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Vsim: Sherman “Red” Yoder Part 1 Flashcards – Quizlet
While assessing Red Yoder in his home, the nurse learns that the patient has urinary incontinence. What age-related changes occur in the urinary tract of …
Source: quizlet.com
Date Published: 3/27/2022
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Sherman _Red_ Yoder – step.html – Date of completion…
View Sherman _Red_ Yoder – step.html from NU 424 at Herzing University. Date of completion 26/1/2021 1901 Sherman “Red” Yoder Age: 80 years Diagnosis: N/A …
Source: www.coursehero.com
Date Published: 5/5/2022
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Sherman “Red” Yoder, Part 1 Documentation Assignments
1) Inspect your feet daily · 2) babe feet in lukewarm, never hot, water. · 3) Be gentle when bathing your feet. · 4) Moisturize your feet but not between your toes …
Source: www.studocu.com
Date Published: 3/14/2022
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Unfolding Case #2 Red Yoder – StudyRes
Red Yoder Unfolding Case #2 Unfolding Case #2 Red Yoder STAGES- Simulation Team Advancing Gerontologic … My name is Sherman Yoder, but I answer to “Red”.
Source: studyres.com
Date Published: 10/20/2022
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VSIM RED YODER part 1 and 2 Guided … – Qwivy
Sherman “Red” Yoder, Part 1 & 2 (answered) … How d the simulated experience of Red Yoder’s case make you feel? … sherman red yoder vsim steps.
Source: qwivy.com
Date Published: 12/19/2022
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Vsim red yoder part 1 guided reflection 6 16 – Studypool
Sherman “Red” Yoder, Part 1 & 2 (answered) Gued Reflection Questions Opening Questions How d the simulated experience of Red Yoder’s case make you feel?
Source: www.studypool.com
Date Published: 7/23/2022
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vSim® for Nursing Gerontology – Virtual Simulation
Sherman Red Yoder – Part 3, Assessment of Functional Decline and Family Conflict; Millie Larsen – Part 1, Urinary Tract Infection with Confusion; Millie Larsen …
Source: laerdal.com
Date Published: 3/14/2022
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주제와 관련된 이미지 sherman red yoder vsim steps
주제와 관련된 더 많은 사진을 참조하십시오 지역 vsim. 댓글에서 더 많은 관련 이미지를 보거나 필요한 경우 더 많은 관련 기사를 볼 수 있습니다.
주제에 대한 기사 평가 sherman red yoder vsim steps
- Author: 19-215석수안
- Views: 조회수 319회
- Likes: 좋아요 1개
- Date Published: 2021. 8. 24.
- Video Url link: https://www.youtube.com/watch?v=UPwbSBWc_qY
What is red Yoder experiencing?
Red has been a widower for 10 years. His son, Jon, manages the farm now, but Red is still involved in the decision making. Red’s current medical problems include insulin dependent diabetes complicated by an open foot wound. He also has some incontinence and difficulty sleeping.
Why are first generation antihistamines eg diphenhydramine Benadryl ]) considered inappropriate for the older adult?
First generation antihistamines such as diphenhydramine are listed under the AGS Beers category of medications to avoid for many or most older adults. Diphenhydramine is associated with sedation and cognitive impairment and should be avoided, especially in older adults with delirium [9].
What is the most significant factor leading to glucose intolerance among older adults?
Impaired pancreatic β-cell adaptation to insulin resistance appears to be an important contributing factor to age-related glucose intolerance and risk for diabetes.
Why are first generation antihistamines considered inappropriate for the older adult?
First-generation antihistamine use is considerably associated with an increased risk of injurious falls or fracture among the elderly. Introduction: First-generation antihistamines are considered potentially inappropriate for elderly patients owing to anticholinergic side effects.
How would you apply the knowledge and skills that you obtained in red Yoder case to an actual patient care situation?
8. How would you apply the knowledge and skills that you obtained in Red Yoder’s case to an actual patient care situation? I would apply the knowledge and skills I gained from this simulation by conducting thorough and detailed assessments that include both the patient and the family member.
What is spices assessment tool?
SPICES is an acronym for a brief protocol for multidimensional assessment to identify risk factors related to caring for older adults: skin integrity; problems eating; incontinence; confusion; evidence of falls; and sleep disturbance [4].
What should you not mix with antihistamines?
Taking antihistamines with other medicines, food or alcohol
Examples of medicines that could cause problems if taken with antihistamines include some types of: antidepressants. stomach ulcer or indigestion medicines. cough and cold remedies that also contain an antihistamine.
Why does Benadryl cause dementia?
Long-term use of anticholinergic drugs is associated with increased dementia risk. Potential harm to the brain: Long-term anticholinergic use has been associated with increased dementia risk; diphenhydramine can impair many cognitive functions including memory.
What is the safest antihistamine for seniors?
Loratadine, cetrizine, and fexofenadine all have excellent safety records. Their cardiovascular safety has been demonstrated in drug-interaction studies, elevated-dose studies, and clinical trials. These three antihistamines have also been shown safe in special populations, including pediatric and elderly patients.
Can you be glucose intolerant but not diabetic?
You do not have to have a diagnosis of diabetes to be glucose intolerant. However, being glucose intolerant increases your risk of developing type 2 diabetes. Blood tests are used to distinguish a diagnosis between glucose intolerance and diabetes (see below).
What is the normal blood sugar level for a 70 year old female?
Normal ranges of blood sugar levels are between 70 and 130 mg/dL before eating meals. The American Diabetes Association recommends seniors have blood glucose levels of less than 180 mg/dL two hours after eating. Not every senior has the same care needs, which means they don’t all need the same type of at-home care.
What medications can cause glucose intolerance?
- Thiazides.
- Diazoxide.
- Glucocorticoids.
- Calcineurin inhibitors, such as cyclosporine and tacrolimus.
- Oral contraceptives.
- Beta-adrenergic agonists.
- Nicotinic acid.
- Thyroid hormone.
Why can’t over 65s take Benadryl?
Because age-related changes occur in the cholinergic system, there is concern that strong anticholinergic effects may lead to a decline in cognitive function or even precipitate delirium in older adults. Diphenhydramine can have significant cognitive and performance-related adverse effects even in younger patients.
Do first-generation antihistamines cause dementia?
Moreover recent studies reported that anticholinergics including first-generation antihistamine drugs increase the incidence of dementia [23, 24]. Hence, first-generation H1-antihistamine drugs should not be used, in particular, for older people with dementia.
What are the long term effects of taking antihistamines?
These common side effects include sedation, impaired motor function, dizziness, dry mouth and throat, blurred vision, urinary retention and constipation. Antihistamines can worsen urinary retention and narrow angle glaucoma. The antihistamines rarely cause liver injury.
Why can’t over 65s take Benadryl?
Because age-related changes occur in the cholinergic system, there is concern that strong anticholinergic effects may lead to a decline in cognitive function or even precipitate delirium in older adults. Diphenhydramine can have significant cognitive and performance-related adverse effects even in younger patients.
Why is the use of first-generation H1 antihistamines discouraged in clinical practice today?
First-Generation H1-Antihistamines
But perhaps their greatest drawback is their ability to cross the blood-brain barrier and interfere with histaminergic transmission.
Can Benadryl cause hallucinations in the elderly?
Hallucinations aren’t a typical side effect of Benadryl. However, they can occur in people who take very high doses of Benadryl. If you experience hallucinations while taking Benadryl, don’t take any more of the medication. If you think you need medical treatment, call your doctor or 911.
What is a common adverse effect of first-generation antihistamines H1 blockers )?
First-generation H1 antihistamines
This potentially leads to adverse CNS symptoms such as drowsiness, sedation, somnolence, fatigue, and headache. More importantly, it potentially impairs cognitive function, memory, and psychomotor performance.
Vsim: Sherman “Red” Yoder Part 1 Flashcards
Educating the patient with diabetes about self-care concerns, including skin care, is critical. One of the major complications of diabetes mellitus is ulcer development on the feet. What teaching points should the nurse provide to the patient with diabetes?
Gerontology Case Red Yoder Part1 jasgou 1752
Sherman “R ed” Y oder , P art 1
Document ation Assignment s
1. 1. Document your a ssessment findings for Red Y oder ba sed on use of the
SPICES assessment tool.
SPICES= Sleep Disorders, Problems with eating or feeding, Incontinence, Confusion,
Evidence of Falls, Skin break down.
During the assessment, Red reveals that he is having sleeping problems and some
urgency incont inence. He also makes statements that should cue learners that further
assessments are needed of his diet, medication, and alcohol use, and to rule out el der
abuse.. Concerns expressed by the daughter -in-law about his ability to care for himself
should were also discuss in todays meeting.
2. Document assessment findings r elated to sleep and alcohol use for Red Y oder .
Upon the completion of my assessment findings of Mr. Red Y onder, I have determined
that Mr . Y onder does not suffer from sleep disturbanc es . Besides waking up multiple
times during the night to use the rest room. He takes more than 60 minutes to fall asleep
and he wakes up multiple times during the evening T’s restaurant to use the restroom. He
has no problems or diffi culty with snoring breathing or pain. He said he keeps his room at
a comfortable temperature so no problems there. He does not suf fer from any bad dreams
for nightmares. Mr. Y onder is currently taking Benadryl at least twice a week. Along with
a slight increase in his alcohol consumption, as according to his niece Judy .
3. 3. Based on your assessment , document the nursing interventions related t o wound care
for R ed Y oder .
Interventions should focus on caring for the f oot wound, preventing further skin breakdown,
and keeping Mr . Y oder ’ s blood glucose level under control.
4. 4. Following the assessment of Red Y oder , document the patient education
provi ded that relates to the management of diabetes, with specific attention to
car e of the lower extr emities ..
1) Inspect your feet daily
2) babe feet in lukewarm, never hot, water .
3) Be gentle when bathing your feet.
4) Moisturize your feet but not between your toes because that could encourage a
fungal infection.
From vSi m for Nur sing | Geron tology © W olters Kl uwer Health.
Red Yoder
Overview
Red Yoder is an 80-year-old farmer who lives alone in the farmhouse where he grew up. It is located 20 miles outside of town. Red has been a widower for 10 years. His son, Jon, manages the farm now, but Red is still involved in the decision making. Red’s current medical problems include insulin dependent diabetes complicated by an open foot wound. He also has some incontinence and difficulty sleeping.
Monologue
Red is awaiting a visit from the home health nurses. He relates that he has an open wound on his big toe that developed after walking in a new pair of shoes. When his daughter-in-law Judy saw the wound, she called the family doctor, who suggested a visit by the wound care nurse who works with the home health agency. Red agreed as long as his VA benefits cover the costs. Red is aware that his son and daughter-in-law have concerns about him living alone, but Red insists that while he needs a little help from Jon and Judy at times, he is still capable of caring for himself.
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The Pathophysiology of Hyperglycemia in Older Adults: Clinical Considerations
Nearly a quarter of older adults in the U.S. have type 2 diabetes, and this population is continuing to increase with the aging of the population. Older adults are at high risk for the development of type 2 diabetes due to the combined effects of genetic, lifestyle, and aging influences. The usual defects contributing to type 2 diabetes are further complicated by the natural physiological changes associated with aging as well as the comorbidities and functional impairments that are often present in older people. This paper reviews the pathophysiology of type 2 diabetes among older adults and the implications for hyperglycemia management in this population.
Diabetes is one of the leading chronic medical conditions among older adults, with high risk for vascular comorbidities such as coronary artery disease, physical and cognitive function impairment, and mortality. Despite decades of effort to prevent diabetes, diabetes remains an epidemic condition with particularly high morbidity affecting older adults. In fact, nearly 11 million people in the U.S. aged 65 years or older (more than 26% of adults aged 65 years or older) meet current American Diabetes Association criteria for diabetes (diagnosed and undiagnosed), accounting for more than 37% of the adult population with diabetes ( 1 ). At the same time, adults 65 years or older are developing diabetes at a rate nearly three-times higher than younger adults: 11.5 per 1,000 people compared with 3.6 per 1,000 people among adults aged 20–44 years old ( 1 ). However, increasing research in diabetes and aging has improved our understanding of the pathophysiology of diabetes and its association with aging and led to the development of a number of antihyperglycemic medications. The mechanism of diabetes complications has been previously reviewed ( 2 ). The current paper reviews the pathophysiology of type 2 diabetes among older adults and the implications for hyperglycemia management in this population.
