Date accepted: - Grand Valley State University



Simulation Design TemplateDate: Discipline: Expected Simulation Run Time: Location: File Name: Student Level: Guided Reflection Time: Location for Reflection: Admission Date: | Today’s Date: Brief Description of ClientName: Gender: Age: Race: Weight: Height: Religion: Major Support: Support Phone: Allergies: Immunizations: Primary Care Provider/Team: Past Medical History: History of Present Illness: Social History: Primary Medical Diagnosis: Surgeries/Procedures & Dates: Nursing Diagnoses: Psychomotor Skills Required Prior to Simulation: -565153175000Cognitive Activities Required Prior to Simulation:[i.e. independent reading (R), video review (V), computer simulations (CS), lecture (L)]1968510604500Simulation Learning ObjectivesGeneral Objectives:Simulation Scenario Objectives:-195838382000References, Evidence-Based Practice Guidelines, Protocols, or Algorithms Used for This Scenario:Fidelity (choose all that apply to this simulation)Setting/Environment: FORMCHECKBOX ER FORMCHECKBOX Med-Surg FORMCHECKBOX Peds FORMCHECKBOX ICU FORMCHECKBOX OR / PACU FORMCHECKBOX Women’s Center FORMCHECKBOX Behavioral Health FORMCHECKBOX Home Health FORMCHECKBOX Pre-Hospital FORMCHECKBOX Other: Simulator Manikin/s Needed: Props: Equipment Attached to Manikin: FORMCHECKBOX IV tubing with primary linefluids running at FORMCHECKBOX mL/hr FORMCHECKBOX Secondary IV line running at mL/hr FORMCHECKBOX IV pump FORMCHECKBOX Foley catheter FORMCHECKBOX mL output FORMCHECKBOX PCA pump running FORMCHECKBOX IVPB with running at FORMCHECKBOX mL/hr FORMCHECKBOX 02 FORMCHECKBOX FORMCHECKBOX Monitor attached FORMCHECKBOX ID band FORMCHECKBOX Other: Equipment Available in Room: FORMCHECKBOX Bedpan/Urinal FORMCHECKBOX Foley kit FORMCHECKBOX Straight Catheter Kit FORMCHECKBOX Incentive Spirometer FORMCHECKBOX Fluids FORMCHECKBOX IV start kit FORMCHECKBOX IV tubing FORMCHECKBOX IVPB Tubing FORMCHECKBOX IV Pump FORMCHECKBOX Feeding Pump FORMCHECKBOX Pressure Bag FORMCHECKBOX 02 delivery device (type) FORMCHECKBOX Crash cart with airway devices and emergency medications FORMCHECKBOX Defibrillator/Pacer FORMCHECKBOX Suction FORMCHECKBOX Other: Medications and Fluids: (see chart) FORMCHECKBOX IV Fluids FORMCHECKBOX Oral Meds FORMCHECKBOX IVPB FORMCHECKBOX IV Push FORMCHECKBOX IM or SCDiagnostics Available: (see chart) FORMCHECKBOX Labs FORMCHECKBOX X-rays (Images) FORMCHECKBOX 12-Lead EKG FORMCHECKBOX Other: Documentation Forms: FORMCHECKBOX Provider Orders FORMCHECKBOX Admit Orders FORMCHECKBOX Flow sheet FORMCHECKBOX Medication Administration Record FORMCHECKBOX Graphic Record FORMCHECKBOX Shift Assessment FORMCHECKBOX Triage Forms FORMCHECKBOX Code Record FORMCHECKBOX Anesthesia / PACU Record FORMCHECKBOX Standing (Protocol) Orders FORMCHECKBOX Transfer Orders FORMCHECKBOX Other: Recommended Mode for Simulation: (i.e. manual, programmed, etc.) Student Information Needed Prior to Scenario: FORMCHECKBOX Has been oriented to simulator FORMCHECKBOX Understands guidelines /expectations for scenario FORMCHECKBOX Has accomplished all pre-simulation requirements FORMCHECKBOX All participants understand their assigned roles FORMCHECKBOX Has been given time frame expectations FORMCHECKBOX Other:Roles/Guidelines for Roles: FORMCHECKBOX Primary Nurse FORMCHECKBOX Secondary Nurse FORMCHECKBOX Clinical Instructor FORMCHECKBOX Family Member #1 FORMCHECKBOX Family Member #2 FORMCHECKBOX Observer/s FORMCHECKBOX Recorder FORMCHECKBOX Physician/Advanced Practice Nurse FORMCHECKBOX Respiratory Therapy FORMCHECKBOX Anesthesia FORMCHECKBOX Pharmacy FORMCHECKBOX Lab FORMCHECKBOX Imaging FORMCHECKBOX Social Services FORMCHECKBOX Clergy FORMCHECKBOX Unlicensed Assistive Personnel FORMCHECKBOX Code Team FORMCHECKBOX Other: Important Information Related to Roles:Report Students Will Receive Before SimulationTime: 104775635000Significant Lab Values:refer to chartProvider Orders:refer to chartHome Medications:refer to chart10477514922500 Scenario Progression OutlineTiming (approx.)Manikin/SP ActionsExpected InterventionsMay Use the Following Cues0-5 minRole member providing cue: Cue: 5-10 minRole member providing cue: Cue: 10-15 minRole member providing cue: Cue: 15-20 minRole member providing cue: Cue: Debriefing/Guided Reflection Questions for This Simulation(Remember to identify important concepts or curricular threads that are specific to your program)222255334000How did you feel throughout the simulation experience?Describe the objectives you were able to achieve.Which ones were you unable to achieve (if any)?Did you have the knowledge and skills to meet objectives?Were you satisfied with your ability to work through the simulation?To Observer: Could the nurses have handled any aspects of the simulation differently?If you were able to do this again, how could you have handled the situation differently?What did the group do well?What did the team feel was the primary nursing diagnosis?How were physical and mental health aspects interrelated in this case?What were the key assessments and interventions?Is there anything else you would like to discuss?Complexity – Simple to ComplexSuggestions for Changing the Complexity of This Scenario to Adapt to Different Levels of Learners 1063313298100 ................
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