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Part 1: Simulation Case Planning Information (See instructions on last page.)Course or Event Name: (Open for viewing in Outlook)Spectrum Health Ortho SimulationScenario Title: (major event in the scenario- not for display)Compartment SyndromePatient Name (Cerner or Other)Richard Sambora (George Asparagus in Cerner train)Planning TeamNameEvent CoordinatorEvent EducatorJoel Vedders- Graduate StudentVickie Slot, Katie Emery, Becky Schra, Molly Christians, Emily SorrelJoel VeddersUnits/ Departments Involved 4 North, 2South, 3EG, 3HCost Center if ApplicableEmail contactAddressPhonejoel.vedders@Target Group(s)/Professions/NumberProfession 2/Number etc. How many/eventNew RN's (ortho) on orientation8-10 nurses (approx)8-10 (approx.) Setting/Location of Activityin-situ Simulation lab Room-Sim bay 246Scheduled Preferred DatesJuly 14-Practice run throughJuly 16- Actual eventPreferred TimesFrequency Run 1 timeEstimated Total Event/course TimeLearner orientation-Pre-briefEncounter- (ie 2, 10 minute sims)Debriefing- (ie 40 minute learner led discussion using attached evaluation tool)1 hours 30 minutes1-30 minute sim Debrief after simulation 30-45 min Estimated Total Simulation Time1 hour 15 minSim Lab/Room type set up General med surgManikin(s) task trainers/other/SPStandard PatientPersonnel Needed Number of participants/role Other Players: Standard Patient, 2 educators to run/facilitate the simulationEducator roles (hand-off report) (secretary)(physician)Learner roles (1-primary nurse, 1-for documentation, 1-Nurse Aid to take vitals at beginning of simulation, 3-4- to assist with pt transfer)Supplies/Props Needed/files (x-ray)SimPad and patient monitor software, external fixator, splint, medications, ace wrap, Meds- Dilaudid, norco, Supplies- Syringes 5- 3 mls, 3-10mLs, Needles 3-20 ga., 3-18 ga., Chlorhexadine swabs-3, Nasal cannula, Pulse ox probe, V /pump set up with NS, Blue slip sheet, Ice packs, Role cards, Phone numbers on whiteboard for recordingRoom/Patient set upStretcher and empty bed for transfer. Part 2: Program Information Educational RationaleCurrent Gap/Safety Issue/Problem/Training Need (example orientation, medication)Within the past decade a greater emphasis was placed on the care of the orthopedic trauma patient population at Spectrum Health Butterworth in Grand Rapids, Michigan. As a result of this increased commitment, an operating room (OR) dedicated solely to these patients was instituted. The ability to take a patient immediately from the emergency room to the OR ensued. Consequently, surgical emergencies such as acute compartment syndrome (ACS) are seen with less frequency on the inpatient units. Therefore, ACS has become a low frequency, high risk event. Nurses play a vital role in identifying the early signs and symptoms of ACS and taking the appropriate actions. If ACS goes unrecognized, it can have devastating consequences. This can include muscle necrosis, permanent nerve damage, and even amputation. (Fry, Wade, Smith, & Asensio-Gonzales, 2013). The purpose of this simulation is to teach nurses how to identify ACS in its early stages, effectively communicate (SBAR) their nursing assessment, take appropriate action, and anticipated the treatment of this emergent diagnosis. In an effort to collect data about staff's baseline knowledge of compartment syndrome, surveys were sent to three groups of experts. Ortho leadership, charge nurses, and educators/CNS's were asked three questions. The results of those who responded to the survey are listed below. Personal communication with orthopaedic trauma surgeons was completed, and two cases of compartment syndrome with negative patient outcomes were also reviewed. Course objectives were developed based on the data collected.1.) What topics do you feel need to be included in education about compartment syndrome?57% of the respondents requested education related to the recognition/signs and symptoms of compartment syndrome52% of the respondents requested education related to nursing actions/ nursing interventions33% of the respondents requested education related to the treatment of compartment syndrome.29% of the respondents requested education related to the urgency of compartment syndrome19% of the respondents requested education related to the causes/mechanism of