Date accepted:



Simulation Design Template

Date: March 11, 2013 File Name: End-of-life

Discipline: Nursing Student Level: 3rd semester ASN

Expected Simulation Run Time: 45 min Guided Reflection Time: 60 min

Location: Simulation classroom Location for Reflection: Debriefing room

|Admission Date: March 10th |Psychomotor Skills Required Prior to Simulation |

| |Physical, psychosocial, and spiritual assessment |

|Today’s Date: March 11th |Symptoms at end-of-life |

| |Communication skills |

|Brief Description of Client |Use of electronic vital sign equipment |

|Name: Sandra B. United |Oxygen administration |

| |Post mortem care and expiration checklist documentation |

|Gender: F Age: 33 Race: Caucasian |Port needle removal |

| |Foley catheter removal |

|Weight: 47.62 kg (105 lbs) | |

|Height: 152.4 cm (5 feet 5 inches) | |

| |Cognitive Activities Required prior to Simulation [i.e. independent reading (R), video |

|Religion: Catholic |review (V), computer simulations (CS), lecture (L)] |

| | |

|Major Support: Mother, father, brother, and friends. |Pre-simulation assignment: |

| |Read the End-of-Life Power Point lecture (L) |

|Phone: 555-820-5307 |Read the journal article: (R) |

| |Sherman, D. W., Matzo, M. L., Pitorak, |

|Allergies: Sulfa |E., Ferrell, B. R., & Malloy, P. (2005). |

| |Preparation and care at the time of |

|Immunizations: Current |death: Content of the ELNEC |

| |curriculum and teaching strategies. |

|Attending Physician/Team: Dr. Timothy Jones |Journal for Nurses in Staff Development, |

| |21(3), 93-100. |

|Past Medical History: Fibromyalgia, chronic anemia, |Complete the Caring Conversations for Young |

|depression, tonic-clonic seizures. |Adults (R) available via web link |

| | |

|History of Present illness: Biopsy of left shoulder nevi 8 |Read the Missouri Advance Directive (R) available via web link |

|months ago revealed a melanoma that has now metastasized to | |

|the bone and brain. The patient has received seven, monthly | |

|cycles of chemotherapy. Ineffective disease control and | |

|declining patient condition prompted the patient to request | |

|Hospice services one week ago. Yesterday, the mother came from| |

|out-of-town to visit and was alarmed by her daughter’s | |

|decrease in level of consciousness and respiratory difficulty | |

|which lead to an EMS call and hospital admission. The | |

|patient’s mother is struggling to accept the daughter’s | |

|decision to stop aggressive treatment and allow a natural | |

|death. | |

| | |

|Social History: Single with no children. Worked as a | |

|pharmaceutical representative for Lilly and has traveled | |

|extensively. Family lives out of the area. Many supportive | |

|friends. Strong spiritual support from a local church | |

|congregation. | |

| | |

|Primary Medical Diagnosis: Stage IV malignant melanoma. | |

| | |

|Surgeries/Procedures & Dates: Surgical excision of right | |

|shoulder nevi with port placement 8 months ago. | |

| | |

|Nursing Diagnoses: | |

|Acute Pain | |

|Compromised family coping | |

|Death Anxiety | |

|Decreased cardiac output | |

|Fear | |

|Grieving | |

|Hopelessness | |

|Impaired oral mucous membranes | |

|Impaired swallow | |

|Ineffective airway clearance | |

|Ineffective breathing pattern | |

|Powerlessness | |

|Spiritual Distress | |

|Social Isolation | |

|Self Care Deficit | |

Simulation Learning Objectives

1. Perform a physical assessment and analyze the findings to manage end-of-life symptoms;

2. Practice therapeutic support and compassionate end-of-life communication;

3. Assess spiritual needs and provide culturally sensitive nursing care;

4. Demonstrate a patient and family-centered approach to care;

5. Analyze the completed advanced directive and advocate to uphold the patient’s wishes;

6. Utilize nursing process to develop an individualized plan of care;

7. Evaluate personal beliefs and values that influence a nurse’s ability to provide care to the dying;

8. Perform the nurse-to-nurse death verification and death documentation utilizing a standardized expiration checklist.

9. Demonstrate post mortem care and safe handling precautions;

10. Practice interdisciplinary collaboration as death approaches and at the time of death.

Fidelity (choose all that apply to this simulation)

