S I M U L A T I O N PEDIATRIC ASTHMA. Patient Name: Patrick A. Armstrong

Transcription

1 SKILL FOCUS: Management f a Pediatric Patient n a Mechanical Ventilatr Due t a Severe Asthma Exacerbatin DISCIPLINE: Nursing LEVEL: 4 PEDIATRIC ASTHMA Estimated Time: 60 minutes Debriefing Time: 60 minutes Scan t Begin Patient Name: Patrick A. Armstrng SCENARIO OVERVIEW Patrick Armstrng is a 16-year-ld male patient with knwn asthma. He called 911 while experiencing an asthma exacerbatin that was wrsening when he was trying t drive t the Emergency Department. In the Emergency Department, his cnditin deterirated and he did nt respnd t medical treatment, s he was intubated and placed n mechanical ventilatin. Students are entering the situatin 30 minutes after he was intubated and placed n a ventilatr. State 1 cnsists f patient and ventilatr assessment accrding t current rders, while als respnding therapeutically t the father, wh arrives and becmes frantic due t his sn s cnditin. In State 2, the patient becmes increasingly agitated, and students shuld update the prvider and request new rders. In State 3, the ventilatr alarms begin t sund. Students shuld call Respiratry Therapy, remve the patient frm the ventilatr, and use a resuscitatin bag t ventilate the patient until Respiratry Therapy arrives. In State 4, students receive a vide handff reprt frm the Respiratry Therapist. They shuld then prvide a handff reprt t the ICU nurse. PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

2 LEARNING OBJECTIVES 1. Integrate evidence-based practice, while using the nursing prcess, t care fr a pediatric patient with asthma n a ventilatr 2. Perfrm a fcused respiratry assessment n a patient n a ventilatr 3. Safely administer respiratry system medicatins 4. Effectively utilize therapeutic cmmunicatin while caring fr a pediatric patient experiencing an acute, severe exacerbatin f asthma 5. Demnstrate effective interprfessinal cmmunicatin CURRICULUM MAPPING WTCS NURSING PROGRAM OUTCOMES Implement ne's rle as a nurse in ways that reflect integrity, respnsibility, ethical practices, and an evlving prfessinal identity as a nurse cmmitted t evidence-based practice, caring, advcacy and quality care Demnstrate apprpriate written, verbal, and nnverbal cmmunicatin in a variety f clinical cntexts Integrate scial, mathematical, and physical sciences, pharmaclgy, and pathphysilgy in clinical decisin making Prvide patient centered care by utilizing the nursing prcess acrss diverse ppulatins and health care settings Minimize risk f harm t patients, members f the healthcare team and self thrugh safe individual perfrmance and participatin in system effectiveness Lead the multidisciplinary health care team t prvide effective patient care thrughut the lifespan Use infrmatin and technlgy t cmmunicate, manage data, mitigate errr, and supprt decisin-making PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

3 NURSING FUNDAMENTALS Maintain a safe, effective care envirnment fr adults f all ages Use apprpriate cmmunicatin techniques Use the nursing prcess Prvide nursing care fr patients with alteratins in xygenatin Adapt nursing practice t meet the needs f diverse patients in a variety f settings COMPLEX HEALTH ALTERATIONS I Evaluate nursing care fr patients with chrnic alteratins in the respiratry system COMPLEX HEALTH ALTERATIONS II Evaluate nursing care fr patients with critical/life threatening situatins SIMULATION LEARNING ENVIRONMENT & SET-UP PATIENT PROFILE Name: Patrick A. Armstrng Allergies: NKDA DOB: 11/16/20xx Age: 16 MR#: 1116 Gender: Male Height: cm (5 ft 11 in) Weight: 109 kg (240 lbs) Admitting Diagnsis: Severe Asthma Attack (J45.50) Surgical Histry: Nne Cde Status: Full cde Ethnicity: African American Spiritual Practice: Unknwn Primary Language: English PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

4 EQUIPMENT/SUPPLIES/SETTINGS Patient Nte placement f multiple QR cdes fr anatmically crrect lung sunds. Mnitr Settings Pulse 72, BP 112/78, RR 12, O2 sat 100% Ventilatr Settings Vent settings are: Vlume Cntrl, rate = 12, tidal vlume = 500, FiO2 = 100 % and PEEP = 7 (Facilitatr Nte: Settings d nt match what was given in reprt purpsefully fr discussin abut the imprtance f gd inter-prfessinal cmmunicatin.) Supplies Equipment t btain vitals including xygen saturatin Ventilatr (if available; therwise use media n ipad) Resuscitatin bag and mask Phne t call Respiratry Therapy and ICU nurse Medicatins (Images f IV labels available by scanning QR cdes) Terbutaline IV Ketamine IV Fentanyl IV PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

5 QR CODES REPORT PATIENT PATIENT ID FAMILY MEMBER VENTILATOR ALARM TERBUTALINE IV KETAMINE IV VENTILATOR PICTURE RT REPORT FACILITATOR FENTANYL IV PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

6 CHEST QR CODES Cut alng the dtted lines t create a flded QR cde fr each anatmical lcatin. Fld each sectin alng the slid line t create a bi-fld f the diagram and QR cde, then apply t the simulatr in the apprpriate anatmical lcatin. ANTERIOR 2 ANTERIOR 3 ANTERIOR 6 ANTERIOR 7 POSTERIOR 0 POSTERIOR 1 POSTERIOR 4 POSTERIOR 5 PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

