Date accepted:



Simulation Design Template(revised March 2018)Lauren Smith End-of-Life Pediatric SimulationDate: 5/20/19Discipline: NursingExpected Simulation Run Time: 30-45 minLocation: Peds Sim 1Today’s Date:: File Name: End-of-life scenarioStudent Level: Junior/SeniorGuided Reflection Time: Twice the amount of time that the simulation runs.Location for Reflection: debriefing roomBrief Description of ClientName: Lauren SmithDate of Birth: 3/5/2016Gender: F Age: 3 years Weight: 34 lbs (15.45 kg) Height: 36” (91.44 cm)Race: white/non-HispanicReligion: EpiscopalMajor Support: Kim and David Smith Support Phone: (716) 888-8888Allergies: NKDA Immunizations: Up-to-date per AAP guidelinesAttending Provider/Team: Dr. Koothrappali/Team 3Past Medical History: RSV + bronchiolitis 1/2018History of Present Illness: Patient was found at the bottom of the swimming pool, she was underwater for an unknown amount of time. Patient was resuscitated and admitted to the PICU 3 days ago. Neurology consult revealed that Lauren is brain-dead. Family meeting has taken place, parents wish to withdraw support and be with Lauren. Parents have elected to not donate Lauren’s organs. Social History: Lives with Mom and Dad along with 6-year-old brotherPrimary Medical Diagnosis: Accidental Drowning, Acute Respiratory Distress Syndrome (ARDS), hypoxic-ischemic encephalopathySurgeries/Procedures & Dates: Endotracheal intubation 5/17/19Central Line 5/17/19MRI Brain 5/17/19 – consistent with cerebral edemaEEG Brain 5/17/19 – burst suppression notedMRI Brain 5/19/19 – consistent with cerebral edema, unable to differentiate grey/white matterEEG Brain 5/19/19 – no electrical activity noteApnea test 5/19/19 – no respiratory effort despite the rise in CO2Psychomotor Skills Required of Participants Prior to Simulation (list skills)1. Vital signs – temp, respiratory rate, apical pulse and BP (monitor)2. Pediatric physical assessment 3. Discontinuing a peripheral IV4. Therapeutic communication with patient and patient family476251206500Cognitive Activities Required of Participants Prior to Simulation(textbooks, lecture notes, articles, websites, etc.)Bennett, R. & LeBaron, V. (2019). Parental perspectives on roles in end-of-life decision making in the pediatric intensive care unit: An integrative review. Journal of Pediatric Nursing, 46, 18-25. doi:10.1016/ jpedn.2019.02.029Dryden-Palmer, K., Haut, C., Murphy, S., & Moloney-Harmon, P. (2018). Logistics of withdrawal of life-sustaining therapies in PICU. Pediatric Critical Care Medicine, 19 (8), S19-S25. doi: 10.1097/ PCC.00000000000016218572519113500Simulation Learning ObjectivesGeneral Objectives (Note: The objectives listed below are general in nature and once learners have been exposed to the content, they are expected to maintain competency in these areas. Not every simulation will include all of the objectives listed.)Practice standard precautions.Employ strategies to reduce risk of harm to the patient.Conduct assessments appropriate for care of patient in an organized and systematic manner.Perform priority nursing actions based on assessment and clinical data.Reassess/monitor patient status following nursing municate with patient and family in a manner that illustrates caring, reflects cultural awareness, and addresses psychosocial municate appropriately with other health care team members in a timely, organized, patient-specific manner.Make clinical judgments and decisions that are evidence-based.Practice within nursing scope of practice.Demonstrate knowledge of legal and ethical obligations. Simulation Scenario Objectives 1. Demonstrates professionalism in behaviors while caring for dying patient2. Utilize therapeutic communication 3. Assess spiritual and cultural needs of patient and family during dying4. Demonstrate patient and family-centered approach to care5. Evaluate personal beliefs and values that influence ability to provide care to the dyingCritical Elements1. Utilizes standard precautions2. Introduces self to patient and family3. ID patient 4. Utilizes therapeutic communication with family 5. Assess patient care needs 6. Communicates with the health care provider 7. Performs clinical skills correctly: IV discontinuation 8. Assess spiritual and cultural needs of the patient/family9. Maintains professionalism throughout the scenario20002514922500For Faculty: References, Evidence-Based Practice Guidelines, Protocols, or Algorithms Used for This Scenario:Aldridge, M. (2017). Standardized patients portraying parents in pediatric end-of-life simulation. Clinical Simulation in Nursing, 13, 338-342. doi:10.1016/j.ecns.2018.05.012Cole, M. & Foito, K. (2019). Pediatric end-of-life simulation: Preparing the future