injury 19% of the respondents requested education related to the identification of early vs. late sign of compartment syndrome.14% of the respondents requested education related to neuro-vascular assessment.14% of the respondents requested education related the prognosis of the patient with delayed treatment of compartment syndrome.10% of respondents requested education of the diagnosis and treatment of compartment syndrome as well as the care of the patient post-fasciotomy.Other items mentions once included follow-up care, where to find Stryker monitor, types of injuries more likely to develop compartment syndrome, how to care for the patient with chronic pain, what is compartment syndrome, difference between post-op pain and pain from compartment syndrome, not just calling for pain meds, when to call the doctor, and differential diagnosis.2.) Have you cared for a patient with compartment syndrome in the past?42% of respondents had not cared for a patient with compartment3.) Could you please list some of the signs and symptoms that may alert you to the possibility of a developing compartment syndrome? 100% of the respondents were able to identify Pallor (which includes pale skin, poor cap refill, and cool extremity) as a symptom of compartment syndrome90% of the respondents recognized Pain (out of proportion to injury, uncontrolled pain) as one of the symptoms of compartment syndrome. Of those only 16% included pain with passive stretch as an indicator of compartment syndrome.62% of the respondents recognized Pressure (swollen or tight extremity) as one of the symptoms of compartment syndrome.62% of the respondents recognized Paresthesia's (including numbness and tingling) as one of the symptoms of compartment syndrome.47% of the respondents recognized Pulselessness (including weak or absent pulse) as one of the signs of compartment syndrome.21% of the respondents recognized Paralysis (including inability to dorsiflex/plantar flex foot) as one of the symptoms of compartment syndrome.Overarching GoalPrepare new orthopedic nurses to care for a patient experiencing complications of a trauma by recognizing complications, prioritizing interventions , and effectively communicate with HC team. requiring specialized pain management, Participant Objectives: Knowledge, skills, attitudes, teamwork, organizational goals- state in behavioral terms, (QSEN, ACGME, CNE, CME competencies etc.). If you are not clear how to do this, proceed to next step. By the completion of this simulation and debriefing activity the learner will be able to:1. Describe the etiology and pathophysiology of compartment syndrome including internal and external causes. (knowledge, comprehension) (cognitive domain)2. Explain the signs, symptoms, and potential consequences of undiagnosed compartment syndrome. (comprehension, application) (cognitive domain)3. Recognize and respond appropriately to complications of orthopedic injuries. )(psychomotor domain)4. Demonstrate proper transfer & positioning of a patient with compartment syndrome. (application)(psychomotor domain)5. Demonstrate effective communication with family, patient, and healthcare team. (application)(psychomotor domain)6. Explain how compartment syndrome is diagnosed and its expected treatment. (analysis)(psychomotor domain)7. Experience the challenges of treating pain in an opiate tolerant patient. (comprehension, application)(affective domain)Case summary of events: Give a brief summary overview of the whole scenario and how it will unfold including the end point. This is for facilitators/coordinator eyes only. Orthopaedic patient with bilateral lower extremity fractures returns from CT scan at change of shift requiring transfer from stretcher to hospital bed. Patient is opioid tolerant and nursing staff is having difficulty controlling patient’s pain. As scenario progresses patient’s pain becomes increasingly worse and unable to control due to a developing compartment syndrome in the left leg. Participants need to demonstrate safe transfer of a patient with an external fixator, recognize signs and symptoms of compartment syndrome, and demonstrate effective communication with interdisciplinary team. Case ends with decision to take patient to surgery for fasciotomy. Case could also end with symptom improvement after loosening splint.Pre-requisite