7 RIGHT AXILLARY 1 LEFT AXILLARY 1 PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

8 TEACHING PLAN PREBRIEF The facilitatr shuld lead this prtin f the simulatin. The fllwing steps will guide yu thrugh Prebrief. Scan the QR cde: Scan t Begin while students are in Prebrief Meet Yur Patient (n ipad) and explain hw the ipad wrks in the simulated learning envirnment including: Explain hw t use the ipad scanner and QR cdes. Remind students that there are multiple QR cdes in the simulatin, but they shuld nly scan them if they think it will prvide data necessary fr their assessment and evaluatin f the patient. Describe hw a QR Cde sund will wrk in the scenari. Shw them hw t use the ARISE stethscpe and the symbl n the QR Cde that signifies when a QR Cde is audi. Example: QR Cde: Chest As the facilitatr, yu shuld be aware that thrughut the simulatin sme QR cdes are necessary t the prgramming f the ipad cntent. Directins fr which QR cdes are required (t be scanned) in each state are listed under each state f the dcumentatin belw. The QR cdes are als in BOLD type. Medicatin Hyperlinks All medicatins are underlined and hyperlinked t DailyMed, which is a medicatin reference hused by the Natinal Library f Medicine. Students can click n these links during the simulatin fr up-t-date medicatin cntent, labels, and package insert infrmatin. Discuss the simulatin Learning Objective(s) (n ipad) as well as any ther Prebrief materials Get Reprt n ipad Pssible Facilitatr Questins What imprtant infrmatin did yu gather frm the nursing reprt that is imprtant t fllw up n? Play the Patient vide n ipad Pssible Facilitatr Questins What are yur pririties as yu enter the rm? PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

9 Review initial tabbed cntent as a grup. Encurage students t rganize and priritize a plan f care fr when they enter the rm. Review the Sedatin Prtcl and the Ventilatr Order Set tgether befre entering the rm PROTOCOL See Appendix A fr a printable versin f the RASS Sedatin Prtcl ORDERS Facilitatr Nte: The Ventilatr Order Set, which includes evidence-based rders t prevent Ventilatr Assciated Pneumnia, is als available in a printable versin in Appendix B Prvider Orders Date Time Order Tday 3 hurs ag Albuterl/Ipratrpium nebulizer; may repeat x 3 Respiratry Therapy cnsult STAT IV Methylprednislne (1 mg/kg, maximum 125 mg) STAT Mnitr Vital Signs and Alertness at least every 2 minutes Immediately ntify MD r call rapid respnse if signs f impending respiratry failure such as: altered mental status, inability t speak, intercstal retractins, wrsening fatigue James Emersn, M.D. Tday 2 hurs ag Magnesium IV 75 mg/kg, max f 2.5 g administered ver 20 minutes, STAT ABG STAT James Emersn, M.D. Tday 1 hur ag Terbutaline IV infusin at 10 mcg/kg/min ---- James Emersn, M.D. Tday 30 minutes ag Rapid Sequence Intubatin by RT Vent settings: Vlume Cntrl, rate f 12, tidal vlume f 500, FiO2 100 % and PEEP f 7. Cntinue Terbutaline IV infusin at 10 mcg/kg/min Cntinue Ketamine IV infusin 60mcg/kg/min Cardipulmnary mnitring Prtable CXR STAT PA and Lateral ABG STAT STAT Pulmnlgy Cnsult 0.9% NS at 150 ml/hur Transfer t ICU when bed available James Emersn, M.D. PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

10 Tday NOW VENTILATOR ORDER SET Nursing and Respiratry Care Elevate head f bed at 30 degrees r greater Evaluate need fr kinetic bed therapy Cuff pressure cm H2O Circuit changes: nly when visibly siled r mechanically malfunctining Humidifiers r misture exchangers: change nly when visibly siled r mechanically malfunctining Oral care: Assess ral cavity and lips every 6-8 hurs and prn fr hydratin, lesins, thrush, pressure ulcers, infectin Oral care and brush teeth fr 1-2 minutes every 6-8 hurs with 2% chlrhexidine Apply water-sluble lip balm every 6-8 hurs after ral care t maintain misture Use a dedicated suctin line fr endtracheal suctining f respiratry secretins Rtate psitin f ral endtracheal tube at least every 24 hurs r use ETT hlder that takes pressure ff muth Assess patient daily fr sedatin reductin and readiness t extubate per agency guidelines Medicatins Famtdine 20 mg IV every 12 hurs fr stress ulcer prphylaxis Enxaparin 40 mg subq every 24 hurs fr prphylaxis Ntify prvider if bleeding ccurs Discntinue if platelet levels drp by 50% frm baseline PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

11 MAR Medicatin Administratin Recrd Scheduled Methylprednislne IVP 109 mg Last Given 2.5 hurs ag Etmidate STAT per RT Succinylchline STAT per RT Famtdine 20 mg IV every 12 hurs fr stress ulcer prphylaxis Last Given 30 minutes ag Last Given 30 minutes ag Enxaparin 40 mg subq every 24 hurs fr prphylaxis Ntify prvider if bleeding ccurs Discntinue if platelet levels drp by 50% frm baseline Cntinuus Infusin Intravenus magnesium sulfate (75 mg/kg, maximum 2.5 g administered ver 20 minutes) STAT Ketamine 60mcg/kg/min Started 2 hurs ag; Ended 1.5 hurs ag Started 30 minutes ag Terbutaline IV infusin at 10 mcg/kg/min Started 60 minutes ag PRN Albuterl and Ipratrpium nebulizer up t three times, every 20 minutes Last Given Tday 3.5 hurs ag 3 hurs ag 2.5 hurs ag PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

12 VITAL SIGNS Screen is pen fr entry and nt verified against any parameters; Patient ID must be scanned befre entering vitals. Facilitatr Nte: Simulatr settings are: Pulse 72, BP 112/78, RR 12, O2 sat 100% PROGRESS NOTES Prgress Ntes Date/Time Tday/ 30 minutes ag Respiratry Therapy Tday/30 minutes ag ED Prvider Nte Admitted via ER fr acute asthma attack. Attempted cntinuus DuNeb nebulizer, IV Methylprednisne, IV Magnesium and IV Terbutaline withut imprvement. Patient develped decreased level f cnsciusness and ABGs came back with PaO2 58 and PaCO2 44. Ntified Dr. Emersn and perfrmed Rapid Sequence Intubatin using Etmidate and Succinylchline. Has a #7.5 ETT secured n the right with a Hllister, 23 at the teeth. Vent settings are Vlume Cntrl, rate f 12, tidal vlume f 500, FiO2 100 % and PEEP f 7. Still receiving IV Terbutaline infusin at 10 mcg/kg/min and Ketamine 60mcg/kg/min. Cntinues t have scattered wheezing thrugh upper lbes. --- Randy Thibideau, RRT Was infrmed by Respiratry Therapist that patient cnditin declining. Was intubated and placed n ventilatr by R/T. Cntinue IV Terbulatine and Ketamine. Awaiting bed t transfer t ICU. Ordered pulmnlgy cnsult STAT James Emersn, M.D. LABS-DIAGNOSTICS CBC with Differential On admissin Units Reference Range WBC 11.8 x10 3 ul F: /M: RBC 4.8 x10 6 ul F: /M: Hgb 12.6 g/dl F: /M: HCT 38.6 % F: /M: PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