nurse to care for the needs of the child and family. Journal of Pediatric Nursing, 44, e9-e12. doi:10.1016/j.pedn.2018.09.005Dryden-Palmer, K., Garros, D., Meyer, E., Farrell, C. & Parshuram, C. (2018). Care for dying children and their families in the PICU: Promoting clinician education, support, and resilience. Pediatric Critical Care Medicine, 19(8), s79-s85. doi:10.1097/PCC.0000000000001594666751016000Setting/Environment FORMCHECKBOX Emergency Room FORMCHECKBOX Medical-Surgical UnitX Pediatric Unit FORMCHECKBOX Maternity Unit FORMCHECKBOX Behavioral Health UnitX ICU FORMCHECKBOX OR / PACU FORMCHECKBOX Rehabilitation Unit FORMCHECKBOX Home FORMCHECKBOX Outpatient Clinic FORMCHECKBOX Other: Equipment/Supplies (choose all that apply to this simulation)Simulated Patient/Manikin/s Needed: Female, child manikin. Recommended Mode for Simulator: manual(i.e. manual, programmed, etc.) Other Props & Moulage: Equipment Attached to Manikin/Simulated Patient:X ID band X IV tubing with primary line fluids running at _60_mL/hrX Secondary IV line running at _5__mL/hr FORMCHECKBOX IVPB with _______ running at mL/hrX IV pump FORMCHECKBOX PCA pump FORMCHECKBOX Foley catheter with ___mL outputX 02 via ventilatorX Monitor attached FORMCHECKBOX Other: Other Essential Equipment: VentilatorMedications and Fluids: FORMCHECKBOX Oral Meds: noneX IV Fluids: FORMCHECKBOX IVPB: none FORMCHECKBOX IM or SC: noneEquipment Available in Room: FORMCHECKBOX Bedpan/urinal FORMCHECKBOX 02 delivery device (type) FORMCHECKBOX Foley kit FORMCHECKBOX Straight catheter kit FORMCHECKBOX Incentive spirometer FORMCHECKBOX FluidsX IV start kit – supplies to discontinue IV or saline flush IV FORMCHECKBOX IV tubing FORMCHECKBOX IVPB tubing FORMCHECKBOX IV pump FORMCHECKBOX Feeding pump FORMCHECKBOX Crash cart with airway devices and emergency medications FORMCHECKBOX Defibrillator/pacerX Suction FORMCHECKBOX Other: 666751016000RolesX Nurse 1X Nurse 2 FORMCHECKBOX Nurse 3X Provider (physician/advanced practice nurse) FORMCHECKBOX Other healthcare professionals: (pharmacist, respiratory therapist, etc,) FORMCHECKBOX Observer(s) FORMCHECKBOX Recorder(s)X Family member #1X Family member #2X Clergy FORMCHECKBOX Unlicensed assistive personnel FORMCHECKBOX Other:Guidelines/Information Related to RolesLearners in role of nurse should determine which assessments and interventions each will be responsible for, or facilitator can assign nurse 1 and nurse 2 roles with related rmation on behaviors, emotional tone, and what cues are permitted should be clearly communicated for each role. A script may be created from Scenario Progression Outline.Student RN #1. Assigned to care for the patient that shift – performs nursing care including assessment of patient and therapeutic communication with family and other health care providers. Student RN #2. Assigned to care for the patient that shift – performs bedside check and therapeutic communication with family and other health care providers.Physician. This role will be played by a graduate assistant or faculty member. The physician will come in and speak to the family prior to withdrawal of support. They will also be present for extubation and discontinuation of intravenous fluids and medication. Parent #1 – Mother. This role will be played by an actor who is able to portray a mom with a dying child. Mom will be sad and at times distraught by the situation, alternating crying, and anger. Parent #2- Father. This role will be played by an actor who is able to portray a dad with a dying child. Dad will be portrayed as mainly stoic until the child is pronounced dead. Then dad is to cry. Clergy Member. This role can be played by an actor or graduate student. They will be asked to come to the bedside to provide emotional support. Their presence at the end will be determined by the family members. If the student nurses are not providing therapeutic communication, this person will stay in the room to role model the behavior for them.666751016000Pre-briefing/BriefingPrior to report, participants will need pre-briefing/briefing. During this time, faculty/facilitators should identify expectations and orient participants to the environment, scenario, roles, time allotment, and objectives.WelcomeWelcome to the simulation lab, I am Professor (insert name here). I will be guiding you today during your pediatric simulation experience. We have actors here today who will be participating in the scenario as parents and clergy. There are also two graduate students who will be playing the role of night nurse and physician along with assisting behind the scenes during the scenario. Your clinical instructor is also here with us today to observe and assist in debriefing. A