Hyperglycemia develops in type 2 diabetes when there is an imbalance of glucose production (i.e., hepatic glucose production during fasting) and glucose intake (i.e., food ingestion) as opposed to insulin-stimulated glucose uptake in target tissues, mainly skeletal muscle. Multiple factors in an older person contribute to such an imbalance of glucose regulation, as illustrated by Fig. 1 . Although resistance to peripheral insulin action contributes to altered glucose homeostasis, current evidence has found that the direct effect of aging on diabetes pathophysiology is through impairment of β-cell function, resulting in a decline in insulin secretion.
Type 2 diabetes is by far the most prevalent form of diabetes in older adults and is an age-related disorder. The criteria for diagnosing diabetes are the same for all age groups because the risks of diabetes-related complications are associated with hyperglycemia over time across all age groups ( 3 ). Older adults are at high risk for the development of type 2 diabetes due to the combined effects of genetic, lifestyle, and aging influences. These factors contribute to hyperglycemia through effects on both β-cell insulin secretory capacity and on tissue sensitivity to insulin. The occurrence of type 2 diabetes in an older person is complicated by the comorbidities and functional impairments associated with aging.
Genome-wide association studies have consistently found that p16 INK4a , a cyclin-dependent kinase inhibitor (CDKI), encoded by the Cdkn2a locus, is associated with type 2 diabetes risks ( 6 ). Expression of p16 INK4a was increased in aging mice ( 7 ), and an additional copy of p16 INK4a was associated with markedly reduced pancreatic islet cell proliferation ( 8 ). β-Cell proliferation was increased in p16 INK4a knockout mice. Therefore, p16 INK4a increases with age and appears to mediate an age-associated decline in the replicative capacity of mouse islets; p16 INK4a could be a potential link between aging, metabolic derangements, and β-cell failure in type 2 diabetes.
There is a strong genetic predisposition to type 2 diabetes ( 4 ). The genetic susceptibility to type 2 diabetes is polygenic, involving a number of variants, where each allele has a modest effect on the risk of disease in an individual person. Genome-wide association studies, linkage analysis, candidate gene approach, and large-scale association studies have identified ∼70 loci conferring susceptibility to type 2 diabetes ( 5 ). These genetic alleles appear to affect the risk of type 2 diabetes primarily through impaired pancreatic β-cell function, reduced insulin action, or obesity risk.
In the setting of genetic and lifestyle-related risk factors, aging contributes to the development of type 2 diabetes through impaired β-cell function and impaired β-cell adaptation to insulin resistance (9,10) leading to impaired insulin secretion (11,12), as illustrated in Fig. 1. Studies in rodents and humans have found that aging may exert a distinct influence on β-cell turnover as well as function.
In older patients who have developed diabetes, autoimmune destruction of β-cells is rarely observed. Limited pathologic investigation suggests that total β-cell mass may be moderately reduced, but severe loss of β-cell mass is uncommon. Pancreatic β-cell mass in adult humans exists in a dynamic state such that the cells can undergo compensatory changes to maintain euglycemia. Aging is thought to be associated with reduced capacity to regenerate β-cells, as suggested by studies involving rodents (13–15) and humans (16–18). On the one hand, for example, the β-cell toxin streptozotocin, partial pancreatectomy, or exendin-4 were more effective in stimulating β-cell proliferation in younger mice (younger than 12 months old) than in older mice (13–15,19). On the other hand, the age-associated decline in β-cell function in older rats has been shown to be reversible with glucagon-like peptide 1 (GLP-1; exendin) treatment (20), suggesting stimulation of β-cell regeneration (21). In humans, the baseline β-cell population and appropriate association with other islet cell types is established before 5 years of age (22). Other studies using C14 or Ki67 have found that human adult β-cell turnover is very low (16,17,22,23). Similarly among middle-aged and older adults, minimal β-cell regeneration was observed after a mean follow-up period of 1.8 ± 1.2 years after a 50% partial pancreatectomy: β-cell mass and new β-cell formation were not increased, and β-cell turnover was unchanged (18). The follow-up time of this study may have been too short for human β-cells to replicate, but other studies have also found evidence of slow β-cell proliferation in humans with advancing age (24,25). The decline in β-cell replication was directly associated with a decrease in the expression of a transcription factor known as the pancreatic and duodenal homeobox 1 (pdx1) (26). Thus, the overall evidence suggests that human β-cells survive for a long time and are unlikely to be replenished by replications once adulthood is reached (27). Several age-related potential molecular pathways have been found to restrict β-cell regeneration. For example, the replication refractory period, the time between cell divisions (G0 stage of cell cycle), appears to lengthen with age (28); the replicative capacity of β-cells might be reduced due to accumulation of DNA mutations with aging.
Therefore, β-cell function in human adults might be enhanced in the setting of hyperglycemia or insulin resistance to maintain euglycemia. Pancreatic β-cells appear to primarily compensate for limited replication capacity through hyperplasia and hypertrophy. However, a number of studies have demonstrated a decline in β-cell function and insulin secretion with age in rodents (26). In humans, as shown in Fig. 2, the insulin secretion rate in response to glucose was significantly and progressively decreased in older individuals, with the greatest impairment in older individuals with impaired glucose tolerance compared with older individuals with normal glucose tolerance or with younger individuals matched for degree of insulin resistance (9). In fact, a 50% reduction in β-cell secretory capacity has been observed in older men compared with younger men in response to arginine stimulation (29).
Figure 2 View largeDownload slide Impaired β-cell function in human aging: response to nicotinic acid–induced insulin resistance. Reprinted with permission from Chang et al. (9). Plasma glucose concentrations and insulin secretion rate (ISR) are shown over time during intravenous glucose infusions, comparing young people (mean age, 26 years) with normal glucose tolerance (NGT; n = 15) and old people (mean age, 70 years) with NGT (n = 16) or with impaired glucose tolerance (IGT; n = 14). Glucose levels during the variable glucose infusion rate and degree of insulin resistance were similar in the three study groups. ISR was significantly and progressively decreased in the two older groups, with the greatest impairment in old IGT. P = 0.0002, old IGT vs. young and old IGT vs. old NGT; and old NGT vs. young NGT. Data are means ± SE. Figure 2 View largeDownload slide Impaired β-cell function in human aging: response to nicotinic acid–induced insulin resistance. Reprinted with permission from Chang et al. (9). Plasma glucose concentrations and insulin secretion rate (ISR) are shown over time during intravenous glucose infusions, comparing young people (mean age, 26 years) with normal glucose tolerance (NGT; n = 15) and old people (mean age, 70 years) with NGT (n = 16) or with impaired glucose tolerance (IGT; n = 14). Glucose levels during the variable glucose infusion rate and degree of insulin resistance were similar in the three study groups. ISR was significantly and progressively decreased in the two older groups, with the greatest impairment in old IGT. P = 0.0002, old IGT vs. young and old IGT vs. old NGT; and old NGT vs. young NGT. Data are means ± SE. Close modal
Impaired pancreatic β-cell adaptation to insulin resistance appears to be an important contributing factor to age-related glucose intolerance and risk for diabetes. Although aging per se has a minimal effect on insulin action directly (30), many older individuals develop insulin resistance as a result of diminished physical activity, obesity, and loss of lean body mass, particularly those with a disproportional loss of skeletal muscle over adipose tissue. Age had no independent effect on insulin sensitivity when controlled for obesity; age-related reductions in insulin sensitivity are likely the result of an age-related increase in adiposity rather than a consequence of advanced chronological age (31).
Insulin resistance with aging appears to reflect predominantly lifestyle factors such as poor diet and diminished physical activity. These changes lead to decreased lean body mass and increased adiposity, particularly visceral adiposity, with aging. More than 35% of U.S. adults aged 60 years or older are obese, having a BMI of 30 kg/m2 or greater (3). An absolute or relative increase of body adiposity, particularly central body adiposity, often associated with advancing age, appears to account in large part for the age-related increase in insulin resistance (32,33). Even among adults without diabetes, intraabdominal fat mass correlates with insulin resistance and age after controlling for obesity (34). However, insulin resistance is more closely associated with abdominal adiposity than with age (35,36). In addition to excessive caloric intake, increased body adiposity is partly related to a sedentary lifestyle, which is common among older adults; for example, only 12% of adults aged 75 or older engage in 30 min of physical activity 5 or more days per week, and 65% report no leisure time physical activity (37). Increasing physical activity in older adults reduces insulin resistance (38), reduces the risk of developing diabetes (39), and improves glycemic control in people with diabetes (40).
Low-grade inflammation and stress-response changes associated with obesity and aging are likely to contribute to the increased risk of type 2 diabetes among older adults (41). Aging and obesity are both thought to be independently associated with the development of low-grade inflammation (42), and proinflammatory cytokines, such as C-reactive protein, interleukin 6, and tumor necrosis factor-α, have been found to inhibit insulin signaling and increase insulin resistance and risk of type 2 diabetes (41,43).
The role of mitochondrial function in aging and type 2 diabetes remains unclear. Older adults were found to have a decrease in mitochondrial function compared with younger adults (i.e., decreased ATP synthesis); however, older adults with normal glucose tolerance had similar ATP production level compared with older adults with impaired glucose tolerance (44). On the other hand, exercise reverses age-related declines in mitochondrial oxidative capacity and ATP production, which may be part of the underlying mechanism through which exercise improves insulin sensitivity (44,45).