|Setting/Environment |Medications and Fluids |

|ER |IV Fluids:       |

|X Med-Surg |X Oral Meds: Roxanol (morphine) 20 mg (20 mg/ml) oral solution; Ativan |

|Peds |(lorazepam) 1mg (2 mg/ml) oral solution; Transderm Scop (scopolamine) 1.5mg|

|ICU |patch |

|OR / PACU |IVPB:       |

|Women’s Center |IV Push:       |

|Behavioral Health |IM or SC:       |

|Home Health | |

|Pre-Hospital |Diagnostics Available |

|X Other: Oncology Unit |Labs |

| |X-rays (Images) |

|Simulator Manikin/s Needed: Sim Man as 33 year old dying female |12-Lead EKG |

| |Other:       |

|Props: | |

|Positioned on right side propped with pillows Turban or bandana on head |Documentation Forms |

|Foley catheter in place with 50 ml dark yellow urine |X Physician Orders |

|Left chest port accessed with infusion plug and occlusive dressing |Admit Orders |

|Round band aid labeled as Scopolamine patch placed behind left ear |Flow sheet |

|Purple nail beds |X Medication Administration Record |

|Purple blotching on toes and knees |Kardex |

|Dry lips |Graphic Record |

|Personal belongings: blanket, watch, ring, necklace, clothing, slippers, and|Shift Assessment |

|photo album. |Triage Forms |

|Rosary |Code Record |

|Bible |Anesthesia / PACU Record |

|MAR |Standing (Protocol) Orders |

|Active orders |Transfer Orders |

|Advanced directives |Other:       |

|Graceful Passages Music CD and CD player | |

| |Recommended Mode for Simulation (i.e. manual, programmed, etc.) |

| |Scenario is ran manually |

| | |

|Equipment attached to manikin: | |

|IV tubing with primary line       fluids running at       mL/hr | |

|Secondary IV line       running at       mL/hr | |

|IV pump | |

|X Foley catheter 50 mL output | |

|PCA pump running | |

|IVPB with       running at       mL/hr | |

|X 02 per nasal cannula | |

|Monitor attached | |

|X ID band: Sandra B. United DOB 12/25/1980 | |

|X Other: Port accessed with infusion plug | |

| | |

|Equipment available in room | |

|Bedpan/Urinal | |

|Foley kit | |

|Straight Catheter Kit | |

|Incentive Spirometer | |

|Fluids | |

|IV start kit | |

|IV tubing | |

|IVPB Tubing | |

|IV Pump | |

|Feeding Pump | |

|Pressure Bag | |

|X 02 delivery device (type) nasal cannula | |

|Crash cart with airway devices and emergency medications | |

|Defibrillator/Pacer | |

|Suction | |

|Other:       | |

|Roles/Guidelines for Roles |Student Information Needed Prior to Scenario: |

|X Primary Nurse |Has been oriented to simulator |

|X Secondary Nurse |Understands guidelines /expectations for scenario |

|Clinical Instructor |Has accomplished all pre-simulation requirements |

|X Family Member #1: Patient’s mother is at the bedside |All participants understand their assigned roles |

|Family Member #2 |Has been given time frame expectations |

|Observer/s |Other:       |

|Recorder | |

|Physician/Advanced Practice Nurse | |

|Respiratory Therapy | |

|Anesthesia | |

|Pharmacy | |

|Lab | |

|Imaging | |

|Social Services |Report Students Will Receive Before Simulation |

|Clergy |Time: 0700 |

|Unlicensed Assistive Personnel |The patient is a 33 year old female diagnosed with malignant melanoma with |