13 MCV 78.7 fl F: /M: MCH 28 pg MCHC 34 g/dl RDW 13.1 % F: /M: Platelet 309 x10 9 ul F: /M: MPV Neutr Lymph Mn Es Bas ABG Results Tday 60 minutes ag n NRB 100% Tday Nw On Ventilatr Units Reference Range ph PaCO mmhg PaO mmhg HCO mml/l Base Excess mml/l 0+/-3 SaO 2 92% 100% PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

14 IMAGING Imaging Reprt DESCRIPTION: Prtable x-ray pst-intubatin fr asthma exacerbatin. EXAM: Prtable AP chest REASON FOR EXAM: Intubatin COMPARISON EXAM: Nne TECHNIQUE: kvp DISCUSSION: The heart and vasculature are nrmal. Trachea is midline with the endtracheal tube psitined 1 cm abve the carina. All visualized bny structures are unremarkable. Cstphrenic angles are clear with sme mild t mderate flattening f the diaphragm nted. Lung tissue is remarkable fr mild t mderate hyperinflatin. N infiltrates r atelectasis. IMPRESSION: Endtracheal tube is lcated 1 cm abve the carina. Flattened diaphragm and hyperinflatin cnsistent with bstructive lung disrder. Clinical crrelatin suggested. PATIENT EDUCATION Several asthma patient educatin handuts are displayed: Managing Yur Asthma, Asthma Actin Plan, Albuterl MDI with Spacer, Peak Flw, and Advair Diskus. See Appendix C fr printable versins f the handut. LEVEL The State is displayed SCANNER Students use this tab t scan varius QR cdes within the scenari PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

15 EXIT The ipad reads, Are yu sure yu want t exit? All data will be lst. If N is selected, the ipad will return t the tabbed cntent. If Yes is selected, the ipad will let the student(s) exit and prmpt them t cmplete an embedded 3-5 minute survey. PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

16 STATE 1 PATIENT ASSESSMENT Patient Overview Patient is sedated, intubated, and n a mechanical ventilatr. Patient is displaying slightly agitated mvements as students enter rm. A QR Cde: Family Member can be scanned at any time t play a vide f the arrival f the patient s father. Expected Student Behavirs Intrduce themselves t the patient Verify patient identity by scanning QR cde: Patient ID n armband and cmparing t the chart Perfrm a fcused respiratry physical assessment by scanning QR cdes: Chest at varius anatmical lcatins n the simulatr s anterir, medial and psterir chest. (Facilitatr Nte: Students will find wheezing in the upper and medial bilateral lbes.) Assess the ventilatr settings and cmpare t current rders (Facilitatr nte: the settings will nt match what was given in reprt t prmte discussin abut inter-prfessinal cmmunicatin.) Scan QR Cde: Family Member at facilitatr s directin t simulate the arrival f the patient s father. Cmmunicate therapeutically regarding his cncerns. Ntify the prvider f increasing agitatin using SBAR frmat Technician Prmpts Overview: Patient is sedated but ccasinally mving arm as if trying t pull at his endtracheal tube. If acting as the father: Why is Patrick n this machine? Is he in a cma? Why can t he talk t me? Is he dying? He s mving arund like he s in pain. Can yu d smething? PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

17 I culdn t leave wrk s I tld him t g t the Emergency Department. I shuld have just left and picked him up. Hw lng will he be n this machine? Pssible Facilitatr Questins What shuld the nurse assess when a patient is n a ventilatr? What is the Respiratry Therapist s rle when a patient is n a ventilatr? What d the settings mean n the ventilatr? Tidal vlume? PEEP? FiO2? What cmplicatins can ccur when a patient is n a ventilatr? Hw can these cmplicatins be prevented? Hw shuld we explain the ventilatr and ther equipment t cncerned family members? Hw shuld sedatin managed when a patient in n a ventilatr? Tabbed ipad Prmpts & Cntent Changes The scenari will prgress t State 2 when QR Cde: Facilitatr is scanned indicating satisfactry assessment has been cmpleted and prvider has been ntified f increasing agitatin PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

18 STATE 2 NEW ORDERS Overview Students implement new rders. After students scan QR Cde: Fentanyl IV, a 2 minute timer triggers a plaque that autmatically plays f a vide/audi f Ventilatr alarm fllwed by a message, Please assess fr the cause f the ventilatr alarm. Expected Student Behavirs Administer new rder and scan QR Cde: Fentanyl t indicate medicatin was administered. (Nte: QR Cde: Patient ID must be scanned befre administering medicatin.) Students shuld titrate the dse accrding t patient s level f sedatin using the RASS prtcl prvided. Cntinually evaluate patient respnse t interventins and fr signs f wrsening cnditin When ventilatr alarm sunds frm ipad, assess fr causes f alarm. When n cause is immediately, ask team member t call fr Respiratry Therapist STAT; remve patient frm ventilatr; and use resuscitatin bag t ventilate patient until Respiratry Therapist arrives. (Facilitatr Nte: if yu wuld like the ventilatr t cntinue t sund until student perfrm apprpriate interventins, scan QR Cde: Ventilatr alarm.) Technician Prmpts Overview: Patient is sedated. Vital signs shuld start deterirating nce the ventilatr alarm sunds, with O2 sats drpping int the 70s, until students use the Resuscitatin bag prperly and then O2 sats increase int the 80s. Smene may rle play father in rm wh becmes very cncerned abut patient s status What s ging n? Why isn t the ventilatr wrking? Is he dying? The facilitatr shuld direct if the father is in the way f treatment r nt. PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