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Unfolding Case #2 Red Yoder
Transcript
Red Yoder Unfolding Case #2 Unfolding Case #2 Red Yoder STAGES- Simulation Team Advancing Gerontologic Education Strategies Educator’s Toolkit Overview Red Yoder is an 80-year-old farmer who lives alone in the farmhouse he grew up in. It is located 20 miles outside of town. Red has been a widow for 10 years. His son Jon manages the farm now but Red is still involved in the decision making. Jon lives a few miles up the road and he or his wife stop by nearly every day. In the introductory monologue, Red is awaiting a visit from the home health nurses. He relates that he is a newly insulin-dependent diabetic and has an open wound on his big toe that developed after walking in a new pair of shoes. When his daughter-in-law Judy saw the wound, she called the family doctor, who suggested a visit by the wound care nurse who works with the home health agency. Red says he agreed as long as his VA benefits cover the costs. Red is aware that his son and wife have concerns about him living alone, but Red insists that while he needs a little help from Jon and Judy at times, he is still capable of caring for himself. A series of 3 simulation scenarios provide encounters with Red on three separate occasions. Simulation Scenario 1 occurs in Red’s home during a visit by the nurses from the home health agency to assess the breakdown on his toe. During the assessment, Red reveals that he is having sleeping problems and some urgency incontinence. He also makes statements that should cue learners that further assessments are needed of his diet, medication, and alcohol use, and to rule out elder abuse.. Concerns expressed by the daughter-in-law about his ability to care for himself should prompt learners to use the Katz Index of Independence in Activities of Daily Living assessment tool. Other assessment tools recommended for this scenario include SPICES: An Overall Assessment Tool of Older Adults, the Pittsburgh Sleep Quality Index (PSQI), the Elder Mistreatment Assessment and the Alcohol Use and Screening Assessment. A second monologue occurs two weeks later. Red reveals that he is not going to town to meet his friends for coffee today and hopes his friends aren’t worried about him. He has a loss of appetite and his foot with the wound is red and swollen. Red reveals that he has been forgetting to take the antibiotic for the sore on his toe. He is questioning whether to take his insulin since he has not eaten, but his capillary blood glucose monitor reading is 203. Simulation Scenario 2 takes place in the Emergency Room of the local hospital. Jon stopped by to check on Red after one of his friends from the VFW called to say that Red didn’t make it to town for coffee. When Jon arrived to check on his father he was surprised at how red and swollen his foot was. He saw that Red was weak and listless so he called the doctor who said he needed to be seen immediately at the local community hospital because the nearest VA hospital is over 100 miles away. The learner will encounter the older adult’s atypical presentation of sepsis. The assessment tool recommended for this scenario is the Confusion Assessment Method (CAM). 1 Red Yoder Unfolding Case #2 Simulation Scenario 3 occurs 5 days later when Red is scheduled for discharge from the hospital. Jon thinks that Red should move in with him for now, but Red is sure he is able to care for himself, and insists that his confusion was due to the fact that he did not have his glasses or hearing aids for the last week. Learners will need to determine how much, if any, functional decline has occurred while Red has been hospitalized. The risks and benefits of Red’s living arrangements need to be analyzed in collaboration with Red, Jon, Judy and the healthcare team. Suggested tools for this scenario include the Katz Index of Independence in Activities of Daily Living (ADL) and/or the Lawton Instrumental Activities of Daily Living (IADL)Scale, and the Transitional Care Model (TCM): Hospital Discharge Screening Criteria for High Risk Older Adults. Finish the Story Assignment The “Finish the Story” assignment is the same for all cases. Learners have seen the older adult at several snapshots in time. This last assignment in each of the cases calls for the student to “finish the story” and relate where they see the older adult or older couple about three months after their last encounter. This assignment should give faculty insight into what students have learned from the unfolding case. 2 Red Yoder Unfolding Case #2 Introductory Monologue I understand you want to hear my story; well I’m not much for talking, but I can give you the highlights. There’s a lot that’s happened over my 80 years. From the top. My name is Sherman Yoder, but I answer to “Red”. No one around here even remembers my real name. I was born in this house in the downstairs bedroom. Mom had already delivered 6 kids and there was no way I was waiting for Dad to finish feeding the hogs and get Mom to town before I come out. Mom used to love to tell that story. Dad bought this farmhouse and the first hundred acres right before he went off to WWI. The folks saw good times and bad in this ol’ place and so have I. All my brothers and sisters left the land as soon as they could. I was the only one of the lot to care about this place and want to carry on what Dad started. I really haven’t gone far from this spot in my entire life. The one time I got it in my head to try something different; I wound up in Korea with an Army uniform on. I was glad to get back to this place after that stint and here I’ve been ever since. Married the neighbor girl Bessie when I got back. Her dad wasn’t so sure that it would work out since she was 8 years younger than me and she intended to go off to the state college. We sure did prove him wrong; we celebrated our 50th anniversary the week before Bessie died. The ladies at the church had the hall all decorated up and we brought Bessie home from the hospital for the afternoon. She was bound and determined to live for that day; no way did she want her friends to go to that much work for her to not show up. I couldn’t believe it when the ladies had to prepare for the reception after we buried Bessie in that same hall one week later. We had such a good life together. That was 10 years ago. I don’t do much of the farm work anymore. Our son Jon takes care of the crops and the few animals we have. I still go out to the hen house every morning to collect the eggs. I’m a little stiff in the morning, but I get loosened up enough to walk out to gather some fresh eggs to go with my bacon for breakfast. I get in to town at least once a week; on Monday morning me and my buddies meet at the VFW for our coffee and donut break. I get caught up on all the town gossip and we laugh and bellyache about what’s going on in the world. Three weeks ago I celebrated my 80th birthday. My daughter in law, Judy, organized a big “to do” at the church after the Sunday service with cake and ice cream and all the fixings’ for my party. I had a big piece of cake but skipped the ice cream. Doc Baker was there and I knew he would scold me about too much sugar. Six months ago he told me I had diabetes and I started taking a pill for it, but a few weeks ago he put me on insulin. I figure I should be able to eat what I want; come on, I’m not going to live forever, and it was my favorite cake, German chocolate. I ate it in the kitchen so the Doc wouldn’t see me; wouldn’t you know, his office nurse Helen came in the kitchen with a load of dishes just as I was putting the last bite in my mouth. She just winked at me and smiled. After the party I went out to the mall with Jon and the grandkids. I’m not one for shopping much, but I needed a new ink cartridge for my printer and the computer store is the one 3 Red Yoder Unfolding Case #2 place I like to look around in. Too bad we parked clear on the other end of the mall so the kids could go by their favorite stores for Grandpa to buy them a little something. Jon got real mad at me when I asked if I could sit and rest for a while, so I just kept walking. I guess my new shoes were a little tight; I didn’t feel anything but when I got home there was some blood on my sock, and then I saw a sore on my big toe. It must not be too bad since it’s not hurting except when I try to put my shoes on. I showed the sore to Jon and Judy the other day and Judy said she would call the doctor to see what she should put on it. Jon gets so irritated when I need extra help; I hope I can just continue to soak my foot in hot water to clean it out. Judy was a nursing assistant out at the old folk’s home for many years; I’m hoping she will be able to help me with this. I like the idea of the home nurses coming out here as long as my VA benefits pay for it. That way they can see that I’m doing just fine living here on my own. I was searching on the internet for the best way to treat this sore; there are so many sites that talk about foot sores if you’re a diabetic. Some of those pictures of toe sores are pretty scary; I can’t sleep at night thinking about what could happen if this doesn’t heal. Of course I haven’t slept through the night for years. Even the couple of beers I have at night when I’m on the computer don’t seem to be helping anymore. Bessie always gave the kids Benadryl to help them sleep so I’ve been taking a couple when I go to bed; they seem to help me sleep a little better. As a matter of fact, I need to wrap this up now. I promised Jack, my grandson in college that I’d Skype him in a few minutes. He just started the agronomy program at the university. I love to hear about what he’s learning and give him encouragement to come back to the farm. Red’s introductory monologue can be used in a variety of ways. Here are a few to consider: • large class discussion • small group discussion during class or clinical • reflective journaling assignment • web-based assignment: listen to the audio or read the script, then discuss and summarize the group’s conclusions. Focused discussion and questions adapted from: Benner, P., Sutphen, M., Leonard, V., Day, L., & Shulman, L. (2010). Paradigm case: Lisa Day, classroom and clinical instructor. In Educating nurses: A call for radical transformation (p. 133). San Francisco: Jossey-Bass. 1. 2. 3. 4. 5. 6. What are “Red’s” strengths? What are your concerns for this patient? What is the cause of your concern? What information do you need? What are you going to do about it? What is “Red” experiencing? 4 Red Yoder Unfolding Case #2 B. Possible answers to questions: 1. What are “Red’s” strengths? Red has his son and daughter-in-law who live near and are active in his life. He has a close group of friends at the VFW and he has ties to his church. He is cognitively and physically active. 2. What are your concerns for this patient? Red’s sore on his big toe is concerning along with the fact that he has had this for 3 weeks without telling anyone. Several times he speaks of items he eats or drinks that are a concern due to high calorie and fat content (cake, bacon, beer, donuts). He also has a daily intake of alcohol and uses Benadryl to help sleep. Red made two statements about his son (“Jon got real mad”, “Jon gets so irritated”) that bear further assessment to rule out mistreatment. Does Red have adequate finances? 3. What is the cause of your concern? Red is trying to manage his wound on his own without consulting his family or doctor. He is experiencing sleep disturbance. Family dynamics may be the source of anxiety for Red. He also mentioned a concern about his VA benefits paying for the cost of the home care nurse. 4. What information do you need? How is Red managing his diabetes? More information is needed related to his diet, monitoring his blood glucose, and administration of insulin. What is his financial situation? Can he cover the cost of his living and medical costs? Red did not reveal any other difficulties related to incontinence or falls in the monologue. These should be assessed. 5. What are you going to do about it? Utilize the ACES Framework to guide assessments and actions. 