|Code Team |brain and bone metastasis. Chemotherapy treatments have ineffectively |

|Other:       |controlled the melanoma and the patient’s condition has deteriorated. The |

| |patient stopped aggressive chemotherapy treatments last week and was |

|Important Information Related to Roles: |admitted to Hospice services. Her mother, who lives out-of-town, arrived |

|The patient is ready to let go and experience a natural death. The patient’s|yesterday to find her daughter weak, struggling to get out of bed, sleeping|

|mother is struggling with her daughter’s decisions to stop chemotherapy and |most of the time, and experiencing respiratory difficulty. Yesterday, the |

|admit to Hospice services. The mother is not ready to let her daughter go! |mother was alarmed by her daughter’s deterioration and called 911 to have |

|On admission, the mother asked the physician about further chemotherapy and |her daughter admitted to the Oncology Unit. Overnight, the patient’s |

|a second opinion. The physician advised the mother that there were no more |condition deteriorated. At 0600 this morning, the physician was notified of|

|chemotherapy options and a second opinion would not provide new treatment |persistent patient moaning and deteriorating condition. Comfort care orders|

|options. The patient’s mother has been awake all night at the daughter’s |were received. Orders for Roxanol (morphine) oral solution, Transderm Scop |

|bedside. |(scopolamine) patch, and Ativan (lorazepam) oral solution were obtained and|

| |administered at 0615. The patient is nonresponsive and responds only to |

|Significant Lab Values: WBC 1.0 mm/3, Hemoglobin 8.2 g/dL, Hematocrit 26%, |painful stimuli. |

|Platelets 52,000 mm/3 | |

|      | |

| | |

|Physician Orders: | |

|Comfort measures only | |

|Roxanol (morphine) 20 mg/ml every 4 hours prn pain | |

|Transdern Scop (scopolamine) 1.5 mg transdermal patch every 72 hours | |

|Ativan (lorazepam) 1 mg (2mg/ml) oral solution every 8 hours prn | |

|restlessness | |

|Heparin 5ml (100 unit/ml) IV prn after intermittent port infusion | |

| | |

References, Evidence-Based Practice Guidelines, Protocols, or Algorithms Used For This Scenario (site source, author, year, and page):

American Association of Colleges of Nursing. (2008). Peaceful death: Recommended competencies and curricular guidelines for end-of-life nursing care. Retrieved from

Competencies Necessary for Nurses to Provide High-Quality Care to Patients and Families During the Transition at the End of Life:

2. Promote the provision of comfort care to the dying as an active, desirable, and important skill, and an integral component of nursing care.

3. Communicate effectively and compassionately with the patient, family, and health care team members about end-of-life issues.

4. Recognize one's own attitudes, feelings, values, and expectations about death and the individual, cultural, and spiritual diversity existing in these beliefs and customs.

5. Demonstrate respect for the patient's views and wishes during end-of-life care.

6. Collaborate with interdisciplinary team members while implementing the nursing role in end-of-life care.

7. Use scientifically based standardized tools to assess symptoms (e.g., pain, dyspnea [breathlessness] constipation, anxiety, fatigue, nausea/vomiting, and altered cognition) experienced by patients at the end of life.

8. Use data from symptom assessment to plan and intervene in symptom management using state-of-the-art traditional and complementary approaches.

9. Evaluate the impact of traditional, complementary, and technological therapies on patient- centered outcomes.

10. Assess and treat multiple dimensions, including physical, psychological, social and spiritual needs, to improve quality at the end of life.

11. Assist the patient, family, colleagues, and one's self to cope with suffering, grief, loss, and bereavement in end-of-life care.

12. Apply legal and ethical principles in the analysis of complex issues in end-of-life care, recognizing the influence of personal values, professional codes, and patient preferences.

