Code Blue Simulation

Montgomery College Nursing Simulation Scenario Library Scenario File: CODE BLUE Discipline: Nursing Student Level: 3rd Semester Expected Simulation Run Time: 20 minutes Guided Reflection Time: 30 minutes Admission Date: 4/14/xx Psychomotor Skills Required Prior to Today’s Date: 4/15/xx Simulation • Vital Signs Brief Description: • Physical Assessment – cardiac Name: John Goldman • BCLS DOB: 4/1/19xx • Administer IV Push medication Gender: Male Age: 80 • Communication Race: Caucasian • Interdisciplinary Team Work Weight: 76 kg Height: 178 cm Religion: Catholic Major Support: Wife Cognitive Activities Required Prior to Phone: XXX-XXX-XXXX Simulation [i.e. independent reading (R), video Allergies: NKA Immunizations: Flu & Pneumovax last Sept. review (V), computerst simulations (CS), lecture (L)] • Read Pelico 1 Ed. Ch. 15 pp. 437 – 438; ch 17 Attending Physician/Team: Hospitalist pp. 461 – 488 Past Medical History: CAD, HTN, and th CHF. Medications: • Lasix 20mgPO QD • HCTZ 25mg QD History of Present illness: Palpitations with anxiety since two days ago Social History: 40 pack year smoker – none in 20 years, drinks alcohol occasionally. He is retired and lives with his wife in an apartment in a 65+ community. Primary Medical Diagnosis: Palpitations with Anxiety reaction and shortness of breath. Surgeries/Procedures & Dates: None Scenario Overview: An 80-year-old man with a history of coronary artery disease, hypertension, and CHF was admitted to an inpatient Intermediate Care Unit (Telemetry Unit) for heart palpitation and anxiety. On second hospital day, he had sudden onset of confusion, bradycardia, and hypotension. He lost consciousness, and a "code blue" was called. Simulation Learning Objectives • • • • • • • Read Lewis, 8 Ed. Chapters 34, 36, and Appendix A “Cardiopulmonary Resuscitation and Basic Life Support for Health Care Providers” Complete Cardiac Rhythm self-study packet (Course Guide) Study Montgomery College CPR guidelines for adults Watch video: http://www.youtube.com/watch?v=YEjljHme OZk&feature=share&list=PL_2IMx1vzUkDHF Wjz_unmL1FNmtsESo9N Receive orientation to Code Team roles Receive orientation to crash cart Receive orientation to LifePak Nursing Diagnosis: Decreased Cardiac Output r/t cardiac rhythm disturbance Collaborative Problems: Respond appropriately and carry out roles of Code Blue Team 1. Assemble an organized code blue team response. 2. Perform duties appropriate to the participants’ role on the interdisciplinary team. 3. Identify the heart rhythm (VF, VT, Asystole) on monitor. 4. Identify appropriate treatment for the heart rhythm. 5. Initiate proper BLS, as specific in Montgomery College CPR check list for adults. 6. Be able to state defibrillator may be applied as many as three times (200 joules, 200/300 joules, and 360 joules or equivalent) for VF or pulseless VT. 7. Exhibit competent role performance under stressful conditions. 8. Demonstrate therapeutic communication in care of the patient and family. 9. Document the assessment data, patient changes, and intervention completed. Program / Curriculum Specific Objectives Fidelity (choose all that apply to this simulation) Setting/Environment Medications and Fluids o o o o o o o o o o o ER Med Surg Peds ICU OR / PACU Women’s Center Behavioral Health Home Health Pre-Hospital Other ___Telemetry Unite • High Fidelity manniken ○ Oral Meds ○ IV Fluids: NSS 1000mL ○ IVPB ○ IV Push: o Epinephrine o Vasopressin Simulator/Manikin/s Needed: ○ IM / Subcut / Intradermal Props: Cardiac simulator; Vtach – Vfib – ○ Other Asystole; ACLS algorhythms Equipment Attached to Manikin: °IV tubing with primary line NSS fluids running at 50 cc/hr o Secondary IV line __ running at _ cc/hr o IV pump o Foley catheter ________cc output o PCA pump running o IVPB with ___ running at ___ cc/hr o 02 NC @ 2L/min o Monitor attached o ID band o Other: Crash cart with cardiac simulator and Lifepak, adult monitor pads, epinephrine, Vasopressin Equipment Available in Room Bedpan/Urinal Foley kit Straight Cath Kit Incentive Spirometry Fluids: NSS 1000mL IV start kit IV tubing IVPB Tubing IV Pump Feeding Pump Pressure Bag 02 delivery device__Ambu Bag______ Crash cart with airway devices and emergency medications o Defibrillator/Pacer o Suction o Other o o o o o o o o o o o o o Diagnostics Available o o o o X-rays (Images) result Labs 12-Lead EKG Other________ Documentation Forms Admit Orders Physician Orders Flow sheet Medication