6. What is “Red” experiencing? He is experiencing skin breakdown in which the healing processes is complicated by his diabetes. He wants to remain independent, living in his home. The Essential Nursing Actions from the ACES Framework (see chart below) can serve as a guide to learners when deciding what interventions may be appropriate for the older adult in this situation 5 Red Yoder Unfolding Case #2 ACES Framework Assess • Function and Expectations • Coordinate • and Manage Care • Use • Evolving Knowledge • • • • Make Situational Decisions • • • Assess the older adult’s individual aging pattern and functional status using standardized assessment tools. Use effective communication techniques to recognize, respond to, and respect an older adult’s strengths, wishes, and expectations. Include findings of assessment of older adult’s cognition, mood, physical function, and comfort to fully assess the individual aging pattern. Manage chronic conditions, including atypical presentations, in daily life and during life transitions to maximize function and maintain independence. Assist older adults and families/caregivers to access knowledge and evaluate resources. Advocate during acute exacerbations of chronic conditions to prevent complications. Understand geriatric syndromes and unique presentations of common diseases in older adults. Access and use emerging information and research evidence about the special care needs of older adults and appropriate treatment options. Interpret findings and evaluate clinical situations in order to provide high quality nursing care based on current knowledge and best practices. Analyze risks and benefits of care decisions in collaboration with the interdisciplinary team and the older adult and family/caregivers. Evaluate situations where standard treatment recommendations need to be modified to manage care in the context of the older adult’s needs and life transitions. Consider the older adult’s wishes, expectations, resources, cultural traditions, and strengths when modifying care approaches. Simulation Scenario 1 This scenario takes place in Red’s home with the arrival of the home health nurses. They will assess Red’s physical and mental status as well as his home environment. They will notify the physician of their findings. Second monologue: Occurs two weeks later. “As much as I hate to miss it, I don’t think I’ll go into town today. I never miss Monday morning coffee at the VFW with my buddies. Sometimes my friends worry about me; they will probably wonder where I am. I know it’s only 20 miles, but I just haven’t felt like eating the last couple of days; maybe I’ve got the flu that’s going around. I’m not sure if I should take my insulin because I’m not eating, but my blood sugar was 203 when I poked my finger this morning. How can that be when I’m not eating? Wow! I just took of my sock to check on my sore and my whole foot is red and big. I haven’t looked at it for a few days; it was just a little pink the last time I checked it. I should have paid closer attention to those pills I was supposed to take, that antibiotic. The nurse 6 Red Yoder Unfolding Case #2 wanted to make sure I didn’t get an infection in that toe. She comes tomorrow to change the bandage; I’d better make sure to take the antibiotic today.” Red’s second monologue can also be used in a variety of ways. Here are a few to consider: • large class discussion • small group discussion during class or clinical • reflective journaling assignment • web-based assignment: listen to the audio or read the script, then discuss and summarize the group’s conclusions. Focused discussion and questions adapted from: (Benner, et al. 2010, p.133.) 1. What are “Red’s” strengths? 2. What are your concerns for this patient? 3. What is the cause of your concern? 4. What information do you need? 5. What are you going to do about it? 6. What is “Red” experiencing? B. Possible answers to questions: 1. What are “Red’s” strengths? Red has assessed his wound and his blood glucose and is aware that there is a problem. 2. What are your concerns for this patient? Red’s foot is red and swollen and he has a loss of appetite. 3. What is the cause of your concern? Older adults may have an atypical presentation of sepsis. Red does not indicate that he is going to call his son or doctor to talk about how he is feeling and what his foot looks like. 4. What information do you need? There is a need to assess for signs and symptoms of infection, understanding that older adults may have an atypical presentation. There might be an absence of fever, absence of leukocytosis. Presentation of an infection in an older adult may be falls, decreased appetite or fluid intake, confusion, or change in functional status. 5. What are you going to do about it? Utilize the ACES Framework (above) to guide assessments and actions: 6. What is “Red” experiencing? From his assessment, there is a local and perhaps systemic infection occurring. 7 Red Yoder Unfolding Case #2 The second simulation takes place at the local hospital. Jon stopped by to check on Red after one of his friends from the VFW calls to say that Red didn’t make it for coffee. The nearest VA hospital is over 100 miles away and the doctor told him that Red needed to be seen immediately. He is admitted for possible sepsis. The focus of this simulation is an emphasis on the atypical presentation of sepsis in the older adult. (See Simulation Template #2) Simulation Scenario 3 occurs 5 days later when Red is planning for discharge from the hospital. Jon thinks that Red should stay with him for now, but Red is sure he is able to care for himself at home as he has always done. Learners will need to determine how much, if any, functional decline has occurred while Red has been hospitalized. The risks and benefits of Red’s destination need to be analyzed in collaboration with Jon and Judy and the healthcare team. (See Simulation Template #3) “Finish the Story” Assignment Learners have now seen Red at four snapshots in time. The last assignment calls for the student to “finish the story” and relate where they see Red about three months after their last encounter with him. This assignment should give faculty insight into what students have learned from the unfolding case. The assignment may take on any the forms below: • short paper • reflective journal entry • class discussion • small group discussion • online discussion • student presentation using role playing Whatever format you choose, encourage learners to indicate the reasoning behind their end of story, based on what they know about Red. They should consider his history and the risk factors and benefits they considered. The student should cite morbidity and mortality data to support their outcomes. They should relate their beliefs about the role of the nurse in his continued care and cite any community resources or referrals that might be needed. 8 Simulation Design Template- Sherman “Red” Yoder-Simulation #1 Date: Discipline: Nursing Expected Simulation Run Time: Location: Simulated home environment Admission Date: Psychomotor Skills Required Prior to Simulation Today’s Date: Brief Description of Client Name: Sherman “Red” Yoder Gender: Male Age: 80 Weight: 109 kg File Name: “Red” Yoder Simulation #1 Student Level: Guided Reflection Time: 20 minutes Location for Reflection: classroom Race: Caucasian Height: 183 cm Religion: Protestant Phone: 869-555-3452 Allergies: no known allergies 1. 2. 3. 4. 5. Basic health assessment Home environmental assessment Vital signs Blood glucose monitoring Wound assessment and care Cognitive Activities Required prior to Simulation [i.e. independent reading (R), video review (V), computer simulations (CS), lecture (L)] Red’s introductory monologue. (R) Review nursing management of the client with diabetes (activity, diet, monitoring of blood sugar, insulin administration, etc) (R) Immunizations: Influenza last fall; tetanus 2007 Attending Physician/Team: Family Practice: Dr. Frank Baker Past Medical History: Diabetes Type 2 diagnosed ______ (insert month that is six months prior) History of Present illness: Developed an ulcer on his big toe 3 weeks ago. Has been soaking his foot to heal the wound; recently revealed the wound to his family who called Dr. Baker. Social History: Widower; his son Jon lives nearby Primary Medical Diagnosis: Pressure ulcer right great toe Surgeries/Procedures & Dates: L4-5 laminectomy 1976; Transurethral resection of Downloaded from http://sirc.nln.org with the permission of the National League for Nursing and Laerdal Medical. This document may be reproduced as long as it retains the following copyright statement: © Copyright, 2010. Simulation in nursing education: From conceptualization to evaluation. New York: National League for Nursing. Reprinted with permission. If you find this Simulation Design Template useful, we would appreciate hearing from you. Please send an email message with your comments to [email protected] 1 Simulation Design Template- Sherman “Red” Yoder-Simulation #1 the prostate 2005 Nursing Diagnoses: Alteration in tissue integrity; Risk for infection; Ineffective health maintenance Downloaded from http://sirc.nln.org with the permission of the National League for Nursing and Laerdal Medical. This document may be reproduced as long as it retains the following copyright statement: © Copyright, 2010. Simulation in nursing education: From conceptualization to evaluation. New York: National League for Nursing. Reprinted with permission. If you find this Simulation Design Template useful, we would appreciate hearing from you. Please send an email message with your comments to [email protected] 2 Simulation Design Template- Sherman “Red” Yoder-Simulation #1 Simulation Learning Objectives – for faculty 1. The learner will assess the patient’s individual aging pattern and functional status using standardized assessment tools. The suggested tools listed below can be found at http://consultgerirn.org/resources/?tt_request=issue04.pdf • • • • • SPICES: An Overall Assessment Tool of Older Adults Katz Index of Independence in Activities of Daily Living (ADL) The Pittsburgh Sleep Quality Index (PSQI) Elder Mistreatment Assessment Alcohol Use Screening and Assessment 1. The learner will use communication techniques to recognize, respond to and respect an older adult’s strengths, wishes and expectations. 2. The learner will use standardized communication tools to discuss the care of the client with other health care providers. Suggested tools: SBAR – call to Dr. Baker reporting status of wound and recommendation for treatment. 3. The learner will discuss pertinent assessment findings and what was found that was specific to the older adult patient. 4. The learner will implement appropriate interventions based on the assessment data collected. (wound care, education related to management of diabetes (capillary blood glucose measurement, nutrition, medication) 5. Learner will identify geriatric syndrome(s) evident in the simulation (sleep disturbance, skin breakdown) Simulation Learning Objectives – for learners 1. The learner will assess the patient’s individual aging pattern and functional status using standardized assessment tool. 2. The learner will use communication techniques to recognize, respond to and respect an older adult’s strengths, wishes and expectations. 3. The learner will use standardized communication tools to discuss the care of the client with other health care provider. 4. The learner will discuss pertinent assessment findings and what was found that was specific to the older adult patient. 5. The learner will discuss pertinent assessment findings related to the patients diabetic status 7. The learner will implement appropriate interventions based on the assessment data collected. 8. Learner will identify geriatric syndrome(s) evident in the simulation. Downloaded from http://sirc.nln.org with the permission of the National League for Nursing and Laerdal Medical. This document may be reproduced as long as it retains the following copyright statement: © Copyright, 2010. Simulation in nursing education: From conceptualization to evaluation. New York: National League for Nursing. Reprinted with permission. If you find this Simulation Design Template useful, we would appreciate hearing from you. Please send an email message with your comments to [email protected] 3 Simulation Design Template- Sherman “Red” Yoder-Simulation #1 Fidelity (choose all that apply to this simulation) Setting/Environment ER Med-Surg Peds ICU OR / PACU Women’s Center Behavioral Health Pre-Hospital Other: Home health Simulator Manikin/s Needed: Human patient simulator, or standardized patient Props: Manikin dressed in street clothes, environment should look like the home; wound moulage: right great toe should have a wound that has some depth, has bright red tissue and slight redness around the wound. If available, may consider using the foot with the wound on the toe (Laerdal product) and cover the black part of the wound for the first simulation. Equipment attached to manikin: IV tubing with primary line fluids running at mL/hr Secondary IV line running at mL/hr IV pump Foley catheter mL output PCA pump running IVPB with running at mL/hr 02 Monitor attached ID band Other: Equipment available in room Bedpan/Urinal Foley kit Straight Catheter Kit Incentive Spirometer Fluids Medications and Fluids IV Fluids: Oral Meds: IVPB: IV Push: IM or SC: Diagnostics Available Labs X-rays (Images) 12-Lead EKG Other: Documentation Forms Physician Orders Admit Orders Flow sheet Medication Administration Record Kardex Graphic Record Shift Assessment Triage Forms Code Record Anesthesia / PACU Record Standing (Protocol) Orders Transfer Orders Other: Recommended Mode for Simulation (i.e. manual, programmed, etc.) Manual; mechanism needed for transmission of the voice of the patient via manikin Downloaded from http://sirc.nln.org with the permission of the National League for Nursing and Laerdal Medical. This document may be reproduced as long as it retains the following copyright statement: © Copyright, 2010. Simulation in nursing education: From conceptualization to evaluation. New York: National League for Nursing. Reprinted with permission. If you find this Simulation Design Template useful, we would appreciate hearing from you. Please send an email message with your comments to [email protected] 4 Simulation Design Template- Sherman “Red” Yoder-Simulation #1 IV start kit IV tubing IVPB Tubing IV Pump Feeding Pump Pressure Bag 02 delivery device (type) Crash cart with airway devices and emergency medications Defibrillator/Pacer Suction Other: Roles/Guidelines for Roles Primary Nurse Secondary Nurse Clinical Instructor Family Member #1 Family Member #2 Observer/s Recorder Physician/Advanced Practice Nurse Respiratory Therapy Anesthesia Pharmacy Lab Imaging Social Services Clergy Unlicensed Assistive Personnel Code Team Other: Important Information Related to Roles: Family member may be present. (daughter in law or son); they are supportive and want to learn how to care for the wound and how to help Red manage his diabetes. Significant Lab Values: Student Information Needed Prior to Scenario: Has been oriented to simulator Understands guidelines /expectations for scenario Has accomplished all pre-simulation requirements All participants understand their assigned roles Has been given time frame expectations Other: Report Students Will Receive Before Simulation Red is an 80 year old farmer who lives by himself. He has had diabetes for about 6 months and recently began taking insulin. We (nurses from the home health agency) have been asked to see him to evaluate a wound he has from wearing a pair of shoes that were too tight. This wound happened about 3 weeks ago; Red has been treating it by soaking his foot in water. His daughter in law has also asked for an evaluation of his ability to live by himself. We know he is very independent, alert and oriented, drives himself into town at least once a week, and spends a lot of time on his computer. No labs Physician Orders: Downloaded from http://sirc.nln.org with the permission of the National League for Nursing and Laerdal Medical. This document may be reproduced as long as it retains the following copyright statement: © Copyright, 2010. Simulation in nursing education: From conceptualization to evaluation. New York: National League for Nursing. Reprinted with permission. If you find this Simulation Design Template useful, we would appreciate hearing from you. Please send an email message with your comments to [email protected] 5 Simulation Design Template- Sherman “Red” Yoder-Simulation #1 References, Evidence-Based Practice Guidelines, Protocols, or Algorithms Used For This Scenario Reading and Resources: You may wish to have your students review these resources in preparation for the first simulation scenario. 