Surgical Simulation

Surgical Simulation David Moore 52 year old Caucasian male (DOB 6/2/XX) Ht: 72” Wt: 118 Kg C/O “bloating”, N/V, diarrhea and abdominal pain for three days prior to admission Pt was admitted five days ago with bowel obstruction. CT on arrival showed a blockage in the transverse colon. MRI three days ago confirmed colon cancer. NGT was placed on admission to low intermittent suction. It has drained an average of 300mL per shift, green fluid. Foley catheter, also placed on admission, drained an average of 600mL per shift, clear yellow urine. Triple lumen CVC line placed Right subclavian three days ago. TPN infused at 100mL per hr and Lipids 10%, 500mL at 50mL/hr daily. Past Medical History: NIDDM, A Fib, Hypertension Married, three living/healthy children, Long distance Truck driver, smoker (smokes 1 pack per day for 34 years), drinks one case of beer every weekend Home Meds: Glyburide 5 mg PO daily, Lantus 36 units q hs, Coumadin 5 mg PO daily, Multi vitamin daily, ASA 325 mg daily Current Meds: Vancomycin 1 GM q 12 hrs IV, Glyburide 5 mg PO daily, Lantus insulin 36 units q hs, Coumadin 5 mg PO daily, Multi vitamin daily, ASA 325 mg daily, Accu check q6h with Lispro sliding scale coverage At 0600, TPN D/C’d and 0.9% NSS hung at 100mL/Hr. Foley emptied. NGT clamped. Accu check 154. Pt taken to OR. In OR/PACU (0600 – 1700) EBL 1000mL. Received two units of Packed Cells and 5000 mL 0.9% NSS in OR. UOP 350 mL. Returned to floor at 1700. Post-op orders: Transfuse 2 units packed cells. PCA pump with Morphine, basal dose 2 mg/hr, bolus 1 mg q 8 mins. PCA protocol. NGT to low intermittent suction. Foley to straight drainage. Bedrest today. BRPs starting tomorrow. Resume previous medications. Ostomy Nurse to follow. ***It is now 1900. You are working 1900 – 0700 and receiving shift report which includes: Pt is alert/oriented. Abdomen soft. No bowel sounds. Abdominal dressing C/D. NGT draining small amount green drainage. Colostomy bag has small amount of dark red drainage. Foley has small amount of dk amber urine. Pt is using PCA pump and denies pain at this time. Second unit of Packed Cells infused. 0.9% NSS open to flush after packed cells. (Groups of 4 RN, LPN, Charge Nurse on unit, CNA) Equipment Checklist Equipment that should be readily available for the scenario Personal  PPE ( googles, gloves, etc) X Stethoscope X Penlight  Reference Material            Diagnostic X X X X  BP cuff on monitor Thermometer SPO2 monitor and probe ECG monitor Lab reports  Medical Records  Physician Orders    Therapy      X X X   Oxygen source Oxygen delivery adjunct NGT Suction IV Start Kit Crash Cart X NGT to wall suction X colostomy bag on abdomen X foley catheter indwelling   Medications & IV Fluids      X IV NSS with empty bag packed RBCs      X IV Lactated Ringers at KVO X PCA pump X Medication Cart X Blood sugar monitor      Preparation of the Simulator NGT to low suction. Colostomy bag on patient. Abdominal Dressing with sm amount red blood. IV of LR with PCA attached. Foley catheter with sm amount of dk amber “urine” Number and Roles of Participants One Instructor Four or five students nurses Scenario 1 (MI due to low H&H) Pt states “I’m having some chest pain”. Initial V.S.: Temp 97.0 F, Pulse 110, Resp 20, B/P 162/88, O2 sat 97% Student should:         Wash Hands, Introduce self, Identify the Patient Raise HOB Place O2 Do V.S. including O2 Sat Pain assessment check for routine cardiac orders call for 12 Lead Call MD  Request cardiac orders (NTG, MS04,lab work(serial cardiac labs), transfer to monitored unit  Stay with patient and provide support (Offer to call family, Pastor) Scenario 2 (PE due to stasis of position in OR) Pt states “I just got this really sharp pain in my chest and I am having problems breathing” Initial V.S.: Temp Temp 99.0 F, Pulse 110, Resp 28, B/P 162/88, O2 sat 84% Student should:         Wash Hands, Introduce self, Identify the Patient Raise HOB Place O2 Do V.S. including O2 Sat Pain assessment call for 12 Lead Recognize the PT and INR are within normal limits (Pt. on Coumadin) Call MD  Request ABG’s, CT