Use Information Literacy Criteria to Determine Validity and Reliability of the Information

Use Information Literacy Criteria to Determine Validity and Reliability of the Information

Time / Simulation events / Expected Student Performance and QSEN Competencies
Pre simulation preparation / Prior to the Simulation, the student will conduct evidence based research on Multiple Organ Dysfunction Syndrome and the Sepsis Bundle Protocol /
  • Identify one clinical question about Multiple Organ Dysfunction Syndrome, and find evidence to determine best practice for the issue you indentify.
  • Research one article to explain the rationale for the Sepsis Bundle protocol and share your information in the online forum
  • Use information literacy criteria to determine validity and reliability of the information researched
Evidence Based Practice)
4-4:15 pm
4:15 pm / Physical assessment findings unchanged from ER, except patient is more agitated.
Safety issues in the environment (daughter leaves side rail down, there is water on the floor, patient’s ID band is missing)
Abnormal admission labs
Total WBC 10,500 Neutrophils 86 Bands 2%
Glucose 135 BUN 54 Creatinine 1.8
BUN/ Ceatinine ratio 30 GFR 30 ml/ min
Daughter says “I don’t know if I can ever bring my mother home again. It is so much work, but I feel so guilty “
Daughter says “The doctor said my Mom is going for a CAT scan . My sister’s kidneys shut down when she had an X Ray with that dye.”
Daughter says “How come my mother is not getting her diabetes medicine and her heart pill? She has been on these meds for years
Result of finger stick glucose ( 220)
MD gives telephone order for Sliding Scale Insulin.
BG 150-200: 2 unit Regular Insulin sc
BG 201-250: 4 units Regular Insulin sc
BG 251-300: 6 units Regular Insulin sc
BG 301-350: 8 units Regular Insulin sc
BG 351-400: 10 units Regular Insulin sc
BG over 400 call MD
Recheck finger stick glucose in one hour after Insulin / Nurse A :
  • Take report from the ER nurse
  • Assess patient and document findings.
  • Scan the environment to ensure patient safetyand address problems. (Safety)
  • Assess patient for pain and discomfort, using age appropriate methods (PatientCentered Care)
  • Elicit daughter’s expertise in calming patient. Provide religious article for patient as suggested by daughter.
  • Evaluate admission labs in relation to diagnoses and renal function
  • Review Admission orders
  • Identify a “do not use abbreviation”
(Safety)
  • Respond therapeutically to daughter about discharge planning concerns, considering cultural and family specific issues.
  • Collaborate with case manager (Pt.CenteredCare, Collaboration
  • Call MD to question order for contrast medium(Safety, Collaboration)
  • Explain to daughter the rationale for holding CT scan. (Patient CenteredCare)
  • Complete medication reconciliation form, noting rationale for holding Glucophage and Digoxin(Safety )
  • Explain to daughter reasons for holding Digoxin and Glucophage
  • Call MD to obtain alternate order for diabetes management (Collaboration)
  • Read back and confirm telephone order for sliding scale insulin and write in chart (Safety)
  • Delegate blood glucose monitoring to nursing assistant to obtain blood glucose (220) (Teamwork andCollaboration)
Delegate insulin administration to Nurse B(Teamwork andCollaboration)
  • Nurse B administers 4 Units Regular Insulin

4:30-5 pm / Patient says “Don’t touch me down there. Is this going to hurt?”
Nursing assistant positions the catheter bag on the floor / Nurse A
  • Prioritize nursing interventions on admission orders.
  • Identify incorrect IV solution hanging from ER (D5% /0.45 % NS).
  • Change IV solution to 0.45% NS as ordered. Complete a variance form to report the error. (Safety)
  • Observers conduct a root cause analysis of the error
(Quality Improvement, Safety)
  • Start IV 0.45 % @ 80 ml per hour (prime tubing, hang bag, program pump)
  • Prepare to change urethral catheter
  • Nurse B
  • Explain catheterization procedure to patient in appropriate terms and provide privacy
  • Change urethral catheter and connect to bag with urine meter. Maintain asepsis (Safety)
  • Obtain urine for Culture and sensitivity
  • Administer Levaquin IVPB
  • Start Tube feeding (listen to bowel sounds and check for residual first)
  • Document above actions
  • Position catheter bag off floor and instruct Nursing assistant on proper catheter management (Safety)
  • After the simulation students will conduct an in-class simulated quality improvement project to reduce nosocomial urinary tract infections (Quality Improvement)

5:00 pm / Urine output only 20 ml from Foley cath in first hour
MD writes order to increase IV flow rate to 125 ml per hr
Daughter says “My mother is much more confused.
I think there is something wrong.” / Nurse A
  • Notify MD that urine output is only 20ml concentrated urine
  • Verify order for increased IV fluid rate to 125 ml per hour
  • Re program IV pump correctly
  • Reassess vital Signs, heart and lung sounds ,skin , peripheral pulses,O2 saturation