Center for Practical Bioethics. (2012). Caring conversations for young adults. Retrieved March 1, 2013, from

Matzo, M. L., Sherman, D. W., Lo, K., Egan, K. A., Grant, M., & Rhome, A. (2003). Strategies for

teaching loss, grief, and bereavement. Nurse Educator, 28(2), 71-76. doi:

10.1097/00006223200303000-00009

Matzo, M., Sherman, D. W., Sheehan, D. C., Ferrell, B. R., & Penn, B. (2003). Communication

skills for end-of-life nursing care: Teaching strategies from the ELNEC curriculum. Nursing

Education Perspectives, 24(4), 176-183. Retrieved from



Missouri Advance Directives. (2012). Planning for important healthcare decisions. Retrieved March 1, 2013, from

Sherman, D. W., Matzo, M. L., Pitorak, E., Ferrell, B. R., & Malloy, P. (2005). Preparation and care at the time of death: Content of the ELNEC curriculum and teaching strategies. Journal for Nurses in Staff Development, 21(3), 93-100.

Sherman, D. W., Matzo, M. L., Coyne, P., Ferrell, B. R., & Penn, B. K. (2004). Teaching symptom

management in end-of-life care: The didactic content and teaching strategies based on the End-of

Life Nursing Education Curriculum. Journal for Nurses in Staff Development, 20(3), 103-115. doi:

10.1097/00124645-200405000-00001

Smith-Stoner, M. (2009). Using high-fidelity simulation to educate nursing students about end-of-life care. Nursing Education Perspectives, 30(2), 115-120.

Quality and Safety Education for Nurses. (2012). Retrieved from

QSEN Competencies:

Patient-centered Care: Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs.

Knowledge:

▪ Integrate understanding of multiple dimensions of patient centered care: patient/family preferences, values; information, communication, and education; physical comfort and emotional support; involvement of family and friends.

▪ Demonstrate comprehensive understanding of the concepts of pain, suffering, including physiologic models of pain and comfort

▪ Describe the limits and boundaries of therapeutic patient-centered care.

▪ Discuss principles of effective communication

Skills:

▪ Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan and evaluation of care

▪ Provide patient-centered care with sensitivity and respect for the diversity of human experience

▪ Assess presence and extent of pain and suffering

▪ Assess levels of physical and emotional comfort

▪ Elicit expectations of patient and family for relief of pain, discomfort, or suffering

▪ Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs

▪ Recognize the boundaries of therapeutic relationships

▪ Assess own level of communication skill in encounters with patients and families

Attitude:

▪ Value seeing health care situations “through the patients’ eyes”

▪ Respect and encourage individual expression of patient values, preferences and expressed needs

▪ Willingly support patient-centered care for individuals and groups whose values differ from own

▪ Recognize personally held values and beliefs about the management of pain or suffering

▪ Appreciate the role of the nurse in relief of all types and sources of pain or suffering

▪ Appreciate shared decision-making with empowered patients and families, even when conflicts occur

▪ Value continuous improvement of own communication and conflict resolution skills

Teamwork and collaboration: Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care.

Knowledge:

▪ Describe own strengths, limitations, and values in functioning as a member of a team.

▪ Recognize contributions of other individuals and groups in helping patient/family/achieve health goals.

Skills:

▪ Demonstrate awareness of own strengths and limitations as a team member.

▪ Act with integrity, consistency and respect for differing views.

▪ Function competently within own scope of practice as a member of the health care team.

▪ Integrate the contributions of others who play a role in helping patient/family achieve health goals.

Attitude:

▪ Acknowledge own potential to contribute to effective team functioning.

▪ Appreciate importance of intra-and inter-professional collaboration.

▪ Value the perspective and expertise of all health team members.

▪ Respect the centrality of the patient/family as core members of any health care team.