1. The following tools are available at ConsultgeriRN.org http://www.consultgerirn.com/resources • SPICES: An Overall Assessment Tool of Older Adults • Katz Index of Independence in Activities of Daily Living (ADL) and/or The Lawton Instrumental Activities of Daily Living(IADL)Scale • The Pittsburgh Sleep Quality Index (PSQI) • Elder Mistreatment Assessment • Alcohol Use Screening and Assessment 2. This article reviews clinical practice guidelines. Standards of Medical Care in Diabetes—2010; Diabetes Care January 2010 vol. 33 no. Supplement 1 S11-S61; http://care.diabetesjournals.org/content/33/Supplement_1/S3.full.pdf+html (retrieved Aug 17, 2010) 3. This is the American Diabetes Association’s website that would be useful for both faculty and learners. http://www.diabetes.org/ Downloaded from http://sirc.nln.org with the permission of the National League for Nursing and Laerdal Medical. This document may be reproduced as long as it retains the following copyright statement: © Copyright, 2010. Simulation in nursing education: From conceptualization to evaluation. New York: National League for Nursing. Reprinted with permission. If you find this Simulation Design Template useful, we would appreciate hearing from you. Please send an email message with your comments to [email protected] 6 Simulation Design Template- Sherman “Red” Yoder-Simulation #1 Scenario Progression Outline Timing (approximate) 0-5 minutes 5-10 minutes Manikin Actions Expected Interventions May Use the Following Cues Sitting comfortably in chair; alert and oriented; answers all questions. “Judy told me you wanted to check in on me and make sure I’m still o.k. to live out here by myself” “Did you want to look at my foot?” Wash hands Role member providing cue: Patient Cue: Answers to SPICES: Has trouble falling and staying asleep. Drinks a couple of beers (2) before bed to help him sleep. Takes 2 Benadryl recently to help sleep” Advise Red that Benadryl should not be used to help him sleep. Discuss more healthy sleep habits. Skin breakdown on right big toe. Answers to ADL/IADL: Bathes self uses shower chair if needs to sit. Judy does his laundry. He usually wears something easy to put on. Has fallen a couple of times when he gets up too fast. Has urgency with urination occasionally since TURP. Cooks simple meals. Judy brings over casseroles to get his through the week. Answers to PSQI: Goes to bed at 9:00; takes about an hour to fall asleep; gets up at 5:00 in the morning; gets 5 or 6 hours of sleep. Cannot get to sleep within 30 Introduce self Identify patient Begins general assessment If statements related to his son Jon being angry during Red’s monologue are addressed, the Elder mistreatment tool can be used. Assess for orthostatic hypotension. Role member providing cue: Judy Cue: Supportive, she should bring up issues to guide assessment if needed; i.e. “You take a few other medications don’t you? “Did you say you are having trouble sleeping?” Or “When I got your groceries, you wanted more beer than you usually drink in a week” Or “Did you have bacon and eggs again for breakfast today?” (something to stimulate a discussion regarding his diet) Downloaded from http://sirc.nln.org with the permission of the National League for Nursing and Laerdal Medical. This document may be reproduced as long as it retains the following copyright statement: © Copyright, 2010. Simulation in nursing education: From conceptualization to evaluation. New York: National League for Nursing. Reprinted with permission. If you find this Simulation Design Template useful, we would appreciate hearing from you. Please send an email message with your comments to [email protected] 7 Simulation Design Template- Sherman “Red” Yoder-Simulation #1 minutes “once or twice a week” , wakes up in the middle of the night, have to get up to use the bathroom” Rates sleep as “fairly bad” Answers to Elder Mistreatment: All answers indicate no mistreatment Answers to Alcohol Use treatment: “Yes” to question – do you usually take a drink to relax or calm your nerves? All other answers “no” Answers to nutrition screening: “Breakfast every morning – bacon and eggs, 2 pieces of wheat toast with sugar free jelly Lunch: bologna sandwich, glass of milk and bag of baked potato chips” Blood glucose monitoring: “I prick my finger about once a week, or if I’m not feeling good” “It’s usually around 120-130” 10-20 minutes Medication currently taking: Tylenol for knee or back pain. One baby aspirin every day. Multivitamin every day. “The sore on my toe happened when I wore my new shoes too long. I can’t feel anything; it doesn’t hurt. If you show me how to take care of it, I can manage I think.” Assesses wound wearing gloves. Assess pain/sensation Assess wound size including: Color of wound tissue, wound margins, depth, color and temperature of foot; edema, odor, Role member providing cue: Dr. Baker Cue: “Wet to damp saline soaked gauze to wound every day. Home health nurse to monitor wound 2 times a week. Downloaded from http://sirc.nln.org with the permission of the National League for Nursing and Laerdal Medical. This document may be reproduced as long as it retains the following copyright statement: © Copyright, 2010. Simulation in nursing education: From conceptualization to evaluation. New York: National League for Nursing. Reprinted with permission. If you find this Simulation Design Template useful, we would appreciate hearing from you. Please send an email message with your comments to [email protected] 8 Simulation Design Template- Sherman “Red” Yoder-Simulation #1 If time permits drainage, pulses Clindamycin orally, 300mg 4 times a day.” Calls Dr. Baker with the assessment using SBAR. Demonstrates to Red how to clean and dress the wound. Role member providing cue: Judy Cue: Red, I’ll go into town, fill the prescription and get the supplies for dressing the wound. Role member providing cue: Cue: Irrigate wound with normal saline and dress with saline soaked gauze, cover with dry gauze and secure the dry dressing with a gauze wrap. Downloaded from http://sirc.nln.org with the permission of the National League for Nursing and Laerdal Medical. This document may be reproduced as long as it retains the following copyright statement: © Copyright, 2010. Simulation in nursing education: From conceptualization to evaluation. New York: National League for Nursing. Reprinted with permission. If you find this Simulation Design Template useful, we would appreciate hearing from you. Please send an email message with your comments to [email protected] 9 Simulation Design Template- Sherman “Red” Yoder-Simulation #1 Debriefing/Guided Reflection Questions for This Simulation (Remember to identify important concepts or curricular threads that are specific to your program) 1. How did you feel throughout the simulation experience? 2. Describe the objectives you were able to achieve? 3. Which ones were you unable to achieve (if any)? 4. Did you have the knowledge and skills to meet objectives? 5. Were you satisfied with your ability to work through the simulation? 6. To Observer: Could the nurses have handled any aspects of the simulation differently? 7. If you were able to do this again, how could you have handled the situation differently? 8. What did the group do well? 9. What did the team feel was the primary nursing diagnosis? 10. What were the key assessments and interventions? 11. Is there anything else you would like to discuss? 12. How were you able to use the ACES Framework with Red’s situation? (Assess Function and Expectations, Coordinate and Manage Care, Use Evolving Knowledge, Make Situational Decisions) Complexity – Simple to Complex Suggestions for Changing the Complexity of This Scenario to Adapt to Different Levels of Learners 1. Focus and complexity of this simulation can be altered by changing the answers that the patient gives to any assessment. Downloaded from http://sirc.nln.org with the permission of the National League for Nursing and Laerdal Medical. This document may be reproduced as long as it retains the following copyright statement: © Copyright, 2010. Simulation in nursing education: From conceptualization to evaluation. New York: National League for Nursing. Reprinted with permission. If you find this Simulation Design Template useful, we would appreciate hearing from you. Please send an email message with your comments to [email protected] 10 Simulation Design Template- Sherman “Red” Yoder-Simulation #2 Date: File Name: Sherman “Red” Yoder Discipline: Nursing Expected Simulation Run Time: Student Level: Guided Reflection Time: 20 minutes 20 minutes Location: Simulated Emergency Room Admission Date: Today’s Date: Brief Description of Client Name: Sherman “Red” Yoder Gender: Male Age: 80 Weight: 109 kg Race: Caucasian 1. General head to toe assessment including vital signs 2. Focused assessment of circulatory and neurovascular status of foot, and wound 3. Specimen collection: Blood cultures, labs, wound 4. Medication administration: IV, Subcutaneous 5. Oxygen administration Height: 183 cm Religion: Protestant Phone: 869-555-3452 Allergies: Location for Reflection: classroom Psychomotor Skills Required Prior to Simulation NKA Immunizations: Influenza last fall; Tetanus 2007 Attending Physician/Team: Family Practice: Dr. Frank Baker Past Medical History: Diabetes Type 2 diagnosed ______ (insert month that is six months prior) History of Present illness: Developed an ulcer on his big toe 3 weeks ago. Currently treated with oral antibiotic and wet to moist saline soaked dressing daily. Home health nurse last assessed the foot 3 days ago. Cognitive Activities Required prior to Simulation [i.e. independent reading (R), video review (V), computer simulations (CS), lecture (L)] Study care of the client with an infection, specifically sepsis (R) Read atypical presentation of infection by older adults (R) Standardized hand off tool between health care team members (R) The Confusion Assessment Method (CAM) tool (R) Tools in the Try This: ® and How to Try This Series, available at www.ConsultGeriRN.org. Social History: Widower; Son (Jon) lives nearby Primary Medical Diagnosis: R/O sepsis Surgeries/Procedures & Dates: L4-5 laminectomy 1976; Transurethral resection of the prostate 2005 Downloaded from http://sirc.nln.org with the permission of the National League for Nursing and Laerdal Medical. This document may be reproduced as long as it retains the following copyright statement: © Copyright, 2010. Simulation in nursing education: From conceptualization to evaluation. New York: National League for Nursing. Reprinted with permission. If you find this Simulation Design Template useful, we would appreciate hearing from you. Please send an email message with your comments to [email protected] 1 Simulation Design Template- Sherman “Red” Yoder-Simulation #2 Nursing Diagnoses: Infection; Alteration in tissue integrity; Risk for Shock Downloaded from http://sirc.nln.org with the permission of the National League for Nursing and Laerdal Medical. This document may be reproduced as long as it retains the following copyright statement: © Copyright, 2010. Simulation in nursing education: From conceptualization to evaluation. New York: National League for Nursing. Reprinted with permission. If you find this Simulation Design Template useful, we would appreciate hearing from you. Please send an email message with your comments to [email protected] 2 Simulation Design Template- Sherman “Red” Yoder-Simulation #2 Simulation Learning Objectives – for faculty 1. The learner will demonstrate a general head to toe assessment and a focused assessment of patient’s right foot. 2. The learner will assess the patient’s individual aging pattern and functional status using standardized assessment tools. Suggested tool: The Confusion Assessment Method (CAM) 3. The learner will use communication techniques to recognize, respond to and respect an older adult’s strengths, wishes and expectations. 