5:05 pm
5:15 pm / Physical Assessment Findings
Skin is pale, warm and dry
Temp 95.7 F
Heart rate 100
Resp rate 32
B/P 90 / 42
MAP 58
O2 saturation 90 %
Urine output 20 ml after an hour of IV fluid @ 125 ml.
Bowel sounds hypoactive in 2 upper quadrants, absent in lower quadrants
Patient is becoming restless and more confused. Patient states “I am really frightened. When is this airplane going to land? “
Daughtersays “Don’t just let my mother lay there to die. Please do something.”
MD asks daughter to leave the room
MD gives a verbal orders for :
  • IV fluid bolus 0.9 % NS 500 ml in one hour
  • Change O2 to 80 % non-rebreather mask
  • MD writes order forstat labs(labstaff draws specimen for CMP, CBC. Lactate level, coagulation panel, ABG’s, Blood cultures) )
Daughter asks “Why is my mother receiving so much IV fluid? Will her lungs will fill up with fluid”
Resp therapist draws ABG’s and applies high flow 02 / Nurse A.
  • Recognize the signs of Systemic Inflammatory Response Syndrome (SIRS)
  • Apply O2 @ 2 L via nasal canula
  • Stop tube feeding
  • Call a Rapid Response (Safety)
  • Summarizethe patient’s situation
( SBAR format) for Rapid Response Team (Collaboration)
  • Nurse advocates for daughter to remain in room and reassures daughter. (Patient Centered Care)
  • Repeat verbal order for increased IV fluid (Safety)
  • Change IV fluid to 0.9 % Normal Saline 500 ml over one hour
  • Explain rationale for increased IV to daughter
  • Apply pressure to ABG site
  • Ask nursing assistant to deliver ABG specimen on ice
  • Assist Respiratory Therapist with high flow oxygen (Collaboration)

5:20 PM / Physical Assessment Findings
Arouses to loud noise only
B/P 88/40 MAP 56 Heart rate 110
Resp rate 36 O2 Sat 87 %
Lung sounds: crackles auscultated up to mid lobes
Skin is cool and clammy ; Peripheral pulses weak (1+)
Capillary refill 5 seconds
Urine output 5 ml
Patient oozing blood from IV site
Radiologic Technology does portable Chest X Ray as ordered
(shows bilateral, symmetrical fluffy alveolar infiltrates)
ABG Results reported pH 7.30 PCO2 30 PO2 68 HCO3 19
Critical Labs reported
Potassium 6.2 Serum Lactate 5.0 INR 3.5 Platelets 50,000
WBC 16, 500 Bands 13 % Neutrophils 90
BUN 58 Creatinine 3.5 Blood sugar 250
Nursing Assistant does stat EKG as ordered
MD starts a second IV line
MD administers 1 D/50/W and 5 units regular insulin IV / Nurse A
  • Reassess all patient parameters
  • Recognize signs of septic shock
  • Report critical labs, abnormal lung sounds, vital signs and low O2 Satto MD
  • Assist Radiogic Technologist to position the patient for portable chest XRay, with consideration of patient’s comfort.
(Collaboration, team work)
.
  • Receive critical Lab report from Lab staff and report STAT (Safety)
  • Assess EKG for peaked T waves and dysrhythmias
  • Explains the rationale and safety precautions related to Dextrose/Insulin IV.

5:40 pm / MD writes orders for
  • Dopamine 400 mg in 250 ml 0.9 NS. Run @ 5 mcg per kg / min
  • Regular Insulin 10 Units in 500 ml D/ 10%/W IV over one hour
  • BIPAP IPAP @ 10 cm H2O EPAP 5cm H2O.
  • Decrease 0.9 NS IV to 100 ml per hour
  • Transfer to ICU
Resp Therapist changes O2 to BIPAP
Patient says “ Take this thing off my face”
Daughter is hysterical and crying. “Is my mother going to die? She doesn’t want a tube in her throat” / Nurse A and B
  • Reduce 0.9 NS IV fluid to 100 ml /hr
  • Calculate the hourly flow rate for Dopamine drip
Nurse A:
  • Assist Resp therapy with BIPAP
  • Explain reason for BIPAP to patient in appropriate terms (Patient CenteredCare)
  • Prepare to send the patient to ICU
  • Give report to ICU (Collaboration)
  • Complete documentation
(Patient Centered Care):
  • Communicate patient’s wishes to health care team and discuss options with daughter
  • Ask daughter to bring in Advanced Directive
  • Recognize daughter’s anticipatory grieving and communicate appropriately
  • Explain the plan of care to daughter, including renal replacement therapy (CVVH), respiratory management etc.

1

Top View