COPD - Simulation Design Template – Loyalist College

Program: Nursing Course: NURS 2005Review date: June 2013

Original Author/year: Tammy Armstrong(O’Rourke)/2005, Julie Rivers 2013

_X_Learning Activity or___Performance Assessment

Prep/Pre-meeting Time: 0Expected Simulation Run Time: 20 min

Debrief/Guided Reflection Time:20 min

Alternate Activity Location Required: No

Simulation Learning Objectives (Identify related Course Learning Outcome and ProgramTerminal Outcome by number only)

The Student group will:

  1. Perform a priority assessment of a client with an acute exacerbation of COPD, utilizing elements of the RNAO COPD BPG (CLO 1,2,3 , PLO 1,2,3)
  1. Initiate appropriate nursing interventions and prioritize care for the client with an acute exacerbation of COPD, according to evidence based practice guidelines (CLO 1,2,3 , PLO 1,2,3)
  1. Individually identify future learning needs that will augment their knowledge base and support future practice of caring for clients experiencing respiratory distress (CLO 5 , PLO 6.3)

Measurement of Objectives

  1. During scenario, identified by handler events in debrief document
  2. During scenario, identified by handler events in debrief document, discussed in debriefing session
  3. Either verbal during debrief, in clinical learning plan, or through delayed debrief written submission depending on choice of debriefing method.

Skills/Theory required prior to participation in simulation

  • See Course Documentation for prerequisites and co-requisites
  • Passing of NURS 2005 vital signs and medication competencyassessment
  • Participation in oxygenation lab

Student Preparation for Simulation

Review and research pertinent patient information package provided - see Appendix A

Student preparation package to be distributed:Prior to Simulation - included in Blackboard course materials

References, Evidence-Based Practice Guidelines, Protocols, or Algorithms used for this scenario: (site source, author, year, and page)

  • Expert Reviewer: name, credentialsand comments inAppendixF
  • Lewis et al. Chapter 30
  • Jarvis, Chapter 18
  • e-CPS available through Loyalist Library webpage
  • BPG’s - RNAO BPG Nursing Care of Dyspnea, COPD summary and supplement found at:
  • Health Quality Ontario & Ministry of Health and Long-Term Care. (2013, January). Quality-Based Procedures: Clinical Handbook for Chronic Obstructive Pulmonary Disease.pp 46-48

Admission Date: Today’s Date:
Brief Description of Patient:
Name: Mr Sidney Brenner Gender: M
Date of Birth:March 28, 1952
Major Support: spouse
Allergies: NKA Immunizations: up to date
Attending Physician/Team:JR Loyalist
Primary Diagnosis: COPD, dyspnea
History of Present Illness/condition:Excessive level of dyspnea. Began coughing up phlegm this morning.
Past Medical History: 3 year history of COPD, Frequent Respiratory Tract infections, Quit smoking 1 year ago
Social History: Lives with spouse. Mother lives in Nursing Home. Gets short of breath with small amount of physical activity

Fidelity/Logistics

Setting:Med-surg
# of Students:4-5 per group, rotate groups through time frame
Simulator/ Manikin(s) Needed:
(Please list)i.e.Sim Man, task trainer
Sim Man
Props/Moulage:(Please list specific)
ID band
Med cart
Clean holding cart
CPS
Copy of RNAO BPG
Laminated SBAR
Family member script

Equipment:

  • IV pump:Normal Saline sol’n 75cc/hr
  • Secondary IV line 100ml N/S with Ceftriaxone 1 gm empty
  • Oxygen: O2 via nasal cannula @ 2 L/min, need Venturi mask and nebulizer mask in supply cart and aerochamber in med cart
  • Monitor ON: For temp and SPO2 others after 1st manual vitals
  • Catheter: N
  • Manual V/S: Yes forfirst assessment of BP, P and R
  • Other
/ Documentation Forms:
  • Physician Orders Y
  • EDOC N
  • Patient Chart Y
  • Flow Sheet N
  • MAR Y(backup)
  • Diagnostics results N
Mode for Simulation: Independent
A/V Logistics:
  • Video-recording Y
  • As debrief reference Y
  • For Evaluation N