Safety: Minimizes risk of harm to patients and providers through both system effectiveness and individual performance.

Knowledge:

▪ Delineate general categories of errors and hazards in care.

Skills:

▪ Demonstrate effective use of technology and standardized practices that support safety and quality.

▪ Demonstrate effective use of strategies to reduce risk of harm to self or others.

▪ Use appropriate strategies to reduce reliance on memory (such as, forcing functions, checklists).

Attitude:

▪ Value the contributions of standardization/reliability to safety.

Additional Recommended Readings:

Callahan, M., & Kelley, P. (2008). Final gifts. Understanding the special awareness, needs, and communications of the dying. New York: Bantam.

Schagger, M. & Norland, L. (2009). Being present: A nurse’s resource for end-of-life communication. Sigma Theta Tau International.

Wallace, M., Grossman, S., Campbell, S., Robert, T., Lange, J., & Shea, J. (2009). Integration of

end-of-life care content in undergraduate nursing curricula: Student knowledge and perceptions.

Journal of Professional Nursing, 25(1), 50-56. doi: 10.1016/j.profnurs.2008.08.003

Scenario Progression Outline

|Timing |Manikin Actions |Expected Interventions |May Use the Following Cues |

|(approximate) | | | |

|0730 |Assessment Findings: |Student: |Role member providing cue: |

| |Positioned on side, facing patient’s |Interact with nonresponsive adult female |Patient’s mother (live) expresses concern|

| |mother. Pillows propped behind back. |patient (manikin) and patient’s mother |regarding the patient’s condition change |

| |Responds to painful stimuli but is unable|(live). |and attempts to determine relevance: |

| |to communicate. Moans with repositioning.|Perform hand hygiene. |Cue: (Allow the students time to complete|

| |Left chest port is accessed with Huber |Introduce self. |assessment before initiating |

| |needle and infusion plug. |Consider if the patient’s care may be |conversation). |

| |Nail beds cyanotic. Extremities cool. |discussed with the mother. |“Her moaning has decreased since the |

| |Purple blotching of toes and knees. |Take vital signs. |night nurse gave her the liquid pain |

| |Temp 99.6, B/P 80/46, HR 108, R 28, Pulse|Ask patient, “How are you doing?” |medicine.” |

| |Ox 88% 1L. |Attempt to rate pain using the FLACC |“Why has she stopped talking?” |

| |Does not follow commands or track with |scale. |“She seems different today, like she’s |

| |eyes. |Perform physical assessment. |gazing off into space!” |

| |Rapid breathing, with airway congestion. |Increase oxygen to 2 L/min per NC due to |“She’s had nothing to eat or drink, do |

| |Scopolamine patch intact behind left ear.|Pulse Ox reading of 88%. |you think she’s hungry and thirsty?” |

| |Turgor is greater than 3 seconds. |Recognize symptoms of the dying process |“Why is her breathing different?” |

| |Abdomen is firm with hypoactive bowel |and communicate those findings to the |“Why does she have those purple patchy |

| |sounds. Last BM was 3 days ago. |patient’s mother. |areas on her skin?” |

| |Foley has 50 ml dark yellow urine. | | |

|0800 |Pulse Ox improved to 92 % on 2L per NC. |Reassess Pulse Ox. |Role member providing cue: Patient’s |

| | |Educate the patient’s mother regarding |mother |

| | |what to expect at the time of death. |Cue: |

| | |Inform the patient’s mother that Sandra’s|“The doctor said she might be getting |

| | |wishes were outlined in her Advanced |near the end.” |

| | |Directive and that she did not want life |“What happens if her heart stops?” “Will |

| | |prolonging measures. |you do CPR and try to save her?” |

| | |Reinforce that comfort is a priority. |“Do you think she’s going to die soon?” |