Scan, transfer to monitored unit  Stay with patient and provide support (Offer to call family, Pastor) Scenario 3 (Hypoxic due to low H&H) Pt states “I’m really short of breath” Initial V.S.: Temp 97.0 F, Pulse 110, Resp 28, B/P 162/88, O2 sat 90% Student should:       Wash Hands, Introduce self, Identify the Patient Raise HOB Place O2 Do V.S. including O2 Sat Respiratory Assessment Call MD  Request ABG’s, Increase in O2, CXR, Repeat H&H, transfusion  Stay with patient and provide support (Offer to call family, Pastor) Scenario 4 (Peritonitis due to leaking bowel) Pt states “My stomach hurts” Initial V.S.: Temp 102.6 F, Pulse 110, Resp 28, B/P 162/88, O2 sat 96% Student should:      Wash Hands, Introduce self, Identify the Patient Do V.S. including O2 Sat Pain assessment Check wound site (dressing), abdomen (rigid), NGT for patency and drainage Call MD  Request CT scan, labs (CBC with diff)  Prepare for return to OR  Stay with patient and provide support (Offer to call family, Pastor) Scenario 5 (Neuro status change due to over sedation (PCA), or hypoglycemic due to diabetic medication, D/C TPN, and NPO) Initial V.S.: Temp Temp 97.0 F, Pulse 60, Resp 8, B/P 102/58, O2 sat 90% Student should:          Wash Hands, Introduce self, Identify the Patient Place O2 Do V.S. including O2 Sat Turn off PCA Do accu check  If low and responsive, give oral dextrose paste (NPO/NGT)  If low and unresponsive, call for D50 IV  Repeat blood sugar Rapid neuro assessment If blood sugar not the cause, administer Narcan per routine PCA orders Call MD  Request change in appropriate orders (PCA or insulin) Stay with patient and provide support (Offer to call family, Pastor) Additional Potential Scenarios/Issues: Dehydration, Electrolyte imbalance, Kidney problems due to low H&H and low output during surgery, pneumonia due to smoking, stasis of secretions, and immobility during 12 hour surgery, DVT or lower extremity ulcer due to immobility during 12 hour surgery and diabetes, Psychosocial issues (colostomy, ?insurance, etc), __________________ Pt: David Anderson,Moore Charles Victor MR# 215SRC01 Dr. Clark LIST ALLERGIES: Allegany College of Maryland School of Nursing Medication Administration Record none Medication Start/Stop Dose 07011500 Route Freq 15012300 23010700 Vancomycin 1 GM IV q 12 hrs Glyburide 5 mg PO daily Lantus insulin 36 units q hs Coumadin 5 mg PO daily @ 1800 Multi vitamin daily ASA 325 mg daily Accu check q6h with Humalog sliding scale coverage 141-180 2 units 261-300 8 units 181-220 4 units 301-350 10 units 221-260 6 units 351-400 12 units >400 Give 12 units and call MD PCA pump with Morphine, basal dose 2 mg/hr, bolus 1 mg q 8 mins. PCA protocol Signature Init Signature Init Signature Init Pt: David Moore MR# 215SRC01 Dr. Clark Allegany College of Maryland Cumberland, MD 21502 Lab Values Date/ Time Day of Surgery 1700 Lab Test CBC WBC RBC HGB HCT Platelet Diff Bands Segs Mono Lymphs Normal Value Patient Results 4.8-10.8 18.4 4.2-5.4 12.0-16.0 37.0-47.0 150-450 3.2 9.6 28.8 156 5-15 46-80 1-10 16-47 6.0 108 2 22 APTT PT 24.5-38.1 11.0-13.2 36.3 12.2 INR 1.0– 2.0 1.1 Hgb A1C 2.2-4.8 Sputum Cx Negative 6.8 Date/ Time Lab Test Lytes Na Day of Surgery 1700 K CL CO2 Glucose BUN Creat CA Phos Alk Phos Total Protein Albumin Tot Bilirubin Direct Bilirubin AST ALT LD Sed Rate Normal Value Patient Results 136-144 148 3.5-5.1 101-111 23 -32 70-110 6- 20 0.6 -1.2 8.6 10.3 2.4 –4.7 38 - 126 2.9 111 31 68 20 1.3 8.6 3.0 42 6.1 -7.9 5.8 3.5 –4.8 0.2 -1.0 3.3 0.5 0 – 0.3 0.1 15 - 41 10 - 54 98 - 192 0 - 20 40 52 143 11 Pt: David Moore MR# 215SRC01 Dr. Clark Allegany College of Maryland Physician Order Sheet LIST ALLERGIES: None Transfuse 2 units packed cells PCA pump with Morphine, basal dose 2 mg/hr, bolus 1 mg q 8 mins PCA protocol NGT to low intermittent suction Foley to straight drainage Bedrest today. BRPs starting tomorrow Resume previous medications Ostomy Nurse to follow Only one set of orders per page please. Once you sign, date and time, please cross through remaining line Post-op- colostomy David Moore Scenario Overview: Estimated Scenario time: 20 – 