19 When students call fr Respiratry Therapist: Students shuld use SBAR frmat t quickly explain the situatin; if nt, ask apprpriate questins. Pssible Facilitatr Questins What are cmmn causes f ventilatr alarms? What can be dne until Respiratry Therapy arrives? Hw shuld the Resuscitatin bag be used fr this patient? Hw shuld the family member in the rm be managed during an acute situatin? Tabbed ipad Prmpts & Cntent Changes The scenari advances t Level 3 when the QR Cde: Facilitatr is scanned. ORDERS Prvider Orders Date Time Order Tday 3 hurs ag Albuterl/Ipratrpium nebulizer; may repeat x 3 Respiratry Therapy cnsult STAT IV Methylprednislne (1 mg/kg, maximum 125 mg) STAT Mnitr Vital Signs and Alertness at least every 2 minutes Immediately ntify MD r call rapid respnse if signs f impending respiratry failure such as: altered mental status, inability t speak, intercstal retractins, wrsening fatigue James Emersn, M.D. Tday 2 hurs ag Magnesium IV 75 mg/kg, max f 2.5 g administered ver 20 minutes, STAT ABG STAT James Emersn, M.D. Tday 1 hur ag Terbutaline IV infusin at 10 mcg/kg/min Tday 60 minutes ag ---- James Emersn, M.D. Rapid Sequence Intubatin by RT PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

20 Vent settings: Vlume Cntrl, rate f 12, tidal vlume f 500, FiO2 100 % and PEEP f 7. Cntinue Terbutaline IV infusin at 10 mcg/kg/min Cntinue Ketamine IV infusin 60mcg/kg/min Cardipulmnary mnitring Prtable CXR STAT PA and Lateral ABG STAT STAT Pulmnlgy Cnsult 0.9% NS at 150 ml/hur Transfer t ICU when bed available James Emersn, M.D. VENTILATOR ORDER SET Nursing and Respiratry Care Elevate head f bed at 30 degrees r greater Evaluate need fr kinetic bed therapy Cuff pressure cm H2O Circuit changes: nly when visibly siled r mechanically malfunctining Humidifiers r misture exchangers: change nly when visibly siled r mechanically malfunctining Oral care: Assess ral cavity and lips every 6-8 hurs and prn fr hydratin, lesins, thrush, pressure ulcers, infectin Oral care and brush teeth fr 1-2 minutes every 6-8 hurs with 2% chlrhexidine Apply water-sluble lip balm every 6-8 hurs after ral care t maintain misture Use a dedicated suctin line fr endtracheal suctining f respiratry secretins Rtate psitin f ral endtracheal tube at least every 24 hurs r use ETT hlder that takes pressure ff muth Assess patient daily fr sedatin reductin and readiness t extubate per agency guidelines Medicatins Famtdine 20 mg IV every 12 hurs fr stress ulcer prphylaxis Enxaparin 40 mg subq every 24 hurs fr prphylaxis Ntify prvider if bleeding ccurs Discntinue if platelet levels drp by 50% frm baseline PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

21 Tday Nw Titrate Fentanyl 1-3 mcg/kg/hr IV infusin (max 200 mcg/hr) t maintain patient sedatin between 0 and -3 n RASS scale. Respiratry therapy will initiate Sedatin Interruptin Prtcl when patient cnditin is apprpriate Discntinue Ketamine IV infusin James Emersn, M.D. MAR Medicatin Administratin Recrd Scheduled Methylprednislne IVP 109 mg Last Given 3 hurs ag Etmidate STAT per RT 60 minutes ag Succinylchline STAT per RT 60 minutes ag Famtdine 20 mg IV every 12 hurs fr stress ulcer prphylaxis Enxaparin 40 mg subq every 24 hurs fr prphylaxis Ntify prvider if bleeding ccurs Discntinue if platelet levels drp by 50% frm baseline Cntinuus Infusin Terbutaline IV infusin at 10 mcg/kg/min Started 60 minutes ag Fentanyl 1-3 mcg/kg/hur IV infusin (max dse 200 mcg/hr) Titrate t maintain patient sedatin frm 0 t -3 n RASS scale Discntinue per RT when Sedatin Interruptin Prtcl initiated PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

22 PRN Albuterl and Ipratrpium nebulizer up t three times, every 20 minutes Last Given Tday 4 hurs ag 3.5 hurs ag 3 hurs ag Discntinued Intravenus magnesium sulfate (75 mg/kg, maximum 2.5 g administered ver 20 minutes) STAT Discntinued Tday 2 hurs ag Last Given 2 hurs ag Ketamine 60mcg/kg/min Discntinued Last Given Tday 5 minutes ag 5 minutes ag PROGRESS NOTES Date/Time Nte Tday/ 60 minutes ag Respiratry Therapy Tday/60 minutes ag ED Prvider Admitted via ER fr acute asthma attack. Attempted cntinuus DuNeb nebulizer, IV Methylprednisne, IV Magnesium and IV Terbutaline withut imprvement. Patient develped decreased level f cnsciusness and ABGs came back with PaO2 58 and PaCO2 44. Ntified Dr. Emersn and perfrmed Rapid Sequence Intubatin using Etmidate and Succinylchline. Has a #7.5 ETT secured n the right with a Hllister, 23 at the teeth. Vent settings are Vlume Cntrl, rate f 12, tidal vlume f 500, FiO2 100 % and PEEP f 7. Still receiving IV Terbutaline infusin at 10 mcg/kg/min and Ketamine 60mcg/kg/min. Cntinues t have scattered wheezing thrugh upper lbes. --- Randy Thibideau, RRT Was infrmed by Respiratry Therapist that patient cnditin declining. Was intubated and placed n ventilatr by RT. Cntinue IV Terbulatine and Ketamine. Awaiting bed t transfer t ICU. Ordered pulmnlgy cnsult STAT James Emersn, M.D. PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

23 Tday/ Nw ED Prvider Patient becming agitated at +2 as trying t remve ETT in nnpurpseful manner. Ketamine discntinued and IV Fentanyl started with gal t maintain sedatin between 0 and -3 n RASS scale. RT t initiate Sedatin Interruptin prtcl when apprpriate. Initiate transfer t ICU bed James Emersn, M.D. PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