4. The learner will use standardized communication tools to discuss the care of the client with other health care providers. Suggested tools: Standarized hand off tool (I PASS the BATON http://www.ahrq.gov/about/casestudies/ptsafety/ps2010a.htm ) 5. The learner will discuss atypical assessment findings common in the older adult with sepsis. 6. The learner will implement appropriate interventions based on assessments and primary health care provider orders. (Specimen collection: blood culture, CBC, wound; application of oxygen, starting an IV, IV and subcutaneous medication administration) Simulation Learning Objectives – for learners 1. The learner will demonstrate a general head to toe assessment and focused assessments as appropriate. 2. The learner will assess the patient’s individual aging pattern and functional status using standardized assessment tools. 3. The learner will use communication techniques to recognize, respond to and respect an older adult’s strengths, wishes and expectations. 4. The learner will use standardized communication tools to discuss the care of the client with other health care providers. 5. The learner will discuss pertinent assessment findings and what was found that was specific to the older adult patient. 6. The learner will implement appropriate interventions based on the assessments and primary health care provider orders. Downloaded from http://sirc.nln.org with the permission of the National League for Nursing and Laerdal Medical. This document may be reproduced as long as it retains the following copyright statement: © Copyright, 2010. Simulation in nursing education: From conceptualization to evaluation. New York: National League for Nursing. Reprinted with permission. If you find this Simulation Design Template useful, we would appreciate hearing from you. Please send an email message with your comments to [email protected] 3 Simulation Design Template- Sherman “Red” Yoder-Simulation #2 Fidelity (choose all that apply to this simulation) Setting/Environment Medications and Fluids ER Med-Surg Peds ICU OR / PACU Women’s Center Behavioral Health Pre-Hospital Other: Home health Simulator Manikin/s Needed: Minimally, manikin with vital sign assessment capability, or standardized patient Props: Wound moulage: right great toe should have a wound that has some depth, has bright red tissue with opaque drainage. If available, may consider using the foot with the wound on the toe (Laerdal product). Entire foot should be red. Equipment attached to manikin: IV tubing with primary line IV 0.9% NS fluids running at 500 cc’s bolus, repeat X1 Secondary IV line running at mL/hr IV pump Foley catheter mL output PCA pump running IVPB with running at mL/hr 02 Monitor attached ID band Other: Equipment available in room Bedpan/Urinal Foley kit Straight Catheter Kit Incentive Spirometer Fluids IV Fluids: IV 0.9% NS 500 cc’s bolus, repeat X1 Oral Meds: IVPB: Ceftazidime 1 gram IVPB q 8 hours IV Push: IM or SC: Diagnostics Available Labs X-rays (Images) 12-Lead EKG Other: Documentation Forms Physician Orders Admit Orders Flow sheet Medication Administration Record Kardex Graphic Record Shift Assessment Triage Forms Code Record Anesthesia / PACU Record Standing (Protocol) Orders Transfer Orders Other: Recommended Mode for Simulation (i.e. manual, programmed, etc.) Manual or programmed; mechanism needed for transmission of the voice of the patient via manikin Downloaded from http://sirc.nln.org with the permission of the National League for Nursing and Laerdal Medical. This document may be reproduced as long as it retains the following copyright statement: © Copyright, 2010. Simulation in nursing education: From conceptualization to evaluation. New York: National League for Nursing. Reprinted with permission. If you find this Simulation Design Template useful, we would appreciate hearing from you. Please send an email message with your comments to [email protected] 4 Simulation Design Template- Sherman “Red” Yoder-Simulation #2 IV start kit IV tubing IVPB Tubing IV Pump Feeding Pump Pressure Bag 02 delivery device (type) Crash cart with airway devices and emergency medications Defibrillator/Pacer Suction Other: Roles/Guidelines for Roles Primary Nurse Secondary Nurse Clinical Instructor Family Member #1 Family Member #2 Observer/s Recorder Physician/Advanced Practice Nurse Respiratory Therapy Anesthesia Pharmacy Lab Imaging Social Services Clergy Unlicensed Assistive Personnel Code Team Other: Important Information Related to Roles: Family member may be present. (daughter in law or son to give history) Student Information Needed Prior to Scenario: 1. Has been oriented to simulator 2. Understands guidelines /expectations for scenario 3. Has accomplished all pre-simulation requirements 4. All participants understand their assigned roles 5. Has been given time frame expectations 6. Knowledge of previous “Red” monologues and simulation Report Students Will Receive Before Simulation Red Yoder is an 80 year old with a pressure ulcer on his right great toe which developed about 5 weeks ago. Has been treated at home with an oral antibiotic and wet to damp saline dressings daily. He will arrive here in the ER momentarily. Dr. Baker has written preliminary orders. Significant Lab Values: (give to learner upon request after they have been drawn) WBC 11,000 RBC 4.2 Hgb 10.5 HCT 45% NA 140 K+ 4.4 CL 99 Downloaded from http://sirc.nln.org with the permission of the National League for Nursing and Laerdal Medical. This document may be reproduced as long as it retains the following copyright statement: © Copyright, 2010. Simulation in nursing education: From conceptualization to evaluation. New York: National League for Nursing. Reprinted with permission. If you find this Simulation Design Template useful, we would appreciate hearing from you. Please send an email message with your comments to [email protected] 5 Simulation Design Template- Sherman “Red” Yoder-Simulation #2 BUN 20 Creatinine 1.3 Glucose 210 Physician Orders: Emergency Room orders: IV 0.9% NS 500mL bolus; may repeat x 1 Labs: CBC, electrolytes, BUN and creatinine, arterial blood gases, blood culture x2 Wound culture and sensitivity Oxygen at 6 LPM per nasal cannula; titrate to keep SpO2 > 94% Insert urinary catheter Continuous ECG and Sp O2 monitoring Ceftazidime 1 gram IVPB every 8 hours Transfer to medical intensive care Downloaded from http://sirc.nln.org with the permission of the National League for Nursing and Laerdal Medical. This document may be reproduced as long as it retains the following copyright statement: © Copyright, 2010. Simulation in nursing education: From conceptualization to evaluation. New York: National League for Nursing. Reprinted with permission. If you find this Simulation Design Template useful, we would appreciate hearing from you. Please send an email message with your comments to [email protected] 6 Simulation Design Template- Sherman “Red” Yoder-Simulation #2 References, Evidence-Based Practice Guidelines, Protocols, or Algorithms Used For This Scenario Reading and Resources: You may wish to have your students review these resources in preparation for the second simulation scenario. 1. Review medical-surgical nursing text related to care of the patient with sepsis. 2. Confusion Assessment Method Tool: http://consultgerirn.org/uploads/File/Confusion%20Assessment%20Method%20(CAM).pdf 3. Girard TD, Opal SM, Ely EW. Insights into severe sepsis in older patients: from epidemiology to evidence-based management. Clin Infect Dis. 2005 Mar 1;40 (5):719-27. 4. Nelson DP, LeMaster TH, Plost GN, Zahner ML. Recognizing Sepsis in the Adult Patient. AJN. March 2009 Vol. 109, No. 3 Downloaded from http://sirc.nln.org with the permission of the National League for Nursing and Laerdal Medical. This document may be reproduced as long as it retains the following copyright statement: © Copyright, 2010. Simulation in nursing education: From conceptualization to evaluation. New York: National League for Nursing. Reprinted with permission. If you find this Simulation Design Template useful, we would appreciate hearing from you. Please send an email message with your comments to [email protected] 7 Simulation Design Template- Sherman “Red” Yoder-Simulation #2 Scenario Progression Outline Timing (approximate) 0-5 minutes Manikin Actions Expected Interventions May Use the Following Cues Patient drowsy but easily aroused; has trouble keeping track of what’s said. T: 38, HR 86; RR 28; BP 116/64 Wash hands Role member providing cue: Family member Introduce self Identify patient Cue: “Red is usually awake and alert. This is really a change for him” Head to toe assessment 5-15 minutes Patient status remains the same. Able to answer most questions. Not able to focus attention. Rambles at times. Apply O2 Draw labs Initiate IV fluid Begin IV antibiotic VS unchanged. Insert Foley catheter and monitors urine output Role member providing cue: Family member Cue: “How come you said he has an infection? He hasn’t had a fever at home and he doesn’t have one now.” Assesses wound and takes culture gloves. Assess pain/sensation Assess wound size including: Color of wound tissue, wound margins, depth, color and temperature of foot; edema, odor, drainage, pulses Use CAM assessment tool 15-20 minutes Requests lab results. Gives report to the nurse in MICU using a standardized hand off tool Role member providing cue: Family member Cue: Is he going to be o.k.? Can we go to the ICU with him? Downloaded from http://sirc.nln.org with the permission of the National League for Nursing and Laerdal Medical. This document may be reproduced as long as it retains the following copyright statement: © Copyright, 2010. Simulation in nursing education: From conceptualization to evaluation. New York: National League for Nursing. Reprinted with permission. If you find this Simulation Design Template useful, we would appreciate hearing from you. Please send an email message with your comments to [email protected] 8 Simulation Design Template- Sherman “Red” Yoder-Simulation #2 Debriefing/Guided Reflection Questions for This Simulation (Remember to identify important concepts or curricular threads that are specific to your program) 1. How did you feel throughout the simulation experience? 2. Describe the objectives you were able to achieve? 3. Which ones were you unable to achieve (if any)? 4. Did you have the knowledge and skills to meet objectives? 5. Were you satisfied with your ability to work through the simulation? 6. To Observer: Could the nurses have handled any aspects of the simulation differently? 7. If you were able to do this again, how could you have handled the situation differently? 8. What did the group do well? 9. What did the team feel was the primary nursing diagnosis? 10. What were the key assessments and interventions? 11. Is there anything else you would like to discuss? 12. How were you able to use the ACES Framework now that Red has been hospitalized? (Assess Function and Expectations, Coordinate and Manage Care, Use Evolving Knowledge, Make Situational Decisions) Complexity – Simple to Complex Suggestions for Changing the Complexity of This Scenario to Adapt to Different Levels of Learners 1. Have student start IV, perform venipuncture to draw labs, administer IV medication, catheter insertion, ECG application. May have these things done and then have student interpret the data. 2. Include additional findings/information that will require more assessment, such as pressure ulcer, potential elder neglect, and financial concerns. . 3. Students could begin to manage blood glucose. ABG’s could return showing ketoacidosis. Downloaded from http://sirc.nln.org with the permission of the National League for Nursing and Laerdal Medical. This document may be reproduced as long as it retains the following copyright statement: © Copyright, 2010. Simulation in nursing education: From conceptualization to evaluation. New York: National League for Nursing. Reprinted with permission. If you find this Simulation Design Template useful, we would appreciate hearing from you. Please send an email message with your comments to [email protected] 9 Simulation Design Template- Sherman “Red” Yoder-Simulation #2 Downloaded from http://sirc.nln.org with the permission of the National League for Nursing and Laerdal Medical. This document may be reproduced as long as it retains the following copyright statement: © Copyright, 2010. Simulation in nursing education: From conceptualization to evaluation. New York: National League for Nursing. Reprinted with permission. If you find this Simulation Design Template useful, we would appreciate hearing from you. Please send an email message with your comments to [email protected] 10 Simulation Design Template- Sherman “Red” Yoder-Simulation #3 Date: Discipline: Nursing Expected Simulation Run Time: File Name: Sherman “Red” Yoder Student Level: 20 minutes Guided Reflection Time: 20 minutes Location for Reflection: classroom Location: Simulation lab Admission Date: Psychomotor Skills Required Prior to Simulation Today’s Date: 1. Basic head to toe assessment. 2. Assisting a patient with ambulation. 