Role / Description
  • Nurse 1 Primary, assess patient, direct care and attend to patient
  • Nurse 2Secondary, assist primary
  • DocumenterPrepare MAR prior to simulation by using documents in student preparation package and bring a copy to lab on simulation day. Will document assessment data during the scenario. Will be asked to comment on the documentation during debriefing.
  • Resource will have the COPD guideline, CPS and textbook to refer to. The resource person is to help the primary or secondary nurse with information and/or prompts.
  • **Optional role of Peer Reviewer is to make their own notes about their observations of the scenario, particularly in regards to assessment and interventions carried out. The recorder will be asked to comment on their observation during debriefing
  • Charge RN played by Faculty if requiredas confederate to assist student(s)
/ Pre-brief script:Provided by Sim Specialist
Report students will receive before simulation:
  • Refer to Hx of present illness
N
S - Mr. Sidney Brenner is male in his sixties with a 3 year history of COPD. He is being admitted to the medical ward for IV corticosteroid and antibiotic therapy.
B - His antibiotic was given in emerg, he is on oxygen by nasal cannula @ 2 L/min, his last sats were 88%, his last set of vitals were 38.5-90-30 BP 90/60. His family member has accompanied him to the unit.
A - Mr. Brenner is having difficulty communicating due to his excessive level of dyspnea
R - You are to do an initial assessment of Mr. Brenner, and implement appropriate nursing interventions.

Scenario Progression Outline

Timing
(approximate) / Manikin Actions / Expected Interventions / May use the following Cues:
0-1 min
1-6 min
6-15 min / BP 90/60 Vol.9 Gap
Temp 38.4
P - 96
R – 34
O2 sats – 85%
Auscultation Sounds
Lungs: Wheezes
Heart: Normal
Bowel: Hyperactive
O2 sats improve slightly (86) if HOB raised,
O2 sats improve more ifventuri mask applied (88)
O2 sats improve more if meds administered(90-92) / -raise HOB
-Assess T, P, R, BP, O2 sat
*recognize T high, P high, R high, BP low and O2 sat critically low
-Assess current Level of dyspnea using a rating scale
-Auscultate lungs
-Auscultate the chest
*recognize wheeze sound in lungs
-assess O2 delivery system
-may increase flow up to 5 L/min via nasal cannula
-check Dr orders regarding oxygen
-reassess O2 sat
-change O2 delivery system to venturi mask with O2 flow rate 4-6 and 24 or 28% nozzle
-Check Dr orders/MAR for medications to improve respiratory status
-Administer Salbutamol .
-continue use of O2 on pt during med admin
-Reassess respiration, O2 sat and possibly other vitals
Additional actions if dyspnea resolved….
-Check the IV site, pump and med
- Encourage deep breathing and coughing
- Inquire about Hx of illness and Hx of dyspnea / Imbedded cues:
Patient will c/o SOB until nurse raises HOB. If HOB not raised within 1 min pt will ask to sit up
Patient will refer nurse to family member if asked questions due to severe dyspnea
Family member follows Family member script provided to answer patient Hx questionsSee Appendix E
If no meds given by 10 min patient will cue nurses, “can’t you give me something to help with my breathing”

Debriefing / Guided Reflection for this Simulation:

Immediate Verbal Debrief session - 20 min

Questions to guide discussion:

What assessments were important in this client situation?

Were you able to complete all assessments?

What client behaviours required immediate action?

What actions were required for specific behaviours?

What client behaviours or symptoms most concerned you?

Which components of the RNAO BPG were you able to apply in this situation?

Were there any components of the RNAO BPG that you were not able to apply and if so please comment on that.

Reflective learning submission

Students are to submit by email to professor a reflection on this learning activity within 36 hours. Reflection should consist of 1-2 paragraphs and comment on application of RNAO BPG and learning to take forward from participation in this simulation learning activity/including debrief.

Simulation Evaluation Process

For Faculty - See Appendix C

For Students - See Appendix D

Appendix A

Student preparation package for COPD Simulation

Simulation Learning Objectives

The Student group will:

  1. Perform a priority assessment of a client with an acute exacerbation of COPD, utilizing elements of the RNAO COPD BPG.
  1. Initiate appropriate nursing interventions and prioritize care for the client with an acute exacerbation of COPD, according to evidence based practice guidelines.
  1. Individually identify learning and future intended action(s) that will augment their knowledge base and support future practice of caring for clients experiencing respiratory distress.

Brief Description of Patient:

Name: Mr Sidney Brenner Gender: M

Date of Birth: March 28, 1952

Major Support: spouse

Allergies: NKA

Immunizations: up to date

Attending Physician/Team: Dr Loyalist

Primary Diagnosis: COPD, dyspnea

History of Present Illness/condition: Excessive level of dyspnea. Began coughing up phlegm this morning.

