SIMULATION. SKILL FOCUS: Continuous Nebulization DISCIPLINE: Respiratory Therapy LEVEL: 3 PEDIATRIC ASTHMA. Patient Name: Patrick A.

Transcription

1 SKILL FOCUS: Cntinuus Nebulizatin DISCIPLINE: Respiratry Therapy LEVEL: 3 PEDIATRIC ASTHMA Estimated Time: 40 minutes Debriefing Time: 30 minutes Scan t Begin SCENARIO OVERVIEW Patient Name: Patrick A. Armstrng Patrick A. Armstrng is a 16-year-ld male patient wh was brught t the emergency department tday by his friend s dad with a severe exacerbatin f his knwn asthma. His asthma is nrmally well-cntrlled, but there was an unintended expsure t a cat while he was at his friend s huse. Students are called t the patient rm emergently at the beginning f this scenari. Students shuld cmplete an RT cnsult and administer a Duneb treatment while the RN starts an IV and administers sterids. He desn t imprve s students shuld recmmend a cntinuus nebulizer t the prvider. This scenari revlves arund the management f a patient during an acute exacerbatin f asthma, the initiatin and management f a cntinuus albuterl nebulizer, and cmmunicatin with the interprfessinal team. PEDIATRIC ASTHMA SIMULATION UPDATED: JANUARY 25,

2 LEARNING OBJECTIVES 1. Obtain vital signs and interpret fr a pediatric patient 2. Perfrm a fcused respiratry assessment 3. Recgnize and respnd t abnrmal findings 4. Evaluate bjective and subjective data and recmmend treatment ptins t prvider 5. Implement and fllw evidence-based standards and prtcls 6. Safely administer inhaled medicatins 7. Demnstrate apprpriate cmmunicatin 8. Dcument accurately CURRICULUM MAPPING WTCS RESPIRATORY THERAPY PROGRAM OUTCOMES Apply respiratry therapy cncepts t patient care situatins Demnstrate technical prficiency required t fulfill the rle f a respiratry therapist Practice respiratry therapy accrding t established prfessinal and ethical standards RESPIRATORY AND CIRCULATORY PHYSIOLOGY Apply principles f ventilatry mechanics RESPIRATORY DISEASE Interpret results f simple spirmetry Analyze signs, symptms, etilgy, pathgenesis and treatment fr bstructive lung disrders RESPIRATORY PHARMACOLOGY Cmpare and cntrast drug frms, rutes f administratin and vehicles Examine the pharmacdynamics f brnchdilatrs PEDIATRIC ASTHMA SIMULATION UPDATED: JANUARY 25,

3 RESPIRATORY SURVEY Perfrm pulse ximetry Adapt cmmunicatin strategies t a diverse patient ppulatin Review the medical recrd utilizing medical recrd keeping and charting methds cnsistent with hspital plicy and prcedures Utilize infectin cntrl principles Obtain a fcused health histry Evaluate patient data Perfrm a respiratry assessment Obtain vital signs RESPIRATORY THERAPEUTICS 1 Develp a care plan Evaluate xygenatin Assess the need fr medical gas therapy Demnstrate medicatin delivery devices RESPIRATORY NEONATAL/PEDIATRICS Differentiate cardipulmnary diseases/disrders f the nenatal/pediatric patient Develp a therapeutic care plan fr the nenatal/pediatric patient RESPIRATORY CLINICAL COMPETENCIES Apply standard precautins Assess vital signs Perfrm pulse ximetry Perfrm chart review Perfrm a pulmnary exam Administer aerslized medicatin therapy PEDIATRIC ASTHMA SIMULATION UPDATED: JANUARY 25,

4 Set up a large vlume nebulizer PEDIATRIC ASTHMA SIMULATION UPDATED: JANUARY 25,

5 SIMULATION LEARNING ENVIRONMENT & SET-UP ENVIRONMENT Inside rm: Patient in bed, as clse t fwlers psitin as pssible Inside r utside rm: Hand sanitizer and/r sink Outside rm: Cmputer r frm(s) fr dcumentatin PATIENT PROFILE Name: Patrick A. Armstrng DOB: 11/16/20XX Age: 16 MR#: 1116 Gender: Male Height: cm (5 ft 11 in) Weight: 109 kg (240 lbs) Cde Status: Full Cde EQUIPMENT/SUPPLIES/SETTINGS Patient In patient gwn Admitting Diagnsis: shrtness f breath (R06.02) Medical Histry: asthma, unspecified (493.90) Allergies: NKDA Surgical Histry: Nne Ethnicity: African American Spiritual Practice: Unknwn Primary Language: English N mulage ID band present with QR cde Mnitr Settings N mnitr Simulatr vitals: HR 110, RR 30, BP 132/98, Temp 38.4, O2 Sat 95% n nnbreather mask, Pain 4/10 Supplies General PEDIATRIC ASTHMA SIMULATION UPDATED: JANUARY 25,

6 Respiratry Equipment Device t measure Peak Flw (and FEV1) Varius xygen devices Nebulizer Equipment fr a cntinuus nebulizer scenari prtcl has instructins fr bth the HEART and HOPE TM systems Optinal: Cell phne Medicatins (realistic labels are available by scanning the QR cde) Duneb vial Multiuse bttle f Albuterl Bttle Nrmal Saline PEDIATRIC ASTHMA SIMULATION UPDATED: JANUARY 25,

7 QR CODES START PATIENT REPORT PATIENT ID IV SITE DUONEB CONTINUOUS ALBUTEROL SBAR HOPE NEBULIZER HEART NEBULIZER PEDIATRIC ASTHMA SIMULATION UPDATED: JANUARY 25,

8 CHEST QR CODES Cut alng the dtted lines. Fld alng the slid line t create a bi-fld f the diagram and QR cde. ANTERIOR 2 ANTERIOR 3 ANTERIOR 6 ANTERIOR 7 POSTERIOR 0 POSTERIOR 1 POSTERIOR 4 POSTERIOR 5 PEDIATRIC ASTHMA SIMULATION UPDATED: JANUARY 25,

9 RIGHT AXILLARY 1 LEFT AXILLARY 1 PEDIATRIC ASTHMA SIMULATION UPDATED: JANUARY 25,

10 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. Fr sme scenaris, it may be helpful t tell students where the QR cde are lcated. Fr thers, yu may want students t find the QR cdes during their assessments. This is yur chice. Describe hw a QR cde sund will wrk in the scenari. Fr the mst authentic sund experience, student shuld use ear buds r the ARISE stethscpe fr all QR cdes with the fllwing symbl:. Example: QR Cde: Chest Anterir 1 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. Level Up tab This tab tells the cntent in the ipad t change t what is needed fr the next state f a simulatin. It is used a few times in this scenari after the prvider is ntified t display new rders (thse just given ver the phne) and lab results, etc Medicatin QR Cdes The student(s) must scan QR Cde: Patient ID prir t scanning any medicatin. That scan is valid fr 2 minutes and then it times ut. The student(s) will need t scan QR Cde: Patient ID again t give mre medicatins. MAR Hyperlinks On the MAR all medicatins are underlined and hyperlinked t DailyMed, which is a medicatin reference hused by the PEDIATRIC ASTHMA SIMULATION UPDATED: JANUARY 25,

11 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 are yur pririties fr this patient? Hw will yu mdify yur apprach fr a pediatric patient? View Patient vide n ipad Pssible Facilitatr Questins What cmmunicatin strategies culd yu emply when yu assess and evaluate Patrick? The ipad will stp n a white screen. Student shuld prceed directly t the patient rm. Facilitatr Nte Students cannt view the tabbed cntent n the ipad prir t entering the patient s rm as this is an emergency. Five minutes after the ipad lands n the white screen, the ipad will alert students with a kncking sund and display an image f the friend s dad fllwed by a vide f the dad explaining what happened. During this five minutes, the ipad scanner will ONLY wrk fr QR Cdes: Patient ID, IV Site and all Chest sunds. The Duneb will nt wrk until after the vide f the friend s dad is viewed. When the vide ends and students press cntinue the ipad is n the Patient Prfile screen and the patient s chart is available fr review. PEDIATRIC ASTHMA SIMULATION UPDATED: JANUARY 25,

12 STATE 1 RT CONSULT & DUONEB ADMINISTRATION Patient Overview The patient is in bed in a fwler s psitin. He is n a nn-rebreather mask and quite tachypneic. It is clear he is in sme distress. Students shuld assess the patient and administer a Duneb treatment ASAP. Facilitatr Nte Five minutes int the scenari, the ipad will alert students with a sund that his friend s dad wants t speak with them. An image f the dad is displayed n the ipad fllwed by a vide f the dad explaining what happened. When the vide ends and students press cntinue the ipad is n the Patient Prfile screen and the patient s chart is nw available. See the tabbed ipad cntent belw. During the first five minutes, the ipad scanner will ONLY wrk fr QR Cdes: Patient ID, IV Site and all Chest sunds. The Duneb will nt wrk until after the vide f the friend s dad is viewed. Expected Student Behavirs Perfrm apprpriate hand hygiene and infectin cntrl Intrduce themselves and verify the patient (can scan QR Cde: Patient ID) Obtain vital signs and interpret fr a pediatric patient This patient wuld have vitals similar t an adult f his size. Perfrm a fcused respiratry assessment Inspectin Students will nt find any abnrmalities. (May scan QR Cde: IV t see that an IV was started.) Palpatin Students will nt find any abnrmalities. Percussin All areas have hyperresnant tnes. Auscultatin Scan QR Cde: Chest PEDIATRIC ASTHMA SIMULATION UPDATED: JANUARY 25,

13 There are ten QR cdes t apply t the chest see abve Chest QR Cde chart fr lcatins Student will hear diffuse wheezing in all lung fields Students may ask questins as part f this assessment, but it shuld nt delay the administratin f the Duneb. Questining may cntinue int state 2 f the scenari. He is unable and refuses t perfrm a Peak Flw r FEV1 if students ask. Questins can include: Hw lng have yu had asthma? Answer: All my life gasp I guess. Have yu ever been admitted t the hspital fr yur asthma? Answer: I dn t gasp remember, but gasp my mm said I gasp had pneumnia when gasp I was a baby. What are yur triggers? Answer: What are triggers? (He is cnfused and desn t knw what this means.) When the student(s) explains triggers, he says, Cats gasp spring allergies gasp and smetimes when gasp I get a cld. What medicatins d yu take fr yur breathing? Answer: Just my inhaler. Hw ften d yu take them? Answer: Nt that ften gasp I haven t had gasp t take it gasp in a few mnths. D yu take any ther medicatins? Answer: Ibuprfen smetimes. PEDIATRIC ASTHMA SIMULATION UPDATED: JANUARY 25,

14 D yu smke? Answer: N!!! Cach and gasp and my mm gasp wuld kill me! And s wuld me mm! Des anyne in yur husehld smke? Answer: Npe. D yu wn/use a peak flw meter? Answer: I have befre gasp but nt fr gasp a lng gasp time. D yu have an asthma actin plan? Answer: What s that? Recgnize and respnd t abnrmal findings Safely administer nebulized medicatin (Scan QR Cde: Duneb) Technician Prmpts Student(s) must scan QR Cde: Patient ID prir t medicatin administratin. If nt scanned, the ipad will read, ERROR: N patient infrmatin identified. Since the patient is n a nn-rebreather mask, students shuld recgnize the need t place the patient n a nasal cannula r highflw nasal cannula during the administratin f the Duneb. Breath sunds, vitals, etc., d nt change after the administratin f the Duneb. Patient cmplains f shrtness f breath and speaks in 2-3 wrd sentences. He is unable and refuses t perfrm a Peak Flw r FEV1 if students ask. Patient respnses can include: I can t breathe! Why didn t my gasp puffer wrk? Are yu gasp ging t help gasp me? When asked patient histry questins, the patient has a difficult time answering them because f his current cnditin. His respnses shuld be PEDIATRIC ASTHMA SIMULATION UPDATED: JANUARY 25,

15 shrt and in 2-3 wrd respnses. Thrughut any questining, he shuld keep repeating phrases such as: I can t breathe. Please help me. I think gasp I need gasp a nebulizer. Questins (these may cntinue int state 2) can include: Hw lng have yu had asthma? Answer: All my life gasp I guess. Have yu ever been admitted t the hspital fr yur asthma? Answer: I dn t gasp remember, but gasp my mm said I gasp had pneumnia when gasp I was a baby. What are yur triggers? Answer: What are triggers? (He is cnfused and desn t knw what this means.) When the student(s) explains triggers, he says, Cats gasp spring allergies gasp and smetimes when gasp I get a cld. What medicatins d yu take fr yur breathing? Answer: Just my inhaler. Hw ften d yu take them? Answer: Nt that ften gasp I haven t had gasp t take it gasp in a few mnths. D yu take any ther medicatins? Answer: Ibuprfen smetimes. D yu smke? Answer: N!!! Cach and gasp and my mm gasp wuld kill me! And s wuld me mm! Des anyne in yur husehld smke? PEDIATRIC ASTHMA SIMULATION UPDATED: JANUARY 25,

16 Answer: Npe. D yu wn/use a peak flw meter? Answer: I have befre gasp but nt fr gasp a lng gasp time. D yu have an asthma actin plan? Answer: What s that? Pssible Facilitatr Questins Analyze the vital signs: are they within nrmal limits fr his age? Analyze the findings frm yur physical assessment: d yu have any cncerns? Based n yur findings, what is the best curse f treatment t recmmend t the prvider? Tabbed ipad Prmpts & Cntent H&P N reprts available. ORDERS Patient Name DOB MR# Patrick A. Armstrng 11/16/20XX 1116 Allergies Height (cm) Admissin Weight (kg) NKDA Prvider Orders Date Time Order Tday Nw STAT RT Cnsult exacerbatin f asthma STAT Duneb with peak flw pre- and pst- treatment if patient is able RT t update prvider after Cnsult and Duneb O2 t keep SpO2 > 90% PEDIATRIC ASTHMA SIMULATION UPDATED: JANUARY 25,

17 STAT prtable chest x-ray shrtness f breath/asthma STAT CBC with Differential Methylprednislne IV 1 mg/kg STAT Tylenl PO 325 mg every 4-6 hurs prn fr pain and/r fever Place n telemetry and recrd vitals and LOC at least every 2 minutes Electrnically signed, James Emersn, M.D. MAR Patient Name DOB MR# Patrick A. Armstrng 11/16/20XX 1116 Allergies Height (cm) Admissin Weight (kg) NKDA Medicatin Administratin Recrd Scheduled Duneb (unit dse vial), STAT Due Tday Last Given Methylprednislne IV 1 mg/kg, STAT Due Tday Last Given PRN Tylenl PO 325 mg, Every 4-6 hurs prn fr pain and/r fever Last Given DAILY RECORD Patient Name DOB MR# Patrick A. Armstrng 11/16/20XX 1116 Allergies Height (cm) Admissin Weight (kg) NKDA PEDIATRIC ASTHMA SIMULATION UPDATED: JANUARY 25,

18 Daily Recrd Vitals Tday 5 minutes ag Pulse 116 Resp. Rate 34 BP Systlic 138 BP Diastlic 98 Temp ( C) 38.4 O2 Saturatin (%) 85% Applied Oxygen Pain 4 RA VITALS The ipad shws the enterable vitals screen. PROGRESS NOTES N reprts available. LABS-DIAGNOSTICS N reprts available. IMAGING N reprts available. LEVEL 1 / 2 When the Level 1 tab is tapped, the ipad reads, The ipad is at Level 1. After the student(s) scans QR Cde: Duneb, the Level 1 tab will autmatically change t a Level 2 tab (students are nt prmpted abut this). PEDIATRIC ASTHMA SIMULATION UPDATED: JANUARY 25,

19 When the Level 2 tab is tapped, the ipad reads, The ipad is at Level 2. SCANNER Use this t scan available QR Cdes. 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: JANUARY 25,

20 STATE 2 TREATMENT RECOMMENDATION Patient Overview The patient desn t imprve fllwing the Duneb treatment. Hwever, he desn t deterirate either. Students must recmmend a curse f treatment t the prvider. Accrding t evidence-based standards, a cntinuus nebulizer is the best ptin at this time. Students shuld als recgnize the need t mnitr serum K and glucse as well as cntinuus ECG. Expected Student Behavirs Evaluate subjective and bjective data Bth Imaging and Labs have resulted at the beginning f this state (students are nt prmpted t this). Recmmend cntinuus nebulizer t prvider Recmmendatin t include: cntinuus ECG and pulse ximetry mnitring as well as serum K and glucse mnitring. Albuterl causes hypkalemia Stress, albuterl and sterids cause increased hyperglycemia Demnstrate apprpriate cmmunicatin Technician Prmpts Students shuld use the SBAR frmat (scan QR Cde: SBAR) Nthing is needed frm the patient in this state as students shuld be talking with the prvider. The prvider can be played by the technician, facilitatr r anther student. This can be dne either n the phne r face-t-face. The students shuld use SBAR frmat. The persn playing the prvider rle shuld ensure all subjective and bjective data is prvided and accurate. If students have nt included the imaging and lab results in the SBAR, the prvider shuld ask fr them. PEDIATRIC ASTHMA SIMULATION UPDATED: JANUARY 25,

21 Give the fllwing rders t the students and tell them yu are entering them in the EMR: Cntinuus albuterl 15 mg/hr fr 2 hurs then reevaluate peak flw and FEV1 STAT serum electrlytes and glucse level Cntinuus cardiac and pulse ximetry mnitring Strict NPO in case intubatin required Pssible Facilitatr Questins Hw is the SBAR cmmunicatin mdel imprtant t healthcare cmmunicatin? What ther therapies culd be cnsidered if Patrick s cnditin wrsens and/r the cntinuus nebulizer desn t help? Discussin can include: Helix, BiPAP, intubatin, magnesium, etc. Tabbed ipad Prmpts & Cntent MAR Patient Name DOB MR# Patrick A. Armstrng 11/16/20XX 1116 Allergies Height (cm) Admissin Weight (kg) NKDA Medicatin Administratin Recrd Scheduled Due Tday Last Given PRN Tylenl PO 325 mg, Every 4-6 hurs prn fr pain and/r fever Last Given 0500 Discntinued PEDIATRIC ASTHMA SIMULATION UPDATED: JANUARY 25,

22 Duneb (unit dse vial), STAT Discntinued Last Given Tday 10 minutes ag Tday 10 minutes ag Methylprednislne IV 1 mg/kg, STAT Discntinued Last Given Tday 10 minutes ag Tday 10 minutes ag LABS-DIAGNOSTICS Patient Name DOB MR# Patrick A. Armstrng 11/16/20XX 1116 Allergies Height (cm) Admissin Weight (kg) NKDA Labratry Results CBC with Differential [time] 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: 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 PEDIATRIC ASTHMA SIMULATION UPDATED: JANUARY 25,

23 IMAGING Patient Name DOB MR# Patrick A. Armstrng 11/16/20XX 1116 Allergies Height (cm) Admissin Weight (kg) NKDA Imaging Reprt DESCRIPTION: Prtable x-ray t evaluate acute shrtness f breath/asthma. EXAM: Prtable AP chest REASON FOR EXAM: Shrtness f breath/asthma COMPARISON EXAM: Nne TECHNIQUE: kvp DISCUSSION: The heart and vasculature are nrmal. Trachea is midline. All visualized bny structures are unremarkable. Cstphrenic angles are clear with sme flattening f the diaphragm nted. Lung tissue is remarkable fr hyperinflatin. N infiltrates r atelectasis. IMPRESSION: Flattened diaphragm and hyperinflatin cnsistent with bstructive lung disrder. Clinical crrelatin suggested. LEVEL 2/3 When the Level 2 tab is tapped, the ipad displays a plaque that reads, Have yu called the Prvider? If N, the ipad reads, Yu must call the prvider befre advancing t Level 3. If Yes, the ipad reads, The ipad is at Level 3. PEDIATRIC ASTHMA SIMULATION UPDATED: JANUARY 25,

24 STATE 3 CONTINUOUS NEBULIZER Patient Overview The students shuld assemble and implement a cntinuus nebulizer per the plicy included under the Prtcl tab in the ipad. This plicy includes directins fr bth the Hpe and Heart nebulizers. Expected Student Behavirs Implement cntinuus nebulizer A Cntinuus Nebulizer plicy is prvided in the ipad under the Prtcl tab. This tab autmatically appears when the ipad changes frm Level 2 t Level 3. See Appendix A fr a printable versin. Safely administer inhaled medicatins (Scan QR Cde: Cntinuus Albuterl) Ensure patient is placed n a cntinuus ECG and pulse ximetry mnitring. May scan QR Cde: Hpe Nebulizer r QR Cde: Heart Nebulizer fr images f thse cntinuus nebulizers already set up. Demnstrate apprpriate cmmunicatin Dcument accurately Technician Prmpts The patient cntinues t be in mderate distress and nly able t speak in 2-3 wrd sentences. He is anxius and scared and is asking fr his parents wh have nt arrived yet. Patient respnses can include: I still can t gasp breathe very well. I m a little gasp scared. When are my gasp mm and dad gasp ging t get here? PEDIATRIC ASTHMA SIMULATION UPDATED: JANUARY 25,

25 Hw lng gasp till I can gasp play ftball again. When talking abut the cntinuus nebulizer: What is gasp this thing fr? Hw lng gasp d I have gasp t wear it? Pssible Facilitatr Questins Hw will yu address Patrick s cncerns regarding his anxiety, being scared and that his parents are nt present? Tabbed ipad Prmpts & Cntent ORDERS Patient Name DOB MR# Patrick A. Armstrng 11/16/20XX 1116 Allergies Height (cm) Admissin Weight (kg) NKDA Prvider Orders Date Time Order Tday 20 minutes ag STAT RT Cnsult exacerbatin f asthma STAT Duneb with peak flw pre- and pst- treatment if patient is able RT t update prvider after Cnsult and Duneb O2 t keep SpO2 > 90% STAT prtable chest x-ray shrtness f breath/asthma STAT CBC with Differential Methylprednislne IV 1 mg/kg STAT Tylenl PO 325 mg every 4-6 hurs prn fr pain and/r fever Place n telemetry and recrd vitals and LOC at least every 2 minutes Electrnically signed, James Emersn, M.D. Tday Nw Cntinuus albuterl nebulizer 15 mg/hr fr 2 hurs then reevaluate peak flw and FEV1 PEDIATRIC ASTHMA SIMULATION UPDATED: JANUARY 25,

26 STAT serum electrlytes and glucse level Cntinuus cardiac and pulse ximetry mnitring Strict NPO in case intubatin required Electrnically signed, James Emersn, M.D. MAR Patient Name DOB MR# Patrick A. Armstrng 11/16/20XX 1116 Allergies Height (cm) Admissin Weight (kg) NKDA Medicatin Administratin Recrd Scheduled Albuterl nebulizer 15 mg/hr fr 2 hurs Due Tday Last Given PRN Tylenl PO 325 mg, Every 4-6 hurs prn fr pain and/r fever Discntinued Last Given 0500 Duneb (unit dse vial), STAT Discntinued Last Given Tday 10 minutes ag Tday 10 minutes ag Methylprednislne IV 1 mg/kg, STAT Discntinued Last Given Tday 10 minutes ag Tday 10 minutes ag PROTOCOL See Appendix A PEDIATRIC ASTHMA SIMULATION UPDATED: JANUARY 25,

27 LEVEL 3/EXIT When the Level 3 tab is tapped, the ipad reads, The ipad is at Level 3. Five minutes after QR Cde: Cntinuus Albuterl is scanned; the Level 3 tab will autmatically disappear (students are nt prmpted abut this). When the Exit tab is tapped, the ipad reads, Scenari bjectives have been met. Are yu sure yu want t exit the game? 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: JANUARY 25,

28 DEBRIEF Nthing needed frm the ipad. QUESTIONS 1. Hw did yu feel this scenari went? 2. What were the main issues yu had t deal with when caring fr Patrick? 3. Review understanding f learning bjective: Obtain vital signs and interpret fr a pediatric patient. a. What vital signs are within nrmal range fr a 16-year-ld male? b. Interpret Patrick s vital signs: Were they in range? What culd be affecting Patrick s vital signs? 4. Review understanding f learning bjective: Perfrm a fcused respiratry assessment. a. What cncerns did yu find during yur initial assessment and evaluatin? b. Hw wuld yur assessment f Patrick cmpare t what yu wuld expect f an asthmatic patient? c. Did yu alter yur assessment fr this pediatric patient? Why r why nt? d. What pieces f data were significant in Patrick s health histry? e. If yu culd d ver any part f getting Patrick s histry, what wuld it be and why? 5. Review understanding f learning bjective: Recgnize and respnd t abnrmal findings. a. What abnrmal findings did yu find in the vital signs and/r physical assessment? Hw did yu respnd t these findings? 6. Review understanding f learning bjective: Evaluate bjective and subjective data and recmmend treatment ptins t prvider. a. Describe the cnclusins yu made given the available subjective and bjective data. b. Are there any ther pieces f data yu wish yu had? c. Describe the treatment recmmendatins yu will give t the prvider. PEDIATRIC ASTHMA SIMULATION UPDATED: JANUARY 25,

29 7. Review understanding f learning bjective: Implement and fllw t evidence-based standards and prtcls. a. Why is it imprtant t fllw evidence-based standards? b. Hw d prtcls affect a respiratry therapist? 8. Review understanding f learning bjective: Safely administer inhaled medicatins. a. Did yu have any cncerns abut administering the medicatins that were rdered? Why r why nt? b. Wuld yu change anything abut hw yu administered the medicatin? 9. Review understanding f learning bjective: Demnstrate apprpriate cmmunicatin a. Were the cmmunicatin techniques yu used with Patrick effective? Why r Why nt? b. Hw is SBAR cmmunicatin critical t ensuring effective cmmunicatin? c. If Patrick s parents had been with him, hw wuld yu have cmmunicated with them in cmparisn t hw yu cmmunicated with Patrick? d. If yu culd d ver, hw wuld yu change yur cmmunicatin with Patrick r the prvider? 10. Review understanding f learning bjective: Dcument accurately. a. What is imprtant t dcument in yur assessments and interventins? 11. Summary/Take Away Pints a. Tday yu cared fr a pediatric patient wh was experiencing a severe exacerbatin f his knwn asthma. What is ne thing yu learned frm participating in this scenari that yu will take with yu int yur nursing practice? (Each student must share smething different frm what the thers share.) Nte: Debriefing technique is based n INASCL Standard fr Debriefing and NLN Thery Based Debriefing by Dreifuerst. PEDIATRIC ASTHMA SIMULATION UPDATED: JANUARY 25,

30 SURVEY Print this page and prvide t students. Students, please cmplete a brief (2-3 minute) survey regarding yur experience with this ARISE simulatin. There are tw ptins: 1. Use QR Cde: Survey a. Nte: Yu will need t dwnlad a QR cde reader/scanner nt yur wn device (smartphne r tablet). There are multiple free scanner apps available fr bth Andrid and Apple devices frm the app stre. b. This QR cde will nt wrk in the ARIS app. SURVEY 2. Cpy and paste the fllwing survey link int yur brwser: a. PEDIATRIC ASTHMA SIMULATION UPDATED: JANUARY 25,

31 APPENDIX A CONTINUOUS NEBULIZATION 1. Plicy Statements 2. Plicy a. The Respiratry Therapy Department shall prvide cntinuus nebulizatin f a brnchdilatr t patients meeting specified indicatins. b. Indicatins fr cntinuus nebulizer treatment includes severe asthma, severe reactive airway disease and/r impending respiratry failure that is nn respnsive t current evidence-based therapy. c. Patients must be mnitred cntinuusly with a cardiac mnitr and pulse ximetry either in an intensive care setting r in the Emergency Department. d. Albuterl and Levalbuterl are the drugs available thrugh the Pharmacy Department fr this mde f therapy. a. The physician's rder must include the fllwing: i. Type f therapy (cntinuus nebulizatin) ii. iii. iv. Medicatin Dse/hr in mg (cncentratin f medicatin) Duratin f treatment b. The Respiratry Care Practitiner will utilize either the HEART r HOPE nebulizer fr the prcedure. c. The aersl shuld be delivered via an aersl mask and large bre tubing. Oxygen therapy will be adjusted t maintain SpO2 f greater than 92% thrugh the use f a blending system r, when the nebulizer is pwered by cmpressed air, a nasal cannula can be wrn fr lw flw xygen therapy. If mechanical ventilatin is needed, see the Cntinuus Nebulizatin with Mechanical Ventilatin plicy. d. A blender will be used fr patients needing precise FIO2 cntrl. The nebulizer flw must be kept at a cnstant rate and therefre cannt be used t adjust inspired xygen cncentratin. e. A head hd may be used with infants. An adjustment in dse/diluent mixture t accmmdate a 15 L/min flw may be needed. PEDIATRIC ASTHMA SIMULATION UPDATED: JANUARY 25,

32 3. Drug and Dsage Guidelines a. The acceptable dsage range fr albuterl is 5mg/hr t 15mg/hr b. While ptimal dsing fr cntinuus nebulizatin has nt been determined, a dse f 15 mg/hr is recmmended fr patients weighing >20 kg. 4. Medicatin Calculatins a. HEART Nebulizer i. Fllw the specific package guidelines fr prper medicatin administratin. ii. Belw are example guidelines fr several HEART prducts. HEART Flw (Output) 10 lpm (30 ml/hr) 15 lpm (50 ml/hr) Dse 5 mg/hr 10 mg/hr 15 mg/hr 5 mg/hr 10 mg/hr 15 mg/hr Medicine (5 mg/ml) 1 ml 2 ml 3 ml 1 ml 2 ml 3 ml Saline 29 ml 28 ml 27 ml 49 ml 48 ml 47 ml MiniHEART-HiFl Flw (Output) 8 lpm (20 ml/hr) Dse 5 mg/hr 10 mg/hr 15 mg/hr Medicine (5 mg/ml) 1 ml 2 ml 3 ml Saline 19 ml 18 ml 17 ml MiniHEART-LFl Flw 2 lpm (8 ml/hr) (Output) Dse 2.5 mg/hr 5 mg/hr 7.5 mg/hr 10 mg/hr 12.5 mg/hr 15 mg/hr Medicine 0.5 ml 1 ml 1.5 ml 2 ml 2.5 ml 3 ml (5 mg/ml) Saline 7.5 ml 7 ml 6.5 ml 6 ml 5.5 ml 5 ml PEDIATRIC ASTHMA SIMULATION UPDATED: JANUARY 25,

33 UniHEART Flw (Output) 2 lpm (4 ml/hr) 4 lpm (9 ml/hr) Dse 5 mg/hr 10 mg/hr 15 mg/hr 5 mg/hr 10 mg/hr 15 mg/hr Medicine (5 mg/ml) 1 ml 2 ml 3 ml 1 ml 2 ml 3 ml Saline 3 ml 2 ml 1 ml 8 ml 7 ml 6 ml b. HOPE Nebulizer i. Fllw the specific package guidelines fr prper medicatin administratin. ii. Belw are example guidelines fr the HOPE nebulizer. Flw 10 lpm Time 1 hur 2 hurs 3 hurs 4 hurs 5 hurs Saline (after medicatin is added, fill reservir t equal) Dse Medicine (5 mg/ml) Dse Medicine (5 mg/ml) Dse Medicine (5 mg/ml) Dse Medicine (5 mg/ml) Dse Medicine (5 mg/ml) 25 ml 50 ml 75 ml 100 ml 125 ml 5 mg/hr 1 ml 2 ml 3 ml 4 ml 5 ml 7.5 mg/hr 1.5 ml 3 ml 4.5 ml 6 ml 7.5 ml 10 mg/hr 2 ml 4 ml 6 ml 8 ml 10 ml 12.5 mg/hr 2.5 ml 5 ml 7.5 ml 10 ml 12.5 ml 15 mg/hr 3 ml 6 ml 9 ml 12 ml 15 ml PEDIATRIC ASTHMA SIMULATION UPDATED: JANUARY 25,

34 5. Assessment and Dcumentatin a. The patient shuld remain n cntinuus nebulizatin until they have imprved. This shuld be measured by peak flw, FEV1 and patient assessment. b. Criteria fr discntinuance prir t patient imprvement include increased side effects such as increased heart rate, palpitatins, arrhythmias, nausea/vmiting r significant tremrs. In additin, cntinuus nebulizatin shuld nt preclude intubatin if that is deemed necessary. See the Cntinuus Nebulizatin during Mechanical Ventilatin plicy. c. Fllwing cntinuus nebulizatin, a trial f Q2 hur intermittent therapy shuld be attempted. d. The fllwing will be dcumented by a Respiratry Care Practitiner every 30 minutes fr the first tw hurs and every tw hurs thereafter: i. Medicatin cncentratin ii. Nebulizer utput and flwrate iii. FiO2 r supplemental O2 iv. Heart rate & rhythm, Respiratry rate, Bld Pressure and O2 Saturatin v. Breath sunds vi. Peak flw & FEV1 as tlerated vii. Side effects (if applicable) viii. Arterial bld gas infrmatin (if applicable) ix. Level f cnsciusness 6. Precautins a. Fllw cautins as specified in the Medicated Aersl plicy with additinal cnsideratin fr the fllwing: b. The presence f nausea (if a new finding), tremrs and tachycardia indicate the need t discntinue therapy r reduce the medicatin dsage. c. Beta agnists can lwer serum ptassium and raise bld glucse. Mnitring and treatment f any abnrmalities is warranted. d. If the mask is displaced, medicatin will nt be delivered. Thus, patient cperatin and tleratin is criteria fr the prvisin f cntinuus therapy. PEDIATRIC ASTHMA SIMULATION UPDATED: JANUARY 25,

35 CREDITS Medicatin infrmatin frm Natinal Library f Medicine: Daily Med at Pictures frm Shutterstck.cm Sund frm freesund: Drknck.gg by appdc at Wheeze lung sund frm Wikipedia at PEDIATRIC ASTHMA SIMULATION UPDATED: JANUARY 25,

36 STORYLINE REFERENCES American Academy f Allergy, Asthma & Immunlgy. (2017). Peak flw meter. Retrieved frm American Assciatin fr Clinical Chemistry. ( ). CO2. Lab Tests Online. Retrieved frm American Lung Assciatin. (2017). Measuring yur peak flw rate. Retrieved frm Camarg, C., Rachelefsky, G., & Schatz, Michael. (2009). Managing asthma exacerbatins in the emergency department: Summary f the natinal asthma educatin and preventin prgram expert panel reprt 3 guidelines fr the management f asthma exacerbatins. Prceeding f the American Thracic Sciety, 6 (4). Retrieved frm Center fr Disease Cntrl and Preventin (2000). Clinical Grwth Charts: Bys Stature fr age and Weight fr age Grwth Chart. Retrieved frm Dickens, G., McCy, R., WQest, R., Stapczynski, J., & Cliftn, G. (1994). Effect f nebulized albuterl n serum ptassium and cardiac rhythm in patients with asthma r chrnic bstructive pulmnary disease. Pharmactherapy, 14(6), Retrieved frm Grelick, M., Stevens, M., Schultz, T., & Scriban, P. (2004). Perfrmance f a nvel clinical scre, the pediatric asthma severity scre (PASS), in the evaluatin f acute asthma. Academic Emergency Medicine, 11 (1), Retrieved frm PEDIATRIC ASTHMA SIMULATION UPDATED: JANUARY 25,

37 Glbal Initiative fr Asthma. (2016) Pcket guide fr asthma management and Heart Cntinuus Nebulizers. (2016). Retrieved frm HOPE Nebulizer Aersl Therapy fr Adult and Pediatric Patients ( ). Retrieved frm Hwell, J. (2016). Acute severe asthma exacerbatins in children: Intensive care unit preventin. Retrieved frm Hwell, J. (2016). Acute severe asthma exacerbatins in children: Endtracheal intubatin and mechanical ventilatin. UpTDate Literature Review. Retrieved frm management. UpTDate Literature Review. Retrieved frm Jint Cmmissin (2016). Children s Asthma Care. Dwnladed frm Labsn, M. (2013). SBAR A pwerful tl t help imprve cmmunicatins. Retrieved frm 0%93_a_pwerful_tl_t_help_imprve_cmmunicatin/ Medscape. (2017). Peak expiratry flw predictin. Retrieved frm Mses, S. (2017). Status asthmaticus. Retrieved frm PEDIATRIC ASTHMA SIMULATION UPDATED: JANUARY 25,

38 Natinal Heart, Lung and Bld Institute. (2007). Asthma actin plan. Retreived frm Natinal Heart, Lung and Bld Institute. (2007). Natinal asthma educatin and preventin prgram: Expert panel reprt 3: Guidelines fr the diagnsis and management f asthma. Retrieved frm Natinal Heart, Lung and Bld Institute. (2012). Asthma care quick reference: Diagnsing Natinal Institute fr Occupatinal Safety and Health: Respiratry Health Divisin. (2015). Spirmetry Reference value calculatr. Retrieved frm Nievas, I. F. F., & Anand, K. J. S. (2013). Severe acute asthma exacerbatin in children: A stepwise apprach fr escalating therapy in a pediatric intensive care unit. The Jurnal f Pediatric Pharmaclgy and Therapeutics, 18(2), Quality Measures Summary. (2015). Retrieved frm Peak Flw Meter. (2017). Retrieved frm and managing asthma. Retrieved frm Saadeh, C. (2016). Status asthmaticus. Retrieved frm PEDIATRIC ASTHMA SIMULATION UPDATED: JANUARY 25,

39 Sawicki, G., & Haver, K. (2016). Acute asthma exacerbatins in children: Hme/ffice management and severity assessment. UpTDate Literature Review. Retrieved frm Scarfne, R. (2016). Acute asthma exacerbatins in children: Emergency department managementacute asthma exacerbatins in children: Emergency department management. UpTDate Literature Review. Retrieved frm %20children&selectedTitle=1~150 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: JANUARY 25,