3. Wound assessment and wet to damp dressing change. Brief Description of Client Name: Sherman “Red” Yoder Gender: Male Age: 80 Weight: 109 kg Race: Caucasian Height: 183 cm Religion: Protestant Phone: 869-555-3452 Allergies: Cognitive Activities Required prior to Simulation [i.e. independent reading (R), video review (V), computer simulations (CS), lecture (L)] Knowledge related to functional decline in the hospitalized older adult (R) ConsultGeriRN.org Try This:® Series (R) NKA Immunizations: Influenza last fall; Tetanus 2007 Attending Physician/Team: Dr. Frank Baker Past Medical History: Diabetes Type 2 diagnosed ______ (insert month that is six months prior) History of Present illness: Developed an ulcer on his big toe that was treated at home for 2 weeks. Son brought patient to ER 6 days ago and patient treated for sepsis with IV antibiotics. Social History: Widower; Son (Jon) lives nearby Primary Medical Diagnosis: Sepsis Surgeries/Procedures & Dates: L4-5 laminectomy 1976; Transurethral resection of the prostate 2005 Downloaded from http://sirc.nln.org with the permission of the National League for Nursing and Laerdal Medical. This document may be reproduced as long as it retains the following copyright statement: © Copyright, 2010. Simulation in nursing education: From conceptualization to evaluation. New York: National League for Nursing. Reprinted with permission. If you find this Simulation Design Template useful, we would appreciate hearing from you. Please send an email message with your comments to [email protected] 1 Simulation Design Template- Sherman “Red” Yoder-Simulation #3 Nursing Diagnoses: Potential Impaired Home Maintenance; Infection; Alteration in tissue integrity Downloaded from http://sirc.nln.org with the permission of the National League for Nursing and Laerdal Medical. This document may be reproduced as long as it retains the following copyright statement: © Copyright, 2010. Simulation in nursing education: From conceptualization to evaluation. New York: National League for Nursing. Reprinted with permission. If you find this Simulation Design Template useful, we would appreciate hearing from you. Please send an email message with your comments to [email protected] 2 Simulation Design Template- Sherman “Red” Yoder-Simulation #3 Simulation Learning Objectives – for faculty 1. The learner will demonstrate a general head to toe assessment and a focused assessment of patient’s right foot. 2. The learner will assess the patient’s individual aging pattern and functional status using standardized assessment tools. Suggested tool: Katz Index of Independence in Activities of Daily Living (ADL), and the Transitional Care Model (TCM): Hospital Discharge Screening Criteria for High Risk Older Adults 3. The learner will use communication techniques to recognize, respond to and respect an older adult’s strengths, wishes and expectations. 4. The learner will use standardized communication tools to discuss the care of the client with other health care providers. Suggested tools: Standarized hand off tool (I PASS the BATON http://www.ahrq.gov/about/casestudies/ptsafety/ps2010a.htm ) 5. The learner will discuss functional decline of the hospitalized older adult. 6. The learner will implement appropriate interventions based on assessments and primary health care provider orders. (Discharge planning) Simulation Learning Objectives – for learners 1. The learner will demonstrate a general head to toe assessment and focused assessments as appropriate. 2. The learner will assess the patient’s individual aging pattern and functional status using standardized assessment tools. 3. The learner will use communication techniques to recognize, respond to and respect an older adult’s strengths, wishes and expectations. 4. The learner will use standardized communication tools to discuss the care of the client with other health care providers. 5. The learner will discuss pertinent assessment findings and what was found that was specific to the older adult patient. 6. The learner will implement appropriate interventions based on the assessments and primary health care provider orders. Downloaded from http://sirc.nln.org with the permission of the National League for Nursing and Laerdal Medical. This document may be reproduced as long as it retains the following copyright statement: © Copyright, 2010. Simulation in nursing education: From conceptualization to evaluation. New York: National League for Nursing. Reprinted with permission. If you find this Simulation Design Template useful, we would appreciate hearing from you. Please send an email message with your comments to [email protected] 3 Simulation Design Template- Sherman “Red” Yoder-Simulation #3 Fidelity (choose all that apply to this simulation) Setting/Environment Medications and Fluids ER Med-Surg Peds ICU OR / PACU Women’s Center Behavioral Health Pre-Hospital Other: Home health Simulator Manikin/s Needed: Any simulator can be used. A standardized patient (or student playing the role) would facilitate a mobility assessment. Props: Patient will still have a wound on right great toe. Foot no longer red and swollen. Equipment attached to manikin: IV tubing with primary line fluids running at mL/hr Secondary IV line running at mL/hr IV pump Foley catheter mL output PCA pump running IVPB with running at mL/hr 02 Monitor attached ID band Other: Equipment available in room Bedpan/Urinal Foley kit Straight Catheter Kit Incentive Spirometer Fluids IV start kit IV tubing IVPB Tubing IV Pump Feeding Pump IV Fluids: Oral Meds: IVPB: IV Push: IM or SC: Diagnostics Available Labs X-rays (Images) 12-Lead EKG Other: Documentation Forms Physician Orders Admit Orders Flow sheet Medication Administration Record Kardex Graphic Record Shift Assessment Triage Forms Code Record Anesthesia / PACU Record Standing (Protocol) Orders Transfer Orders Other: Recommended Mode for Simulation (i.e. manual, programmed, etc.) Manual or programmed; mechanism needed for transmission of the voice of the patient via manikin Downloaded from http://sirc.nln.org with the permission of the National League for Nursing and Laerdal Medical. This document may be reproduced as long as it retains the following copyright statement: © Copyright, 2010. Simulation in nursing education: From conceptualization to evaluation. New York: National League for Nursing. Reprinted with permission. If you find this Simulation Design Template useful, we would appreciate hearing from you. Please send an email message with your comments to [email protected] 4 Simulation Design Template- Sherman “Red” Yoder-Simulation #3 Pressure Bag 02 delivery device (type) Crash cart with airway devices and emergency medications Defibrillator/Pacer Suction Other: Roles/Guidelines for Roles Primary Nurse Secondary Nurse Clinical Instructor Family Member #1 Family Member #2 Observer/s Recorder Physician/Advanced Practice Nurse Respiratory Therapy Anesthesia Pharmacy Lab Imaging Social Services Clergy Unlicensed Assistive Personnel Code Team Other: Important Information Related to Roles: Family member may be present. (daughter in law or son to discuss concerns about going home) Significant Lab Values: No new labs drawn Student Information Needed Prior to Scenario: 1. Has been oriented to simulator 2. Understands guidelines /expectations for scenario. 3. Has accomplished all pre-simulation requirements 4. All participants understand their assigned roles 5. Has been given time frame expectations 6. Knowledge of previous “Red” monologues and simulation. Report Students Will Receive Before Simulation Morning report: Patient is alert and oriented; vital signs stable. Fasting blood sugar this morning is 118. Red had his usual night of sleep. He was up several times to go to the bathroom. Since his catheter was removed yesterday he has urge incontinency. He is able to ambulate to the bathroom, but it is slow and he is weak. Need to discuss where he is being discharged to. He had been living at home with help from his son and daughter in law. Physician Orders: Discharge tomorrow. Downloaded from http://sirc.nln.org with the permission of the National League for Nursing and Laerdal Medical. This document may be reproduced as long as it retains the following copyright statement: © Copyright, 2010. Simulation in nursing education: From conceptualization to evaluation. New York: National League for Nursing. Reprinted with permission. If you find this Simulation Design Template useful, we would appreciate hearing from you. Please send an email message with your comments to [email protected] 5 Simulation Design Template- Sherman “Red” Yoder-Simulation #3 References, Evidence-Based Practice Guidelines, Protocols, or Algorithms Used For This Scenario Reading and Resources: You may wish to have your students review these resources in preparation for the second simulation scenario. 1. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Chapter 11. Reducing Functional Decline in Hospitalized Elderly. AHRQ Publication No. 08-0043. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/nurseshdbk/; http://www.ahrq.gov/qual/nurseshdbk/docs/kleinpellr_rfdhe.pdf 2. Nursing Standard of Practice Protocol: Assessment of Function in Acute Care http://consultgerirn.org/topics/function/want_to_know_more 3. Katz Index of Independence in Activities of Daily Living (ADL) http://consultgerirn.org/uploads/File/trythis/try_this_2.pdf 4. The Lawton Instrumental Activities of Daily Living(IADL)Scale 5. http://consultgerirn.org/uploads/File/trythis/try_this_23.pdf 6. Transitional Care Model (TCM): Hospital Discharge Screening Criteria for High Risk Older Adults http://consultgerirn.org/uploads/File/trythis/try_this_26.pdf Downloaded from http://sirc.nln.org with the permission of the National League for Nursing and Laerdal Medical. This document may be reproduced as long as it retains the following copyright statement: © Copyright, 2010. Simulation in nursing education: From conceptualization to evaluation. New York: National League for Nursing. Reprinted with permission. If you find this Simulation Design Template useful, we would appreciate hearing from you. Please send an email message with your comments to [email protected] 6 Simulation Design Template- Sherman “Red” Yoder-Simulation #3 Scenario Progression Outline Timing Manikin Actions (approximate) 0-5 minutes Patient alert, oriented VS within normal limits Expected Interventions May Use the Following Cues Wash hands Role member providing cue: Family member Introduce self “I want to go back to my own house” Identify patient 5-15 minutes 15-20 minutes “Of course I was confused Head to toe assessment there for a while. No one gave me my glasses or hearing Begins discussion related to aids” the discharge order that has been written for tomorrow. “I think I can get up and walk around” If using a standardized Administers standardized patient, Red should ambulate tool to assess Red’s level of slowly and with hesitation. function. After walking a short distance If using a standardized say “I’m really tired; I used to patient, learner should walk about all day long with ambulate to assess Red’s no problems” mobility. Assess pain/sensation “At this rate I will wet myself Assess wound size every time I need to get to the including: bathroom. Can I take a urinal Color of wound tissue, home with me?” wound margins, depth, color and temperature of “I’ve been taking more foot; edema, odor, medicine since I’ve been in drainage, pulses the hospital. It seems very complicated. Can you tell Assesses Red’s (or family Judy and I what we are member’s) ability to care supposed to do?” for wound at home. Calls to give hand off to home health agency for follow up care Cue: “Red you haven’t been up and walking. How will you make it to the bathroom?” Role member providing cue: Family member Cue: “Red, at least come and live with us until you get your strength back” “We can get your medication set up and get you used to the new stuff at our house.” Role member providing cue: Family member Cue: (if learner does not talk about how the home health nurse will follow up) “How will the nurses that come out to the house know what’s going on now” “We don’t want Red to end up in the hospital again.” Downloaded from http://sirc.nln.org with the permission of the National League for Nursing and Laerdal Medical. This document may be reproduced as long as it retains the following copyright statement: © Copyright, 2010. Simulation in nursing education: From conceptualization to evaluation. New York: National League for Nursing. Reprinted with permission. If you find this Simulation Design Template useful, we would appreciate hearing from you. Please send an email message with your comments to [email protected] 7 Simulation Design Template- Sherman “Red” Yoder-Simulation #3 Debriefing/Guided Reflection Questions for This Simulation (Remember to identify important concepts or curricular threads that are specific to your program) 1. How did you feel throughout the simulation experience? 2. Describe the objectives you were able to achieve? 3. Which ones were you unable to achieve (if any)? 4. Did you have the knowledge and skills to meet objectives? 5. Were you satisfied with your ability to work through the simulation? 6. To Observer: Could the nurses have handled any aspects of the simulation differently? 7. If you were able to do this again, how could you have handled the situation differently? 8. What did the group do well? 9. What did the team feel was the primary nursing diagnosis? 10. What were the key assessments and interventions? 11. Is there anything else you would like to discuss? 