24 STATE 3 RESPIRATORY THERAPIST GIVES REPORT Overview A timeut in the scenari shuld be implemented, and it shuld be stated t students that the respiratry therapist arrived, adjusted the ET tube and restarted the ventilatr. At the beginning f this state, students view a vide f the Respiratry Therapist giving them a reprt after these interventins have ccurred. Fllwing reprt, a message appears: ICU nurse left a message t call him. Please prvide handff reprt. Expected Student Behavirs Call ICU Nurse and prvide a handff reprt Prepare patient fr transprt t ICU Scan QR Cde: Facilitatr t indicate reprt has been given t ICU nurse and patient is ready t be transprted Technician Prmpts Overview: Patient is sedated. If rle playing the father, pssible respnses include: Hw lng will he be in ICU? When will he be awake s I can talk t him? When students call the ICU Nurse, they shuld use SBAR frmat and include all pertinent infrmatin. Ask questins if infrmatin is nt included. Pssible Facilitatr Questins What infrmatin shuld be prvided t the ICU nurse fr gd cntinuity f care? What kind f care is expected t ccur in the ICU? Tabbed ipad Prmpts & Cntent Changes PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

25 EXIT Students may exit after QR Cde: Facilitatr scanned indicating patient is ready t be transprted PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

26 DEBRIEF SUGGESTED QUESTIONS 1. Reactin: Hw d yu feel this scenari went? (Allw students t vent their emtinal reactins befre delving int learning bjectives.) 2. Review understanding f learning bjective: Integrate evidence-based practice while using the nursing prcess t care fr a pediatric patient with asthma a. Describe evidence-based practices assciated with caring fr a patient n a ventilatr. b. Describe hw the RASS scale is used t evaluate sedatin in patients n a ventilatr c. Outline evidence-based interventins t prevent Ventilatr Assciated Pneumnia. 3. Perfrm a fcused respiratry assessment n a pediatric patient with asthma a. What did yu find n yur initial fcused respiratry assessment fr bth the patient and the ventilatr? b. Was any fllw-up required based n yur assessment? 4. Review understanding f learning bjective: Participate in prcedures used t screen, diagnse, and treat pediatric patients with asthma a. Hw were ABGs used t manage this patient experiencing an acute asthma exacerbatin? b. Hw were Chest Xrays used t manage a patient wh is intubated? 5. Review understanding f learning bjective: Safely administer respiratry system medicatins a. What medicatins were used t treat Patrick s status? i. What is the mechanism f actin fr these medicatin(s)? ii. Were these medicatins effective fr Patrick? 6. Review understanding f learning bjective: Effectively utilize therapeutic cmmunicatin while caring fr a pediatric patient experiencing an acute exacerbatin f asthma a. Hw did yu cmmunicate therapeutically with Patrick s father when he arrived and fund his sn n a ventilatr? b. Hw did yu cmmunicate therapeutically during the acute event? PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

27 c. Hw shuld family members in the rm be managed during a crisis situatin? d. If yu culd d ver, wuld yu change yur therapeutic apprach? 7. Review understanding f learning bjective: Demnstrate effective interprfessinal cmmunicatin and cllabratin a. Did yu utilize any interprfessinal resurces while caring fr Patrick tday? b. Hw did yu cmmunicate yur cncerns? Did yu use SBAR? c. If yu culd d ver, wuld yu change hw yu cmmunicated and cllabrated with ther health care disciplines during the care f yur patient tday? 8. Summarize/Take Away Pints: a. In this scenari yu assessed a patient with asthma wh was intubated and ventilated due t an acute asthma exacerbatin in the ED. What is ne thing yu learned frm participating in this scenari that yu will take int yur nursing practice? (Ask each student t share smething unique frm what the ther students share.) NOTE: Debriefing technique is based n INASCL Standard fr Debriefing and NLN Thery- Based Debriefing by Dreifuerst. PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

28 APPENDIX A: RASS SCALE The Richmnd Agitatin Sedatin Scale Scre Term Descriptin +4 Cmbative Overtly cmbative r vilent; immediate danger t staff +3 Very agitated Pulls n r remves tube(s) r catheter(s) r has aggressive behavir tward staff +2 Agitated Frequent nnpurpseful mvement r patient ventilatr dyssynchrny +1 Restless Anxius r apprehensive but mvements nt aggressive r vigrus 0 Alert and calm Spntaneusly pays attentin t caregiver -1 Drwsy Nt fully alert, but has sustained (mre than 10 secnds) awakening, with eye cntact, t vice -2 Light sedatin Briefly (less than 10 secnds) awakens with eye cntact t vice -3 Mderate sedatin Any mvement (but n eye cntact) t vice -4 Deep sedatin N respnse t vice, but any mvement t physical stimulatin -5 Unarusable N respnse t vice r physical stimulatin PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

29 Instructins fr Use 1. Observe patient. Is patient alert and calm (scre 0)? Des patient have behavir that is cnsistent with restlessness r agitatin (scre +1 t +4 using the criteria abve, under descriptin?) 2. If patient is nt alert, in a lud speaking vice state patient s name and direct patient t pen eyes and lk at speaker. Repeat nce if necessary. Can prmpt patient t cntinue lking at speaker. Patient has eye pening and eye cntact, which is sustained fr mre than 10 secnds (scre -1). Patient has eye pening and eye cntact, but this is nt sustained fr 10 secnds (scre -2). Patient has any mvement in respnse t vice, excluding eye cntact (scre -3). 3. If patient des nt respnd t vice, physically stimulate patient by shaking shulder and then rubbing sternum if there is n respnse t shaking shulder. Patient has any mvement t physical stimulatin (scre -4). Patient has n respnse t vice r physical stimulatin (scre -5). Credit: Sessler, C, Gsnell, M, Grap, M, Brphy, G et al. (2002). The Richmnd Agitatin Sedatin Scale. American Jurnal f Respiratry and Critical Care Medicine, Vl. 166, N. 10 (2002), pp di: /rccm PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