Administration Record Kardex Graphic Record Shift Assessment Triage Forms Code Record Anesthesia / PACU Record Standing (Protocol) Orders Transfer Orders o Other: Two patient’s charts o For 1st scenario, need chart with a DNR order on it. o 2nd scenario Full Code order. o o o o o o o o o o o o Recommended Mode for Simulation (i.e. manual, programmed, etc.) • High Fidelity Roles/Guidelines for Roles ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ Primary Nurse Secondary Nurse Clinical Instructor Family Member #1 (wife) Family Member #2 Observer Physician / Advanced Practice Nurse (Runs the code) Respiratory Therapy Anesthesia Pharmacy Lab Imaging Social Services Clergy Unlicensed Assistive Personnel (Patient Care Technician/Tech) Code Team Other___Supervisor / Recorder 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 o Other ____________________________ Report Students Will Receive Before Simulation: Scenario Overview: John Goldman, an 80-year-old male, history of coronary artery disease, hypertension, and ○ congestive heart failure admitted to Intermediate ○ Care Unit last night for heart palpitations and Important Information Related to Roles anxiety. This morning, he had sudden onset of confusion, bradycardia, and hypotension. He lost • The Instructor hands students role consciousness, and a "code blue" was called. cards, Asks students to identify the rhythm, calls for Defibrillation - and in the first scenario calls off the code when the DNR order is found. • During the second code, the patient converts to sinus rhythm and breaths spontaneously after the epi + 2nd defib. Significant Lab Values: Chest X-ray result: o Pulmonary Congestion + radiographic Cardiomegaly o K. 2.8 Physician Orders MD order on Admission: IV NSS @ 50 mL/hr NPO for possible CATH Cardiac Monitor Bedrest with BRP DNR (first patient scenario only) Electrolytes Chest X-ray You are on the code team and are answering the call. (Overhead “CODE BLUE, SIM LAB, ROOM XXX” As students enter the room – HAND CARDS in this order: • Primary RN: CALL FOR HELP & INITIATE CODE BLUE • TECH: BRING CRASH CART, APPLY • Respiratory Therapist: OXYGENATE LEADS, APPLY CPR BOARD, & ALTERNATE COMPRESSIONS THE PATIENT WITH BAG-MASK VENTILATIONS • SUPERVISOR: RECORD THE • IV NURSE: CHECK IV AND CODE & run the Lifepak / retrieve meds FROM CART ADMINISTER MEDICATIONS Lasix 20mg IV push, BID HCTZ 25mg PO, daily with sip of H2O. Physician Order During Code: 1. Defibrillate with 200 joules 2. Administer Epinephrine, 1mg IV. Push. 3. Defibrillate with 300 joules again. 4. Administer Vasopressin 40 Unit, IV. Push as a single dose for maintaining blood pressure and heart rate and rhythm in second scenario. • SECONDRY RN: BRING THE • CLERGY: SUPPORT WIFE PATIENT”S CHART & CHECK ORDERS • WIFE: ASKS QUESTIONS AS A SPOUSE WHO IS WORRYING ABOUT HUSBAND’S LIFE • FACULTY/ADVANCED PRACTICE NURSE: ORDER MEDS, DEFIBRILLATOR, & ALL OTHER ORDERS References, Evidence-Based Practice Guidelines, Protocols, or Algorithms Used For This Scenario: (site source, author, year, and page) Mad Scientists ACLS Algorhythms: 2007 NCLEX-RN© Test Plan Categories and Subcategories Choose all areas included in the simulation Safe and Effective Care Environment Management of Care ● ● ● ● ● ● ● ● ● ● Advance Directives ● Advocacy ● Case Management ● Client Rights ● Collaboration with Interdisciplinary Team ● Concepts of Management ● Confidentiality / Information Security Consultation ● Continuity of Care ● Delegation ● Safety and Infection Control ● ● ● ● ● ● ● ● Accident Prevention ● Disaster Planning ● Emergency Response Plan Ergonomic Response Plan ● Error Prevention ● Handling Hazardous and Infectious Materials Home Safety ● Injury Prevention ● Health Promotion and Maintenance ● ● ● ● ● ● ● ● ● Aging Process Ante/Intra/Postpartum and Newborn Care Developmental Stages and Transitions Disease Prevention ● Expected Body Image Changes ● Family Planning ● Family Systems Growth and Development ● Health and Wellness ● Psychosocial Integrity ● ● ● ● ● ● ● ● ● ● Abuse/Neglect Behavioral Interventions Chemical and Other Dependencies Coping Mechanisms Crisis Intervention Cultural Diversity End of Life Care Family Dynamics Grief and Loss Mental Health Concepts ● ● ● ● ● ● ● Establishing Priorities Ethical Practice Informed Consent Information Technology Legal Rights and Responsibilities Performance Improvement (QI) ● Referrals Resource Management Staff Education Supervision Medical and