| | |Offer emotional support. |“What happens when death gets close?” |

| | |Be empathetic and compassionate. |“Do you think it hurts to die?” |

| | | |“Her priest brought the Graceful |

| | | |Passages: A companion for living and |

| | | |dying (2003) CD, do you think we should |

| | | |play it for her?” |

| | | |Cue: Play the Graceful Passages music CD |

| | | |(Tracks 10-12) |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

| | | | |

|ROTATE | | | |

|1030 |Breathing is shallow with apnea and |Assess the patient for changes. Focus on|Role member providing cue: Patient’s |

| |decreased respiratory rate. |comfort, positioning, symptom control, |mother |

| |Temp 99.8, B/P 46/30, HR 46, R 8, Pulse |and mouth care. |Cue: |

| |Ox 88% on 2L NC. |Offer emotional support. |“This is so hard to watch!” |

| | |Provide Kleenex. |“She should not be dying at such a young |

| | |Listen, be present, and provide |age!” “I should not out- live my child!” |

| | |therapeutic communication. |“She should still have her whole life |

| | |Encourage the patient’s mother to share |ahead of her!” “I just don’t know what I |

| | |any important last conversations (for |will do without her!” |

| | |example, I am sorry, I love you, it is ok|“Sandra and I had a fight last week.” “I |

| | |to let go, or, I will be alright without |tried to talk her into a second opinion.”|

| | |you). |“She said that she was too tired and too |

| | |Recognize the beliefs and values that |weak to fight this anymore.” “I got angry|

| | |influence the mother’s ability to grieve.|and told her she was giving up and that I|

| | |Encourage reminiscence of life’s |would have no part of it!” “We both |

| | |memories, happy times, and achievements. |cried, I decided it would be better to |

| | |Assess spiritual needs. Ask, is there |talk about it later, but we never did!” |

| | |anyone we could call to be with you? | |

| | |Offer to pray with patient/mother. Offer | |

| | |to contact the patient’s priest or the | |

| | |hospital chaplain. | |

| | | | |

|1048 |Patient takes last breath. |Recognize the patient has stopped |Role member providing cue: |

| | |breathing and death has occurred. |Patient’s mother |

| | |Have a second nurse assess the patient to|Cue: |

| | |verify death. |“Oh no, is she gone?” “Sandra!” |

| | |Reinforce Sandra’s wishes were not to be |“Sandra!” “Do something!” “Are you sure |

| | |kept alive by life prolonging measures. |you can’t do CPR?” |

| | |Be supportive. Utilize therapeutic |“I love you Sandra!” “I love you with all|

| | |communication. |my heart!” “I will miss so much!” |

| | |Notify the hospital chaplain. |“What should I do now?” |

| | |Document the death using the standardized|“I need to step out to make some phone |

| | |expiration checklist. |calls.” |

| | |Notify the physician, transplant |Cue: The instructor role playing the |

| | |services, and interdisciplinary team |mother then steps behind a screen in the |

| | |members that death has occurred. |room so that the students can perform |

| | | |post mortem care and complete the death |

| | | |notification process. |

|1120 |Manikin has a foley and port needle to be|Begin post mortem care. Recognize the |Role member providing cue: Patient’s |

| |removed. |patient is not a candidate for autopsy. |mother |

| | |Remove the port needle and the foley | |

| | |catheter. Recognize bathing would be |Cue: “Can I see Sandra to say goodbye?” |

| | |performed if necessary. | |

| | |Position the patient for the final family|Cue: Patient’s mother steps to the |

| | |viewing. |bedside to say the final goodbye. |

| | |Prepare the room. Gather and bag personal|Patient’s mother cries, holds her |

| | |belongings. |daughter’s hand, rest her head on her |

| | |Demonstrate effective and compassionate |daughter’s arm, and kisses her daughter |

| | |communication. |on the forehead. |

| | |Be supportive during family viewing and | |

| | |final goodbye. Remove the patient’s |Mother states, “I don’t know what I will |

| | |jewelry. Give the personal belongings to |do without you!” “I love you!” “I am |

| | |the patient’s mother. |going to miss you so much, but I know |

| | |After the patient’s mother leaves, obtain|someday I will see you again in heaven!” |

| | |the body bag and prepare the toe tag. | |

| | | |Patient’s mother leaves with her |

| | | |daughter’s personal belongings. |

Debriefing/Guided Reflection Questions for This Simulation

(Remember to identify important concepts or curricular threads that are specific to your program)