knowledge, skills, policy read, Didactics, SHLIO prior to class. Pre-test Basic knowledge of orthopaedic careAble to perform basic neurovascular assessmentAssessment documentationCritical Learner Actions (Write what you hope to see participants do in the simulation or the steps of correct treatment protocol). This can be made into a checklist of expected learner behaviors. Transfer patient with an external fixator from stretcher to bed using blue Patron transfer sheetEffectively interact with family membersPerform initial assessmentNeurovascular exam to lower extremities LE's head to toe assessmentassess skin, wounds, ex-fixAssess painmedication administrationPatients still complaining of pain to bilat LE's call physicianUse SBAR when communicating pain to physician1. Pain meds administeredPatient complains of increased numbness/tingling, swelling(more tight), more pain1. Recognize abnormal symptoms2. Notify physician of abnormal findings3. Reposition to level of the heart4. Loosens splint5. documents notification of physicianPatient still has unrelieved pain and getting worsePatient unable to move toesCommunicates findings to physicianPhysician arrives to floor to assess patient1. Obtains stryker kit2. Assists physician in checking compartment municates with family/patient procedure4. Prepares pt for surgeryPatient sent to surgeryList References Used for ScenarioReal pt. caseJoel VeddersFry, W. R., Wade, M. D., Smith, R. S., & Asensio-Gonzales, J. A. (2013). Extremity compartment syndrome and fasciotomy: a literature review. European Journal of Trauma Emergency Surgery, 39, 561-567. Association of Orthopaedic Nurses website. (2013). , S. M. (2012, April). Acute lower extremity compartment syndrome. Advance for NPs and PAs, 22-27.Schoenly, L. (Ed.). (2013). Core curriculum for orthopaedic nursing (7th ed.). Chicago, IL: National Association of Orthopaedic Nurses.Tzioupis, C., Cox, G., & Giannoudis, P. V. (2009). Acute compartment syndrome of the lower extremity: an update. Orthopaedics and Trauma, 23(6), 433-440.Evaluation Plan: (Develop this Early) Participant/Event1. Pre and Post Perception/Confidence Simulation Survey2. Course/Instructor evaluation Survey?Scenario Implementation Date: July 16, 2014Last Reviewed:Part 3: Facilitator Script (Preparation and Handover Report)Simulation Preparation Patient Information Scenario Handover ReportPreparation: Richard Sambora: George Asparagus (in Cerner Train) Cerner Orders: Trauma Admission: General diet, PT/OT consult for ADL's and mobilization(slide board transfers), Activity: up as tolerated, NWB to Bilat LE, q 2hr NV checks, empty foley q shift, VS q 4 hrs, Pin care with 1/2 strength NS/H2O2 to start Post op day 2. Ice and elevate Bilat LE, Encourage C&DB, IV:NS 100hr, o2 2LMeds- Dilaudid 1 mg IVP q 2hrs, Dilaudid 1mg IVP x1 now, Norco 10/325 (or 5/325, 2tabs) 1 tab PO q 4hrs PRNEnter last set of vitals: BP 138/72, RR: 18 Pulse: 78 Temp: 37.1 Pulse ox: 96%Supplies- Syringes 5- 3 mls, 3-10mLs, Needles 3-20 ga., 3-18 ga.Chlorhexadine swabs-3Nasal cannulaPulse ox probeExternal fixatorIV /pump set up with NS 100/hrBlue slip sheetIce packsRole cards, Phone numbers on whiteboard for recordingStandard patient set up: Patient begins on stretcher and is pushed into room at start of simGown on, 20 or 22 gauge IV right forearm AC, NS hanging 100 ml/hr, foley cath with clear yellow urine, nasal canula on at 2 liters. External fixator to right leg, strapped on and wrapped in ace wrap. Splint to left leg. Roles Assigned:Educators: 2 Give handoff report to nurses at start of sim, then become family memberStart in booth as secretary, Then go move SP into sim room. Do not assist with actual transfer. Go back to booth and handle all phone calls (physician, charge nurse). Play role of physician.Assign learners: 2-3 learners for phase one: 1-2 Primary nurses and One to document assessment/meds 1 learner assigned to Nurse Aide role3 learners (RN's) to assist with patient transfer (depending on weight of SP)The remaining learners will observe (hand out phase 1 observer sheets)Assign new active participant and observer roles for Phase two. Overview of roles in case. See scripting pages 17-20Richard Sambora is just returning from CT scan at change of shift. Nurses are outside the door for report. Secretary places call to nurse that the patient is wheeling