Surgical Asepsis Reporting of Incident/Event/ Irregular Occurrence/Variance Security Plan Standard /Transmission-Based / Other Precautions Use of Restraints/Safety Devices Safe Use of Equipment ● Health Promotion Programs ● Health Screening ● High Risk Behaviors Human Sexuality Immunizations Lifestyle Choices ● Principles of Teaching/Learning Self-Care Techniques of Physical Assessment ● Psychopathology Religious and Spiritual Influences on Health Sensory/Perceptual Alterations Situational Role Changes Stress Management Support Systems Therapeutic Communications ● Therapeutic Environment Unexpected Body Image Changes Physiologic Integrity Basic Care and Comfort ● ● ● ● ● Assistive Devices ● Complementary and Alternative Therapies ● Elimination ● Mobility/Immobility ● Non-Pharmacological Comfort Interventions Pharmacological and Parenteral Therapies ● ● ● ● ● ● Adverse Effects/Contraindications Blood and Blood Products Central Venous Access Devices Dosage Calculation Expected Effects/Outcomes Medication Administration ● ● ● ● Reduction of Risk Potential ● ● ● ● ● Diagnostic Tests ● Lab Values Monitoring Conscious Sedation Potential for Alterations in Body Systems ● Potential for Complications of Diagnostic ● Tests/Treatments/Procedures Physiologic Adaptation ● ● ● ● ● Alterations in Body Systems Fluid and Electrolyte Imbalances Hemodynamics Illness Management Infectious Diseases ● ● ● ● Nutrition and Oral Hydration Palliative/Comfort Care Personal Hygiene Rest and Sleep Parenteral/Intravenous Therapies Pharmacological Agents/Actions Pharmacological Interactions Pharmacological Pain Management ● Total Parenteral Nutrition Potential for Complications from Surgical Procedures and Health Alterations System Specific Assessments Therapeutic Procedures ● Vital Signs Medical Emergencies Pathophysiology Radiation Therapy Unexpected Response to Therapies Scenario Progression Outline Timing Manikin Actions Expected Interventions May Use the Following Cues minutes Manniken is not breathing; cardiac monitor shows V-Fib • Students answer code quickly, receive roles, initiate care • First student assesses for pulse, finds none, calls for help, initiates compressions • Second student brings cart, applies monitor pads, places patient on resuscitation board, clears the room of visitors and extra equipment & alternates compression • Third student begins bagmask ventilations • Fourth student begins documentation, retrieves ordered medications, sets LifePak for defibrillation • Fifth student checks IV and administers Epinepherine when ordered (Vasopressin in second scenario) • Sixth student takes wife aside and consoles her • Seventh student brings chart from desk & reviews orders • Eighth student asks questions as patient’s wife Role member providing cue: Wife: my husband is not responding (approxi mate) First 5 Next 5-10 minutes • Manniken not breathing. • Monitor shows V-fib • (First time scenario is run, shows Asystole after defib) • (Second time scenario is run, shows sinus rhythm after 2nd defib) • Supervisor defibrillates when called for • First student: gets set of vital signs • BP is low • IV nurse: Gives Vasopressin IV push as ordered • First RN checks VS and reports normal values. Tech: Do you need crash cart? Instructor (Resident) • What is the Rhythm? (VF) • What is the treatment that is called for? • Prepare for Defibrillation • I’m clear, You’re clear, we’re all clear • Continue CPR • What is the Rhythm? • What is the treatment? Role member providing cue: Instructor: • Cue: • Give Epinepherine 1 mg IV Push • Repeat Defibrillation • I’m clear, You’re clear, we’re all clear • (First time scenario is run: “STOP CPR – Patient has DNR order on chart”) • (Second time: “Stop CPR – patient has converted to NSR – continue to monitor”) 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 experiences? 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 any person on the Code Team 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 and/or collaborative problems? 10. What were the key assessments and interventions? 11. Is there anything else you would like to discuss? Scenario Specific Questions: 1. How did you feel when the Resident told you to stop CPR in the first scenario? 2. Do you think there was effective use of Delegation? Why or Why not? Program/Curricular Specific Questions: Complexity – Simple to Complex Suggestions for changing the complexity of this scenario to adapt to different levels of learners: