Complex Care NURS 4617 Day 1 Clinical Education Center and Simulation Learning Activities Clinical Education Center 3 rd Floor Welcome, Attendance and Questions/Answers Activity #1 Non-invasive mechanical ventilation interactive learning Activity #2 EKG Rhythm Interpretation and review Activity #3 STEMI video and guided discussion Simulation Center 5 th Floor Welcome, Attendance and Questions/Answers Simulation #1 Simulation #2 Simulation #3 Simulation #4 The Clinical Education Center has new clinical content and nursing application. Please prepare for the simulation scenarios as you would for a clinical day. Read through the material, look up pathophysiology, and medications regarding your patient. Be prepared to provide knowledgeable, effective, and safe patient care in each of the simulation scenarios today. To prepare for the Complex Care simulation experience, please: Review the Get with the Guidelines PowerPoint (provided) and prepare a discharge teaching plan (what are the key items that the patient will need to know prior to going home) for Mr. Pierce utilizing the patient data provided in this workbook. Read before the experience: This workbook Selected procedures as indicated The assigned article(s): Overbaugh, Kristen J. Acute Coronary Syndrome. American Journal of Nursing. 2009; 109(5): 42-52. Ecklund, M. Noninvasive Positive Pressure Ventilation Requires Healthcare Team Spirit. CE Course. Nursing Center. Bring to this experience: This workbook. Please review the simulations in detail. You should be familiar with the patient s PMH, admitting diagnosis, and possible interventions, which include medications Stethoscope Clinical resources i.e. pen, penlight, clipboard Davis Drug book 1
Clinical Education Center Activity #1 Non-invasive and Invasive Mechanical Ventilation and Oxygenation. There will be a guest speaker, Jerome Piccoli, RRT, who will review oxygenation and introduce advanced modes of oxygenation such as CPAP and BiPap. Your role as a student nurse: Review your lecture notes regarding oxygenation as well as mechanical ventilation, both non-invasive and invasive. Procedures: Review Lewis Textbook (Medical-Surgical Nursing), Chapter 66, pp.1703-1713. Activity #2 EKG Rhythm Interpretation and Review Your role as a student nurse: In small groups, interact with team members and actively participate in learning activities regarding rhythm interpretation. You will be provided with EKG rhythm strips. Answer the questions below. 1. What other assessment data would be helpful for you at this time, as it relates to your patient? 2. What are your priorities at this time? What nursing interventions you would like to implement? 3. What medications you can anticipate preparing for your patient, or potentially obtaining an order for? 4. Create an SBAR Report about your patient. Activity #3 Acute Coronary Syndromes Your role as a student nurse: Actively participate in assessment and nursing care for a patient experiencing a Acute Coronary Syndrome event MONA is the common acronym used for initial interventions and treatment of Acute coronary Syndromes. M -- Morphine O -- Oxygen N -- Nitroglycerin A Aspirin Risk Factors Expected Smoking (i.e. cigarettes) Obesity Age (men 45 years or older, women 55 years or older Diabetes Hypertension Stress Unexpected NSAIDS (particularly after previous MI; COX-2 inhibitors Celebrex) Poor oral hygiene Chlamydia infection Stimulants (e.g., cocaine, methamphetamine, caffeine, ephedra, etc.) Women 50 years or younger (e.g. cigarette 2
Hypercholestremia Alcohol (i.e., chronic heavy drinking) Sex (male > female) Diet (e.g., high fat, sodium) Sedentary Lifestyle Family history Ethnicity and Race (i.e. African-Americans) smoking) Trauma Chronic steroid use (rheumatoid arthritis, psoriasis, etc.) Depression Thyroid disease (i.e., hypo-, hyperthyroidism) Sleep Apnea You will be provided with a patient scenario. Answer the questions below. 1. What are some modifiable risk factors for ACS? Non-modifiable? 2. What symptoms might you expect from your patient who is experiencing ACS? 3. What are your nursing priorities? Simulation Your role as a student nurse: Be familiar with the patient s medical orders, MAR, and EMS (hard copy) report The instructor will give you a minute to pre-brief and review the scenario s objectives Be prepared to work for 15 minutes in groups of 3 to complete objectives for each scenario Three students will actively participate in simulation and 3 students will actively observe All 6 students will actively participate for 15 minutes with an instructor guided debrief Guiding points: 3 active simulation participants should divide into nursing roles to meet the patient s needs and scenario objectives You are working with an interdisciplinary team and may consult by phone a Physician, Provider, Charge Nurse, CNA, Pharmacist, Case Manager, Respiratory Therapist, Social Worker, Chaplin, Physical Therapist and others as indicated Role recommendations: o Student 1: Assessment/VS nurse: Role to complete basic assessment, vital signs and communicate findings with team members o Student 2: Interventions/Medication administration nurse: Role to implement nursing interventions to include medication administration o Student 3: Intervention/Primary nurse: Role as leader, situational awareness, communication with provider and to implement nursing interventions 3 active observers should focus on observing simulation and be able to highlight successes and deficits in patient assessment, nursing interventions, and safety. 3
General Patient Medical Information for All Scenarios Today Primary Medical Diagnosis: Anterolateral MI History of Present Illness: Mr. Martin Pierce is a 62 year-old patient Situation: Mr. Martin Pierce is a 62 year-old patient brought in by ambulance for acute onset chest pain at 0530. His wife called 911 when Mr. Pierce began complaining of tingling in his left arm. Additionally, he was clutching his chest with his fist, and she became concerned. The 911 operator advised her to have him chew a regular strength Aspirin; she stated she did not have any in the home. Once in the ambulance, EKG changes were noted on the monitor, so the Paramedics gave him the Aspirin to chew. Paramedics contacted the Emergency Department (ED) to notify them that Mr. Pierce was having an MI, most likely anterior-lateral. Background: History of Hypertension (HTN), Nicotine use/abuse. Allergy: Iodine Medication(s): Hydralazine 25 mg PO twice daily Assessment: Neuro: Alert & Oriented, no neuro deficits. Respiratory: lungs clear, on 2 liters n/c sats about 90% Cardiac: Chest pain treated on scene with Nitroglycerin 0.4 mg with result of pain dropping to 4/10 for 7/10. Rhythm remains SR with ST elevation. Pulses 2+/2+ bilaterally upper and lower extremities. Capillary refill <3 seconds. GI: Abdomen rounded, soft. Bowel sounds active in all quads to auscultation. Non-tender to palpation. GU: He has not voided at this point in time. Msk: Gait steady, smooth movement noted. No crepitation, pain noted on palpation of all joints. Muscle strength 5/5 upper and lower extremities. For access, he has an IV in his right antecubital space. Both lines are saline locked at this time. Recommendations: See Simulation Scenarios Below Scenario #1 New Admission Sim room 3 Recommendations: Admit to the ED by verifying orders as well as implementing them, and educating the patient on the plan of care. As a team please admit this patient to your clinical area and provide any nursing care he may need. Your role as a student nurse: A basic assessment including any needed focused assessments. Please include a set of vital signs. Provide patient education to hospital environment, safety issues and overall plan of care. Verify admission orders, verify MAR, and IV fluids Also provide any nursing care for patient and communication to provider as needed. In preparation for patient transfer to the Cath Lab, prepare and provide report to Cath Lab RN. 4
Clinical Education and Simulation Lab Chest Pain/Acute Coronary Syndrome Emergency Department Orders General Date: Today Time: 0600 Admit to: CCU Telemetry Cath Lab SERVICE: Cardiology Diagnosis STEMI Non-STEMI Unstable Angina Chest Pain Other Condition Good Fair Guarded Allergies NKDA Allergy: Iodine Nursing Vital Signs Per unit routine Every 15 min in ED Activity Diet Call MD if: SBP > mmhg or SBP < mmhg; HR > or HR < ; RR > or RR < ; T > Bed rest Out of bed to chair with assistance (BID, TID) Physical therapy consultation NPO (except for meds) calorie-restricted diet, no caffeine CAD/ACS Diet (4 gram Na, low cholesterol), no caffeine Heart Failure Diet (2 gram Na), no caffeine Other Bed rest with commode privileges Ambulate in hall with assistance (BID, TID) Cardiac rehabilitation consultation IV Fluids HEPLOCK with 3 ml normal saline flush Q12 hours (document on flow sheet 0800H and 2000H) 500 ml_ NS with meq KCL/L @ 25 ml/hour x hours I/O and Weight Foley Strict recording of Ins and Outs with running totals of urine output to be recorded Daily AM weights; record in chart If patient is unable to void, place Foley catheter Monitoring Pulse oximetry: continuous Q Accucheck Q Oxygen O 2 4 L/min nasal cannula for chest pain, shortness of breath, SaO 2 < 93% MD Signature: R. Bowler, MD Pager: 555-321-4567 Date/Time: Today / 0600 5
Clinical Education and Simulation Lab Chest Pain/Acute Coronary Syndrome Emergency Department Orders (Cont d) Laboratory Laboratory Draw the following labs and run STAT: CBC with differential and platelets Basic metabolic panel Cardiac Troponin I NOW PT/INR PTT Other: Other: Medication (ACC/ AHA Guideline Class I Recommendations Indicated in Bold) Aspirin Aspirin 325 mg PO NOW chewed Given by EMS Other: Clopidogrel per Cardiology Clopidogrel 600 mg PO NOW Beta-Blocker per Cardiology Metoprolol tartrate 5 mg IVP over 2 min NOW, repeat Q 5 min X 2 (hold for SBP < 90 mmhg, symptomatic bradycardia, severe reactive airway disease, decompensated HF) Metoprolol 50 mg PO NOW Hold Beta Blocker per MD order Nitroglycerin Nitroglycerin 0.4 mg SL Q 5 min PRN chest pain; MR x 2 Nitroglycerin 100 mg/250 ml D5W IV @ 20 mcg/min, titrate to relief of CP, keep SBP > 100 mmhg Morphine Sulfate 1 mg IVP PRN severe pain MD Signature: R. Bowler, MD Pager: 555-321-4567 Date/Time: Today / 0600 6
Clinical Education and Simulation Lab Medication Reconciliation Inpatient Admission Allergies: _Iodine Source of medication list (circle all that apply) patient medication list, patient/family recall, pharmacy, PCP list, previous discharge paperwork, MAR for facility Medication Name Dose Route Frequency Last Dose Continue/DC 1. Hydralazine 25 mg PO Twice daily Yesterday PM C DC 2. C DC 3. C DC Signature Provider R. Bowler, MD Print Name Bowler Date Today Signature RN K.Reid, RN Print Name Reid Date Today Reviewed on Transfer by Date Reviewed on Discharge by Date Scan to pharmacy 7
Scenario #2 Post Procedure Sim room 3 Recommendations: It is 90 minutes later and Martin Pierce is being transferred from the Cath Lab, post Percutaneous Coronary Intervention (PCI) to your Cardiac clinical area. He received angioplasty and a stent placed to Left Anterior Descending (LAD) coronary artery. He requires a basic assessment, monitoring of PCI puncture site, and, as a team, any nursing care he may need. 8
Clinical Education and Simulation Lab Cath Lab Post Procedure Admission Orders General Date: Today Time: 0830 Ht: 72 inches Wt: 90 Kg Inpatient Admit to: CICU Telemetry Other SERVICE: Cardiology Diagnosis STEMI Non-STEMI Unstable Angina Chest Pain Other Condition Good Fair Guarded Allergies NKDA Allergy: Iodine Vital Signs Nursing VS every 15 min x 4, every 30 min x 2, then every 1 hour x 4. Then, unit routine if stable. Call MD if: SBP > mmhg or SBP < mmhg; HR > or HR < ; RR > or RR < ; T > Groin checks, dorsalis pedis, and post tibial pulses every 15 min x 4, every 30 min x 2, then every 1 hour x 4. Call MD for bleeding, loss of pulses Activity Bed rest until morning Bed rest with commode privileges Out of bed to chair with assistance (BID, TID) Ambulate in hall with assistance (BID, TID) Physical therapy consultation Cardiac rehabilitation consultation Diet NPO (except for meds) calorie-restricted diet, no caffeine CAD/ACS Diet (4 gram Na, low cholesterol), no caffeine Heart Failure Diet (2 gram Na), no caffeine Other IV Fluids HEPLOCK with 3 ml normal saline flush Q12 hours (document on flow sheet 0800H and 2000H) 500 ml NS with meq KCL/L @ _25_ ml/hours; discontinue in a.m. I/O and Weight Foley Strict recording of Ins and Outs with running totals of urine output to be recorded Daily AM weights; record in chart If patient is unable to void, place Foley catheter Monitoring Pulse oximetry: continuous Q Accucheck Q Oxygen O 2 4 L/min nasal cannula for chest pain, shortness of breath, SaO 2 < 93% MD Signature: R. Bowler, MD Pager: 555-321-4567 Date/Time: Today_/ 0830 9
Clinical Education and Simulation Lab Cath Lab Post Procedure Admission Orders (cont d) On Admission to Nursing Unit In A.M. Labs / Tests EKG on arrival and 6 hours later and with CP Portable Chest X-ray on arrival Basic metabolic panel CBC with differential PT/INR PTT (see unit admission order) Portable Chest X-ray in a.m. EKG Others: Fasting Lipid Panel Others: Medications Aspirin 325 mg PO daily Enteric coated Aspirin 81 mg PO QAM Clopidogrel 75 mg PO daily Metoprolol Tartrate 25 mg PO daily (hold for SBP < 90 mmhg, HR < 50) Metoprolol Tartrate 50 mg PO daily (hold for SBP < 90 mmhg, HR < 50) Other: Statin Simvastatin 40 mg PO daily Other lipid lowering agent mg PO (if indicated) Cardiac Heparin Protocol (see attached order) Nitroglycerin 0.4 mg SL every 5 min PRN chest pain; MR x 2 Nitroglycerin 100 mg/250 ml D5W IV @ 20 mcg/min, titrate to relief of CP, keep SBP > 100 mmhg Other: Morphine Sulfate 1 mg IVP Q 2H PRN severe chest pain Docusate Sodium (Colace ) 100 mg PO BID Lisinopril 5 mg PO daily MD Signature: R. Bowler, MD Pager: 555-321-4567 Date/Time: Today / 0830 10
Scenario #3 Day 2 Sim Room 2 Recommendations: It is 1 day post PCI (Hospital Day 2) at 0900. Martin Pierce is anxious and uncomfortable. Your role as a student nurse: A basic assessment. Evaluating the Heparin infusion. Evaluate lab values provided during the simulation. Provide nursing care for patient and communication to provider as needed. You can utilize the order set from Scenario #2 as needed. 11
Clinical Education and Simulation Lab Cardiac Heparin Orders Date / Time Date: Yesterday Time: 1200 Cardiac Heparin Orders Orders Nurse to make calculations based on actual body weight in Kg Pt weight _90 Kg Make all changes as soon as possible Document all heparin adjustments and PTT results Notify Provider if heparin infusion exceeds 2500 units/hour; for any signs of bleeding; for two consecutive aptt levels > 120 seconds Heparin bolus 60 units/kg (Max 4000 units): bolus = units IV No bolus Begin continuous heparin infusion at 18 unit/kg/hr HEPARIN ADJUSTMENTS FOR ALL SUBSEQUENT PTTs: aptt Value in Seconds If less than 30 If 30-39 If 40-49 If 50-80 If 81-90 If 91-100 If greater than 100 Dosage Change Increase infusion by 3 units/kg/hr Increase infusion by 2 units/kg/hr Increase infusion by 1 unit/kg/hr Goal range: no change Decrease infusion by 1 unit/kg/hr Decrease infusion by 2 units/kg/hr Stop infusion for 1 hour; decrease by 3 unit/kg/hr STAT CBC without Diff, aptt, PT/INR prior to start of heparin (if not done within past 24 hours aptt every 6 hours x 2 after any dosage change; Once two consecutive aptts (drawn 6 hours apart) are therapeutic, order aptt every a.m. CBC without Diff every 48 hours while on heparin Physician signature: R. Bowler, MD Printed Physician Name:_Bowler Pager/Phone:_555-321-4567 12
Scenario #4 Day 3, discharge Sim Room 2 Recommendations: It is now hospital day 3 at 1600. Discharge orders have been placed on Mr. Pierce s chart. Your role as a student nurse: Complete any assessment data as needed for patient prior to discharge. Complete the discharge checklist Prepare the patient for discharge. Utilize the teaching plans that you developed in preparation for the simulation. Resources: Get with the Guidelines (GWTG) PowerPoint presentation (provided) Website for Core Measures Acute Myocardial Infarction (able to access through AMC library) http://www.nursingconsult.com/nursing-images/core-measures/ami_core_measure.pdf?from=coremeasure/ 13
Clinical Education and Simulation Lab Medication Reconciliation Inpatient Discharge Form Allergies: _Iodine Source of medication list (circle all that apply) patient medication list, patient/family recall, pharmacy, PCP list, previous discharge paperwork, MAR for facility Medication Name Dose Route Frequency Last Dose Continue/DC 1 ASA EC 325 mg PO Once Daily Yesterday 0900 2 Docusate 100 mg PO Twice Daily Yesterday 1800 3 Simvastatin 40 mg PO Daily Yesterday 0900 4 Lisinopril 5 mg PO Daily Yesterday 0900 5 Metoprolol 50 mg PO Daily Yesterday 0900 6 Clopidogrel 75 mg PO Daily Yesterday 0900 7 Coumadin 2.5 mg PO Each day Yesterday with evening 1800 meal 8 Nitroglycerin 0.4 mg SL As needed for Chest Pain Yesterday 0915 9 Hydralazine 25 mg PO Twice daily 3 days ago PM Signature Provider R. Bowler, MD Print Name Bowler Date Today Signature RN Print Name Date C C C C C C C C C DC DC DC DC DC DC DC DC DC Reviewed on Discharge by Date Scan to pharmacy 14
Clinical Education and Simulation Lab Acute MI Discharge Orders Date / Time Date: Day 3 Time: 1500 Orders AMI Discharge Orders Discharge to: Home SNF LTAC Rehab Other: Medications: Aspirin _325 mg enteric coated PO daily OR CONTRAINDICATED Rationale: Beta Blockade Agent: Metoprolol 50 mg PO daily OR CONTRAINDICATED Rationale: Statin prescribed: Simvastatin 40 mg PO daily Pneumococcal Vaccine Influenza Vaccine OR CONTRAINDICATED Rationale: Other (list separately): Clopidogrel 75 mg PO daily Lisinopril_5mg PO daily Docusate 100 mg PO twice daily Coumadin 2.5 mg PO daily Nitroglycerin 0.4 mg SL as needed for chest pain Activity: _Follow up with primary care physician Vaccinations INDICATED FOR ALL ACS PATIENTS (Adult) CONTRAINDICATIONS: Previous SEVERE reaction to vaccine INDICATED: Administer 0.5 ml IM x 1 dose on day of discharge NOT INDICATED: previously vaccinated, Date Other reason: Patient refusal INDICATED FOR ALL ACS PATIENTS (October thru February) CONTRAINDICATIONS: Allergy to eggs; previous SEVERE reaction to vaccine; history of Guillain-Barre Syndrome INDICATED: Administer 0.5 ml IM x 1 dose on day of discharge NOT INDICATED: previously vaccinated, Date Other reason: Patient refusal Physician Signature: R. Bowler, MD Pager: _555-321-4567 Date/Time: Day 3 / 1500 15
Clinical Education and Simulation Lab Acute MI Discharge Orders (cont d) Patient Education Cardiac Risk Factor Modification Teaching and Documentation ACS Education and Documentation Smoking Status: current former nonsmoker unknown Smoking Cessation Counseling and Patient Education Materials Outpatient Cardiac Rehabilitation Assessment and Referral Nutrition Consultation and Counseling Physician Signature: R. Bowler, MD Pager: 555-321-4567 Date/Time: Day 3 / 1500 16
Discharge Summary Checklist Heart Failure/Post MI with or without Left Ventricular Dysfunction Patient Name: Pierce, Martin Discharge Date: Day 3 Designated follow-up physicians/follow-up dates: Brief medical history/discharge diagnosis: Hypertension/STEMI, Anterior-lateral w/pci Ejection fraction at discharge: 68% MUGA scan Method: Echocardiogram X Cardiac catheterization Were the following discharge medications prescribed? Y N Not Indicated Agent Prescribed Contraindication Ace inhibitor ARB (if ACE inhibitor intolerant or in addition to ACE inhibitor) Beta-Blocker (evidence based*) Aldosterone antagonist Loop diuretic Thiazide diuretic Digoxin Nitrates, prescribed dosage: Sublingual/PRN Topical/Oral Hydralazine Warfarin (specify indication and target INR in comments) ASA Clopidogrel 3 months 6 months 12 months Indefinite Lipid-lowering agents Statin: Other: Y N Comments/ Reasons for Not Prescribing Initials 17
Were the following interventions and counseling measures addressed? Treatment and adherence education Risk-modification counseling (general) Y N Not Applicable Blood pressure controlled Diabetes controlled Smoking cessation recommended Dietitian/nutritionist interview Weight reduction counseling Cardiac rehabilitation interview and enrollment Physical activity counseling Possible need for ICD and/or CRT Which follow-up services were scheduled? Date Performed Comments Will need to reinforce healthy lifestyle choices as it relates to diet and exercise Will need to reinforce healthy lifestyle choices Y N Not Applicable Date Scheduled Cardiologist follow-up X 111 Primary care follow-up X Provided with information regarding smoking cessation Comments Cardiac rehabilitation X Start Date: 1 week Stress test follow-up X X Echocardiogram follow-up, EF determination (assess need for ICD or CRT) Electrophysiology referral or followup (assess need for ICD or CRT) Lipid profile follow-up X Anticoagulation service follow-up X X Electrolyte profile/serum lab work follow-up Clinical summary and patient education record faxed to appropriate physicians X X Initials Initials Adapted, with permission, by the SCA Prevention Medical Advisory Team, from the OPTIMIZE-HF registry toolkit. Sponsored by Medtronic, Inc. April 2007 18