past the desk and they need help getting the patient back to bed.PHASE ONE(initial phase)Nurse 1 (educator): Gives handover report Secretary in phase 1 (2nd educator): Places call to nurse notifying of patient arrival to floorNurse tech phase 1: Obtains vital signs and helps to transfer patient into bed.Nurses 1-2 (student): Primary nurses for patient, performs head to toe assessment, Helps transfer patient into bed, reposition for comfort, administers pain medsNurse 2 (student) DocumentationNurse 3 (student): Helps transfer patient into bed, reposition for comfortNurse 4 (student): Helps transfer patient into bed, reposition for comfortNurse 5 (student): Helps transfer patient into bed, reposition for comfort PHASE TWO (switch primary and documentation nurse)Patient: Right leg feels a little better, begins to complain of increased pain/tightness, numbness/tingling to left leg. Asking for more pain meds/repositioning.Family: Should he be having this much pain in his left leg, I thought is wasn't hurt too bad?Nurse: recognizes change in patient status Performs NV check Administers pain meds (norco) Calls Physician Loosens splintPhysician: Unable to come see patient, orders nurse to loosen splintPHASE THREEPatient: Writhing in pain, starts to complain of inability to move toes on left leg, more numbnessNurse: recognizes changes in patient status, effectively communicates urgency and assessment to physicianPHASE 4Physician: Arrives to patient Room, performs assessment, performs compartment pressure checks, makes pt NPO. Informs pt of impending urgent surgerySimulation endsHandover Report: Weight200 lbs.Height6'3"Allergies NKMADr. Jones Diagnosis : Right tibia fracture/left ankle fractureSituation: We are having a difficult time controlling Mr. Sambora's pain. He's having more pain now with the transfers back and forth from the stretcher in CT. The nurse from CT called to see if we could get him some additional pain medication for him.Background: Let me tell you about Mr. Sambora. He is a 35 year old restrained driver involved in a head on motor vehicle crash. He was the only one in the car. He sustained a severely comminuted right tibial plateau fracture. His left leg was pinned under the dash and they had a difficult time extricating him from the car. There is a fracture in his left ankle, but there is no plan for surgery, it is just in a splint. He sustained no other injuries in the accident. His c-spine was cleared. He was taken from the ER to the OR for surgery. His right leg was already too swollen for Dr. Jones to fix it, so he was placed in an external fixator because the fracture was so unstable. He didn't get back to the floor until midnight. He is a relatively healthy patient with no real medical history. However, he does have chronic back pain and is already on disability from that. So our problem with this gentleman has been pain control. He normally takes 80mg of oxycontin three times a day for his back pain. He received 10 mg of morphine in the PACU, but was still painful. He has 0.5-1 mg of IV dilaudid ordered every 2 hours. I started out with .5 mg at 12:30 because he had all that morphine in the PACU but ended up giving him the other .5 an hour and a half later at 0200. He still didn't get much relief from that so gave him Norco at 0430 . I gave him another 1 mg of dilaudid at 0400 and 0600. They took him for a CT of his leg at 0615 to make sure the external fixator is holding him in good alignment. CT called me and said he was on his way back soon.Assessment: I believe the nurse in CT when she says he is more painful with all of the transfers back and forth to the stretcher so I called the doctor and got a one-time order for a 1 Mg of dilaudid. Recommendation: I think I would give that extra dose when he returns to the floor. Is there anything else you need? I expect he will be back from CT soon. I have to get going. Good luck controlling his pain, he's a real peach!Last Vitals: BP 138/72, RR: 18 Pulse: 78 Temp: 37.1 Pulse ox: 96%Other assessment data: A&O x3, Skin warm and dry. There is a small amount of drainage on the kerlix gauze around the pins of the ex-fix. NV intact Bilateral LE with good pulses. NS running at 100/hr, O2 at 2L (kept this on because he was getting so many narcotics.)Other information:Learner Brief: Learner want to know what they are