tour of the simulation lab would take place at this time including where to place belongings and where the bathroom is located. ExpectationsThe scenario that you will experience today involves end-of-life care of the pediatric patient. We have tried to make this experience as real as possible but it is not a real situation. We ask that participants engage themselves so that there is a better learning experience. We recognize that people can act differently in simulation, keep in mind that the patients may not be real but the clinical situations are real. Practicing in this environment will assist in developing your nursing skills. When you are in the observation role, we ask that you be polite and respectful to your classmates providing constructive feedback only. Scenario ExpectationsDuring the scenario, you will be caring for a child who is brain dead and being withdrawn from life support. Your job is to assess and treat the patient as you would in the hospital including interacting with the family. While you are in the simulation room, we can evaluate your nursing care and provide feedback to promote safe patient care. After the simulation is complete, debriefing will occur allowing exploration of the critical thinking that was behind your actions or inactions. ConfidentialityThis simulation scenario is a formative assessment, meaning that there will not be a grade assigned. It will be used to assist in giving feedback on your clinical performance allowing for improvement in the clinical setting. As with the hospital setting, confidentiality is a must in simulation. You are not to discuss each other’s performance or the clinical cases outside of the simulation lab. Please read and acknowledge agreement with a signature on the confidentiality document for the lab. Scenario BriefingTwo students will be selected to perform the scenario in the role of bedside nurse, they will then be given the following message. The patient is a 3-year-old who has been admitted to the PICU after a drowning accident. Patient was found in at the bottom of the pool after an unknown period of time. Patient was successfully resuscitated and admitted to the PICU. Patient is on maximum medical and respiratory support and unable to maintain adequate oxygenation. Neurology has determined the patient to be brain-dead. A family meeting with health care team has taken place. The parents have decided to withdraw support as there is no chance of recovery. The scenario begins with you receiving bedside report from the night shift as you start your shift. 666751016000Report Students Will Receive Before Simulation(Use SBAR format.)Time: 0700Situation: Good Morning, I am giving report about Lauren as you will be caring for her this morning. Background: Lauren was admitted 3 days ago after a drowning accident. She was found at the bottom of the swimming pool, underwater for an unknown amount of time. Patient was resuscitated and admitted to the PICU 3 days ago. Neurology consult revealed that Lauren is brain-dead. Family meeting has taken place – they plan to withdraw Lauren from life-support this morning. Assessment: Lauren’s vitals have been consistently the same overnight. Most recent assessment at 6 am: Temp 37C, HR 120 bpm, RR 20, BP 110/65, Pulse oximetry 93-94%. She is on a ventilator – peep 8, rate 20. She has no respiratory effort of her own. She is on D5W ? NS at 60 ml/hr and epinephrine drip at 5 ml/hr (1 mcg/kg/min). Parents have been in with her all night, they are awaiting clergy. Recommendation: Check with parents to see what time clergy is coming. Provide emotional support as they will be withdrawing Lauren from support. 10477514922500Scenario Progression OutlinePatient Name:Lauren SmithDate of Birth: 3/5/16Timing (approx.)Manikin/SP ActionsExpected InterventionsMay Use the Following Cues0-3 minmanikin: T 37, HR 120, RR 20, BP 110/65, pulse ox 85%. intubated on ventilatorSP: mom and dad are at the bedside waiting for the minister to comeLearners should begin by:Performing hand hygieneIntroducing self to parents and patientConfirming patient IDRole member providing cue:parents Cue: if student does not introduce themselves, parents are to ask who they are 5-10 minmanikin: vitals remain the same and on ventilator support SP: mom and dad are at bedside observing assessment and waiting for minister to visitLearners should: Obtain vital signs: axillary temperature, apical pulse, respiratory rate, and BP using monitorPerform focused assessment: respiratory and neurologiccheck IV sites and ordersRole member providing cue: parentsCue: ask nurses about Lauren’s BPask to make sure that Lauren’s IV sites are ok and not causing any pain10-15 minmanikin: