Quality and Safety Education for Nurses
TimeSimulation eventsExpected Student Performance and QSEN CompetenciesPre simulation preparation Prior to the Simulation, the student will conduct evidence based research on Multiple Organ Dysfunction Syndrome and the Sepsis Bundle Protocol Identify one clinical question about Multiple Organ Dysfunction Syndrome, and find evidence to determine best practice for the issue you indentify. Research one article to explain the rationale for the Sepsis Bundle protocol and share your information in the online forumUse information literacy criteria to determine validity and reliability of the information researched Evidence Based Practice )4-4:15 pm 4:15 pmPhysical assessment findings unchanged from ER, except patient is more agitated. Safety issues in the environment (daughter leaves side rail down, there is water on the floor, patient’s ID band is missing)Abnormal admission labsTotal WBC 10,500 Neutrophils 86 Bands 2% Glucose 135 BUN 54 Creatinine 1.8 BUN/ Ceatinine ratio 30 GFR 30 ml/ minDaughter says “I don’t know if I can ever bring my mother home again. It is so much work, but I feel so guilty “ Daughter says “The doctor said my Mom is going for a CAT scan . My sister’s kidneys shut down when she had an X Ray with that dye.”Daughter says “How come my mother is not getting her diabetes medicine and her heart pill? She has been on these meds for yearsResult of finger stick glucose ( 220)MD gives telephone order for Sliding Scale Insulin. BG 150-200: 2 unit Regular Insulin scBG 201-250: 4 units Regular Insulin sc BG 251-300: 6 units Regular Insulin scBG 301-350: 8 units Regular Insulin scBG 351-400: 10 units Regular Insulin sc BG over 400 call MDRecheck finger stick glucose in one hour after Insulin Nurse A :Take report from the ER nurseAssess patient and document findings. Scan the environment to ensure patient safety and address problems. (Safety)Assess patient for pain and discomfort, using age appropriate methods (Patient Centered Care) Elicit daughter’s expertise in calming patient. Provide religious article for patient as suggested by daughter. Evaluate admission labs in relation to diagnoses and renal function Review Admission orders Identify a “do not use abbreviation” (Safety)Respond therapeutically to daughter about discharge planning concerns, considering cultural and family specific issues. Collaborate with case manager (Pt. Centered Care, Collaboration Call MD to question order for contrast medium (Safety, Collaboration) Explain to daughter the rationale for holding CT scan. (Patient Centered Care) Complete medication reconciliation form, noting rationale for holding Glucophage and Digoxin (Safety ) Explain to daughter reasons for holding Digoxin and Glucophage Call MD to obtain alternate order for diabetes management (Collaboration)Read back and confirm telephone order for sliding scale insulin and write in chart (Safety) Delegate blood glucose monitoring to nursing assistant to obtain blood glucose (220) (Teamwork and Collaboration) Delegate insulin administration to Nurse B (Teamwork and Collaboration) Nurse B administers 4 Units Regular Insulin 4:30-5 pmPatient says “Don’t touch me down there. Is this going to hurt?” Nursing assistant positions the catheter bag on the floorNurse APrioritize nursing interventions on admission orders. Identify incorrect IV solution hanging from ER (D5% /0.45 % NS). Change IV solution to 0.45% NS as ordered. Complete a variance form to report the error. (Safety) Observers conduct a root cause analysis of the error (Quality Improvement, Safety) Start IV 0.45 % @ 80 ml per hour (prime tubing, hang bag, program pump)Prepare to change urethral catheter Nurse BExplain catheterization procedure to patient in appropriate terms and provide privacyChange urethral catheter and connect to bag with urine meter. Maintain asepsis (Safety) Obtain urine for Culture and sensitivity Administer Levaquin IVPBStart Tube feeding (listen to bowel sounds and check for residual first)Document above actionsPosition catheter bag off floor and instruct Nursing assistant on proper catheter management (Safety) After the simulation students will conduct an in-class simulated quality improvement project to reduce nosocomial urinary tract infections (Quality Improvement) 5:00 pm Urine output only 20 