participating in and why.How many sims? (One simulation) who participates I will be assigning roles (one of you will be a nurse tech, one of you will be the primary nurse, one charge nurse?, the rest of you will observe. The educators will play the role of secretary and physician) how long it will last (15-30 minutes), debrief/discussion (We will be simulating an orthopaedic trauma simulation)Rules of conduct including confidentialityObjective/purpose (ortho equipment, pain mgmt, complications, communication with interdisciplinary team)This may be difficult or easy for you. Errors are common and to be expected. Focus on improving your practice whatever level it is at. Please suspend your disbelief. We have done our best w/I the limits of technology to make this realistic. Please act as if it were. Remember, this is a learning experienceLearners want to know YOUR role in the simulation.I/we will be watching the simulation and facilitating discussion afterwards.This is meant to be a learning experience. We are not here to evaluate your performance, but we will give our observations about what happened.Explain checklists or recording forms that a facilitator might be using. Learners need to know how to interact with the equipment and manikins. (In this case a standard patient)Wash handsShow where to find equipment, (meds, use Cerner, oxygen, crash cart, scan drugs, hang IV whatever you expect)Explain communication (how to call resident, phones,) Get your cues and assessment from the patient and family members if present. You may ask for whatever equipment, procedures, or services you want. (labs etc).For part of assessment not obvious, ask for assessment data (example- neuro numbness/tingling, is the foot cool can you wiggle toes, pulse? )Learners will need to know how to perform in a simulation.Get learners properly positioned (inside or outside the room) Assign appropriate simulation roles. Your role is to be primary nurse, secondary nurse, Cerner charting, family member, resident, observer whatever. Be very clear on the roles in simulation! Handout observer checklistsGive role cue cards to those playing confederates Help participants understand how to use their team members, which may be different in a simulation than real life. Ask for any questionsGive handover report to start the simulation (include time in shift)Part 4: Scenario Progression Outline (Storyboard) This section will be completed by simulation center staffScenario Overview: Patient involved in head on car crash with prolonged extrication. Left leg was pinned and patient sustained a left ankle fracture, it is splinted but does not require surgery. Patient sustains a right tibial plateau fracture. Patient is taken to the operating room for placement of external fixation to right leg. Because of patient's chronic pain it is difficult to manage his pain. Throughout scenario pain progressively gets worse in patients left leg with the development of signs and symptoms of compartment syndrome. Scenario ends with physician coming to assess patient and preparing the patient for emergent fasciotomy. Patient is not in the room at the beginning of shift change. Nurse to Nurse shift change report happens in the hallway. Baseline Arrival State: patient is stable but quite painful, restless and moaning when arrives to the room. Scenario begins when unit secretary calls to notify nurse of patient arrival to the floor. Family member is sleeping in a chair next to the bed. Unit Secretary:When given the cue: call Ascom Phone;" Your patient just rolled by the desk from Cat Scan, I will call a couple of people to help you transfer."Participant Actions: Prior to arrivalNurse to Nurse shift change report (this may take a few minutes as oncoming nurse may ask questions)Off-going nurse leavesCall from secretary takes place about patient's return to floorArrival to RoomRaise bed to appropriate height for transferAddresses sleeping family to move out of the way while transfer occurs (optional)Places slip sheet for transferMakes sure enough staff present for transfer.transfers patient with external fixator appropriatelyPositions patient appropriatelyVS are obtained by nurse tech.Begins head to toe assessmentDilaudid administeredTeaching Points: Be clear on rolesMake sure you get a good handover report from the night shift nurse. Delegate