30 minutes Guided Reflection time: 30 minutes Target Group: NUR 215 Brief Summary: This case presents a client with colon cancer who undergoes surgery for removal of cancer and creation of a colostomy. He was in surgery for 12 hours and had an estimated blood loss of 1000mL. He received 2 units of packed cells during surgery. He has been transferred back to a Medical/Surgical floor for post-op care. The student is expected to recognize patient issues and complaints and respond accordingly. Learning Objectives:      Evaluate patient assessment information including vital signs Identify variances from expected post-op outcomes Prioritize patient needs Implement therapeutic communication Implement direct communication and delegation skills with multidisciplinary team members Assignment 1. What do you think is happening with this patient? 2. What do you think is the cause of this problem? 3. What actions should the RN do? 4. What can be delegated to the LPN? CNA? Charge nurse? Post-Op Simulation (David Moore) Scenario 1 (MI) Student/Role: RN_________________________________________ LPN ________________________________________ CNA_________________________________________ Charge Nurse__________________________________ Correct Treatment #1 (MI)         Wash Hands, Introduce self, Identify the Patient Raise HOB Place O2 Do V.S. including O2 Sat Pain assessment check for routine cardiac orders call for 12 Lead Call MD  Request cardiac orders (NTG, MS04,lab work(serial cardiac labs), transfer to monitored unit  Stay with patient and provide support (Offer to call family, Pastor) Comments: Post-Op Simulation (David Moore) Scenario 2 (PE) Student/Role: RN_________________________________________ LPN ________________________________________ CNA_________________________________________ Charge Nurse__________________________________ Correct Treatment #2 (PE) Student should:         Wash Hands, Introduce self, Identify the Patient Raise HOB Place O2 Do V.S. including O2 Sat Pain assessment call for 12 Lead Recognize the PT and INR are within normal limits (Pt. on Coumadin) Call MD  Request ABG’s, CT Scan, transfer to monitored unit  Stay with patient and provide support (Offer to call family, Pastor) Comments: Post-Op Simulation (David Moore) Scenario 3 (Hypoxia) Student/Role: RN_________________________________________ LPN ________________________________________ CNA_________________________________________ Charge Nurse__________________________________ Correct Treatment       Wash Hands, Introduce self, Identify the Patient Raise HOB Place O2 Do V.S. including O2 Sat Respiratory Assessment Call MD  Request ABG’s, Increase in O2, CXR, Repeat H&H, transfusion  Stay with patient and provide support (Offer to call family, Pastor) Comments: Post-Op Simulation (David Moore) Scenario 4 (Peritonitis) Student/Role: RN_________________________________________ LPN ________________________________________ CNA_________________________________________ Charge Nurse__________________________________ Correct Treatment     Wash Hands, Introduce self, Identify the Patient Do V.S. including O2 Sat Pain assessment Check wound site (dressing), abdomen (rigid), NGT for patency and drainage  Call MD  Request CT scan, labs (CBC with diff)  Prepare for return to OR  Stay with patient and provide support (Offer to call family, Pastor) Comments: Post-Op Simulation (David Moore) Scenario 5 (Change in LOC) Student/Role: RN_________________________________________ LPN ________________________________________ CNA_________________________________________ Charge Nurse__________________________________ Correct Treatment          Comments: Wash Hands, Introduce self, Identify the Patient Place O2 Do V.S. including O2 Sat Turn off PCA Do accu check  If low and responsive, give oral dextrose paste (NPO/NGT)  If low and unresponsive, call for D50 IV  Repeat blood sugar Rapid neuro assessment If blood sugar not the cause, administer Narcan per routine PCA orders Call MD  Request change in appropriate orders (PCA or insulin) Stay with patient and provide support (Offer to call family, Pastor)