ml from Foley cath in first hour MD writes order to increase IV flow rate to 125 ml per hrDaughter says “My mother is much more confused. I think there is something wrong.” Nurse ANotify MD that urine output is only 20 ml concentrated urineVerify order for increased IV fluid rate to 125 ml per hour Re program IV pump correctly Reassess vital Signs, heart and lung sounds ,skin , peripheral pulses, O2 saturation 5:05 pm 5:15 pm Physical Assessment FindingsSkin is pale, warm and dry Temp 95.7 FHeart rate 100 Resp rate 32B/P 90 / 42MAP 58 O2 saturation 90 % Urine output 20 ml after an hour of IV fluid @ 125 ml. Bowel sounds hypoactive in 2 upper quadrants, absent in lower quadrantsPatient is becoming restless and more confused. Patient states “I am really frightened. When is this airplane going to land? “Daughter says “Don’t just let my mother lay there to die. Please do something.” MD asks daughter to leave the roomMD gives a verbal orders for :IV fluid bolus 0.9 % NS 500 ml in one hour Change O2 to 80 % non-rebreather mask MD writes order for stat labs (lab staff draws specimen for CMP, CBC. Lactate level, coagulation panel, ABG’s, Blood cultures) ) Daughter asks “Why is my mother receiving so much IV fluid? Will her lungs will fill up with fluid” Resp therapist draws ABG’s and applies high flow 02 Nurse A.Recognize the signs of Systemic Inflammatory Response Syndrome (SIRS) Apply O2 @ 2 L via nasal canulaStop tube feeding Call a Rapid Response (Safety) Summarize the patient’s situation ( SBAR format) for Rapid Response Team (Collaboration) Nurse advocates for daughter to remain in room and reassures daughter. (Patient Centered Care)Repeat verbal order for increased IV fluid (Safety) Change IV fluid to 0.9 % Normal Saline 500 ml over one hourExplain rationale for increased IV to daughter Apply pressure to ABG site Ask nursing assistant to deliver ABG specimen on ice Assist Respiratory Therapist with high flow oxygen (Collaboration) 5:20 PM Physical Assessment Findings Arouses to loud noise only B/P 88/40 MAP 56 Heart rate 110 Resp rate 36 O2 Sat 87 % Lung sounds: crackles auscultated up to mid lobes Skin is cool and clammy ; Peripheral pulses weak (1+)Capillary refill 5 secondsUrine output 5 ml Patient oozing blood from IV siteRadiologic Technology does portable Chest X Ray as ordered (shows bilateral, symmetrical fluffy alveolar infiltrates) ABG Results reported pH 7.30 PCO2 30 PO2 68 HCO3 19 Critical Labs reported Potassium 6.2 Serum Lactate 5.0 INR 3.5 Platelets 50,000 WBC 16, 500 Bands 13 % Neutrophils 90BUN 58 Creatinine 3.5 Blood sugar 250 Nursing Assistant does stat EKG as orderedMD starts a second IV lineMD administers 1 D/50/W and 5 units regular insulin IVNurse A Reassess all patient parameters Recognize signs of septic shock Report critical labs, abnormal lung sounds, vital signs and low O2 Sat to MDAssist Radiogic Technologist to position the patient for portable chest XRay, with consideration of patient’s comfort.(Collaboration, team work) . Receive critical Lab report from Lab staff and report STAT (Safety) Assess EKG for peaked T waves and dysrhythmias Explains the rationale and safety precautions related to Dextrose/Insulin IV. 5:40 pm MD writes orders for Dopamine 400 mg in 250 ml 0.9 NS. Run @ 5 mcg per kg / min Regular Insulin 10 Units in 500 ml D/ 10%/W IV over one hour BIPAP IPAP @ 10 cm H2O EPAP 5 cm H2O. Decrease 0.9 NS IV to 100 ml per hourTransfer to ICU Resp Therapist changes O2 to BIPAPPatient says “ Take this thing off my face” Daughter is hysterical and crying. “Is my mother going to die? She doesn’t want a tube in her throat”Nurse A and BReduce 0.9 NS IV fluid to 100 ml /hrCalculate the hourly flow rate for Dopamine drip Nurse A: Assist Resp therapy with BIPAPExplain reason for BIPAP to patient in appropriate terms (Patient Centered Care) Prepare to send the patient to ICU Give report to ICU (Collaboration)Complete documentation(Patient Centered Care):Communicate patient’s wishes to health care team and discuss options with daughterAsk daughter to bring in Advanced DirectiveRecognize daughter’s anticipatory grieving and communicate appropriatelyExplain the plan of care to daughter, including renal replacement therapy (CVVH), respiratory management etc. ................
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