when appropriatePHASE 2Standard pt.: Awake, painful, restless.While patient on stretcher: Asking for more pain meds.When ready for transfer to bed states" Please be careful with my leg, they let it drag behind at Cat Scan and it also killed me." "I hope you guys know what you're doing!" "This contraption on my leg freaks me out"Screams when transferredTech takes vitals/Nurse performs assessmentBP 140/78 RR 18, SPO2 94% on pulse ox Temp 37.1 (Enters data in computer)Normal assessmentPulses present and equal to bilat LE, nv checks normalPatient asking for more pain meds while on the stretcherPt c/o pain 10 out of 10Pt states "you have got to get me something more for pain" Dilaudid IVP givenProceed to next state. (30 min time lapse) Increasing pain in left leg: Upon entering the room with pain meds patient is complaining of increased pain, tightness, and tingling in left leg.When nurse calls physician, he says He cannot come up right now because he is in the ER with a patient. Directs nurse to cut open/loosen splint and give pain meds (norco)Participant Actions: Administers pain meds (norco due)Performs NV examRecognize change in patient statusEffectively communicates findings to physician Repositions patient for comfortLoosens splint/communicates reason to ptTeaching pointsSituation awareness (Symptom changes)Anticipated needsEffective communicationStandard Pt: : Pt still restless in bed trying to get comfortable. Pt:"Can you see if i have anything else ordered for pain?" Even after the pain meds pt starts to complain "These pain meds aren’t working. I am having a lot more pain, N/T, and tightness in my left leg." “my pain is a little better in my right leg" "Can you try to reposition my legs, they are so uncomfortable?"Family member" Should he be having more pain in the left? I didn't think that one was hurt too badly.” If learner does not call physician, insist they call.Nurse calls doctor again. Proceed to next state.Family member prompts progression to next phase: "I can't believe it has been 30 minutes since your last pain med and it's getting worse!When nurse calls physician to report new findings, physician states "I will be right up to assess the patient" Participant Actions: Recognizes change in patient statusEffectively communicates urgency of new findings to physician Standard Pt: Patient now writhing in uncontrolled pain: Pt now complaining of difficulty moving toes on left footPatient" What is going on? Why is this happening" It's killing me! I can't move my toes now!You have got to do something for my pain!!!!Proceed to next state.Dr. arrives to patient's room. Diagnoses patient with compartment syndrome, Physician arrives to patient roomParticipant Actions: Physician arrives and assesses pt. Nurse locates Stryker monitor and supplies for physician, checks compartment pressures on patient leg.Pt made NPOEffectively communicates with patient and family member Reinforced information about compartment syndrome that was explained by physician/surgeonOperator Instruction: Physician: passively stretches big toe on left.Patient: Screams!!What's happening? What is that needle and kit for? What's compartment syndrome? Why do I need surgery?Trigger(s)End of casePart 5 Debriefing Session ScriptFacilitators names: Joel VeddersDefine the rules: How are we going to do this debriefing. How long will it last. Your roleReview what the simulation was designed to teach or assess. (shed light on current state of transfers)Objectives: By the completion of this simulation and debriefing activity the learner will be able to:1. Describe the etiology and pathophysiology of compartment syndrome including internal and external causes. (knowledge, comprehension) (cognitive domain)2. Explain the signs, symptoms, and potential consequences of undiagnosed compartment syndrome. (comprehension, application) (cognitive domain)3. Recognize and respond appropriately to complications of orthopedic injuries. )(psychomotor domain)4. Demonstrate proper transfer & positioning of a patient with compartment syndrome. (application)(psychomotor domain)5. Demonstrate effective communication with family, patient, and healthcare team. (application)(psychomotor domain)6. Explain how compartment syndrome is diagnosed and its expected treatment. (analysis)(psychomotor domain)7. Experience the challenges of treating pain in an opiate tolerant patient. (comprehension, application)(affective domain)Debriefing Questions: Taken from PEARLS method- Eppich and REACTION??