Past Medical History: 3 year history of COPD, Frequent Respiratory Tract infections, Quit smoking 1 year ago

Social History: Lives with spouse. Mother lives in Nursing Home. Gets short of breath with small amount of physical activity

Readings/Resources:

Jarvis, C. (2009). Physical examination & Health Assessment (1st Canadian ed.). Toronto: Saunders Elsevier.

Review Chapter 18 with specific attention to assessment and obstructive pulmonary disease information

Lewis, S. H. (2010). Medical-Surgical Nursing in Canada: Assessment and Management of Clinical Problems (2nd Canadian ed.). Toronto: Elsevier Canada.

ReviewChapter 30

Registered Nurses Association of Ontario. (n.d.). Nursing Care of Dyspnea:The 6th Vital Sign in Individuals with Chronic Obstructive Pulmonary Disease. Retrieved from Registered Nurses' Association of Ontario:

Canadian Pharmacists Association.(2013). e-CPS. Ottawa, Ontario, Canada.

Available from Loyalist Library site

Health Quality Ontario & Ministry of Health and Long-Term Care. (2013, January). Quality-Based Procedures: Clinical Handbook for Chronic Obstructive Pulmonary Disease. pp 46-48

Role / Description

Nurse 1 Primary -assess patient, direct care and attend to patient

Nurse 2 Secondary - assist primary nurseand document assessment data during the scenario

**It would also be helpful for Primary and Secondary nurse to make point form notes or a plan of action prior to lab and give to documenter/resource to use during simulation

Documenter/Resource - Prepare MAR prior to simulation by using documents in student preparation package and bring a copy to lab on simulation day. You will have the COPD guideline, CPS and textbook to refer to. The resource person is to help the primary or secondary nurse with information and/or prompts during the simulation.

Family member - Will have a script and will participate in simulation as directed by faculty or sim specialist

Doctor’s orders

Sidney Brenner
BD: March 28, 1952
Hosp #:
ALLERGIES: NKA

HSL HEALTH CARE

PHYSICIAN’S ORDERS

DATE TIME
Ceftriaxone 1 gram IV daily for 7 days
Salbutamol 100 micrograms/puff, 2-6 puffs inhaled via Metered Dose Inhaler (MDI) with spacer/mask q2h PRN
Ipratropium 20 micrograms/puff, 4 puffs inhaled via Metered Dose Inhaler (MDI) with spacer/mask q4h
Titrate oxygen to achieve a target of 88-92% with an O2 flow rate of 1-2 L/min by nasal prongs or venturi mask - 24-28%
Fluticasone 500 micrograms/salmeterol 50 micrograms per inhalation (AdvairDiskus) 1 inhalation BID
Prednisone 30 mg PO daily for 7 days
Acetaminophen 650 mg PO q 4 h prn for temp >38.6
Continuous infusion IV Normal Saline 75 ml/hr until drinking well
Dr. Loyalist

MAR Template

Appendix B

COPD completed MAR

Appendix C

FACULTY SIMULATION EVALUATION – COPD sim

Please select from Likert scale the extent to which you felt this group of students met the learning activity objectives.

1 2 3 4 5

< 50% met with < 50% met with > 50% met >75% met 90-100% met

Critical elements non critical elements

missed missed

  1. Performed a comprehensive assessment of a client with COPD, utilizing elements of the RNAO COPD BPG

1 2 345

  1. Initiated appropriate nursing interventions and prioritized care for the client with COPD, according to evidence based practice guidelines

1 2 345

  1. Individually identified future learning needs that will augment their knowledge base and support future practice of COPD clients

1 2 345

Please enter any comments related to ratings for learning objectives completion.

Please comment on the flow of the simulation, ie time factors for this activity.

Please note any changes or definite “keepers” that you would suggest for running this simulation in the future.

Appendix D

Student COPD Evaluation

STANDARD STUDENT COPD SIMULATION EVALUATION

  1. The simulation provided my group the opportunity to perform a comprehensive assessment of a client with COPD, utilizing elements of the RNAO COPD BPG

Strongly Disagree ------Disagree ------Agree ------Strongly Agree

  1. The simulation provided my group the opportunity to initiate appropriate nursing interventions and prioritize care for the client with COPD, according to evidence based practice guidelines

Strongly Disagree ------Disagree ------Agree ------Strongly Agree

  1. The simulation provided me the opportunity to identify future learning needs that will augment my knowledge base and support future practice of caring for COPD clients

Strongly Disagree ------Disagree ------Agree ------Strongly Agree

**Alternate student evaluation for more in-depth analysis Questions can be used on survey format such as Socrative, Survey monkey or Fluid Survey.