30 APPENDIX B: VENTILATOR ORDER SET (VAP BUNDLE) Nursing and Respiratry Care Elevate head f bed at 30 degrees r greater Evaluate need fr kinetic bed therapy Cuff pressure cm H2O Circuit changes: nly when visibly siled r mechanically malfunctining Humidifiers r misture exchangers: change nly when visibly siled r mechanically malfunctining Oral care: Assess ral cavity and lips every 6-8 hurs and prn fr hydratin, lesins, thrush, pressure ulcers, infectin Oral care and brush teeth fr 1-2 minutes every 6-8 hurs with 2% chlrhexidine Apply water-sluble lip balm every 6-8 hurs after ral care t maintain misture Use a dedicated suctin line fr endtracheal suctining f respiratry secretins Rtate psitin f ral endtracheal tube at least every 24 hurs r use ETT hlder that takes pressure ff muth Assess patient daily fr sedatin reductin and readiness t extubate per agency guidelines Medicatins Famtdine 20 mg IV every 12 hurs fr stress ulcer prphylaxis Enxaparin 40 mg subq every 24 hurs fr prphylaxis Ntify prvider if bleeding ccurs Discntinue if platelet levels drp by 50% frm baseline Credit: Hw-t Guide: Prevent Ventilatr-Assciated Pneumnia. Cambridge, MA: Institute fr Healthcare Imprvement; (Available at PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

31 APPENDIX C: PATIENT EDUCATION HANDOUTS MANAGING YOUR ASTHMA If yu suffer frm asthma, an bstructive disease f that affects lungs, yu're nt alne. Over 26 millin peple in the U.S. are affected by asthma. With asthma, the airways in the lungs are narrwed, inflamed, r twitchy. The bstructin f the airways can make it difficult t breathe. Asthma symptms can be well managed using the fllwing guidelines: LIFESTYLE MODIFICATIONS Be aware f yur asthma symptms. Learn abut yur symptms f asthma. One f the mst cmmn symptm f asthma is wheezing. It is a musical, high-pitched, whistling sund made when airflw is blcked in the lungs. Smetimes, the nly symptm f asthma is cughing. The cugh is usually nn-prductive, chrnic, and mstly at night. Yu may als ntice shrtness f breath, difficulty breathing r chest tightness. Knw yur Asthma Actin Plan. Fllw the advice prvided by yur health care prvider. Every persn with asthma is different, and yur Asthma Actin Plan will give yu specifics fr yur particular asthma symptms and lifestyle. This can take the guess-wrk ut if yu experience an asthma attack and can be shared with thers if yu need assistance. Use yur peak flw meter. Track yur asthma using a peak flw meter. The peak flw meter measures hw fast yu can push air ut f the lungs. Decreases in peak flw meter results can signal an upcming asthma attack, s it's imprtant t mnitr yur results. PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

32 Knw when t see yur prvider. If yu ntice an increase in episdes, severity, r symptms at night yu shuld talk with yur prvider. Als, if yu're limiting yur nrmal activities, missing a lt f wrk r schl, r feel like yu're nt reaching yur persnal best n a regular basis yu shuld see yur dctr. A visit is als a gd idea if yur asthma medicatins dn t seem t wrk anymre, r yu're using quick-relief inhalers mre than twice per week. Yu shuld als see yur dctr at least nce a year fr new prescriptins fr yur medicatin. Seek emergency treatment when necessary. Asthma can becme a serius, life-threatening cnditin very quickly, s yu shuld seek immediate assistance if yu have the fllwing symptms: Severe difficulty breathing Lips, fingers, r fingernails turning blue Feeling as thugh yu are abut t pass ut Nt being able t walk r talk in full sentences. Recgnize the medicatins used t treat yur asthma. The gal f asthma treatment is t cntrl yur symptms and maintain yur lung functin ver time. Albuterl is a quickrelief medicine t help pen yur airways. It is als used during a severe asthma attack. Advair is a lng-term cntrl medicines used t reduce inflammatin f yur lungs and t decrease the frequency and severity f asthma attacks. Hwever, Advair is nt useful during an acute asthma attack. PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

33 Avid allergic triggers Identify allergens that trigger yur asthma. Allergens are substances that cause allergic reactins. Cmmn utdr allergens include pllens frm grass, trees, and weeds. Cmmn indr allergens include dust mites, cckraches, mld, and pets. While it may nt always be pssible t avid allergens, yu can talk t yur dctr abut allergy treatments r medicatins. Yu can als try t decrease the effects f allergens n asthma by: Aviding yard wrk Tracking the pllen reprt Cvering mattresses and pillws with hypallergenic cvers Using HEPA air filters Replacing carpet with wd r tile flrs Remving garbage frm the hme daily Using bait statins r traps t cntrl raches (r calling an exterminatr) Cleaning damp areas weekly t prevent mld grwth Aviding the use f vaprizers and humidifiers Aviding pets with fur r feathers Other triggers t avid Watch fr medicine r illness triggers. Clds, flu, and sinus infectins are sme upper respiratry illnesses that can irritate yur airways and cause asthma attacks. T fight these illnesses, frequently wash yur hands and get a flu sht every year. Nte: sme aspirin and anti-inflammatry medicines like ibuprfen and naprxen are respnsible fr sme asthma flare-ups. Check labels n ver-the-cunter and prescriptin medicatins t avid these substances. PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

34 Avid smke If yu smke, stp smking. Smking irritates the mucus linings f the airways which stimulates them t prduce mre mucus than nrmal. It als greatly increases yur risk f ther lung prblems and cancer. If yu have asthma, yu shuld quit smking t give yur sensitive lungs a chance t recver. Avid being arund smke in general. Secnd hand smke can als wreak havc n the linings f yur airways s try t avid being arund cigarette smke as much as pssible. Exercise Strengthen yur lungs thrugh mderate exercise. While strenuus exercise when yur lungs are weak culd lead t an asthma attack, mderate exercise can actually strengthen yur lungs. Start with light r mderate exercises, like walking, and wrk yur way int a mre challenging wrkut regimen. Exercise mst days f the week fr at least 30 minutes. Talk with yur prvider t tailr an exercise rutine that fits the limitatins f yur asthma. Cntent adapted frm: PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