1. How did you feel throughout the simulation experience?

     

2. Describe the objectives you were able to achieve?

     

3. Which ones were you unable to achieve (if any)?

     

4. Did you have the knowledge and skills to meet objectives?

     

5. Were you satisfied with your ability to work through the simulation?

     

6. To Observer: Could the nurses have handled any aspects of the simulation differently?

     

7. If you were able to do this again, how could you have handled the situation differently?

     

8. What did the group do well?

     

9. What did the team feel was the primary nursing diagnosis?

     

10. What were the key assessments and interventions?

     

11. Is there anything else you would like to discuss?

Complexity – Simple to Complex

Suggestions for Changing the Complexity of This Scenario to Adapt to Different Levels of Learners

1. The patient could be lethargic but capable of communicating with the students.

2. The patient could have uncontrolled pain that warranted a student to collaborate with the physician or a palliative care team member in order to obtain and administer newly ordered comfort care medications.

3. The patient’s mother could arrive at the hospital to find that her daughter is dying or has died.

4. The setting could be in a home environment with hospice services instead of an acute care setting.

5. The dying patient could be pediatric patient with a young adult parent at the bedside.

6. The dying patient could be geriatric with a middle aged adult child at the bedside.

7. Additional family members could be present at the bedside with conflicting beliefs and opinions regarding aggressive treatment versus natural death.

8. An estranged family member could arrive ready to make amends and say final goodbyes.

9. Cultural diversity could be incorporate to include cultural differences regarding beliefs and values that pertain to death.

Expiration Checklist

|Cessation of vital signs |  |  |

|Cessation of vital signs verified by | | |

|Cessation of vital signs time | | |

|Pronouncement |  |  |

|Patient pronounced by | | |

|Time patient pronounced | | |

|Pastoral care notification |  |  |

|Name of Chaplain notified and time | | |

|Family notification |  |  |

|Name of persons notified and time | | |

|Contact number | | |

|Physician notification |  |  |

|Name and time of attending physician notified | | |

|Name and time of second physician notified | | |

|Autopsy |  |  |

|Organ/tissue donation |  |  |

|Time organization notified | | |

|Organization representative name | | |

|Is patient eligible to donate | | |

|Family approached regarding | | |

|Approached by | | |

|Organ donation approval | | |

|House supervisor notification |  |  |

|Name of house supervisor notified | | |

|Time house supervisor notified | | |

|Emotional support |  |  |

|Bereavement memories | | |

|Mementos | | |

|Post mortem care |  |  |

|Isolation precautions | | |

|Body identifiers | | |

|Care of body | | |

|Expiration comments | | |

|S |SITUATION (3/11/13 Shift Report) |

| |Initials/DOB/Sex: |Sandra B. United | |Female | |

| |12/25/80 | | | | |

| |Surgery: Port-a-cath placed for chemotherapy 8 months ago. | | | | |

| |History of this admission: diagnosed with metastatic melanoma 8 months ago. Enrolled in Hospice last week with DNR orders. |

| |Family called 911 yesterday due to increased drowsiness and difficulty breathing. |

|B |BACKGROUND |

| |Past History: Fibromyalgia, Chronic Anemia, Depression |Labs/Procedures/Tests: MRI-8 |Allergies: Sulfa |