“How did that feel?” How did it go? In one-2 sentences give me your first impression. DESCRIPTION??“Can someone summarize what the case was about from a medical point of view? What were the main issues you had to deal with?”ANALYSISPick one of the three methods belowLearner Self-Assessment (e.g. Plus-Delta)“What aspects of the case do you think you managed well?”“What aspects of the case would want to change?”Directive feedback and teachingI noticed you [insert performance gap here].Next time, you may want to … [closegap]…because [provide rationale]Focused Facilitation (e.g. Advocacy-Inquiry)Elicit underlying rationaleAre there any outstanding issues we haven’t discussed yet before we start to close?APPLICATION/SUMMARIZING??Learner Driven: “I like to close the debriefing by having each you state one two take-aways that will help you in the future”.Pre-Simulation Confidence SurveyKey: 1=no confidence 2=Not very confident 3= somewhat confident 4=very confident Rate your confidence in the following activities:1. Taking care of a patient with opiate tolerance? 1 2 3 42. Completing a neurovascular assessment? 1 2 3 43. Advocating for your patient when communicating with the physician? 1 2 3 44. Caring for a patient with an external fixator? 1 2 3 4 Post-Simulation Confidence SurveyKey: 1=no confidence 2=Not very confident 3= somewhat confident 4=very confident Rate your confidence in the following activities:1. Taking care of a patient with opiate tolerance? 1 2 3 42. Completing a neurovascular assessment? 1 2 3 43. Advocating for your patient when communicating with the physician? 1 2 3 44. Caring for a patient with an external fixator? 1 2 3 4 Educational Activity Evaluation ToolKey: 1=Strongly disagree 2= Disagree 3=Agree 4=Strongly agreePlease follow the above key and respond to each statement by circling a number.1. The instructor was knowledgeable about the material presented. 1 2 3 4 2. The instructor communicated clearly throughout the educational activity. 1 2 3 4 3. .The teaching strategies used were effective. 1 2 3 4 4. The educational offering increased my knowledge of acute compartment syndrome. 1 2 3 4 5. I feel more confident in my ability to recognize the signs and symptoms of compartment syndrome 1 2 3 4 6. I can apply what I learned today in my nursing practice. 1 2 3 4 7. The physical environment was conducive to learning. 1 2 3 4 What was effective about this experience today?Please list any suggestions you have so we may continue to improve these sessions:Phase 1 ScriptSecretary (Educator #2): Calls phone in patient room. “Your patient is back from CT scan, and is rolling to the room right now.” “He looks pretty painful.”Patient: Acting restless and painful on the stretcher“I need something more for pain”When ready to transfer to bed “Please be careful with my leg, they let it drag behind at Cat Scan and it almost killed me.”“I hope you know what you’re doing.” “This contraption on my leg freaks me out.”Screams when transferred “#%*&*@”Family: "Are you going to get him more pain medication?" "I can't stand seeing him like this." Expected actions during this phaseParticipant Actions: Prior to arrivalNurse to Nurse shift change report (this may take a few minutes as oncoming nurse may ask questions)Off-going nurse leavesCall from secretary takes place about patient's return to floorArrival to RoomRaise bed to appropriate height for transferAddresses sleeping family to move out of the way while transfer occurs (optional)Places slip sheet for transferMakes sure enough staff present for transfer.transfers patient with external fixator appropriatelyPositions patient appropriatelyDilaudid administeredVS are obtained by nurse tech.Begins head to toe assessmentPhase 2 ScriptPatient: "These pain meds aren’t working." "Do I have anything else due for pain?" I am having a lot more pain, N/T, and tightness in my left leg." “my pain is a little better in my right leg" "Can you try to reposition my legs, they are so uncomfortable?" If nurse does not check if more pain meds can be given, ask learner if anything else is due.If nurse does not perform NV exam ask "Is it normal that I have numbness and tingling in my toes, and