as needed.

Complex Care Day NURS 4617 1 CEC/Sim Workbook 11

Clinical Education and Simulation Lab

Cardiac Heparin Orders

Date / Time Cardiac Heparin Orders
Date: Yesterday Time: 1200

Orders

Nurse to make calculations based on actual body weight in Kg

Pt weight _90 Kg Make all changes as soon as possible Document all heparin adjustments and PTT results

Notify Provider if heparin infusion exceeds 2500 units/hour; for any signs of bleeding; for two consecutive aPTT levels > 120 seconds

Heparin bolus 60 units/Kg (Max 4000 units): bolus = ______________units IV

No bolus Begin continuous heparin infusion at 18 unit/Kg/hr

HEPARIN ADJUSTMENTS FOR ALL SUBSEQUENT PTTs: aPTT Value in Seconds If less than 30 If 30 - 39 If 40 - 49 If 50 - 80 If 81 - 90 If 91 - 100 If greater than 100 Dosage Change Increase infusion by 3 units/Kg/hr Increase infusion by 2 units/Kg/hr Increase infusion by 1 unit/Kg/hr Goal range: no change Decrease infusion by 1 unit/Kg/hr Decrease infusion by 2 units/Kg/hr Stop infusion for 1 hour; decrease by 3 unit/Kg/hr

STAT CBC without Diff, aPTT, PT/INR prior to start of heparin (if not done within
past 24 hours

aPTT every 6 hours x 2 after any dosage change; Once two consecutive aPTTs
(drawn 6 hours apart) are therapeutic, order aPTT every a.m.

CBC without Diff every 48 hours while on heparin

Physician signature:____ R. Bowler, MD __________________________________ Printed Physician Name:_Bowler_____________________ Pager/Phone:_555-321-4567 Complex Care Day NURS 4617 1 CEC/Sim Workbook 12

Scenario #4 Day 3, discharge

Sim Room 2 Recommendations: It is now hospital day 3 at 1600. Discharge orders have been placed on Mr. Pierces 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=coremeasure/

Complex Care Day NURS 4617 1 CEC/Sim Workbook 13

Clinical Education and Simulation Lab

Medication Reconciliation Inpatient Discharge Form

Allergies: _Iodine_______________________________________

Source of medication list (circle all that apply) patient medication list, patient/family recall, pharmacy, PCP list, previous discharge paperwork, MAR for facility Medication Name 1 ASA EC 2 Docusate 3 Simvastatin 4 Lisinopril 5 Metoprolol 6 Clopidogrel 7 Coumadin Dose 325 mg 100 mg 40 mg 5 mg 50 mg 75 mg 2.5 mg Route PO PO PO PO PO PO PO Frequency Once Daily Twice Daily Daily Daily Daily Daily Each day with evening meal As needed for Chest Pain Twice daily Last Dose Yesterday 0900 Yesterday 1800 Yesterday 0900 Yesterday 0900 Yesterday 0900 Yesterday 0900 Yesterday 1800 Yesterday 0915 3 days ago PM Continue/DC C C C C C C C DC DC DC DC DC DC DC

8 Nitroglycerin

0.4 mg

SL

DC

9 Hydralazine

25 mg

PO

C
Date Today Date

DC

Signature Provider R. Bowler, MD Signature RN

Print Name Print Name

Bowler

Reviewed on Discharge by ______________________ Date_____________ Scan to pharmacy

Complex Care Day NURS 4617 1 CEC/Sim Workbook 14

Clinical Education and Simulation Lab

Acute MI Discharge Orders
Date / Time Date: Day 3 Time: 1500 Orders

AMI Discharge Orders

Discharge to: Medications:

Home

SNF

LTAC

Rehab

Other: _______________

Aspirin _325___mg enteric coated PO daily

OR

CONTRAINDICATED Rationale: ______________________________________________ CONTRAINDICATED Rationale: _________________________________________ CONTRAINDICATED Rationale: _________________________________________

Beta Blockade Agent: Metoprolol 50 mg PO daily ___________________________

OR

Statin prescribed: Simvastatin 40 mg PO daily _____________________________

OR

Other (list separately):