35 PEAK FLOW RATE Peak flw rate (r peak expiratry flw rate) is the measurement f hw much air yu can blw ut f yur lungs in ne breath. It is useful fr yu t measure and track this because it will help yu knw when yur asthma is flaring up and/r when yu shuld seek medical attentin. STEPS FOR PERFORMING THE PEAK FLOW RATE PROCEDURE: 1. Ensure the muthpiece is clean and free f bstructins. 2. Ensure the marker is set t zer. 3. Stand up r sit upright. PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

36 4. Take as deep a breath in as yu can and hld it. 5. Place the muthpiece in yur muth and frm as tight a seal as pssible arund it with yur lips. 6. Breathe ut as hard as yu can thrugh yur muth. Plug yur nse if yu have t. 7. Observe and recrd the reading. 8. Repeat the prcess at least 2 mre times and recrd the highest reading. PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

37 9. Take yur readings every day. If pssible, yur readings shuld be taken abut the same time every day. 10. Keep a daily jurnal f yur peak flw rates as well as any ther asthma-like symptms yu experience (such as cughing r wheezing). 11. Bring yur jurnal t dctrs appintments. This will help him/her make sure yu are taking the prper asthma medicatins. 12. Find yur nrmal peak flw rate and track yur peak flw zne. Related patient educatin handuts: NORMAL PEAK FLOW RATE, ASTHMA ACTION PLAN Cntent adapted frm: and PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

38 USING AN MDI WITH A SPACER If yu have been diagnsed with a lung disease such as asthma r COPD, the use f an MDI (metered dse inhaler), like Albuterl r Flvent, may be indicated. These instructins will ensure yu are using the MDI and Spacer crrectly. STEPS FOR USING AN MDI WITH A SPACER: 1. Take ff the MDI cap. The cap is a small cvering lcated ver the muthpiece t prevent freign bjects frm getting in the MDI. Ensure the muthpiece and spray hle are clean. 2. Shake the MDI. Hld the inhaler in a vertical psitin with ne hand and shake it 10 t 15 times. 3. Prime the MDI. If this is the first time yu ve used the MDI r if yu have nt used it in mre than a week, yu need t prime it. This ensures the inhaler delivers the crrect amunt f medicine when used. Yu prime the MDI by squeezing the canister dwn int the plastic muthpiece, emitting a single spray. IMPORTANT: After yu prime the MDI, yu need t repeat Step 2 Shake the MDI. PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

39 4. Cnnect the MDI and the spacer. Cnnect the MDI muthpiece t the back end f the spacer. Depending n the spacer and muthpiece yu have, they may click tgether neatly, r the muth piece might simply slide in thrugh a narrw rubber slit. 5. Breathe ut as much as yu can. Ideally, yu want t empty yur lungs as much as pssible. 6. Place the spacer s muthpiece in yur muth. It shuld sit just abve yur tngue. Keep yur lips clsed arund it. Lift yur chin up slightly. Hld the inhaler between yur pinter finger and thumb. 7. Squeeze the inhaler nce then breathe in the medicatin slwly and deeply. Pull air int yur lungs thrugh yur muth until yu reach yur peak capacity. Sme spacers have a whistle n them. Listen fr the whistle. If yu hear it, yu are breathing in t rapidly. If yu dn t hear it, yu are breathing in at an acceptable rate. PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

40 8. Remve the spacer muthpiece frm yur muth. Hld yur breath fr abut 10 secnds. Then, exhale slwly and deeply thrugh yur muth. 9. Shake the MDI. If yu are prescribed a secnd puff f the MDI, yu must shake the MDI again (like in Step 2) befre repeating Steps 4-8. Cntent adapted frm: PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

41 NORMAL PEAK FLOW RATE T create yur asthma actin plan, yu need t find yur nrmal peak flw rate. This is dne by recrding yur peak flw rate fr tw weeks at abut the same time f day when yur asthma is under cntrl. Then, yu and yur dctr will determine what a nrmal peak flw rate is fr yu. Once yu knw yur nrmal peak flw rate, fllw the zne system n yur Asthma Actin Plan. This system helps yu and yur dctr decide hw t treat yur asthma. The zne system can be cmpared t the clrs f a traffic light. Green Zne 80% t 100% f yur nrmal peak flw rate signals g. Yur asthma is under gd cntrl. Cntinue t fllw the green zne f yur asthma actin plan. Yellw Zne 50% t 80% percent f yur nrmal peak flw rate signals cautin. Yur symptms culd get better r wrse. Fllw the yellw zne f yur asthma actin plan. Red Zne Less than 50% f yur nrmal peak flw rate signals stp. This a Medical Alert! Cntact yur healthcare prvider nw and fllw the red zne f yur asthma actin plan. Related patient educatin handuts: PEAK FLOW METER, ASTHMA ACTION PLAN Cntent adapted frm: and PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

42 HOW TO USE ADVAIR DISKUS Advair is a prescriptin drug cntaining fluticasne and salmeterl that helps asthma sufferers prevent asthma attacks. Advair cmes in an easy-t-perate disc-shaped inhaler called the "Diskus." Knwing hw (and when) t use yur Advair inhaler prperly is vital t preventing asthma symptms. STEPS FOR USING THE ADVAIR DISKUS: 1. Expse the muthpiece. Hld the Discus hrizntal in ne hand. With yur ther hand, put yur thumb n the the small curved sectin. Slide it away frm yu. The inner part f the Diskus shuld turn and click int place. The muthpiece is nw expsed. Turn the muthpiece twards yu. 2. Push the lever t prepare the dse. Hld the inhaler flat and level with the muthpiece facing yu. Use yur finger t slide the lever until yu feel it click int place. The dse is nw ready. 3. Breathe ut as much as yu can. Ideally, yu want t empty yur lungs cmpletely. 4. Inhale. Bring the Advair inhaler t yur muth. Place yur lips n the PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