it feels so tight?" If learner still doesn't perform exam, continue to complain of symptoms. If learner does not communicate change to physician say "I don't think this is right, can you call the doctor?"Physician (Educator 1): “I can’t come to see him right now. I am in the ER with another patient.” “Did you say this was on his left side?” “Are his toes warm? Can he wiggle them?” “ The ace wrap is just taped on over the splint why don’t you unwrap it to see if that gives him some relief.” “ If he is due for Norco, give him some of that too.”Patient: As the nurse unwraps splint, ask "why are you doing that?" "Isn't it broken?"Family member to nurse: “Should he be having more pain in the left? I didn't think that one was hurt too badly.”Expected actions during this phaseParticipant Actions: Administers pain meds (norco due)Performs NV examRecognize change in patient statusEffectively communicates findings to physician Repositions patient for comfortLoosens splint/communicates reason to ptFamily member: I can't believe it has been 30 minutes since your last pain medication and it is actually worse now! This prompts the progression into phase 3.Phase 3 ScriptPatient: Patient" What is going on? Why is this happening" It's killing me! I can't move my toes now! You have got to do something for my pain!!!! (pt. writhing in pain)Physician (educator #1): Do not give diagnosis. If learner does not tell you what they think is going on, ask the learner what they think is going on. If the learner reports compartment syndrome, say "I will be right up to assess the patient"If they report some other complication, ask questions to confirm.Expected actions during this phaseParticipant Actions: Recognizes change in patient statusEffectively communicates urgency of new findings to provider (SBAR)Phase 4 ScriptPhysician (After arriving in room) (educator #1) : Performs assessment (checks both limbs, assesses pain), pulls back on great toe.(pt screams) I wonder if this is maybe compartment syndrome?” Can you grab me the Stryker monitor from the cabinet?”Patient: What’s compartment syndrome?Physician (educator #1): Pretends to perform pressure check and gets elevated readings. Can you write these numbers down for me? (45, 38, 30, 42)“Can you enter a verbal order from me to make him NPO? I am going to quick call my attending he is going to need surgery. Let’s get him ready to go.”Expected actions during this phasePhysician arrives and assesses pt. (passively stretches big toe on left)Nurse locates Stryker monitor and supplies for physician, who checks compartment pressures on patient leg.Pt made NPOEffectively communicates with patient.Reinforced information about compartment syndrome that was explained by physician/surgeonObserver Checklist Phase 1TaskYesNoUnsureRaises bed to appropriate height for transferPlaces slip sheet for transferEnlisted enough staff help for transferTransfers patient with external fixator appropriatelyPositions patient appropriatelyPain medication administeredHead to toe assessment performedIf you were the nurse managing this patient, would you have done anything the same or differently related to the following: transfer, pain management, communication, assessment?Was the transfer handled safely for the patient and staff? What makes for a safe transfer?Observer Checklist Phase 2TaskYesNoUnsureAdministers pain meds (Norco due)Performs NV examRecognize change in patient statusEffectively communicates findings to physicianRepositions patient for comfortLoosens splint/communicates reason to ptIf you were the nurse managing this patient, would you have done anything the same or differently related to pain management, neurovascular exam, communication, patient management?If you were to communicate with the physician, what would you say?Observer Checklist Phase 3TaskYesNoUnsureRecognizes change in patient statusEffectively communicates urgency of new findingsWhat do you think is the patient’s primary problem? Observer Checklist Phase 4TaskYesNoUnsureNurse locates Stryker monitor and supplies for physician, checks compartment pressures on patient legPatient made NPOEffectively communicates with patient and family memberReinforced information about compartment syndrome that was explained by physician/surgeon ................
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