| | |months ago showed extensive lymph| |

| | |node involvement | |

| | |MRI 3 months ago-Extensive bone | |

| | |and brain metastasis. | |

| | |Labs: see below | |

|A |ASSESSMENT |

| |Activity: Turn patient every 2 hours|Weight: |GU |Foley |

| | |Admission: 105 lbs | | |

| |V.S.: T 99.2, B/P 80/46, HR 108, |Today: 105 lbs; 47.62 kg | |I & O: Input 100ml |

| |R 28, Pox 88% | | | |

| | | | |Urine: 100ml |

|Neuro |GCS: 5 | | |

|  | | | |

|  | | | |

| |Purposeful movement with painful | |Skin |Color/Temp/Turgor: Pale. Cool extremities. Turgor >3. Nail beds |

| |stimulation | | |cyanotic. Purple blotching toes/knees. |

| | | | | |

|CV |Rhythm/Tones: Tachycardia | |Edema: - |

|  | | | |

|  | | | |

|  | | | |

| |Pacer/AV Wires: NA |Metabolic | |

| |Peripheral Pulses: Weak/=, cap refill 5 sec | | |

| |Attach Strip with interpretation: NA |Pain/ |Moaning in pain at 0615 and administered |

| | |Comfort | |

|Lungs |02 Sat: 88 % on 2L per min per NC | |Meds: Roxanol 20 mg/ml at 0615 |

|  | | |Scopolamine 1.5 mg transdermal patch at 0615 |

|  | | |Ativan 1mg (2 mg/ml) oral solution at 0615 |

|  | | |Comfort care only. |

|  | | | |

|  | | | |

| |Breath Sounds: Diminished throughout with airway rattle. |Drains/Incisions/Closure Device/Dressings: Right Port |

| |Trach: NA | |

| |Bubble/Osc:NA | |

| | | |

|R |RECOMMENDATION |

| |Skills/Education/Discharge?: | | |To Do or Report: |

| | | | |Dr. Jones was called at 0600 and new orders were received. New comfort medications were|

| | | | |administered at 0615. |

| | | | |Patient’s mother has been at the bedside all night. Patient’s father has driven to St.|

| | | | |Louis University to pick up the patient’s brother. |

| | | | |

| | | |

| |Patient’s Initials/Student’s Name: |

| | | | | | | |

ACTIVE PHYSICIAN ORDERS

Pt Name: Sandra B. United DOB 12/25/80 Room 7560 Allergies: Sulfa

1. Bed rest

2. Comfort care

3. DNR

4. Vital signs every 4 hours

5. I&O every shift

6. Diet as tolerated

7. Use port for IV access

8. Roxanol (morphine) 20 mg/ml every 4 hours prn pain

9. Transdern Scop (scopolamine) 1.5 mg transdermal patch every 72 hours

10. Ativan (lorazepam) 1 mg (2mg/ml) oral solution sublingual every 8 hours prn restlessness

11. Heparin 5ml (100 unit/ml) IV prn after port use

Medication Administration Record

|Date |Scheduled Medications |Dosage |Time |Route |Due |

|3/11/13 |Transdern Scop (scopolamine) |1.5 mg Transdermal |Every 72 hours |Transdermal |3/14/13 0615 |

|Date |PRN Medications |Dosage |Time |Route |Due |

|3/11/13 |Roxanol (morphine) |20 mg/ml |0615 |Sublingual |Every 4 hours prn |

|3/11/13 |Ativan (lorazepam) |1 mg (2mg/ml) |0615 |Sublingual |Every 8 hours prn |

|3/10/13 |Heparin |5ml (100 unit/ml) |1630 |Intravenous |After intermittent use or every|

| | | | | |4 weeks. |

| Simulation Evaluation for________________________ | | | | | |

| Date:_________________________ | | | | | | |

| | | | | | | |

|1 |I feel this |  |  |  |  |  |

| |exercise has helped| | | | | |

| |me to apply | | | | | |

| |knowledge rather | | | | | |

| |than just memorize | | | | | |

| |knowledge. | | | | | |

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download