What was your role in the simulation?

Did you read the RNAO COPD BPG prior to coming to lab today?

To what degree did the RNAO COPD BPG prepare you for this learning activity?

How would you rate your understanding of care of the COPD patient before the scenario?

Did you sense urgency at any point in the COPD patient scenario?

What degree of anxiety did you feel during the scenario?

What would you say your major learning style is?

How would you rate your understanding of care of the COPD patient after the scenario?

Overall, how would you rate this learning activity?

Would you recommend this learning activity for other concepts?

If yes, please list other concepts you would find this helpful for:

Additional comments:

Appendix E

COPD

Family Member Script

Does he have any allergies?

No

When did this episode of dyspnea start?

He started having trouble yesterday after dinner. You know his mother has a cold and she lives in a nursing home. I told him not to go visit her! Would you visit your mother if she was sick and you had a lung condition?

Can you rate his dyspnea on a scale of 1 - 10 right now?

I would say it is about a 7 right now.

What is his usual level of dyspnea, on a scale of 1 - 10?

He is usually a 3.

Have you noticed if his feet have been swollen?

No, but mine swell up all the time.

Does he use his accessory muscles to breath?

I don=t know what you mean.

Yes, I noticed he was doing that last night.

Does he have a cough?

He didn’t have one last night, but I noticed this morning that he started to cough up some phlegm.

What colour was the phlegm?

Yellowish white and thick.

Does he usually have a cough and phlegm?

No, not usually.

Does he experience frequent respiratory tract infections?

Yes, he usually gets at least 4 or 5 every winter. That is one of the reasons I told him not to visit his mom. I make him get his flu shot, but it doesn’t seem to help.

Does he get short of breath with activity?

Yes, he’s OK if he sits still, but if he gets up and walks he gets short of breath. He can hardly make it up the stairs any more.

Simulation Design Template

Is he a smoker?

He used to smoke until a year ago, when he got home oxygen. I made him quit because I was afraid he would blow the house up.

How much did he smoke?

About 2 packs per day.

How long did he smoke for?

30 years

Is he on oxygen at home?

Yes

What is it set at?

We put the dial to number 1 or 2.

Is he on medications at home?

Yes he takes puffers a blue one, a green one and an orange one.

Does he use a spacer with his puffers?

No. They gave him one, but he says it doesn’t work.

Appendix F - External Review documentation

External Peer Review Feedback for COPD Sim review May 2013

External Reviewer information

LouanneMelburn, RN, BSN, M A Ed

Professional Practice Leader for Medicine and Emergency at QHC

Previous experience clinical work in Medicine, Emergency and ICU

Review Feedback

Email correspondence below:

Looks good Julie. I might add crackles to the lung sounds and change puffs to 2-6 puffs. If the patient is in acute distress and able to use a puffer we would often start with 6 puffs of each. If unable to use anareo-chamber then we would use a nebulizer. I have attached the draft order set that is almost complete you can have a look. The only thing that has not been decided is on whether it should be 6 or 8 puffs and if we will give a range. For example 2-8 puffs. I also attached the order set for oxygen. Hope this helps

Louanne

From: Julie Rivers [mailto:
Sent: May-23-13 10:43 AM
To:Melburn, LouAnne
Subject: COPD simulation advice

Hi Louanne,

I have attached orders used for our COPD sim, can you advise if they correlate with COPD pathway? If you have any other info to share re COPD guidelines I would appreciate it.

Also I have included below vitals, would they be realistic in your estimation?

Initial vitals:

BP 90/60 Vol.9 Gap

Temp 38.4

P - 96

R – 34

O2 sats – 85%

Lungs: Wheezes

Heart: Normal

O2 sats improve slightly (86) if HOB raised or O2 nasal cannula flow rate increased from 2-5L/min, more if venturi mask applied (88) and more if meds administered properly (90-92)

Thanks,

Julie

QUINTE HEALTH CARE OXYGEN ORDER SET

Oxygen/MD/04-11/V3 Sent to Pharmacy Date: ______Time: ______Page 1/1

Respiratory

Oxygen ______% or ______L/minute

Adjust O2 to (check one only): Achieve target SpO2 of 92% OR

Achieve target SpO2 of ______-- ______%

If SpO2 is greater than the target ordered above, decrease O2 by 1 – 2 L/minute or 10% increments until the target SpO2 is

achieved

If SpO2 is below the target ordered above, increase O2 as necessary to achieve the target SpO2

Repeat and record SpO2 at least 10 minutes after each oxygen change