12. What are the risks and benefits of Red’s transition from the hospital to his home? Use the ACES Framework to assess and evaluate this situation. (Assess Function and Expectations, Coordinate and Manage Care, Use Evolving Knowledge, Make Situational Decisions) Complexity – Simple to Complex Suggestions for Changing the Complexity of This Scenario to Adapt to Different Levels of Learners 1. Learner could reinforce teaching related to management of patient’s diabetes (diet, assessing his blood glucose, insulin administration) 2. Learner could administer morning medication (e.g. insulin, oral antibiotic) and perform a.m. cares (which would be a good way to assess Red’s ability to perform his ADL’s) 3. Red’s responses to the functional assessment can be altered and the destination for his discharge changed. He could have very little functional decline, or he could have so much decline that his family is unable to care for him at home. Downloaded from http://sirc.nln.org with the permission of the National League for Nursing and Laerdal Medical. This document may be reproduced as long as it retains the following copyright statement: © Copyright, 2010. Simulation in nursing education: From conceptualization to evaluation. New York: National League for Nursing. Reprinted with permission. If you find this Simulation Design Template useful, we would appreciate hearing from you. Please send an email message with your comments to [email protected] 8 PATIENT CHART Sherman “Red” Yoder STUDENT NAME:_______________________________ PATIENT INITALS: _____S.Y.______________________ CLINICAL DATE(S): _____________________________ INSTRUCTOR: _______________ Patient Name:__Sherman Yoder _Rm#___16 DOB_02/02/1930 Age__80_ Date Admit:_______ MRN _000-555-555 Dr. Baker, Frank Physician’s Orders Allergies: NKA Date/Time: (insert current day and time) Emergency Room orders: IV 0.9% NS 500mL bolus; may repeat x 1 Labs: CBC, electrolytes, BUN and creatinine, arterial blood gases, blood culture x2 Wound culture and sensitivity Oxygen at 4 liter per nasal cannula; titrate to keep SpO2 > 94% Insert urinary catheter Continuous ECG and Sp O2 monitoring Ceftazidime 1 gram IVPB every 8 hours Transfer to medical intensive care Dr. Frank Baker Patient Name:__Sherman Yoder _Rm#___16 DOB_02/02/1930 Age__80_ Date Admit:_______ MRN _000-555-555 Dr. Baker, Frank Physician Progress Notes Allergies: Date/Time: Patient Name:__Sherman Yoder _Rm#___16 DOB_02/02/1930 Age__80_ Date Admit:_______ MRN _000-555-555 Dr. Baker, Frank NURSING NOTES Date: Patient was admitted via emergency room earlier today. He has a history of diabetic wound; we don’t know how well he has been taking care of himself as he is confused. Initial Nurse signatures Nurse Signature Initial Nurse Signature Patient Name:__Sherman Yoder _Rm#___16 DOB_02/02/1930 Age__80_ Date Admit:_______ MRN _000-555-555 Dr. Baker, Frank Medication Administration Record Allergies: Scheduled & Routine Drugs Date of order Medication ●Dosage ●Route • Frequency Hours to be Given Dates given / (insert) Ceftazidime 1 gram IVPB every 8 hours / (insert to fit simulation timing) Intravenous Therapy Date of order (insert) Initial IV solution, Rate ordered Date/Time hung 0.9% NS 500mL Nurse signatures Nurse Signature Initial Nurse Signature / Patient Name:__Sherman Yoder _Rm#___16 DOB_02/02/1930 Age__80_ Date Admit:_______ MRN _000-555-555 Dr. Baker, Frank Medication Administration Record Intramuscluar legend: Subcutaneous site code: A=RUOQ ventrogluteal B=LUOQ ventrogluteal C=R Deltoid D=L Deltoid E=R Thigh Lateral F=L Thigh Lateral 1=RUQ abdomen 2=LUQ abdomen 3=RLQ abdomen 4=LLQ abdomen 5=RU arm 6=LU arm 7=R leg 8=L leg Allergies: Date of order PRN MEDICATIONS Medication ●Dosage ● Route • Frequency Date Time Site Initials Date Time Site Initials Date Time Site Initials INSULIN ADMINISTRATION Date Time Site GMR Initials Date Time Site GMR Initials Initial Nurse signatures Nurse Signature Initial Nurse Signature Patient Name:__Sherman Yoder _Rm#___16 DOB_02/02/1930 Age__80_ Date Admit:_______ MRN _000-555-555 Dr. Baker, Frank Vital Signs Record Date Time Temperature C0 F0 40 104 39.5 39 38.5 38 37.5 37 36.5 36 0400 0800 1200 1600 2000 2400 0400 0800 1200 1600 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 102 101 100 99 98 97 96 BP Pulse 2 O Saturation Weight Respirations GMR Nurse Initials Patient Name:__Sherman Yoder _Rm#___16 DOB_02/02/1930 Age__80_ Date Admit:_______ MRN _000-555-555 Dr. Baker, Frank Intake & Output Bedside Worksheet INTAKE TUBE IV FEED ORAL IVPB OTHER Total Intake this shift: URINE OUTPUT Emesis NG Drains Type: Total Output this shift: (This is a worksheet to be used at the bedside to keep track of each intake or output. The totals will then be recorded on the 24 hour Fluid Balance sheet.) Fluid Measurements • • • • • 1 ml = 1 cc 1 ounce = 30 cc 8 ounces = 240 cc 1 cup = 8 ounces = 240 cc 4 cups = 32 ounces = 1 quart or liter= 1000 cc Sample Measurements • • • • • • • Coffee cup = 200 cc Clear glass = 240 cc Milk carton = 240 cc Small milk carton = 120 cc Juice, gelatin or ice cream cup = 120 cc Soup bowl = 160 cc Popsicle half = 40 cc Other NURSING ASSESSMENT FLOWSHEET GENERAL APPEARANCE: [ ] male [ ] female DOB:_____________ Age_________Ethnicity_________ Occupation _________________ Religion_______________ [ ] awake [ ] cheerful [ ] crying [ ] sleeping [ ] lethargic [ ] calm [ ] agitated [ ] anxious [ ] combatative [ ]fearful SKIN [ ] (see wound care sheet)[ ] see nursing notes Braden scale score: [ ] risk skin breakdown COLOR: [ ]acyanotic [ ] pale [ ] ruddy [ ] jaundiced [ ] cyanotic TEMP: [ ] warm/dry [ ] hot [ ] cool [ ]cold/clammy [ ]diaphoretic TURGOR: [ ]<3 sec [ ] > 3 sec HAIR: [ ] shiny [ ]dry/faking [ ]balding [ ] lesions [ ] lice Patient Yoder _Rm#___16 Patient Name:__Sherman Information DOB_02/02/1930 Age__80_ Date Admit:_______ MRN _000-555-555 Dr. Baker, Frank RESPIRATORY[ ] see nursing notes RESPIRATIONS: Rate______ O2_________ SPO2______% [ ]reg [ ] even [ ] irreg [ ] labored [ ] uses accessory muscles [ ] cough BREATH SOUNDS: RIGHT: [ ] clear [ ] crackles [ ] wheezes [ ] decreased [ ] absent Left: [ ] clear [ ] crackles [ ] wheezes [ ] decreased [ ] absent THORAX: [ ] even expansion [ ] uneven expansion SMOKING: cigarettes pk/day ____________ [ ] cigars [ ] marijuana [ ] cocaine NEUROLOGICAL[ ] see nursing notes GASTROINTESTINAL/NUTRITION [ ] see nursing notes ORIENTATION: [ ] person [ ] place [ ] time [ ] Disoriented: [ ] confused [ ] impaired memory RESPONDS TO: [ ] name [ ] stimuli [ ] non-responsive SPEECH: [ ] clear [ ] garbled [ ] slurred [ ] aphasic [ ] inappropriate [ ] cannot follow conversation FACE: [ ] symmetrical [ ] drooping [ ] drooling EYES: [ ] PERRLA [ ] unequal [ ] drooping lid SIGHT: [ ] no correction [ ] glasses [ ] contacts [ ] blind HEARING: [ ] WNL [ ] HOH [ ] hearing aid Hx: [ ] seizures [ ] CVA [ ] brain injury [ ] spinal injury [ ] other APPEARANCE: [ ] flat [ ] round [ ] obese [ ] soft [ ]gravid BOWEL SOUNDS: [ ] active [ ] hypoactive [ ] hyperactive [ ] absent PALPATION: [ ] non-tender [ ] tender (location)__________ [ ] mass (location) _____________ LAST BM:________[ ] incontinent [ ] stoma- _______ [ ] constipation [ ] diarrhea [ ] mucous [ ] blood Diet:______________ [ ] impaired swallowing [ ] choking [ ] NG tube Color drainage______________[ ] Feeding tube [ ] tube feeding Type: ______________ Rate:_________ MUSCULOSKELETAL[ ] see nursing notes GENITOURINARY[ ] see nursing notes [ ] Voids [ ] catheter [ ] stoma GAIT: [ ] steady [ ] unsteady [ ] non-ambulatory ACTIVITY: [ ] up ad lib [ ] walker [ ] cane [ ] crutches [ ] wheelchair Assist: [ ] x1 [ ] x2 [ ] lift [ ] bed bound HAND GRIPS: Amputation [ ] right [ ] left Location____________ RIGHT: [ ] strong [ ] weak [ ] flaccid [ ] contractures LEFT: [ ] strong [ ] weak [ ] flaccid[ ] contractures ROM: ARMS: [ ] full [ ] weak [ ] flaccid [ ] contractures LEGS: [ ] full [ ] weak [ ] flaccid [ ]contractures [ ]TED hose AMPUTATION: [ ] right [ ] left [ ] BKA [ ] AKA [ ] other SPINE: [ ]kyphosis [ ] scoliosis [ ] osteoporosis OTHER: [ ] Cast location:___________ [ ] Traction_____________ APPEARANCE OF URINE: [ ] clear [ ] light yellow [ ] amber [ ] brown [ ]cloudy [ ] sediment [ ] red/wine [ ] clots BLADDER: [ ] soft [ ] firm/distended [ ] incontinent FEMALES: LMP: _________ [ ] WNL [ ] dysmenorrheal Birth control:[ ] yes [ ] no [ ] BSE monthly [ ] menopause [ ] taking estrogen SEXUALITY: [ ] sexually active [ ] safe sex MED HX: [ ] urinary retention [ ] BPH [ ] Frequent UTI CARDIOVASCULAR[ ] see nursing notes PAIN ASSESSMENT: [ ] see nursing notes [ ] see MAR HEART SOUNDS: [ ] normal S1-S2 [ ] Abnormal S3-S4 [ ] murmur PULSE: APICAL: [ ]reg [ ] irreg [ ] strong [ ] faint RADIAL: [ ]reg [ ] irreg [ ] strong [ ] faint [ ] nonpalpable PEDALIS: [ ]reg [ ] irreg [ ] strong [ ] faint [ ] nonpalpable EXTREMITY COLOR & TEMP: [ ] warm [ ] cool [ ] cold [ ] acyanotic [ ] cyanotic [ ]discolor EDEMA: [ ] none [ ] generalized (anasarca) Site #1________________ [ ] pitting [ ] 1+ [ ] 2+ [ ] 3+ [ ] 4+ [ ]non-pitting Site #2 ________________ [ ] pitting [ ] 1+ [ ] 2+ [ ] 3+ [ ] 4+ [ ]non-pitting CAPILLARY REFILL: Fingers [ ] brisk [ ] slow Toes: [ ] brisk [ ] slow Hx: [ ] Pacemaker [ ] HTN [ ] CAD [ ] CHF [ ] PVD Other:_______ PRECIPITATING:_____________________________________ QUALITY:___________________________________________ REGION:____________________________________________ SEVERITY 0-10/10: Now _____ at worst ______at best _______ TIMING: SAFETY:[ ] see nursing notes [ ] Fall risk PRECAUTIONS: [ ] side rails x_______ [ ] bed down [ ] call light [ ] nightlight [ ] restraints [ ] wrist [ ] vest FLUID BALANCE [ ] see nursing notes INTAKE: [ ] PO [ ] IV: Solution: ____________Rate_______ ml/hr SITE LOCATION: _____________ [ ] clean [ ] patent [ ] redness [ ] swelling [ ]cool [ ] hot [ ] pain [ ] tubing change [ ] dressing change MUCOUS MEMBRANES: [ ] moist [ ]pink [ ]dry [ ]sticky [ ] coated Today’s wt:______________ Yesterday’s wt:__________________ DISCHARGE/TEACHING: [ ] see nursing notes NEEDS:__________________________________________________ ______________________________________________ TYPE OF LEARNER: [ ] visual [ ] auditory [ ] kinesthetic Educational level _____________Family present: [ Y] [N] NURSE SIGNATURE: Time completed: REASSESSMENT: TIME ________ [ ] no change [ ] see nurses notes [ ] initials___ TIME ________ [ ] no change [ ] see nurses notes[ ] initials___ TIME ________ [ ] no change [ ] see nurses notes[ ] initials___ Patient Name:__Sherman Yoder _Rm#___16 DOB_02/02/1930 Age__80_ Date Admit:_______ MRN _000-555-555 Dr. Baker, Frank Risk Assessments & Nursing Care Date: Braden Scale Score: Fall Risk Score: Date: Braden Scale Score: Fall Risk Score: Time Hourly PAIN ASSESSMENT Intensity (1-10/10) Pain Type (see legend) Intervention (see legend) PATIENT POSITION PO FLUIDS (ml) IV SITE/RATE CHECKED PATIENT HYGIENE WOUND ASSESSMENT WOUND BED WOUND DRAINAGE WOUND CARE Nurse Initials Initial Nurse Signature Initial Nurse Signature LEGEND: *= see nursing notes PAIN TYPE: A- aching T- throbbing ST- stabbing B- burning SH- shooting P- pressure PAIN INTERVENTIONS: 1- Relaxation/Imagery 2 – Distraction 3- Reposition 4-Medication WOUND ASSESSMENT # 1-4 Pressure Ulcer stage I – Incision R – Rash SK – skin tear E –Echymosis A – Abrasion POSTIONING: B- back R- right L- left C- chair A- ambulatory WOUND BED: D– Dry & intact S – Sutures/ staples G – Granulation tissue P – Pale Y – Yellow B- Black PT. HYGIENE: b- bedbath p- partial bath g- grooming f- foot care WOUND DRAINAGE: 0 – none S – Serous P – Purlulent S – Serosanguinous B – Bright red blood D – Dark old blood a- assist bath sh- shower m mouth care n- nail care WOUND CARE: C – Cleaned with NS G – Gauze dressing W – Gauze wrap A – ABD pad M – Medication O – other ** Patient Name:__Sherman Yoder _Rm#___16 DOB_02/02/1930 Age__80_ Date Admit:_______ MRN _000-555-555 Dr. Baker, Frank LAB TEST WBC HGB HCT CHEMISTRIES NA+ K+ GLUCOSE MAGNESIUM PHOSPHORUS BNP ABG’S PH PCO2 HCO3 PO2 RESULT NORMAL RANGE
SOLUTION: Vsim red yoder part 1 guided reflection 6 16
Sherman “Red” Yoder, Part 1 & 2 (answered) Guided Reflection Questions Opening Questions How did the simulated experience of Red Yoder’s case make you feel? The home assessment was a new simulation for me. In this scenario the regular head to toe assessment wasn’t necessary, but it never hurts to get a full picture of the patient. This simulation provided extensive practice with asking questions and gaining a health picture for this patient. I thought that it was difficult to ask the questions without the form in from of me to go by. What nursing actions did you feel were appropriate within this scenario? This simulation provided extensive practice with asking questions and gaining a health picture for this patient. The nurse needed to assess the patient, identify concerns and plan care for the patient. Discussing Red’s understanding of his diagnosis of diabetes and the necessity to stick to the correct insulin routine, diet and exercise and discussing his sleep and alcohol use patterns were all appropriate. Assessing his foot ulcer and evaluating Red’s ability to care for the wound and the availability of family support was also important. Scenario Analysis Questions* EBP What are the priority nursing actions for Red Yoder based on physical findings and social and family interaction? Educating Red on how alcohol use can affect diabetes outcomes is important. Addressing adherence to a diabetic diet and staying hydrated was important and was also acknowledging and …
vSim® for Nursing Gerontology | Virtual Nursing Simulation
vSim for Nursing allows each student to have a different experience with the patient. By recording interactions throughout the patient care scenario, the personalized feedback log is generated, customized to the user experience, Each time students repeat the scenario, they will receive a personal feedback log outlining their clinical reasoning choices.
vSim Score – Immediate feedback calculated based on severity of errors
Main Opportunity for Improvement – Identify key focus areas
Basic View – Review a timeline of student actions with feedback and remediation
Detailed View – View patient status at the time of student actions
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