____Clopidogrel 75 mg PO daily_____________________________________________ Lisinopril_5mg PO daily________________________________________________ ____Docusate 100 mg PO twice daily________________________________________ ____Coumadin 2.5 mg PO daily_____________________________________________ ____Nitroglycerin 0.4 mg SL as needed for chest pain________________________

Activity: _Follow up with primary care physician___________________________

Vaccinations Pneumococcal Vaccine INDICATED FOR ALL ACS PATIENTS (Adult) CONTRAINDICATIONS: Previous SEVERE reaction to vaccine INDICATED: Administer 0.5 mL IM x 1 dose on day of discharge NOT INDICATED: previously vaccinated, Date _______ Other reason:_____________ Patient refusal INDICATED FOR ALL ACS PATIENTS (October thru February) CONTRAINDICATIONS: Allergy to eggs; previous SEVERE reaction to vaccine; history of Guillain-Barre Syndrome INDICATED: Administer 0.5 mL IM x 1 dose on day of discharge NOT INDICATED: previously vaccinated, Date _______ Other reason:_____________ Patient refusal

Influenza Vaccine

Physician Signature: ____ R. Bowler, MD _________________ Pager: _555-321-4567____________ Date/Time: Day 3 / 1500__________________________________

Complex Care Day NURS 4617 1 CEC/Sim Workbook 15

Clinical Education and Simulation Lab

Acute MI Discharge Orders (contd)
Patient Education

Cardiac Risk Factor Modification Teaching and Documentation ACS Education and Documentation Smoking Status: current former nonsmoker unknown Smoking Cessation Counseling and Patient Education Materials Outpatient Cardiac Rehabilitation Assessment and Referral Nutrition Consultation and Counseling Physician Signature: __ R. Bowler, MD _____________________ Pager: 555-321-4567________ Date/Time: Day 3 / 1500_________________________________

Complex Care Day NURS 4617 1 CEC/Sim Workbook 16

Discharge Summary Checklist Heart Failure/Post MI with or without Left Ventricular Dysfunction
Patient Name: Pierce, Martin Discharge Date: Day 3 Designated follow-up physicians/follow-up dates: Brief medical history/discharge diagnosis: Hypertension/STEMI, Anterior-lateral w/PCI Ejection fraction at discharge: 68% Method: Echocardiogram X Cardiac catheterization MUGA scan
Were the following discharge medications prescribed? Y N Not Indicated Agent Prescribed Contraindication Y Ace inhibitor ARB (if ACE inhibitor intolerant or in addition to ACE inhibitor) Beta-Blocker (evidence based*) Aldosterone antagonist Loop diuretic Thiazide diuretic Digoxin Nitrates, prescribed dosage: Sublingual/PRN N Comments/ Reasons for Not Prescribing Initials

Topical/Oral
Hydralazine Warfarin (specify indication and target INR in comments) ASA

Clopidogrel

6 months 12 months Indefinite

3 months Lipid-lowering agents Statin: Other:

Complex Care Day NURS 4617 1 CEC/Sim Workbook 17

Were the following interventions and counseling measures addressed? Treatment and adherence education Risk-modification counseling (general) Blood pressure controlled Diabetes controlled Smoking cessation recommended Dietitian/nutritionist interview Weight reduction counseling Cardiac rehabilitation interview and enrollment Physical activity counseling Possible need for ICD and/or CRT Which follow-up services were scheduled? Cardiologist follow-up Primary care follow-up Cardiac rehabilitation Stress test follow-up Echocardiogram follow-up, EF determination (assess need for ICD or CRT) Electrophysiology referral or followup (assess need for ICD or CRT) Lipid profile follow-up Anticoagulation service follow-up Electrolyte profile/serum lab work follow-up Clinical summary and patient education record faxed to appropriate physicians

Not Applicable

Date Performed

Comments

Initials

Not Applicable Date Scheduled
111

Will need to reinforce healthy lifestyle choices as it relates to diet and exercise Will need to reinforce healthy lifestyle choices

Provided with information regarding smoking cessation

Y N

Comments

Initials

X X X

X X

Start Date: 1 week

X X X X

Adapted, with permission, by the SCA Prevention Medical Advisory Team, from the OPTIMIZE-HF registry toolkit. Sponsored by Medtronic, Inc. April 2007

Complex Care Day NURS 4617 1 CEC/Sim Workbook 18