unchangedSP: mom and dad are visibly more upset as time goes on during the shift as it is approaching the designated time for withdrawal of supportLearners should:provide comfort using therapeutic communicationask parents when the minister is coming – call if it is later than expectedRole member providing cue: ParentsCue: ask the nurse if they have heard from the ministercry worse or get angry if students do not use proper communication techniques15-20 minmanikin: unchangedSP: mom and dad are with the minister – administering last rites/prayer to LaurenLearners should:be respectful of parent’s religious beliefsremain quiet in the background or participate in the last rite ceremonyobtain the physician when the ceremony completeRole member providing the cue:ministerCue: ask the nurses to remain in the room ask the nurse to be quiet and respectful if necessary20-25 minmanikin: extubated by the physician – no respiratory effort notedSP: mom and dad are at the bedside crying while watching the physician and nurse disconnect medical supportLearners should:comfort the parents during this timesaline lock IV’s, turn off IV pump and monitorsRole member providing the cue: minister or physicianCue: point out the behavior of the grieving parents 25-30 minmanikin: HR begins to slow, rate between 60-80. No respiratory effortSP: mom and dad sitting with manikin placed in their laps Learners should: assist in transfer of Lauren into parents lap to be held monitor HR – notify physician when absentprovide comfort for parents – throughout the process and especially after Lauren is pronounced deadRole member providing the cue: ministerCue: ask the nurse to see if Lauren has a heartbeat to see if she has passed666751016000666751016000Debriefing/Guided Reflection Themes for this scenario: Therapeutic communication and care for the dying pediatric patient. 1. Students will be asked to complete a plus/delta worksheet outlining the positive and negative (those which need improvement) aspects of the scenario. 2. Debriefing questions specific to this scenario:1. What do you feel went well during the simulation?2. What was your first reaction to the sign-out you received?3. What difficulty did you have in caring for a child who was being withdrawn from support?4. Which communication skills did you use when interacting with the family? 5. How did this experience differ from your thoughts about patient death in pediatrics?6. Did you find it difficult to administer an opioid to a dying patient?7. How did you feel at the end of the scenario regarding the care you provided?We do not expect you to introduce all of the questions listed below. The questions are presented only to suggest topics that may inspire the learning conversation. Learner actions and responses observed by the debriefer should be specifically addressed using a theory-based debriefing methodology (e.g., Debriefing with Good Judgment, Debriefing for Meaningful Learning, PEARLS). Remember to also identify important concepts or curricular threads that are specific to your program.How did you feel throughout the simulation experience?Give a brief summary of this patient and what happened in the simulation.What were the main problems that you identified?Discuss the knowledge guiding your thinking surrounding these main problems.What were the key assessment and interventions for this patient?Discuss how you identified these key assessments and interventions.Discuss the information resources you used to assess this patient. How did this guide your care planning? Discuss the clinical manifestations evidenced during your assessment. How would you explain these manifestations? Explain the nursing management considerations for this patient. Discuss the knowledge guiding your thinking.What information and information management tools did you use to monitor this patient’s outcomes? Explain your thinking.How did you communicate with the patient?What specific issues would you want to take into consideration to provide for this patient’s unique care needs?Discuss the safety issues you considered when implementing care for this patient. What measures did you implement to ensure safe patient care?What other members of the care team should you consider important to achieving good care outcomes?How would you assess the quality of care provided?What could you do improve the quality of care for this patient? If you were able to do this again, how would you handle the situation differently?What did you learn from this experience?How will you apply what you learned today to your clinical practice?Is there anything else you would like to discuss?666751016000 ................
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