43 muthpiece. Breathe in deeply. Take yur entire breath thrugh yur muth in rder t inhale the cmplete dse. Dn't breathe thrugh yur nse. Keep the inhaler flat and level as yu breathe. This ensures the medicine is dispensed prperly. 5. Hld it in. Hld yur breath fr at least 10 secnds (r as lng as yu can) after inhaling. The medicine needs a shrt amunt f time t be fully absrbed. After 10 secnds (r as lng as yu're able t hld yur breath), breathe ut slwly, smthly and evenly. Yu can start breathing nrmally. 6. Rinse yur muth. Rinse yur muth ut with clean water. D this each time yu take a dse f Advair. Finish by gargling befre yur spit the water ut. D nt swallw the water yu use t rinse. This is t prevent a fungal infectin f the thrat called Thrush. Advair can cause an imbalance f the rganisms in yur muth which allws this fungus t take hld. 7. Clse and stre the inhaler. Slide the Diskus clsed again. The dse dial will autmatically mve frward ne number. Put the inhaler smeplace safe and clean fr easy access in the future. Stre Advair in a cl, dry place where it isn't within the reach f children. An Advair inhaler can be used fr ne mnth after it is first remved frm the fil. PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

44 8. Using Advair Respnsibly When in dubt, always fllw yur health care prvider's directins. The specifics fr when t take Advair vary frm patient t patient. Advair is a prescriptin drug, s yu'll need t meet with a prvider befre yu can use it. 9. Use Advair as prescribed t prevent attacks. Advair is typically used nce in the mrning and nce in the evening. Try t take yur Advair dses at rughly the same time each day. 10. Take ne dse at a time. Yu may nt be able t taste r smell the medicine when yu inhale it, but it's still there. D nt duble an Advair dse even if yu feel yur symptms wrsen. The medicine takes time t wrk. Yur prvider will be able t recmmend alternative treatments fr sudden, severe symptms 11. Take the medicine until yu are directed t stp. Just like yu shuldn't take the medicine mre ften than it's prescribed, yu als wn't want t take it less ften. If yu stp t early, yur symptms can wrsen. PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

45 12. Dn't use Advair t treat asthma attacks. The medicine in Advair is nt meant t stp sudden, acute asthma attacks. Instead, carry a prescribed "rescue inhaler" such as Albuterl fr use during an acute attack. Cntent adapted frm: PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

46 CREDITS Asthma actin plan frm Natinal Heart, Lung and Bld Institute at Ventilatr Assciated Pneumnia. Cambridge, Massachusetts: Institute fr Healthcare Imprvement; [2017] at Medicatin infrmatin frm Natinal Library f Medicine: Daily Med at Nrmal lung sund frm Thinklabs Medical, LLC, Centennial, CO at Patient educatin files adapted frm OSCE Skills and wikihw at and Pictures frm Shutterstck.cm Richmnd Agitatin Sedatin Scale (2002) frm Sessler, C, Gsnell, M, Grap, M, Brphy, G et al. (2002). The Richmnd Agitatin Sedatin Scale. American Jurnal f Respiratry and Critical Care Medicine, Vl. 166, N. 10 (2002), pp di: /rccm Wheeze lung sund frm Wikipedia at REFERENCES Sessler, C, Gsnell, M, Grap, M, Brphy, G et al. (2002). The Richmnd Agitatin Sedatin Scale. American Jurnal f Respiratry and Critical Care Medicine, Vl. 166, N. 10 (2002), pp di: /rccm PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

47 Fuchs, B, Bellamy, C, and Finlay, G (2016) Sedative-analgesic medicatins in critically ill adults: Selectin, initiatin, maintenance and withdrawal. In: UptDate, Pst TW (Ed), UptDate, Waltham, MA. (Accessed n February 21, 2017) Glbal Initiative fr Asthma (2016). Pcket Guide fr Asthma Management and Preventin. Dwnladed frm: Hw-t Guide: Prevent Ventilatr-Assciated Pneumnia. Cambridge, MA: Institute fr Healthcare Imprvement; (Available at Institute fr Healthcare Imprvement (2017). Ventilatr Assciated Pneumnia. Dwnladed frm: Jacbi, J., Fraswer, GL, Cursin DB et al. (2002). Emergency department sedatin f ventilated adults. In: Mechanical Ventilatin f Adults in the Emergency Department, UptDate, Pst TW (Ed), UptDate, Waltham, MA. (Accessed n February 21, 2017) Jint Cmmissin (2016). Children s Asthma Care. Dwnladed frm Kersn, A. G., DeMaria, R., Mauer, E., Jyce, C., Gerber, L. M., Greenwald, B. M., &... Traube, C. (2016). Validity f the Richmnd Agitatin-Sedatin Scale (RASS) in critically ill children. Jurnal f Intensive Care, 465. Natinal Heart, Lung, Bld Institute (2007) The Expert Panel Reprt 3 (EPR 3) Guidelines fr the Diagnsis and Management f Asthma. Dwnladed frm: Sawicki, G. and Haver, K. (2016). Acute asthma exacerbatins in children: Hme/ffice management and severity assessment. In: UptDate, Pst TW (Ed), UptDate, Waltham, MA. (Accessed n August 1, 2016) PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,

48 Scarfne, R. (2016). Acute asthma exacerbatins in children: Emergency department management. In UptDate, TePas E (Ed), UptDate, Waltham, MA (Accessed n February 22, 2017) This wrk by the Wiscnsin Technical Cllege System TAACCCT IV Cnsrtium is licensed under a Creative Cmmns Attributin 4.0 Internatinal license. Third party marks and brands are the prperty f their respective hlders. Please respect the cpyright and terms f use n any webpage links that may be included in this dcument. This wrkfrce prduct was funded by a grant awarded by the U.S. Department f Labr s Emplyment and Training Administratin. The prduct was created by the grantee and des nt necessarily reflect the fficial psitin f the U.S. Department f Labr. The U.S. Department f Labr makes n guarantees, warranties, r assurances f any kind, express r implied, with respect t such infrmatin, including any infrmatin n linked sites and including, but nt limited t, accuracy f the infrmatin r its cmpleteness, timeliness, usefulness, adequacy, cntinued availability, r wnership. This is an equal pprtunity prgram. Assistive technlgies are available upn request and include Vice/TTY (771 r ). PEDIATRIC ASTHMA SIMULATION UPDATED: MAY 12,